Every finding on record at North Port Rehabilitation and Nursing Center

Based on Observation, interview, and record review the facility failed to provide maintenance services to ensure a clean, safe, and comfortable environment in the residents' designated smoking area and 1 (Rosebud unit) of 1 unit observed with stained ceiling tiles, and 2 (Rooms #134 and #176) of 60 rooms observed. The findings included: On 7/14/24 at 9:26 a.m., a nursing staff member was observed wiping condensation from the air conditioner vent near the Rosebud Nursing station. Eleven of the ceiling tiles around the vent showed signs of leaking from the ceiling. An area of black growth was observed on the wall near the ceiling next to the rosebud nursing station. On 7/15/24 at 11:00 a.m., in an interview the Regional Manager of Operations said the roof was leaking. On 7/11/24 an inspector came out and was working on obtaining an estimate for the necessary repairs. She provided documentation from a roofing company describing the damage found to the roof on 7/11/23. She stated a lot of what was seen on the tiles is from condensation from the air conditioning. The Regional Manager of operations verified the black growth on the wall near the nursing station and said she was not made aware of the black organic growth on the wall. On 7/18/24 11:20 a.m., the Director of Maintenance said the facility was working on a quote to fix the roof and address the condensation on the air conditioning vents. On 7/14/24 at 1:52 p.m., in an interview Resident #6 said the tent which was the designated smoking area in the courtyard had been leaking. The resident said when it rains and they are out smoking, they get wet. On 7/17/24 at 2:19 p.m., observation of the designated smoking area in the courtyard showed the tent had a large opening directly down the middle of the roof that extended the entire length of the roof line. On 7/18/24 at 11:20 a.m., in an interview the Director Of Maintenance said he found out the tent was leaking on 7/17/24. The maintenance Director said nursing staff were supposed to use the facility's electronic system to document areas in need of repair. The Director Of Maintenance said staff needed to be instructed to enter maintenance issues in the system to ensure repairs are completed in a timely manner. On 7/14/24 at 11:20 a.m., the door to the closet next to the window in room [ROOM NUMBER] was observed in disrepair. On 7/18/24 at 11:20 a.m., the Director of Maintenance verified the closet needed to be repaired but no one had informed him of the damage to the closet door in room [ROOM NUMBER]. 38570 On 7/14/24 at 10:32 a.m., during an observation into the shared bathroom of room [ROOM NUMBER] noted on the back of the toilet there were two (2) urinals and two (2) wash basins. The items were not noted to have either resident name or room number and bed. An emesis basin was also noted to be sitting on the side of the sink with a toothbrush and toothpaste in it. These items were also not labeled with resident name or room number and bed. room [ROOM NUMBER] was occupied by two residents at the time of the observation. On 7/15/24 at 8:54 a.m., during a second observation into bathroom in room [ROOM NUMBER] the resident personal items of two (2) urinals and two (2) wash basins on the back of the toilet with no labeling observed. The 2-wash basin were different colors on pink and one was light gold. they were sitting in one another. The urinal were tucked behind the wash basins. The Emesis basin was also still on the counter beside the sink with no noted labeling as to which resident it belonged to. the sink had a cabinet below it and it had 2 door on it, but the doors had no knobs to open the cabinet to put items below the sink. On 7/17/24 at 3:10 p.m., during a third observation of the bathroom in room [ROOM NUMBER] accompanied by LPN Staff L, again we observed the 2 urinals and 2 wash basins on the back of the toilet and the emesis basin still did not have labeling on it as to which resident it belonged to. During an interview on 7/17/24 at 3:11 p.m., LPN Staff L verified the personal items in room [ROOM NUMBER] were not labeled making it impossible to know which resident they belonged to. During an interview on 7/18/24 at 1:06 p.m. Director of Nursing (DON) said the residents personal items kept in their bathrooms should be labeled with their name and room number and bed and kept separate from the other persons things in the room. DON states that like in the cabinet below the sink, one resident items she be on one side and the others on the other side and labeled. DON said that if items are found commingled together without being labeled they should be thrown away and the resident given new ones. She said what the surveyor found was cross contamination.

Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Residents #20, #33, and #167) of 8 sampled residents dependent on staff for activities of daily living, including showers, incontinent care and nail care. The findings included: 1. Record review revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included history of Bipolar Disorder, Anxiety, Major Depressive Disorder, Unspecified Mood Disorder, Dementia with behavioral disturbance, Confusional Arousal, Congestive Heart Failure, Chronic Kidney Disease, Anemia, and Hypertension. The Admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #20's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 07. The assessment noted Resident #20 was dependent on staff for personal hygiene. On 7/15/24 at 9:28 a.m. Resident #20 was observed lying in the bed. Resident #20's left hand was contracted. Resident #20 was not able to open her left hand. The resident's fingernails to the right and left hand were long and extended approximately 1/2 inch with an accumulation of a brown substance under the nails. On 7/17/24 at 9:47 a.m., in an interview Certified Nursing Assistant (CNA) Staff T said activities staff were responsible for residents nail care. On 7/17/24 at 9:49 a.m., in an interview Licensed Practical Nurse (LPN) Staff H said the activities staff were responsible for residents' nail care. Staff H said the CNAs can also clip fingernails as needed. On 7/18/24 at 10:00 a.m., the Acting Director of Rehabilitation was observed working with Resident #20 and trying to open her left hand. In an interview, the Director verified Resident #20's nails were long and dirty. The Director said the resident's nails needed to be clipped to prevent them from digging into her left hand, and cleaned. On 7/18/24 at 10:40 a.m., during a joint observation the Director of Nursing (DON) verified Resident #20's nails needed to be clipped and cleaned. The DON said the CNAs were responsible to clip the resident's nails and keep them clean. 2. Review of the clinical record for Resident #33 revealed an admitted [DATE] with a history of Dementia. The Quarterly MDS dated [DATE] noted the resident's cognition was severely impaired. Review of the care plan revealed Resident #33 had self-care deficit with Activities of Daily Living (ADLs) related to activity intolerance. The resident's ADL needs and participation varied. The interventions noted the resident was dependent on staff for bathing needs, including transfer into and out of shower. On 7/15/24 at 3:54 p.m., in an interview Resident #33's daughter said she found her mother in the hallway today soaked through with urine and feces. She said this happens all the time and she spoke to the administration. Resident #33's daughter said she had spoken with the administration verbally about the issue and it keeps happening. Resident #33's daughter said her mother does not receive showers regularly. She said her mother suffered a bacterial infection on her face because staff were not bathing her regularly. Review of the bathing history revealed Resident #33 received a total of three showers (6/22/24, 7/3/24 and 7/13/24) from 6/19/24 through 7/13/24. On 7/17/24 at 11:20 a.m., in a telephone interview CNA Staff U she said she worked at the facility until May 2024. Staff U said residents were being left soaked in urine and caked in feces. They were always short-staffed at night and she would be assigned 20 to 25 residents at night. Staff U said when she brought up her concerns to the DON and the Administrator at the time she was told to forget about it. It was not that important. She stated she felt leaving residents unchanged would cause skin breakdown and she could no longer work for the facility. On 7/17/24 at 1:35 p.m., in an interview LPN Staff I said the last couple nights CNAs have complained about the workload, they have 25 patients. Staff I said she's had CNAs complain during the morning change of shift that residents are soaked through with urine, and had to completely change the bedding of four residents as they were soaked through with urine. On 7/18/24 at 10:55 a.m., in an interview the Director of Nursing said Resident #33's daughter had not reported any care concerns to her. She said she would have written the verbal complaint as a grievance. 25618 3. On 7/14/24 at 1:39 p.m., in an interview with Resident #167 and Resident #167's husband, they said Resident #167 had not received a shower since being admitted to the facility on [DATE]. Resident #167 said she had asked the facility staff multiple times if they could assist her with a shower but they keep telling her she had to wait until her shower day to receive her shower and get her hair washed. Resident #94's husband said he would assist his wife with her shower if he could, but his wife is unsteady on her feet, and he didn't want her to fall. They said the nursing staff promised to give her a shower tonight. On 7/15/24 at 1:46 p.m., in an interview with Resident #94 and Resident #94's granddaughter, they said the nursing staff did not give Resident #94 her shower on 7/13/24 as promised. The granddaughter said she had to give her grandmother a shower and wash her hair on the afternoon of 7/15/24 with assistance from one of the nursing staff. Resident #94 said she felt a lot better now that she had a shower and was able to get her hair washed. Review of Resident #94's medical record revealed she was admitted to the facility on [DATE] with diagnosis of polyneuropathy, low back pain, polyarthritis, syncope and collapse and a need for assistance with personal care. The Nail Care and Shower Schedule revealed Resident #94's showers are due every Wednesday and Saturday morning. Review of Resident #94's shower documentation noted Resident #94 had not received her scheduled showers on 7/3, 7/6, 7/10, and 7/13 as required. Further review of Resident #94's medical record revealed no documentation Resident #94 had refused her scheduled showers on 7/3, 7/6, 7/10, and 7/13. On 7/17/24 at 11:43 a.m., in an interview with Staff L, Unit Manager, she said all residents were scheduled for a shower 2 times a week, and the resident's Certified Nursing Assistant (CNA) were required to give the resident their shower as scheduled. She said if a resident refused their shower, the CNA was required to inform the resident's nurse. If the resident continued to refuse their shower, the CNA and nurse were required to document the refusal in the resident's medical record. She said the facility has a dedicated CNA who assisted with the resident's schedule shower each day, but it was the resident's assigned CNA who was responsible to ensure their resident received their scheduled shower each day. On 7/17/24 at 11:55 a.m., interview with Staff T, CNA, he said he was the assigned CNA to do the resident's daily shower. He said he had 18 to 20 resident showers to do each day. He said if he was assigned to another task because the facility is low on staff and/or a CNA had called off for that day, he was unable to do the resident showers and resident assigned CNA for that day was responsible to complete their resident scheduled shower for that day. Staff T said he had not given Resident #94 a shower since she was admitted to the facility. He said Resident #94 was cooperative and would not refuse care and/or a shower if it had been offered to her. On 7/17/24 at 12:19 p.m., in an interview with Staff L, Unit Manager, she confirmed after she reviewed Resident #94's medical record that Resident #94 had not received her scheduled showers on 7/3, 7/6, 7/10, and 7/13 as required, and she was unable to find the required documentation why Resident #94 had not received her required scheduled showers.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 (Resident #418) of 1 sampled resident receiving dialysis. The findings included: 1. The facility policy and procedure titled, Standards and Guidelines: Dialysis Care, with an effective date of 10/2014 and a revision date of 1/2024, stated the facility will implement individualized plans of care to include the interdisciplinary team as well as the dialysis care team in coordination with the attending physician. The Procedure included, Correspondence from the dialysis center will be addressed by facility staff and will be recorded in the plan of care as indicated; The facility will provide a snack/meal to the resident per request prior to or after dialysis appointment . Review of the clinical record revealed Resident #418 was admitted to the facility on [DATE]. Diagnoses included End Stage Renal Disease (ESRD), Hypertension (HTN), Anemia and Infrarenal abdominal aortic aneurysm. The physician's orders included hemodialysis (treatment to filter wastes and water from the blood) at a local dialysis center every Monday, Wednesday and Friday related to ESRD. Review of Resident #418's dialysis patient's information form titled, Tracking my numbers for June 2024 noted the plan for the month was, You need more protein now that you are on dialysis. The form noted the Albumin (Protein in the blood that helps fight infections and aids in healing) was 3.5. The goal was 4 or higher. The physician's orders dated 6/19/24 specified large protein portions for diet. On 6/24/24 the facility's Registered Dietitian documented in a nutritional evaluation Resident #418 may benefit from additional protein-rich foods per the diagnosis of ESRD dependence on hemodialysis three times a week. The intervention was to, Initiate large protein portions. Review of the laboratory results dated [DATE] showed the resident's albumin level was 3.5 for a reference range of 3.5 to 5.2 gram per deciliter. On 7/3/24 the Registered Dietitian (RD) from the dialysis center documented in a communication form to the facility Resident #418's albumin was 3.5. Under special instructions the RD documented to Please add daily protein supplement. The clinical record lacked documentation that a daily protein supplement was added to the resident's diet as requested by the Registered Dietitian. On 7/17/24 at 12:43 p.m., in a telephone interview the facility's Regional Registered Dietitian said she could not locate documentation showing the intervention to add large protein portions to the resident's diet had been effective. On 7/18/24 at 2:40 p.m., Licensed Practical Nurse (LPN) Staff G said she asked the Director of Nursing (DON) who verified the lack of documentation that a daily protein supplement was added to the resident's diet. 2. The facility policy Medication Administration (Revised 1/2024) documented Medications are administered in accordance with prescriber orders, including any required time frame . Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . Medications errors are documented, reported, and reviewed by the QAPI [Quality Assurance and Performance Improvement] committee to inform process changes and the need for additional training . If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall document the rational in the resident's medical record and notify the physician and the responsible party if indicated . Review of the physician's orders revealed Resident #418's medications regimen included: Nifedipine ER extended release 24-hour 60 mg once daily for high blood pressure; Metoprolol 25 mg give 2 tablets by mouth two times a day for high blood pressure. Renvela oral tablet 800 mg, take two tablets three times a day with meals for control of phosphorus levels. Omeprazole capsule 40 mg give one capsule by mouth one time a day for infrarenal abdominal aortic aneurysm ruptured. Review of the Medication Administration Record (MAR) for June 2024 and July 2024 showed the scheduled 9:00 a.m. Metoprolol was not documented as administered on 6/19/24, 6/21/24, 6/28/24, 7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/12/24, and 7/15/24. The scheduled 9:00 a.m. dose of Nifedipine ER 60 mg was not documented as administered on 6/19/24, 6/21/24, 6/24/24, 6/28/24, 7/1/24, 7/2/24, 7/3/24, 7/8/24, 7/12/24 and 7/15/24. The scheduled 9:00 a.m. dose of Renvela 800 mg was not documented as administered on 6/19/24, 6/21/24, 6/24/24, 6/28/24, 7/1/24, 7/2/24, 7/3/24, 7/4/24, 7/5/24, 7/8/24, 7/10/24, 7/12/24 and 7/15/24. On 7/16/24 at 8:29 a.m., in an interview Resident #418 said on dialysis days, the facility does not provide him with breakfast or lunch on dialysis days. He said they give him a diet drink which he doesn't like. Resident #418 said, Sometimes I have a protein bar. The resident verified the facility did not provide him with the Renvela to take with his food at the dialysis center. The scheduled 9:00 a.m. dose of Omeprazole was not documented as administered on 6/24/24, 6/28/24, 7/1/24, 7/2/24, 7/3/24, 7/4/24,7/5/24, 7/8/24, 7/10/24, 7/12/24, and 7/15/24. In addition, the MAR lacked documentation physician's ordered daily Aspirin, Nephro-Vite, and Zinc were administered as scheduled at 9:00 a.m. on dialysis days. On 7/10/24 the physician issued an order for Resident #418 for Vitamin D3, Give 2000 IU by mouth one time a day for Vitamin D3, result 38.1. The MAR for July 2024 lacked documentation the Vitamin D3 was administered on Friday 7/12/24 and Monday 7/15/24. On 7/17/24 at 8:59 a.m., in an interview Registered Nurse (RN) Staff J said she was assigned to Resident #418. Staff J verified Resident #418 did not get his morning medications on dialysis days when he's out of the building. RN Staff J said she has not notified the physician his orders were not followed and Resident #418 did not receive the ordered medications on dialysis days. On 7/17/24 at 9:41 a.m., in an interview the Director of Nursing said she was not aware Resident #418 was not receiving the physician's ordered medications on dialysis days. She said the medication administration time should be changed on dialysis days, and the medications can also be given at dialysis. She said any nurse could call the physician, get an order and make the changes. The Administrator was present during the interview.

Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure 6 residents of 40 residents surveyed (#3, #14, #20 #33, #58, and #65) received appropriate ADL care and ensured call lights were answered in a timely manner. The findings included: On 7/15/24 at 11:47 a.m. Resident #3 said she waits an hour for staff to respond to her call light. Last night I was up all night because any time I had to urinate I would have to wait an hour to get back to bed. The aide came in and said what do you want I explained I needed wiped and assisted back to bed by lifting my legs. The aide wiped me and left the room. I put my light back on and she came back and said what do you want I explained I needed someone to lift my legs in the bed. The aide told me she had other things to do. She said she had to tell her it would only take a minute for her to lift her legs. She said it is hard when the aid does not know what you need. On 7/15/24 at 1:20 p.m. Resident #65 said when she uses her call light it takes a long time for staff to respond. She said the 11 p.m. to 7 a.m. shift is the worst. On 7/16/24 at 10:54 a.m. an emergency call light was observed sounding an alarm. Resident #58 was observed in the hallway waving his hands above his head summoning for help. Licensed Practical Nurse, Staff H came to the nurse's station and looked at the red beeping light on the emergency panel above her and sat down to chart at the computer. Resident #58's room alarm was sounding for 7 minutes and 47 seconds before a Certified Nursing Assistant walked by and assisted the resident to the bathroom. On 7/16/24 at 11:06 a.m. Resident #58 said he had put his call light on because he had to use the bathroom, Resident #58 said he waited for 15 minutes, and he had a bowel movement and had to urinate. Resident #58 said there was no one for him to talk to about the issue. The resident said if staff would come when I ask, I could make it to the bathroom. Resident #58 was asked how he felt, and he said it made him feel horrible. On 7/16/24 1:30 p.m., the Unit manager said all call lights should be responded to within 5-10 minutes. All Staff should be answering call lights. On 7/18/24 at 9:54 a.m. Licensed Practical Nurse, Staff H, said Resident #14 keeps turning his light on. Staff H said Resident #14 thinks he is the only one here. Staff H said, I go in and ask what do you want and he says I want my aide. Staff H said, I told him she will come at 10:30 a.m. but it doesn't sink in sometimes. The light keeps ringing, we go by and say to him motel 6 the light is always on. At that time a Certified Nursing Assistant came to nurse's station and told Staff H Resident #14 requested to see the nurse or the head nurse regarding his call light not being answered. Resident #20 is a [AGE] year-old female who was admitted to the facility on [DATE] with a history of Bipolar Disorder, Anxiety, Major Depressive Disorder, Unspecified Mood Disorder, Dementia with behavioral disturbance, Confusional Arousal, Congestive Heart Failure, Chronic Kidney Disease, Anemia, and Hypertension. On 7/15/24 at 2:37 p.m. in a telephone interview Resident #20's daughter said when she visits her mother they use the call light to her get up or change her brief. She said after 10 to 15 minutes she would have to stand in the hallway and try to flag a staff member down. On 7/15/24 at 9:28 a.m. Resident #20 was observed lying in the bed. Resident #20's left hand was observed to have contractures and to be unable to open her hand. The resident's fingernails on both hands were long and dirty. On 7/17/24 at 9:47 a.m. Certified Nursing Assistant (CNA), Staff T said activities staff was responsible to do nail care on the residents. On 7/17/24 at 9:49 a.m. Licensed Practical Nurse, Staff H said activities was responsible to do nail care on the residents. Staff H said the aides can clip nails as well if needed. On 7/18/24 at 10:00 a.m., The Acting Director of Rehabilitation was observed working with the resident to open her left hand. The Director verified Resident #20's nails were long and dirty. The Director said the resident had to have her nails clipped and cleaned to prevent them from digging into her left hand. On 7/18/24 at 10:40 a.m. The Director of Nursing (DON) Observed the resident's nails and verified they needed clipped and cleaned. The DON said the CNAs were responsible to clip the resident's nails and keep them clean. Review of the clinical record for Resident #33 revealed an admitted [DATE] with a history of Dementia. The Quarterly MDS dated [DATE] noted the resident's cognition was severely impaired. Review of the care plan revealed Resident #33 had self-care deficit with Activities of Daily Living (ADLs) related to activity intolerance. The resident's ADL needs and participation varied. The interventions noted the resident was dependent on staff for bathing needs, including transfer into and out of shower. On 7/15/24 at 3:54 p.m., in an interview Resident #33's daughter said she found her mother in the hallway today soaked through with urine and feces. She said this happens all the time and she spoke to the administration. Resident #33's daughter said she had spoken with the administration verbally about the issue and it keeps happening. Resident #33's daughter said her mother does not receive showers regularly. She said her mother suffered a bacterial infection on her face because staff were not bathing her regularly. Review of the bathing history revealed Resident #33 received a total of three showers (6/22/24, 7/3/24 and 7/13/24) from 6/19/24 through 7/13/24. On 7/17/24 at 11:20 a.m., in a telephone interview CNA Staff U she said she worked at the facility until May 2024. Staff U said residents were being left soaked in urine and caked in feces. They were always short-staffed at night and she would be assigned 20 to 25 residents at night. Staff U said when she brought up her concerns to the DON and the Administrator at the time she was told to forget about it. It was not that important. She stated she felt leaving residents unchanged would cause skin breakdown and she could no longer work for the facility. On 7/17/24 at 1:35 p.m., in an interview LPN Staff I said the last couple nights CNAs have complained about the workload, they have 25 patients. Staff I said she's had CNAs complain during the morning change of shift that residents are soaked through with urine, and had to completely change the bedding of four residents as they were soaked through with urine.

Based on observation, review of facility's policies and procedures, and staff interviews the facility failed to ensure 4 (Residents #4, #63, #67 and #418) of 5 sampled residents were free from significant medication errors. The findings included: The facility policy Medication Administration (Revised 1/2024) documented Medications are administered in accordance with prescriber orders, including any required time frame . Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . Medications errors are documented, reported, and reviewed by the QAPI [Quality Assurance and Performance Improvement] committee to inform process changes and the need for additional training . If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall document the rational in the resident's medical record and notify the physician and the responsible party if indicated . 1. On 7/15/24 at 11:43 a.m., observation of the medication cart of the rose bud unit with Licensed Practical Nurse (LPN) Staff S revealed several pills in two unlabeled plastic medication cups. One cup had three pills which LPN Staff S said were Resident #4's Carvedilol 6.25 milligrams (mg) (Blood pressure medication), Eliquis 2.5 mg (anticoagulant) and Hydroxyzine 25 mg (antianxiety). The cup was stored on an alcohol wipe labeled with Resident #4's name. LPN Staff S said the medications were scheduled to be given at 8:00 a.m. Photographic evidence obtained. Review of the clinical record for Residents #4 revealed a physician's order for Carvedilol 6.25 mg to be administered two times a day for high blood pressure. The morning dose of Carvedilol was scheduled to be administered at 8:00 a.m. The physician's order for Eliquis 2.5 mg specified to administer one tablet by mouth two times a day for atrial fibrillation (type of irregular heart rate). The morning dose of Eliquis was scheduled to be administered at 8:00 a.m. In an interview during the observation, LPN Staff S verified he did not administer the Carvedilol and the Eliquis within the required time frame. One cup had seven pills which LPN Staff S identified as Midodrine 2.5 mg ( to treat low blood pressure), Eliquis 2.5 mg, Oxcarbazepine 150 mg, Tylenol 325 mg (2 tablets) for pain and Gabapentin 300 mg (two tablets) for neuropathy. LPN Staff S said the medications belonged to Resident #63 and were scheduled to be administered at 8:00 a.m. The medication cup was stored on an alcohol pad labeled with Resident #63's name. Photographic evidence obtained. 2. Review of the clinical record for Resident #63 revealed a physician's order dated 4/8/24 to administer Midodrine 2.5 mg, one tablet by mouth in the morning for hypotension (low blood pressure) and Midodrine 5 mg, one tablet by mouth at bedtime. The morning dose of Midodrine was scheduled to be administered at 8:00 a.m. The physician's order for Eliquis 2.5 mg specified to administer one tablet by mouth two times a day for a history of DVT (Deep Vein Thrombosis). The morning dose of the Eliquis was scheduled to be administered at 8:00 a.m. The physician's order for Oxcarbazepine specified to administer one tablet by mouth two times a day for mood disorder. The morning dose of Oxcarbazepine was scheduled to be given at 8:00 a.m. The physician's order specified to administer Gabapentin 300 mg, two capsules by mouth three times a day for neuropathy (nerve pain). The medication was scheduled to be administered at 8:00 a.m., 1:00 p.m., and 5:00 p.m. LPN Staff S verified he did not administer the medications to Resident #63 within the required time frame. 3. On 7/15/24 at 2:04 p.m., Resident #67 was observed in bed. She appeared very upset. She said she did not know the nurse who was on duty today. He was trying to trick her and give her pills that she already took. Resident #67 said she always takes her morning medications with her breakfast and never in the afternoon. A medication cup with five pills was observed unsecured on the resident's bedside table. On 7/15/24 at 2:15 p.m., in an interview LPN Staff S verified he left the cup of medications unattended at the resident's bedside. LPN Staff S said he got behind with his medication administration and the medication cup contained the resident's morning medications which were scheduled to be given at 9:00 a.m. LPN Staff S said the medications left at bedside included Ferrous Sulfate, Gabapentin, Labetalol, and Keppra. Review of the Medication Administration Audit report revealed Resident #67's physician's orders included: Ferrous Sulfate 325 mg, give one tablet by mouth two times a day for supplementation medication with meals. Gabapentin capsule 100 mg, give one capsule by mouth two times a day for pain. Labetalol HCL oral tablet 200 mg, give one tablet by mouth two times a day for hypertension (High blood pressure). Keppra tablet 250 mg, give 1.5 tablet by mouth two times a day for seizure. The morning dose of Ferrous Sulfate, Gabapentin, Labetalol, and Keppra were scheduled to be administered at 9:00 a.m. The administration time documented was 2:17 p.m., 5 hours and 17 minutes beyond the scheduled time. 4. Review of the clinical record for Resident #418 revealed an admitted [DATE]. Diagnoses included End Stage Renal Disease (ESRD), and Hypertension. The physician's orders included hemodialysis (treatment to filter wastes and water from the blood) every Monday, Wednesday and Friday related to ESRD at a local dialysis center. The physician's ordered medications included: Nifedipine ER extended release 24-hour 60 mg once daily for high blood pressure; Metoprolol 25 mg give 2 tablets by mouth two times a day for high blood pressure. Ranvela oral tablet 800 mg, take two tablets three times a day with meals for control of phosphorus levels. Omeprazole capsule 40 mg give one capsule by mouth one time a day for infrarenal abdominal aortic aneurysm ruptured Review of the Medication Administration Record (MAR) for June 2024 and July 2024 showed on dialysis days (Mondays, Wednesdays and Fridays) the scheduled 9:00 a.m. Metoprolol was not documented as administered on 6/19/24, 6/21/24, 6/28/24, 7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/12/24, and 7/15/24. The scheduled 9:00 a.m. dose of Nifedipine ER 60 mg was not documented as administered on 6/19/24, 6/21/24, 6/24/24, 6/28/24, 7/1/24, 7/2/24, 7/3/24, 7/8/24, 7/12/24 and 7/15/24. The scheduled 9:00 a.m. dose of Ranvela 800 mg was not documented as administered on 6/19/24, 6/21/24, 6/24/24, 6/28/24, 7/1/24, 7/2/24, 7/3/24, 7/4/24, 7/5/24, 7/8/24, 7/10/24, 7/12/24 and 7/15/24. The scheduled 9:00 a.m. dose of Omeprazole was not documented as administered on 6/24/24, 6/28/24, 7/1/24, 7/2/24, 7/3/24, 7/4/24,7/5/24, 7/8/24, 7/10/24, 7/12/24, and 7/15/24. On 7/16/24 at 8:29 a.m., in an interview Resident #418 said he goes to dialysis on Mondays, Wednesdays and Fridays. The resident said he leaves the facility around 5:30 a.m. and returns at approximately 2:00 p.m. Resident #418 said no one checks his blood pressure before he goes to dialysis and he does not get his morning medications on dialysis days. On 7/17/24 at 8:59 a.m., in an interview Registered Nurse (RN) Staff J said she was assigned to Resident #418. Staff J verified Resident #418 did not get his morning medications on dialysis days when he's out of the building. RN Staff J said she has not notified the physician his orders were not followed and Resident #418 did not receive the ordered medications on dialysis days. On 7/17/24 at 9:41 a.m., in an interview the Director of Nursing said she was not aware Resident #418 was not receiving the physician's ordered medications on dialysis days. She said the medication administration time should be changed on dialysis days, and the medications can also be given at dialysis. She said any nurse could call the physician, get an order and make the changes. The Administrator was present during the interview. On 7/18/24 at 10:04 a.m., in a telephone interview the Advanced Practice Registered Nurse said the standard protocol is for the provider to be notified of any missed or late medication, and document in the record. She said she would have wanted to be informed of the missed medications for Residents #4, #63, #67 and #418.

Based on observation and interview, the facility failed to store medications in a safe, secure manner for 3 (Residents # 67, #4, and #63) of 3 residents reviewed for medication storage. The findings included: Medication Storage and Labeling policy issued 3/2021 and Revised 1/2024 said Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles . Procedure noted Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received . The nurse staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. On 7/14/24 at 11:11 a.m., Resident #67 was observed in bed. Nystatin powder and multiple pills were noted in a medicine cup on her breakfast tray. Resident #67 stated the nurse leaves these here so I can take them with my breakfast. Photographic documentation obtained. On 7/15/24 at 2:04 p.m., a medication cup with five pills was observed unsecured on Resident #67's bedside table. In an interview Resident #67 said the nurse was trying to trick her into taking the medications she already took that morning. On 7/15/24 at 2:15 p.m., in an interview LPN Staff S verified he left the medications unattended at the resident's bedside. On 7/15/24 at 11:43 a.m., observation of the medication cart on the rose bud unit with Licensed Practical Nurse (LPN) Staff S revealed several pills in two unlabeled plastic medication cups placed on an alcohol wipe packet. One alcohol wipe was labeled with Resident #4's name and the other wipe was labeled with Resident #63's name. In an interview LPN Staff S said the cup with the three pills were Resident #4's morning medications and contained the resident's Carvedilol 6.25 milligrams (mg) (Blood pressure medication), Eliquis 2.5 mg (anticoagulant) and Hydroxyzine 25 mg (antianxiety). Photographic evidence obtained. LPN Staff S said the other cup contained seven pills and were Resident #63's morning medications including, Midodrine 2.5 mg ( to treat low blood pressure), Eliquis 2.5 mg, Oxcarbazepine 150 mg, Tylenol 325 mg (2 tablets) for pain and Gabapentin 300 mg (two tablets) for neuropathy. Photographic evidence obtained. LPN Staff S verified the medications were not labeled and stored in accordance with the facility's policy and procedures. He said they should have been discarded when not administered to the residents on time.

Based on record review, resident representative and staff interviews, the facility failed to promote the residents' rights to be involved in medication management, including being informed of the risks and benefits for use of psychotropic medications for 1 (Resident #20) of 5 residents reviewed for unnecessary medication use. The findings included: Review of the clinical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included history of Bipolar Disorder, Anxiety, Major Depressive Disorder, Unspecified Mood Disorder, Dementia with behavioral disturbance, and Confusional Arousal. The Admission Minimum Data Set (MDS) dated [DATE] (Federally mandated assessment to evaluate the health and functional capabilities of residents) noted Resident #20's cognition was severely impaired with a Brief Interview for Mental Status Score of 07. The MDS noted the resident was displaying verbal (threatening others, screaming at others, cursing at others) and physical behavioral symptoms (hitting, kicking, pushing, scratching, grabbing) directed toward others one to three days. Review of the physician's orders and the Medication Administration Record (MAR) for April 2024, May 2024 and July 2024 revealed Resident #20 was administered the following psychotropic medications: Buspirone HCL 10 mg (milligrams) one tablet by mouth two times a day for antianxiety from 4/25/24 to 4/30/24. (Discontinued on 4/30/24). Depakote 125 mg one tablet by mouth two times a day for bipolar disorder from 4/26/24 through 5/5/24. (Discontinued on 5/5/24). Depakote 125 mg one tablet by mouth two times a day related to unspecified mood (affective) disorder from 5/11/24. Haloperidol 1 mg one tablet by mouth two times a day for antipsychotics/antimanic agents one dose on 4/25/24. Haloperidol (antipsychotic) 2 mg one tablet by mouth two times a day for behavior from 4/25/24 to 5/5/24. (Discontinued on 5/5/24). Risperdal (antipsychotic) 0.5 mg one tablet by mouth two times a day for bipolar with mania and agitation from 4/30/24 to 5/5/24. (Discontinued on 5/5/24). Risperdal 1 mg one tablet by mouth in the morning for Parkinson's with agitation and anxiety from 6/7/24 through 7/12/24 (Discontinued on 7/12/24). Risperdal 0.5 mg one tablet at bedtime for Parkinson's with behavioral mood and agitation on 6/6/24 through 7/12/24 (Discontinued on 7/12/24). Risperdal 1 mg one tablet by mouth two times a day for Parkinson's with agitation and anxiety starting on 7/12/24. Seroquel 50 mg one tablet by mouth two times a day for major depressive disorder, recurrent on 4/27/24 and 4/28/24. (Discontinued on 4/28/24). Seroquel 100 mg one tablet three times a day related to Bipolar Disorder on 4/28/24 through 5/3/24. (Discontinued on 5/3/24). Alprazolam 0.25 mg one tablet by mouth every eight hours as needed for anxiety for 14 days one dose on 4/25/24 and 4/26/24. (Discontinued on 4/26/24). Alprazolam 0.5 mg one tablet by mouth every eight hours as needed for anxiety for 14 days, one does on 4/27/24, 4/29/24 and 4/30/34 (Discontinued on 5/5/24). Alprazolam 0.5 mg orally every 8 hours as needed for agitation, one dose given on 7/5/24, 7/10/24, 7/14/24, 7/17/24, and two doses on 7/7/24. Haloperidol lactate 5mg per ml, 10 mg IM on 4/27/24 related to unspecified mood disorder. Haloperidol lactate 5mg per milliliter (ml), 5 mg intramuscularly (IM) on 4/28/24, and 4/30/24. The care plan initiated on 4/25/24 noted Resident #20 uses antipsychotic medications related to behavior management, diagnosis of depression. The interventions included to educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms as indicated. Review of the electronic medical record showed no documentation Resident #20 or resident representative were informed of the treatment, risks and benefits related to the use of the psychotropic medications. On 7/15/24 at 2:38 p.m., in an interview Resident #20's Daughter-in-Law said she nor her husband were informed Resident #20 was receiving multiple psychotropic medications and were not informed of the risks or benefits related to the psychotropic medications. She said no one told them about Resident #20's behaviors and the multiple Haldol injections. On 7/16/24 at 1:11 p.m., in an interview the Administrator and the Director of Nursing (DON) verified Resident #20 was not capable of making informed decisions regarding her medical decisions. The DON said Resident #20's son and daughter-in-law were involved in her care. Multiple requests were made to the Director of Nursing on 7/16/24 at 1:11 p.m., 7/17/24 at approximately 11:00 a.m., and on 7/18/24 at approximately 10:30 a.m., to provide documentation Resident #20 and her family were involved in the medication management process, informed of the risks and benefits and consented to the use of psychotropic medications. As of 7/18/24 the DON failed to provide the requested information.

Based on record review and interview, the facility failed to ensure 1(Resident #39) of 3 sampled residents reviewed received the Skilled Nursing Advance Beneficiary of Non-coverage (CMS-10123) to inform the resident of potential liability for payment and related standard claim appeal rights. The findings included: Review of Resident #39's census data information revealed Resident #39's services in the facility were covered by Medicare Part A, effective 11/17/2023. Review of Resident #39's coverage notice records revealed a Notice of Medicare Non-Coverage form that documented Resident #39's skilled nursing services would end on 2/13/24. Review of the Beneficiary Protection Notification Review form completed by the Minimum Data Set Coordinator revealed the facility initiated Resident #39's discharge from Medicare Part A Services with benefit days remaining. Review of Resident #39's coverage notice records failed to reveal any documentation that Resident #39 had been provided with the Skilled Nursing Advance Beneficiary of Non-Coverage notice (CMS-10123). On 7/18/24 at10:45 a.m., in an interview the Admissions Coordinator stated, We have a corporate resource who is like a case worker who helps us if the Resident has an unusual plan or something. She stated the facility would get the formed signed denoting the conversation occurred with the Resident or responsible party but was unable to provide the signed form for Resident #39.

Based on record review, resident family and staff interviews, the facility failed to ensure the Baseline Care Plan (BCP) was provided to the resident and their representative with a summary of the baseline care plan that included but was not limited to the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and any updated information for 1 (Resident #94) of 3 residents reviewed for BCP. The findings included: Review of Resident #94's medical record revealed she was admitted to the facility on [DATE] with admission diagnoses of altered mental status, hypertension, muscle weakness, open wound of lower leg, and paroxysmal tachycardia. The Admission Nursing Evaluation dated 1/3/24 stated the BCP was reviewed by the Interdisciplinary Team (IDT) and Other, and a copy of the BCP and medication reconciliation were offered to the resident/representative/family member. The nurse also documented they had discussed the physician orders, treatment, plan of care, medications and discharge planning with the resident and/or responsible party. On 7/16/24 at 8:53 a.m., in an interview with the Minimum Data Set (MDS) Coordinator, she said the admitting nurse was responsible to complete each resident's BCP within 48 hours and was required to provide the resident and/or their representative or family a copy of the BCP which included the initial goals, a summary of the resident's medications and dietary instructions, any services and treatments in progress and any updated information. She said no residents and/or their families were provided a copy of the baseline care plan during their care plan conference attended by the resident and/or their family and the IDT which was held no later than 28 days after the resident was admitted to the facility. The MDS Coordinator confirmed Resident #94 was admitted to the facility on [DATE] and the admitting nurse documented she had completed the BCP on 1/3/24 and provided a copy to the resident/representative/family. The MDS Coordinator said Resident #94's initial admission care plan meeting was held on 2/8/24 and she was unable to find documentation Resident #94's Power of Attorney (POA) was given a copy of Resident #94's BCP as required. On 7/16/24 at 10:00 a.m., in an interview with Staff R, a Registered Nurse (RN), she said she had worked at the facility for 1.5 years. She said when a resident was admitted to the facility, the admitting nurse was required to complete the BCP which was part of the Admission Nursing Evaluation. She said nursing was not required to give a copy to the resident and/or their family. Staff R stated she believed the MDS office was required to provide a copy of the BCP to the resident and/or their representative/family. On 7/16/24 at 10:10 a.m., in an interview with Staff L, Unit Manager, she said she had worked at the facility for over 6 years. She said the admission nurse was responsible for completing the BCP in the Admission Nursing Evaluation within 48 hours of the resident being admitted to the facility. She said the MDS office was required to provide a copy of the BCP to the resident and/or family member. On 7/16/24 at 10:30 a.m., in an interview with Resident #94's daughter, she said her mother was admitted to the facility on [DATE] due to cognitive decline and was deemed incompetent prior to her admission to the facility. She said she was Resident #94's POA and the facility had not told her or provided her with her mother's admitting diagnoses, medication list and/or other pertinent information. She said neither she nor her brother were offered and/or provided a copy of Resident's BCP. On 7/16/24 at 11:04 a.m., in an interview with the Director of Nursing, she confirmed Resident #94 was admitted to the facility on [DATE] with a primary diagnosis of altered mental status and Resident #94's daughter is Resident #94's POA. The DON also confirmed Resident #94's admitting nurse documented in the Admission Nursing Evaluation, dated 1/3/24, she had completed the BCP on 1/3/24 and offered a copy to the resident/representative/family member. The Admission Nursing Evaluation did not identify who was offered a copy of the BCP whether it be the resident, their representative or the family member. The Admission Nursing Evaluation noted the BCP was reviewed with the IDT and Other but did not include the Resident/Representative/Family Member or the Physician/Physician's Assistant (PA)/Advance Practice Registered Nurse (APRN). The DON said she was unable to find documentation the nursing department had provided Resident #94's daughter (her POA) a copy of Resident #94's BCP with the required information within 28 days of admission to the facility as required per federal regulation.

Based on review of the clinical record, review of facility policy and procedures and staff interviews, the facility failed to have documentation of blood sugar results as ordered for 1(Resident #53) of 1 resident reviewed with diabetes. The findings included: The facility policy Physician Orders issued 1/1/23 documented All physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident's medical record during that shift. Review of the clinical record revealed Resident #53 had a readmitted [DATE] with diagnoses including stage 3 chronic kidney disease and type 2 diabetes. The physician orders included to inject Lantus insulin, 10 units subcutaneously at bedtime. The physician's orders dated 1/16/24 read, May obtain finger-stick blood sugar twice daily. Notify physician for results < (less than) 60 and > (greater than) 300. Review the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for April 2024, May 2024, June 2024 and July 2024 showed each day at 9:00 a.m., and 9:00 p.m., the nurses placed a check mark and their initials on the MAR indicating the blood sugar via finger-stick was obtained. The MARs did not document the blood sugar results for each finger-stick. Review of the electronic blood sugar summary for Resident #53 from 1/16/24 through 7/17/24 showed the following blood sugar results: On 2/21/24 at 10:08 p.m., 241 milligrams per deciliter (mg/dl). On 7/15/24 at 9:27 p.m., 156 mg/dl. On 7/16/24 at 5:28 a.m.,132 mg/dl. On 7/16/24 at 9:22 p.m., the blood sugar was 333 mg/dl. There was no documentation the physician was notified of the blood sugar result greater than 300 mg/dl as specified in the physician's order dated 1/16/24. On 7/17/24 at 5:38 a.m., 135 mg/dl. No other blood sugar results were documented in the clinical record. On 7/18/24 at 1:08 p.m., in an interview Licensed Practical Nurse (LPN) Staff I said all documentation is put into the computer system, we have no paper documents. The only time we would use paper is if the computer system has gone down. The LPN said for blood sugars the computer prompts the nurse to enter the blood sugar result and the amount of insulin provided for sliding scale. The results can be entered manually in the system, and if they are just getting blood sugar monitoring you can do that too, you put your initials and then put in the blood sugar. Staff I confirmed the facility did not record the blood sugar results on paper. On 7/18/24 at 1:22 p.m., in an interview Registered Nurse Staff J said, blood sugars are documented in the computer system only, there is no paper charting here, no paper charts. Everything is documented in the computer system. On 7/15/24 multiple requests were made to the Director of Nursing for documentation of blood sugar results for Resident #53 from 1/16/24 through 7/15/24 but the requested documentation was not provided. On 7/15/24 at 1:54 p.m., the facility obtained a new physician's order that read, Obtain finger-stick blood sugar twice daily. Notify physician for results < 60 or >300 two times a day for hypoglycemia.

Based on staff interview and medical record review, the facility failed to notify the resident representative of significant changes for two (Resident #4 and Resident #6) of 4 residents reviewed for significant changes. The findings included: The facility policy issued 5/2017 and revised 6/2023 for Change in Resident Condition or Status - Resident Rights Standard states the facility shall notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Resident #4 was admitted to the facility on [DATE] from the hospital for rehab after Urinary Tract Infection and Cerebrovascular Accident. Her BIMS (Brief Interview for Mental Status) was 99 which indicates resident not cognitively intact. A skin check dated 3/7/24 in Resident #4's medical record read Stage 3 Pressure Injury 90% slough and 10% granulation tissue noted with moderate amount serosanguinous drainage with no odor, defined wound edges, erythema noted to peri wound, no noted tunneling, sinus tracking, or undermining. No s/s (signs or symptoms) of infection noted at this time. Resident unable to rate pain but verbalizes pain during cleansing. Treatment placed. Resident repositioned on side. There was no change in condition or notifications found for the pressure wound development in Resident #4's medical record at that time. On 4/16/24 at 12:48 a.m., in an interview Staff A, RN (Registered Nurse), accompanied by The Director of Nursing (DON) said her initial exam of Resident #4 was on 3/7/24 when she first discovered the pressure wound to her sacrum. She put in a consult to wound care at that time. She said the daughter was visiting her mother during wound care rounds on 3/11/24 and she notified her of the pressure wound at that time. She documented this in nurse progress notes. She said she notified the daughter of the new pressure wound and treatment plan. Per the DON, any wound/pressure wound would be considered a significant change in condition. She said notifications to the family should be made for all changes in conditions. Progress notes documented on 3/11/24 by Staff A showed This nurse and wound Nurse Practitioner rounded on resident. Resident has unstageable pressure injury to her sacrum. Resident #6 was readmitted to the facility on [DATE] with history of dementia and chronic kidney disease. His BIMS (Brief Interview for Mental Status) was 99 which indicates resident not cognitively intact. The facility Matrix identified Resident #6 as having a facility acquired pressure wound. Resident #6 had an Initial Wound care consult conducted on 2/13/24 documented by the Wound NP (Nurse Practitioner). There was no change in condition or notifications found for Pressure Wound development in Resident #6's medical record. On 4/16/24 at 12:21 p.m., in an interview with the Administrator and the DON, the DON said a PIP (Performance Improvement Plan) for notifying the physician and family when wounds are identified was developed yesterday. They were unable to provide any evidence or documentation for Resident #4 or Resident #6 change in conditions due to pressure wounds, or provide documentation of family notifications. The DON and Administrator said it was not completed for either resident and it should have been.

Based on record review, review of facility's policy and procedure, resident representative and staff interview, the facility failed to implement their policies and procedures, and immediately address an allegation of staff to resident abuse for 1 (Resident #1) of 3 residents reviewed for abuse. The findings included: Review of the facility's policy, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of unknown origin( ANEMMI) revision 10/2022 noted physical abuse included, Hitting, slapping, pinching, and kicking. The policy listed several criterias, including any resident or family complaint of physical harm, pain or mental anguish resulting from willful infliction from others, will be considered as possible ANEMMI. The policy specified any employee having either direct or indirect knowledge of any event that mighty consitute Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of unknown origin must report the event promptly. Residents will be protected from harm during an investigation. Staff person or persons suspected of ANEMM will be suspended immediately pending result of the investigation. Review of the facility's abuse investigations revealed on 11/20/23 (Monday) at approximately 3:20 p.m., a police officer came to the facility to interview Resident #1. Resident #1 stated, sometimes yesterday [Sunday 11/19/23] someone punched him in the face. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included Bipolar Disease, Major Depressive Disorder, Restlessness and Agitation, Anxiety, Acute pain. Resident #1 required total assistance for personal care. On Monday 11/20/23, Licensed Practical Nurse (LPN) Staff T documented a statement noting on Sunday afternoon the nurse told her Resident #1's friend said someone hit him. She went to Resident #1 and asked what had happened. Resident #1 replied nothing. The resident's friend again said Resident #1 told her someone hit him. LPN Staff T documented when she asked Resident #1 where he was hit, he said to the left side of his cheek. LPN Staff T documented she spoke to the Certified Nursing Assistant (CNA) who was taking care of the resident. The CNA said Resident #1 refused to be changed, was kicking at them, cursing them, kicking one of the CNAs on her breast, damaging her glasses. On Monday 11/20/23, LPN Staff S wrote a statement noting the nurse for the 3:00 p.m., to 11:00 p.m., shift stated Resident #1's visitor said that someone had hurt him on the face, but she did not observe any injury. On 11/26/23 at 1:20 p.m., in a telephone interview, Resident #1's friend said on Sunday 11/19/23 when she walked into the resident's room, two CNAs were providing incontinent care. He has wounds on his feet. His foot got bumped causing a lot of pain and agitated him. He was yelling and cursing at the CNAs and said that she had hit him in the left eye and pointed to just below the left eye. One of the CNAs said Resident #1 had hit her in the chest as she was bending over. The CNA did not say that she hit him, but she did not deny hitting him either. She did not say anything either way. She said she was concerned about it because he had never accused anyone of hitting him ever. She reported the incident to LPN Staff S who works on Sundays. LPN Staff S said she would notify the supervisor. Shortly after, the supervisor came in, she looked at Resident #1's eye and said she did not see any redness. She tended to side with the aides because the resident tended to get upset. She said she would go back to the CNAs and get their side of the story. Resident #1's visitor said she never heard back from anyone after that, the supervisor never came back in the room. On 11/26/23 at 2:30 p.m., in a telephone interview, LPN Staff S said on 11/19/23 Resident #1's friend said last weekend the resident's friend reported to her two CNAs were providing care, and one of them hit him in the face. The friend described the staff to her, and what they were wearing. She reported the incident to the desk nurse, LPN Staff T who got up right away and looked for the staff described. On 11/26/23 at 2:45 p.m., in an interview LPN Staff T said when LPN Staff S reported the alleged incident to her, she went in the room to speak to Resident #1. At first, the resident said, nothing happened. When asked again, he pointed to his face and said someone hit him. She said she did not see any marks or bruising. She said Resident #1 would kick or punch when he is being changed. She identified the two CNAs who were providing care to the resident but did not notify anyone about the allegation until the police came to the facility a day or two later. On 11/27/23 at 11:40 a.m., CNA Staff W said on 11/19/23 she was assisting CNA Staff V changing Resident #1. When they turned Resident #1 to his side, CNA Staff V was in front ho him. He grabbed CNA Staff V's hand and kicked her in the chest. Her glasses were hanging on her shirt, and he broke them. On 11/27/23 at 11:46 a.m., CNA Staff V verified on 11/19/23 she helped CNA Staff W providing incontinent care for Resident #1. She said Resident #1 was violent and required two CNAs and two nurses when providing care to him. She said, I do not abuse people. CNA Staff W said she rolled Resident #1 to one side, he does not like that, he wants it done quickly. She said she turned to him and put her hand on his head. Resident #1 then hit her in the chest and broke her glasses. She said she reported the incident to LPN Staff S. The CNA said the resident's friend was in the room, behind the privacy curtain when they were providing care and did not say anything. There was no documentation of steps taken by the facility on 11/19/23 to immediately report, investigate and protect Resident #1 from harm during the investigation. On 11/27/23 at 11:00 a.m., the Director of Nursing (DON) said she was not aware of the allegation of staff to resident abuse until 11/20/23 when the police officer came to the facility. She said no one called her that Sunday. On 11/27/23 at 1:25 p.m., the Administrator said no one called her on 11/19/23 to report the allegation of abuse. She said she reported it to the appropriate authorities on 11/20/23, Once the police came.

Based on record review, review of facility's policy and procedure, resident and staff interview, the facility failed to ensure the reporting of an allegation of staff to resident abuse to the State Survey Agency, and Adult Protective Services within the specified timeframe for 1 resident (Resident #1) of 3 residents reviewed for abuse. The findings included: Review of the facility's policy, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of unknown origin( ANEMMI) revision 10/2022 noted, with response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect . 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 bodily injury . The facility procedure noted, 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: Director of Nursing, ANEMMI Prevention Coordinator, or Risk Manager so that appropriate reporting and investigation procedures take place immediately . Review of the facility's abuse investigations revealed on 11/20/23 (Monday) at approximately 3:20 p.m., a police officer came to the facility to interview Resident #1. Resident #1 stated, sometimes yesterday [Sunday 11/19/23] someone punched him in the face. On Monday 11/20/23, Licensed Practical Nurse (LPN) Staff T documented a statement noting on Sunday afternoon the nurse told her Resident #1's friend said someone hit him. She went to Resident #1 and asked what had happened. Resident #1 replied nothing. The resident's friend again said Resident #1 told her someone hit him. LPN Staff T documented when she asked Resident #1 where he was hit, he said to the left side of his cheek. LPN Staff T documented she spoke to the Certified Nursing Assistant (CNA) who was taking care of the resident. The CNA said Resident #1 refused to be changed, was kicking at them, cursing them, kicking one of the CNAs on her breast, damaging her glasses. On 11/26/23 at 1:20 p.m., in a telephone interview, Resident #1's friend said on Sunday 11/19/23 when she walked into the resident's room, two CNAs were providing incontinent care. He has wounds on his feet. His foot got bumped causing a lot of pain and agitated him. He was yelling and cursing at the CNAs and said that she had hit him in the left eye and pointed to just below the left eye. One of the CNAs said Resident #1 had hit her in the chest as she was bending over. The CNA did not say that she hit him, but she did not deny hitting him either. She did not say anything either way. She said she was concerned about it because he had never accused anyone of hitting him ever. She reported the incident to LPN Staff S who works on Sundays. LPN Staff S said she would notify the supervisor. Shortly after, the supervisor came in, she looked at Resident #1's eye and said she did not see any redness. She tended to side with the aides because the resident tended to get upset. She said she would go back to the CNAs and get their side of the story. Resident #1's visitor said she never heard back from anyone after that, the supervisor never came back in the room. On 11/26/23 at 2:30 p.m., in a telephone interview LPN Staff S verified she worked on Sunday 11/19/23. She verified Resident #1's friend reported to her Resident #1 said two CNAs were providing care, and one of them hit him in the face. She reported the incident to the desk nurse, LPN Staff T who got up right away and looked for the staff described. On 11/26/23 at 2:45 p.m., in an interview LPN Staff T verified on 11/19/23 LPN Staff S reported to her Resident #1's friend said two CNAs were providing care, and one of them hit him in the face. She verified she did not notify anybody until the police came to the facility another day or maybe a couple of days later. There was no documentation that the allegation of staff to resident abuse was reported to the State Survey Agency or Adult Protective Services on 11/19/23 within the required time frame. The abuse investigation noted the allegation was reported to the State Survey Agency and the Abuse Registry on 11/20/23. On 11/27/23 at 11:00 a.m., the Director of Nursing (DON) said she was not aware of the allegation of staff to resident abuse until 11/20/23 when the police officer came to the facility. She said no one called her that Sunday. On 11/27/23 at 1:25 p.m., the Administrator said apparently on 11/19/23 when two CNAs were taking care of Resident #1, he hit CNA Staff V in the shoulder. She said Resident #1's friend visited every Sunday and mentioned the resident reported to the staff nurse that someone hit him. She said no one called her on 11/19/23 to report the allegation of abuse. She said she reported it to the appropriate authorities on 11/20/23, Once the police came.

Based on observations, records review, review of policies and procedures, the facility failed to implement their policies and procedures and accommodate the preferences of 4 (Residents #2, #4, #6 and #7) of 4 residents reviewed for smoking. The findings included: Review of the undated facility's document titled, Resident smoking at North Port Rehab signed by each resident who smokes noted, 1. I agree to follow the smoking schedule set forth by the facility. The times are posted on the door to the door to the courtyard. 2. I agree to follow the policy and procedure on smoking, and I am only allowed to smoke with supervision. 3. I will not smoke outside by myself. 4. I agree to smoke only in the designated smoking area only. 5. I agree I will not smoke in my room. 6. I agree I will not smoke around oxygen. 7. I agree to turn in my cigarettes and lighter or any other smoking materials to the person that is supervising me smoking. 8. I agree not to keep my smoking materials in the room. I understand that if I do not follow the above guidelines my smoking privileges may be revoked. By signing this I understand and will follow the guidelines. Review of the undated facility's policy titled, Tobacco- Restrictive Policy Acknowledgement signed by each resident who smokes noted, Policy: It is the policy of the Facility to discourage any smoking in the facility. However, we are also understanding of the fact that as a skilled nursing and rehabilitation facility, some of our residents may choose to smoke. Therefore, the facility will designate an outside smoking area to accommodate the request of those individuals . Procedure: Staff will dispense the resident's cigarettes, light the cigarette, and stay with the resident until the cigarette is properly extinguished . All residents smoke with supervision and will do so only in the designated area. All cigarettes, lighters, and any other smoking materials will be kept in the nurse's station . The bottom of the form had a space for the resident to sign acknowledging receipt of a copy of the smoking policy and a copy of the designated smoking times and place. Reviewed sign of designated smoking times which stated Courtyard Smoking Area. Staff attendance with residents who smoke. All smoking materials must be in a designated container and collected when smoking is finished. No smoking items in resident rooms. Times/ Department; 9am/ Nursing; 11am /Activity; 1pm/Activity; 4pm/ Activity; 7pm/Nursing; 9pm/Nursing. Review of the clinical records for Resident #2 documents in Minimum Data Set (MDS) dated [DATE] a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. Review of clinical records for Resident #4 documents in Minimum Data Set (MDS) dated [DATE] a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of clinical records for Resident #6 documents in Minimum Data Set (MDS) dated [DATE] a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of clinical records for Resident #7 documents in Minimum Data Set (MDS) dated [DATE] a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. On 10/17/23 at 10:25 a.m., Resident #2 said he was a smoker and said his only complaint about the facility was, They tell us constantly we must have someone with us to smoke but then they are not there at the scheduled time. We can't smoke until 9:00 a.m., and the last time at night is at 10:00 p.m. That is a long time for anyone who has smoked. Sometimes they don't even show up. On 10/17/23 at 11:30 a.m., Resident #4 said he is a smoker and, the facility only does a good job about smoking about 50/50. The 11:00 a.m., 1:00 p.m., and 4:00 p.m. are good. The 9:00 a.m. and 7:00 p.m. are terrible. I don't do the 9:00 p.m. round. We complain but it doesn't do any good. On 10/17/23 at 4:20 p.m., observed resident smoking time in progress. Certified Nursing Assistant (CNA) Staff M was present supervising seven smokers including Residents #2, #4, #6 and #7. Resident #6 said, Half the time they don't come out here and we miss our smoke break. There is no set person to do it. No one showed up yesterday morning at all. Resident #7 said, It isn't fair they make us follow their rules but then they don't do the things they say they will. On 10/18/23 at 8:30 a.m., Registered Nurse (RN) Unit Manager Staff F confirmed that nursing covers smoke breaks half of the time and activities the other half. Staff F said there was not a set assigned person to cover from nursing and the evening supervisor usually covered the two evening times. She said the facility did not keep track of who covered the smoking time and had no way to show the times had been accommodated. On 10/18/23 at 11:45 a.m., the Director of Nursing (DON) said regarding smoking time coverage, We did a town hall two weeks ago and they (the smokers) brought that concern. We have divided the responsibility between nursing and activities. We don't keep track of who is going, and it is not officially assigned. When asked to provide proof that the smoking times have been covered, the DON replied, No I don't have anything to show who covered each time. On 10/18/23 at 12:30 p.m., CNA Staff M said he frequently covers the smoking times, and the coverage was inconsistent. Staff M said there was no set routine or assignment for the smoking coverage. CNA Staff M said, I understand the smokers being upset. The majority of them are with it and know exactly what is going on. If they say they did not get to smoke then it is true. On 10/18/23 at 1:05 p.m., the facility Administrator confirmed that there was not an assigned person for each smoking time, and no way to show the smoking times had been conducted as scheduled.

Based on observation, staff interviews and facility policy review, the facility failed to prepare food in accordance with professional standards for food service safety. This failure is evidenced by staff having personal drinks, personal phones, and a bucket of sanitizing agent on the food preparation counter during meal preparation. The findings included: Review of facility policy titled Food Storage with an effective date of 1/15/2021 noted, To ensure that all food served by the facility is of excellent quality and safe for consumption, all food will be stored according to the current Federal and State Food Code . Do not use or store cleaning materials or other chemicals where they might contaminate foods . On 10/17/23 at 10:00 a.m., a tour of the meal preparation area of the kitchen was done with Dietary cook/ supervisor Staff B. Staff B said, Sorry about the mess, I am making lunches now. An uncovered container of steamed whole Brussel sprouts, an uncovered container of chopped meat, and utensils were observed on the meal preparation counter. Two personal cell phone, two personal drinks and a bucket of unlabeled liquid with a cloth were also observed in the food preparation area. Staff B said the bucket contained a sanitizing agent with chemicals and should not be next to the open food items but stored under the counter. Staff B said the two drinks and the two phones were her personal items and should not be in the area with the residents' meals. Staff B said, I know they are not supposed to be there. I have just been busy. I know, I know, it is an infection control thing. I'll fix it now and remove everything. On 10/17/23 at 4:45 p.m., the observation of the personal items and the bucket of sanitizing agent stored on the counter next to the uncovered containers of Brussel sprouts and chopped meat were shared with the Dietary Manager. The dietary manager said, That is not acceptable. The bucket should be under the counter and never near food. Personal food and phones should not be near the food either. The dietary manager confirmed personal phones and drinks on the meal preparation station were an infection control issue. On 10/18/23 at 1:05 p.m., the facility Administrator confirmed the bucket of sanitizer, personal phones and personal drinks should not have been in the food preparation station in the kitchen. The Administrator said, This is not acceptable.

Based on observation, record review, staff and resident representative interviews, the facility failed to ensure 1 (Resident #8) of 7 sampled residents was treated with dignity and respect in that the facility failed to ensure the resident was properly dressed when transported to an outside provider's appointment. The findings included: On 10/17/23 at 11:55 a.m., Resident #8 was observed in a reclining wheelchair in the lobby with her sister. She was partially covered with a blanket, and was wearing a long, short sleeved T-shirt. Resident #8's sister lifted the blanket which showed the resident was dressed in a T-shirt and incontinent brief. The shirt was not long enough to cover the brief. She was not wearing any bottoms, socks, or shoes. An orthopedic boot was observed on the resident's right lower leg. Resident #8's sister was visibly upset and speaking to the staff in a loud voice saying, I should call the police. My sister had plenty of warm clothing and you sent her out to the doctor's office with just a shirt and a diaper. It was 57 degrees this morning. On 10/17/23 at 12:10 p.m., Resident #8's sister who was her Power of Attorney said Resident #8 had been at the facility for about two weeks. She said, My sister had an appointment with her orthopedist scheduled this morning and I was concerned it would be chilly. I could not go with her to the appointment so yesterday I came with warm clothing specifically for this morning's appointment. I brought long pajamas, socks and sneakers anticipating it was going to be 57 degrees. I asked a friend to meet her at the appointment. The friend called me saying she was dressed inappropriately in just a T-shirt and incontinent brief. My sister is not cognitively intact after her stroke, but she can say if she is cold. She did say to our friend and to me that she was cold. They put something on her that wasn't even hers and sent her out to the appointment. People should not be treated that way. It was so upsetting to see her dressed like that when she came back to the facility. She can't fight for herself. I need to do it for her. Review of clinical records revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, and aphasia (language disorder affecting ability to communicate). The resident's care plan initiated on 10/17/23 noted the resident needs assistance with activities of daily living (ADLs). Staff was to encourage and assist with all ADLs. Review of the AccuWeather website at https://www.accuweather.com/en/us/north-port/34287/october-weather/347853 showed on 10/17/23 the weather in North Port Florida had a low of 59 degrees Fahrenheit (F) and high of 73 degrees F. On 10/17/23 at 3:50 p.m., Registered Nurse (RN) Staff D assigned to Resident #8 said she did not see what the resident was wearing when she left for the appointment. She said, It is not treating them well. It was wrong and I know. It should not have happened. I did not know what she had and what she didn't, but it isn't right that she went out dressed like that. On 10/17/23 at 4:00 p.m., RN unit manager Staff E said, the Certified Nursing Assistant (CNA) assigned to the resident did not look for clothing in her room and it was inappropriate for weather and for dignity to send the resident to an appointment dressed the way she was. On 10/18/23 at 11:45 a.m., the Director of Nursing (DON) verified the T-shirt Resident #8 wore to the doctor's appointment on 10/17/23 did not cover the incontinent brief and did not belong to her. She said the CNA did not look for appropriate clothing for the resident and did not ask anyone for clothes. On 10/18/23 at 12:30 p.m., CNA Staff M who transported Resident #8 to the doctor's appointment on 10/17/23 said, I went and picked her up from her room. I asked the CNA assigned, let's put some pants on her. The CNA said she will be ok. I knew better but I just went along with it. She was wearing a long T-shirt, but it did not cover the brief. I put a blanket on her as well, but I know she shouldn't have gone out like that. I feel bad and won't lie about it. On 10/18/23 at 12:50 p.m., CNA Staff R said she was assigned to Resident #8 on 10/17/23. She said, The nurse told me she had an appointment at 9:30 a.m. I cleaned her up. Another resident had an emergency. The driver was here, I told her she had no clothes in the closet. I knew it was cold outside. I could not find any bottoms. I know she had no clothes, and I should have gone to find some bottoms. It was cold and I know that you need to have the residents dressed appropriately. I never did this before and will never again. I know she was not dressed appropriately. I am sorry that happened yesterday.

Based on record review, review of the policies and procedures, observation, and staff interview, the facility failed to evaluate and modify interventions to prevent avoidable accidents for 1 resident (#358) of 1 resident reviewed who was identified as being at risk for falls and sustained multiple falls while at the facility, including a fall resulting in a transfer to the hospital. The findings included: The policy and procedure for managing falls and fall risk stated the staff would identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and minimize complications from falling. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factors for each resident at risk of falls or with a history of falls. The resident-centered approaches to managing fall and fall risk state if a fall recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the assessment of the nature or category of falling, until falling is reduced or until the reason for the continuation of the falling is identified as unavoidable. Staff will identify and implement relevant interventions (e.g., hip padding, or treatment of osteoporosis, as applicable) to try to minimize the serious consequences of falling. Resident #358 was admitted to the facility on [DATE] after a fall resulting in a lumbar (back) fracture. The 14-day minimum data set (MDS) with an assessment reference date (ARD) of 6/21/22 indicated the resident's brief interview for mental status (BIMS) score was 7. (The BIMS test is used to get a quick snapshot of how well the resident is functioning cognitively at the moment. The total BIMS score ranges from 0-15. A score of 13-15 is indicative of intact cognition. A score of 8-12 indicates moderate impaired cognition. A score of 0-7 indicates severe cognitive impairment.) The MDS indicated resident #358 required one person's physical assistance for transfers. The facility determined Resident #358 was at risk for falls related to a history of falls, cognitive impairment, impulsiveness, impaired balance, and mobility. The care plan was implemented on 6/16/2022. The interventions on 6/16/2022 included anticipating resident needs, assisting with mobility, encouraging the use of proper footwear, i.e., non-skid, well-fitted shoes, maintaining a clutter-free environment, monitoring adverse side effects of medications, placing call bell within reach, placing personal belongings within reach, provide adequate lighting, initiate a psychiatric consult. On 6/25/22, a clinical record review revealed resident #358 was found on the floor at the foot of his bed at 2:15 a.m. He told staff he was trying to use the bathroom. Resident #358 was sent to the emergency room for evaluation and admitted for a suspected acute back fracture. On 3/30/23 at 2:24 p.m., during a review of the fall investigation the Administrator said Resident #358 had a suspected lumbar fracture. The Administrator said they did not have studies from the hospital showing a diagnosis of lumbar fracture. Review of the progress notes revealed on 6/29/22, Resident #358 was observed on the floor after an unwitnessed fall. The Certified Nursing Assistant (CNA) documented in the initial report the resident stated he was going to the bathroom. A new skin tear on the left elbow was noted. Nurse assessment documented resident denied pain. New therapy interventions were added to the care plan. Resident #358 needs mod-min assistance with a four-wheel walker device, balance training, endurance training, gait training, positive reinforcement, therapeutic exercise, gait training, and verbal cues for safety sequencing and pacing. On 6/30/22 at 3:00 p.m., the nurse documented in a progress note Resident #358 had an unwitnessed fall and was observed lying on the floor. The resident was coming back from the bathroom and lost his balance. A head-to-toe assessment was completed. Resident #358 was encouraged to wear proper footwear and to call for assistance. On 3/30/23 at 2:24 p.m., during a review of the fall investigation the Assistant Director of Nursing (ADON) said the investigation did not state if the resident was using his walker, or had proper footwear at the time of the fall. The care plan was updated on 7/1/2022 with new interventions which included a floor mat on one side of the bed, the bed in the lowest position, and a toileting schedule. On 7/19/22 at 8:57 a.m., a progress note documented Resident #358 was observed on the floor to the left side of his bed. He complained of back pain at that time. On 3/30/23 at 2:24 p.m., during a review of the investigation with the Administrator and the Assistant Director of Nursing, the ADON said the investigation did not specify if the resident had access to his call bell, if he was wearing shoes, if the bed was in the lowest position or if the resident had been assisted to the toilet. No new interventions or revisions were added to the care plan to address the cause of the fall or minimize the risk of further avoidable falls. On 8/18/22 at 7:08 p.m., a progress note documented Resident #358 was observed sitting on the floor. The facility investigation noted Resident #358 spouse had visited and left him sitting in the chair. The resident said he was going to meet his wife. The investigation report noted a head-to-toe assessment was completed, the walker was to be placed within reach, and he would be referred to rehab services for screening. The facility said they educated resident #358's wife not to leave him alone. On 9/4/22 at 8:00 a.m., Resident #358 had an unwitnessed fall. The CNA alerted the nurse she observed Resident #358 on the floor on the right side of the bed. On 3/30/23 at 2:24 p.m., during a review of the investigation, the ADON said the resident's call light was not on, and the resident was wearing slip-resistant socks. The resident stated, I was all over the bed, then on the floor. The resident was assisted back to bed, a head-to-toe assessment was completed, no injuries were found, and a floor mat was in place to the right side of the bed. Neurochecks were to be implemented for 72 hours, and hourly safety checks were started. On 9/21/22 at 10:55 a.m., a progress note documented Resident #358 was found on the floor after an unwitnessed fall. The nurse reported resident was found sitting on his buttocks on the floor near his bed. Vital signs were assessed, resident denies hitting his head. He stated he was trying to use the bathroom. No injuries were noted ,and the resident was assisted back to bed. The resident was educated to use the call light as an immediate intervention, and the physician was notified. No new or changed interventions were identified or added to the care plan. On 11/12/22 at 6:33 p.m., Resident #358 was heard yelling from his room after an unwitnessed fall. Resident #358 was assessed for injuries and pain. No new interventions or care plan revisions were noted to ensure the residents' safety. On 12/4/22 at 7:00 p.m., resident #358 had a witnessed fall where she heard the resident calling out for help and sliding off the bed to the floor. The resident was assessed, and no injuries were noted other than mild back pain. He was assisted to his wheelchair. No revised or new interventions were added to the care plan to ensure the resident's safety. On 12/16/2022, the facility reported resident #358's mattress was changed to a scoop mattress, and hourly safety checks were initiated. On 3/29/23 at 2:57 p.m., the Administrator and Corporate [NAME] President stated the fall investigation was internal and could not be shared. The Corporate [NAME] President stated he would ask the Administrator to review the fall history. On 3/29/23 at 4:19 p.m., observation of Resident #358's room with Licensed Practical Nurse (LPN) Staff M failed to reveal the fall mat was in place as per the care plan. She said the resident's room had some flooding, perhaps the fall mats were removed at that time and never replaced. On 3/30/23 at 10:21 a.m., the Regional [NAME] President reviewed the hourly safety check documentation. He confirmed the flow sheets provided did not reflect Resident #358 being checked hourly. On 3/30/23 at 1:05 p.m., observation of Resident #358's bed with LPN Staff O revealed Resident #358 did not have a scoop mattress in place to prevent him from rolling out of bed as per the interventions listed in the care plan . On 3/30/23 at 2:24 p.m., the Administrator stated that most of Resident #358 falls were unwitnessed. After a resident fall, we ask what happened, question the staff, and ask them where the resident was found. Usually, the MDS coordinator will update the care plan. Resident #358 should be reevaluated, and interventions be evaluated after each fall. The ADON and regional vice president both confirmed the care plan had not been updated after each fall to ensure the resident's safety and prevent avoidable falls.

Based on observation, clinical record review and staff interviews, the facility failed to administer medications according to physician's orders and manufacturer's specification for 4(Residents #9, #18, #41 and #509) of 5 residents observed for medication administration. Three licensed nurses on the morning shift with 26 opportunities were observed. Eleven medication errors were observed resulting in a 42.31% error rate. The findings included: 1. On 3/27/23 at 9:59 a.m., Registered Nurse (RN) Staff B was observed administering an enteric coated aspirin 81 milligrams (mg) to Resident #18. RN Staff B removed the medication from the bottle and placed it in a clear medication pouch and crushed the tablet. RN Staff B placed the crushed tablet in applesauce and administered the medication to Resident #18. Crushing enteric coated tablets may result in the drug being released too early, destroyed by stomach acid or irritating the stomach lining. 2. On 3/27/23 at 10:05 a.m., RN Staff B was observed administering 3 medications to Resident #41 including a tablet of Amantadine HCL 100 mg RN Staff B and Breo Ellipta Aerosol Powder 100-25 Microgram (mcg) inhaler. RN Staff B placed the Amantadine tablet into a clear plastic pouch, crushed the medication and placed it in applesauce. Review of the manufacturer guidelines for Amantadine HCL specified to swallow the tablets whole. (https://www.gocovri.com/pdfs/gocovri-prescribing-information.pdf) Staff B handed the inhaler to Resident #41 who inhaled 1 puff. The nurse finished the medication administration and left the room. She did not instruct the resident to rinse her mouth and spit out the water after the use of the inhaler. Review of the pharmacy label of the Breo Ellipta inhaler revealed specifications to rinse mouth thoroughly after each use. 3. On 3/27/23 at 10:10 a.m., RN Staff B was observed administering 8 medications to Resident #9 including Acetaminophen 325 mg one tablet, Depakote 125 mg 2 capsules, Famotidine 10 mg tablet, Norvasc 5 mg tablet, Gabapentin 100 mg capsule, Norvasc 5 mg tablet and Potassium Chloride 20 milli equivalent (meq) tablet. She placed the medications into a plastic pill cup. RN Staff B counted the medications in the medication cup twice and confirmed there were 8 pills in the cup. Upon reconciliation with the physician's orders, it was revealed an order to administer Tylenol 325 mg administer 2 tablets, Norvasc 5 mg administer 1 tablet. The physician's orders revealed an order to administer Atenolol 25 mg 1 tablet and Glipizide 5 mg 1 tablet that were not administered during observation of the medication administration. On 3/28/23 at 9:25 a.m., RN Staff B did not remember the observed medications errors with Resident #18, #41 and #9. RN Staff B said she was unaware the instructions for the Breo Ellipta inhaler included rinsing the mouth after use. Photographic evidence obtained. On 3/28/23 at 12:00 p.m., the Regional Nurse Consultant confirmed RN Staff B signed the medication administration record (MAR) on 3/27/23 at 9:01 a.m., for resident #9 indicating all the medications were administered, including the Atenolol 25 mg and the Glipizide 5 mg tablets, before administering the medications. 4. On 3/27/23 at 10:20 a.m., RN Staff C was observed administering eight different medications to resident #509 including, Amlodipine Besylate 1 tablet (medication used to treat hypertension), Magnesium Oxide 400 mg. The RN counted the medications in the medication cup twice and confirmed there were 8 pills in the cup before handing the medication cup to Resident #509. Resident #509 took the medication cup from the nurse and swallowed the medications with water. RN staff C returned to the medication cart and ended the medication observation before moving on to another resident. Upon reconciliation with the physician's order, it was revealed the Amlodipine Besylate was ordered for 10 mg, give 5 mg one time a day. The physician's order for the magnesium oxide specified to administer 250 mg twice a day. The physician's order specified to administer Cholecalciferol 1000 units 2 tablets daily and Lipitor 40 mg that were not administered during the medication observation. Review of the MAR revealed RN Staff C had documented all ordered medications were administered. On 3/28/23 at 9:45 a.m., in an interview RN Staff C she said she had administered 5mg of Amlodipine Besylate to Resident #509. Staff C said the Amlodipine Besylate was in a separate medication card with only pill left and she threw the medication card away after removing the medication. The RN said she gave magnesium oxide 250 mg. She said she gave all the ordered medications, and her initial pill count was not correct. Review of the medication card for Amlodipine Besylate revealed the medication dose was 10 mg. Review of the stock bottle of magnesium oxide revealed the medication dose was 400 mg per tablet. Photographic evidence obtained. On 3/28/23 at 12:00 p.m., the Regional Nurse Consultant confirmed RN Staff C had signed the MAR indicating all ordered medications were administered during the medication observation. On 3/28/23 at 12:20 a.m., in a phone interview the Pharmacist said Resident #509 had a physician order for Amlodipine 10 mg, give 5 mg daily since 12/26/22. The Pharmacist said the physician order was confusing and should have been clarified with the physician. The Pharmacist said the pharmacy had only sent Amlodipine Besylate 10 mg tabs and had never sent 5 mg tablets. The pharmacist said the Amlodipine Besylate 10 mg tablets were not scored and could not be cut in half. The Pharmacist said it was an error and confirmed Resident #509 had not received the amlodipine 5 mg tablets from the pharmacy and had received Amlodipine Besylate 10 mg tablets since 12/26/22. On 3/29/23 at 4:52 p.m., in a phone interview the Medical Director said the facility had not informed him Resident #509 had received Amlodipine Besylate 10 mg daily and not the 5 mg ordered. I was not made aware of the error; the facility did not notify me of that one. The Medical Director confirmed the facility had not informed him of the medication errors observed during the medication administration for Resident's #9, #18, #41 and #509.

Based on observation, record review and staff and family interview the facility failed to implement effective corrective actions to maintain compliance for deficiencies identified during the recertification survey completed on 3/31/23. The findings included: 1. On 5/15/23 at 12:38 p.m., quarter bed rails were observed in the up position for Resident #501, admitted [DATE]. At the time of the observation, Resident #501 said they have been on her bed since admission and said no one discussed the risks vs benefits of side rails with her and she said she did not sign a consent for use of bed rails. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/5/23 that noted rails were not necessary at the time. 2. On 5/15/23 at 1:20 p.m., quarter bed rails were observed in the up position for Resident #502, admitted [DATE]. At the time of the observation, Resident #502's husband said the rails have been on the bed since admission and said no one discussed the risks vs benefits of side rails with him and he said he did not sign a consent for use of bed rails. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/6/23 that noted rails were not necessary at the time. 3. On 5/15/23 at 1:39 p.m., quarter bed rails were observed in the up position for Resident #500, admitted [DATE]. At the time of the observation, Resident #500 was unable to verbally communicate. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/11/23 that noted rails were not necessary at the time. On 5/15/23 at approximately 2:30 p.m., during a tour, the facility Director of Nursing confirmed the quarter rails were in the up position on the beds of Resident #500, #501 and #502 and said they should not be in use. 4. On 5/15/23 at 11:04 a.m., observation revealed the Foley catheter drainage bag for Resident #500 was touching the floor in his room and was not covered with a privacy bag. Photographic evidence obtained 5. On 5/15/23 at 12:57 p.m., observation revealed the Foley catheter drainage bag for Resident #92 laying on the floor in his room and was not covered with a privacy bag. On 5/15/23 at approximately 2:30 p.m., observation revealed the Foley catheter drainage bag for Resident #92 laying on the floor in his room and was not covered with a privacy bag. 6. On 5/15/23 at 1:19 p.m., observation revealed the Foley catheter tubing for Resident #39 laying on the fall mat on the floor in her room. The catheter drainage bag was touching the floor and was not covered with a privacy bag. Photographic evidence obtained On 5/15/23 at approximately 2:30 p.m., observation revealed the Foley catheter drainage bag and tubing for Resident #39 was laying on the fall mat on the floor in her room and was not covered with a privacy bag. On 5/15/23 at approximately 2:30 p.m., during a tour, the facility Director of nursing confirmed the Foley catheter drainage bags and or tubing for Resident #92 and #39 were laying on the floor or on the floor mat and the Foley catheter bags were not covered with a privacy bag for Residents #39, #92, and #500. She said the catheter bags and/or tubing for Resident #92 and #39 were laying on the floor or fall mat because the low bed was in the low position. On 5/16 23 at approximately 1:17 p.m., the Administrator and the Director of Nursing said they had been completing weekly audits of bed rails and proper catheter care and they had been in compliance, so they switched to biweekly audits on 5/11/23.

Based on observation, record review and staff and family interview the facility failed to implement effective corrective actions to maintain compliance for deficiencies identified during the recertification survey completed on 3/31/23. The findings included: 1. On 5/15/23 at 12:38 p.m., quarter bed rails were observed in the up position for Resident #501, admitted [DATE]. At the time of the observation, Resident #501 said they have been on her bed since admission and said no one discussed the risks vs benefits of side rails with her and she said she did not sign a consent for use of bed rails. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/5/23 that noted rails were not necessary at the time. 2. On 5/15/23 at 1:20 p.m., quarter bed rails were observed in the up position for Resident #502, admitted [DATE]. At the time of the observation, Resident #502's husband said the rails have been on the bed since admission and said no one discussed the risks vs benefits of side rails with him and he said he did not sign a consent for use of bed rails. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/6/23 that noted rails were not necessary at the time. 3. On 5/15/23 at 1:39 p.m., quarter bed rails were observed in the up position for Resident #500, admitted [DATE]. At the time of the observation, Resident #500 was unable to verbally communicate. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/11/23 that noted rails were not necessary at the time. On 5/15/23 at approximately 2:30 p.m., during a tour, the facility Director of Nursing confirmed the quarter rails were in the up position on the beds of Resident #500, #501 and #502 and said they should not be in use. 4. On 5/15/23 at 11:04 a.m., observation revealed the Foley catheter drainage bag for Resident #500 was touching the floor in his room and was not covered with a privacy bag. Photographic evidence obtained 5. On 5/15/23 at 12:57 p.m., observation revealed the Foley catheter drainage bag for Resident #92 laying on the floor in his room and was not covered with a privacy bag. On 5/15/23 at approximately 2:30 p.m., observation revealed the Foley catheter drainage bag for Resident #92 laying on the floor in his room and was not covered with a privacy bag. 6. On 5/15/23 at 1:19 p.m., observation revealed the Foley catheter tubing for Resident #39 laying on the fall mat on the floor in her room. The catheter drainage bag was touching the floor and was not covered with a privacy bag. Photographic evidence obtained On 5/15/23 at approximately 2:30 p.m., observation revealed the Foley catheter drainage bag and tubing for Resident #39 was laying on the fall mat on the floor in her room and was not covered with a privacy bag. On 5/15/23 at approximately 2:30 p.m., during a tour, the facility Director of nursing confirmed the Foley catheter drainage bags and or tubing for Resident #92 and #39 were laying on the floor or on the floor mat and the Foley catheter bags were not covered with a privacy bag for Residents #39, #92, and #500. She said the catheter bags and/or tubing for Resident #92 and #39 were laying on the floor or fall mat because the low bed was in the low position. On 5/16 23 at approximately 1:17 p.m., the Administrator and the Director of Nursing said they had been completing weekly audits of bed rails and proper catheter care and they had been in compliance, so they switched to biweekly audits on 5/11/23.

Based on record review, observation and interview the facility failed to provide services to evaluate the use of a Foley catheter for 1 (Resident #171) of 1 sampled resident and failed to provide services to restore normal bladder function for 1 (Resident #183) of 2 sampled residents. The findings included: 1. On 10/12/15 at 1:20 p.m., the Unit Manager (UM) said Resident #171 was seeing a urologist, at the Veteran's Administration (VA), but did not have an appointment date yet. She also said the resident had a Foley catheter, was experiencing [MEDICAL CONDITION] and had frequent urinary tract infections (UTI's). Presently, the resident is on contact precautions for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) in his urine. Review of the medical record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Coli. A significant change MDS (Minimum Data Set) dated 8/21/15 said the resident has a Brief Interview for Mental Status score of 8, out of a possible 15; indicating cognitive impairment. It also said the resident did not have a Foley catheter. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A laboratory report, dated 10/2/15 for urine culture, stated, over 100,000 Proteus mirabilis(Bacteria) and 50,000 to 100,[MEDICAL CONDITION] (MRSA- antibiotic resistant bacteria, patients [MEDICAL CONDITION] should be placed on Contact Isolation. On 10/12/14 at 10:30 a.m., the resident was observed sitting in a wheelchair in his room. He had a Foley catheter in place, connected to gravity drainage. On 10/13/15 at 10:00 a.m., observation of the resident revealed the resident did not have a Foley catheter. When questioned, the resident stated, They took that out a couple of weeks ago. At 10:30 a.m., the UM said the Foley catheter came out on the night shift and could not be replaced. The resident was being sent out to the hospital for replacement of the catheter. On 10/14/15 at 12:30 p.m., review of the medical record revealed no documentation on record regarding the services received by the resident when he was sent to the hospital for replacement of the Foley catheter on 10/13/15. The UM said the daughter had the papers regarding the care given at the hospital. The UM contacted the hospital and obtained documentation of treatment and discharge from the hospital, dated 10/13/15 with a time of 11:25 a.m., through 1:52 p.m. This documentation was faxed to the facility on [DATE] at 1:05 p.m., over 23 hours after the treatment was done and recommendations were given by the hospital. The documentation, [AGE] year old male presents to the Emergency Department complaining of [MEDICAL CONDITION]. Patient was sent from his nursing home and needs a Foley catheter placed for [MEDICAL CONDITION]. Denies any abdominal pain or fevers. No other complaints. Aftercare Instructions: Keep the Foley in until he sees the urologist and no antibiotic unless he has a fever. Clinical impression: acute [MEDICAL CONDITION], chronic bacterial colonization of the urinary tract. On 10/15/15 at 11:30 a.m., the Director of Nursing said the physician's orders [REDACTED]. Nursing note dated 9/1/15 has documentation resident's daughter said she will have to schedule resident to be seen through the VA. Facility Social Worker documented in progress note dated 9/10/15 the residents daughter has registered Resident # 171 with the VA clinic and is waiting for an appointment for the urology consult that was ordered. 2. Resident #183 was admitted [DATE] and discharged [DATE] to hospice due to [MEDICAL CONDITION]. The resident was assessed as being continent of urine on admission. On 8/24/15 Resident #183 had a significant change in condition and was assessed as being incontinent of urine 1 to 7 times weekly. Review of the CNA documentation showed Resident #183 was incontinent on 8/8/15 2 times on the 7:00 a.m. to 3:00 p.m. shift. The resident was continent until 8/24/15 when she was incontinent 2 times on the 3:00 p.m. to 11:00 p.m. shift. On 8/25/15 she was incontinent 3 times on the 11:00 p.m. to 7:00 a.m. shift. On 8/29/15 she was incontinent 2 times on the 7:00 a.m. to 3:00 p.m. shift. On 8/30/15 she was incontinent 1 time on the 3:00 p.m. to 11:00 p.m. shift. On 10/15/15 at 10:20 a.m., the Assistant Director of Nursing after reviewing the medical record verified Resident #183 had become incontinent at times and there had not been a care plan for incontinence initiated. Review of the MDS dated [DATE] reads, Functional (can't get to the toilet in time due to physical disability, external obstacles, or problems thinking or communicating). On 8/25/15 Registered Nurse (RN) Staff K documented on the MDS, Will become more incontinent as she becomes weaker from [MEDICAL CONDITION]. Will proceed to care plan related to skin breakdown and urinary infections. On 10/15/2015 at 10:33 a.m., RN Staff K said if residents decline in urinary function they should be placed on a 7-day toileting program. She verified Resident #183 had not been placed on a toileting program or care planned for incontinence.