Every finding on record at Live Oak Healthcare and Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure food items were stored in a safe and sanitary manner. Findings include:During an observation on 6/22/2026 at 9:30 AM, water was pouring from the dishwasher in the main kitchen onto the floor resulting in pooled water on the kitchen floor. During interview on 6/22/2026 beginning at 9:30 AM, the Certified Dietary Manager stated water had routinely poured from the dishwasher onto the kitchen floor during her employment. During interview on 6/22/2026 beginning at 9:30 AM, Staff A, Dietary Aide, stated, It's been like that for a while [water pouring from the dishwasher]. I think a part may be broken.During an observation on 6/22/2026 at 9:38 AM, there were two (2) thawed 4 ounce containers of a nutritional supplement stored in the refrigerator of the East Hall nourishment room. There were instructions written on the supplement carton that directed the thawed substance be used within 14 days of thawing. There was no thawed-on date inscribed on the supplement cartons.During interview on 6/22/2026 beginning at 9:38 AM, the Certified Dietary Manager stated the cartons of thawed supplement should have a date inscribed on them noting the date the supplements were thawed.During an observation on 6/22/2026 at 9:48 AM, there was no working thermometer in the South Hall nourishment room freezer, and there was one (1) carton of thawed supplement. There were instructions written on the supplement carton that directed the thawed substance be used within 14 days of thawing. There was no thawed-on date inscribed on the supplement carton. There was a speckled black and brown substances on the interior top, right, and left sides and lower metal guards of the ice machine. The flooring on the left side of the ice machine was discolored with a dark brown substance, and water was pooled at the door of the nourishment room. During an interview on 6/22/2026 beginning at 9:48 AM, the Certified Dietary Manager stated the nutritional supplements should have been given to residents last night before the observation. There is no working thermometer in the South Hall nourishment room freezer, there is speckled black and brown substances on the interior top, right, and left sides and lower metal guards of the ice machine and the ice machine needs cleaning. The flooring on the left side of the ice machine is discolored with a dark brown substance and water is pooled at the door of the nourishment room. Review of the policy and procedure titled, Cold Foods last reviewed 1/28/2026, read, 2. All perishable foods will be maintained at a temperature of 41 F [Fahrenheit] or below, except during necessary periods of preparation and service. 3. Freezer temperatures will be maintained at a temperature of 0 F [Fahrenheit] or below. 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded.Review of the policy and procedure titled, Ice last reviewed 1/28/2026, read Ice will be prepared and distributed in a safe and sanitary manner. 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. 4. Ice bins will be cleaned monthly and as needed.Review of the policy and procedure titled, Equipment last reviewed 1/28/2026, read All foodservice equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in cleaning and maintenance of all equipment. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed.

Based on record review and interview, the facility failed to ensure an updated Preadmission Screening and Resident Review (PASRR) was completed for a resident diagnosed with a serious mental disorder for 1 of 4 residents, Resident #7, reviewed for PASRR. Findings include: Review of Resident #7's Face Sheet documented a diagnosis of, Psychosis not due to a substance or known physiological condition Onset Date 3/19/2025. Review of Resident #7's PASRR dated 06/14/2024 did not document the resident had a diagnosis of psychosis not due to a substance or known physiological condition. Review of Resident #7's Psychological progress note dated 5/18/2026 documented psychosis as a diagnosis. During an interview on 6/24/2026 at 11:40 AM, the Assistant Director of Nursing confirmed a Level I PASRR had not been updated for Resident #7 to include the mental health diagnosis of psychosis. During an interview on 6/24/2026 at 9:10 AM, the Social Services Director stated, The IDT [Interdisciplinary] Team is responsible for PASRR'S. Review of the policy and procedure titled, Administration PASSR Significant Change read, Significant Change: is a major decline or improvement in a resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions; the decline is not considered self-limiting (NOTE: Self-limiting is when the condition will normally resolve itself without further intervention or by staff implementing standard clinical interventions to resolve the condition. Requires interdisciplinary review and/or revision of the care plan. This does not change the facility's requirement to immediately consult with a resident's physician of changes.

Based on interview and record review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was completed for residents with a serious mental disorder diagnosis at the time of admission for 2 of 6 residents, Residents #15 and #176, reviewed for PASRR.Findings include:1) During an interview on 06/22/2026 at 9:40 AM Resident #15 stated he was tired and he did not want to talk.Review of Resident #15's medical record documented the resident was admitted on [DATE], with a readmission on [DATE] and diagnoses to include major depressive disorder, recurrent, unspecified; restlessness and agitation.Review of Resident #15's PASRR dated 5/08/2026 revealed there were no mental illnesses or suspected mental illnesses documented. Review of Resident #15's Psychiatric admission Note dated 5/15/2026 read, Patient seen today for an initial psych evaluation to rule out symptoms of depression and anxiety given current physical functioning and reduced mobility. Patient currently receives psychotropic medication management. PMH [Primary Medical History]/Problem List: Patient has an active mental health diagnosis. F33.9: major depressive disorder, recurrent, unspecified Status: Resolved Onset Date: 05/10/2026; F33.0: Major depressive disorder, recurrent, mild Status: Active Onset Date: 05/17/2026; R45.1: restlessness and agitation Status: Active Onset Date: 05/10/2026. Review of Systems: Depression, Depressed mood, Insomnia, Loss of energy, Markedly diminished interest; Anxiety, Being easily fatigued. Assessment/Plan: F33.0 - Major depressive disorder, recurrent, mild. Staff to monitor, document, and report worsening symptoms of depressive symptoms: feelings of sadness/depressed mood hopelessness poor concentration loss of interest/lack of pleasure sleep disturbances tiredness and decreased energy change in weight and appetite feelings of worthlessness/guilt suicidal ideations, suicidal intent, suicidal plan. Continue Escitalopram 5 mg [milligrams] daily.Review of Resident #15's Care Plan read, Focus - [Resident #15's name] has a psychosocial well-being problem r/t [related to] lack of motivation and little to no interest in doing things he enjoys, DX [diagnosis] depression. Date Initiated: 05/11/2026. Focus - The resident uses antidepressant medication r/t depression/insomnia. Date Initiated: 05/21/2026. Focus - [Resident #15's name] has DX: depression and agitation. Resident currently expressed feeling down and depressed, trouble sleeping. Date Initiated: 05/11/2026. Review of Resident #15's physician orders dated 5/08/2026 read, Quetiapine Fumarate Oral Tablet 25 MG [milligrams] (Quetiapine Fumarate): Give 25 mg by mouth one time a day for agitation.Review of Resident #15's physician orders dated 5/09/2026 read, Escitalopram Oxalate Tablet: Give 1 tablet by mouth one time a day for depression.2) Review of Resident #176's medical record documented the resident was admitted on [DATE] with medical diagnoses to include dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of Resident #176's PASRR dated 6/17/2026 documented the resident had no mental illness or suspected mental illness.Review of Resident #176's Acute Care Progress Note dated 6/19/2026 read, The patient is a [AGE] year-old female skilled nursing facility resident with a medically complex history significant for encephalopathy, acute kidney failure, dementia, hyperlipidemia, essential hypertension, end stage renal disease, and dependence on renal dialysis who was evaluated today as a new admission while receiving on site hemodialysis. At the time of examination, the patient appeared comfortable and in no acute distress. She was alert and oriented, although speech was limited and communication consisted primarily of brief verbal responses and nonverbal gestures including head nodding and head shaking. Due to underlying cognitive impairment and communication limitations, the patient was unable to clearly express her anticipated length of stay or discharge plans. Given her history of end stage renal disease requiring chronic dialysis in conjunction with dementia and prior encephalopathy, the patient remains medically fragile and at increased risk for metabolic derangements and clinical decompensation. A comprehensive review of her chronic conditions and current treatment needs was performed as part of the admission evaluation. Problem List: N18.6 - End stage renal disease F03.90 - Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Plan: Continue scheduled hemodialysis treatments on Monday, Wednesday and Friday and coordinate care with nephrology and dialysis staff regarding treatment tolerance and volume status: Maintenance dialysis is essential for management of end stage renal disease and prevention of life threatening metabolic and fluid abnormalities.During an interview on 6/24/2026 at 9:45 AM the Regional Nurse Consultant stated that the Social Services Assistant was responsible for reviewing PASRRs when residents were first admitted . The IDT [Interdisciplinary Team] team met the day after the resident was admitted making sure the pieces were all in place. During an interview on 6/24/2026 at 10:35 AM the Social Services Assistant stated she reviews the screening PASRRs when residents are first admitted and they are reviewed the next day by the IDT team in the Clinical Meeting. They review the PASRRs to see if the resident may need special services, require a level II PASRR, to identify any mental illness that would require special services or possibly other review or other [clinical/residential] setting. They would go through the diagnoses to identify any that would trigger [the need for special services, additional review, or another setting]. If a diagnosis was not checked [on the screening PASRR] they would go digging to see if there was a history of the condition, if it was an active diagnosis, or if the resident was being treated. If there were clinical questions or concerns, they would refer it to the ADON (Assistant Director of Nursing).During an interview on 6/24/2026 at 10:42 AM the ADON stated that if a resident was admitted with a diagnosis of a mental illness and it wasn't on the PASRR then the PASRR should have been updated.Review of the policy and procedure titled, Administration - PASRR, with a last review date of 1/28/2026 read, Purpose: To ensure compliance with regulations for Preadmission Screening Resident Reviews. Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and individuals identified with MD or ID are evaluated to receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. The facility will ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need and the most appropriate setting, when a significant change in their status occurs. Preadmission Screening and Resident Review (PASRR): is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/ or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); 3) and receive the services they need in those settings. Procedure - Preadmission Screening: 1. The External Liaison or Internal admission Staff/Designee will obtain a completed pre-admission screen (PASRR Level I) on individuals being admitted to the SNF prior to admission.

Based on observation, interview, and record review, the facility failed to ensure residents received needed care and services for the application of topical medication for 1 of 3 residents, Resident #24, reviewed for skin conditions.Findings include:During an observation on 6/22/2026 at 9:35 AM Resident #24's left elbow was red and swollen.During an interview on 6/22/2026 at 9:35 AM Resident #24 stated the facility did an x-ray on his left elbow that didn't show anything. He was not receiving any treatment. Review of Resident #24's medical record documented the resident was admitted on [DATE] with medical diagnoses to include cellulitis of left lower limb; type 2 diabetes mellitus without complications; acute kidney failure, unspecified; unspecified atrial fibrillation (an irregular and often rapid heart rate); peripheral vascular disease, unspecified; personal history of transient ischemic attack (a temporary blockage of blood flow to the brain, often called a mini-stroke), and cerebral infarction without residual deficits (occurs when brain tissue dies due to a lack of blood flow).Review of Resident #24's physician orders dated 6/04/2026 read, Diclofenac Sodium External Gel 3% (Diclofenac Sodium (Actinic Keratoses)): Apply to left elbow topically every 8 hours for inflammation for 5 days. There was no amount or dose documented in the order.Review of Resident #24's physician orders dated 6/14/2026 read, Diclona External Gel 1-4.5% (Diclofenac Sodium-Lidocaine HCl (Topical)): Apply to Low back, shoulder, elbow topically four times a day for pain for 10 days. There was no amount or dose documented in the order.Review of Resident #24's MAR/TAR (Medication Administration Record/Treatment Administration Record) for the period of 6/01/2026 through 6/23/2026 documented Diclofenac Sodium External Gel 3% (Diclofenac Sodium (Actinic Keratoses)): Apply to left elbow topically every 8 hours for inflammation for 5 days -Start Date 06/04/2026 2200 (10:00 PM). The MAR documented the medication was administered as ordered by the physician three times daily from 6/04/2026 through 6/09/2026 by the initialing of the licensed nurse.Review of Resident #24's MAR/TAR for the period of 6/01/2026 through 6/23/2026 documented Diclona External Gel 1-4.5% (Diclofenac Sodium-Lidocaine HCl (Topical)): Apply to Low back, shoulder, elbow topically four times a day for pain for 10 days -Start Date 06/14/2026 1500 [3:00 PM]. There was documentation of the application of the physician ordered medication for two to four times daily from 6/14/2026 through 6/23 2026. The MAR documented the medication was not administered per the physician's order. Dated 06/17/2026 the medication was initialed as administered twice and dated 6/21-22/2026 the medication was initialed as administered three times.During an interview on 6/23/2026 at 12:20 PM Resident #24 stated the nurses are supposed to be putting something on his elbow four times a day, but they hadn't been putting it on.During an interview on 6/23/2026 at 1:32 PM Staff C, LPN (Licensed Practical Nurse) stated she had applied Resident #24's Voltaren (Diclofenac Sodium) to his shoulder and back, but she was not aware that it was also supposed to be applied to his elbow. She used a medicine cup when dosing the gel, but she did not fill it completely. The order was usually dosed in grams, but she would have to check with the physician about how much she was supposed to apply. Review of Resident #24's most recent MDS (Minimum Data Set) Assessment, a Medicare 5-day assessment dated [DATE] documented his BIMS Score as 14 out of 15 which indicated he was cognitively intact.Review of Resident #24's Care Plan read, Focus - The resident is AT RISK FOR or has POTENTIAL FOR pain r/t [related to] history of surgery, other disease/disorder causing pain, left elbow. Date Initiated: 03/25/2026. Interventions included - Administer and monitor for effectiveness and for possible side effects from routine and/or PRN [as needed] pain medications (see MAR/physician orders.) Date Initiated: 03/25/2026.Review of the mayoclinic.org/drugs-supplements/diclofenac-topical-application-route/description/drg-20063434 read, Dosing: The dose of this medication will be different for different patients. Follow your doctor's orders or the directions on the label. The amount of medication you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine. Precautions: It is very important that your doctor check your progress at regular visits. This will allow your doctor to make sure this medicine is working properly and to decide if you should continue to use it. Blood and urine tests may be needed to check for unwanted effects. This medicine may increase your risk of having a heart attack or stroke. This is more likely in people who already have heart disease or in people who use this medicine for a long time. This medicine may cause bleeding in your stomach or bowels. These problems can happen without warning signs. This is more likely if you have had a stomach ulcer in the past, if you smoke or drink alcohol regularly, are over [AGE] years of age, are in poor health, or are using certain other medicines (eg [for example], other NSAIDs [non-steroidal anti-inflammatory drug], steroid medicine, blood thinners).Review of the policy and procedure titled Clinical-Medication Administration, with a last review date of 1/28/2026, read, Purpose: to administer medications as per providers orders and in accordance with regulatory guidelines and practice standards. Guidelines for medication administration: read orders to ensure the information is clear and accurate. Clarify questions with the charge nurse or the provider as needed. Observe the rights of medication administration right dose.Review of the policy and procedure titled Clinical - Physician Orders, with the last review date of 1/28/2026 read, Purpose: Physician/physician extender's orders are administered upon the clear complete order of an individual lawfully authorized to prescribe. Procedure: B.) Order Clarification Requests: 2. When an order is received, if there is any question regarding the Rights of Medication Administration (i.e., right resident, right medication, right dose, right route, right frequency), the licensed nurse will attempt to contact the prescribing physician to obtain clarification. Communication/communication attempt should be documented in the clinical record.

Based on observation, interview, and record review, the facility failed to ensure an assistive optical device was provided for 1 of 3 residents, Resident #57, reviewed for assistive devices. Findings include:During an observation on 06/22/2026 at 10:00 AM, Resident #57 was observed watching television, the resident was not wearing eyeglasses.During an interview on 06/22/2026 at 10:00 AM, Resident #57 stated she had an eye appointment in January but had not received the glasses she was told would be coming for her.Review of Resident #57's electronic medical record listed a diagnosis of hypertensive retinopathy.Review of the optometry consultation dated 01/21/2026 completed by (name of the optometry provider) read under the section titled Fitting/Adjusting Specs/Ordering bifocal eyeglasses were ordered for Resident #57.During an interview on 06/24/2026 at 1:50 PM, Staff H, Social Services stated an optometrist visits the facility monthly. Eyeglasses are typically delivered to the facility monthly; however, no eyeglasses for Resident #57 were included in the last shipment. The facility has experienced issues with the optometry provider changing physicians. Resident #57 was seen by optometry on 01/21/2026 and the last optometry service provided at the facility was on 03/23/2026. Staff H stated she had not contacted the optometry provider to determine the status of Resident #57's eyeglasses.Review of the electronic medical record revealed no documentation the ordered eyeglasses had been received by the facility or provided to Resident #57. There was no documentation in the record the facility staff had followed up with the optometry provider regarding the delayed delivery of the eyeglasses.

Based on observation, interview, and record review, the facility failed to ensure the facility was free of accident hazards when not securing oxygen tanks/cylinders in 1 of 3 resident's rooms, Resident #176, reviewed for respiratory care.Findings include: During an observation on 6/22/2026 at 9:40 AM Resident #176 was sitting in her wheelchair beside her bed. There was an oxygen cylinder/tank standing unsecured on the floor between the Resident's bed and the bathroom (Photographic evidence obtained). During an observation on 6/22/2026 at 11:30 AM Resident #176 was out of her room. There was an oxygen tank containing over 1000 PSI (pounds per square inch) of oxygen standing unsecured on the floor between the Resident's bed and the bathroom. (Photographic evidence obtained). During an interview on 6/22/2026 at 11:35 AM Staff E, CNA (Certified Nursing Assistant) stated Resident #176's oxygen tank should not be sitting on the floor; it should be in a rolling cart or on her wheelchair. The oxygen tank sitting on the floor is not clean and is not safe. During an interview on 6/22/2026 at 11:37 AM Staff C, LPN (Licensed Practical Nurse) stated Resident #176's oxygen tank had to be in a holder for safety reasons. During an interview on 6/22/2026 at approximately 1:00 PM the ADON (Assistant Director of Nursing) stated portable oxygen tanks needed to be kept in either rolling carts or strapped on the resident's wheelchair. Review of the policy and procedure titled Nursing - Oxygen Administration with the last review date of 1/28/2026, read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 3. Assemble the equipment and supplies as needed. Equipment and Supplies: The following equipment and supplies will be necessary when performing the procedure: 3. Portable oxygen cylinder (secured to O2 [oxygen] cart or wheelchair). Safety Considerations: 4. E-tanks have a high amount of pressure and can be dangerous if not properly secured.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents, Resident #176, reviewed for respiratory care.Findings include: During an observation on 6/22/2026 at 9:40 AM Resident #176 was sitting in her wheelchair beside her bed. The resident was being administered oxygen at 2 liters per minute (2L/min) via nasal canula attached to an oxygen concentrator. Review of Resident #176's medical record documented the resident was admitted on [DATE] with medical diagnoses to include encephalopathy, unspecified; dependence on renal dialysis; end stage renal disease; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #176's physician orders for the period of 6/18/2026 through 6/23/2026 revealed there was no physician order for the administration of oxygen. During an observation on 6/24/2026 at approximately 10:00 AM Resident #176 was lying in bed. The resident was being administered oxygen at 2L/min via nasal canula attached to an oxygen concentrator. During an interview on 6/24/2026 at 10:48 AM Staff D, LPN (Licensed Practical Nurse) stated Resident #176 was on oxygen; she had taken her vital signs earlier that morning and she (Resident #176) was being administered oxygen. They did vitals every shift. If the resident was on oxygen there should be an order and the nurses would document on the MAR (Medication Administration Record, the administration of oxygen. The admission Nurse would start a new resident on oxygen based on the hospital paperwork. If the resident came on oxygen and there wasn't an order, the admission Nurse should contact the MD (Medical Doctor) for an order and clarification of the rate. Staff D, LPN confirmed there was no physician order in the medical record for the administration of oxygen for Resident #176. During an interview on 6/24/2026 at 4:14 PM the DON (Director of Nursing) stated the expectation is for a resident being administered oxygen there is to be a physician's order for the oxygen that included the rate, the delivery method, and the duration. Nurses are expected to assess the resident and document their findings. The DON confirmed there was no physician order in the medical record for the administration of oxygen for Resident #176. Review of the policy and procedure titled Nursing - Oxygen Administration, with the last review date of 1/28/2026, read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Oxygen is used to treat known or suspected hypoxia or hypoxemia. Oxygen is also used to treat increased work-of-breathing. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Process: 1. Verify Physicians orders. Review of the policy and procedure titled Clinical - Physician Orders, with the last review date of 1/28/2026 read, Purpose: Physician/physician extender's orders are administered upon the clear complete order of an individual lawfully authorized to prescribe. Procedure: B.) Order Clarification Requests: 2. When an order is received, if there is any question regarding the Rights of Medication Administration (i.e., right resident, right medication, right dose, right route, right frequency), the licensed nurse will attempt to contact the prescribing physician to obtain clarification. Communication/communication attempt should be documented in the clinical record.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection when staff failed to use appropriate Personal Protective Equipment (PPE) when entering contact precautions rooms for 2 of 3 residents, Residents #38 and #89, reviewed for transmission-based precautions.Findings include:During an observation on 6/22/2026 at 11:08 AM Resident #38's door had a sign displayed documenting Contact Isolation Precautions and there was a Personal Protective Equipment (PPE) holder containing gowns, gloves, and disposable equipment. A Housekeeper was observed entering the room with a spray bottle and a cloth. The Housekeeper donned a pair of gloves before entering the room, and remained in the room for approximately five (5) minutes. She could be overheard conversing in Spanish with Resident #38.During an interview on 6/22/2026 at 11:12 AM Staff E, Housekeeper indicated she did not speak English. She shook her head yes to indicate that she had seen the isolation sign hanging on Resident #38's door and the PPE.Review of Resident #38's physician orders dated 6/16/2026 read, Isolation type: Contact - Diagnosis: ESBL: urine every shift for 7 Days.2) During an observation on 6/22/2026 at 11:18 AM there was a sign posted on Resident #89's door documenting the resident was on Contact Isolation precautions. There was a PPE holder on the door that contained isolation gowns, gloves, and disposable equipment. Staff F, CNA (Certified Nursing Assistant) walked in the room passing Resident #89 sitting in a wheelchair. Staff F, CNA picked up an item and spoke with the resident. She did not don gloves or a gown before entering the room. During an interview on 6/26/2026 at 11:00 AM Staff F, CNA stated for Contact precautions she knew that she needed to put everything on (PPE) and watch what she touched when she was in the resident's room (Resident #89). She had entered Resident #89's room on Monday (06/22/2026) without putting on gloves or a gown because she didn't think he was in the room. She knew she should put on a gown and gloves to go into a room with Contact precautions.During an interview on 6/24/2026 at 1:30 PM the Infection Preventionist stated for residents on Contact Isolation precautions, the staff would, [NAME] your gown and gloves, that's all you need for contact. Put it [PPE/gown and gloves] on before you enter the room and take it off before they leave the room. Between me and [name of the Assistant Director of Nursing] we do education for everyone. Review of Resident #89's physician orders dated 6/18/2026 read, Isolation type: (specify - Contact) Diagnosis: (MRSA [Methicillin Resistant Staphylococcus Aureus] /Enterococcus Faecalis in wound) every shift for 10 DaysReview of Resident #89's medical record documented the resident was admitted on [DATE] with medical diagnoses to include local infection of the skin and subcutaneous tissue, unspecified; polyneuropathy, unspecified (primary).Review of the policy and procedure titled, Infection Prevention and Control Program Overview with the last review date of 1/28/2026 read, Policy: The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Elements of the Program include: Standards, guidelines, and practices which promote consistent adherence to evidence-based infection control practices. Definitions: Transmission-based precautions (a.k.a. [also known as] Isolation Precautions): actions (precautions) implemented, in addition to standard precautions, that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. Note: Although the regulatory language refers to isolation, the nomenclature widely accepted and used in this guidance will refer to transmission-based precautions instead of isolation.Review of the policy and procedure titled, Infection Control-Transmission Based Precautions with the last review date of 1/28/2026 read, Purpose: To identify the need for transmission-based precautions and implementation of infection control practices necessary to prevent the spread of pathogens. Procedure: 2. Contact Precautions: c. Health care personnel caring for residents on contact precautions wear a gown and gloves for interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry is preferred prior to prolonged resident contact and doffing the PPE before exiting the room is done to contain pathogens.

Based on record review and interview, the facility failed to ensure staff followed physician-ordered parameters for blood pressure medications for 1 of 5 residents reviewed for medication administration (Resident #1).Findings include: Review of Resident #1's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included Extended Spectrum Beta Lactamase (ESBL) Resistance, urinary tract infection, subacute osteomyelitis, acquired absence of right leg below knee, acquired absence of left leg below knee, type 2 diabetes mellitus with diabetic polyneuropathy, end stage renal disease, dependence on renal dialysis, and essential (primary) hypertension.Review of Resident #1's physician order dated 8/12/2025 read, Midodrine HCl [hydrochloride] Oral Tablet 10 MG [milligrams] (Midodrine HCl), Give 1 tablet by mouth every 6 hours for hypotension hold for SBP [Systolic Blood Pressure] more than 110.Review of Resident #1's Medication Administration Record (MAR) for August 2025 for administration of 1 Midodrine HCl Oral Tablet 10 MG showed the resident received the medication on 8/15/2025 at 12:00 AM for Blood Pressure (BP) of 114/76, on 8/17/2025 at 12:00 AM for BP of 115/67, on 8/18/2025 at 12:00 PM for BP of 114/67, on 8/19/2025 at 6:00 AM for BP of 114/74, and on 8/24/2025 at 12:00 AM for BP of 122/80.Review of Resident #1's progress notes from 8/15/2025 through 8/25/2025 showed no physician notification regarding the administration of Midodrine HCl on 8/15/2025, 8/17/2025, 8/18/2025, 8/19/2025, and 8/24/2025.Review of Resident #1's physician order dated 9/3/2025 read, Midodrine HCl Oral Tablet 10 MG (Midodrine HCl), Give 1.5 tablet by mouth every 6 hours for hypotension, hold for SBP > (greater than) 130.Review of Resident #1's MAR for September 2025 for administration of 1.5 Midodrine HCl Oral Tablet 10 MG showed the resident received the medication on 9/26/2025 at 12:00 PM for BP of 152/53, and at 6:00 PM for BP of 152/53.Review of Resident #1's progress notes from 9/26/2025 through 9/27/2025 showed no physician notification regarding the administration of Midodrine HCl on 9/26/2025.During an interview on 11/19/2025 at 4:30 PM, Staff B, Licensed Practical Nurse (LPN), stated that regarding Resident #1's Midodrine order, she routinely took his blood pressure before giving blood pressure medications and documented it on the MAR. She was not sure how she missed the parameter for holding Resident #1's Midodrine on 8/17/2025 at midnight and confirmed that it was a medication error.During an interview on 11/20/2025 at 12:23 PM, Staff C, LPN, stated that Resident #1's Midodrine order in September included a parameter to hold the medication if his systolic blood pressure was greater than 130. The 2 doses she administered on 9/26/2025 (at 12:00 PM and 6:00 PM) were medication errors, because his systolic blood pressure was higher than 130.During an interview on 11/19/2025 at 12:15 PM, the Director of Nursing (DON) stated, Medications and treatments are to be administered as ordered. All physician orders are to be reviewed and entered as written. The nurse should reach out to the physician to clarify any questions.Review of the facility policy and procedure titled Administering Medications with an effective date of 4/1/2022 and a revision date of 2/21/2023 read, Purpose: To ensure that medications are administered in a safe and timely manner, and as prescribed. General Guidelines. 3. Medications are administered in accordance with prescriber orders, and current standards of practice.

Based on record review and interview, the facility failed to inform the resident representative of an accident that required physician intervention for 1 of 3 residents reviewed for falls (Resident #2). Findings include: During an interview on 8/6/2025 at 10:10 AM, Resident #2 stated that she had fallen, getting in bed and her knee got stuck, and she had to have x-rays. Review of Resident #2's nursing progress notes dated 7/10/2025 read, Note Text: This nurse entered resident's room to administer PM [afternoon] medication when resident stated that she was hurting from a fall that occurred earlier in the day. Resident stated that her right leg gave out when the CNA [Certified Nursing Assistant] was attempting to put her back in bed which resulted in her right leg twisting and going under the bed. Roommate states she witnessed said incident. This nurse palpated hip area down to her lower extremity. Resident showed signs of pain with facial grimacing and screaming for me to stop. Xray ordered for rule out. Scheduled pain medication administered at that time. Review of Resident #2's records showed no notification of the resident representative regarding the incident documented on 7/10/2025. During an interview on 8/6/2025 at 5:33 PM, the Director of Nursing (DON) stated, The expectation for a fall, whether reported or witnessed, is to complete an incident report and to complete a change in condition report, assess the resident, notify the PCP [primary care physician] and the family. There was no notification to family regarding a fall. Review of the facility policy and procedure titled Nursing- Change in Condition with an effective date of 4/1/2022, and a revision date of 4/4/2023 read, Purpose: To identify and communicate changes in condition to the physician and other employees to implement interventions to prevent further deterioration and possibly prevent hospitalization. Procedure. 7. The resident's family/legal representative/health care agent should be notified about the change in condition as required.

Based on record review and interview, the facility failed to ensure staff promptly reported an accident resulting in injury for physician intervention for 1 of 3 residents reviewed for falls (Resident #2). Findings include: During an interview on 8/6/2025 at 10:10 AM, Resident #2 stated that she had fallen, getting in bed and her knee got stuck, and she had to have x-rays. Review of Resident #2's nursing progress notes dated 7/10/2025 read, Note Text: This nurse entered resident's room to administer PM [afternoon] medication when resident stated that she was hurting from a fall that occurred earlier in the day. Resident stated that her right leg gave out when the CNA [Certified Nursing Assistant] was attempting to put her back in bed which resulted in her right leg twisting and going under the bed. Roommate states she witnessed said incident. This nurse palpated hip area down to her lower extremity. Resident showed signs of pain with facial grimacing and screaming for me to stop. Xray ordered for rule out. Scheduled pain medication administered at that time. Review of Resident #2's records showed no change of condition assessments or interdisciplinary team (IDT) notes regarding the fall reported on 7/10/2025. During an interview on 8/6/2025 at 5:33 PM, the Director of Nursing (DON) stated, The expectation for a fall, whether reported or witnessed, is to complete an incident report and to complete a change in condition report, assess the resident, notify the PCP [primary care physician] and the family; provide first aid if required and follow the physician's order. The SBAR [a report that includes Situation, Background, Assessment, and Recommendations] triggers 72 hours of post-fall documentation, and the IDT [interdisciplinary team] meets and reviews the change or fall. They ask questions to come up with a root cause. They determine the interventions to prevent future falls. They make updates to the care plan. And they follow up to reassess whether the interventions were successful or need to be modified. There was no SBAR or Change in Condition documentation for [Resident #2's name] regarding a recent fall. Review of the facility policy and procedure titled Nursing- Change in Condition with an effective date of 4/1/2022, and a revision date of 4/4/2023 read, Purpose: To identify and communicate changes in condition to the physician and other employees to implement interventions to prevent further deterioration and possibly prevent hospitalization. Procedure: 1. All staff are encouraged to promptly report any changes in condition to the charge nurse, supervisor or DNS [Director of Nursing Services]/ADNS [Assistant Director of Nursing Services] or designee immediately. This may include but not be limited to accidents resulting in injury, or with the potential to require physician intervention. 3. The Physician/Nurse Practitioner shall be made aware of the condition change and pertinent assessment findings. 4. The resident shall be monitored until condition significantly improves.

Based on observation and interview, the facility failed to ensure the nurse staffing data was posted on a daily basis. Findings include: During an observation upon entrance to the facility on [DATE] at 9:00 AM, the nurse staffing information in the reception area was dated Friday 1/31/2025. During an interview on 2/3/2025 at 9:05 AM, the Administrator confirmed the nurse staffing data posted was for 1/31/2025 and not 2/3/2025. During an interview on 2/5/2025 at 2:00 PM, when a policy on posting of nurse staffing information was requested, the Administrator stated the facility did not have a policy and he expected it to be posted accurately daily.

Based on record review and interview, the facility failed to ensure the attending physician documented their rationale related to pharmacy recommendations and failed to ensure to implement the physician's agreed changes for 3 of 5 residents reviewed for drug regimen, Residents #23, #101, and #124. Findings include: 1) Review of the Drug Regimen Review for Resident #23 dated 3/22/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Lamotrigine (Lamictal) for Mood without recent attempt to taper. Please evaluate and consider an attempt at gradual dose reduction with eventual discontinuation or document inability to do so. Please note: abrupt cessation not recommended. Consider a slow taper over 4 weeks then discontinue. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #23 dated 4/24/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Alprazolam 0.25 mg [milligram] daily without recent attempt to taper. Please evaluate current need. Consider taper to 0.25 mg every other day with eventual discontinue or document inability to do so. There was no physician response documented on recommendation. Review of the Drug Regimen Reviews for Resident #23 dated 8/16/2024 and 11/12/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Trazodone 100 mg at bedtime for insomnia without recent attempt to taper. Please evaluate, consider trial taper 50 mg at bedtime or document inability to do so. There was no physician response documented on recommendation. Review of the Drug Regimen Reviews for Resident #23 dated 12/13/2024 and 1/29/2025 showed it read, Consultant Pharmacist Recommendations: Currently receiving Alprazolam which can increase risk of dizziness and falls. Per clinical record, with recent falls. Please evaluate, consider tapering dose or implementing alternative treatment if necessary . Currently receiving Aripiprazole (Abilify) which can increase risk of falls. Per clinical record, with recent falls. Please evaluate, consider tapering dose or implementing alternative treatment if necessary. There was no physician response documented on recommendation. Review of the Drug Regimen Reviews for Resident #23 dated 1/29/2025 showed it read, Consultant Pharmacist Recommendations: Currently receiving Gabapentin which has potential for dizziness and drowsiness, increasing the risk of falls. Per clinical record, with recent falls. Please evaluate possible causal relationship. Consider trial taper to discontinue Gabapentin, if appropriate. There was no physician response documented on recommendation. Review of Resident #23's Medication Regimen Review for Resident #23 dated 6/10/2024 showed the physician agreed with Consultant Pharmacist's recommendation for adding pain parameters to avoid misuse for Oxycodone. The physician signed off on 6/17/2024. Review of Resident #23's physician orders showed no order to implement the physician's agreed changes on 6/17/2024. Review of Resident #23's Medication Regimen Review for Resident #23 dated 9/19/2024 showed the physician agreed with the Consultant Pharmacist's recommendation for evaluation of current need and discontinuation of Lactulose by ordering to change the order to PRN (as needed) and agreed with the Consultant Pharmacist's recommendation for adding pain parameters for Oxycodone. The physician signed off on 10/3/2024. Review of Resident #23's physician orders showed no order to implement the physician's agreed changes on 10/3/2024. 2) Review of the Drug Regimen Review for Resident #101 dated 3/22/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Tramadol which has potential for dizziness and drowsiness, increasing the risk of falls. Per clinical record, with recent falls. Please evaluate possible causal relationship. Consider trial discontinue Tramadol and start alternate therapy (i.e. Ibuprofen or Acetaminophen), if necessary. The physician disagreed with the recommendation on 3/26/2024, but no reason was documented. Review of the Drug Regimen Review for Resident #101 dated 5/9/2024 showed it read, Consultant Pharmacist Recommendations: Currently with routine fingerstick blood sugar monitoring. Please consider add order to notify MD [Medical Doctor] if results <70 or > 300, if appropriate, There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #101 dated 6/10/2024 showed it read, Consultant Pharmacist Recommendations: Currently with active order for sliding scale insulin coverage without order for long-acting or basal insulin. Long term use not recommended due to higher risk of hypoglycemia without improvement in hyperglycemia management. Consider discontinue insulin coverage and taper fingerstick order to two times a week, AM and PM, notify MD if results below 70 or greater than 250, if appropriate. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #101 dated 7/10/2024 showed it read, Consultant Pharmacist Recommendations: Currently with active order for Senna prn which has not been used in greater than 30 days. Please evaluate current need and discontinue if appropriate . Currently has an active order for Acetaminophen prn for fever which has not been used in greater than thirty days. Please consider discontinue unused order at this time. (Please also note that any new use of acetaminophen for fever at this time would require your notification of a change in medical status, making the presence of a prn order for acetaminophen unnecessary.) There was no physician response documented on recommendation. Review of the Drug Regimen Reviews for Resident #101 dated 8/16/2024 and 9/19/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Oxcarbazepine. Per order, use is for a diagnosis other than an approved psychiatric condition. Please evaluate accuracy of diagnosis. If the diagnosis is inaccurate and the resident currently is using this mediation for an approved use such as Bipolar Disorder, or other chronic enduring psychiatric condition, please update the medication order accordingly. If no approved chronic enduring psychiatric diagnosis exists, please consider implementing gradual dose reductions or discontinuing at this time . Currently has an active order for Lorazepam prn without a specified stop date. Please note that CMS guidelines do not allow maintaining open ended orders for PRN psychotropics on medication profiles. Please evaluate and consider discontinue Lorazepam prn, if appropriate. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #101 dated 10/22/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Loratadine without a stop date. Please evaluate. Consider add stop date now if appropriate . Currently receiving Simvastatin (Zocor) for dyslipidemia. Unable to located recent serum lipid profile in chart. Recommended 3 months after start then annually. Please consider ordering . Currently has an active order for Lorazepam prn without a specified stop date. Please note that CMS guidelines do not allow maintaining open ended orders for PRN psychotropics on medication profiles. Please evaluate and consider discontinue Lorazepam prn, if appropriate . Currently receiving Oxcarbazepine. Per order, use is for a diagnosis other than an approved psychiatric condition. Please evaluate accuracy of diagnosis. If the diagnosis is inaccurate and the resident currently is using this mediation for an approved use such as Bipolar Disorder, or other chronic enduring psychiatric condition, please update the medication order accordingly. If no approved chronic enduring psychiatric diagnosis exists, please consider implementing gradual dose reductions or discontinuing at this time. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #101 dated 11/12/2024 showed it read, Consultant Pharmacist Recommendations: Currently with active order for Guaifenesin LA [long acting] (Mucinex) prn which has not been used recently. Please evaluate current need and discontinue if appropriate . Currently has an active order for Lorazepam prn without a specified stop date. Please note that CMS guidelines do not allow maintaining open ended orders for PRN psychotropics on medication profiles. Please evaluate and consider discontinue Lorazepam prn, if appropriate . Currently receiving Oxcarbazepine. Per order, use is for a diagnosis other than an approved psychiatric condition. Please evaluate accuracy of diagnosis. If the diagnosis is inaccurate and the resident currently is using this mediation for an approved use such as Bipolar Disorder, or other chronic enduring psychiatric condition, please update the medication order accordingly. If no approved chronic enduring psychiatric diagnosis exists, please consider implementing gradual dose reductions or discontinuing at this time. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #101 dated 12/13/2024 showed it read, Consultant Pharmacist Recommendations: Currently has active order for Hydrocodone/APAP [Acetaminophen] without a stop date. Emerging data highlights an association between opioid administration and delirium. Please evaluate duration of therapy. Consider add stop date of 14 days, if appropriate . Currently has an active order for Lorazepam prn without a specified stop date. Please note that CMS guidelines do not allow maintaining open ended orders for PRN psychotropics on medication profiles. Please evaluate and consider discontinue Lorazepam prn, if appropriate . Currently receiving Oxcarbazepine. Per order, use is for a diagnosis other than an approved psychiatric condition. Please evaluate accuracy of diagnosis. If the diagnosis is inaccurate and the resident currently is using this mediation for an approved use such as Bipolar Disorder, or other chronic enduring psychiatric condition, please update the medication order accordingly. If no approved chronic enduring psychiatric diagnosis exists, please consider implementing gradual dose reductions or discontinuing at this time. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #101 dated 1/29/2025 showed it read, Consultant Pharmacist Recommendations: Currently has an active order for Lorazepam prn without a specified stop date. Please note that CMS guidelines do not allow maintaining open ended orders for PRN psychotropics on medication profiles. Please evaluate and consider discontinue Lorazepam prn, if appropriate . Currently receiving Oxcarbazepine. Per order, use is for a diagnosis other than an approved psychiatric condition. Please evaluate accuracy of diagnosis. If the diagnosis is inaccurate and the resident currently is using this mediation for an approved use such as Bipolar Disorder, or other chronic enduring psychiatric condition, please update the medication order accordingly. If no approved chronic enduring psychiatric diagnosis exists, please consider implementing gradual dose reductions or discontinuing at this time. There was no physician response documented on recommendation. 46523 3) Review of the Drug Regimen Review for Resident #124 dated 4/23/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Megestrol (Megace) for appetite stimulation and weight gain. Long term use not recommended due to increased thromboembolic risk with use. Please evaluate. Consider add stop date x [times] 14 days, if appropriate . Currently with active order for sliding scale insulin coverage without standing order medication for diabetes. Long term use not recommended due to higher risk of hypoglycemia without improvement in hyperglycemia management. Consider discontinue insulin coverage and taper fingerstick order to two times a week, AM and PM, notify MD if results below 70 or greater than 250, if appropriate There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #124 dated 5/9/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Lansoprazole (Prevacid) for GI [Gastrointestinal] prophylaxis. Long term use for this indication is not recommended due to increased risk of pneumonia, fractures and C. difficile [Clostridium difficile], and development of vitamin B12 deficiency. Please evaluate continued need. Consider trail taper to every other day for 14 days then discontinue, if appropriate . Currently with active order for Ondansetron (Zofran) prn which has not been used in over 30 days. Please evaluate current need and discontinue if appropriate . Currently with active order for sliding scale insulin coverage without standing order medication for diabetes. Long term use not recommended due to higher risk of hypoglycemia without improvement in hyperglycemia management. Consider discontinue insulin coverage and taper fingerstick order to two times a week, AM and PM, notify MD if results below 70 or greater than 250, if appropriate . Currently receiving Mirtazapine (Remeron) for anorexia which can increase risk of dizziness and falls with recent documented falls. Please evaluate risk versus benefit and discontinue, if appropriate . Per clinical record resident with recent falls, recommended to check 25-hydorxyvitamin D levels in those with advanced age and recent falls. Please consider ordering and if necessary initiating vitamin D3 50,000IU capsule once weekly for 6 weeks then monthly thereafter. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #124 dated 9/19/2024 showed it read, Consultant Pharmacist Recommendations: Currently receiving Mirtazapine (Remeron) which can increase risk of dizziness and falls, with recent documented falls, Please evaluate risk versus benefit and discontinue, if appropriate . Currently with active order for Hydrocodone /APAP which can increase risk of falls with recent documented falls per clinical record. Please evaluate possible causal relationship. Consider tapering dose or implementing alternative treatment, if appropriate. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #124 dated 10/22/2024 showed it read, Consultant Pharmacist Recommendations: Per clinical record resident with recent falls. A daily intake of 800-1,000 IU [International Unit] of Vitamin D is currently recommended in the elderly to maintain bone health and reduce the risk of falls and factures. Please evaluate. Consider adding Vitamin D3 1000IU once daily, if appropriate. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #124 dated 11/12/2024 showed it read, Consultant Pharmacist Recommendations: Currently has an active order for Lorazepam prn without a specified stop date. Please note that CMS guidelines do not allow maintaining open ended orders or prn psychotropics on medication profiles. Please evaluate and consider discontinuing Lorazepam prn, if appropriate. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #124 dated 12/13/2024 showed it read, Consultant Pharmacist Recommendations: Currently with active order for Hydrocodone /APAP which can increase risk of falls with recent documented falls per clinical record. Please evaluate possible causal relationship. Consider tapering dose or implementing alternative treatment, if appropriate . Currently receiving Mirtazapine (Remeron) which can increase risk of dizziness and falls, with recent documented falls, Please evaluate risk versus benefit and discontinue, if appropriate . Currently receiving Quetiapine (Seroquel) which can increase risk of falls. Per clinical record, with recent falls. Please evaluate, consider tapering dose or implementing alternative treatment, if necessary. There was no physician response documented on recommendation. Review of the Drug Regimen Review for Resident #124 dated 1/28/2025 showed it read, Consultant Pharmacist Recommendations: Currently receiving Hydroxyzine (Atarax) as an anxiolytic. Please note: hydroxyzine is NOT recommended for use as an anxiolytic. Consider taper to prn for one week and discontinue, or document inability to do so . Currently receiving Quetiapine (Seroquel). Per order, use is for diagnosis other than an approved psychiatric condition. Please evaluate accuracy of diagnosis. If the diagnosis is inaccurate and the resident currently is using this medication for an approved use such as Schizophrenia, Bipolar Disorder, or other chronic enduring psychiatric condition, please update the medication order accordingly. If no approved chronic enduring psychiatric diagnosis exists, please consider implementing gradual dose reduction and discontinues at this time. There was no physician response documented on recommendation. During an interview on 2/6/2025 at 10:15 AM, the Director of Nursing (DON) confirmed the pharmacist recommendations had not been reviewed by physicians and that the recommendations that were agreed upon had not been implemented Residents #23, #101, and #124. The DON further confirmed when the physician disagreed, they did not document a reason. She stated her expectation was that the recommendations were printed, presented to the physicians and then any agreed upon changes recorded in the resident's medical records.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 10.81 percent. Findings include: 1) Review of Resident #11's physician order dated 10/18/2023 showed it read, Trazodone HCl Oral Tablet 150 mg [milligram] (Trazodone HCl), Give 150 mg by mouth two times a day for depression. Review of Resident #11's physician order dated 1/2/2025 showed it read, Tizanidine HCl Oral Tablet 4 mg (Tizanidine HCl), Give 2 tablet by mouth four times a day for muscle spasms. During an observation on 2/3/2025 at 11:12 AM, Staff E, Licensed Practical Nurse (LPN), began to pour Resident #11's medications into a medication cup. Staff E poured one tablet of Tizanidine 4 mg. Staff E did not pour Trazodone 150 mg (milligram). Staff E began to pour water into a medication cup and was getting ready to give the medications to Resident #11. Staff E was asked to review the medications that were in her medication cup. During an interview on 2/3/2025 at 11:15 AM, Staff E, LPN, stated, I am missing the Trazodone and Tizanidine should be two tablets instead of one. During an interview on 2/7/2025 at 10:37 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, One time missed dose of medication does not have an impact to the patient. The nurses have not contacted me recently for any complaints of discomfort or pain. 2) During an observation on 2/4/2025 at 8:03 AM, Staff F, LPN, entered Resident #206's room and handed him a medication cup that contained medications. Resident #206 asked Staff F what the medications were in his cup. Staff F stated she did not know because she was training and Staff G, LPN, was the one to prepare the medication. Staff F and Resident #206 went outside of the room. Staff G was standing next to the medication cart. Resident #206 asked Staff G what the medication were in his cup. Staff G stated what was in the medication cup and asked Resident #206 if he wanted his multivitamin. Resident #206 stated he would take the multivitamin. Staff G opened the medication cart and poured the multivitamin into the medication cup that was originally given to Resident #206. Staff G handed the medication cup back to Resident #206. During an interview on 2/6/2025 at 9:36 AM, Staff G, LPN, stated, I normally put all his [Resident #206] medications in the medication cup. I overlooked the multivitamin. It was just so hectic. Review of Resident #206's physician order dated 12/25/2024 showed it read, Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ [with] Minerals), Give 1 tablet by mouth one time a day for at risk for malnutrition. 3) During an observation on 2/5/2025 at 11:30 AM, Staff H, Registered Nurse (RN), began to prepare Resident #116's medications. Staff H placed a Lansoprazole Delayed Release 30 mg capsule into a medication cup. Staff H donned a pair of gloves and opened Lansoprazole Delayed Release capsule. Staff H asked a certified nursing assistant to grab him some warm water in a Styrofoam cup. Staff H proceeded to walk to Resident #116's room. Staff H placed Resident #116's feeding on hold and proceeded to check gastric tube for placement. Staff H was getting ready to premix the medications with water. Staff H was requested to check the delayed released medication. During an interview on 2/5/2025 at 11:49 AM, Staff H, RN, stated, [Resident #116's name] has a gtube [gastric tube]. She should not have an order for delayed release medication. The medication should be in liquid form. During an interview on 2/5/2025 at 5:00 PM, Staff H, RN, stated, I got clarification and the doctor changed the medication to the liquid due to the size of her tubing because it could clog the tubing due to the size. Review of Resident #116's physician order dated 8/22/2024 showed it read, Lansoprazole Oral Capsule Delayed Release 30 mg (Lansoprazole), Give 1 capsule via G-tube in the morning for GERD [Gastro-Esophageal Reflux Disease]. During an interview on 2/6/2025 at approximately 10:15 AM, the Director of Nursing stated, Delayed release medication should not be administered via gastric tube. If a nurse sees an order that is questionable, they should contact the provider for notification. The nurses should be validating all the medications against the MAR [Medication Administration Record] before giving. Review of the facility policy and procedure titled Administering Medications with the last review date of 1/13/2025 showed it read, Purpose: To ensure that medications are administered in a safe and timely manner, and as prescribed. General Guidelines . 3. Medications are administered in accordance with prescriber orders, and current standards of practice . 8. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication . 19. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall enter the correct code into the bos [Sic.] on eMAR [electronic Medication Administration Record] followed by nursing note if indicated. 20. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the facility policy and procedure titled Medication Dispensing System with the last review date of 1/13/2025 showed it read, Policy: All medications will be prepared (blister cards, vials, Artromick box) and administered in a manner consistent with the general requirements outlined in this policy. Procedure . G. Prior to Medication Administration: 1. Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer. Review of the facility policy and procedure titled Administering Medications Through an Enteral Tube with the last review date of 1/13/2025 showed it read, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . General Guidelines . 5 . c . Do not crush enteric coated, sustained release, buccal, sub-lingual, or enzyme-specific medications. Notify physician and obtain guidance.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 of 6 residents reviewed for blood pressure medication, residents reviewed for medication, Residents #40 and #122, 1 of 3 residents reviewed for dialysis care, Resident #80, 1 of 10 residents reviewed for advance directives, Resident #127, and 1 of 8 residents sampled for oxygen therapy, Resident #28. Findings include: 1) Review of Resident #80's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses including end stage renal disease, sepsis, and anemia. Review of Resident #80's Dialysis Hand Off Communication Report dated [DATE] showed no information documented for presence of bruit/thrill, catheter dressing, signs/symptoms of infection upon his return to the facility. Review of Resident #80's Dialysis Hand Off Communication Report dated [DATE] showed no information documented for presence of bruit/thrill, catheter dressing, signs/symptoms of infection upon his return to the facility. Review of Resident #80's Admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident as being on dialysis. Review of Resident #80's physician orders showed no current order for dialysis. During an interview on [DATE] at 10:53 AM, the Director of Nursing (DON) stated, He [Resident #80] does not have a current order for dialysis. He goes to the dialysis center each day during the week unless he refuses. 2) Review of Resident #127's health records showed a Do Not Resuscitate Order signed on [DATE]. Review of Resident #127's physician order dated [DATE] showed it read, Full code. Review of Advance Directive Discussion form for Resident #127 dated [DATE] showed the resident wished to withhold cardiopulmonary resuscitation. During an interview on [DATE] at 11:05 AM, Resident #127 stated, I do not want CPR [cardiopulmonary resuscitation] at all. During an interview on [DATE] at 11:10 AM, Staff A, Licensed Practical Nurse (LPN), stated, He [Resident #127] is a full code. I would instruct staff to start CPR. During an interview on [DATE] at 11:13 AM, the DON confirmed the full code status in the electronic health record system was incorrect and stated, [Resident #127's name] has a DNR [Do not resuscitate order]. 46523 3) Review of Resident #40's physician order dated [DATE] showed it read, Amlodipine Besylate Oral Tablet 5 mg [milligram] (Amlodipine Besylate), Give 1 tablet by mouth one time a day for HTN [hypertension]. Review of Resident #40's Medication Administration Record (MAR) for [DATE] showed code 4 (vitals outside of parameters for administration) was documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident #40's physician order dated [DATE] showed it read, Isosorbide Mononitrate Oral Tablet (Isosorbide Mononitrate), Give 30 mg by mouth in the morning for hypertension. Review of Resident #40's MAR for [DATE] showed code 4 (vitals outside of parameters for administration) was documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 9:00 AM, the DON stated, I reached out to the provider and order needs to include parameters to hold if systolic blood pressure is less than 110. Nurses communicate with the provider. They should document the notification in the system. During an interview on [DATE] at 9:22 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, Usually staff do communicate with me about parameters and holding medications. I would not be able to remember the dates. All my blood pressure medications have parameters. I usually have hold parameters for systolic blood pressure less than 110 and heart rate less than 60. 4) Review of Resident #122's physician order dated [DATE] showed it read, Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML [milliliters] (Insulin Glargine), Inject 20 units subcutaneously two times a day for DM [Diabetes Mellitus], Hold for BS<70 [Blood Sugar less than 70] and notify MD [Medical Doctor]. Review of Resident #122's MAR for [DATE] showed code 9 (other/see progress notes) was documented on [DATE] at 6:30 AM for blood glucose level of 100, code 13 (no insulin required) was documented on [DATE] at 6:30 AM for blood glucose level of 102, code 5 (hold/see progress notes) was documented on [DATE] at 4:30 PM for blood glucose level of 101, and code 13 (no insulin required) was documented on [DATE] at 4:30 PM for blood glucose level of 112. Review of Resident #122's MAR for [DATE] showed code 4 (vitals outside of parameters for administration) was documented on [DATE] a 4:30 PM for blood glucose level of 147, code 9 (other/see progress notes) was documented on [DATE] at 6:30 AM for blood glucose level of 78, code 9 (other/see progress notes) was documented on [DATE] at 6:30 AM with no blood glucose level documented, code 4 (vitals outside of parameters for administration) was documented on [DATE] at 6:30 AM for blood glucose level of 141, and no entry was documented on [DATE] at 6:30 AM. During an interview on [DATE] at 8:53 AM, the Medical Doctor #2 stated, The nurses communicate with me and tell me when they are going to hold insulin. I would have to go back to my notes and review which days. [Resident #122's name] A1C is 6.9 which is stable. Holding is the right thing to do. He does not even need insulin. I have instructed the Director of Nursing to place him on oral medication. During an interview on [DATE] at 9:55 AM, Staff I, LPN, stated, Nurses are expected to follow the parameters in the medication and document why they have held the medication. During an interview on [DATE] at 10:31 AM, Staff O, LPN, stated, I would have to look at my notes. I do not know why the entry would be blank because I check all my blood sugars and administer the insulin based on the parameters. During an interview on [DATE] at 3:10 PM, the DON stated, I would expect nurses to document in the system the notifications and conversations with the provider. During an interview on [DATE] at 8:38 AM, Staff J, LPN, stated, I do not recall not giving the insulin. Maybe it was an error on my part and documented the wrong code. That was an error. I would normally call the provider if there was a question, or I needed to hold a medication. I would make a note in the progress note. During an interview on [DATE] at 8:51 AM, Staff N, LPN, stated, If the medication is being held, I contact the provider. I only come to the facility on ce a week or every two weeks. If I have any questions on medication, I contact the provider or the unit manager and write the notification in a nursing note. During an interview on [DATE] at 9:14 AM, Staff Q, LPN, stated, I don't remember much about that day. I think his blood sugar was low, and I was trying to get it up. I normally put it in a progress note. Not sure why it is not there. Review of the facility policy and procedure titled Documentation of Medication Administration with the last review date of [DATE] showed it read, Policy Statement: A medication administration record is used to document all medication administered. Policy Interpretation and Implementation: 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication record (MAR). 2. Administration of medication is documented immediately after it is given. Review of the facility policy and procedure titled Administering Medications with the last review date of [DATE] showed it read, Purpose: To ensure that medications are administered in a safe and timely manner, and as prescribed. General Guidelines . 19. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall enter the correct code into the bos [Sic] on eMAR [electronic Medication Administration Record] followed by nursing note if indicated. 49846 5) Review of Resident #15's physician order dated [DATE] showed it read, Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro), Inject as per sliding scale: if ,d+[DATE]=2 units; ,d+[DATE]=4 units; ,d+[DATE]=6 units; ,d+[DATE]=8 units; ,d+[DATE]=10 units; subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic neuropathy, unspecified for bg >400 or <60 [blood glucose greater than 400 or less than 60], call MD. Review of Resident #15's MAR for [DATE] for administration of Humalog showed no entries documented on [DATE] at 9:00 PM, on [DATE] at 6:30 AM and 9:00 PM, on [DATE] at 6:30 AM and 4:30 PM. During an interview on [DATE] at 3:30 PM, the [NAME] Director of Nursing stated, I could not find any other supporting document for the missing entries on the medication record. The nurses will also document blood sugars on the blood sugar vital sign task. During an interview [DATE] at 3:34 PM, the DON stated, There should have been documentation of blood sugars when it was done, and any coverage that would have been given. During an interview on [DATE] at 8:59 AM, the Medical Doctor #1 stated, [Resident #15's name] diabetes is well managed. The staff is usually very good at contacting me in regards to insulin, medications and parameters. I think there is more concern with documentation not with the care provided. He is on two other oral diabetic medications and his A1C is 6.6. [Resident #15] is stable. During an interview on [DATE] at 10:15 AM, Staff O, LPN, stated, [Resident #15's name] I don't recall not taking blood sugars or providing coverage if needed. I worked on [DATE] and [DATE]. I do not know why there are blanks in the system. 50695 6) During an observation on [DATE] at 9:47 AM, Resident #28 was in bed. The resident was not receiving oxygen. During an observation on [DATE] at 10:34 AM, Resident #28 was lying in bed with eyes closed and glasses on. Resident #28 was receiving oxygen via nasal cannula at 3.5 liters per minute. During an observation on [DATE] at 12:18 PM, Resident #28 was receiving oxygen via nasal cannula at 4.5 liters per minute. Review of Resident #28's physician orders showed an order dated [DATE] for administration of oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath. Review of Resident #28's Treatment Administration Record (TAR) for February 2025 showed the resident received oxygen at the rate of 2 liters per minute on [DATE] on both twelve-hour shifts, [DATE] on both twelve-hour shifts, and on [DATE] on the first twelve-hour shift. During an interview on [DATE] at 12:25 PM, Staff D, Registered Nurse (RN), stated, I signed off on [Resident #28's name] oxygen this morning. We are supposed to check that he has O2 [oxygen] on, and I think we just have to check his O2 [oxygen saturation] level. I didn't know that the rate was there too when I signed it. During an interview on [DATE] at 2:50 PM, the DON stated, I expect the nurses to confirm all the rights, including the right rate and the number of hours they are receiving oxygen. Review of the facility policy and procedure titled Nursing- Oxygen Administration with the last review date of [DATE] showed it read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record . 3. The rate of oxygen flow, route, and rationale.

Based on observation, interview, and record review, the facility failed to ensure residents' right to live in a manner that promoted their quality of life for 1 of 57 residents sampled, Resident #135. Findings include: Review of Resident #135's admission record showed the resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus, major depressive disorder, unspecified mood (affective) disorder, and acquired absence of left leg below knee. Review of Resident #135's Service Dog Card showed it read, The Americans with Disabilities Act of 1990 mandates the handler and their service dog shall have full access to all public places. It is Federal law. Handler: [Resident #135's Name], Dog Name: [Resident #135's dog's name], Breed: Mixed, ID Number: [Service Dog ID]. The card contained a photo of the service dog. Review of Resident #135's Minimum Data Set (MDS) assessment dated [DATE] under Section GG- Functional Abilities for self-care showed the resident was independent for eating, oral hygiene, toileting hygiene, self-showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. For mobility, the resident was independent for rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. During an interview on 2/6/2025 at 3:32 PM, Resident #135 stated, Not having my service animal has caused me great distress. I get depressed and very agitated. The facility says they have 24-hour monitoring, but that is not the case. The dog was a rescue, and I had to nourish it back to health. I took it to training so now he is my diabetes dog. Since 11/19/2024, I have been trying to get permission to bring it. They said no it's not going to happen. The options they gave me were to pay for a private room or a sitter, but I cannot afford it. I am afraid to lose him. Review of Resident #135's Advanced Registered Nurse Practitioner (ARNP) visit note dated 12/27/2024 showed it read, HPI [History of Present Illness] General . Patient seen today for an initial psych evaluation to rule out symptoms of depression and anxiety given recent medical hospitalization , current physical functioning, and reduced mobility. Patient is seen and examined, sitting up at bedside finishing lunch, in no acute apparent distress . Her mood is euthymic; affect is appropriate. Mood is congruent to affect . She voices her depression is managed at this time but her anxiety is not . She voices her frustration with not being allowed to have her service dog with her at bedside. Review of Resident #135's Advanced Registered Nurse Practitioner (ARNP) visit note dated 1/17/2025 showed it read, HPI General . The patient is being seen today for a follow up visit . Patient seen and examined, at bedside, in no acute apparent distress . She shares a recent issue that caused her increased stress at facility Review of Systems: Depression: depressed mood and insomnia, Anxiety: Excessive anxiety and worry, Not able to control worry . Aggravating factors: Ongoing medical problems and life stressors and being in the facility. During an interview on 2/6/2025 at 4:10 PM, the Administrator stated that he has had no interactions or met Resident #135 prior to about 10 minutes ago when he went to her room to discuss the direction the facility was going to take regarding her service animal. During an interview on 2/7/2025 at 2:25 PM, Resident #135's ARNP stated, I did initial evaluation when we first encounter together. She has a long history of mental history, psychosocial history and anxiety. She has pretty severe history of anxiety, but has nothing to do with the dog. She has suicidal ideation. It is not about the dog just has a lot of coping to do. She is going to have a lot of future adjustments. She is not sleeping well and other underlying health conditions.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 of 4 residents reviewed for discharge, Resident #150. Findings include: Review of Resident #150's admission record showed the resident was admitted to the facility on [DATE]. Review of Resident #150's physician order dated 1/13/2025 showed it read, Discharge home with [Name of Home Care Provider]- SN [skilled Nursing] for wound care to left heel, scrotum, left ischium, left plantar, right elbow, right ischium, and sacrum. PT [Physical therapy] to evaluate and treat. Review of Resident #150's Discharge Return not Anticipated MDS assessment dated [DATE] showed the resident was discharged to short-term general hospital. During an interview on 2/5/2025 at 10:37 AM, the MDS Coordinator confirmed that Resident #150's discharge status was coded as short-term general hospital. The MDS Coordinator stated, It has been coded wrong. The patient was not discharged to a hospital. The patient was discharged home. When requested a policy for MDS assessments, the MDS Coordinator stated, We use the RAI [Resident Assessment Instrument] specified by the State.

Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 of 3 residents reviewed for behaviors, Resident #48. Findings include: Review of Resident #48's admission record showed the resident was admitted on [DATE] with diagnoses including encephalopathy, seizures, major depressive disorder, pseudobulbar affect, schizoaffective disorder and mood disorder due to known physiological condition. Review of Resident #48's physician order dated 10/11/2024 showed it read, Nuedexta Oral Capsule 20-10 mg [milligrams] (Dextromethorphan HBr-Quinidine Sulfate), Give 1 capsule via G-tube [gastric tube] two times a day for PBA [Pseudobulbar Affect: a neurological condition characterized by involuntary and uncontrollable episodes of laughing or crying, often in inappropriate situations]. Review of Resident #48's care plan did not reveal a focus for care and services related to pseudobulbar affect. During an interview on 2/6/2025 at 4:15 PM, the MDS Coordinator stated, After reviewing [Resident #48's name] care plan, I do not see that he is care planned for Pseudobulbar Affect. Review of the facility policy and procedure titled Nursing-Care Plans-Comprehensive-Person Centered with the last review date of 1/13/2025 showed it read, Purpose: To ensure the development and implementation of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents' physicals , psychosocial and functional needs.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with currently accepted professional principles for 2 of 6 residents reviewed for medication administration, Residents #6 and #87. Findings include: 1) During an observation on 2/5/2025 at 9:00 AM, Resident #87 was eating breakfast in her room. There was a small plastic cup containing medications on top of her bedside. During an interview on 2/5/2025 at 9:00 AM, Resident #87 stated, I take my medication with food and not on an empty stomach. Review of Resident #87's physician orders revealed no orders for self-administering medications. During an interview on 2/6/2025 at 8:24 AM, Staff L, Registered Nurse (RN), stated, I left the medication at bedside. [Resident #87's name] likes to take her medication with food. I know this is not normal practice and is wrong. During an interview 2/6/2025 at 9:09 AM, the Director of Nursing (DON) stated, It is not protocol to leave the medication at bedside and maybe we can get the order changed for her [Resident #87], so she gets her medication when breakfast is served and staff not leave the medication at bedside. Medication should not be left unattended. 51447 2) During an observation on 2/4/2025 at 3:08 PM, there was a white oval pill sitting on Resident #6's shirt. During an interview on 2/4/2025 at 3:09 PM, Staff U, Licensed Practical Nurse (LPN), confirmed there was a medication on Resident #6's shirt and stated the nurse should stay until the medication was taken. Review of the facility policy and procedure titled Medication Dispensing System with the last review date of 1/13/2025 showed it read, Policy: All medications will be prepared (blister cards, vials, Artromick box) and administered in a manner consistent with the general requirements outlined in this policy. Procedure . J. Medication Administration . 8. Ensure that the customer swallows all the medication(s).

Based on observation, interview, and record review, the facility failed to ensure the residents who are unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal and oral hygiene for 2 of 4 residents reviewed for ADL care, Residents #88, and #131. Findings include: 1) During an observation on 2/4/2025 at 9:24 AM, Resident #88 was lying in bed. The resident's face was oily, her lips were dry and cracked with a dried crusty substance on them, and her mouth was dry when she tried to talk. During an observation on 2/4/2025 at 10:52 AM, Resident #88's lips were dry and cracked with a dried crusty substance on them, and her mouth was dry when she tried to talk. Review of Resident #88's admission record showed the resident was admitted on [DATE] with the diagnoses including encephalopathy, muscles weakness, and failure to thrive. Review of Resident #88's MDS dated [DATE] showed the resident was dependent for performing personal hygiene (oral hygiene) under Section GG- Functional Abilities. During an interview on 2/7/2025 at 8:39 AM, Staff P, CNA, confirmed Resident #88 did not receive ADL care and stated, On average, the CNAs will have 16 to 18 residents in their assignments. I feel like I can meet the needs of my residents because I have a lot of experience being a CNA, but other CNAs who are newer tend to have difficulty getting the tasks done. 2) During an observation on 2/3/2025 at 2:30 PM, Resident #131's lips were cracked and had a buildup on them. His teeth were discolored with a thick film on them and his mouth was dry. During an observation on 2/4/2025 at 8:46 AM, Resident #131's teeth had a thick film substance on them. His mouth was dry, and his lips were cracked and had a substance buildup on them. During an observation on 2/5/2025 at 10:55 AM, Resident #131's lips were dry and had a substance caked on them. His teeth were discolored with a thick film on them and his mouth was dry. During an interview on 2/5/2025 at 10:55 AM, Resident #131 stated that he had not had any (ADL) care so far today and if they provided care to him like oral care, he would be a lot more comfortable and would like to have it done. Review of Resident #131's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, muscle weakness, polyosteoarthritis and dorsalgia. Review of Resident #131's Minimum Data Set (MDS) dated [DATE] showed the resident was dependent for performing oral hygiene, showering/bathing and personal hygiene under Section GG- Functional Abilities. During an interview on 2/5/2025 at 11:12 AM, Staff B, Certified Nursing Assistant (CNA), stated, I have not been able to care for [Resident #131's name] yet today because I have been taking care of the other residents in the assignment. It is hard to meet the needs of all residents in an assignment because there are so many residents, and the residents tend to require a lot of care. During an interview on 2/6/2025 at 9:08 AM, the Director of Nursing stated that her expectation for the staff would be to provide each resident with the ADL care they need based on their care plan. During an interview with the Administrator on 2/7/2025 at 2:00 PM, when a policy on ADL assistance was requested, no policy was provided.

Based on record review and interview, the facility 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 prior to employment as a licensed practical nurse providing care and services for 17 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #39, #10, #7, #29, and #66. The failure of ensuring an individual is licensed as a practical 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, suctioning of a tracheostomy [trach] without training can predispose the resident to bradycardia (slow heart rate) and hypoxia (a state in which oxygen is not available in sufficient amounts), 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 include: Review of Staff A's personnel file documented an application for employment dated 12/29/2022. The application had two social security numbers and two dates of birth documented. The application listed two work experience references and three personal/professional references. The file did not provide documentation of the verification of prior employment or for the personal/professional references. The College, Business School, Military (most recent first) documented Staff A completed General Studies/Nursing [year documented], with the birth date provided at the time of interview the applicant would have been [AGE] years of age when the course of study was completed. Staff A's Level II background screening had a different spelling of the first name on the employment application, social security card, and the driver license on record. The nursing license on file provided a different spelling of the first name, had a middle name, a single last name, a different address, the address on the application, driver license, and Level II background were from a different state. The nursing license was originally issued in 2014 in the state of Florida, the driver license on record was issued in 2020 in the state of Georgia. The Basic Life Support card on file has a different last name. The file did not contain a practical nursing license for the person named on the application. The nursing license on record was not made a part of the record until 5/1/2023 at 11:02 AM as verified by the date and time printed on the document, and not at the time of hire. 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 Practical Nurse in the State of Florida. Review of Staff A's time clock punch in and out documented Staff A worked 17 shifts in the facility for the period of 2/3/2023 through 4/25/2023. Review of the admission record for Resident #39 documented the resident was admitted on [DATE] with diagnosis to include acute respiratory failure (a life-threatening disease where the air sacs in the lungs cannot release oxygen into the blood), gastrointestinal hemorrhage (gastrointestinal bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit, but isn't always visible, the level of bleeding can range from mild to severe and can be life-threatening), sepsis (a life threatening response by the body to infection that can lead to tissue damage, organ failure and death), anemia, type 2 diabetes mellitus, severe protein calorie malnutrition, paroxysmal atrial fibrillation (an irregular heart beat), gastroesophageal reflux disease, cognitive communication deficit, aphasia (the inability to speak), status tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help a person breath), status gastrostomy (a tube inserted into the stomach to provide nutrition). Review of the Medication Administration Record (MAR) for Resident #39 dated 2/4/2023, 4/7/2023, 4/8/2023, 4/15/2023, 4/18/2023 documented Staff A completed a check of Resident #39's temperature, oxygen saturation to include trach orders for monitoring oxygen saturation, observed for signs and symptoms of COVID-19 virus, evaluated the resident's pain level, flushed Resident #39's enteral tube/g-tube with 60 ml of water flush, checked the stomach residual via g-tube, started enteral tube feeding of Osmolite, and documented the total amount of enteral feeding administered. Dated: 2/5/2023, 4/8/2023, 4/9/2023, 4/16/2023, 4/19/2023, 4/20/2023, Staff A completed fingerstick for blood sugars. Dated 4/4/2023, 4/8/2023, 4/9/2023, 4/16/2023, 4/19/2023, 4/20/2023 Staff A administered ipratropium-albuterol inhalation solution via trach, levetiracetam via g-tube, metoprolol tartrate via g-tube, rosuvastatin calcium via g-tube, gabapentin, insulin detemir 58 units subcutaneously (an injection made below the dermis and epidermis, not into the muscle). Dated 2/4/2023 Staff A administered guaifenesin via g-tube. Review of the Treatment Administration Record (TAR) dated 2/4/2023 Staff A documented applying skin prep to Resident #39's bilateral heels, performed suctioning to the resident's tracheostomy, provided trach care, verified trach (tracheostomy) oxygen at 2 liters per minute, applied barrier cream to the resident's coccyx, applied dexamethasone dipropionate external cream to the resident's chest and arms, documented the head of the bed at 30-45 degrees, and provided ostomy care. Review of the admission record for Resident #10 documented the resident was admitted on [DATE] with diagnosis to include chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus, major depressive disorder, atherosclerotic heart disease, hypertension, insomnia, bradycardia (heart rate that is too slow), restless legs syndrome, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation), hypothyroidism, heart failure (severe failure of the heart to function properly, especially as a cause of death), gastro-esophageal reflux disease, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), history of infectious and parasitic diseases, difficulty walking, and orchitis. Review of the MAR for Resident #10 dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023, and 4/19/2023 Staff A administered Basaglar KwikPen insulin glargine 50 units subcutaneously, Eliquis (a medication that can cause bleeding, which can be serious), Flomax, Lipitor, ropinirole HCL, trazodone HCL, Oscal, clonidine HCL, hydralazine HCL, and Tylenol. Dated 3/9/2023 Staff A administered hydralazine. Dated 3/9/2023, 3/16/2023, 3/18/2023, 4/16/2023, 4/19/2023, and 4/20/2023 Staff A administered levothyroxine sodium. Dated 4/15/2023 and 4/16/2023 Staff A administered Debrox Otic Solution in both ears. Dated 4/16/2023, 4/19/2023, and 4/20/2023 Staff A administered clonidine HCL and hydralazine HCL. Dated 3/08/2023, 3/17/2023, 4/15/2023, 4/17/2023, and 4/18/2023 Staff A applied a Pain Relief Maximum Strength 4% Patch transdermally (absorbed through the skin) for pain. All medications were administered by mouth unless otherwise indicated. Review of the MAR for Resident #10 dated 3/08/2023, 3/17/2023, 4/15/2023, and 4/18/2023 Staff A obtained the resident's temperature, oxygen saturation, and evaluated the pain level. Dated 3/9/2023, 3/16/2023, 3/18/2023, 4/16/2023 4/19/2023 and 4/20/2023 Staff A perform accuchecks (to measure glucose/sugar in the veins whole blood). Dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023 and 4/19/2023 Staff A monitored for signs and symptoms of bleeding. Review of the admission record for Resident #7 the resident was readmitted on [DATE], with an initial admitted [DATE] with diagnosis to include metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), end stage renal disease (the kidneys cease functioning), dependence on renal dialysis (when you have kidney failure, the kidneys do not filter blood the way they should. The result is waste, and toxins build up in the bloodstream. Dialysis does the work of the kidneys removing the waste products and excess fluid from the blood) , acute kidney failure, type 2 diabetes mellitus with hyperglycemia (high blood sugar), morbid severe obesity, acquired absence of right leg below the knee, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease (a slow and progressive circulation disorder), essential primary hypertension, atrial fibrillation, lymphedema (swelling due to build-up of lymph fluid in the body), and acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). Review of the MAR for Resident #7 dated 3/7/2023, 3/17/2023 Staff A administered atorvastatin calcium, melatonin, simethicone, decubi-vite, metoprolol tartrate, Novolin 70/30 insulin 19 units subcutaneously, Flomax. Dated 3/16/2023, 3/18/2023 Staff A administered simethicone. Dated 4/15/2023, 4/18/2023, 4/19/2023 Staff A administered tamsulosin, simethicone, metoprolol tartrate, flecainide acetate, atorvastatin calcium, melatonin, nephron-vite, ferrous sulfate, aspirin. Dated 4/8/2023, 4/16/2023, 4/17/2023, and 4/18/2023 Staff A administered hydralazine HCL. All medications were administered by mouth unless otherwise indicated. Review of the MAR for Resident #7 dated 4/16/2023, 4/19/2023, 4/20/2023 documented Staff A observed the resident for cough and deep breathing exercises for 5 minutes. Dated 4/15/2023 and 4/19/2023 Staff A observed the resident for signs and symptoms of COVID-19. Dated 3/7/2023, 3/16/2023, 3/17/2023, 3/18/2023, 4/15/2023 Staff A obtained the resident's temperature and oxygen saturation. Dated 4/15/2023, 4/16/2023, 4/18/2023, 4/19/2023, and 4/20/2023 Staff A performed a finger stick for blood glucose. Dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023, and 4/19/2023 Staff A evaluated the resident's pain level. Dated 3/13/2023, 3/9/2023, 3/16/2023, 3/17/2023, and 3/18/2023 Staff A performed accuchecks. Review of the admission record for Resident #29 documented the resident was admitted on [DATE] with diagnosis to include acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), sepsis, urinary tract infection, dysphagia (swallowing difficulties), hydronephrosis with renal and ureteral calculus obstruction (dilatation and distension of the renal collecting system of one or both kidneys due to obstruction of urine outflow distal to the renal pelvis), polyneuropathy, anxiety disorder, anemia, hypothyroidism, hyperlipidemia, severe protein calorie malnutrition, depression, seizures, essential primary hypertension, acute embolism and thrombosis of unspecified deep veins of lower extremity bilateral, unspecified asthma, acute respiratory failure with hypoxia, osteoarthritis, obstructive and reflux uropathy, chronic kidney disease stage 4, personal history of malignant neoplasm of uterus, personal history of COVID-19 and status gastrostomy. Review of the MAR for Resident #29 dated 3/22/2023, 3/23/2023, and 3/30/2023 documented Staff A administered atorvastatin. Dated 3/23/2023, 3/24/2023, and 3/29/2023 administered levothyroxine via g-tube, mirtazapine via g-tube, Vimpat via g-tube. Dated 4/7/2023 and 4/8/2023 Staff A administered atorvastatin via g-tube. Dated 4/8/2023 and 4/9/2023 administered levothyroxine sodium via g-tube, mirtazapine via g-tube, Vimpat via g-tube. Dated 4/24/2023 and 4/25/2023 administered sodium bicarbonate via g-tube. Dated 4/25/2023 administered Lipitor via g-tube, metoprolol tartrate via g-tube, Remeron via g-tube, and Vimpat via g-tube. Review of the MAR for Resident #29 dated 3/22/2023, 3/23/2023 and 3/30/2023 documented Staff A assessed for enteral feed residuals, administered enteral feeding via g-tube. Dated 3/22/2023, 3/23/2023, 3/28/2023 and 3/30/2023 Staff A administered enteral feeding via g-tube, flushed the enteral feeding tube every hour with 10 ml of water, flushed the enteral feeding tube with 50 ml of water before and after medications and feedings, documented the enteral feeding intake, evaluated the resident's pain level, observed the resident for signs and symptoms of COVID-19, and obtained the resident's temperature and oxygen saturation. Dated 4/7/2023 and 4/8/2023 evaluated the resident's pain level, obtained the resident's temperature and oxygen saturation, observed for signs and symptoms of COVID-19, obtained the resident's temperature and oxygen saturation, documented the enteral feeding intake, assessed the enteral feeding residual, administered enteral feeding of Osmolite, flushed the enteral feeding tube with 10 ml of water every hour, flushed the enteral feeding tube with 50 ml of water before and after medications/feedings. Dated 4/24/2023 observed for signs and symptoms of COVID-19, administered enteral feeding of Isosource at 60 ml per hour x 24 hours and documented enteral feeding of Osmolite at 60 cc [cubic centimeters] per hour, assessed enteral feeding residuals, flushed the enteral feeding tube with 45 ml of water every hour, flushed the enteral feeding tube with 50 ml of water before and after medications/feedings, evaluated the resident's pain, documented the enteral feeding intake Dated 4/25/2023 Staff A documented cough and deep breathing exercises for 5 minutes, documented the enteral feeding intake, and evaluated the resident's pain level. Review of the TAR for Resident #29 dated 4/7/2023 and 4/24/2023 Staff A documented repositioning the resident every 2 hours. Dated 4/7/2023 Staff A provided wound care to the resident's coccyx. Dated 4/7/2023, 4/24/2023 Staff A documented checking the nephrostomy (a catheter/tube that drains urine from the kidneys) insertion site for signs and symptoms of infection or bleeding to the site to the right back and left back, check the head of bed up at 30-45 degrees. Dated 4/7/2023 Staff A checked for patency of the resident's indwelling Foley catheter, checked the leg anchor for the resident's indwelling Foley catheter, ensured the specialty air mattress was functioning properly and was at the proper setting. Dated 4/24/2023 checked the leg anchor for the resident's indwelling Foley catheter, monitored the resident's bowel sounds, Staff A administered an enema to Resident #66. Review of the admission record for Resident #66 documented the resident was admitted on [DATE] with diagnosis to include gastritis, diaphragmatic hernia, toxic encephalopathy (brain dysfunction caused by toxic exposure), acute respiratory failure, epilepsy (a brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions associated with abnormal electrical activity in the brain), anemia, aortic arch syndrome (structural problems in the arteries that branch off of the aortic arch), dysphagia, unspecified glaucoma, hypothyroidism, type 2 diabetes mellitus, hypertension, diastolic congestive heart failure (occurs if the left ventricle muscle becomes stiff or thickened), paralysis of vocal cords and larynx bilaterally (hoarseness and abduction of the vocal cords increasing aspiration risk), cognitive communication deficit, personal history of benign neoplasm of the brain (a mass of cells that grow slowly in the brain), personal history of COVID-19, personal history of traumatic brain injury, status tracheostomy, status gastrostomy. Review of the MAR for Resident #66 dated 4/19/2023 and 4/20/2023 documented Staff A administered oxcarbazepine via g-tub, lisinopril via g-tube, vitamin D3 via g-tube, Coreg via g-tube, Depakene via g-tube, atorvastatin calcium via g-tube, Keppra via g-tube, lacosamide via g-tube, magnesium oxide via g-tube, phenobarbital via g-tube, potassium chloride via g-tube, sennosides-docusate via g-tube, and zegerid via g-tube. Review of the MAR dated 4/18/2023 and 4/19/2023 documented Staff A evaluated Resident #66 for pain level, monitored the resident's trach oxygen saturation, observed the resident for signs and symptoms of COVID-19, assessed for enteral feed residuals, flushed the enteral feed tube with 50 ml of water before and after medications/feedings, flushed the enteral feed tube every hour with 70 ml of water, documented the enteral feed total intake. Dated 4/19/2023 and 4/20/2023 Staff A performed finger sticks for blood glucose. Dated 4/18/2023 Staff A evaluated the resident's temperature and oxygen saturation. Review of the TAR for the dates of 4/18/2023 through 4/19/2023 when Staff A was the attending staff person for Resident #66 there is no documentation dated 4/18/2023 of the resident having been provided trach care to verify the equipment was plugged into a red socket, the oxygen settings, humidification, and bottle storage. Dated 4/19/2023 there is no documentation the resident was provided trach care to include removing the non-disposable inner cannula and cleaning, verification of the trach oxygen at 7 liters with 100% humidification, scrubs to both eyes, trach suctioning, and verification the head of the bed was up to 30-45 degrees to prevent aspiration. Documentation was requested from the Director of Nursing (DON) on 5/17/2023 at 9:10 AM to verify the resident received the physician ordered care. No documentation was provided. During an interview on 5/17/2023 at 9:10 AM the DON stated, I have recently taken over this job and did not hire that employee [Staff A]. I was here when the Administrator was notified that she was being investigated by [NAME] for identity theft of a nurse and they tracked her here by her cell phone. The administrator worked with that detective and the [name of the local law enforcement agency], and she was arrested here after she clocked in for her shift. Once we learned about this, we began an investigation. She had a background screening that came back eligible and did present a driver's license and social security card. Unfortunately, her license was in a different name. I can't tell you how this happened. We did not do the proper license verification. There were not any reference checks completed and her previous employers were not contacted to determine if she had actually worked for them. I don't know how this occurred. It should not have happened. We should never have hired her with the conflicting dates of birth and with the conflicting social security numbers. I do believe that it should have been escalated when she gave those, I think probably to the human resources' responsible person and the Administrator. After that we absolutely should have verified that she had a valid nursing license and requested that she bring in a copy of her license before we allowed her to work. During an interview on 5/17/2023 at 4:18 PM Staff B, Licensed Practical Nurse (LPN) stated, I did run this persons [Staff A] AHCA (Agency for Healthcare Administration) background screen. I used to do all the background screenings and managed the roster and things like that. Once I completed those, I would give them to HR [Human Resources] and then they would hire them in the system and do their part. Well, in April of 2022, Bedrock took over. They wanted my position to be more nursing and to do infection control, so then that's when the HR started taking over the backgrounds, but there was a transition, so I would still help [Staff C's name], like showing her how to resubmit backgrounds and how to pull new backgrounds so everything was complete. I did the background on [Staff A's name] in January after that I've given information to the HR, to [Staff C's name]. Well on our applications there is not a section for an employee's date of birth or social security number. I wrote the date of birth and social security number she gave me when I talked with her a few weeks after her interview when she let me know she wanted to proceed with becoming an employee. I then tried to do her background screening and she was not in the system with the original birthdate that she gave me. I wrote the [date written] and the social security number that is on there [the employee application]. So, then I had to call her and tell her I can't find her. That is when she told me that someone had stolen her identity and the government issued her new cards and a new birthdate. She then gave me a new birthdate and social security number. It was a different birthdate of [birth date given] and a new social security number. Once I put in the new information on the background screening, she came back as eligible, and it was the same person that I interviewed. I didn't think a thing, I have had others give me the wrong social security number so, I didn't think to escalate this to anyone else in HR. I did not tell [Staff C's name] about it. It did not concern me at all. I'm not a criminal so I believed her. Her background screening per AHCA came back eligible. I didn't question it all. I mean people mix up things, but when I put in her last name with that social her picture pulled up the social matched the date of birth on there and matched her picture that was on there, everything matched with the second date of birth. I did not bring any concerns about this to [Staff C's name], she cleared and was eligible. I did her interview. I do have the application in front of me when I interview. I didn't look at her education and ask her any questions about that. We just talked about her experiences, if she had taken [care of] trachs, her general experiences, if she was comfortable with g-tubes and medications. I didn't look at how her name was spelled and see that it was not the correct spelling. She did tell me that she got divorced and that's why there was a different name and that she had her identity stolen. I don't know how the license verification was done. The day that this was all being investigated we found out that the license verification wasn't in her file. I guess that's when she [Staff C's name] did it. I don't know when or if she did it when she [Staff A's name] was hired. I'm not HR. During a telephone interview on 5/19/2023 at 9:20 AM the previous Nursing Home Administrator stated, I was notified on I believe it was 4/24 or 4/25/23 by a detective in [NAME] that they believed they had tracked a nurse with a fraudulent nursing license, and they were working in our building. I verified his identity and began to assist him in any way I could. Looking back at our files we determined that she [Staff A] gave two different social security numbers and she was called and changed her social security number and birth date. This got missed by [Staff B and Staff C's names]. I was not aware that the nursing license was not in the file and that she did not provide a copy of the nursing license. I would say the HR Manager should have caught this and brought it to the attention of someone when she gave multiple birthdays and social security numbers, that would be an immediate red flag. It should come to corporate HR and the Administrator. [Staff B's name] was well aware of the changing date of birth and social security number. At some point they both knew and should have responded, and we should not have hired her [Staff A]. We, upon investigation, suspended [Staff C's name] because she was in the role and had the responsibility to make sure that all aspects of the employment process is fully implemented and followed. Ultimately, administrators are responsible for the overall running of the building and all disciplines. This [Staff C's name] had been in HR since about last August or September, there is some debate on the amount of training she received, and she was learning on the fly. The mistake was made because they were not properly trained and did not understand the severity of the situation when [Staff B's name] was provided with two different birthdates and social security numbers. [Staff C's name] was in that role less than one year and they were trying to combine the role she had previously been in with HR responsibilities and make [Staff B's name] role more nursing. They put themselves [Bedrock] in this position by inadequately training [Staff C's name] to fulfill her role. During a telephone interview on 5/19/2023 at 3:30 PM the Medical Director stated, I was notified immediately on Friday night that there was a nurse who was fraudulent and without a license that had been practicing with the residents. She was not properly cleared to work and the system to verify her license and identification was not followed. The police arrested her [Staff A] at the facility very late on Friday and we met on Monday to do a QAPI [Quality Assurance Performance Improvement] we did conduct the root cause. The names were different, and the nursing license was not verified. Luckily nothing happened to any of my residents nor other physicians' residents. It is imperative that we verify these things and have these systems in place, they promote and protect patients. They ensure that we provide a minimum standard of care that non licensed nurses cannot provide. There was great potential for harm if she had come across a situation that she was unfamiliar with. I hope we now have the system to safeguard all the residents in place and we will keep monitoring this to make sure this never happens again. She would not have the necessary knowledge to care for a tracheostomy tube, or possibly understand what to do if the resident accidentally decannulated [removed the tracheostomy] themselves. Gastrostomy tube medication administration is more complex with possible gastric perforation if not verified as present in the correct place and would require assessment skills that nurses have. Review of the policy and procedure titled, Abuse: Florida dated 4/1/2022 read, Definitions Of Abuse and Neglect: f. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy: It is the policy of Bedrock care that each resident will be free from ABUSE. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Objectives Of Abuse Policy: The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and Performance Improvement (QAPI) program. Our facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. Treating a nursing home resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and or potentially abusive attitude toward the resident(s). Overview of seven components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting and Response. A. Screening Components: It is the policy of this facility to screen employees and volunteers (as applicable per volunteer policy) prior to working with residents. Screening components include verification of certification and verification of license and criminal background check. Procedure: 1. Employee Screening and Training: 1a. New employees have a background check as appropriate board registrations and certifications regarding the prospective employee's background. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. C. License Staff: The facility will not employ or otherwise engage a licensed professional who: a. Has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. b. In addition, the facility will report to the state licensing authorities any knowledge it has of the actions by a court of law against an employee which would indicate unfitness for service as a licensed professional. Review of the policy and procedure titled, Employee Personnel Records dated 4/1/2022 read, Bedrock Care maintains certain records for each employee which are directly related to his/her employment. Personnel records contain the following data: The employee's full name, address, date of birth, sex, and Social Security Number, Employment references, letters, etc., Copy of current licenses (as applicable). The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the Root Cause Analysis provided by the facility was an untitled document provided by the facility, with no date or time indicated read, Problem statement: [Staff A's name] worked in nursing home without a valid license. Why? Detective notified facility of identity theft by [Staff A's name] questioning accuracy of nursing license. Why? Level 2 AHCA clearing house background [Staff A's name] eligible for employment. Why? Forms of identification matched spelling of name identical on Social Security and driver's license. Why? No results on OIG exclusion list [Staff A's name]. Why? License verification on FDOH (Florida Department of Health) [a different nurses name] clear/active root causes:1. Identity theft. 2. Spelling of name on driver's license and nurses license not match. 3. Middle name different on level 2 and nurse license. Review of the Performance Improvement Plan dated 5/1/2023 documented [Medical Director's name] was notified of the removal of [Staff A's name] from the facility. The Staff Developer and Regional Nurse conducted a quality review of 30 licensed nurses to ensure proper identification and valid and active nursing license in their file. Completed 5/1/23 for 30 of 30 licensed nurses. No discrepancies found. Seventy-seven resident assessments were completed by the Director of Nursing on residents that were provided care and services by [Staff A's name]. No areas of concern noted. Completed 5/1/2023. Discharge resident records were reviewed by the Director of Nursing with no concern noted [TRUNCATED]

Based on record review and interview, the facility failed to ensure policies and procedure 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 prior to employment as a licensed practical nurse providing care and services for 17 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #39, #10, #7, #29, and #66. Findings include: Review of the policy and procedure titled, Abuse: Florida dated 4/1/2022 read, Definitions Of Abuse and Neglect: f. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy: It is the policy of Bedrock care that each resident will be free from ABUSE. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Objectives Of Abuse Policy: The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and Performance Improvement (QAPI) program. Our facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. Treating a nursing home resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and or potentially abusive attitude toward the resident(s). Overview of seven components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting and Response. A. Screening Components: It is the policy of this facility to screen employees and volunteers (as applicable per volunteer policy) prior to working with residents. Screening components include verification of certification and verification of license and criminal background check. Procedure: 1. Employee Screening and Training: 1a. New employees have a background check as appropriate board registrations and certifications regarding the prospective employee's background. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. C. License Staff: The facility will not employ or otherwise engage a licensed professional who: a. Has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. b. In addition, the facility will report to the state licensing authorities any knowledge it has of the actions by a court of law against an employee which would indicate unfitness for service as a licensed professional. Review of Staff A's personnel file documented an application for employment dated 12/29/2022. The application had two social security numbers and two dates of birth documented. The application listed two work experience references and three personal/professional references. The file did not provide documentation of the verification of prior employment or for the personal/professional references. The College, Business School, Military (most recent first) documented Staff A completed General Studies/Nursing [year documented], with the birth date provided at the time of interview the applicant would have been [AGE] years of age when the course of study was completed. Staff A's Level II background screening had a different spelling of the first name on the employment application, social security card, and the driver license on record. The nursing license on file provided for a different spelling of the first name, had a middle name, a single last name, a different address, the address on the application, driver license, and Level II background were from a different state. The nursing license was originally issued in 2014 in the state of Florida, the driver license on record was issued in 2020 in the state of Georgia. The Basic Life Support card on file has a different last name. The file did not contain a practical nursing license for the person named on the application. The nursing license on record was not made a part of the record until 5/1/2023 at 11:02 AM as verified by the date and time printed on the document, and not at the time of hire. 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 Practical Nurse in the State of Florida. Review of Staff A's time clock punch in and out documented Staff A worked 17 shifts in the facility for the period of 2/3/2023 through 4/25/2023. Review of the admission record for Resident #39 documented the resident was admitted on [DATE] with diagnosis to include acute respiratory failure (a life-threatening disease where the air sacs in the lungs cannot release oxygen into the blood), gastrointestinal hemorrhage (gastrointestinal bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit, but isn't always visible, the level of bleeding can range from mild to severe and can be life-threatening), sepsis (a life threatening response by the body to infection that can lead to tissue damage, organ failure and death), anemia, type 2 diabetes mellitus, severe protein calorie malnutrition, paroxysmal atrial fibrillation (an irregular heart beat), gastroesophageal reflux disease, cognitive communication deficit, aphasia (the inability to speak), status tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help a person breath), status gastrostomy (a tube inserted into the stomach to provide nutrition). Review of the Medication Administration Record (MAR) for Resident #39 dated 2/4/2023, 4/7/2023, 4/8/2023, 4/15/2023, 4/18/2023 documented Staff A completed a check of Resident #39's temperature, oxygen saturation to include trach orders for monitoring oxygen saturation, observed for signs and symptoms of COVID-19 virus, evaluated the resident's pain level, flushed Resident #39's enteral tube/g-tube with 60 ml of water flush, checked the stomach residual via g-tube, started enteral tube feeding of Osmolite, and documented the total amount of enteral feeding administered. Dated: 2/5/2023, 4/8/2023, 4/9/2023, 4/16/2023, 4/19/2023, 4/20/2023, Staff A completed fingerstick for blood sugars. Dated 4/4/2023, 4/8/2023, 4/9/2023, 4/16/2023, 4/19/2023, 4/20/2023 Staff A administered ipratropium-albuterol inhalation solution via trach, levetiracetam via g-tube, metoprolol tartrate via g-tube, rosuvastatin calcium via g-tube, gabapentin, insulin detemir 58 units subcutaneously (an injection made below the dermis and epidermis, not into the muscle). Dated 2/4/2023 Staff A administered guaifenesin via g-tube. Review of the Treatment Administration Record (TAR) dated 2/4/2023 Staff A documented applying skin prep to Resident #39's bilateral heels, performed suctioning to the resident's tracheostomy, provided trach care, verified trach (tracheostomy) oxygen at 2 liters per minute, applied barrier cream to the resident's coccyx, applied dexamethasone dipropionate external cream to the resident's chest and arms, documented the head of the bed at 30-45 degrees, and provided ostomy care. Review of the admission record for Resident #10 documented the resident was admitted on [DATE] with diagnosis to include chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus, major depressive disorder, atherosclerotic heart disease, hypertension, insomnia, bradycardia (heart rate that is too slow), restless legs syndrome, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation), hypothyroidism, heart failure (severe failure of the heart to function properly, especially as a cause of death), gastro-esophageal reflux disease, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), history of infectious and parasitic diseases, difficulty walking, and orchitis. Review of the MAR for Resident #10 dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023, and 4/19/2023 Staff A administered Basaglar KwikPen insulin glargine 50 units subcutaneously, Eliquis (a medication that can cause bleeding, which can be serious), Flomax, Lipitor, ropinirole HCL, trazodone HCL, Oscal, clonidine HCL, hydralazine HCL, and Tylenol. Dated 3/9/2023 Staff A administered hydralazine. Dated 3/9/2023, 3/16/2023, 3/18/2023, 4/16/2023, 4/19/2023, and 4/20/2023 Staff A administered levothyroxine sodium. Dated 4/15/2023 and 4/16/2023 Staff A administered Debrox Otic Solution in both ears. Dated 4/16/2023, 4/19/2023, and 4/20/2023 Staff A administered clonidine HCL and hydralazine HCL. Dated 3/08/2023, 3/17/2023, 4/15/2023, 4/17/2023, and 4/18/2023 Staff A applied a Pain Relief Maximum Strength 4% Patch transdermally (absorbed through the skin) for pain. All medications were administered by mouth unless otherwise indicated. Review of the MAR for Resident #10 dated 3/08/2023, 3/17/2023, 4/15/2023, and 4/18/2023 Staff A obtained the resident's temperature, oxygen saturation, and evaluated the pain level. Dated 3/9/2023, 3/16/2023, 3/18/2023, 4/16/2023 4/19/2023 and 4/20/2023 Staff A perform accuchecks (to measure glucose/sugar in the veins whole blood). Dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023 and 4/19/2023 Staff A monitor for signs and symptoms of bleeding. Review of the admission record for Resident #7 the resident was readmitted on [DATE], with an initial admitted [DATE] with diagnosis to include metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), end stage renal disease (the kidneys cease functioning), dependence on renal dialysis (when you have kidney failure, the kidneys do not filter blood the way they should. The result is waste and toxins build up in the bloodstream. Dialysis does the work of the kidneys removing the waste products and excess fluid from the blood) , acute kidney failure, type 2 diabetes mellitus with hyperglycemia (high blood sugar), morbid severe obesity, acquired absence of right leg below the knee, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease (a slow and progressive circulation disorder), essential primary hypertension, atrial fibrillation, lymphedema (swelling due to build-up of lymph fluid in the body), and acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). Review of the MAR for Resident #7 dated 3/7/2023, 3/17/2023 Staff A administered atorvastatin calcium, melatonin, simethicone, decubi-vite, metoprolol tartrate, Novolin 70/30 insulin 19 units subcutaneously, Flomax. Dated 3/16/2023, 3/18/2023 Staff A administered simethicone. Dated 4/15/2023, 4/18/2023, 4/19/2023 Staff A administered tamsulosin, simethicone, metoprolol tartrate, flecainide acetate, atorvastatin calcium, melatonin, nephron-vite, ferrous sulfate, aspirin. Dated 4/8/2023, 4/16/2023, 4/17/2023, and 4/18/2023 Staff A administered hydralazine HCL. All medications were administered by mouth unless otherwise indicated. Review of the MAR for Resident #7 dated 4/16/2023, 4/19/2023, 4/20/2023 documented Staff A observed the resident for cough and deep breathing exercises for 5 minutes. Dated 4/15/2023 and 4/19/2023 Staff A observed the resident for signs and symptoms of COVID-19. Dated 3/7/2023, 3/16/2023, 3/17/2023, 3/18/2023, 4/15/2023 Staff A obtained the resident's temperature and oxygen saturation. Dated 4/15/2023, 4/16/2023, 4/18/2023, 4/19/2023, and 4/20/2023 Staff A performed a finger stick for blood glucose. Dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023, and 4/19/2023 Staff A evaluated the resident's pain level. Dated 3/13/2023, 3/9/2023, 3/16/2023, 3/17/2023, and 3/18/2023 Staff A performed accuchecks. Review of the admission record for Resident #29 documented the resident was admitted on [DATE] with diagnosis to include acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), sepsis, urinary tract infection, dysphagia (swallowing difficulties), hydronephrosis with renal and ureteral calculus obstruction (dilatation and distension of the renal collecting system of one or both kidneys due to obstruction of urine outflow distal to the renal pelvis), polyneuropathy, anxiety disorder, anemia, hypothyroidism, hyperlipidemia, severe protein calorie malnutrition, depression, seizures, essential primary hypertension, acute embolism and thrombosis of unspecified deep veins of lower extremity bilateral, unspecified asthma, acute respiratory failure with hypoxia, osteoarthritis, obstructive and reflux uropathy, chronic kidney disease stage 4, personal history of malignant neoplasm of uterus, personal history of COVID-19 and status gastrostomy. Review of the MAR for Resident #29 dated 3/22/2023, 3/23/2023, and 3/30/2023 documented Staff A administered atorvastatin. Dated 3/23/2023, 3/24/2023, and 3/29/2023 administered levothyroxine via g-tube, mirtazapine via g-tube, Vimpat via g-tube. Dated 4/7/2023 and 4/8/2023 Staff A administered atorvastatin via g-tube. Dated 4/8/2023 and 4/9/2023 administered levothyroxine sodium via g-tube, mirtazapine via g-tube, Vimpat via g-tube. Dated 4/24/2023 and 4/25/2023 administered sodium bicarbonate via g-tube. Dated 4/25/2023 administered Lipitor via g-tube, metoprolol tartrate via g-tube, Remeron via g-tube, and Vimpat via g-tube. Review of the MAR for Resident #29 dated 3/22/2023, 3/23/2023 and 3/30/2023 Staff A assessed for enteral feed residuals, administered enteral feeding via g-tube. Dated 3/22/2023, 3/23/2023, 3/28/2023 and 3/30/2023 Staff A administered enteral feeding via g-tube, flushed the enteral feeding tube every hour with 10 ml of water, flushed the enteral feeding tube with 50 ml of water before and after medications and feedings, documented the enteral feeding intake, evaluated the resident's pain level, observed the resident for signs and symptoms of COVID-19, and obtained the resident's temperature and oxygen saturation. Dated 4/7/2023 and 4/8/2023 evaluated the resident's pain level, obtained the resident's temperature and oxygen saturation, observed for signs and symptoms of COVID-19, obtained the resident's temperature and oxygen saturation, documented the enteral feeding intake, assessed the enteral feeding residual, administered enteral feeding of Osmolite, flushed the enteral feeding tube with 10 ml of water every hour, flushed the enteral feeding tube with 50 ml of water before and after medications/feedings. Dated 4/24/2023 observed for signs and symptoms of COVID-19, administered enteral feeding of Isosource at 60 ml per hour x 24 hours and documented enteral feeding of Osmolite at 60 cc [cubic centimeters] per hour, assessed enteral feeding residuals, flushed the enteral feeding tube with 45 ml of water every hour, flushed the enteral feeding tube with 50 ml of water before and after medications/feedings, evaluated the resident's pain, documented the enteral feeding intake Dated 4/25/2023 Staff A documented cough and deep breathing exercises for 5 minutes, documented the enteral feeding intake, and evaluated the resident's pain level. Review of the TAR for Resident #29 dated 4/7/2023 and 4/24/2023 Staff A documented repositioning the resident every 2 hours. Dated 4/7/2023 Staff A provided wound care to the resident's coccyx. Dated 4/7/2023, 4/24/2023 Staff A documented checking the nephrostomy (a catheter/tube that drains urine from the kidneys) insertion site for signs and symptoms of infection or bleeding to the site to the right back and left back, check the head of bed up at 30-45 degrees. 4/7/2023 Staff A checked for patency of the resident's indwelling Foley catheter, checked the leg anchor for the resident's indwelling Foley catheter, ensured the specialty air mattress was functioning properly and was at the proper setting. Dated 4/24/2023 checked the leg anchor for the resident's indwelling Foley catheter, monitored the resident's bowel sounds, Staff A administered an enema to Resident #66. Review of the admission record for Resident #66 documented the resident was admitted on [DATE] with diagnosis to include gastritis, diaphragmatic hernia, toxic encephalopathy (brain dysfunction caused by toxic exposure), acute respiratory failure, epilepsy (a brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions associated with abnormal electrical activity in the brain), anemia, aortic arch syndrome (structural problems in the arteries that branch off of the aortic arch), dysphagia, unspecified glaucoma, hypothyroidism, type 2 diabetes mellitus, hypertension, diastolic congestive heart failure (occurs if the left ventricle muscle becomes stiff or thickened), paralysis of vocal cords and larynx bilaterally (hoarseness and abduction of the vocal cords increasing aspiration risk), cognitive communication deficit, personal history of benign neoplasm of the brain (a mass of cells that grow slowly in the brain), personal history of COVID-19, personal history of traumatic brain injury, status tracheostomy, status gastrostomy. Review of the MAR for Resident #66 dated 4/19/2023 and 4/20/2023 Staff A administered oxcarbazepine via g-tub, lisinopril via g-tube, vitamin D3 via g-tube, Coreg via g-tube, Depakene via g-tube, atorvastatin calcium via g-tube, Keppra via g-tube, lacosamide via g-tube, magnesium oxide via g-tube, phenobarbital via g-tube, potassium chloride via g-tube, sennosides-docusate via g-tube, and zegerid via g-tube. Review of the MAR dated 4/18/2023 and 4/19/2023 documented Staff A evaluated Resident #66 for pain level, monitored the resident's trach oxygen saturation, observed the resident for signs and symptoms of COVID-19, assessed for enteral feed residuals, flushed the enteral feed tube with 50 ml of water before and after medications/feedings, flushed the enteral feed tube every hour with 70 ml of water, documented the enteral feed total intake. Dated 4/19/2023 and 4/20/2023 Staff A performed finger sticks for blood glucose. Dated 4/18/2023 Staff A evaluated the resident's temperature and oxygen saturation. Review of the TAR for the dates of 4/18/2023 through 4/19/2023 when Staff A was the attending staff person for Resident #66 there is no documentation dated 4/18/2023 of the resident having been provided trach care to verify the equipment was plugged into a red socket, the oxygen settings, humidification, and bottle storage. Dated 4/19/2023 there is no documentation the resident was provided trach care to include removing the non-disposable inner cannula and cleaning, verification of the trach oxygen at 7 liters with 100% humidification, scrubs to both eyes, trach suctioning, and verification the head of the bed was up to 30-45 degrees to prevent aspiration. Documentation was requested from the Director of Nursing (DON) on 5/17/2023 at 9:10 AM to verify the resident received the physician ordered care. No documentation was provided. During an interview on 5/17/2023 at 9:10 AM the DON stated, I have recently taken over this job and did not hire that employee [Staff A]. I was here when the Administrator was notified that she was being investigated by [NAME] for identity theft of a nurse and they tracked her here by her cell phone. The administrator worked with that detective and the [name of the local law enforcement agency], and she was arrested here after she clocked in for her shift. Once we learned about this, we began an investigation. She had a background screening that came back eligible and did present a driver's license and social security card. Unfortunately, her license was in a different name. I can't tell you how this happened. We did not do the proper license verification. There were not any reference checks completed and her previous employers were not contacted to determine if she had actually worked for them. I don't know how this occurred. It should not have happened. We should never have hired her with the conflicting dates of birth and with the conflicting social security numbers. I do believe that it should have been escalated when she gave those, I think probably to the human resources' responsible person and the Administrator. After that we absolutely should have verified that she had a valid nursing license and requested that she bring in a copy of her license before we allowed her to work. During an interview on 5/17/2023 at 4:18 PM Staff B, Licensed Practical Nurse (LPN) stated, I did run this persons [Staff A] AHCA (Agency for Healthcare Administration) background screen. I used to do all the background screenings and managed the roster and things like that. Once I completed those I would give them to HR [Human Resources] and then they would hire them in the system and do their part. Well, in April of 2022, Bedrock took over. They wanted my position to be more nursing and to do infection control, so then that's when the HR started taking over the backgrounds, but there was a transition, so I would still help [Staff C's name], like showing her how to resubmit backgrounds and how to pull new backgrounds so everything was complete. I did the background on [Staff A's name] in January after that I've given information to the HR, to [Staff C's name]. Well on our applications there is not a section for an employee's date of birth or social security number. I wrote the date of birth and social security number she gave me when I talked with her a few weeks after her interview when she let me know she wanted to proceed with becoming an employee. I then tried to do her background screening and she was not in the system with the original birthdate that she gave me. I wrote the [date written] and the social security number that is on there [the employee application]. So, then I had to call her and tell her I can't find her. That is when she told me that someone had stolen her identity and the government issued her new cards and a new birthdate. She then gave me a new birthdate and social security number. It was a different birthdate of [birth date given] and a new social security number. Once I put in the new information on the background screening, she came back as eligible, and it was the same person that I interviewed. I didn't think a thing, I have had others give me the wrong social security number so, I didn't think to escalate this to anyone else in HR. I did not tell [Staff C's name] about it. It did not concern me at all. I'm not a criminal so I believed her. Her background screening per AHCH came back eligible. I didn't question it all. I mean people mix up things, but when I put in her last name with that social her picture pulled up the social matched the date of birth on there and matched her picture that was on there, everything matched with the second date of birth. I did not bring any concerns about this to [Staff C's name], she cleared and was eligible. I did her interview. I do have the application in front of me when I interview. I didn't look at her education and ask her any questions about that. We just talked about her experiences, if she had taken [care of] trachs, her general experiences, if she was comfortable with g-tubes and medications. I didn't look at how her name was spelled and see that it was not the correct spelling. She did tell me that she got divorced and that's why there was a different name and that she had her identity stolen. I don't know how the license verification was done. The day that this was all being investigated we found out that the license verification wasn't in her file. I guess that's when she [Staff C] did it. I don't know when or if she did it when she [Staff A] was hired. I'm not HR. During a telephone interview on 5/19/2023 at 9:20 AM the previous Nursing Home Administrator stated, I was notified on I believe it was 4/24 or 4/25/23 by a detective in [NAME] that they believed they had tracked a nurse with a fraudulent nursing license, and they were working in our building. I verified his identity and began to assist him in any way I could. Looking back at our files we determined that she [Staff A] gave two different social security numbers and she was called and changed her social security number and birth date. This got missed by [Staff B and Staff C's names]. I was not aware that the nursing license was not in the file and that she did not provide a copy of the nursing license. I would say the HR Manager should have caught this and brought it to the attention of someone when she gave multiple birthdays and social security numbers, that would be an immediate red flag. It should come to corporate HR and the Administrator. [Staff B's name] was well aware of the changing date of birth and social security number. At some point they both knew and should have responded, and we should not have hired her [Staff A]. We, upon investigation, suspended [Staff C's name] because she was in the role and had the responsibility to make sure that all aspects of the employment process is fully implemented and followed. Ultimately, administrators are responsible for the overall running of the building and all disciplines. This [Staff C's name] had been in HR since about last August or September, there is some debate on the amount of training she received, and she was learning on the fly. The mistake was made because they were not properly trained and did not understand the severity of the situation when [Staff B's name] was provided with two different birthdates and social security numbers. [Staff C's name] was in that role less than one year and they were trying to combine the role she had previously been in with HR responsibilities and make [Staff B's name] role more nursing. They put themselves [Bedrock] in this position by inadequately training [Staff C's name] to fulfill her role. During a telephone interview on 5/19/2023 at 3:30 PM the Medical Director stated, I was notified immediately on Friday night that there was a nurse who was fraudulent and without a license that had been practicing with the residents. She was not properly cleared to work and the system to verify her license and identification was not followed. The police arrested her [Staff A] at the facility very late on Friday and we met on Monday to do a QAPI [Quality Assurance Performance Improvement] we did conduct the root cause. The names were different, and the nursing license was not verified. Luckily nothing happened to any of my residents nor other physicians' residents. It is imperative that we verify these things and have these systems in place, they promote and protect patients. They ensure that we provide a minimum standard of care that non licensed nurses cannot provide. There was great potential for harm if she had come across a situation that she was unfamiliar with. I hope we now have the system to safeguard all the residents in place and we will keep monitoring this to make sure this never happens again. She would not have the necessary knowledge to care for a tracheostomy tube, or possibly understand what to do if the resident accidentally decannulated [removed the tracheostomy] themselves. Gastrostomy tube medication administration is more complex with possible gastric perforation if not verified as present in the correct place and would require assessment skills that nurses have. The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the Root Cause Analysis provided by the facility was an untitled document provided by the facility, with no date or time indicated read, Problem statement: [Staff A's name] worked in nursing home without a valid license. Why? Detective notified facility of identity theft by [Staff A's name] questioning accuracy of nursing license. Why? Level 2 AHCA clearing house background [Staff A's name] eligible for employment. Why? Forms of identification matched spelling of name identical on Social Security and driver's license. Why? No results on OIG exclusion list [Staff A's name]. Why? License verification on FDOH (Florida Department of Health) [a different nurses name] clear/active root causes:1. Identity theft. 2. Spelling of name on driver's license and nurses license not match. 3. Middle name different on level 2 and nurse license. Review of the Performance Improvement Plan dated 5/1/2023 documented [Medical Director's name] was notified of the removal of [Staff A's name] from the facility. The staff Developer and Regional Nurse conducted a quality review of 30 licensed nurses to ensure proper identification and valid and active nursing license in their file. Completed 5/1/23 for 30 of 30 licensed nurses. No discrepancies found. Seventy-seven resident assessments were completed by the Director of Nursing on residents that were provided care and services by [Staff A's name]. No areas of concern noted. Completed 5/1/2023. Discharge resident records were reviewed by the Director of nursing with no concern noted. Completed 5/1/2023. Medication Administration Records, Treatment Administration Records and narcotic sheets were reviewed by the Director of Nursing with no concern noted. Completed 5/1/2023. Grievances were reviewed by the Director of Nursing and no concerns with [Staff A's name] noted. Completed 5/1/2023. Education: The DON, Administrator, Human Resource Director and the Staff Developer were educated by the Staff Developer on Policy/Procedure: Employee Personnel Records to include the Employee's full name, address, date of birth, Social Security Number, job application, job description, orientation and training program records, performance evaluations and employment references; Policy/Procedure: New Hire Checklist; OIG Exclusion; AHCA Clearinghouse Roster; Verifying Active and Valid Nursing License; including the Original Nursing License and the Verified Active License placed in the Employee File. Completed 5/1/2023. Bedrock Rehabilitation and Nursing Center at Suwannee currently has 30 Licensed Nursing Staff. Current Licensed Nursing Staff received education by the Staff Developer and education was completed on 5/1/2023. Education included for Licensed Nursing Staff Policy/Procedure: Abuse/Neglect; Policy/Procedure: License Verification/proper acceptable identification. Completed 5/1/2023. One hundred sixty seven of 167 total employees received education by the Staff Developer on abuse and neglect. Completed 5/1/2023. Bedrock Rehabilitation and Nursing Center at Suwannee implemented a new hire checklist to ensure proper identification documentation is collected prior to employment. Completed 5/1/2023. On 5/1/2023, harm no longer existed for the residents of Bedrock Rehabilitation and Nursing Center at Suwannee. Actions to prevent further deficient practice r/t licensed nurse identification discrepancy began on 5/1/2023 are as follows: Newly hired Licensed Nurses will receive education in orientation, as stated above. The new hire checklist will be completed by the Human Resource Director with every newly hire [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 implement policies and procedures to verify the identity, credentials and licensure of an individual prior to employment as a licensed practical nurse providing care and services for 17 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #39, #10, #7, #29, and #66. Findings include: Review of Staff A's personnel file documented an application for employment dated [DATE]. The application had two social security numbers and two dates of birth documented. The application listed two work experience references and three personal/professional references. The file did not provide documentation of the verification of prior employment or for the personal/professional references. The College, Business School, Military (most recent first) documented Staff A completed General Studies/Nursing [year documented], with the birth date provided at the time of interview the applicant would have been [AGE] years of age when the course of study was completed. Staff A's Level II background screening had a different spelling of the first name on the employment application, social security card, and the driver license on record. The nursing license on file provided for a different spelling of the first name, had a middle name, a single last name, a different address, the address on the application, driver license, and Level II background were from a different state. The nursing license was originally issued in 2014 in the state of Florida, the driver license on record was issued in 2020 in the state of Georgia. The Basic Life Support card on file has a different last name. The file did not contain a practical nursing license for the person named on the application. The nursing license on record was not made a part of the record until [DATE] at 11:02 AM as verified by the date and time printed on the document, and not at the time of hire. 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 Practical Nurse in the State of Florida. Review of Staff A's time clock punch in and out documented Staff A worked 17 shifts in the facility for the period of [DATE] through [DATE]. Review of the job description titled, Licensed Practical Nurse read, Education/Work Experience Requirements: Education: Graduate of accredited school of nursing. Certificate/Licenses: Current, active license as Licensed Practical Nurse in state of employment. Work Experience: One year experience providing direct care to residents in long term care setting preferred. Review of the job description titled, Nursing Home Administrator read, Reports to Regional Director of Operations. Job Description: The Nursing Home Administrator (NHA) assumes full-time administrative authority, responsibility, and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees and the provision of care and services rendered in accordance with professional standards, and in compliance with state and federal laws and regulations. Collaborates with consultants, contractors, referring physicians, community resources, government agencies and advocacy groups. Implements operational and financial objectives of management and allocates resources in an efficient and economical manner to attain or maintain the highest practicable physical, mental, and psycho-social well-being of each resident. Specialized Knowledge & Skills: To perform the job successfully, an individual should demonstrate the following competencies: Current knowledge of state and federal laws governing the operation of nursing facilities. Knowledge of licensing and payment programs, general business practices, nursing practice, psychology of resident care, personal care and social services, therapeutic and supportive long-term care and services, and environmental health and safety relevant to nursing facility operations. Knowledge of state personnel licensing and registration requirements. Knowledge of human resource principles, labor laws and union contracts, were applicable, to manage personnel functions and to supervise Department Heads in personnel matters. Able to apply facility personnel policies to facts regarding employment actions without regard to race, religion, age, national origin, sex, or disability. Able to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. Ability to foster interdisciplinary cooperation and coordination of quality assurance and quality improvement efforts. Able to develop and implement administrative policies and procedures that reflect the facility philosophy and mission in compliance with state and federal laws and regulations. Review of the job description titled, Director of Nursing read, The Director of Nursing Services assumes full administrative and clinical authority, responsibility and accountability for the delivery of nursing services in the facility. Manages employees in the provision of care and services according to professional standards of practice, consistent with facility philosophy of care and state and federal laws and regulations. Develops and implements policies and procedures consistent with current law. In collaboration with Nursing Home Administrator, allocates department resources in an efficient and economic manner to enable each resident to attain and maintain the highest practicable physical, mental, and psycho-social well-being. Collaborates with other departments, professionals, consultants, and organizations, including government agencies and advocacy groups, to develop support and coordination of resident care, related administrative functions and to represent the interests of the facility. Makes daily rounds on unit to supervise, observe, examine, interview residents, to evaluate staffing needs, to monitor regulatory compliance, to achieve the care environment and to evaluate staff interactions and clinical skills competency. Develops and maintains nursing policies and procedures that reflect current standards of nursing practice and facility philosophy of care consistent with state and federal laws and regulations. Communicates and interprets policies and procedures to nursing staff. Monitors practice for effective implementation. Hires and retains qualified competent nursing staff to provide nursing and nursing related services to attain or maintain highest practicable physical, mental, and psycho-social well-being of each resident. Conducts interviews, provides regular performance reviews, takes appropriate job actions, reviews job actions taken by subordinates to assure that staff meet qualification and performance standards and can perform all essential functions of the job. Review of the job description titled, Human Resources Manager read, Human Resources Manager is responsible for the overall administration, coordination and evaluation of the Human Resources function at the facility level. Implements all Human Resources Policies and Procedures. Manages facility employees in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. Solves practical problems and deals with a variety of concrete variables in situations where only limited standardization exists. Acts as an employee advocate by performing the following duties: 1. Ensure that all policies, procedures, and reporting requirements are followed in compliance with corporate. 2. Recruits, interviews, tests, and assists department heads with selection of qualified employees to fill vacant positions. During an interview on [DATE] at 9:10 AM the Director of Nursing (DON) stated, I have recently taken over this job and did not hire that employee [Staff A]. I was here when the Administrator was notified that she was being investigated by [NAME] for identity theft of a nurse and they tracked her here by her cell phone. The administrator worked with that detective and the [name of the local law enforcement agency], and she was arrested here after she clocked in for her shift. Once we learned about this, we began an investigation. She had a background screening that came back eligible and did present a driver's license and social security card. Unfortunately, her license was in a different name. I can't tell you how this happened. We did not do the proper license verification. There were not any reference checks completed and her previous employers were not contacted to determine if she had actually worked for them. I don't know how this occurred. It should not have happened. We should never have hired her with the conflicting dates of birth and with the conflicting social security numbers. I do believe that it should have been escalated when she gave those, I think probably to the human resources' responsible person and the Administrator. After that we absolutely should have verified that she had a valid nursing license and requested that she bring in a copy of her license before we allowed her to work. During an interview on [DATE] at 4:18 PM Staff B, Licensed Practical Nurse (LPN) stated, I did run this persons [Staff A] AHCA (Agency for Healthcare Administration) background screen. I used to do all the background screenings and managed the roster and things like that. Once I completed those I would give them to HR [Human Resources] and then they would hire them in the system and do their part. Well, in April of 2022, Bedrock took over. They wanted my position to be more nursing and to do infection control, so then that's when the HR started taking over the backgrounds, but there was a transition, so I would still help [Staff C's name], like showing her how to resubmit backgrounds and how to pull new backgrounds so everything was complete. I did the background on [Staff A's name] in January after that I've given information to the HR, to [Staff C's name]. Well on our applications there is not a section for an employee's date of birth or social security number. I wrote the date of birth and social security number she gave me when I talked with her a few weeks after her interview when she let me know she wanted to proceed with becoming an employee. I then tried to do her background screening and she was not in the system with the original birthdate that she gave me. I wrote the [date written] and the social security number that is on there [the employee application]. So, then I had to call her and tell her I can't find her. That is when she told me that someone had stolen her identity and the government issued her new cards and a new birthdate. She then gave me a new birthdate and social security number. It was a different birthdate of [birth date given] and a new social security number. Once I put in the new information on the background screening, she came back as eligible, and it was the same person that I interviewed. I didn't think a thing, I have had others give me the wrong social security number so, I didn't think to escalate this to anyone else in HR. I did not tell [Staff C's name] about it. It did not concern me at all. I'm not a criminal so I believed her. Her background screening per AHCA came back eligible. I didn't question it all. I mean people mix up things, but when I put in her last name with that social her picture pulled up the social matched the date of birth on there and matched her picture that was on there, everything matched with the second date of birth. I did not bring any concerns about this to [Staff C's name], she cleared and was eligible. I did her interview. I do have the application in front of me when I interview. I didn't look at her education and ask her any questions about that. We just talked about her experiences, if she had taken [care of] trachs, her general experiences, if she was comfortable with g-tubes and medications. I didn't look at how her name was spelled and see that it was not the correct spelling. She did tell me that she got divorced and that's why there was a different name and that she had her identity stolen. I don't know how the license verification was done. The day that this was all being investigated we found out that the license verification wasn't in her file. I guess that's when she [Staff C] did it. I don't know when or if she did it when she [Staff A] was hired. I'm not HR. During an interview on [DATE] at 8:05 AM the Administrator stated, I have just assumed this role on Monday of this week. I am aware of the incident but have yet to fully review all the documentation. It was my understanding that the total investigation was handed over to the police when requested. In this case it appears that there was a failure in the HR process, it was not followed according to policy and procedure. I would expect that once two different IDs were given someone would have been notified. During a telephone interview on [DATE] at 9:20 AM the previous Nursing Home Administrator stated, I was notified on I believe it was ,d+[DATE] or [DATE] by a detective in [NAME] that they believed they had tracked a nurse with a fraudulent nursing license, and they were working in our building. I verified his identity and began to assist him in any way I could. Looking back at our files we determined that she [Staff A] gave two different social security numbers and she was called and changed her social security number and birth date. This got missed by [Staff B and Staff C's names]. I was not aware that the nursing license was not in the file and that she did not provide a copy of the nursing license. I would say the HR Manager should have caught this and brought it to the attention of someone when she gave multiple birthdays and social security numbers, that would be an immediate red flag. It should come to corporate HR and the Administrator. [Staff B's name] was well aware of the changing date of birth and social security number. At some point they both knew and should have responded, and we should not have hired her [Staff A]. We, upon investigation, suspended [Staff C's name] because she was in the role and had the responsibility to make sure that all aspects of the employment process is fully implemented and followed. Ultimately, administrators are responsible for the overall running of the building and all disciplines. This [Staff C's name] had been in HR since about last August or September, there is some debate on the amount of training she received, and she was learning on the fly. The mistake was made because they were not properly trained and did not understand the severity of the situation when [Staff B's name] was provided with two different birthdates and social security numbers. [Staff C's name] was in that role less than one year and they were trying to combine the role she had previously been in with HR responsibilities and make [Staff B's name] role more nursing. They put themselves [Bedrock] in this position by inadequately training [Staff C's name] to fulfill her role. During a telephone interview on [DATE] at 3:30 PM the Medical Director stated, I was notified immediately on Friday night that there was a nurse who was fraudulent and without a license that had been practicing with the residents. She was not properly cleared to work and the system to verify her license and identification was not followed. The police arrested her [Staff A] at the facility very late on Friday and we met on Monday to do a QAPI [Quality Assurance Performance Improvement] we did conduct the root cause. The names were different, and the nursing license was not verified. Luckily nothing happened to any of my residents nor other physicians' residents. It is imperative that we verify these things and have these systems in place, they promote and protect patients. They ensure that we provide a minimum standard of care that non licensed nurses cannot provide. There was great potential for harm if she had come across a situation that she was unfamiliar with. I hope we now have the system to safeguard all the residents in place and we will keep monitoring this to make sure this never happens again. She would not have the necessary knowledge to care for a tracheostomy tube, or possibly understand what to do if the resident accidentally decannulated [removed the tracheostomy] themselves. Gastrostomy tube medication administration is more complex with possible gastric perforation if not verified as present in the correct place and would require assessment skills that nurses have. Review of the policy and procedure titled, Employee Personnel Records dated [DATE] read, Policy: Bedrock care maintained certain records for each employee which are directly related to his/her employment. Policy interpretation and implementation: Federal and state regulations require that the facility maintain an individual personnel record for each employee. However, it shall be the employee's responsibility to provide the HR [Human Resources] Director with the required data. This responsibility also entails notifying, in writing, the HR Director of any change in the required data and keeping the required data current. Should it become necessary for an employee to furnish additional data or records, the employee will be notified in writing or electronically by the HR director, and such data must be completed and provided to the HR director within the time frame specified on the notice. Personnel records contain the following data: The employee's full name, address, date of birth, sex, and Social Security number, job application, job description(s), orientation and training program records, performance evaluations, employment references, letters, etc. Copy of current licenses (as applicable), others as appropriate or necessary, date of termination/discharge. The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the Root Cause Analysis provided by the facility was an untitled document provided by the facility, with no date or time indicated read, Problem statement: [Staff A's name] worked in nursing home without a valid license. Why? Detective notified facility of identity theft by [Staff A's name] questioning accuracy of nursing license. Why? Level 2 AHCA clearing house background [Staff A's name] eligible for employment. Why? Forms of identification matched spelling of name identical on Social Security and driver's license. Why? No results on OIG exclusion list [Staff A's name]. Why? License verification on FDOH (Florida Department of Health) [a different nurses name] clear/active root causes:1. Identity theft. 2. Spelling of name on driver's license and nurses license not match. 3. Middle name different on level 2 and nurse license. Review of the Performance Improvement Plan dated [DATE] documented [Medical Director's name] was notified of the removal of [Staff A's name] from the facility. The staff Developer and Regional Nurse conducted a quality review of 30 licensed nurses to ensure proper identification and valid and active nursing license in their file. Completed [DATE] for 30 of 30 licensed nurses. No discrepancies found. Seventy-seven resident assessments were completed by the Director of Nursing on residents that were provided care and services by [Staff A's name]. No areas of concern noted. Completed [DATE]. Discharge resident records were reviewed by the Director of nursing with no concern noted. Completed [DATE]. Medication Administration Records, Treatment Administration Records and narcotic sheets were reviewed by the Director of Nursing with no concern noted. Completed [DATE]. Grievances were reviewed by the Director of Nursing and no concerns with [Staff A's name] noted. Completed [DATE]. Education: The DON, Administrator, Human Resource Director and the Staff Developer were educated by the Staff Developer on Policy/Procedure: Employee Personnel Records to include the Employee's full name, address, date of birth, Social Security Number, job application, job description, orientation and training program records, performance evaluations and employment references; Policy/Procedure: New Hire Checklist; OIG Exclusion; AHCA Clearinghouse Roster; Verifying Active and Valid Nursing License; including the Original Nursing License and the Verified Active License placed in the Employee File. Completed [DATE]. Bedrock Rehabilitation and Nursing Center at Suwannee currently has 30 Licensed Nursing Staff. Current Licensed Nursing Staff received education by the Staff Developer and education was completed on [DATE]. Education included for Licensed Nursing Staff Policy/Procedure: Abuse/Neglect; Policy/Procedure: License Verification/proper acceptable identification. Completed [DATE]. One hundred sixty seven of 167 total employees received education by the staff developer on abuse and neglect. Completed [DATE]. Bedrock Rehabilitation and Nursing Center at Suwannee implemented a new hire checklist to ensure proper identification documentation is collected prior to employment. Completed [DATE]. On [DATE], harm no longer existed for the residents of Bedrock Rehabilitation and Nursing Center at Suwannee. Actions to prevent further deficient practice r/t licensed nurse identification discrepancy began on [DATE] are as follows: Newly hired Licensed Nurses will receive education in orientation, as stated above. The new hire checklist will be completed by the Human Resource Director with every newly hired Licensed Nurse to include verification of identification, employment history reference, and licensure verification. Review of the witness statements documented statements were completed by the Administrator of the facility at the time the incident occurred and by Staff B. An Ad Hoc [done for a particular purpose as necessary] Risk Management and QAA [Quality Assessment and Assurance] meeting was conducted on [DATE] with the development of a performance improvement plan as follows: The Ad Hoc meeting was attended by the Administrator, Director of Nursing, Medical Director, and Risk Manager with eight additional members in attendance. Policies included: Verifying nurse license and driver's license match exactly the names must match exactly. Identified clinical risks or safety hazards include: Employee practicing without a license. Employee distributed medications and rendered treatments without a nurse's license. Grievance log reviewed was documented as Yes. Complaints are a concern related to clinical issues, include employee practicing as a nurse without a license. Implementation of new employee checklist to be included in employee file: Employee information: Full name, job title. Pre employment: Application signed includes resume if applicable, test if applicable, background authorization/check clearing house Florida, OIG [Office of Inspector General] exclusion, WOTC [Work Opportunity Tax Credit], offer letter, references (2) 19 (if alien enter expiration date into Greymar [a healthcare operations software]), W4, EEOC [Equal Employment Opportunity Commission], disability, [NAME]. License/certification: license copy, license verification including out of state, CPR [cardiopulmonary resuscitation] copy, IV [intravenous] certification copy, scan and enter into Greymar. Review of an audit dated [DATE] documented the facility conducted interviews with all cognitively intact residents who were under the care of Staff A, there were no concerns identified. Seventy seven MAR/TAR reviews were completed. The Director of Nursing verified that all residents cared for by Staff A, 77 of 77 residents were assessed, 32 residents were interviewed. There were no concerns documented. Review of an audit dated [DATE] documented narcotic sheets and counts were reviewed for the east wing with no areas of concerns or discrepancies in narcotic counts. Review of an audit dated [DATE] documented the facility conducted 30 out of 30 Licensed staff photo identification and license verification. Review of an audit dated [DATE] documented the facility conducted 77 chart reviews on residents cared for by Employee to determine any changes in condition, transfer to hospital. There were no concerns identified. Review of an audit dated [DATE] documented on the New Hire Checklist implemented for all new hires. There were no nursing staff hired since [DATE]. Seven Certified Nursing Assistants (CNAs) were hired, with all required verifications and checklist present in employees' personnel files. Review of an audit dated [DATE] documented the Regional Nurse Consultant conducted education with the Administrator, DON, and Staff Educator, Staff Development Nurse, and HR Manager consisting of the New Hire process: Copy of license, license verification, 19. (two forms of approved identification with no issues identifying) OIG exclusion, Background Screening and adding to AHCA clearinghouse roster. Review of the in-service sign in sheets dated [DATE] documented Abuse and Neglect training and education was completed for 167 out of 167 employees. Review of the in-service sheet dated [DATE] documented the identity verification and nursing licensure requirement education completed by Staff Development Nurse for 30 out of 30 licensed staff. Interviews were conducted on [DATE] - [DATE] with 26 Certified Nursing Assistants, 12 Licensed Practical Nurses and 6 Registered Nurses who confirmed abuse and neglect training and education was provided. During interviews conducted on [DATE] the administrative staff verbalized understanding of the new hiring process and the actions to take if issues arise. Review of the 7 employee files for newly hired CNAs documented each employee file contained the New Hire Checklist, and identification and certifications matched. Review of the current licensed staff roaster for the period of [DATE] through [DATE] verified by employment dates there were no newly hired licensed nursing staff for this period of time.

Based on interview and record review the facility failed to ensure all residents the right to be free from neglect for 1 of 3 residents reviewed for elopement, Resident #1 eloped and was found 0.7 miles from the facility involved in a motor vehicle accident. Resident #1 did not survive. Findings include: Review of the nursing progress note dated [DATE] midnight written by the Director of Nursing (DON) read, Resident noted to be absent from facility at appox [SIC] with wander guard alarm sounding. Elopement policy and procedure implemented including interior/exterior search. Resident location identified. Authorities involved at this time. MD [Medical Doctor] family notified. Review of the Exception Report documented, Effective Date [DATE]. 1. Date/Time of Occurrence [DATE], 2340 [12:40 AM]. 2. Description of event: Resident eloped from facility resulting in fatality. 2a. Location of event: 3. Hall/Corridor. 13. Other. 2b. If event happened in the location of 13. Other, please state the location: Point of exit Laundry Room exit Door . 4. Orientation - Check all that apply: d. Person . A3. Injury - 1a. Is there an injury? Yes . 1c. If other, please specify: fatality. Review of the medical record for Resident #1 documented the resident is a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of the Wandering Risk Observation Record dated [DATE] documented Resident #1 as an elopement risk with a score of 10. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 read Wander Guard Tag #00EAC1, Exp [expire] date: [DATE]. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On exam today he is alert/awake, ambulatory in hall w/o [without] assistive device. He is oriented to self. Confused re: [regarding] situation. Offers no complaints, states he is waiting for a ride home. During a telephone interview on [DATE] at 10:57 AM Staff A, Certified Nursing Assistant (CNA) stated, I was taking care of him [Resident #1] that night and I saw him walking up and down the hallway, that was normal for him. I was down the hallway sitting and I noticed that I hadn't seen him [Resident #1] pass me by and that wasn't normal. The last time I saw him was at about 11:20 PM when another CNA asked if he was ready for bed, and he didn't want to go to bed yet. I guess it was about 20 minutes later when I went to his room, and he wasn't there. I found his nurse [Staff E's name] and told her I couldn't find him [Resident #1]. I went to all the wings starting at about 11:45 PM telling them we couldn't find him [Resident #1]. There was no code overhead because by that time everyone was looking for him. I don't know if he had a wander guard, not sure because he always had on long pants and shoes on. I did tell [Staff B's name] that the resident was missing. I went into the laundry room and told him [Staff B]. I did not hear any door alarming when I went and told him. He did not tell me that the door had been open or alarming when I spoke to him. During an interview on [DATE] at 2:10 PM Staff F, CNA stated, I was working nights on [DATE] and the last time I saw [Resident #1's name] was at about 10:50 PM. He was just hanging around the nurses' station and going back and forth to his room. I started my rounds, and I was in with another CNA who was on 1:1 and that's when [Staff A's name] told me that he was missing. I guess that was about 11:45 PM and that's when I started to look in every room. We couldn't find him, so we started to search outside, but he wasn't there either. There was not any alarms going off when I was looking for him. I stayed in the building and didn't search outside. Other people did that. About 12:30 PM they told us there was an accident. During a telephone interview conducted on [DATE] at 2:20 PM Staff C, Registered Nurse (RN) stated, I began work at 7 PM that night and had just come back from leave after seven weeks. I remember that he was fairly quiet [Resident #1], staying at the nurse's station or going to his room. He didn't show any exit seeking behaviors. I was not in the hall. I was giving meds when the CNA [Staff A's name] came up to me and asked if I had seen him. This was about 11:45 PM, she said she couldn't find him, he was not in his room. I stopped what I was doing and asked everyone to begin looking for him. We couldn't find him inside, so we began to search outside. We still couldn't find him, so another CNA got in her car and began to search for him, she came back maybe about 12:20 AM or 12:30 AM and told us there was an accident and [Staff E's name] went to the accident and identified that it was [Resident #1's name]. I called the Director of Nursing. During a telephone interview conducted on [DATE] at 2:31 PM Staff G, CNA stated, I was not working on his unit and at about quarter to twelve the Nurse [Staff C's name] came down and told us that a resident was missing. So, we searched in the building, all of the rooms and then outside. After we couldn't find him, I got in my car and checked for him. I went down the road and I saw the police lights. He was stopping everyone. I explained we were searching for a missing resident, and he told me there was an accident, someone was hit by a car and that he couldn't say anything else. That's when I came back and the nurse [Staff E's name] went down and identified him. During a telephone interview conducted on [DATE] at 4:16 PM Staff B, Laundry Aide stated, I was working that night and when I came back from my break, I heard the door alarming. I came in the front door, and I left by the front door when I went on break. I never went out that door that was alarming. When coming back from break, there were no nurses asking me if I saw anyone, any resident. I did not see anyone when I came in. I guess that I went to lunch about 11:15 PM or so and came back about 11:45 PM. I heard the alarm going off at the door near the laundry and I didn't see any resident, so I turned off the alarm. I didn't tell any of the nurses the alarm was sounding off. About five or ten minutes later, that's when the CNA told me a resident was missing. They were just starting to search for the resident. I didn't tell anyone that the alarm had been ringing. During an interview on [DATE] at 5:10 PM Staff D, CNA stated, I was late clocking out and last saw the resident [Resident #1] at the nurses' station that was about 11:20 or 11:30 PM. When I left the building, I did not hear any alarms going off. During an interview on [DATE] at 6:55 AM Staff J, CNA stated, I have worked nights for 30 plus years. I was on the night that [Resident #1's name] went missing. I wasn't on his unit. I guess at about 11:50 PM they came to my unit, and we did a search of my wing. We searched each room. Once nobody could find him, we did an outside search. It was [Staff C's name] the RN that came and told me he was missing. There was no alarms going off when I searched my unit. During an interview on [DATE] at 7:00 AM Staff I, CNA stated, I was on the night the resident [Resident #1] went missing. I think it was [Staff A's name] that came and told me there was a resident missing. There were no alarms going off when I went around the building. I guess that was about 11:45 to midnight. Nobody called a code gray overhead. They just came to the unit and told us. During an interview conducted on [DATE] at 9:25 AM the Nursing Home Administrator (NHA) stated, We were notified at around 12:15 AM, I was called by the Director of Nursing. She told me that [Resident #1's name] was missing and couldn't be found in or outside the building. At about 12:45 AM she told me that he had been involved in an accident and had passed away. I was already on my way to the facility when I got that call. We started an immediate investigation and training of all staff on elopement procedures. We spoke to all the staff involved and completed our reports. During the investigation we determined that because the double doors were closed, staff was not able to hear the alarm going off. When [Staff B's name] came back from break, he heard the alarm going off and that's when the staff was asked if he saw the resident. We have completed 100% of training with the exception of four people out on leave. We also included the agency staff in the training, we trained on abuse and neglect, elopement of residents, and conducted elopement drills. We have put alarms on all interior doors that are leading to the exit doors. We contacted [name of company] for enunciators and are waiting on quotes for installation and our corporate engineer is expected tomorrow to determine if there are any additional measures we might need. We placed a staff at the exit doors 24 hours a day until we can get the enunciators installed at the nurses' stations. During an interview conducted on [DATE] at 9:40 AM the Director of Nursing (DON) stated, I was notified somewhere around midnight, and I immediately let the Administrator know that [Resident #1's name] was missing. I was in here [the facility] by 12:30 AM maybe sooner. I only live 15 minutes away. By the time I came in, I was told that the resident [Resident #1's name] had been hit by a car and had died . We started an immediate investigation, spoke with everyone involved, and determined that the resident had exited through the door closest to the laundry room. [Staff B's name] had heard the alarm sounding when he came back from break and turned the alarm off, at the same time the staff were looking for the resident [Resident #1]. We have completed all training and education with staff related to abuse and neglect, elopement, elopement drills, Code Gray, and who to notify and when to begin notifications. I have trained our agency staff and we have plans to continue to educate staff when hired and when they first work if they are agency staff. We have all leadership clinical and non-clinical staff sitting at the exit door nearest the laundry. We tested all the wander guards to make sure they were working; we reevaluated all wander risk residents and made sure our wander books are up to date at each nurses' station and at the front desk. Review of the care plan for Resident #1 read, Focus: Wanderguard for safety purposes. Interventions: Change wanderguard as ordered. Check wanderguard for expiration [DATE] and OOEA serial number every shift. Check wanderguard at the exit door every shift. ensure name is on list of wandering residents and pictures to be kept at nurses station lobby and therapy. If exit seeking behavior noted place resident on one to one supervision until behavior subsides. Notify supervisor, DON, nurse and social services immediately if exiting behavior is noted. Observe for changes in behavior, cognition or care needs and notify physician as indicated. Observe whereabouts routinely and redirect as needed. Provide a safe and secure environment. Wanderguard in place at all times. Wanderguard in place, check routinely for proper function. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the policy and procedure titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property dated [DATE] reads, Policy. It is the policy of this center that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, each resident will also be protected from those practices and omissions, which if left unchecked, could lead to abuse. Further, each resident will be treated with respect and dignity at all times. The center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care. Residents will not be subjected to abuse by anyone, including but not limited to, center staff, other residents, consultants, volunteer staff, contract staff, family members, friends, or others. Definitions. Neglect. Neglect means the failure of the center, its associates or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the policy and procedure titled, Elopement: Missing Resident Procedure/Drill dated [DATE], reads: Policy Statement. It is the policy of Bedrock Care [known as Suwannee Health and Rehabilitation Center] to provide a safe and secure environment for all residents. In the event of resident elopement, it is the policy of Bedrock Care to implement its policies/procedures immediately to locate the resident in a timely manner. To comply with regulatory agencies, conduct announced or unannounced drill to locate missing resident. The drill will also suffice the regulation for emergency preparedness. Review of the policy and procedure titled, Elopement dated [DATE] reads Policy Statement. It is the policy of the facility to provide a safe and secure environment for all residents. In the event of resident elopement, it is the policy to implement its procedures immediately to locate the resident in a timely manner. Purpose. 1. To assure safety and security of all residents. 2. To establish policies and procedures in the event of a missing resident. a. Assure notification of appropriate individuals who can provide support and assistance in the event of an elopement. b. Assure that authorities are notified as required. c. Provide prompt and appropriate intervention(s) should an elopement occur. 3. To train and maintain staff awareness of the importance of resident safety and security. Definition: CMS defines elopement as when a resident leaves the premises or a safe area without authorization and or necessary supervision. Procedure. 1. Assessment. a. Residents will be assessed for the following: i. Ability to independently ambulate and/or have independent locomotion with assistive devices (i.e. (wheelchair, walker, etc.) ii. Behaviors that could be reviewed: 1. Confusion, [CONDITION(S)] and/or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . History of wandering and/or attempting to exit hospital, home or other facility prior to admission. 4. Current patterns of wandering. iii. The resident will be assessed for any physical injuries resulting from the actual elopement once located. 2. Multi-Faceted interventions for residents at risk: i. Resident will have a picture taken/printed and placed on profile sheet maintained in elopement binder. 1. Verbal consent is acceptable for picture. 2. Refusals will be reported to administration so the interdisciplinary team can strategize next steps including obtaining previous picture form family, ii. Adjust staffing as indicated; particularly during times when a resident is agitated and/or making attempts to exit. iii. Encourage resident to participate in appropriate group activity iv. Notify Responsible Party v. Implement and/or update care plan for resident, vi. Ensure facilities disaster and emergency preparedness plan are up to date with plans to locate any missing resident. 3. Environment such as but not limited to: a Magnetic Exit Door Lock System: i. Exit doors are equipped with a magnetic locking system. ii. Maintenance shall routinely monitor the electronic doors, locks and exit devices for proper functioning. iii. The exit doors remain automatically locked at all times but can be opened by the following methods: 1. Entering the correct number code into the respective keypad beside the door a. Note: Doors unlock when fire alarm is activated 2. Attempts to open the door without utilizing the above mechanisms will sound an alarm at the door. b. Staff present at the main entrance during suggested hours, c. signage d. Elopement/missing persons prevention drills. Review of the policy and procedure titled, Wandering/Missing Residents dated [DATE] reads, It is the policy of this Center to ensure the safety and well-being of each resident within the environment of the Center while meeting their needs and sustaining a quality of life they can enjoy. Residents are not considered wandering or missing if the resident is on Center premises/being chaperoned by Center staff or a family member. Policy Interpretation and Implementation. 1. It is the responsibility of all personnel to report any confused or disoriented resident attempting to leave the center or suspected of being missing to the charge nurse as soon as possible. 2. Should an employee observe a confused or disoriented resident attempting to leave the center he or she should: a. Attempt to prevent the departure; b. Obtain assistance from other staff; c. Instruct another staff member to inform the Charge Nurse/Director of Nursing Services that a resident is attempting to leave the center; and d. Follow care plan for specific instructions. 3. If a resident goes from the Center but is within Center grounds, the employee should: a. Examine the resident for injuries; b. Contact the attending physician and report what happened; c. Contact the resident's legal representative (family) and inform him or her of the incident; d. Make appropriate documentation in the resident's medical record regarding residents last known whereabouts, time resident was located, and what time resident was returned within the Center; and e. Monitor resident whereabouts every 30 minutes until behavior subsides. Check door alarms for activation. F. Pharmacy consultant will review medications within 30 days. 4. Should an employee discover that a resident is missing from the Center, he or she should: a. Determine if the is out on pass or authorized leave. If not: b. Make thorough search of the building and premises. If not located: c. Notify the Administrator and the Director of Nursing; d. Notify the resident's representative (family); e. Notify the attending physician; f. Notify the sheriff and police department; g. Provide search teams with resident's identification information; and h. Make an extensive search of the surrounding area. 5. Upon return of the resident to the Center, the Director of Nursing or Charge Nurse should: a. Examine the resident for injuries; b. Contact the attending physician and report findings and condition of the resident. Follow orders; c. Notify the residents legal representative (family); d. Notify the search team(s) that resident has been located; e. Make appropriate documentation in the resident's medical record regarding residents last known whereabouts, time resident was located, and what time resident was returned within the Center; and f. Monitor residents whereabouts every 30 minutes until behavior subsides. Check door alarms for activation. g. Pharmacy consultant will review medications within 30 days. Review of the Ad Hoc QAPI (Quality assurance performance improvement) meeting dated [DATE] revealed the meeting included policy and procedure review for abuse and neglect, elopement and wander risk. The performance improvement plan was discussed and implemented. Review of Inservice training records revealed that 100 % of staff were trained beginning on [DATE] on abuse and neglect, wandering risk assessments, and wandering residents. Review of maintenance log door screamers were installed on the eat wing, west wing and patio doors. Review of the audit logs dated [DATE] reveal that all residents were reassessed for wandering 15 out of 15. Review of the elopement drills were reviewed dated [DATE] 74 staff attended. Review of [NAME] healthcare quote dated [DATE] was provided to the facility for wireless remote annunciators. Interviews were conducted on [DATE] with four RNs, two LPNs, 15 CNAs, five Personal Care Assistants (PCA), and six ancillary staff to include medical records, case management, laundry department, and minimum data set to verify staff understanding of the education provided on how to ensure others are informed of the sounding alarms and the policy and procedure related to elopement and neglect.

Based on interview, record review, and review of facility policy, the facility failed to ensure the resident environment remained free of accident hazards for 1 of 8 unsupervised smokers (Resident #216). Resident #216's repeated unsafe smoking behavior and refusal to comply with facility directives for safe smoking, placed all facility residents at risk of serious harm, death from fire or explosion, including when he singed his hair, while smoking, on 2/18/15. The facility failed to develop an effective smoking screening tool (assessment) and a policy that ensured staff and residents were educated and monitored. These facility actions caused an immediate jeopardy situation, which was determined to exist on 2/18/15. Due to the validation of the facility's Allegation of Compliance the immediacy of the jeopardy was lifted on 3/29/15 and the scope/severity reduced to a D isolated with no actual harm with potential for more than minimal harm. The nursing home administrator was informed of the immediate jeopardy on 3/27/15 at 2:00 PM. Findings: A review of the clinical record for resident #216 showed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident had the following progress notes in his clinical record: A Social Services Note dated 6/4/14 revealed: " On 6/3/14 Resident #216 was seen by staff outside giving a supervised smoker a cigarette." The note further stated Resident #216 was reeducated on the smoking rules and was informed that his behaviors were against the rules. It further stated Resident #216 agreed to not share cigarettes and that " he 'd abide by the rules. " A Licensed Practical Nurse (LPN) Employee R note dated 7/30/14 stated: " Resident in room smoking at 8:30 AM, cigarette put out by staff. Informed resident he was not allowed to smoke in room due to policy, and he could harm self, all lighters and cigarettes removed from patient, pt (patient) stated I had all his cigarettes, notified adon (Assistant Director of Nursing) of situation, resident is now a supervised smoker ". A Licensed Practical Nursing (LPN) Employee S note dated 11/5/14 stated: " South wing nurse reported resident flicking his lighter inside the building. West wing nurse went to check on him. She found him inside the building by the patio door smoking. Resident said he was getting out of the wind to light his cigarette. Nurse asked resident to go outside and smoke ". A Social Services note dated 11/7/14 stated: On 11/6/14 Resident #216 was spoken to " concerning an issue of smoking at the courtyard door, inside the building and of helping a supervised smoker to smoke. He tried to down play both issues, but I informed him emphatically that if he had another smoking infraction, he would be placed onto supervised smoking for his and other ' s safety. He stated to understand, but continued to give an excuse ". A Licensed Practical Nurse (LPN) Employee T note dated 12/19/14 stated: "Resident is on supervised smoking ". A Licensed Practical Nurse (LPN) Employee U note dated 1/1/15 stated: " Resident outside smoking a cigarette, unsupervised. Went outside and asked resident what he was doing he stated waiting for the smokers to come out, I informed him that's not for another 30 min. Resident stated okay and continuing smoking ". A Licensed Practical Nurse (LPN) Employee Q note dated 2/18/15 stated: " Resident went out for smoking (is unsupervised smoker) and was witnessed by CNA". CNA stated "she observed resident accidently catch his hair on fire and then quickly put it out ". A Social Services note dated 3/23/15 stated: " He is an unsupervised smoker at this time, but must turn in his smoking materials to nursing staff at the conclusion of each smoke break". A Social Service note dated 3/25/15 stated: Resident #216 " is a completely unsupervised smoker at this time. He does not have to turn in smoking material following smoking episodes as stated in his 3/23/15 annual review note. An interview was conducted with Resident #216 on 3/26/15 at 11:08 AM in his room. He showed the surveyor his lighter which he kept in his coat pocket, four loose cigarettes, and a full pack of cigarettes. When asked why he had not returned his lighter the previous night (as stated in the facility smoking policy), he stated, "I keep the lighter sometimes at night. I have privileged status". He acknowledged, " Yes, I ' ve burned my clothes once or twice ". Concerning when his hair caught fire on 2/18/15, he stated, " The wind blew and my hair caught fire. It went out in a flash. I got a haircut after that." Employees E (Certified Nursing Assistant) and P (Minimum Data Set Assistant) were observed providing supervision on the smoking patio on 3/26/15 at 1:17 PM. Resident #216 was smoking in the patio area. He was observed dropping a lit cigarette on the concrete floor. A cognitively impaired resident was observed walking through the patio wearing only socks as footwear. She narrowly missed stepping on the lit cigarette. Neither staff intervened. Interviews were conducted with Employees E and P on 3/26/15 at 1:28 PM. Employee P stated that this was the first time she had supervised the smoking area. Employee E stated she often works the smoking patio as a supervisor. She stated she had been trained as a smoking supervisor. Her duties, as she understood them, were to ensure people were hydrated when smoking and to ensure one particular resident wears a smoking apron and smoked only two cigarettes. The facility provided no further information regarding interventions for the facility's smoking supervision training. An interview was conducted with Employee B on 3/26/15 at 2:24 PM. She related that she had smoking duty yesterday. She stated each wing has a list naming who is a supervised smoker. When supervising smokers she observes their manual dexterity with handling the cigarette. She stated that smoking supervision consists of supervision and assisting the smoker to light the cigarette. She stated that Resident #216 will sneak cigarettes to supervised smokers. An interview was conducted with the Administrator, Director of Nursing, Risk Manager, Corporate Regional Nurse Consultant and Assistant Director of Nursing west wing on 3/26/15 at 4:42 PM. The interview indicated none of them were aware of the incident of 2/18/15 when resident #216's hair caught fire, nor was an investigation conducted. The managers had no further information regarding Resident #216 's smoking behavior. A review of the facility document entitled " Smoker Screen " for resident #216, dated 3/14/14, and another dated 3/25/15, gave no evidence the facility included in its assessment the resident ' s psychiatric issues, behavior issues, or repeated non-compliance with facility rules for safe smoking. An interview was conducted with Employee A, on 3/26/15 at 2:56 PM. She stated that as a smoking screener, she makes decisions by watching the resident smoke. She observes the residents to see if they drop cigarettes, burn themselves, or fall asleep. Unsupervised smoking status is determined by observation of the resident at the time of the screening she related. She said past unsafe smoking behavior is not considered in determining unsupervised smoking status. There was no further information provided by the facility regarding the inclusion of the assessment for the resident ' s psychiatric issues, behavior issues, or repeated non-compliance with facility rules for safe smoking. An interview was conducted with Employee O, on 3/29/15 at 10:46 AM. Employee O completed a "Smoker Screen " on 3/14/14 placing Resident #216 as an unsupervised smoker. She stated "I can't remember them telling that (to consider behavior and past noncompliance). No, just basically if they were safe ". An interview was conducted with the Social Services Director on 3/26/15 at 3:26 PM. He stated that residents can keep cigarettes, but have to turn in lighting material at 10:00 PM. When advised that Resident #216 did not turn his lighter in, the previous night, he stated, "I was not informed of that." Concerning the incident on 2/18/15 when Resident #216 ' s hair caught fire, he stated, "I saw that note too. No one informed us. Who saw it did not report it. She should have done an incident report" . He stated that Resident #216 was caught smoking in the building near an exit on 12/3/14. Prior to that, he was found smoking in his room. He also related that Resident #216 has a history of smoking noncompliance and switches between supervised and unsupervised smoking status periodically. To move back to smoking status, Resident #216 had to verbalize his noncompliance and promise to adhere to the smoking policy. An interview was conducted with the Administrator, Corporate Director of Operations, and Corporate Regional Nurse Consultant on 3/27/15 at 10:45 AM. The Director of Operations stated, " Starting with the smoking assessment, we acknowledge the form may need revisiting. "He stated, "The assessment tool may have not been adequate". They provided no further information regarding any other interventions or supports used for the safe smoking programs. The facility implemented the following measures that resulted in the Immediate Jeopardy being removed as of 3/29/15 at 3:00 PM. The facility provided a plan of corrective action to the survey team on 03/29/15 at 3:00 PM. The plan was reviewed to verify implementation and operationalization. The plan included: " The facility has determined that the root cause of the problem was a failure of the identified nursing staff to properly assess/reassess residents who smoke. Further, the nursing staff failed to monitor a safe environment while residents were smoking along with the lack of reporting unsafe incidences to the appropriate department Supervisor or the Risk Manager. The facility failed to investigate incidents of unsafe smoking practice. It is the policy of this facility to have systems in place to ensure resident safety while they are smoking to prevent fires or explosions. When made aware of the smoking issues, the facility executed the following: 1. All ignition materials were immediately confiscated from all smoking residents (14) and stored at the nurse's stations on 3/26/15 by 9:00 PM. 2. The smoking policy was revised on 3/26/15 to designate that all residents will be supervised while smoking. 3. All residents who smoke were advised they must be supervised when smoking as of 3/26/15 at 9:00 PM. 4. All residents who smoke were rescreened 3/26/15. 5. All staff have been or will be inserviced on the new smoking policy, all residents that smoke will be supervised, completion of incident reports, investigation of reported unsafe incidences and observing for non-compliance with a report to the Risk Manager if any non-compliance with regards to the smoking policy is noted prior to working, by Nursing Administration. Any staff that was not able to receive the training as of the date of this allegation of compliance has been removed from the schedule and will not be permitted to work until they have received the appropriate training. 6. For Associates and Supervisors : All accidents and/or incidents regardless of nature, must be reported to your supervisor and /or Risk Manager immediately. Accidents/ incidents will be analyzed at monthly Quality Assurance meetings, to determine if the intervention needs revision. 7. For the Risk Manager: All accidents and/or incidents regardless of nature, must be reported to Director of Nursing and/or the Administrator immediately. Accidents/ incidents will be analyzed at monthly Quality Assurance meetings, to determine if the intervention needs revision. 8. The Quality Assurance Committee met on 3/28/15 which resulted in an approval of a revised smoking policy. The committee members received training regarding the new policy at that time. Care plans of residents who smoke will be reviewed by the committee during the monthly committee meeting. The plans will be compared to any new incidences which will then require revisions. All smoking issues/concerns will be reviewed weekly during Risk Management meetings. All new staff will be trained on the new policy and procedures. During an observation on 3/27/15 from 6:50 am until 7:30 AM at the facility time clock, a Registered Nurse, Employee Z, was in-servicing all staff, that all residents are to be supervised when smoking. They were directed to inform a nurse if they see any resident smoking without supervision and no resident should have cigarettes or lighter, which are now locked. Also each staff member entering the building, for the shift, was observed to read and sign the facility 's " New Smoking Policy Alert. " The alert, dated 3/26/15, stated the following: As of today all residents will be supervised while smoking. Residents are not allowed to have cigarette lighters. Remove all lighters and turn them into immediate supervisor. All smoking related incidents must be immediately reported to your supervisor. Any non-compliance with the smoking policy must be immediately reported to the Risk Manager or your supervisor. All nurses must complete an incident report for all smoking related incidents. Also during the observation on 3/27/15 from 6:50 am until 7:30 AM, the nurse in-servicing first shift staff, checked each third shift staff as they clocked out to determine if they had been in-serviced on the new smoking alert. One hundred percent of the third shift staff reported they had, which was confirmed through a review of the employee check list. A comparison of the staffing list with the inservice sign- in sheets was completed by the team. Also during the observation on 3/27/15 at 7:05 AM, at the time clock, located next to the smoking patio, 6 smokers were observed going to the smoking patio. A Certified Nursing Assistant (CNA), was observed bringing out a locked container. She was observed to open the locked container, remove a cigarette for each smoker and light each resident's cigarette with a lighter from the container. She stated the Director Of Nursing had called her last evening and in-serviced her on the new smoking policy. She signed the " New Smoking Policy Alert " this morning at the time clock. Resident #216, was observed to be one of the 6 smokers, as was resident #44 (prior to 3/27/15 both were unsupervised smokers.) An interview with Resident #216 on 3/27/15 at 7:07 AM revealed he was now a supervised smoker and the facility kept his cigarettes and lighter. He further stated he "didn ' t like it and that when surveyors left, things would go back the way they were because the Governor smoked and he would take care of things." He stated the facility informed him of the new smoking policy last night and searched his room for lighters. Also during the observation on 3/27/15 at 7:09 AM an interview was done with the Resident Council President, resident #44, who had been an unsupervised smoker. He stated the facility asked him for his smoking materials last night and he gave them to the Nurse. He stated the Social Service Director was with the nurse and they informed him of the new smoking policy. He stated that he was told the facility would meet with the smokers, in the near future, to determine if the scheduled times of smoking met the residents ' needs. He was confident the facility and the smokers could work it out. Interviews with third shift staff on 3/27/15 at 6:58 am, revealed they all were in-serviced last night that all residents are to be supervised when smoking and not to have lighters or cigarettes. Random interviews with staff were conducted on 3/27-28/15 to verify the staff's understanding of the inservice information. There were no discrepancies. An observation of the smoking patio on 3/27/15 at 7:05 PM, revealed 8 smokers on the smoking patio with 2 staff. Resident #216 was observed entering the smoking patio. The CNA was observed to open a container remove a cigarette and give it to resident #216. She was then observed to get a lighter out of the container and light his cigarette. She then returned the lighter to the container. The CNA, Employee J, stated she was trained in the new smoking policy last night. She stated all smokers are now supervised smokers and are not to keep their smoking materials, the facility keeps them. She noted she was to report to the Risk Manager all smoking incidents. An interview was attempted with resident #216 on 3/27/15 at 7:09 PM, regarding the facility meeting his smoking needs and he cursed the surveyor, blaming her for the change. An observation on 3/29/15 at 11:00AM, on the smoking patio, revealed 7 smokers on the patio with 1 staff member. The Activity Assistant, was observed to give each of the smokers a cigarette from the container and light their cigarettes. Resident #216 was among the smokers. At 11:04 AM the staff member stated she had been in-serviced on the new smoking rules on 3/27/15 when she clocked in. She stated all smokers are supervised and their smoking materials are to be kept in the container. She further stated she would report any smoking concerns to her supervisor. A Review of all the newly signed job descriptions and in- service trainings for all of the nursing staff and supervisory staff was completed on 3/29/15 at 3:00 PM. All staff had been trained in the smoking policy regarding assessments, reporting incidences, maintaining smoking materials and monitoring the residents while they smoke, as well as the Quality Assurance reviews. (cross reference to F490 and F520)

Based on observation, interview and record review, it was determined the administrator failed to oversee the facility and use the facility resources ' effectively and efficiently to ensure the safety and well-being of all residents and to protect the residents from the unsafe smoking practices of 1 of 16 resident who smoked cigarettes (#216). This could cause serious harm or death from fire and/or explosion. This was evidenced by the failure to develop and implement an effective and efficient system to identify and remedy the unsafe smoking practices of Resident #216. The nursing home administrator failed to ensure that residents who smoked were adequately screened (#216). This was evidenced by the failure to ensure smokers were adequately screened before the determination was made the resident could smoke unsupervised, including resident #216. Immediate Jeopardy was also identified at- F323, scope and severity (J) - Safe environment and supervision- and F 520, Scope and Severity (J) - Quality Assurance. Immediate Jeopardy was determined to exist beginning on 2/18/15 and removed as of 3/29/15. The Nursing Home Administrator was informed of the immediate jeopardy on 3/27/15. Due to the validation of the facility's Allegation of Compliance the immediacy of the jeopardy was removed on 3/29/15 and the scope/severity reduced to a D. Findings: A review of the Administrator ' s job description dated 1/22/08 indicated the following duties and responsibilities among others: " Lead and direct the overall operation of the facility in accordance with resident needs, ensure fire and safety practices are followed and to work with facility management staff and consultants in planning all aspects of facility operations. " A review of the clinical record for resident #216 showed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of the clinical record for resident #216 revealed he had not followed facility directives for safe smoking on 6/4/14, 7/30/14, 11/5/14, 1/1/15, and caught his hair on fire on 2/18/15. Through a review of the facility " Internal Risk Management and Quality Assessment and Assurance " meeting signature page for June 25, 2014, July 30, 2014, August 27, 2014, September 24, 2014, October 29, 2014, November 26, 2014, December 31, 2014, January 28, 2015 and February 25, 2015 it was noted that the facility Administrator attended each meeting. During an interview with Administrator on 3/28/15 at 3:40 PM he stated that resident #216 ' s unsafe smoking had not been addressed by the QAA committee during the last year. He stated he walked through the facility, which included the outside smoking area and was familiar with the guidance about resident smoking. A review of the facility document entitled " Smoker Screen " for resident #216, dated 3/14/14 and another dated 3/25/15 gave no evidence the facility included in its assessment the resident ' s psychiatric issues, behavior issues, or repeated non-compliance with facility rules for safe smoking. During an interview with the Administrator, Corporate Director of Operations and Corporate Regional Nurse Consultant on 3/27/15 at 10:45 AM, the Corporate Director of Operations stated " Starting with the smoking assessment, we acknowledge the form may need revisiting. " He further stated " The assessment tool may have not been adequate. " The facility implemented the following measures that resulted in the Immediate Jeopardy being removed as of 3/29/14 at 3:00 PM. The facility provided a plan of correction action presented to the survey team on 03/29/15 at 3:00 PM. The plan was reviewed to verify implementation and operationalization. The plan included: " The facility has determined that the root cause of the problem was a failure of the identified nursing staff to properly assess/reassess residents who smoke. Further, the nursing staff failed to monitor a safe environment while residents were smoking along with the lack of reporting unsafe incidences to the appropriate department Supervisor or the Risk Manager. The facility failed to investigate incidents of unsafe smoking practice. It is the policy of this facility to have systems in place to ensure resident safety while they are smoking to prevent fires or explosions. When made aware of the smoking issues, the facility executed the following: 1. All ignition materials were immediately confiscated from all smoking residents (14) and stored at the nurse's stations on 3/26/15 by 9:00 PM. 2. The smoking policy was revised on 3/26/15 to designate that all residents will be supervised while smoking. 3. All residents who smoke were advised they must be supervised when smoking as of 3/26/15 at 9:00 PM. 4. All residents who smoke were rescreened 3/26/15. 5. All staff have been or will be inserviced on the new smoking policy, all residents that smoke will be supervised, completion of incident reports, investigation of reported unsafe incidences and observing for non-compliance with a report to the Risk Manager if any non-compliance with regards to the smoking policy is noted prior to working, by Nursing Administration. Any staff that was not able to receive the training as of the date of this allegation of compliance has been removed from the schedule and will not be permitted to work until they have received the appropriate training. 6. For Associates and Supervisors : All accidents and/or incidents regardless of nature, must be reported to your supervisor and /or Risk Manager immediately. Accidents/ incidents will be analyzed at monthly Quality Assurance meetings, to determine if the intervention needs revision. 7. For the Risk Manager: All accidents and/or incidents regardless of nature, must be reported to Director of Nursing and/or the Administrator immediately. Accidents/ incidents will be analyzed at monthly Quality Assurance meetings, to determine if the intervention needs revision. 8. The Quality Assurance Committee met on 3/28/15 which resulted in an approval of a revised smoking policy. The committee members received training regarding the new policy at that time. Care plans of residents who smoke will be reviewed by the committee during the monthly committee meeting. The plans will be compared to any new incidences which will then require revisions. All smoking issues/concerns will be reviewed weekly during Risk Management meetings. All new staff will be trained on the new policy and procedures. During an observation on 3/27/15 from 6:50 am until 7:30 AM at the facility time clock, a Registered Nurse, Employee Z, was in-servicing all staff, that all residents are to be supervised when smoking. They were directed to inform a nurse if they see any resident smoking without supervision and no resident should have cigarettes or lighter, which are now locked. Also each staff member entering the building, for the shift, was observed to read and sign the facility 's " New Smoking Policy Alert. " The alert, dated 3/26/15, stated the following: As of today all residents will be supervised while smoking. Residents are not allowed to have cigarette lighters. Remove all lighters and turn them into immediate supervisor. All smoking related incidents must be immediately reported to your supervisor. Any non-compliance with the smoking policy must be immediately reported to the Risk Manager or your supervisor. All nurses must complete an incident report for all smoking related incidents. Also during the observation on 3/27/15 from 6:50 am until 7:30 AM, the nurse in-servicing first shift staff, checked each third shift staff as they clocked out to determine if they had been in-serviced on the new smoking alert. One hundred percent of the third shift staff reported they had, which was confirmed through a review of the employee checklist. Also during the observation on 3/27/15 at 7:05 AM, at the time clock, located next to the smoking patio, 6 smokers were observed going to the smoking patio. A Certified Nursing Assistant (CNA), was observed bringing out a locked container. She was observed to open the locked container, remove a cigarette for each smoker and light each resident's cigarette with a lighter from the container. She stated the Director Of Nursing had called her last evening and in-serviced her on the new smoking policy. She signed the " New Smoking Policy Alert " this morning at the time clock. Resident #216, was observed to be one of the 6 smokers, as was resident #44 (prior to 3/27/15 both were unsupervised smokers.) An interview with Resident #216 on 3/27/15 at 7:07 AM revealed he was now a supervised smoker and the facility kept his cigarettes and lighter. He further stated he "didn ' t like it and that when surveyors left, things would go back the way they were because the Governor smoked and he would take care of things." He stated the facility informed him of the new smoking policy last night and searched his room for lighters. Also during the observation on 3/27/15 at 7:09 AM an interview was done with the Resident Council President, resident #44, who had been an unsupervised smoker. He stated the facility asked him for his smoking materials last night and he gave them to the Nurse. He stated the Social Service Director was with the nurse and they informed him of the new smoking policy. He stated that he was told the facility would meet with the smokers, in the near future, to determine if the scheduled times of smoking met the residents ' needs. He was confident the facility and the smokers could work it out. Interview with third shift staff on 3/27/15 at 6:58 am, revealed they all were in-serviced last night that all residents are to be supervised when smoking and not to have lighters or cigarettes. An observation of the smoking patio on 3/27/15 at 7:05 PM, revealed 8 smokers on the smoking patio with 2 staff. Resident #216 was observed entering the smoking patio. The CNA was observed to open a container remove a cigarette and give it to resident #216. She was then observed to get a lighter out of the container and light his cigarette. She then returned the lighter to the container. The CNA, Employee J, stated she was trained in the new smoking policy last night. She stated all smokers are now supervised smokers and are not to keep their smoking materials, the facility keeps them. She noted she was to report to the Risk Manager all smoking incidents. An interview was attempted with resident #216 on 3/27/15 at 7:09 PM, regarding the facility meeting his smoking needs and he cursed the surveyor, blaming her for the change. An observation on 3/29/15 at 11:00AM, on the smoking patio, revealed 7 smokers on the patio with 1 staff member. The Activity Assistant, was observed to give each of the smokers a cigarette from the container and light their cigarettes. Resident #216 was among the smokers. At 11:04 AM the staff member stated she had been in-serviced on the new smoking rules on 3/27/15 when she clocked in. She stated all smokers are supervised and their smoking materials are to be kept in the container. She further stated she would report any smoking concerns to her supervisor. A Review of all the newly signed job descriptions and in- service trainings for all of the nursing staff and supervisory staff was completed on 3/29/15 at 3:00 PM. All staff had been trained in the smoking policy regarding assessments, reporting incidences, maintaining smoking materials and monitoring the residents while they smoke, as well as the Quality Assurance reviews. (cross reference to F323 and F520)

Based on administrative record review and interview, as well as an observation, it was determined the Quality Assessment (QA) committee failed to identify quality concerns related to the safety of all residents in regards to 1 of 8 unsupervised smokers (#216), and his repeated unsafe smoking behaviors and his refusal to comply with the facility directives for safe smoking, inside and outside of the building. The QAA committee failed to identify an ineffective screening tool and screening process which determined whether a resident should be considered eligible to smoke unsupervised and keep their smoking items (lighter, cigarettes) in their personal possession. The QAA committee failures placed the facility residents at risk for serious harm and death from fire and/or explosion. Immediate Jeopardy was also identified at: F 323, Scope and Severity (J) - Safe environment and supervision. F 490, Scope and Severity (J) - Administration uses resources effectively and efficiently Immediate Jeopardy was determined to exist beginning on 2/18/15 and removed on 3/29/15. The Nursing Home Administrator was informed of the immediate jeopardy on 3/27/15. Due to the validation of the facility's Allegation of Compliance the immediacy of the jeopardy was lifted on 3/29/15 and the scope/severity reduced to a D. Findings: A review of the clinical record for resident #216 showed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident had the following progress notes in their clinical record: A Social Services Note dated 6/4/14 stated: On 6/3/14 resident #216 was seen by staff outside giving a supervised smoker a cigarette. The note further stated resident #216 was reeducated on the smoking rules and was informed that his behaviors were against the rules. It further stated resident #216 agreed to not share cigarettes "and that he'd abide by the rules ". A Licensed Practical Nurse (LPN) Employee R note dated 7/30/14 stated: " Resident in room smoking at 8:30 AM, cigarette put out by staff. Informed resident he was not allowed to smoke in room due to policy, and he could harm self, all lighters and cigarettes removed from patient, pt stated I had all his cigarettes, notified adon of situation, resident is now a supervised smoker". A Licensed Practical Nurse (LPN) Employee S note dated 11/5/14 stated: " South wing nurse reported resident flicking his lighter inside the building. West wing nurse went to check on him. She found him inside the building by the patio door smoking. Resident said he was getting out of the wind to light his cigarette. Nurse asked resident to go outside and smoke ". A Social Services note dated 11/7/14 stated: On 11/6/15 resident #216 was spoken to " concerning an issue of smoking at the courtyard door, inside the building and of helping a supervised smoker to smoke. He tried to down play both issues, but I informed him emphatically that if he had another smoking infraction, he would be placed onto supervised smoking for his and other ' s safety. He stated to understand, but continued to give an excuse ". A Licensed Practical Nurse (LPN) Employee T note dated 12/19/14 stated: " Resident is on supervised smoking ". A Licensed Practical Nurse (LPN) Employee U note dated 1/1/15 stated: " Resident outside smoking a cigarette, unsupervised. Went outside and asked resident what he was doing he stated waiting for the smokers to come out, I informed him that ' s not for another 30 min. Resident stated okay and continuing smoking ". A Licensed Practical Nurse (LPN) Employee Q note dated 2/18/15 stated: " Resident went out for smoking (is unsupervised smoker) and was witnessed by CNA". CNA stated " she observed resident accidently catch his hair on fire and then quickly put it out". A Social Services note dated 3/23/15 stated: "He is an unsupervised smoker at this time, but must turn in his smoking materials to nursing staff at the conclusion of each smoke break ". A Social Service Note dated 3/25/15 stated: Resident #216 "is a completely unsupervised smoker at this time. He does not have to turn in smoking material following smoking episodes as stated in his 3/23/15 annual review note". An observation of resident #216 on 3/26/15 at 1:09 PM, on the outdoor smoking patio, showed the resident had taken a cigarette and a lighter out of his pocket and had lit a cigarette. At 1:16 PM, the resident was observed to drop his lit cigarette on the ground (concrete). At 1:17 PM, a cognitively impaired resident was observed walking across the patio, wearing only socks on her feet, barely missing the lit cigarette with her socked feet. Through a review of the facility " Internal Risk Management and Quality Assessment and Assurance " meeting signature page for June 25, 2014, July 30, 2014, August 27, 2014, September 24, 2014, October 29, 2014, November 26, 2014, December 31, 2014, January 28, 2015 and February 25, 2015 it was noted that the facility Social Service Director and the facility Risk Manager attended each of the facility monthly Internal Risk Management and Quality Assessment and Assurance meeting, as well as the Medical Director. During an interview with the Social Service Director on 3/29/15 at 8:40 AM, he stated he had attended each Internal Risk Management and Quality Assessment and Assurance meeting. He also stated that although he was aware of, and had counseled resident #216 on his unsafe smoking behavior, he had not brought that information to the committee. He stated his function on the committee revolved around resident ' s advance directives. During an interview with the facility Risk Manager and Committe chairperson, the Director of Nursing on 3/29/15 at 8:45 AM, she stated she had attended each Internal Risk Management and Quality Assessment and Assurance meeting. She further stated she tracks and trends facility " exception " reports. She further stated that each incident resident #216 had of unsafe smoking should have resulted in an " exception " report. She stated resident #216 would have been followed up on had exception reports been done and the " exception reports " " would have triggered QA ". During an interview with the Administrator, Corporate Director of Operations and Corporate Regional Nurse Consultant on 3/27/15 at 10:45 AM, the Corporate Director of Operations stated " Starting with the smoking assessment, we acknowledge the form may need revisiting. " He further stated " The assessment tool may have not been adequate. " During an interview, on 3/29/15 at 8:54 AM, with a Registered Nurse working from a medication cart, she stated she was not familiar with " exception reports " or why and when to complete one. During an interview with the facility Medical Director, on 3/29/15 at 10:49 AM, he stated he was unaware of unsafe smoking at the facility and it had not come up in QA. A review of the facility document entitled " Smoker Screen " for Resident #216, dated 3/14/14 and another dated 3/25/15 gave no evidence the facility included in its assessment the resident ' s psychiatric issues, behavior issues, or repeated non-compliance with facility rules for safe smoking. During an interview with the LPN Employee W, on 3/29/15 at 10:46 AM, who had completed his smoking screen dated 3/25/15, she stated she was trained by a supervisor on how to do smoking screens. " I can ' t remember them telling that (to consider behavior and past noncompliance). No, just basically if they were safe " at the time of the screen. The facility implemented the following measures that resulted in the Immediate Jeopardy being removed as of 3/29/14 at 3:00 PM and the scope and severity was reduced to a "D " . The facility provided a plan of correction action presented to the survey team on 03/29/15 at 3:00 PM. The plan was reviewed to verify implementation and operationalization. The plan included: " The facility has determined that the root cause of the problem was a failure of the identified nursing staff to properly assess/reassess residents who smoke. Further, the nursing staff failed to monitor a safe environment while residents were smoking along with the lack of reporting unsafe incidences to the appropriate department Supervisor or the Risk Manager. The facility failed to investigate incidents of unsafe smoking practice. It is the policy of this facility to have systems in place to ensure resident safety while they are smoking to prevent fires or explosions. When made aware of the smoking issues, the facility executed the following: 1. All ignition materials were immediately confiscated from all smoking residents (14) and stored at the nurse's stations on 3/26/15 by 9:00 PM. 2. The smoking policy was revised on 3/26/15 to designate that all residents will be supervised while smoking. 3. All residents who smoke were advised they must be supervised when smoking as of 3/26/15 at 9:00 PM. 4. All residents who smoke were rescreened 3/26/15. 5. All staff have been or will be inserviced on the new smoking policy, all residents that smoke will be supervised, completion of incident reports, investigation of reported unsafe incidences and observing for non-compliance with a report to the Risk Manager if any non-compliance with regards to the smoking policy is noted prior to working, by Nursing Administration. Any staff that was not able to receive the training as of the date of this allegation of compliance has been removed from the schedule and will not be permitted to work until they have received the appropriate training. 6. For Associates and Supervisors : All accidents and/or incidents regardless of nature, must be reported to your supervisor and /or Risk Manager immediately. Accidents/ incidents will be analyzed at monthly Quality Assurance meetings, to determine if the intervention needs revision. 7. For the Risk Manager: All accidents and/or incidents regardless of nature, must be reported to Director of Nursing and/or the Administraotr immediately. Accidents/ incidents will be analyzed at monthly Quality Assurance meetings, to determine if the intervention needs revision. 8. The Quality Assurance Committee met on 3/28/15 which resulted in an approval of a revised smoking policy. The committee members received training regarding the new policy at that time. Care plans of residents who smoke will be reviewed by the committee during the monthly committee meeting. The plans will be compared to any new incidences which will then require revisions. All smoking issues/concerns will be reviewed weekly during Risk Management meetings. All new staff will be trained on the new policy and procedures. During an observation on 3/27/15 from 6:50 am until 7:30 AM at the facility time clock, a Registered Nurse, Employee Z, was in-servicing all staff, that all residents are to be supervised when smoking. They were directed to inform a nurse if they see any resident smoking without supervision and no resident should have cigarettes or lighter, which are now locked. Also each staff member entering the building, for the shift, was observed to read and sign the facility 's " New Smoking Policy Alert. " The alert, dated 3/26/15, stated the following: As of today all residents will be supervised while smoking. Residents are not allowed to have cigarette lighters. Remove all lighters and turn them into immediate supervisor. All smoking related incidents must be immediately reported to your supervisor. Any non-compliance with the smoking policy must be immediately reported to the Risk Manager or your supervisor. All nurses must complete an incident report for all smoking related incidents. Also during the observation on 3/27/15 from 6:50 am until 7:30 AM, the nurse in-servicing first shift staff, checked each third shift staff as they clocked out to determine if they had been in-serviced on the new smoking alert. One hundred percent of the third shift staff reported they had, which was confirmed through a review of the employee check list. Also during the observation on 3/27/15 at 7:05 AM, at the time clock, located next to the smoking patio, 6 smokers were observed going to the smoking patio. A Certified Nursing Assistant (CNA), was observed bringing out a locked container. She was observed to open the locked container, remove a cigarette for each smoker and light each resident's cigarette with a lighter from the container. She stated the Director Of Nursing had called her last evening and in-serviced her on the new smoking policy. She signed the " New Smoking Policy Alert " this morning at the time clock. Resident #216, was observed to be one of the 6 smokers, as was resident #44 (prior to 3/27/15 both were unsupervised smokers.) An interview with Resident #216 on 3/27/15 at 7:07 AM revealed he was now a supervised smoker and the facility kept his cigarettes and lighter. He further stated he "didn ' t like it and that when surveyors left, things would go back the way they were because the Governor smoked and he would take care of things." He stated the facility informed him of the new smoking policy last night and searched his room for lighters. Also during the observation on 3/27/15 at 7:09 AM an interview was done with the Resident Council President, resident #44, who had been an unsupervised smoker. He stated the facility asked him for his smoking materials last night and he gave them to the Nurse. He stated the Social Service Director was with the nurse and they informed him of the new smoking policy. He stated that he was told the facility would meet with the smokers, in the near future, to determine if the scheduled times of smoking met the residents ' needs. He was confident the facility and the smokers could work it out. Interview with 3rd shift staff on 3/27/15 at 6:58 am, revealed they all were in-serviced last night that all residents are to be supervised when smoking and not to have lighters or cigarettes. An observation of the smoking patio on 3/27/15 at 7:05 PM, revealed 8 smokers on the smoking patio with 2 staff. Resident #216 was observed entering the smoking patio. The CNA was observed to open a container remove a cigarette and give it to resident #216. She was then observed to get a lighter out of the container and light his cigarette. She then returned the lighter to the container. The CNA, Employee J, stated she was trained in the new smoking policy last night. She stated all smokers are now supervised smokers and are not to keep their smoking materials, the facility keeps them. She noted she was to report to the Risk Manager all smoking incidents. An interview was attempted with resident #216 on 3/27/15 at 7:09 PM, regarding the facility meeting his smoking needs and he cursed the surveyor, blaming her for the change. An observation on 3/29/15 at 11:00AM, on the smoking patio, revealed 7 smokers on the patio with 1 staff member. The Activity Assistant, was observed to give each of the smokers a cigarette from the container and light their cigarettes. Resident #216 was among the smokers. At 11:04 AM the staff member stated she had been in-serviced on the new smoking rules on 3/27/15 when she clocked in. She stated all smokers are supervised and their smoking materials are to be kept in the container. She further stated she would report any smoking concerns to her supervisor. A Review of all the newly signed job descriptions and in- service trainings for all of the nursing staff and supervisory staff was completed on 3/29/15 at 3:00 PM. All staff had been trained in the smoking policy regarding assessments, reporting incidences, maintaining smoking materials and monitoring the residents while they smoke, as well as the Quality Assurance reviews. (cross reference to F323 and F490)