Every finding on record at Luxe at Jupiter Rehabilitation Center (The)

Based on observation, interview, and record review, the facility failed to coordinate care to ensure 2 of 3 sampled cognitively impaired residents, were appropriately accompanied and or able to be seen at scheduled appointments. Resident #2 had a scheduled new patient cardiology appointment and the facility failed to inform the resident representative of the appointment, failed to ensure needed pre-authorization as per his insurance, failed to send the resident appropriately clothed to ensure comfort, and failed to accompany the resident to the appointment. Resident #4, who was also cognitively impaired, was sent unaccompanied to a medical appointment at the Veteran Affairs (VA) Medical Center.The findings included:1) Review of the record revealed Resident #2 was admitted to the facility on [DATE] with a diagnosis of cognitive communication deficit. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale, indicating severe cognitive impairment. This same MDS also documented the resident had bilateral lower extremity impairment, needed the total assistance from staff for transfers, toileting, and lower body needs, while needing substantial to maximum assistance from staff for upper body needs. Review of the Transportation Appointment log for 10/03/25 documented Resident #2 had an appointment at 10:45 AM, with the name of the cardiologist and address of the cardiology office listed on the log. This log documented the resident's insurance was providing the transportation with a pick-up time of 9 to 9:30 AM. Review of the record lacked any order or progress note related to the cardiology appointment. Review of the resident's care plans revealed as of 08/27/25 the resident had a potential for ADL (activities of daily living) self-care deficit and may need dependent assistance for care; the resident had an indwelling urinary catheter; had an altered cardiovascular status; and was at risk for falls with a history of falls. During a phone interview on 10/22/25 at 10:33 AM, the cardiology office Practice Manager explained that Resident #2 had a new patient cardiology appointment scheduled for 10/03/25. The Practice Manager explained that when an appointment was made with a resident who resides in a facility, especially a cognitively impaired resident, their office staff explains the paperwork that is needed and that the resident must be accompanied by facility staff or a family member to assist with the resident and obtain needed paperwork. The Practice Manager explained Resident #2 was dropped off by a driver, who handed the receptionist paperwork, and started to leave. The driver was asked if anyone was accompanying the resident, and the driver stated he was just told to drop off the resident and left. The Practice Manager explained their receptionist was unable to reach anyone at the facility, and further explained she herself had called multiple times, speaking with the receptionist of the facility, who had no knowledge of the appointment, and that she was put through to staff on numerous calls but was never able to speak with any nursing staff. The Practice Manager stated she left messages requesting the facility to call back, which never happened. The Practice Manager explained that their office staff also reached out to the three family members listed on the resident's face sheet but did not get a response until after the resident left. A voice message was left by a family member of Resident #2, who apologized and stated she was unaware of the appointment. During the continued phone interview on 10/22/25 at 10:33 AM, when asked to describe what she saw with Resident #2, the Practice Manager stated she saved the video of the main waiting area for that date and pulled it up while on the phone. The Practice Manager described Resident #2 arriving at the cardiologist's office, wearing two hospital gowns and hospital socks, sitting in a wheelchair. The Practice Manager stated the resident was wearing oxygen and was constantly playing with his gown, exposing his adult brief. She noted the tubing of an indwelling urinary catheter as well. The Practice Manager stated her staff provided him with a paper cover, used for patients during diagnostic testing, but the resident crumpled it up and offered it to another resident in the waiting area. The Practice Manager stated the office thermostat was maintained at 72 degrees F. The Practice Manager concluded by explaining Resident #2 was never seen by the physician and was eventually picked up and taken back to the facility. She explained the information provided by the facility did not even have the correct transportation company listed, as she had called the listed company and they had no knowledge of the resident. Review of the 45-minute-long video of the main waiting area, provided by the cardiology office, revealed the following: Resident #2 was wheeled into the office and placed in front of the receptionist's window. The man who pushed him into the office, dropped off some papers, started to leave when he was apparently called back, motioned that he dropped off the resident, and left. There were five other patients in the waiting room at that time. Resident #2 was wearing two short-sleeved hospital gowns and hospital type socks. Resident #2 was left in front of the receptionist's window in his wheelchair for a couple of minutes. When two additional patients arrived to check in, an office staff member moved the resident out of the way of the receptionist's window and placed him near the chairs located near the entrance door. Resident #2 was observed continuously manipulating his hospital gown exposing his legs and adult brief. At approximately 5 minutes into the video, office staff provided a paper-type cover, spread it out, and covered the lap of Resident #2. The resident immediately crumbled it up and offered it to another patient sitting next to him. Throughout the 45-minute video, Resident #2 continued to play with his gown and the crumpled-up cover. The resident also was observed trying to manipulate the wheelchair locks. At about 20 minutes into the video, the resident threw the crumpled cover onto the floor. About 21 minutes into the video, a newly arrived person picked up the crumpled cover and handed it back to the resident, who was playing with his urinary catheter tubing at that time. At approximately 22 minutes, the resident was observed either blowing his nose and or wiping his face with the crumpled-up paper cover, that had just been on the floor. At 27 minutes into the video, Resident #2 was observed holding the urinary catheter bag and then dropped in onto the left footrest of his wheelchair, as the resident's left foot was between the two footrests. About 45 minutes into the video, Resident #2 was wheeled out of the cardiologist's office by two men, neither of which were the man who dropped him off originally and wheeled out of the office. Review of a letter dated 10/03/25 from the cardiology office to the facility documented in part that Resident #2 was not seen for his scheduled new appointment due to several critical issues including the failure to obtain prior authorization as per his insurance requirements; lack of accompaniment by a nurse, staff member, or family representation which led to the inability to complete required intake forms; and no valid form of identification. This letter also documented multiple efforts by both the front desk staff and office manager that were made and they were unable to reach the facility's head nurse, manager, or any of the three listed emergency contacts. This letter documented, For the safety and care of all patients, any patient who cannot advocate for themselves must be accompanied by a family member or facility staff (e.g., a nurse) during all medical appointments. This letter was signed by the cardiology office Practice Manager. Review of additional documents provided by the cardiology office revealed as per a call log, their staff attempted to call the facility 13 times on 10/03/25 between 10:24 AM and 11:30 AM. The cardiology office also provided a written voice message from the family member dated 10/03/25 at 2:25 PM, that apologized for not being available for the appointment but, I was not aware that he had a doctor's appointment today because the facility does not communicate well with me. During an interview on 10/22/25 at 12:40 PM, when asked the process for residents with physician appointments, Staff A, receptionist, stated the nurse's make the appointments and the receptionist from their memory care unit schedules all transportation services for the campus. Staff A explained if the resident had private insurance, they would use whatever the insurance provided, but if they don't have insurance the facility would provide transportation with their vehicle and Staff B, Transportation Driver. During an interview on 10/22/25 at 12:59 PM, when asked the process for residents with physician appointments, Staff B, Transportation Driver, explained the receptionist for the memory care unit sets up all the transportation and puts the paperwork in a binder at the receptionist's desk in the facility. The driver stated he checks the binder daily and arranges his day. When asked if staff accompany the residents, the driver stated, very occasionally. The driver volunteered he feels staff are needed as a resident may try to unbuckle or need some type of help. The driver is unsure who would make the decision for staff to accompany a resident. When asked if he transported Resident #2 to the cardiologist appointment on 10/03/25, the driver stated he did not recall the name or face and did not believe he transported that resident. During a phone interview on 10/22/25 at 1:44 PM, when asked about the process for resident appointments, Staff C, Licensed Practical Nurse (LPN) and direct care nurse for Resident #2 on 10/03/25, explained there were numerous ways she was made aware of appointments. The LPN stated she was informed by the resident and or family, the home board for communication, or the banner on the electronic record. The LPN explained she would let the Certified Nursing Assistant (CNA) know what time they needed to have the resident ready and would prepare and send paperwork with the resident, to include a face sheet and medication record. When asked if a resident was accompanied by staff to the appointments, the LPN stated they do not, but if there was a need it would be communicated to the Unit Manager. The LPN volunteered she had not had that situation. When asked if she recalled Resident #2, the LPN stated she did and that the resident was not alert and oriented, was very forgetful, and would not be appropriate to go to an appointment alone. When asked if she recalled the appointment for Resident #2 on 10/03/25, the LPN stated she had and had communicated previously with the resident's daughter about the need to go with the resident for appointments and the daughter had been doing so. The LPN stated the resident had a lot of appointments and she assumed the daughter would be there as the Unit Manager and schedulers usually coordinate that. The LPN stated, I guess that one's on me . I just thought she would be there but did not check with her about that appointment. When asked how Resident #2 was dressed for the appointment, the LPN stated he had no clothing at the facility, so she made sure the CNAs double-gowned him to make sure he was covered. When asked if there was any facility practice of supplying residents who have no clothing with clothing the LPN stated she was not aware of anything. During an interview on 10/22/25 at 3:07 PM, the Assistant Director of Nursing (ADON) explained she had been at the facility about three weeks and had known about the appointment issues with Resident #2 on 10/03/25. The ADON stated they spoke with staff involved who explained a process they thought was working, so the ADON started monitoring the appointments and identified additional resident appointment concerns. The ADON stated they put a new process in place just yesterday, 10/21/25. When asked the criteria for determining if a resident was able to go to an appointment independently, the ADON stated they would go primarily by the resident's most current BIMS score. The ADON further stated a resident would need a BIMS of 12 or 13 and higher to be considered safe to go to an appointment independently. When asked if a resident with a BIMS of 9 could independently go to an appointment, the ADON stated, No, that would not be appropriate. 2) A record review revealed that Resident #4 was admitted to the facility on [DATE]. His diagnoses included Unspecified Sequelae of Cerebral Infarction, Metabolic Encephalopathy, Mild Cognitive Impairment of Uncertain or Unknown Etiology, Cerebral Ischemia, Dysphagia, Pharyngoesophageal Phase (difficulty swallowing), Unsteadiness on Feet, and Chronic Post Traumatic Stress Disorder. Resident #4's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE], was 9. This indicated that Resident #4 had moderate cognitive impairment. A record review of the Resident #4's electronic medical record revealed a progress note entered on 10/22/25 at 8:23 am that documented Resident LOA for Apt VA follow up colonoscopy procedure. LOA stands for leave of absence. Apt VA stands for Appointment Veterans Affairs. During an interview on 10/22/25 at 9:00 am, Resident #4 was sitting alone outside the front door of the facility. He was wearing a Veteran's hat. He said he was waiting to be picked up to go to a follow-up exam. When he was asked how Veterans usually inquire about Veterans Affairs Benefits, Resident #4 said that there were monthly meetings held in the Senior Center. He explained that the person who ran the meetings was always helpful when he had any questions. A few minutes later, a CNA exited the facility. While she passed Resident #4, she told him she left his breakfast in his room. They exchanged some dialogue. Then, the CNA walked towards the parking lot and Resident #4 remained waiting in his wheelchair in front of the entrance to the facility. There were no facility employees outside with him after the CNA left. During an observation on 10/22/25 at approximately 10:30 am, Resident #4 was picked up for his appointment. The driver helped him get into the van. During interview with Resident #4 in his room on 10/22/25 at 4:58 pm, after he returned from his appointment, he explained that he was driven to the Veterans Affairs (VA) Medical Center by transportation provided by the VA. When asked the name of the transport company he said it was called: Special Modes for transportation. Resident #4 said They dropped me off. When asked how he got back to the facility, he explained that after appointments, there's a waiting spot that everyone knows, and I went to that spot, and they picked me up. When Resident #4 was asked if there was someone from the facility with him during the appointment, or a member of his family with him when he was there, he said No one accompanied me to the appointment. He added that his family did not live in this state.

Based on observation, interview, and record review, the facility failed to maintain dignity for 1 of 3 sampled residents, as evidenced by sending Resident #2, who was severely cognitively impaired, to a physician's appointment wearing two hospital gowns. He was left unattended for 45 minutes in the main waiting area of the physician's office, where 42 people entered during that time.The findings included:Review of the record revealed Resident #2 was admitted to the facility on [DATE] with a diagnosis of cognitive communication deficit. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale, indicating severe cognitive impairment. This same MDS also documented the resident had bilateral lower extremity impairment, needed the total assistance from staff for transfers, toileting, and lower body needs, while needing substantial to maximum assistance from staff for upper body needs.During a phone interview on 10/22/25 at 10:33 AM, the cardiology office Practice Manager explained that Resident #2 had a new patient cardiology appointment scheduled for 10/03/25. The Practice Manager explained that when an appointment was made with a resident who resides in a facility, especially a cognitively impaired resident, their office staff explains that the resident must be accompanied by facility staff or a family member to assist with the resident. The Practice Manager explained Resident #2 was dropped off by a driver, who handed the receptionist paperwork, and started to leave. The driver was asked if anyone was accompanying the resident, and the driver stated he was just told to drop off the resident and left. The Practice Manager explained their receptionist was unable to reach anyone at the facility, and further explained she herself had called multiple times, speaking with the receptionist of the facility, who had no knowledge of the appointment, and that she was put through to staff on numerous calls but was never able to speak with any nursing staff. The Practice Manager stated she left messages requesting the facility to call back, which never happened. The Practice Manager explained that their office staff also reached out to the three family members listed on the resident's face sheet but did not get a response until after the resident left. A voice message was left by a family member of Resident #2, who apologized and stated she was unaware of the appointment.During the continued phone interview on 10/22/25 at 10:33 AM, when asked to describe what she saw with Resident #2, the Practice Manager stated she saved the video of the main waiting area for that date and pulled it up while on the phone. The Practice Manager described Resident #2 arriving at the cardiologist's office, wearing two hospital gowns and hospital socks, sitting in a wheelchair. The Practice Manager stated the resident was wearing oxygen and was constantly playing with his gown, exposing his adult brief. She noted the tubing of an indwelling urinary catheter as well. The Practice Manager stated her staff provided him with a paper cover, used for patients during diagnostic testing, but the resident crumpled it up and offered it to another resident in the waiting area. The Practice Manager stated the office thermostat was maintained at 72 degrees F.Review of the 45-minute-long video of the main waiting area, provided by the cardiology office, revealed the following: Resident #2 was wheeled into the office and placed in front of the receptionist's window. The man who pushed him into the office, dropped off some papers, started to leave when he was apparently called back, motioned that he dropped off the resident, and left. There were five other patients in the waiting room at that time. Resident #2 was wearing two short-sleeved hospital gowns and hospital type socks. Resident #2 was left in front of the receptionist's window in his wheelchair for a couple of minutes. When two additional patients arrived to check in, an office staff member moved the resident out of the way of the receptionist's window and placed him near the chairs located near the entrance door. Resident #2 was observed continuously manipulating his hospital gown exposing his legs and adult brief. At approximately 5 minutes into the video, office staff provided a paper-type cover, spread it out, and covered the lap of Resident #2. The resident immediately crumbled it up and offered it to another patient sitting next to him. Throughout the 45-minute video, Resident #2 continued to play with his gown and the crumpled-up cover. The resident also was observed trying to manipulate the wheelchair locks. At about 20 minutes into the video, the resident threw the crumpled cover onto the floor. About 21 minutes into the video, a newly arrived person picked up the crumpled cover and handed it back to the resident, who was playing with his urinary catheter tubing at that time. At approximately 22 minutes, the resident was observed either blowing his nose and or wiping his face with the crumpled-up paper cover, that had just been on the floor. At 27 minutes into the video, Resident #2 was observed holding the urinary catheter bag and then dropped in onto the left footrest of his wheelchair, as the resident's left foot was between the two footrests. About 45 minutes into the video, Resident #2 was wheeled out of the cardiologist's office by two men, neither of which were the man who dropped him off originally and wheeled out of the office. During that video, 42 people were noted to enter the cardiology office through the door next to Resident #2.Review of additional documents provided by the cardiology office revealed as per a call log, their staff attempted to call the facility 13 times on 10/03/25 between 10:24 AM and 11:30 AM. The cardiology office also provided a written voice message from the family member dated 10/03/25 at 2:25 PM, that apologized for not being available for the appointment but, I was not aware that he had a doctor's appointment today because the facility does not communicate well with me.During an interview on 10/22/25 at 12:59 PM, when asked the process for residents with physician appointments, Staff B, Transportation Driver, explained the receptionist for the memory care unit sets up all the transportation and puts the paperwork in a binder at the receptionist's desk in the facility. The driver stated he checks the binder daily and arranges his day. When asked if staff accompany the residents, the driver stated, very occasionally. The driver volunteered he feels staff are needed as a resident may try to unbuckle or need some type of help. The driver is unsure who would make the decision for staff to accompany a resident.During a phone interview on 10/22/25 at 1:44 PM, when asked about the process for resident appointments, Staff C, Licensed Practical Nurse (LPN) and direct care nurse for Resident #2 on 10/03/25, explained there were numerous ways she was made aware of appointments. The LPN stated she was informed by the resident and or family, the home board for communication, or the banner on the electronic record. The LPN explained she would let the Certified Nursing Assistant (CNA) know what time they needed to have the resident ready and would prepare and send paperwork with the resident, to include a face sheet and medication record. When asked if a resident was accompanied by staff to the appointments, the LPN stated they do not, but if there was a need it would be communicated to the Unit Manager. The LPN volunteered she had not had that situation. When asked if she recalled Resident #2, the LPN stated she did and that the resident was not alert and oriented, was very forgetful, and would not be appropriate to go to an appointment alone. When asked if she recalled the appointment for Resident #2 on 10/03/25, the LPN stated she had, and had communicated previously with the resident's daughter about the need to go with the resident for appointments and the daughter had been doing so. The LPN stated the resident had a lot of appointments and she assumed the daughter would be there as the Unit Manager and schedulers usually coordinate that. The LPN stated, I guess that one's on me . I just thought she would be there but did not check with her about that appointment. When asked how Resident #2 was dressed for the appointment, the LPN stated he had no clothing at the facility, so she made sure the CNAs double-gowned him to make sure he was covered front and back. When asked if there was any facility practice of supplying residents who have no clothing with clothing the LPN stated she was not aware of anything. During an interview on 10/22/25 at 2:10 PM, when asked if she was aware Resident #2 was sent out to a physician appointment alone and in a hospital gown, the Social Services Director (SSD) stated, Oh no . we don't do that . it is just common sense.During an interview on 10/22/25 at 3:07 PM, the Assistant Director of Nursing (ADON) explained she had been at the facility about three weeks and had known about the appointment issues with Resident #2 on 10/03/25. When asked if she was aware of the way in which Resident #2 was dressed at the appointment, the ADON stated she was made aware after he had already left the facility and staff informed her they had not wanted him to miss the appointment. The ADON stated there was a lost and found with clothing that could have been used for Resident #2.

Based on observation, interview and record review, the facility failed to ensure sufficient staffing to provide timely and appropriate care and services as evidenced by verbal complaints from residents, family, and staff, which resulted in dignity concerns, the lack of call light response, wound care and activity of daily living (ADLs) care concerns. This concerned multiple residents, including Residents #256, #250, #72, #10, #23, #254, #11, #46, #62, #29, #27, #55, #73, #68, #45, #75, #83, #23, #251, #10, #50, and #85. The findings included: 1) The clinical record for Resident #256 indicated admission to the facility on [DATE]. The care plan initiated on 03/21/25 noted that Resident #256 had the potential for an ADL self-care deficit due to varying participation, fatigue, and chronic medical conditions. On 03/31/25, at 11:16 AM, Resident #256 was observed at the nursing station alongside two family members. He was noted to have facial hair that needed to be shaved, and he appeared confused. An interview with his wife revealed concerns about his care; she indicated that aides had refused to shave him when she requested it. She stated the aides told her they don't do that. Although she brought a razor to help shave him, the aide did not do a good job. 2) The clinical record revealed that Resident #250 was admitted to the facility on [DATE] with diagnoses including medically complex conditions. The admission assessment, reference date 03/28/25, recorded a brief interview for a mental status score of 15, which indicated Resident #250 was cognitively intact. This assessment recorded no mood or behavior concerns. This comprehensive assessment recorded under section GG for functional abilities and goals that Resident #250 required partial/moderate assistance with toileting hygiene, and toilet transfer. She needed supervision or assistance with personal hygiene. The care plan initiated on 03/26/25 indicated Resident #250 had an ADL self-care deficit related to ADL needs and participation varying, fatigue, and chronic medical conditions. Interventions included encouraging and assisting with all ADL tasks as indicated and tolerated by the resident, including bed mobility, transfers, toileting tasks, and personal/oral hygiene. On 03/31/25 at 11:55 AM, during an interview process with Resident #250, she revealed the aides don't usually show up when she calls, and when they finally do come, they have an attitude. She explained that last week, she needed her adult brief changed because all the diuretics she had taken, made her urinate a lot. She called an aide to change her and the aide said, I did it an hour ago. She said, I know, but I want to be changed again. The aide said, Well, I don't want to right now. Resident #250 explained that this morning (on 03/31/25), an aide came in; she asked her to change her adult brief, the aide said, I am the only one here right now, I will try to get to you sometime later, and left the room without changing her. 3) The clinical record revealed that Resident #23 was admitted to the facility on [DATE] with diagnosis including respiratory failure. The annual comprehensive assessment, reference date 12/18/24, recorded a brief interview for a mental status score of 15, which indicated Resident #23 was cognitively intact. This assessment recorded no mood or behavior concerns. This assessment recorded under the section GG for functional abilities and goals that Resident #23 required substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and chair/bed-to-chair transfer. She required partial/moderate assistance with upper body dressing and sitting to stand. The care plan revised on 12/24/24 indicated Resident #23 had an ADL self-care deficit related to chronic medical conditions, extensive assistance in more than five areas of ADLs. Interventions included encourage and assist with all ADL tasks as indicated and tolerated by the resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, and personal hygiene. On 03/31/25 at 12:04 PM, an interview was conducted with Resident #23; she stated, This is a pretty place, but the care is no good; the staff doesn't care about the residents. She expressed her concerns about the lack of staff, mentioning that it often takes the caregivers 45 minutes to an hour to respond to her call light. She added, The CNAs don't have time to take her outside even for 15 minutes. She doesn't get visitors often, so it would be nice to go outside occasionally. On 04/01/25, at 2:42 PM, a follow-up interview was conducted with Resident #23. She reiterated that when she calls for assistance to be changed, it took a long time for the staff to come-ranging from 45 minutes to an hour. She desired to be able to get out of bed at least three times a week, but when she requested this, the CNAs have informed her that they cannot assist her due to concerns about her safety if she falls. Some have also mentioned that there were not enough staff available to help them. On 04/04/25, the Director of Nursing was interviewed from 11:55 AM to 12:14 PM, with a follow-up discussion at 2:00 PM. During these sessions, the Director was made aware of the concerns residents and their families raised. Each problem was articulated to her. 4) A review of the clinical record revealed that Resident #73 was admitted to the facility on [DATE], with a diagnosis that included cancer. The admission assessment, dated 02/25/25, indicated a brief interview during which the resident scored 15 on the mental status assessment, which indicated she was cognitively intact. This assessment noted no concerns regarding mood or behavior. This assessment recorded under the section GG pertaining to functional abilities and goals, that Resident #73 required substantial to maximal assistance with tasks such as toileting hygiene, showering, and lower body dressing. She needed partial to moderate assistance with upper body dressing and transitioning from lying to sitting. Additionally, she required supervision or minimal assistance to roll from side to side. Resident #73 depended on staff for assistance putting on and taking off footwear, standing from a sitting position, and transferring between the chair and bed. The care plan, dated 02/26/25, indicated that Resident #73 experienced ADL (Activities of Daily Living) self-care deficit related to chronic medical conditions. Interventions included encouraging and assisting with all ADL tasks tolerated by the resident, such as locomotion, bathing, bed mobility, transfers, toileting, meals, and personal hygiene. The care plan also noted that Resident #73 was at risk for complications related to bowel and bladder incontinence. Suggested interventions included encouraging, offering, and assisting with toileting tasks and the use of adaptive equipment as needed. Incontinence care was to be provided with each incident, as tolerated. The plan further indicated that Resident #73 had pressure ulcers in the sacral and bilateral buttock areas and was receiving oral antibiotic therapy for bacteriuria (the presence of bacteria in urine). During an interview with Resident #73, she expressed concerns regarding insufficient staff availability, lack of assistance with ADLs, and inadequate responses to call lights. She stated, The facility is gorgeous, but I have concerns about communication. She explained that the volume of the call system in her room is too faint, making it difficult for her to hear staff and for them to hear her. She reported that staff often turned it off when she pressed the call button without responding or checking on her. She emphasized that her many life-threatening conditions necessitate prompt staff response. In one instance, she revealed that staff had left her sitting in a soiled adult brief for over an hour. On 04/03/25 at 1:22 PM, and again at 4:13 PM, a follow-up interview with Resident #73 was conducted. She reiterated that when she calls staff for incontinent care, their response time ranges from one hour to an hour and a half. She described an experience from the previous night where she activated the call light, but the staff turned it off without speaking or coming to her room to address her concerns. 5) On 03/31/25 at 10:31 AM, the nurse practitioner (NP) at the Emerald [NAME] unit told the surveyor, Staff F, a Registered Nurse, is brand new and was given a difficult assignment, which is not fair to this nurse. The surveyor informed the NP that she was not an employee of the facility but a state surveyor. 6) On 04/02/25 at 9:13 AM, a nurse, Staff I, was interviewed regarding staffing levels. She expressed concern about the facility's insufficient staffing. She mentioned that when the first floor is fully occupied, she is responsible for 21 residents at the Emerald [NAME] unit, while another nurse managed another 21 residents at the East unit. Staff I highlighted that the residents on the first floor have high acuity levels, (explained they require more complex and frequent care). She explained that multiple residents sometimes call for assistance simultaneously, making it difficult for her to promptly attend to their needs. This situation has led to delays in their care and medication administration. Sometimes, a single resident may require her attention for an extended period, leaving other residents waiting for help. In long-term care settings, resident acuity refers to the level of care and support a resident need based on their medical, physical, and cognitive conditions. High acuity indicates that residents have complex or chronic health issues, which require continuous medical supervision or frequent assistance with daily living tasks and often necessitate specialized care and resources. 7) On 04/04/25, at 2:57 PM, Staff E, a nurse, was interviewed. She stated that she primarily works on the first floor, specifically in the Emerald [NAME] unit, where staffing was inadequate, given the heavy assignments. She was responsible for 21 residents daily, most with high acuity levels. Staff E expressed concern that some of the residents were not ready for a skilled nursing facility and others would be better suited for memory care due to behavioral issues. During the interview, she mentioned having to keep Resident #256 at the nursing station to monitor him due to his behavioral issues and fall risk concerns, all while also administering medications to other residents. Often, she had to watch three fall-risk residents at the nursing station, and when she left the unit for medication administration, no one was available to supervise them. She noted that finding Certified Nursing Assistants (CNAs) to help watch residents was challenging, as they usually occupied with their tasks in the rooms. Staff E expressed frustration with the facility's staffing practices, stating, If they were to staff by acuity, we would have more help. At times, only three aides were assigned to the first floor, which complicated care. When the first floor was full, each CNA had 14 residents to manage. On some days, there was no wound care nurse available, so she had to take on wound care tasks, medication administration through G-tubes, intravenous treatments, and admissions. Additionally, she noted that residents had frequently complained about the lack of staffing. She reported this issue to the previous unit manager on the first floor, who voiced her frustration of being overwhelmed, and stated,the unit manager couldn't take it anymore, and resigned. Staff E mentioned that there was no unit manager on the first floor right now. She also pointed out that sometimes, only one nurse was responsible for 30 residents on the second floor, making timely care difficult. She stated, Then the managers wonder why the residents complain about waiting so long before someone attends to them. 8) On 04/04/25 at 3:43 PM, a phone interview was conducted with Staff F, a nurse. She explained she had 21 residents sometimes, and it was challenging to attend to their needs on time; when a resident called, the expectation was to respond immediately, and if she did, it could cause a delay in the medication administration and care. There were some fall-risk residents on the first floor at the Emerald unit. Those residents were placed at the nursing station to be monitored by the nurse. Staff F stated, We were supposed to have a CNA staying at the nursing station to watch those residents, but most of the time, the CNAs were busy with their tasks in the rooms. She further stated, Staffing was short at the facility. She added that when she had to move to administer medication to the residents in their rooms, they didn't have people to watch the fall-risk residents at the nursing station, and they could get up and fall. She explained that the first floor was primarily the rehab unit. Stated, Everyone knows the first floor was difficult, especially at the Emerald [NAME] unit; this assignment was challenging. They usually assigned two nurses on the first floor, one for each unit (Emerald [NAME] and East), and since we don't have a unit manager on the first floor, it was more complex; when the unit manager was there, it helped. When a resident had an emergency or complaint, the unit manager could handle the resident; now, the floor nurse had to do everything. 9) On 04/04/25, at 3:58 PM, an interview and review of staffing assignments and schedules were conducted with the Staff Coordinator. She indicated that the first floor was supposed to be staffed with four CNAs and two nurses, while the second floor was meant to have four CNAs and two nurses. The second floor typically had the lowest number of residents, usually has the lowest amount of staffing based on census number. The third floor was to be staffed similarly: four CNAs and two nurses. The staffing coordinator explained, I don't staff by acuity, only by census. She mentioned that the clinical managers would inform her if staffing adjustments based on acuity were necessary. During the interview, she defined acuity as high-risk and very ill residents. She confirmed she often had high-risk residents on the first floor. If she overstaffed the facility, she needed to explain to the clinical management why. The clinical managers were responsible for notifying her if additional staff were required on a particular floor. The first floor frequently housed many residents requiring immediate rehabilitation services, and residents with respiratory conditions such as chronic obstructive pulmonary disease (COPD). She noted that nurses and CNAs often requested more staff, and she communicated this need to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). During the interview, specific days were selected for review, covering the period from March 2, 2025, to March 29, 2025. It was noted that on March 23, 2025, the staffing for the first floor during the first shift (7 AM - 7 PM) included two nurses and four CNAs, while the second shift (7 PM - 7 AM) had two nurses and three CNAs. For the second floor, the first shift had two nurses and three CNAs, and the second had two nurses and two CNAs. On March 26, 2025, on the first shift the first floor had two nurses and four CNAs; and the second floor had two nurses and three CNAs. On the second shift, first floor had one nurse and three CNAs; and the second floor second shift had one nurse, a supervisor, and two CNAs. On March 29, 2025, the first floor once again had two nurses and four CNAs during the first shift, and the second floor's second shift had two nurses and three CNAs. 25404 10) An observation of wound care was made on 04/02/25 beginning at 10:06 AM. The wound care nurse was accompanied by the regional nurse for that facility. When asked if she usually helps out with the wounds, the Regional nurse stated that she did as she was in the building Monday through Thursday. During an interview on 04/03/25 at 11:22 AM, when asked if she normally has a second staff member to assist her with wound care, especially for the residents who are totally dependent upon staff for their care, the wound care nurse shook her head no. When asked if the regional nurse who helped her the previous day had ever helped her, the wound care nurse stated, not really. When asked if she does the wounds by herself, the wound care nurse stated, Yes, but they are supposed to be getting me someone to help on the days the wound care physician is in the building for rounds. During a supplemental interview on 04/03/25 at 2:19 PM, when asked if she does the wound care for all the wounds in the facility, the wound care nurse stated she did all the care except for the residents with surgical wounds. When asked if she works 7 days a week, she stated no and explained she worked Monday through Friday, and she believed the weekend supervisor completed the care over the weekends, but she was not sure. When asked how she completes the care for the residents who are totally dependent upon care by staff, the wound care nurse stated, It's hard. There are not enough CNAs (Certified Nursing Assistants) and they are busy. I usually have to tell them to come get me when they are ready to do care or have time to help me, which means I'm all over the place. The wound care nurse stated she has requested assistance for the wound care. Review of the list of residents with wounds revealed there were 18 current residents with wounds that would be treated by the wound care nurse, including sampled Residents #254, #11, #46, #62, #29, #27, #55, #73, #68, and #45. Of those 18 residents, 5 of the 18 residents had between 2 and 4 wounds each. 11) During the survey conducted from 03/31/25 through 04/04/25, nine residents complained of cold food, including Residents #75, #83, #23, #251, #10, #29, #50, #27, and #85. Some of the residents stated the food sits in the carts out in the hallways too long before being delivered. Refer to citation at F804. During an interview on 04/04/25 at approximately 2:00 PM, when told of the numerous cold food complaints, the Registered Dietitian (RD) stated she was aware of the complaints and had done numerous temperatures in the kitchen with no concerns identified. The RD agreed it was more than likely due to the trays sitting in the hallway for an extended time, and possibly due to a staffing issue.

Based on interview and record review, the facility failed to ensure residents were treated with dignity during activities of daily living (ADLs) care and failed to provide care upon request for 7 of 33 residents reviewed for dignity (Residents #254, 251, 256, 55, 83, 250, and # 23). The findings included: 1) The clinical record indicated that Resident #254 was admitted to the facility on [DATE] with a diagnosis that included depression. The admission assessment, dated 03/09/25, included a brief interview with a mental status score of 14, which indicated that Resident #254 was cognitively intact. The assessment noted mood symptoms such as feeling down, depressed, or hopeless but recorded no behavioral symptoms. On 03/31/25, at 9:41 AM, during an interview with Resident #254, she stated that the staff had spoken foreign languages in her room during care, which made her uncomfortable as she did not understand what they were saying or doing. 2) The clinical record revealed that Resident #251 was admitted to the facility on [DATE], and 03/23/25, with diagnoses including medically complex conditions. On 03/31/25, at 10:55 AM, Resident #251, alert and coherent, reported, the staff was rough and pushy during care. They are not caring and are disrespectful. They do not greet him when they encounter him. They don't say hello. They do not work well together. 3) The clinical record for Resident #256 indicated admission to the facility in 03/20/25. The care plan initiated on 03/21/25 noted that Resident #256 had the potential for an ADL self-care deficit due to varying participation, fatigue, and chronic medical conditions. On 03/31/25, at 11:16 AM, Resident #256 was observed at the nursing station alongside two family members. He was noted to have facial hair that needed to be shaved, and he appeared confused. An interview with his wife revealed concerns about his care. She indicated that aides had refused to shave him when she requested it. She stated the aides told her they don't do that. Although she brought a razor to help shave him, the aide did not do a good job. 4) The clinical record for Resident #55 documented admission to the facility on [DATE] and 02/04/25, with diagnoses including anxiety and depression. On 02/14/25, the quarterly comprehensive assessment recorded a brief interview with a mental status score of 15, indicating that Resident #55 was cognitively intact. The assessment noted no mood symptoms but did report verbal and behavioral symptoms. On 03/31/25, at 11:29 AM, during an interview with Resident #55, he expressed that staff sometimes do not speak English while providing care, which he found rude. He wished he could understand what they were saying. 5) The clinical record for Resident #83 indicated admission to the facility on [DATE], with diagnoses including anxiety and depression. The admission assessment, reference date 02/08/25, recorded a brief interview with a mental status score of 12, indicating that Resident #83 was cognitively intact. The assessment did not note any mood or behavioral symptoms. On 03/31/25, at 11:41 AM, during an interview with Resident #83, she stated the staff has a nasty attitude. They argue while caring for her and do not work together. 6) The clinical record revealed that Resident #250 was admitted to the facility on [DATE] with diagnoses including medically complex conditions. The admission assessment, reference date 03/28/25, recorded a brief interview for a mental status score of 15, which indicated Resident #250 was cognitively intact. This assessment recorded no mood or behavior concerns. This comprehensive assessment recorded under section GG for functional abilities and goals that Resident #250 required partial/moderate assistance with toileting hygiene, upper body dressing, rolling left and right, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. She required substantial/maximal assistance with showering/bathing, dressing her lower body, and putting on/taking off footwear. She needed supervision or assistance with personal hygiene. The care plan initiated on 03/26/25 indicated Resident #250 had an ADL self-care deficit related to ADL needs and participation varying, fatigue, and chronic medical conditions. Interventions included encouraging and assisting with all ADL tasks as indicated and tolerated by the resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, and personal/oral hygiene. On 03/31/25 at 11:55 AM, during an interview with Resident #250, she revealed the aides don't usually show up when she calls, and when they finally do come, they have an attitude. She explained that last week, she needed a diaper change with all the diuretics she had taken, makes her pee a lot. She called an aide to change her and the aide said, I did it an hour ago. She said, I know, but I want to be changed again. The aide said, Well, I don't want to right now. She filed a complaint with the facility. They did not talk to her about the resolution. Resident #250 explained that this morning (on 03/31/25), an aide came in; she asked for a diaper change, the aide said, I am the only one here right now; I will try to get to you sometime later, and left the room without changing her. She finally got up and went to the bathroom by herself. 7) The clinical record revealed that Resident #23 was admitted to the facility on [DATE] with diagnosis including respiratory failure. The annual comprehensive assessment, reference date 12/18/24, recorded a brief interview for a mental status score of 15, which indicated Resident #23 was cognitively intact. This assessment recorded no mood or behavior concerns. This comprehensive assessment was recorded under the section GG for functional abilities and goals. Resident #23 required substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and chair/bed-to-chair transfer. She required partial/moderate assistance with upper body dressing and sitting to stand. She needed supervision or touching assistance to roll left and right and sitting on the side of the bed. The care plan revised on 12/24/24 indicated Resident #23 had an ADL self-care deficit related to chronic medical conditions, extensive assistance in more than five areas of ADLs. Interventions included encourage and assist with all ADL tasks as indicated and tolerated by the resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, and personal hygiene. On 03/31/25 at 12:04 PM, an interview was conducted with Resident #23. She stated this is a pretty place, but the care is no good; the staff doesn't care about the residents. She explained there was no hot water in her bathroom. One time, during care, a certified nursing assistant (CNA) poured cold water on her; it took her breath away; she was shocked, and she stopped breathing for a few seconds. At 12:20 PM, the surveyor checked the water temperature of the shower and sink. The surveyor let the water run until 12:23 PM (about 3 minutes); the surveyor placed her hand under the running water; there was no hot water. On 04/01/25, at 11:46 AM, the surveyor turned on the water and let it run until 11:49 AM; the water was cold. On 04/04/25, the Director of Nursing was interviewed from 11:55 AM to 12:14 PM, with a follow-up discussion at 2:00 PM. During these sessions, the Director was made aware of the concerns residents and their families raised. Each problem was articulated to her. On 04/04/25 at 2:11 PM, an interview was conducted with Staff E, a nurse. During the discussion, Staff E expressed concerns regarding instances in which staff members communicated in a foreign language in the presence of residents. She noted that this practice occasionally makes her uncomfortable, leading her to believe the conversation may be about her.

Based on observations, interviews, and record reviews, the facility failed to provide food that was palatable and at acceptable food temperatures for 9 residents (Residents #75, #83, #23, #251, #10, #29, #50, #27, and #85) out of 10 residents investigated for food concerns. This had the potential to affect 111 out of 112 residents on PO (by mouth) diets. The findings included: 1) A record review revealed that Resident #23 was admitted to the facility on [DATE]. Her diagnoses included Acute Respiratory Failure with Hypoxia, Sjogren syndrome with Lung Involvement, Irritable Bowel Syndrome, and Gastro-esophageal Reflux Disease. Her diet order dated 03/31/25 was for a Regular diet. This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE] was 15. This indicated that Resident #23 was cognitively intact. During an interview with Resident #23 on 04/02/25 at 12:30 PM, when asked how her lunch was today, Resident # 23 said that the food was good today for a change. The green beans were cooked enough, and she could eat them. Usually, they were crunchy. Resident #23 also said that the temperature of the food was hot, and most of the time it wasn't hot. 2) A record review revealed that Resident #75 was admitted to the facility on [DATE]. His diagnoses included Heart Failure, Respiratory Failure, Gastro-esophageal Reflux Disease, and he was at risk for malnutrition. Resident #75's diet order as of 03/31/25 was for a Regular diet, with Regular texture, and thin consistency fluids. This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE] was 15. This indicated that Resident #75 was cognitively intact. During an interview on 03/31/25 at 4:30 PM, Resident #75 complained and said that every meal was served cold. He added that he voiced his complaint to the nursing aides, to nurses, and to the management. During an interview with Resident #75 on 04/03/25 at 9:39 AM, the resident said he was served scrambled eggs, waffles soaked in water, grits, and bacon for breakfast. He explained that every item on his meal tray was cold. 3) A record review revealed that Resident #83 was admitted to the facility on [DATE]. Her diagnoses included Fracture of Shaft of Left Femur, Atherosclerotic Heart Disease, and Anxiety Disorder. Her diet order dated 02/01/25 was for a Regular diet, that was Regular texture, with Thin consistency fluids. During an interview conducted on 03/31/25 at 11:41 AM, Resident #83 voiced concern about the food. She said it was not served hot. During an interview conducted on 04/03/25 at 9:45 AM, the resident said she didn't eat breakfast at all. She added that it was cold even after they reheated it. 4) A record review of Resident #251 revealed that he was admitted to the facility on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive, and Muscle Wasting to Multiple Sites. This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE] was 14. This indicated that Resident #251 was cognitively intact. During an interview with Resident #251 on 04/01/25 at 5:15 PM, the resident said that it bothered him when he received cold cabbage, cold meat, or anything that was supposed to be eaten hot. 5) During an interview with Resident #251 on 04/03/25 at 9:50 AM, when asked how his breakfast was this morning, he replied that he loved eggs, but the food was tasteless. Everything was so bland. He said he sent food back to the kitchen and when they brought him a new plate of food, the food was still tasteless. Resident #251 said that he could not eat food without spices. He compared food without spices to eating grass. 6) A test tray was requested from the kitchen on 04/02/25 at 1:20 PM, when the dietary aides had almost finished loading up the meal trays onto the cart for delivery to the 3rd floor. The two surveyors and the RD followed the meal cart to the 3rd floor. The test tray was tested on [DATE] at 1:55 PM after the last resident on the 3rd floor was served. The thermometer was calibrated. The temperatures of the foods were taken, and the foods were tasted. The food was warm. The temperature was acceptable to the surveyors. The surveyors tasted pasta, meat sauce, green vegetables, and peaches. The taste of the pasta and the taste of the green vegetables was unsatisfactory. These foods may have tasted better if they had some seasoning added. The taste of the meat sauce and the peaches was acceptable. 25404 7) Review of the record revealed Resident #10 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale. During an interview on 03/31/25 at 3:33 PM, when asked about the care and services at the facility, Resident #10 stated his only concern was the food. The resident explained that he eats breakfast in his room and that the food trays sit out in the hall way too long. During a supplemental interview on 04/01/25 at 9:48 AM, Resident #10 stated the breakfast was an hour late and still cold. When asked what he had, Resident #10 stated, The same thing I always get . eggs and a piece of cold bread thrown on the plate that they call toast. On 04/02/25 at 9:17 AM, Resident #10 had just received his breakfast meal. He lifted the covering and stated, We've never had this before (as he held up the large portion of bacon). When you are not here I get eggs over easy and a piece of cold bread. 8) Review of the record revealed Resident #27 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact as evidenced by a BIMS score of 14, on a 0 to 15 scale. During an interview on 04/02/25 at 9:59 AM, when asked the temperature of her breakfast, Resident #27 stated, barely warm. 9) Review of the record revealed Resident #29 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, on a 0 to 15 scale, indicating he was cognitively intact. During an interview on 03/31/25 at 11:29 AM, when asked about the food, Resident #29 stated the food was always cold. The resident stated he had complained about it and they told him they were going to get some type of warmer in the kitchen. Resident #29 stated if they got one, the food is still cold. The resident stated he eats in his room. On 04/03/25 at 1:59 PM, when asked about the temperature of his lunch, Resident #29 stated, Not hot, but better. The resident volunteered, I suspect the food is not sitting out in the hall as long this week since you all are here (referring to the State survey team). Observations during the survey week revealed Resident #29 was usually one of the last resident's served, if not the last. 10) Review of the record revealed Resident #50 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident was cognitively impaired with a BIMS score of 03, on a 0 to 15 scale. Although Resident #50 was cognitively impaired, the resident was conversational and able to make his needs known. On 04/02/25 at 9:39 AM, when asked the temperature of his food, Resident #50 stated, It's barely warm. 11) Review of the record revealed Resident #85 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident was cognitively intact with a BIMS score of 12. During an interview on 03/31/25 at 3:38 PM, Resident #85 stated his food was always cold. The resident stated he eats all of his meals in his room. On 04/03/25 at 2:04 PM, Resident #85 stated he had received his meal about 5 minutes prior. The resident stated hot tea was not even warm and potatoes were luke warm. The resident volunteered that his eggs that morning were cold. 12) During an interview on 04/04/25 at approximately 2:00 PM, when told of the numerous cold food complaints, the Registered Dietician (RD) stated she was aware of the complaints and had done numerous temperatures in the kitchen with no concerns identified. The RD agreed it was more than likely due to the trays sitting in the hallway for an extended time, and possibly due to a staffing issue.

Based on observations, record reviews and interviews the facility failed to follow their policy for loss of hot water and ensure sufficient hot water was available to the residents in their rooms and showers for 8 of 34 sampled residents (Residents #29, #27, #13, #301, #302, #303, #68, #23). The findings included: 1) Review of a policy titled, Water Temperatures Safety Checks documented that the facility will make every effort to provide water tempeatures between 105 and 115 degrees Fahrenheit. Water temperatures are checked every morning at different locations in the facility and documented. There is no date or policy number for this policy. Review of a policy titled, Loss of Hot Water revised 01/25 documented the facility is committed to maintaining a safe and comfortable environment for all residents. In the event of a hot water loss, prompt actions will be taken to ensure resident needs are met ad compliance with Florida regulations is maintained. Procedure: 1. Immediate response; Assessment: Upon discovering a loss of hot water, the maintenance supervisor will assess the cause and estimated time for repair. 2. Personal Hygiene: Use alternative methods such as pre-warmed water from external sources or no-rinse bathing products to maintain hygiene. 3. Regulatory Compliance: Water temperature are maintained between 105 to 115 degrees F. 4. Residents and families: Provide timely updates regarding the situation and expected resolution. 5. Maintain detailed records of the outage, actions taken and communications made. 2) On 04/01/25 at 8:50 AM the surveyor randomly began checking water temperatures from the faucet using a dial stem thermometer' (after the thermometer was calibrated). The following rooms had temperatures that were below 105 degrees. room [ROOM NUMBER]- 80 degrees room [ROOM NUMBER]- 80 degrees room [ROOM NUMBER]- 80 degrees room [ROOM NUMBER]- 90 degrees room [ROOM NUMBER]- 80 degrees room [ROOM NUMBER] 90 degrees The Administrator showed the surveyor several texts regarding the hot water issue. One text was dated 02/25/25, which said, FYI we are still having issues, no hot water on the 3rd floor. Another text dated 03/20/25, from the Maintenance Director, said we have hot water issues here in the SNF (Skilled Nursing Facility). Unit 127-138. It takes a long time for the water to get hot. We had to run the water for 45 minutes in each room to get hot water. The administrator also gave the surveyor several texts wanting to know why they are getting complaints of no hot water. Review of an email dated 01/30/25 from previous Maintenance Director stated, the circulation pump that pushes hot water to the west side of the third floor is down. I called Roto Rooter which came out, the tech called a few parts shop but they do not have in storage, will have to call a few plumbing companies to see if they have in stock. On 01/31/25, The circulation pump on the third floor is being worked on. Ordering pump today and will be repaired as soon as it arrives. A review of a Resident Council grievance on 01/30/25 documented that a resident on the third floor complained that there was no hot water for days. Under resolution, dated 02/10/25, it documented that a pump was replaced. 3) Review of Resident #302's medical records revealed resident was admitted on [DATE]. He has diagnoses to include Visual Loss, Hypertension, Type II Diabetes Mellitus, Delirium, COPD (Chronic Obstructive Pulmonary Disease). His BIMS score was not completed since he was a new admission, but the resident was alert, oriented and able to answer all questions by the surveyor. During an interview on 03/31/25 at 1:15 PM, Resident #302 stated that the water is cold, he can't take a shower or shave. The surveyor felt water and it was cold, ran it for several minutes and it did not get warm. 4) Review of Resident #301's medical records revealed that the resident was admitted [DATE] and was discharged [DATE]. Resident stated that the water is cold in her room and she can't shower or wash up. 5) Review of Resident #68's medical records revealed that the resident was admitted to the facility on [DATE] with diagnoses to include Multiple Sclerosis, Essential Hypertension, Spondylolosthesis, Fusion of the Spine-Lumbar Region, Major Depressive Disorder and Anxiety. During an observation and an interview with Resident #68 on 04/01/25 at 9:20 AM, the surveyor went into resident's room and observed the water running with no one near the faucet. The resident stated she didn't do it, the CNA (Certified Nursing Assistant) did it. She is waiting for the CNA to change her. Staff P, CNA came in and stated she turned the water on, she has to let it run for 15-45 minutes until it gets warm. She thinks they told her it was a water pump that was bad. 6) Review of Resident #303's records revealed that Resident #303 was admitted to the facility on [DATE] and discharged [DATE]. The resident had diagnoses to include Type II Diabetes Mellitus, Hypertension, and Dysphagia and Aphasia Following a Cerebral Infarction. During an interview on 04/04/25 at 12:50 PM with Staff H, CNA she was asked if she had taken care of Resident #303 before. She stated yes. She was then asked if this resident ever had any complaints and she said yes, he complained the water was not hot. The surveyor asked what did she do. She stated she had notified the Maintenance Director. 7) On 03/31/25 at 12:04 PM Resident # 23 voiced her concerns to a surveyor. She stated she has no hot water. The staff poured cold water on her during care, it took her breath away, she was shocked. She hasn't been able to take a shower due to the lack of hot water. At 12:20 PM the surveyor proceeded to check the water (shower and sink) and let the water run until 12:23 PM, and there was no hot water. 8) During an interview on 04/02/25 at 10:17 AM with Resident#3, who had a BIMS of 15, she stated that there is no hot water, you can't take a shower, and she was not sure how long it has been out. 9) During a telephone interview on 04/03/25 at 10:08 AM with the owner of Plumbing Company he stated a supervisor had been onsite as well as a few of their plumbers to service and inspect the nursing home facility. He stated that the facility does have hot water but it is taking too long to reach their rooms. We found a few check valves for cold water supply not functioning. The problem is the disproportion of cold water getting into the water supply piping. I don't remember replacing a circulation pump. The first service we did was changing the check valves. We are still replacing them. We have replaced 4 check valves and the mixing valve needs to be replaced. I have only been on this project since the middle of February. I wasn't doing this in January. A month ago we did check valves at the ALF( Assisted Living) but this week we have been doing checks valves at the SNF. Did 4 checks valves at SNF waiting on mixing valves to come in. The check valves were faulty and the cold water was over powering the hot water to come through. 10) During an interview on 04/04/25 at 10:27 AM with the Maintenance Director he stated that this is the first week that the plumbing company has been here. I've been here for 3 weeks and the second day I found out that there was an issue with water but on the ALF side. On the SNF side it was this past Saturday 03/30/25 that hot water was not up to correct temperatures. Randomly I do weekly temps in different rooms on each floor. It depends maybe 4-5 on each floor, depends on time of day and if I don't get pulled away. I document that. I get a weekly task and monthly task. Not sure why the higher number rooms are having an issue. The surveyor asked about the text that he sent on 03/20/25 but he had no response. The surveyor reviewed the employee roster and showed that the Maintenance Director's hire date was 02/11/25. 25404 11) Review of the record revealed Resident #27 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview and observation 03/31/25 at 10:51 AM, when asked if there was an issue with the provision of hot water, Resident #27 stated, They haven't had hot water for about a month. Have you ever taken a cold shower? It's not fun! The surveyor ran the hot water faucet in the resident's bathroom sink, which was located next to the shower, for several minutes, and the water did not get warm. 12) Review of the record revealed Resident #29 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a scale of 0 to 15, indicating the resident was cognitively intact. During an interview on 03/31/25 at 11:28 AM, when asked if there was any problem with the provision of hot water, Resident #29 stated, There is no hot water. It has been an issue for at least two months. The resident then volunteered, about two or three weeks ago a nurse came in and told me, good news they are coming to fix the hot water, but it didn't get fixed. Resident #29 confirmed direct care staff knew about the cold water as the aides would comment about it during care. During an interview on 04/02/25 at 6:06 PM, when asked about any problems with hot water, Staff J, Certified Nursing Assistant (CNA) stated, They fixed it today. When asked if there were issues previously, the CNA would not respond directly, but kept saying, they fixed it. When told a resident had said there had been no hot water for a month or two, the CNA stated, No, maybe two weeks. During an interview on 04/02/25 at 6:09 PM, when asked if there had been any problems with the hot water, Staff K, Licensed Practical Nurse (LPN) stated, They were here today and fixed it. When asked if it had been a problem in the past, the LPN would not say. When told residents were saying there have been problems for a month or two, the LPN stated, I heard it happened before, and they fixed it. I really don't have any more information than that. 50895 13) A record review revealed that Resident #13 was admitted on [DATE] with diagnoses that included Cerebrovascular Accident, Hemiplegia or Hemiparesis. The brief interview of mental status score per the minimum data set completed on 01/14/25 was 14. This indicated that Resident #13 was cognitively intact. During an interview on 03/31/25 at 03:37 PM, Resident #13 complained about no hot water. He said he needed hot water to shower and to shave. When asked for how long this problem had occurred, Resident #13 said it felt like there hasn't been hot water for a year. During an observation on 03/31/25 at 03:40 PM, the surveyor turned on the hot water and let the water run for approximately three minutes. The water felt a little warm and then it felt cool.

Based on observation, interview, and record review, the facility failed to honor food preferences for 5 of 10 sampled residents, Residents #27, #29, #44, #50, and #85, who had food complaints, as evidenced by the failure to follow the meal ticket and menu. The findings included: 1) Review of the record revealed Resident #27 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale. Review of a dietary progress note dated 02/04/25, documented in part, Resident #27 would like to update her food preferences, to include a chef garden salad with ranch dressing as an entree every Monday, Wednesday, and Friday. A subsequent progress note dated 02/18/25 documented the resident was happy with the updated food preferences. Review of a dietary assessment by the Registered Dietitian (RD) on 02/27/25 revealed the resident now had wounds and nutritional interventions to include fortified foods was added. During an interview on 03/31/25 at 10:40 AM, Resident #27 stated she had lost 25 pounds and was too thin. Stated she recently spoke with someone and they added a chef salad, which she stated she really enjoyed. The resident showed the surveyor a recent menu ticket that documented the chef salad. This ticket also documented the intervention of fortified foods. When asked about oatmeal at breakfast, the resident stated she did not like their oatmeal because they put something in it that makes it gummy. Resident #27 also had the preference of whole milk at every meal, further stating, I don't always get it, but I'm happy if I get it twice a day. Resident #27 further stated they keep bringing her coffee that she does not like, she prefers hot tea, referring back to her menu ticket. An observation of Wednesday's lunch meal on 04/02/25 at 1:58 PM revealed Resident #27 did not get her chef salad. Photographic evidence obtained. When asked if she wanted to request one now, the resident provided half of her leftover salad from a previous day and stated, I knew I wouldn't get it so I saved this. An observation on 04/03/25 at 1:56 PM revealed a chef salad on the tray of Resident #27, although the menu ticket documented chef salad on Monday, Wednesday, and Friday. Photographic evidence obtained. During an interview on 04/04/25 at 2:06 PM, when shown the photo of the resident's Wednesday lunch meal, the Certified Dietary Manager (CDM) agreed. When asked why the salad on Monday, Wednesday, and Friday, the CDM stated, Resident preference. The CDM confirmed that anything extra on the menu ticket is resident preference. When told of the resident's complaint regarding the gummy oatmeal, the CDM explained the oatmeal becomes thicker as it sits. 2) Review of the record revealed Resident #29 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, on a 0 to 15 scale, indicating he was cognitively intact. This same MDS documented the resident weighed 232 pounds. During an observation and interview on 04/02/25 at 2:02 PM, Resident #29 had finished his lunch and complained of the small portion. The resident provided a photo of his lunch meal that he had taken on his cell phone. Photographic evidence obtained. The resident stated that when he gets his money for the month he will need to supplement his intake by ordering some extra food. The resident stated he was a big guy and needed more. Review of his meal ticket documented double protein portion. During an interview on 04/04/25 at 2:01 PM, when shown the photo of Resident #29's lunch from 04/02/25, both the RD and CDM agreed he was served a regular portion of meat instead of the requested double protein portion. 3) Review of the record revealed Resident #44 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident was cognitively intact with a BIMS score of 13, on a 0 to 15 scale. Review of the current order dated 12/29/24 documented Resident #44 was ordered fortified foods at meals. During an observation and interview on 04/01/25 at 10:19 AM, the activity assistant entered the resident's room to pick up her breakfast tray. Resident #44 stated she was missing her peanut butter and jelly sandwich (PB&J), dry cereal and coffee that morning. The activity assistant stated she would inform the kitchen. Resident #44 stated she really enjoyed the uncrustables (a brand of sandwich) that they started giving her a few weeks ago but then stopped. When asked how often she would like them, the resident stated every morning. Resident #44 confirmed she had not gotten the PB&J sandwich that day or the previous. Resident #44 volunteered she had sugar that morning for her coffee, but no coffee, and milk for her cereal, but no cereal. An observation on 04/02/25 at 9:49 AM revealed Resident #44 did not receive a peanut butter and jelly sandwich as per her breakfast ticket menu. Photographic evidence obtained. An observation on 04/03/25 at 1:33 PM lacked the chef's soup as documented on her menu ticket. Photographic evidence obtained. During the continued interview on 04/04/25 at approximately 2:00 PM, the RD stated the residents love the uncrustables and it could be provided to Resident #44. The RD and CDM were shown the meal ticket and breakfast meal without any PB&J sandwich and agreed with the finding. 4) Review of the record revealed Resident #50 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident was cognitively impaired with a BIMS score of 03, on a 0 to 15 scale. Review of the current orders revealed as of 09/18/23 the resident was to receive both large portions and fortified foods with meals. Review of a progress note dated 12/10/24 by the RD documented the resident agreed to large portions, as he had lost weight in the past. A subsequent note dated 02/24/25 by the RD documented to continue large portions and fortified foods. An observation on 04/02/25 at 9:39 AM lacked fortified oatmeal. When asked if he wanted the oatmeal, Resident #50 stated, I stopped eating oatmeal as a kid. During a subsequent observation on 04/03/25 at 1:08 PM, a regular sized portion of meat was noted on the resident's lunch tray. When asked if the portion was a large meat portion, the RD shook her head no. Photographic evidence obtained. At 1:26 PM, upon completing the meat provided, when asked if he would have eaten more meat if he had more, Resident #50 stated, I probably would have. When asked if he wanted more at that time, he stated, Not now since I've started my dessert. During a phone interview on 04/04/25 at 9:04 AM, when asked about the resident's previous weight loss, the resident's wife stated he had lost weight after being in the hospital and was initially put on a pureed diet. She stated when his diet was upgraded, his weight increased as well. The wife stated she would like him to maintain his weight. When asked if he likes oatmeal, the wife stated she had never seen him eat oatmeal, even prior to admission. On 04/04/25 at 1:52 PM, when asked if she asks residents who are ordered fortified foods if they like oatmeal, the RD stated she typically does, but if the resident had dementia or was asleep, she may not ask. 5) Review of the record revealed Resident #85 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident was cognitively intact with a BIMS score of 12. The resident was noted to have a current weight as of 03/06/25 of 137 pounds and was underweight as per his BMI (body mass index) score of 18.7. The resident had been underweight since admission. A nutritional evaluation by the RD on 02/03/25 documented the resident desired a gradual weight gain and that interventions would be put into place to include fortified foods. During an interview on 03/31/25 at 3:38 PM, Resident #85 stated he had lost weight. The resident explained he was supposed to be on fortified foods and that sometimes his ticket gets messed up. When asked if he has voiced his concerns, the resident stated he tries to speak with the RD about the food and she tells him to call the CDM, who doesn't answer the phone. Resident #85 further stated he doesn't always get his milk and that he received chocolate milk once or twice. Review of the resident's meal ticket documented fortified foods and chocolate milk on Monday, Wednesday, and Friday. An observation on 04/02/25 at 1:55 PM revealed a lack of any type of milk or fortified foods. Photographic evidence obtained. An observation on 04/03/25 at 2:04 PM revealed a lunch plate with meat and potatoes. The menu ticket documented, gravy on meat and starch. The potatoes lacked any gravy. Photographic evidence obtained. When asked if he would have liked the gravy on the potatoes he stated, Of course, but I just have to accept what I get at this point. During an interview on 04/04/25 at 2:09 PM, the CDM stated they did not have any chocolate milk this week, but he was sure the resident had received it in the past. The CDM and RD agreed with the other findings when shown the photos of the meal trays.

Based on observations, interviews, and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 111 of 112 residents on PO (by mouth) diets. The findings included: A. During the initial tour of the Main Kitchen on 03/31/25 at 9:15 AM, accompanied by the Kitchen Manager and the Regional Manager of Dietary, the following was observed: 1. The [NAME] microwave had light and dark brown debris on all sides of the interior of the microwave. The kitchen managers agreed with this finding and said they will clean it up right away. 2. To the right of the coffee station, 2 recessed circular insets were dirty. One had brown liquid on the bottom. The Kitchen Manager wiped it out. The plastic utensil holder close to the round insets had brown residue on the top and spots of black powdery residue. 3. The 2 [NAME] double-door ovens had black and brown residue on the exterior of the front of the ovens. There was a pool of brown fluid on the lower bottom right corner of the oven. [NAME] liquid drippings from the pool of liquid dripped onto the tiled floor. 4. The reach-in Delfield fridge had 3 plastic cups with fluid in them. They were not labeled. When the Kitchen Manager was asked what kind of juice or fluid was in the cup, the Kitchen Manager said they were thickened fluids. When asked how will the staff would know if a thick fluid was nectar thick or honey thick, the Kitchen Manager said I don't know how thick the fluids are. The Kitchen Manager took the cups of thickened fluid and said they will be thrown out. 5. The interior of Manitowoc ice machine had a thick white substance and a blue substance stuck on the area of the hinges that were directly above the ice. 6. A rack of metal shelves that stored small plastic cups, bowls, and glasses had tan, yellow, and brown residue on the bottom shelf. 7. The floor under the metal shelves was dirty. It had a plastic cap, a round foil cover, paper, and food on it. B. The nourishment room on the first floor was observed on 03/31/25 at 10:20 AM. The surveyor was accompanied by the Kitchen Manager, and the Regional Manager of Dietary. 1. A 1000 ml bottle of Jevity 1.5 (nutrition formula) was opened with yellow-tan liquid splattered on the exterior of the cap and bottle. Approx 200 milliliters remained. It was not dated to indicate when this item was opened. 2. A small Styrofoam cup with a plastic lid was on the shelves inside the door of the refrigerator. An orange disposable coffee cup from McDonald's was next to the Jevity on the shelves inside the door. These items were not labeled. 3. The [NAME] Cottage Cheese was not labeled with a name, a date, or a room number. 4. A brown paper bag of food had no date on it. A review of the policy title Outside Foods revised 04/30/2024 said that food and beverages will be discarded without a name or date, past package expiration dates, and all perishable items after 3 days. C) During an observation on 04/02/25 at 11:24 AM, the surveyor entered the kitchen and requested that temperatures be taken for the lunch meal. The garbage pail in the kitchen overflowed with garbage. The lid was not closed. The corporate RD instructed the staff to take the garbage outside immediately. The corporate RD told the surveyor that the garbage pail was in the process of being removed. D) During an observation on 04/03/25 at 9:17 AM , the surveyor requested to see the ice machine to determine if it had been cleaned up. Upon further observation, and a discussion with the Regional Manager of Dietary, it was discovered that the ice machine had a crack on the left side of the lid close to the door hinge. The Regional Manager of Dietary explained that the white and blue colored substances were used as sealants because of the crack. Rust was observed to the left of the cracked part. Photographic evidence obtained.

Based on observation, record review and interview the facility failed to ensure an assessment and an order for side rails for 1 of 1 sampled resident reviewed for side rails (Resident #302). The findings included: Observations were made from 03/31/25 to 04/02/25 of Resident #302's bed. He has 2 metal side rails up on the right side and 1 metal side rail up on the left side. On 04/02/25-04/04/25 observations were made of a larger bed in Resident #302's room with 1 side rail up on each side of the bed by the head of the bed. A review of Resident #302's records revealed Resident #302 was admitted to the facility on [DATE] with diagnoses to include Visual Loss, Hypertension, Type II Diabetes Mellitus, Unspecified Delirium, and COPD (Chronic Obstructive Pulmonary Disease). A review of the Admission Assessment for bed rails dated 03/18/25 documents that side rails are not needed. There was no Physician Orders or documentation on further assessing the resident for side rails. During an interview on 04/04/25 at 4:40 PM with the ADON (Assistant Director of Nursing), the surveyor asked who is responsible for doing assessments for side rails. She stated Rehab does it. During an interview on 04/04/25 at 4:45 PM with the Rehab Director he was asked who is responsible for doing assessments for bed rails. He stated Nursing. During an interview on 04/04/25 at 4:50 PM with Staff O, LPN (Licensed Practical Nurse), she was asked who does bed rail assessments? she stated Nursing and Rehab do the bed rail assessments. If the Admission Assessment documents that the resident needs bed rails then we put an order in. She acknowledged that this resident does not have an order for bed rail and the assessment says no rails needed.

Based on observations, interviews, and record reviews, the facility failed to follow the physician's order for the administration of enteral feeding for 1 of 2 sampled residents (Resident #31), reviewed for enteral feeding. The findings included: A record review revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included Traumatic Subarachnoid Hemorrhage without loss of consciousness, Unspecified Protein Calorie Malnutrition, Major Depressive Disorder, Dementia, and Muscle Wasting in Multiple Sites with Atrophy. This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE] was 4. This indicated that Resident #31 had severe cognitive impairment. A record review revealed Resident #31's most recent weight on 03/09/25 was 93.8 pounds. Her Body Mass Index (BMI) was 18.3. This indicated that Resident #31 was underweight. She lost 8 pounds in six months from 101.8 pounds on 09/02/24 to 93.8 pounds. The MDS quarterly assessment completed on 02/20/25 documented that Resident #31 received 51% or more of the calories ingested daily via percutaneous endoscopy gastrostomy (PEG) tube enteral feedings, and 51% or more fluids from PEG tube enteral feedings. Resident #31 was dependent on enteral feeding to meet her daily needs for nutrition. This included hydration. A record review of Resident #31's care plan for nutrition last revised on 03/31/25, documented that the resident was at risk for malnutrition because she had inadequate intake of nutrition by mouth. Enteral PEG tube feedings was her primary source of nutrition. She had a history of weight loss, and in addition to receiving feeding by PEG tube, Resident #31 also received food by mouth. Her food by mouth diet order dated 03/31/2025 was for a regular diet, with a mechanical soft texture, and thin consistency fluids. A record review showed that Resident #31's current enteral feeding diet order dated 03/10/25 was for a continuous feeding of Jevity 1.5 to be administered at 85 milliliters per hour for 12 hours daily between 7:00 PM and 7:00 AM. The doctor's order specified that the total amount of 1,020 ml of Jevity was to be infused. There was another active order for a bolus feeding (administered all at the same time) of 237 milliliters to be administered at 5:00 PM daily. A record review of the Registered Dietitian's (RD) progress note on 03/10/25 revealed Resident #31 often refused the 5:00 PM bolus feedings. The RD recommended increasing the rate of Jevity 1.5 from 80 milliliters per hour to 85 milliliters per hour. This increase in rate also increased the volume of Jevity to be administered. In addition, the RD's progress note documented Resident #31's difficulty swallowing and poor intake of foods by mouth. An observation during the initial screening activity on 04/01/25 at 09:39 AM revealed that Resident #31's tongue was dry, and the tip of her tongue was deep red. A vertical crevice was observed on the tip of her tongue. The surveyor offered the resident water from the cup that was on her tray table. The resident accepted the cup in her hand and drank some water. During an observation on 04/02/25 at 6:12 PM, Resident #31 was lying down in bed. The surveyor asked the resident to stick out her tongue and Resident #31 complained that her tongue was dry. During an interview with Staff Q (Registered Nurse) on 04/03/25 at 2:12 PM, the surveyor shared her concern about Resident #31's dry mouth. Staff Q said that Resident #31's lips were dry, and she liked to drink water with ice. An observation on 04/04/25 at 7:04 AM revealed Resident #31 was in bed, receiving enteral feeding. The rate of feeding was 80 milliliters per hour. The total amount of Jevity that was administered, based on the amount of formula that remained in the plastic 1000 ml bottle, was approximately 540 ml. The doctor's order specified the total volume to be administered between 7:00 PM and 7:00 AM was 1,020 ml. Approximately 460 ml of Jevity 1.5 remained in the plastic bottle. An interview on 04/04/25 at 7:15 AM was conducted with Staff C, the nurse who provided Resident #31 with care during the night shift. The surveyor asked Staff C to view the tube feeding pump and to describe the rate of administration of the Jevity formula that was in progress. Staff C said that the rate was 80 milliliters per hour. When asked to check the doctor's order in Resident #31's medical record, Staff C said that the order specified 85 milliliters per hour. The surveyor asked why she provided the Jevity at 80 milliliters per hour, and Staff C said that she didn't open and check the order for the administration of Jevity. She also said she wasn't informed of the change in the administration rate during the change of shift report.

Based on interviews, record review, and policy review, the facility failed to ensure supervision and staff training for 1 of 4 sampled residents (Resident #19), reviewed for falls. The findings included: Review of the policy titled, Falls - Managing, Preventing, and Documentation revised 01/2024, documented, in part, Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Documentation: . 2. The resident's care plan should be updated timely with the new interventions determined by the interdisciplinary team. Review of the record revealed Resident #19 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 had a Brief Interview for Mental Status (BIMS) score of 6, on a 0 to 15 scale, indicating the resident was cognitively impaired. Review of the current care plan initiated 11/13/24 revealed Resident #19 was at risk for falls related to cognitive deficit, use of psychotropic medications, decreased endurance, and a history of falls. Review of progress note dated 03/17/25 written by Staff A, Licensed Practical Nurse (LPN) revealed that Resident #19 was in her room and observed lying on the floor on her right side. A fall risk evaluation was completed after care was provided and family was notified. The fall risk evaluation revealed that Resident #19 was oriented to self, not place and time and had periods of confusion. She presented with an altered awareness of physical environment and lack of understanding of physical limitations. During a family interview on 04/01/25 at 9:42 AM, Resident #19's husband stated that his wife fell out of the wheelchair when she was left alone in her room. During an interview on 04/02/25 at 12:10 PM, Staff A, LPN stated that a staff member from the Activities department pushed Resident #19 in her wheelchair back into her room and left her alone and did not notify the nursing staff that Resident #19 was back in her room. During an interview on 04/02/25 at 12:47 PM, the Activities Director stated that it was Staff G, a part time Activity Assistant, who brought Resident #19 back to her room on 03/17/25 as Staff G did not know that the resident should be taken to the nursing station instead of her room. When asked how Staff G, would've known which residents need to be brought to the nursing station instead of their rooms and if there was a policy for that she replied, I am not sure, but I think it is in the resident's care plan. Review of the current care plan initiated on 03/03/25 that includes interventions carried over from 2024, lacked any intervention related to the need to always keep Resident #19 with staff while positioned in her wheelchair. Furthermore, the list of interventions and approaches did not include training for all facility staff to communicate with the nursing staff when Resident #19 is positioned in her wheelchair and returned to her room after attending activities, an outing or therapy. Review of the facility investigation completed after Resident #19's fall on 03/17/25, revealed education only to Staff G, the Activity Assistant involved in the incident, and lacked education to all staff.

Based on record review and interview, the facility failed to ensure care and services for 5 of 34 sampled residents, as evidenced by the failure to implement the bowel program for Resident #44, failure to follow blood pressure parameters for Resident #10 and #23, failure to ensure the provision of a urology appointment for Resident #62, and failure to notify the physician of blood sugar levels as per physician order for Resident #303. The findings included: 1) Review of the record revealed Resident #44 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current care plan initiated on 08/26/24 revealed Resident #44 was at risk for bowel irregularity related to decreased mobility, and potential side effects of medications. The documented goal was that the resident would have a bowel movement at least once every three days. One of the interventions was to administer the medications as per physician orders. Review of the current physician orders revealed Resident #44 was on two routine medications daily for constipation. The resident also had three orders for medications as needed, to include Milk of Magnesium for Constipation Bowel Protocol, a Bisacodyl (a laxative) suppository as needed for constipation, and a Fleet Enema to be administered if no bowel movement in 5 days. Review of the documented bowel management in the resident's record, along with the corresponding Medication Administration Records (MARs) for Resident #44 revealed the following: On 02/10/25 on the day shift (7 AM to 7 PM) through 02/14/25 on the day shift, a total of 4 1/2 days, the record lacked any documented bowel movement or the administration of any as needed medication for constipation. On 02/22/25 on the night shift (7 PM to 7 AM) through 02/25/25 on the night shift, a total of 3 1/2 days, the record lacked any documented bowel movement or the administration of any as needed medication for constipation. On 03/16/25 on the night shift through 03/19/25 on the day shift, a total of 3 days, the record lacked any documented bowel movement or the administration of any as needed medication for constipation. During an interview on 04/01/25 at 10:34 AM, Resident #44 stated she gets constipation and had an issue with it every month. The resident stated the pain she gets when constipated was horrible. Resident #44 confirmed she was taking something every day, but did not think it was enough. When asked if she gets anything as needed or upon her request, the resident stated once in a while she gets Milk of Magnesia. During an interview on 04/04/25 at 12:37 PM, when asked to explain the Bowel Protocol, Staff L, Licensed Practical Nurse (LPN), explained that the electronic dashboard would notify the nurse when a resident does not have a bowel movement in three days. The LPN stated when notified, she would confirm the lack of a bowel movement with the resident and or staff. The LPN explained that when she is notified, she would provide the as needed dose of Milk of Magnesium to the resident listed on the dashboard. When asked specifically about Resident #44, the LPN agreed the resident had an issue with constipation. During a side-by-side review of the record at this time, the LPN agreed with the findings. 2) Review of the record revealed Resident #10 was admitted to the facility on [DATE]. Review of the current orders revealed the order initiated on 09/30/24 for the blood pressure medication Metoprolol 25 milligrams, to give two tablets twice daily. This order further documented the physician ordered parameters that the resident was not to receive the medication if his systolic blood pressure (SBP/upper number) was less than 110 or his heart rate was less than 60. Review of the December 2024 Medication Administration Record (MAR) documented the Metoprolol was administered to Resident #10 on 12/06/24 at 9 AM with a heart rate of 54. During a side-by-side review of the record and interview on 04/04/25 at 12:22 PM, Staff L, LPN, agreed with the findings and stated the medication should have been held. 39167 3) Resident #23 was admitted to the facility on [DATE] with diagnoses including respiratory failure and hypertension (high blood pressure). An annual comprehensive assessment on 12/18/24 included a brief interview with a mental status score of 15, indicating that Resident #23 was cognitively intact. This assessment did not record any concerns related to mood or behavior. According to the physician's order from 12/14/23, Amlodipine was prescribed to be administered one tablet by mouth every 12 hours for the management of hypertension, with the stipulation to hold the medication if the systolic blood pressure was below 110. However, a review of the March 2025 medication administration record (MAR) evidenced the lack of adherence to these parameters. Amlodipine was administered outside of the established parameters on several occasions: - On 03/05/25, at 9 PM, the recorded blood pressure was 98/67, and the medication was administered. - On 03/18/25, at 9 AM, the blood pressure was 102/65, and the medication was again given. - On 03/25/25, at 9 AM, the blood pressure was noted as 107/63, and the medication was administered. - On 03/25/25, at 9 PM, the blood pressure was recorded at 109/64, and the medication was administered. During an interview with the Director of Nursing (DON) on 04/04/25, at 11:55 AM, the DON was made aware of the issue regarding the noncompliance with the physician's orders concerning blood pressure medication administration and the associated parameter. 33103 4) Review of Resident #62 records revealed that Resident #62 was admitted to the facility on [DATE]. He has diagnoses to include Chronic Kidney Disease, Acute Kidney Failure, Malignant Neoplasm of Prostate, Retention of Urine, Obstructive and Reflux Uropathy. A review of the physician's orders revealed that the resident has an indwelling urinary catheter. A review of a physician's progress note dated 04/02/25 documents that he palpable hardened mass to right side of scrotum. Another progress note dated 02/19/25 patient seen today in bed prior to going to Urology appointment. Earlier this week he complained of pain and swelling to scrotum. Palpable hardened mass noted to right side of scrotum along with scrotal swelling. Patient report that pain has improved. He also continues to have penile discharge. Spoke with him about ensuring these issues are addressed with Urology today. He returned with an order for a scrotal ultrasound scheduled for 03/31/2025. at 11:00 AM. Surveyor reviewed the Physician's order and did see an order for a Urology appointment on 03/31/2025 at 11:00 AM. During an interview on 03/31/25 at 10:30 AM, Resident #62 stated to the surveyor that he was upset, he is waiting to be picked up to go to the Urologist at 11:00 AM for a test. He said he mentioned it to the nurse, but she said he did not have one and no one appeared to be taking him. During an interview on 03/31/25 at 10:45 AM, with Staff M, RN she was asked about a medical appointment today 03/31/25 at 11:00 AM She stated, he is confused, I don't see an appointment. During an interview on 04/02/2025 at 8:58 AM with Staff M, RN, she was asked again about Resident #62's Urology appointment that was scheduled for Monday 03/31/25. She stated she wasn't aware he had an appointment until the Surveyor brought it to her attention. She had texted the Activities Director around 10:45 AM asking if he had one. She said usually if they have an appointment it will pop up on the computer as a one-time order but for him it wasn't put in correctly, so it didn't pop up. She said that Activities will set up the transportation. During an interview on 04/02/25 at 9:05 AM with Staff N, Unit Manager, she stated that she spoke to the resident yesterday and she called the Urologist to find out about his appointment but have not heard back from them yet. During an interview on 04/02/25 at 9:45 AM with the Activities Director she remembers the text the nurse sent her about this resident on Monday 03/31/25. The Activities Director stated we will set up the residents' transportation if they are long-term care residents. The surveyor then stated that this resident is long term care. During a subsequent interview on 04/02/25 with Staff N, Unit Manager, she stated the resident was communicating with the doctor's office and had changed his appointment himself. The surveyor stated that it has been on the computer since 02/20/25. Staff N then stated the resident told someone and they put it on the computer but did not put it in correctly and since he made the appointment we were not aware that he needed transportation. The surveyor stated that this appointment has been scheduled for over a month and they had an opportunity to get transportation scheduled, which she acknowledged. During an interview with Staff N, Unit Manager, on 04/04/25 at 11:50 AM she was asked about this resident transportation for the upcoming appointment. She said the Activities driver was going to pick him up. During a telephone interview on 04/04/25 at 12:50 PM with the Activities Director she stated she only oversees transportation for outings and ALF. The unit manager would take care of the resident going to the doctor's appointment. 5) Review of Resident #303 records revealed Resident #303 was admitted to the facility on [DATE] and discharged [DATE]. The resident had diagnoses to include Type II Diabetes Mellitus, Hypertension, and Dysphagia and Aphasia following a Cerebral Infarction. A review of the Physician's Order revealed Accu-Chek twice daily; If blood sugar is above 250 to notify the MD/ARNP start date 03/05/25 0630. A review of the MAR (Medication Administration Record) revealed 3 days that the Accu-Chek was taken, and the blood sugar was above 250 but the physician or ARNP was not notified. On 03/17/25 Blood Sugar 301 at 06:30 AM. On 03/16/25 Blood Sugar 295 at 4:30 PM. On 03/08/25 Blood Sugar 252 at 4:30 PM. The resident is also on Glucophage Tablet 1000 MG (Metformin HCl) Give 1 tablet by mouth two times a day for Diabetes; Insulin Glargine Solution 100 UNIT/ML Inject 15 unit subcutaneously at bedtime for diabetes. During an interview on 04/04/25 at 3:39 PM with the DON (Director of Nursing) the Surveyor asked her where the nurses document when they notify the physician or ARNP. She stated they are documenting either in the computer on the MAR which sometimes floats over to Progress Note or putting it in the progress note. The surveyor requested to pull up Resident #303's MAR and progress notes. She reviewed them and acknowledged that she does not see any notes that the physician or ARNP was notified and should have been per the order.

Based on record review, policy review and interview the facility failed to obtain an ordered laboratory result for a medication (Depakote) for 1 of 1 sampled Resident (Resident #61). The findings included: The facility policy titled, Standards and Guidelines: Physician's Orders, revised on 01/2024 documented in part: Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated. Resident #61 was admitted to the facility on [DATE] with diagnoses to include in part Hypertension, Major depressive disorder, Congestive heart failure, Atrial fibrillation, Anemia, Protein calorie malnutrition and a brief psychotic disorder. On 11/27/24 Resident #61 was ordered 750 mg Depakote Sprinkles by mouth two times a day for mood disorder. The order was changed on 02/13/25 to read Depakote 500 mg 1 tablet two times a day for mood disorder. The facility has a pharmacist consultant who reviews all the medications for each resident once a month. This prevents under and over medications of the residents, and possible side effects from their medications. In January 2025, the pharmacist reviewed Resident #61's medications. The pharmacist had recommendations for the medication, Depakote. Part of the recommendation for Resident #61 was for the physician to order a serum level for the Depakote. The pharmacist stated they were unable to locate a serum level in the chart. The physician agreed and a serum level was ordered to be collected on 02/25 for the medication Depakote. The medication Depakote has a significant impact on brain chemistry. The right dosage is essential. If too little is given, then the symptoms may not be controlled, and too much of the medication can lead to toxicity. The laboratory results were reviewed for Resident #61. A Valproic Acid (Depakote) serum level could not be located in the resident's record. On 04/03/25 at approximately 5:00 PM, the findings were discussed with the ADON (Assistant Director of Nursing) and the Administrator. The laboratory result for the Depakote serum level was unable to be located.

Based on observation, interview, and record review, the facility failed to properly administer oxygen therapy for 2 of 2 sampled residents, as evidenced by failure to ensure proper physician orders for oxygen use for Resident #302, and that the prescribed physician order for oxygen was followed for Resident #54. The findings included: Review of the Policy titled, Standards and Guidelines for Oxygen Administration revised 12/2023, documented, in part, Oxygen therapy is administered by way of an oxygen mask, cannula or other device per physicians' orders with the appropriate flow of oxygen. 1) Observations of Resident #302 from 03/31/25 to 04/03/25 revealed that the resident is on oxygen by nasal cannula. The setting of his oxygen is set at 4.5 LPM (liters per minute). A review of Resident #302's records revealed Resident #302 was admitted to the facility on [DATE] with diagnoses to include COPD (Chronic Obstructive Pulmonary Disease) with Acute Exacerbation, Chronic Respiratory Failure with Hypercapnia, Dependent on Oxygen, Hypertension, and Type II Diabetes Mellitus. A review of the Physician's Orders documented continuous O2 (Oxygen) will tolerated every shift start 03/20/25. It does not state the LPM nor what type of device the resident should be using. During an interview on 04/02/2025 with Staff N, Unit Manager/RN she was asked what the process is for a resident on oxygen. She stated they check the O2 every shift, he has COPD and the O2 is set at 3 LPM, every Thursday they change his cannula. She was asked to review the resident's O2 orders. She read off that it showed continuous O2 will tolerated every shift start 03/20/25. She said OK and didn't seem concerned that the order did not have how many LPM nor by what method. We went into resident's room and to observe the oxygen rate. She stated it was at 4.5 LPM. The resident interjected and stated that he always has it at 4 LPM at home but because he is more active here at the facility it is at 5 LPM. The Unit Manager stated she will call the physician to get orders updated. On 04/02/25 it now reads Respiratory-Oxygen: Continuous. Encourage and assist resident to use O2 @ 4.5L via NC continuously as tolerated for COPD every shift for COPD and Respiratory-Oxygen Tubing Change: Change O2 tubing/mask/bag Q week and PRN every night shift every Thursday for monitoring. Photographic evidence obtained. 52127 2) Review of record revealed Resident #54 was admitted to the facility on [DATE]. On 03/14/25, Resident #54 was admitted to the hospital with diagnosis of Acute Respiratory Failure, and was readmitted to the facility on [DATE] with a respiratory care order for Oxygen at 2 liters via nasal cannula as needed for shortness of breath/dyspnea on exertion every 24 hours. Observation on 04/01/25 at 8:10 AM, Resident #54 was in bed awake on oxygen on 4 liters via nasal cannula. Observation on 04/01/25 at 11:15 AM, Resident #54 was in bed and awake on 4 liters of oxygen via nasal cannula. During an interview on 04/02/25 at 11:07 AM, Staff A, Licensed Practical Nurse (LPN) was asked about Resident #54's oxygen order as she was leaving resident #54's room. Staff A checked her computer stating the order is for 2 Liters. During an observation after the interview with Staff A, on 04/02/25 at 11:10 AM, Resident #54 was in bed awake with 4 Liters of oxygen via a nasal cannula. Photographic evidence obtained.

Based on policy review, observation, record review, and interview, the facility failed to ensure timely IV (intravenous) dressing changes for 1 of 1 sampled resident, Resident #29. The findings included: Review of the policy titled, IV Dressing Change revised 11/2024 documented in part, Standard: This purpose of this procedure is to minimize catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Procedure: 1. Dressing changes to be completed if it becomes damp, loosened or visibly soiled and at least every 7 days. Review of the record revealed Resident #29 was admitted to the facility on [DATE]. Review of the current orders revealed a midline IV catheter was ordered on 03/20/25 for the resident to receive IV medications. These orders also contained instructions to flush the IV before and after two current antibiotics that were being administered via the IV line, to include daptomycin and meropenem. These orders lacked any instructions for the nursing staff to change the IV dressing. A wound culture dated 01/03/25 revealed the resident had a wound that was infected with a multi-drug resistant organism (MDRO). During an interview on 03/31/25 beginning at 11:31 AM, when asked why he was on contact precautions, Resident #29 stated he had a wound infection. A mid-line catheter was noted to the resident's right arm. The dressing was lose all around the perimeter and dated 03/20. When asked about the dressing changes, Resident #29 stated, It wouldn't have been changed then (03/20/25) if I wouldn't have said anything. I have to beg them to change it. Then when the nurses do finally change it, they complain the whole time. During an interview on 04/03/25 at 2:08 PM, when asked if she does the IV dressing changes for a mid-line IV, Staff L, Licensed Practical Nurse (LPN) stated she does not, but would as the Unit Manager or another Registered Nurse (RN) to complete the task. When asked how she knows when it is due, the LPN stated it would pop up on her computer. When asked if she had noticed the mid-line for Resident #29, the LPN stated, Yes, it was dated 03/20 and I corrected that on 04/01/25. The LPN agreed it was completed late. When asked to locate and provide the order for the mid-line dressing change, the LPN stated she did not see it in the computer, but it should be changed every 7 days.

Based on interview and review of the client's Arbitration agreements, the facility failed to ensure the arbitration agreement is explained to the resident or representative in a manner they understand (Resident #306), and had a signature from the resident or representative if they agree to the arbitration agreement (Residents #87, #306, and #307). This is for 3 of 3 residents reviewed for arbitration. The findings included: During the entrance conference on 03/31/25 at 9:47 AM, the surveyor requested a list of residents that currently reside in the facility since 09/16/19 that entered into a binding arbitration agreement. On 04/02/25 the Surveyor was given a list of residents that had a zero, 1 or 2 next to their name. Further review of the arbitration agreement revealed zero meant that the residents did not sign the arbitration agreement, the #1 they agreed to the arbitration agreement and signed the document one time and the #2 meant they have 2 or more arbitration agreements that they have signed. There are two areas the resident or representative sign. The first is acknowledgment of understanding of the Arbitration Agreement and the second part is agreeing to the arbitration agreement, and that the resident also received a copy of the agreement. The Surveyor chose three residents that had the number 1 next to their name and were recently admitted to the facility. A review of Resident #87's medical records revealed this resident was admitted to the facility on [DATE]. He has a BIMS (Brief Interview for Mental Status) of 15 out of 15, which meant his cognition is intact. Review of the Arbitration Agreement had Resident #87's name on the document as well as the name of a resident representative. There is no signature by the resident or representative in both areas that is supposed to be signed, but it documented an electronic signature by a staff representative. During an interview with Resident #87 on 04/04/25 at 1:10 PM, the surveyor asked if anyone from the facility spoke to him about the arbitration agreement. (Surveyor had this resident's documents in hand). The resident stated, he was so drugged up when he came from the hospital that he cannot recall anything. He said he is his POA (Power of Attorney). A review of Resident #306 medical records revealed this resident was admitted to the facility on [DATE]. The resident does not have a BIMS score due to just being admitted but is able to answer all questions asked by the surveyor. A review of the resident's Arbitration Agreement documents his name on the form. During an interview on 04/04/25 at 1:20 PM with Resident #306, the Surveyor asked this resident if anyone spoke to him and explained what the Arbitration Agreement was. He stated no. His wife was in the room and she was asked the same question and she stated no. The Surveyor asked the resident if he electronically signed the document agreeing to the Arbitration Agreement. He stated no. Asked if he received a copy of the agreement he stated no. A review of Resident #307 medical records revealed this resident was admitted to the facility on [DATE]. Resident does not have a BIMS score due to just being admitted . A review of the resident's Arbitration Agreement documents his name on the form along with a Resident Representative. There is no signature from Resident #307 or his Representative in the two required signature areas. During an interview on 04/04/25 at 1:35 PM with the Admissions Director she was asked if she does the arbitration agreements. She stated that the Concierge takes care of them, but she is the one who guided her. During an interview on 04/04/25 at 1:40 PM with the Concierge she was asked if she does the Arbitration Agreements with the residents. She stated that she does the Admissions Packet and the Arbitration Agreements. The surveyor showed her the list of residents and she stated that it is not the right list. She obtained a list, said the residents that have a 1 next to their name signed the agreement and the one that have 0 next to their name did not sign. The Concierge stated that she does everything on a tablet and showed the surveyor. She gave an example and pulled up a resident and stated this resident refused to sign. He has 0 next to his name. She stated that she puts a note in that they do not want to sign. The resident and or representative do not sign the document when agreeing to the arbitration agreement. The Concierge just taps each section on the computer.

Based on observation, interviews and clinical record review, the facility failed to ensure that residents who are unable to carry out their activities of daily living to maintain personal hygiene, grooming, mobility are provided the necessary care and services in a timely manner. The facility also failed to maintain accurate documentation of the care and services that are provided. This failure affected 3 of 6 sampled residents (Resident #1, #5 and a confidential random resident). The findings included: 1) Review of the clinical record for Resident #5 revealed that the resident was admitted to the facility on [DATE] with diagnoses which included, Dysphasia following Cerebral Infarction, Pneumonitis following ingestion of other solids and liquids, Acute Respiratory Failure, Sepsis, Cardiac Arrest due to other underlying conditions, Gastrostomy, Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side and Metabolic Encephalopathy. Review of the 03/04/25 plan of care revealed that the resident takes nothing by mouth and receives enteral feeding. It is noted that the resident is dependent for the performance of his activities of daily living including bathing, bed mobility, transfers and is incontinent of bowel and bladder. An observation of Resident # 5, conducted on 03/06/25 at approximately 2:15 PM revealed that the resident was lying in bed with the top sheet removed, exposing his adult incontinent brief, which was obviously wet. The surveyor summoned the aide, Staff E, at this time. An interview was conducted with Staff E, who admitted that the last time she provided care for Resident #5 was about 10:30 AM this morning, approximately 4 hours ago. 2) A review of the Paramedic Trip records dated 02/25/25 at 10:59 AM for Resident #1, documented, upon arrival the crew found the patient (pt), unresponsive and lying in bed. The pt had a CPAP (Continuous Positive Airway Pressure) machine on his face with normal respirations, a strong radial pulse with cool extremities. The pt has old urine soiling his clothing and his bed sheets. The PA (Physician Assistant) on scene advised that the pt is being treated for the flu and a UTI (Urinary Tract Infection), he is on multiple antibiotics and steroids. They advised that the pt is normally alert and talking with no deficits. The facility is unable to tell the crew how long the pt has been unresponsive. The clinical record for Resident #1 revealed that the resident was admitted to the facility on [DATE] with diagnoses which included, Obstructive Sleep Apnea, Shortness of Breath, Chronic Kidney Disease, Stage 4, Diabetes Mellitus Type 2 with circulatory complications, and Influenza. An interview was conducted with the Day Registered Nurse, Staff B, on 03/05/25 at 3:20 PM. She works from 7:00 AM to 7:00 PM. She stated that [on 02/25/25] she saw the resident around 7:45 AM-8:00 AM and he was sleeping with his CPAP. She stated she received report that the resident was okay, and that the resident was sleeping with his CPAP. No distress. She stated she went in to try to wake him and he would not wake up. His vital signs were ok, and she said she checked his blood sugar earlier and it was 140. She said she does recall the resident's bed sheet being wet the last hour before he was sent out, but she didn't recall any discoloration being on the sheet. An interview was conducted with the Day Certified Nursing Assistant, Staff D, on 03/05/25 at 3:30 PM. She stated when she made rounds at 7:00-7:30 AM, the resident was sleeping with his CPAP on. When breakfast arrived, they noted that he didn't respond. She reported she changed the resident before and after breakfast. She stated she changed the residents' pull up not the sheets. She didn't recall that the residents' sheets were wet. She reported the resident had on a shirt and diaper. She denied that she changed the linen, she just changed the resident. Review of the Activities of Daily Living Task sheet revealed that the staff failed to document the performance of any activities of daily living for Resident #1 on 02/24/25 and 02/25/25. Review of Resident #1's Plan of Care, it documented the resident is at risk for complications r/t (related to) bowel and/or bladder incontinence with interventions which included: Monitor/observe for potential complications of incontinence. Notify MD as indicated. Monitor/report PRN (as needed) any possible causes of incontinence including, but not limited to, bladder infection, constipation, loss of bladder tone, muscle weakness, decreased bladder capacity, diabetes, Stroke, medication side effects. Preventative skin care/treatments as ordered/indicated. Provide incontinence care with each incontinence episode as tolerated. Urinal within reach. Review of Resident #1's Plan of Care documented the resident has an potential for ADL selfcare deficit r/t ADL needs and participation vary, Fatigue, chronic medical conditions. Flu A with respiratory infection. The interventions included: Toileting: the resident will need the extensive help of one or two staff to stand and transfer on and off the toilet, commode or bed pan. The resident will probably need you to wipe, redress, and wash their hands. Be prepared with 2 people to assist for resident safety during the transfer. Transfer: the resident is limited to extensive and may need assistance x 1 or x 2 for transfers in and out of chair or bed. This may fluctuate with weakness, fatigue, and weight bearing status. 3) A confidential random resident interview was conducted on 03/06/25 in the afternoon, when the resident reported that he has issues with the night shift staff providing care. He recalled a couple of nights ago, that he put on his call light because he was incontinent. They answered the light and stated they would be back, but they did not come back to change him until 4 hours later.

Based on observation, record review and interview, the facility staff failed to provide necessary treatment and services to promote healing and prevent infection of existing pressure wounds. The failure affected 2 of 6 sampled residents, Resident #2, who arrived at the hospital with maggots in the wound and Resident #6 who did not receive the prescribed treatment for tissue granulation and autolytic debridement. The findings included: 1) Clinical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Dementia and Heart Failure. Review of the Minimum Data Set with reference date of 12/31/24 documented the resident was assessed as moderately impaired for skills of daily decision making, had a urinary catheter, was incontinent of bowel and had an unstageable pressure wound, present on admission. Review of care plan dated 11/08/24 documented the resident has a pressure ulcer to the right hip. The goal documented the resident's pressure ulcer will show signs of healing as evidenced by decrease in size, improved appearance, and be free from infection by/through review date. Interventions included the following: Administer medications and treatments as ordered, monitor for signs of infection, nutritional approaches to maintain optimal wound healing, obtain and monitor lab/diagnostic work as ordered and provide incontinent care after each incontinent episode, apply barrier cream as needed. Review of physician's order dated 01/08/25 documented, Treatment: Cleanse right hip with normal saline or wound cleaner, apply skin prep to peri-wound, pack lightly with Honey gel, cover with bordered gauze and change three times a week (Monday, Wednesday, and Friday for wound) and as needed loss of integrity. Further record review revealed on 01/15/25 Resident #2 was transferred to the local hospital due to altered mental status between the hours of 7 PM to 8 PM. An interview with the Wound Nurse conducted on 01/22/25 at 12:17 PM revealed the nurse took over wound care duties on 01/14/25. Resident #2 wounds included an intact blister to the heel and an open wound to the hip. Wound Nurse stated she performed the wound care on 01/14/25 and 01/15/25 and did not notice any signs of infection or foreign bodies. On 01/15/25 the dressing was done around 7 AM. The Wound Nurse stated she had verbal training with the Director of Nursing upon agreeing to the position and that she is receiving additional training today with the certified Wound Nurse. As a floor nurse she has performed wound care, and it entailed following the physician's orders, no specific training was provided. An interview with the Physician Assistant (PA), Wound Care Provider, conducted on 01/22/25 at 1:50 PM revealed her recollection of Resident #2's wounds. The PA rounded on 01/13/25 and the hip wound was clean. The PA was asked what causes maggots in a wound and stated typically if the wound is not taken care of, contamination with feces, urine or other organisms but she is not an expert. She further explained that some providers will use them for therapeutic purposes, but they do not utilize that practice. Review of photographic evidence from the hospital dated 01/15/25 at 10:55 PM indicates the resident's wound to the right hip had a soiled dressing with maggots. An interview with the Risk Coordinator and Director of the Intensive Care Unit on 01/23/25 at 2:16 PM revealed the nurse discovered the maggots when the dressing was removed for skin evaluation upon arrival to the unit and stated the dressing was not dated. Record review revealed the hospital records provided the following information: Resident #2 presented to the emergency department on 01/15/25 at 8:04 PM due to Altered Mental Status. Hospitalist notes dated 01/16/25 documented the following: According to reports, the patient was nonverbal on arrival apparently was sent in secondary to altered mental status and decreased function. Patient found to be in septic shock, have bilateral lower lobe pneumonia as well as urinary tract infection and elevated Troponin. He was admitted to the intensive care unit, started on Levophed drip and his wounds were dressed. Patient was found to have live maggots in the dressings of his right hip wound. Following this, wound care did see the patient and took multiple pictures and addressed his multiple wounds. Review of the personnel files revealed the current Wound Nurse is a Licensed Practical Nurse, with no documented prior wound care experience and it is noted the job description requirement included Registered Nurse License. Please refer to additional evidence validating the lack of competency in the provision of wound care during observation of care involving Resident #6. 2) Clinical record review conducted on 01/21/25 revealed Resident #6 was readmitted to the facility on [DATE]. Review of the Minimum Data Set assessment with reference date of 11/15/24 documented the resident was assessed as independent with skills for daily decision making, has urinary catheter, ostomy, and multiple wounds, three stage III, one stage IV, and one unstageable pressure ulcers. Review of the care plan dated 08/01/24 titled, Resident has a pressure ulcer, right and left ischium, posterior neck and mid back related to traumatic injury, documented interventions as administer treatments as ordered by the physician and monitor for signs of infection. Review of physician orders dated 11/29/24 documented as follows: Treatment: Cleanse left ischial with Dakin's 1/4 strength, pat dry, apply skin prep to peri-area of the wound, then apply Collagen Powder and Calcium Alginate and cover with silicone foam dressing daily and as needed (PRN) until resolved. Cleanse right ischial with Dakin's 1/4 strength, pat dry, apply skin prep to peri-area of the wound, then apply Collagen Powder and Calcium Alginate and cover with silicone foam dressing daily and PRN until resolved. Cleanse sacrum with Dakin's 1/4 strength, pat dry, apply skin prep to peri-wound, collagen powder, calcium alginate and cover with silicone foam dressing daily and PRN. Observation of wound care conducted on 01/21/25 starting at 11:30 AM revealed Resident #6 in bed, alert and oriented and consented to the observation. The Wound Nurse and the Unit Manager prepared supplies for Resident #6, performed hand hygiene and donned protective equipment. Then the Wound Nurse removed the three dressings to the right and left ischium and to the sacrum. After removing the dirty dressing, the Wound Nurse performed hand hygiene, donned clean gloves and proceeded to clean the wounds with Dakin's solution, 1/4 strength, then used the wound cleanser spray, applied to clean gauze and cleansed the skin around the wound that had white residue in between the wounds. The Wound Nurse then performed hand hygiene, donned clean gloves and applied border dressing to each of the three wounds. The Wound Nurse failed to follow physician's orders, the nurse did not apply the prescribed Collagen Powder and Calcium Alginate. An interview conducted on 01/21/25 at 12:18 PM with the Wound Nurse and Unit Manager confirmed the Wound Nurse did not follow the physician's order for wound care, the Wound Nurse failed to apply the collagen powder and calcium alginate to the right and left ischial and the sacral wound.

Based on record review, policy review and interview, the facility staff failed to report an allegation of neglect for 1 of 2 sampled residents reviewed for neglect (Resident #2). The findings included: Review of the facility policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) revised on 01/2024 documented the following: Standard: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property and mistreatment, collectively known and referred to as ANEMMI and hereafter defined, will not be tolerated by anyone, including staff, residents, volunteers, family members, legal guardians, resident representatives, friends or any other individuals. The Health Center Administrator is responsible for assuring that Residents' Rights of personal privacy, confidentiality and dignity will be respected for all aspects of care and services and that resident safety, including freedom from risk of ANEMMI, holds the highest priority. Definitions 2. NEGLECT: 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 mental illness. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but a facility fails to provide them, to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish or emotional distress. Identification: Any resident event that is reported to any staff by resident, family, other staff or any other person will be considered as possible ANEMMI if it meets any of the following criteria: a. Any indication of possible willful infliction of injury to include unexplained bruising. b. Unreasonable confinement, to include unwanted restriction of access to all resident areas of the building. c. Any resident or family complaint of physical harm, pain or mental anguish resulting from willful infliction from others. d. Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental, and psychological well-being to include toileting issues. e. Any complaint of the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families or within their hearing distance. f. Any complaint of sexual harassment, sexual coercion, or sexual assault. g. Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action. h. Any behavior control strategy involving corporal punishment. Any complaint of humiliation, harassment, threats of punishment or deprivation. j. Any allegation of misappropriation of resident property. REPORTING AND RESPONSE Policy: All allegations of possible ANEMMI will be immediately reported to the Abuse Hotline by the Administrator or Designee and will be evaluated to determine the direction of the investigation. Procedure: Any and all staff observing or hearing about such events must report the event immediately to the Administrator, Immediate Supervisor AND one of the following: Directors of Nursing, ANEMMI Prevention Coordinator, or Risk Manager, so that appropriate reporting and investigation procedures take place immediately. It will also be reported to other officials in accordance with State and Federal Regulations. Any and all employees are empowered to initiate immediate action as appropriate by contacting the Abuse Hotline at [PHONE NUMBER] if they witness such an event or have reasonable cause to suspect such an event has indeed occurred. However, contacting the Abuse Hotline does not alleviate the responsibility to immediately notify the Administrator, Immediate Supervisor AND one of the following: Director of Nursing, ANEMMI Prevention Coordinator, or Risk Manager. A. IMMEDIATE REPORT In accordance with CFR 483.12(c)(1), with response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the vents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. The ANEMMI Prevention Coordinator will also submit to The Agency for Health Care Administration (AHCA) Federal Immediate/5-Day Report. B. REPORT OF INVESTIGATION (Five Day Report): The facility ANEMMI Prevention Coordinator will send the result of facility investigations to the State Survey Agency within five working days of the incident. This will be completed using the same AHCA Federal/Five day report. C. REPORTING OF A SUSPICION OF CRIME (EJA) The facility will annually notify covered individuals of their reporting obligations if there is a reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from the facility. 'Covered individuals that have reporting obligations under the Elder Justice Act are owners, operators, employees, managers, agents and contractors of long-term care facilities. Review of the facility's incident logs, grievances and reportable logs dated 10/24 thru 01/25 conducted on 01/21/25 revealed no entries related to Resident #2. On 01/21/25 at 3:08 PM a request for laboratory test results for Resident #2 was made, the Regional Nurse Consultant informed the surveyor that the facility had a soft file addressing the concerns reported by the hospital regarding Resident #2's care. Interview with Regional Nurse Consultant on 01/22/25 at 10:57 AM revealed on 01/17/25, the facility's Marketing Director sent her an email with a picture of Resident #2's wound, located on his foot. The email was sent due to concerns from the hospital regarding the condition of the resident's wound. The Regional Nurse Consultant stated that she had attempted to contact the hospital, but no one returned her call. Then she discussed the concern with the rest of the clinical team, a soft file was created, they did a deep dive, reviewed the record and implemented a performance improvement project for skin and wounds. The facility completed a timeline and determined they provided appropriate care and documented interviews including the hospitalist and noted he had no personal knowledge of maggots in the resident's wound. Record review revealed the hospital records provided the following information: Resident #2 presented to the emergency department on 01/15/25 at 8:04 PM due to Altered Mental Status. Hospitalist notes dated 01/16/25 documents the following: According to reports, the patient was nonverbal on arrival apparently was sent in secondary to altered mental status and decreased function. Patient found to be in septic shock, have bilateral lower lobe pneumonia as well as urinary tract infection and elevated Troponin. He was admitted to the intensive care unit, started on Levophed drip and his wounds were dressed. Patient was found to have live maggots in the dressings of his right hip wound. Following this, wound care did see the patient and took multiple pictures and addressed his multiple wounds. Interview with the Regional [NAME] President of Marketing (RVPM) conducted on 01/22/25 at 1:40 PM, revealed on 01/17/25 he received an email from a staff member from the Medical Director's office. The staff sent an email alleging the hospital was concerned with the lack of care to Resident #2's wounds. The RVPM stated that he lacks clinical expertise and forwarded the email to the clinical consultant. During an interview with the Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC) conducted on 01/23/25 at 3:36 PM, the leadership was asked why the facility did not report the allegation of neglect regarding Resident #2's wounds. The NHA explained she did not receive allegations of neglect or pictures from the hospital. The information filtered thru the marketing team and the corporate leadership. The photos were shared by the practitioner with the Director of Nursing, but up to now, she has not seen them. The Regional Nurse Consultant stated they received the pictures from the hospital and the wounds seemed the same as to the information they had in the medical record, they did not identify anything wrong with the wound. When asked as to why the event was investigated, the RNC explained they did complete a thorough investigation, interviews and timeline and determined the facility provided care for Resident #2's wound, and this was done to respond to the hospital concerns. The NHA added the facility was compiling this file to address the issue with the hospital but no one from the hospital called them with allegations of neglect. The leadership was asked again as to why the concerns regarding the condition of the resident's wounds were not identified as an allegation of neglect, which is defined as failure to provide necessary care and services and acknowledged that is possible that they waited too long, they were trying to address the issue with the hospital and their investigation revealed the resident received appropriate care. Review of facility documents including reportable event and incident logs failed to provide evidence the facility identify the hospital concerns regarding Resident #2's care to his wound as an allegation of neglect.

Based on observation, record review, policy review and interview, the nursing staff failed to implement the facility policy for the storage of nebulizer equipment. The failure affected 1 of 6 sampled residents (Resident #1). The findings included: Record review revealed the facility's policy titled, Respiratory Treatment Administration, last revised 12/2023 documented Nebulizers are administered per physician's orders and nebulizer tubing is stored in a hygienic manner (i.e. labeling bag with date tubing was change). Additional guidelines: Report other information in accordance with facility policy and professional standards of practice. Observation of care conducted on 01/22/25 starting at 9:10 AM revealed Resident #1 was lying in her bed. A nebulizer machine was observed on the nightstand, the nebulizer mask was dirty, stained with yellow substance, and it was inside a plastic bag from a grocery store with a bread label. The mask was connected to the nebulizer machine. The resident's spouse informed the surveyor that the staff does not change the mask and that he put it inside the plastic bag, because they leave the mask on top of the table. On 01/22/25 at 9:20 AM, Staff B, a Licensed Practical Nurse, confirmed the nebulizer mask was not dated, was not sure when it was last changed and confirmed the mask and tubing should not be stored inside of a plastic bread bag from a grocery store, and that she will replace it immediately. Clinical record review conducted on 01/21/25 and 01/22/25 revealed Resident #1 was prescribed on 12/31/24, Ipratropium-Albuterol Solution 0.5-2.5 milligrams/3 milliliters, inhale orally two times a day for Shortness of Breath, the resident has a medical history of Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set, annual assessment with reference date 12/02/24, documented the resident was assessed as severely impaired for skills of daily decision making, requires extensive assistance with activity of daily living, has shortness of breath when lying flat and is receiving antibiotic medications. Review of the Care Plans dated 11/13/24, documented the resident is at risk for altered respiratory status/difficulty breathing related to episodes of shortness of breath and upper respiratory infection. The interventions include: Monitor for signs of respiratory distress and report to physician: Increased Respirations; Decreased Pulse Oximetry; Increased Heart Rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Administer medication/inhalers/nebulizers as ordered. Administer oxygen as ordered. Change tubing, per facility protocol/MD order and PRN. Notify MD as indicated. Review of the medication and treatment administration records dated 01/2025 failed to document when the staff changed the nebulizer tubing/mask and storage bag.

Based on interview, observation, and record review, the facility failed to provide appropriate supervision to prevent an elopement, which resulted in two vulnerable residents who were able to leave the facility and travel along a busy roadway with a likelihood of being hurt, killed or lost, for 2 of 3 sampled residents reviewed for an elopement risk (Resident #1 and Resident #2). Due to the likelihood that serious injury, harm and death could've occurred with Resident #1 and #2, a finding of Immediate Jeopardy was identified. The Immediate Jeopardy noncompliance started on 11/07/24 and is determined to be ongoing. The facility's Administrator was notified of Immediate Jeopardy and given the Immediate Jeopardy Template on 11/21/24 at 11:20 AM. The findings included: 1) Clinical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Depression, and Dementia. The admission Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 with a Brief Interview for Mental Status (BIMS) score of 07, which indicted Resident #1 was severely cognitively impaired. This MDS documented Resident #1 exhibited moods including: Feeling down, depressed, or hopeless; Trouble falling asleep, staying asleep or sleeping too much. Feeling tired or having little energy. Poor appetite or overeating. Trouble concentrating on things such as reading the newspaper or watching TV. Moving or speaking so slow that other people could have noticed. Review of the physician orders dated 10/08/24, 10/09/24, 10/14/24, 10/15/24, and 11/02/24 revealed Resident #1 received the following psychotropic medications including: Donepezil oral Tablet, 5 MG (milligrams), 1 tablet by mouth at bedtime for Dementia. Quetiapine Fumarate Oral Tablet 75 MG by mouth in the evening for Dementia and Psychosis. Sertraline Oral Tablet 25 MG, give 0.5 tablet by mouth one time a day for Dementia. Memantine Oral Tablet 10 MG 1 tablet by mouth two times a day for Dementia. Mirtazapine Tablet 7.5 MG 1 tablet by mouth at bedtime for Poor Appetite secondary to Depression. Depakote Oral Tablet Delayed Release 250 MG, 1 tablet by mouth two times a day for Mood Disorder. Additional review of physician orders dated 11/06/24 documented to monitor (Resident #1) for elopement, as he has been seen in other resident's rooms. Further review of the clinical records, including medication and treatment administration records, and progress notes revealed the physician order to monitor (Resident #1) for elopement had not been transcribed. There was no documentation of monitoring Resident #1 for elopement in the records. Review of the care plans initiated on 10/10/24 documented Resident #1 had impaired cognitive function/impaired thought processes related to a diagnosis of Encephalopathy, diagnosis of Dementia and BIMS less than 12. On 11/07/24 at approximately 11:00 PM, Resident #1 walked from the 2nd floor via the elevator, unlocked the front door and exited the building to an uneven terrain with multiple tripping hazards and a busy 6 lane road. Resident #1 was located by the police approximately 1 mile from the facility on 11/08/24 at 1:02 AM, transported to a Medical Center for evaluation and returned to the facility by transport at 5:00 AM. Review of Staff A's (Licensed Practical Nurse/LPN) written statement documented on 11/07/24 at approximately at 10 PM, Staff A provided Resident #1 with his scheduled nighttime medications. Approximately 10:30 PM, Resident #1 was seen leaving the nursing station headed towards his room. Approximately 11:00 PM, Resident #1 was not actually in his room. A search was started. At approximately 11:30 PM, the police were notified after an unsuccessful search by the staff. Review of Staff B's (Certified Nursing Assistant/CNA) written statement revealed on 11/07/24 at approximately 10:00 PM, Resident #1 was walking the hallway. Staff B told him to sit in the chair at the nursing station, as Staff B was assisting another resident to her bed. At approximately 10:10 PM, Staff B finished up with the resident and proceeded to do rounds and did not see Resident #1. At approximately 10:15 PM, Staff B notified the nurse and began to look for Resident #1. Review of Staff C's (Certified Nursing Assistant/CNA) written statement recorded on 11/07/24 at 9:50 PM revealed, Staff C was sitting in the middle of the hallway and Resident #1 approached Staff C and stated that he wanted to see a show. Staff C told Resident #1 to return to his room. Staff C called the nurse, and the nurse brought him back to his room. At 10:20 PM, another CNA informed Staff C that Resident #1 was not in his room, and the staff started searching each room and outside of the facility. On 11/19/24 at 11:30 AM, an interview was held with the Nursing Home Administrator (NHA) and an inquiry was made regarding Resident #1's elopement. The NHA explained, it was believed that Resident #1 forcefully opened the facility front door, he walked out to the sidewalk, and made a right, which leads to a small street that goes to the SWA (Solid Waste Authority). Resident #1 then made a right turn that led towards a 6-lane road. The NHA further explained the front door was locked at night after the receptionist leaves. At this time, the sensor is turned off and the sensor will not open the door, once the door is approached. One must unlock the door and physically pry the door open. On 11/19/24 at 2:20 PM, an interview was held with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). An inquiry was made regarding how the staff monitored Resident #1 for elopement, and where the monitoring for the elopement was documented. The DON voiced the staff did not see the monitor for elopement order until 11/07/24 at 7 PM. On 11/19/24 at 2:33 PM, a phone interview was completed with Staff A. She voiced that she was the nurse on duty. The last time she saw Resident #1 was around 10:20 PM, in which he was at the nursing station. She further explained that typically Resident #1 comes out his room, asks for tea, then wanders to other resident's rooms. Staff A stated she kept him at the nursing station to keep an eye on him. However, at approximately 10:25 PM, she left him alone at the nursing station and went to pass medications for her other residents. The pathway Resident #1 allegedly took was walked by the Surveyor on 11/20/24 at 10:20 AM, accompanied with the NHA for approximately 3/4 of a mile and stopped at the corner of two major roads where Resident #1 allegedly turned and went further southbound. The police picked Resident #1 up between this location and a diner approximately a quarter mile up the road, located on a local six-lane road, which is a three lane each direction and very busy. During this walk with the NHA, it was noted that the path was all even sidewalks with an occasional crosswalk that sloped down slightly where it entered the road and then back up to the sidewalk. Along the sidewalk, there were mostly wooded areas and office buildings. Review of the Interdisciplinary Team (IDT) notes dated 11/08/2024 at 5:22 AM (after the resident eloped and was returned to the facility), indicated on 11/07/24 at approximately 11:00 PM, Resident #1 was not observed in his room. The local law enforcement located Resident #1, had him transported to the emergency room for evaluation, and was Resident #1 returned to the facility on [DATE] at 5:00 AM. 2) A review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included: Non-Alzheimer's Dementia, Anxiety disorder, Depression, and Psychotic disorder. According to progress notes dated 11/18/24 at 7:18 PM, Resident #2 was alert with intermittent confusion. The quarterly MDS assessment, with a reference date of 10/14/24, recorded a BIMS score of 06, indicating severe cognitive impairment. Review of care plans initiated on 07/12/2024 recorded Resident #2 had a communication problem related to impairment in cognitive status, Language Barrier. She required an interpreter. Resident #2 had a diagnosis of Dementia, and further decline was expected with the progression of disease processes. On 11/16/24 at 12:45 AM, Resident #2 walked and walked down 3 flights of stairs via stairwell and exited to a sidewalk with uneven terrain with multiple tripping hazards. The resident was located across the street at a Rehabilitation Hospital at 1:33 AM (this is a small street with a crosswalk between facilities, which is not on the same property) and returned to the facility by the police at 1:33 AM. Review of Resident #2's progress notes, dated 11/16/24 revealed the following: -Evening shift - resident was seen in room periodically throughout the evening. No concerns were noted. No exit seeking behaviors. -12:00 AM - Resident was toileted and returned to bed. -12:30 AM - Resident was in bed with eyes closed. -12:45 AM - Resident was not in her room. -1:00 AM-Resident was not in her room, wheelchair near bed, walker at the foot of her bed. -1:14 AM-Nurse went outside in front of the center and informed [the Receptionist] that the resident was missing. Immediately started searching all rooms and informed co-workers. -1:16 AM-Code orange announced. Elopement search initiated. -1:19 AM-Texted DON (Director of Nursing). -1:25 AM-911 called by the receptionist at the Rehab Hospital. She had found the resident outside the front doors and called the nurse manager at the facility. (No police report because the resident was brought right back). -1:30 AM - Provided police with resident's face sheet. -1:33 AM - Police confirmed they had the resident and drove her back to the center. The resident was calm and smiling. Two officers helped her out of the police car and walked her to the front door. The resident was wearing pajamas and wrapped in a blanket. -1:35 AM - Nurse escorted the resident to her room via wheelchair. She was pleasant and calm. Assessment completed, no skin impairments or pain noted. -1:40 AM-Thorough investigation was initiated, including interviews, reenactment, resident assessment, and a review of employee files and resident's medical record. Review of a psychiatric note dated 11/17/2024 at 00:00 (midnight), documented [Resident #2] was alert and oriented times one, on/off confused. Resident #2 reported that last night she was walking by herself and got out the facility by the stairs. Reported she just wanted to walk as usual around the facility because she walks every day with caregiver. An interview was held with the NHA on 11/19/24 at 3:11 PM, who reported that after the elopement involving Resident #1, the facility conducted full house elopement risk assessments on all residents. During the assessment there were two residents identified, and they were relocated to reside on the third floor. He further stated that Resident #2 has been in the facility since July 2024 and she likes to wander and because of her lower BIMS score, the facility moved her to the 3rd floor. He added that a lot of changes have occurred with Resident #2. She had a change in environment, she had a memory deficit, the psychiatrist has changed her medications, her daughter visited from [another state] they took her out, so that created a lot of stimulation for her. She was able to walk, she was doing better in therapy, she went out looking for her niece. When the facility interviewed her regarding the elopement incident, she said she took the stairs from the 3rd floor to elope. It was revealed that the staff called the NHA around 12 AM, reported they were looking for Resident #2, and she was later found at the post-acute rehab across from the facility. The NHA stated, Resident #2 did not elope through the front door, she went out through the side doors. He explained that if the side doors are pushed for 15 seconds, they will automatically open. He further added that after the elopement involving Resident #1, screamer alarms were added to the exit doors of the facility to alert staff when the doors are opened. On 11/22/24 beginning at 10:47 AM, a tour of the entire facility was conducted with the Maintenance Director, checking on all exit doors in the facility starting from the 3rd floor. At 11:06 AM, the Maintenance Director accompanied the two surveyors to the exit door at the stair well in the back of the building on the 3rd floor, near the elevator, and it was checked. When the Maintenance Director pushed on the door, the screamers sounded very loud, and the alarms went off. No staff responded to the sound of the alarms. Despite corrections were put in place after the elopements, the staff failed to respond to the sound of the exit alarms. On 11/22/24 at 11:10 AM, the stairwell where Resident #2 allegedly eloped was checked. Director. When the Maintenance Director pushed on the door after 15 seconds, the screamers went off, sounded very loud. No staff responded to the sound of the alarm. Despite corrections were put in place after the elopements, the staff failed to respond to the sound of the exit alarms. On 11/22/24 at 11:21 AM, the exit door/stairwell at the second floor was checked. The Maintenance Director pushed on the door; the alarms sounded. Despite corrections were put in place after the elopements, the staff failed to respond to the sound of the exit alarms. On 11/22/24 at 11:26 AM, the exit door/stairwell was checked at the second floor. The Maintenance Director pushed on the door; the alarms sounded. Despite corrections were put in place after the elopements, the staff failed to respond to the sound of the exit alarms. On 11/22/24 at 11:29 AM, a tour began at the first floor to check the exit doors at the stairwell. When the Maintenance Director pushed on the first exit door, the alarm sounded. Despite corrections were put in place after the elopements, the staff failed to respond to the sound of the exit alarms. On 11/22/24 at 11:33 AM, an observation was made of the alarmed door that led into the kitchen. This alarmed door was observed propped wide open. Further observation revealed there was a dietary office located inside of the kitchen that had a door leading to the outside of the facility, which was not alarmed. The main kitchen exit door leading to the outside exterior grounds of the facility was also not alarmed. It was noted that during this observation, there were no kitchen staff present, which would have allowed any resident to exit the building unnoticed. On 11/22/24 at 11:38 AM, the exit door that led to the parking lot was checked at the first floor. When the Maintenance Director pushed on the door, the alarms went off. Despite corrections were put in place after the elopements, the staff failed to respond to the sound of the exit alarms. On 11/22/24 at 11:42 AM, during the tour, an inquiry was made regarding the lack of response by the staff when the alarms sounded. The Maintenance Director confirmed this concern and stated that he would need to conduct additional in-services, regarding the staff's lack of response to the door alarms. On 11/22/24 at 2:34 PM, another observation of the exit door that led to the kitchen was conducted. This door was still wide open after it was brought to the Maintenance Director's attention at the time of the tour.

Based on record review and interview the facility failed to ensure daily wound care for 1 of 4 sampled residents with surgical incisions (Resident #2). The lack of daily wound care for Resident #2 resulted in maceration of the surgical skin flap resulting in exposure to the bone with need for additional surgery; and the facility failed to ensure appropriate care and services for 1 of 2 sampled residents with an IV (intravenous) line (Resident #1). The lack of timely response to needed care for a Peripherally Inserted Central Catheter (PICC) line dislodgement for Resident #1 on 09/04/24 resulted in psychological harm as evidenced by staff and family report that the resident was irate and hysterical. The findings included: 1. Review of the record revealed Resident #2 was admitted to the facility on [DATE] and send to the hospital directly from a surgical post-operative office visit on 09/03/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident had a surgical wound. Review of the hospital record revealed the surgeon placed Negative Pressure Wound Therapy (NPWT) to Resident #2's surgical wound on 08/21/24, and it was discontinued at the hospital on 08/26/24 prior to admission to the facility. The Wound Care Consult from the hospital documented the right foot wound care as to clean with normal saline, pat dry well, and cover. Review of the physician order dated 08/26/24, upon arrival to the facility, instructed staff to clean the right foot surgical wound with normal saline, pat dry, apply a non-adherent dressing, and secure daily. A second wound care order dated 08/29/24, written by the facility's wound care nurse and signed off by the facility's rehab physician, documented staff were to cleanse the right toe surgical wound daily with Vashe Wound Therapy External Solution (wound cleanser), pat dry, apply collagen to site, cover with a silicone foam dressing daily. This order also documented to protect the peri wound with skin prep and included a PRN order every 8 hours as needed. Review of the Treatment Administration Records (TARs) revealed wound care was not provided to Resident #2 on 08/09/24 and 08/31/24 as evidenced by a lack of nurse signature on those two dates. Review of the associated progress notes lacked any reason for the lack of care. Further review of the progress notes and scanned documents lacked any communication or order from the surgeon related to the change in wound care orders. During a phone interview on 09/26/24 at 1:10 PM, the adult daughter of Resident #2, who is also a physician, explained that during the resident's surgical follow-up office visit on 09/03/24, her father (Resident #2) told the surgeon the wound care had not been provided daily. Upon observation of the surgical site by the surgeon, he stated the lack of wound care macerated the skin flap, resulting in the skin flap not working and additional damage to the toe, resulting in the need for hospitalization and further surgery. During an interview on 10/03/24 at 3:43 PM, when asked why the wound care order for Resident #2 was changed and not completed as ordered, the First Floor Unit Manager did not know and was unable to find rationale in the record. The Unit Manager confirmed the order change was written by the facility's wound care nurse and further explained she does rounds with a wound care provider. During a side-by-side review of the record the Unit Manager was unable to locate any notes from the wound care provider. During a phone interview on 10/03/24 at 5:04 PM, when asked why the wound care order was changed, the facility's wound care nurse stated she had called the surgeon to schedule the follow-up appointment for Resident #2, and while on the phone she was given the verbal order for the change. The wound care nurse stated she thought that the new order was what the surgeon wanted. When asked if there was any documentation of this, the wound care nurse stated they had faxed over the order. The faxed order was never located or provided. 2. Review of the record revealed Resident #1 was admitted to the facility on [DATE] and transferred out the the hospital on 09/04/24, after dislodgement of the resident's Peripherally Inserted Central Catheter (PICC/intravenous access through a vein in the arm and threaded into a large vein near the heart). Review of the Medication Administration Record (MAR) revealed the IV antibiotic Invance 1 gram was started at 5:33 PM by Staff C, RN, who was the assigned direct care nurse for Resident #1 on 09/04/24 during the day shift. Review of the PPD Detail Report (a report generated for staff clocking in and out) revealed Staff C had clocked out at 6:24 PM on 09/04/24. A change in condition form and progress note, both dated 09/04/24 at 7:15 PM but created eight days after the event on 09/12/24 by the Assistant Director of Nursing (ADON), simply documented the PICC line was noted on the floor with a small quantity of blood on the floor, sheets and adjacent to the IV site on the resident's right arm. During an interview on 10/02/24 at 3:59 PM, Staff B, RN, confirmed he worked the 12 hour day shift. When asked what happened on 09/04/24 with Resident #1's PICC line, the RN explained he was by himself as the other nurse for the day had left early. Staff B explained the other nurse had given report to him, explaining she had hung an IV antibiotic, and Resident #1's PICC would need to be flushed. Staff B stated he went to flush the IV and a CNA stated there was an emergency as she had pulled the IV out. The RN stated he had two CNAs help clean the resident up and emergency personnel arrived. The RN stated he asked why they were there, and the emergency personnel stated the family had called them. The RN stated by the time the emergency personnel came, he had finished and was trying to get a gown, when the emergency personnel told him to get out. Staff B stated the resident was fine, and the resident was left with the CNAs and the paramedics. Staff B would not describe the blood but just kept saying she was fine when 911 came to the room. The RN did say there was some blood on her personal clothing (top) and so they had to get a hospital gown. When asked why he did not write a progress note about the incident, Staff B, RN stated it was shift change and Resident #1 was not on his assignment, so he didn't write anything. During an interview on 10/02/24 at 2:29 PM, Staff E, CNA assigned to Resident #1 on 09/04/24, explained she works the day shift from 7 AM to 7:30 PM. When asked about the incident with Resident #1's PICC line, the CNA stated she had checked on the resident during her last rounds between 6:30 PM and 6:45 PM, and the resident was fine. The CNA stated she heard about the incident but did not see anything, stating she thought it happened after shift change. Review of the PPD Detail Report ( documented Staff E, CNA, clocked out at 7:30 PM. (Note as documented below, the family member stated [Resident #1] phoned him at 6:50 PM and was hysterical about the PICC line being out, thus the event happened before Staff E clocked out.) During an interview on 10/02/24 at 2:43 PM, Staff D, CNA who was asked to assist by Staff B, covering RN, explained Resident #1 was not on her assignment, but it was change of shift and Staff B, covering RN, grabbed her to assist. The CNA stated upon arrival to the room, Resident #1 was hysterical. There was blood. We were there just two minutes and the door flew open, and the paramedics took over. When asked how much blood, Staff D stated she was told not to describe it as drenched, and would not quantify, but stated there was blood all over the resident's clothes and the bed. The CNA again stated she and Staff B, covering RN, were only in the room about two minutes before the emergency personnel arrived. As per a phone interview on 09/26/24 at 2:23 PM with law enforcement, paramedics and law enforcement were on the premises at 7:10 PM. During a phone interview on 10/02/24 at 5:34 PM, Staff F, CNA explained she worked the night shift from 7 PM to 7:30 AM. When asked about the incident on 09/04/24 with Resident #1's PICC line, the CNA explained she had clocked in downstairs a little before 7 PM, and took the back elevator to the second floor. Review of the PPD Detail Report documented Staff F clocked in at 6:42 PM. The CNA stated as soon as the elevator doors opened on the second floor, she heard screaming. The CNA stated she dropped her stuff at the nurse's station, and ran into the room of Resident #1, and her gown was drenched in blood. The CNA stated she went to try and find her day nurse, could not find her, so she went to the back side of the unit and found Staff B, RN and told him Resident #1 was bleeding and it was a lot. When asked if the resident was in bed, the CNA stated she was and that there was a lot of blood there as well. Staff F, CNA, stated that a day shift CNA finally came and said she (the resident) had been like that for about an hour. When asked which day shift CNA she was speaking about, Staff F, CNA described Staff D, CNA. When asked again about what time she arrived on the second floor, Staff F again stated, just a little before 7 PM. During an interview on 10/03/24 at 4:00 PM, when asked if she was in the building when the PICC line for Resident #1 came out, the ADON stated she was not, but was nearby and returned to the facility. When asked what she observed, the ADON stated the resident was gone by the time she returned. When asked why she entered the note about the event, the ADON stated she was assisting Staff B, covering RN, and asking him what happened so she would initiate a report. When asked why she documented a small amount of blood in the progress note, the ADON stated because that is what she saw after the incident. When asked what Staff B told her, the ADON stated Staff B said he received report from the other nurse and that there was an antibiotic running that would need to be checked. He stated he was notified by a CNA on the other side of the unit that the machine was beeping. When he went into the room, he saw the line on the floor and blood on the bed, floor, and gown. The RN verbalized the resident was irate. The RN told the ADON he had asked the CNA to apply a new gown and change the linens, and that the paramedics arrived while the CNA went to get a gown, and they took over. When asked if any of the other day shift staff who worked the second floor, or if any of the night shift staff were interviewed since the event happened at or near shift change, the ADON stated not to her knowledge. The ADON did state that Staff D, CNA told her via phone that the resident was drenched with blood . blood was all over. The ADON stated she asked her how she could be drenched with blood and the CNA stated there was a lot of blood. The ADON stated at the end of the phone conversation, she asked Staff D to email her a statement. During a phone interview on 10/03/24 at 9:50 AM, the family member of Resident #1 explained he had just left the faciity on [DATE], and was still driving, when he received a call from [Resident #1]. The adult family member stated she was hysterical about her IV coming out, there was blood everywhere, and staff were not answering the call bell, so he called 911. When asked what time he called 911, the family member looked at his cell phone history and stated at 6:50 PM.

Based on record review and interview, the facility failed to ensure appropriate care and services for 1 of 2 sampled residents with an IV (intravenous) line (Resident #1). The lack of timely response to needed care for a Peripherally Inserted Central Catheter (PICC) line dislodgement for Resident #1 on 09/04/24 resulted in psychological harm as evidenced by staff and family report that the resident was irate and hysterical. The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE] and transferred out the the hospital on 09/04/24, after dislodgement of the resident's Peripherally Inserted Central Catheter (PICC/intravenous access through a vein in the arm and threaded into a large vein near the heart). Review of the Medication Administration Record (MAR) revealed the IV antibiotic Invance 1 gram was started at 5:33 PM by Staff C, RN, who was the assigned direct care nurse for Resident #1 on 09/04/24 during the day shift. Review of the PPD Detail Report (a report generated for staff clocking in and out) revealed Staff C had clocked out at 6:24 PM on 09/04/24. A change in condition form and progress note, both dated 09/04/24 at 7:15 PM but created eight days after the event on 09/12/24 by the Assistant Director of Nursing (ADON), simply documented the PICC line was noted on the floor with a small quantity of blood on the floor, sheets and adjacent to the IV site on the resident's right arm. During an interview on 10/02/24 at 3:59 PM, Staff B, RN, confirmed he worked the 12 hour day shift. When asked what happened on 09/04/24 with Resident #1's PICC line, the RN explained he was by himself as the other nurse for the day had left early. Staff B explained the other nurse had given report to him, explaining she had hung an IV antibiotic, and Resident #1's PICC would need to be flushed. Staff B stated he went to flush the IV and a CNA stated there was an emergency as she had pulled the IV out. The RN stated he had two CNAs help clean the resident up and emergency personnel arrived. The RN stated he asked why they were there, and the emergency personnel stated the family had called them. The RN stated by the time the emergency personnel came, he had finished and was trying to get a gown, when the emergency personnel told him to get out. Staff B stated the resident was fine, and the resident was left with the CNAs and the paramedics. Staff B would not describe the blood but just kept saying she was fine when 911 came to the room. The RN did say there was some blood on her personal clothing (top) and so they had to get a hospital gown. When asked why he did not write a progress note about the incident, Staff B, RN stated it was shift change and Resident #1 was not on his assignment, so he didn't write anything. During an interview on 10/02/24 at 2:29 PM, Staff E, CNA assigned to Resident #1 on 09/04/24, explained she works the day shift from 7 AM to 7:30 PM. When asked about the incident with Resident #1's PICC line, the CNA stated she had checked on the resident during her last rounds between 6:30 PM and 6:45 PM, and the resident was fine. The CNA stated she heard about the incident but did not see anything, stating she thought it happened after shift change. Review of the PPD Detail Report documented Staff E, CNA, clocked out at 7:30 PM. (Note as documented below, the family member stated [Resident #1] phoned him at 6:50 PM and was hysterical (about the PICC line being out) thus the event happened before Staff E clocked out). During an interview on 10/02/24 at 2:43 PM, Staff D, CNA who was asked to assist by Staff B, covering RN, explained Resident #1 was not on her assignment, but it was change of shift and Staff B, covering RN, grabbed her to assist. The CNA stated upon arrival to the room, Resident #1 was hysterical. There was blood. We were there just two minutes and the door flew open, and the paramedics took over. When asked how much blood, Staff D stated she was told not to describe it as drenched, and would not quantify, but stated there was blood all over the resident's clothes and the bed. The CNA again stated she and Staff B, covering RN, were only in the room about two minutes before the emergency personnel arrived. As per a phone interview on 09/26/24 at 2:23 PM with law enforcement, paramedics and law enforcement were on the premises at 7:10 PM. During a phone interview on 10/02/24 at 5:34 PM, Staff F, CNA explained she worked the night shift from 7 PM to 7:30 AM. When asked about the incident on 09/04/24 with Resident #1's PICC line, the CNA explained she had clocked in downstairs a little before 7 PM, and took the back elevator to the second floor. Review of the PPD Detail Report documented Staff F clocked in at 6:42 PM. The CNA stated as soon as the elevator doors opened on the second floor, she heard screaming. The CNA stated she dropped her stuff at the nurse's station, and ran into the room of Resident #1, and her gown was drenched in blood. The CNA stated she went to try and find her day nurse, could not find her, so she went to the back side of the unit and found Staff B, RN and told him Resident #1 was bleeding and it was a lot. When asked if the resident was in bed, the CNA stated she was and that there was a lot of blood there as well. Staff F, CNA, stated that a day shift CNA finally came and said she (the resident) had been like that for about an hour. When asked which day shift CNA she was speaking about, Staff F, CNA described Staff D, CNA. When asked again about what time she arrived on the second floor, Staff F again stated, just a little before 7 PM. During an interview on 10/03/24 at 4:00 PM, when asked if she was in the building when the PICC line for Resident #1 came out, the ADON stated she was not, but was nearby and returned to the facility. When asked what she observed, the ADON stated the resident was gone by the time she returned. When asked why she entered the note about the event, the ADON stated she was assisting Staff B, covering RN, and asking him what happened so she would initiate a report. When asked why she documented a small amount of blood in the progress note, the ADON stated because that is what she saw after the incident. When asked what Staff B told her, the ADON stated Staff B said he received report from the other nurse and that there was an antibiotic running that would need to be checked. He stated he was notified by a CNA on the other side of the unit that the machine was beeping. When he went into the room, he saw the line on the floor and blood on the bed, floor, and gown. The RN verbalized the resident was irate. The RN told the ADON he had asked the CNA to apply a new gown and change the linens, and that the paramedics arrived while the CNA went to get a gown, and they took over. When asked if any of the other day shift staff who worked the second floor, or if any of the night shift staff were interviewed since the event happened at or near shift change, the ADON stated not to her knowledge. The ADON did state that Staff D, CNA told her via phone that the resident was drenched with blood . blood was all over. The ADON stated she asked her how she could be drenched with blood and the CNA stated there was a lot of blood. The ADON stated at the end of the phone conversation, she asked Staff D to email her a statement. During a phone interview on 10/03/24 at 9:50 AM, the family member of Resident #1 explained he had just left the faciity on [DATE], and was still driving, when he received a call from his [Resident #1]. The family member stated she was hysterical about her IV coming out, there was blood everywhere, and staff were not answering the call bell, so he called 911. When asked what time he called 911, the family member looked at his cell phone history and stated at 6:50 PM.