Every finding on record at Northbrook Center for Rehabilitation and Healing

Based on interview and record review the facility failed to implement care plan interventions for 1 resident, Resident #10, of 2 residents reviewed for nutrition and failed to develop care plan interventions for 1 resident, Resident #2, of 1 resident reviewed for pressure ulcer/injury. Findings include: Review of Resident #10's care plan revealed Resident #10 had a potential nutritional problem with risks for weight fluctuations, dehydration and skin breakdown related to a need for a therapeutic diet and variable appetite. Resident #10's care plan documented nutritional interventions that included recording intake of each meal. Review of Resident #10's task response history, 7/7/2026 through 8/4/2026, showed facility staff had failed to document 3 meals on 1 of 19 days, had failed to document 2 meals on 11 of 19 days and failed document 1 meal on 7 of 19 days. During an interview on 8/5/2026 at 10:35 AM, Staff B, Licensed Practical Nurse/Unit Manager stated the facility certified nursing assistants were responsible to record residents' meal intake. During an interview on 8/5/2026 at 11:04 AM, the Director of Nursing acknowledged Resident #10's nutritional care plan intervention to record her meal intake had not been implemented. She stated she would expect staff to record Resident #10's meal intake as required by her nutritional consultant. 2)Review of Resident #2's physician order dated 7/23/2026 read, Cleanse sacrum with normal saline, pat dry, ZINC oxide to peri wound, apply MED HONEY GEL, CALCIUM ALGINATE ROPE, super absorbent pad and cover with super absorbent dressing. everyday shift for Pressure ulcer. Enhance barrier precautions. AND as needed for If soil or dislodged. Review of Resident #2's [Name of Wound Care Provider] care note dated 7/7/2026 read, Wound Assessment(s) Wound #1 Sacral is a Stage 4 Pressure Injury Ulcer and has received a status of Not Healed. Review of Resident 2's [Name of Wound Care Provider] care dated 8/4/2026 read, Wound Assessment(s) Wound #1 Sacral is a Stage 4Pressure Injury Ulcer and has received a status of Not Healed. Review of Resident #2's care plan did not document a focus and interventions for pressure ulcers. During an interview on 8/5/2026 at 10:03 AM with MDS Coordinator stated, We go off the skin sweeps and also the Renew notes. The care plan does not have a focus of pressure ulcer. The latest skin sweeps did not document the pressure ulcer. I will add it to the care plan. During an interview on 8/6/2026 at 8:10 AM with the Director of Nursing stated, I would expect [Resident #2's name] to have been care planned for pressure ulcer. Review of the facility policy and procedure titled Resident Assessment Instrument Comprehensive Care Plane Policy with a last review date of 5/28/2026 read, Policy Statement: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care.

Based on observation, interview, and record review the facility failed to serve food in a sanitary manner and failed to date resident food items in 1 of 2 nourishment rooms. Findings inlcude: During an observation on 8/3/2026 at 9:26 AM of A Wing Nourishment room with the CDM the refrigerator had a container with the name and room number of a resident. Container did not have a date. Inside the container there was a closed packed of dressing and salad in a zip lock bag that had pieces of lettuce in a light brown color. [photographic evidence obtained] During an interview on 8/3/2026 at 9:26AM with the CDM stated, The zip-lock bag should be dated. All food brought in should be thrown away in 3 days. During an observation on 8/3/2026 at 11:59 AM Staff F [NAME] was observed grabbing three bowls at a time with one hand holding the bowls by the inside surface of the bowl. During observation on 8/5/2026 at 11:40 AM Staff G [NAME] was serving the meal as Staff H Dietary Aide would call out the ticket meal. Staff G [NAME] was observed putting his finger inside the plate. Staff G Poured the food. The cauliflower came into contact with Staff G's gloved hand. Staff G was observed touching multiple serving handles and heating plates. When Staff H would call out for a grilled cheese, Staff G would grab the grill cheese and put it on a plate and hand it to the Kitchen Aide and then the tray was placed on the meal cart to be delivered to residents. During an interview on 8/5/2026 at 12:55 PM with CDM stated, Staff are to grab the bowl and not touch the inside of the bowl. Normally staff would use tongs and not touch food with their gloved hands. No fingers are to be in the surface of the plate. Food should be toss after three days of being brought in. It should have a date. Review of the facility policy and procedure titled Food Receiving and Storage with a last review date of 5/28/2026 read, Policy Statement. Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: All food belonging to residents must be labeled with the resident's name, item and date. Review of the facility policy and procedure titled Food Handling with a last review date of 5/28/2026 read, Policy Statement. Food shall be handled in a proper method to ensure retention of flavor, appearance, quality, nutrients, and the safeguard against contamination. Policy Interpretation and Implementation. 3. When it is necessary it is necessary for staff to touch food during preparation, they must wash their hands immediately before beginning the process. Disposable gloves are used.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for 3 of 8 residents, Residents #2, #18, and #23, reviewed Minimum Data Set assessments. Findings include: 1)Review of Resident #2's physician order dated 6/24/2026 read, Oxygen @ 2 L/Min [at 2 liters per minute] continuous inhalation via NC [nasal cannula] every shift. Review of Resident #2's Medication Administration Record for the month of July 2026 documented the use of oxygen. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] Section O Special Treatments, Procedures and Programs did not document oxygen use and Section GG Functional Abilities did not document upper extremity impairment. Review of Resident #2's provider visit note dated 7/1/2026 read, The patient has significant history of CVA with residual left-sided deficits, aphasia, PEG tube dependence, chronic pai, narcotic dependence, and an unstageable coccygeal pressure injury requiring ongoing wound care. During an interview on 8/5/2026 at 9:50 AM with the Director of Rehabilitation stated, [Resident #2's name] has left side deficit. During an interview on 8/6/2026 at 9:23 AM with RN MDS Coordinator stated, I looked back at therapy notes and she did have an impairment in her left shoulder it was a missed coding in my part. 2) During interview with Resident #18 through Spanish speaking Surveyor #46523 on 08/03/2026 at 10:50AM Resident stated in Spanish that there is language barrier for communication between her and the facility staff. Review of Resident #18's Minimum Data Set (MDS) Annual Dated 07/01/2026 documented in Section A 1110, Language (Primary): English. During interview with Staff L, Registered Nurse (RN), Minimum Data Set (MDS) on 08/06/2026 at 8:38 AM stated we can communicate with her. We have Spanish speaking Certified Nursing Assistant (CNA's). Although I am not her primary nurse. I cannot tell you how much English she speaks. I will recode it. During observation of Resident #18 on 08/04/2026 7:58 AM, Resident was up on side of bed talking to herself in Spanish while eating breakfast. During interview with Staff B, Licensed Practical Nurse) LPN unit manager on 08/04/2026 at 7:50AM she stated Resident #18 speaks Spanish but understands English. We have A day shift and night shift employee available to translate if needed and we use a communication board. During interview with Staff I, Certified Nursing Assistant (CNA) on 08/04/2026 at 8:18AM she stated, I speak Spanish; I work full time and every other weekend. I do not know how they communicate with [Resident #18's Name] when I am not here. During phone interview with Family Member #3 on 08/04/2026 at 11:21 PM, she stated, My aunt is straight out of Puerto Rico. English is not her preferred language. She has never spoken fluent English. She knows about 3 words. They call me when they don't think she is understanding something important. She has been there long enough that I think they just have gotten able to understand each other. 3)Review of Resident #23's physician order dated 12/19/25 read, Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) - Give 2 tablet by mouth one time a day for major depressive disorder. Review of Resident #23's psychiatry notes dated 04/15/26 read, This is a [age of Resident #23] patient with a past psychiatric history of depression and dementia; Plan of Action: I decided to continue Risperdal for schizoaffective disorder and Sertraline for depression; Diagnoses Rationale and Justifications: MDD, recurrent: The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient, and they have occurred without any underlying substance use or organic brain pathology (I have added dx from meds). Review of Resident #23 Minimum Data Set (MDS) dated [DATE] Section I Active Diagnoses did not document depression diagnosis. During an interview on 08/05/2026 at 03:00 PM, the MDS Coordinator stated that according to Resident #23's psychiatry note dated 04/15/26, the depression diagnosis should have been added to the MDS Section I.

Based on interview and record review the facility failed to provide an accurate State of Florida Agency of Health Care Administration Preadmission Screening and Resident Review (PASRR) for 1 (Resident #118) of 6 residents reviewed for behavioral services. Findings include: Review of Resident #118's State of Florida Agency for Health Care Administration Preadmission Screening (PASSR) and Resident Review dated 5/26/2026 did not include anxiety disorder. Review of Resident #118's admission record shows resident was admitted on [DATE] with diagnosis including but not limited to anxiety disorder [onset date 3/21/2026]. Review of Resident #118 's physician order dated 3/25/2026 read, Hydroxyzine HCI Oral Tablet 10 MG (Hydroxyzine HCI) give 1 tablet by mouth three times a day for anxiety. Review of Resident #118's [Name of Third-Party Psychiatry Provider]'s Subsequent Note dated 3/25/2026 read, Chief Complaint: Depression, anxiety and Dementia. History of Presenting Illness: Staff reports [Resident #118's Name] has restless anxiety symptoms. During an interview on 8/5/2026 at 12:21 PM, the Director of Nursing stated, [Resident #118's name] has a diagnosis of depression and anxiety. The PASSR did not include anxiety diagnosis documented. It needed to be reviewed.Review of the facility policy and procedure titled Pre-admission Screening and Resident Review (PASRR), with a last review date 5/28/2026 read, Overview. All persons, regardless of payer or age, needing admission to a Nursing Facility must first be screened for possible mental illness or the presence of an intellectual disability (ID) or both (Level I).

Based on observation, interview and record review the facility failed to ensure 1 resident, Resident #12, of 2 residents reviewed for activities of daily living who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Findings include: On 8/3/2026 at 1:25 PM, Resident #12 was observed in her room lying in her bed. Resident #12 was observed to have long fingernails on both hands. Resident #12's fingernails on both hands were discolored with dark and light brown substances. During interview on 8/3/2026 beginning at 1:25 PM, Resident #12 reported she had requested her fingernails be trimmed and cleaned, but staff had not done so. Review of Resident #12's care plan, date initiated 9/4/2025, revealed Resident #12 had an activities of daily living self-care performance deficit related to cognitive decline and required assistance of 1 staff to complete personal hygiene tasks. During interview on 8/5/2026 beginning at 8:58 AM, Staff A, Licensed Practical Nurse/Unit Manager, stated Resident #12 would not let the aides trim her fingernails, but she would let nurses trim her fingernails. On 8/5/2026 at 9:05 AM, Resident #12's fingernails were observed with Staff A, Licensed Practical Nurse/Unit Manager. Resident #12 was observed to have long fingernails on both hands. Resident #12's fingernails on both hands were discolored with dark and light brown substances. During interview on 8/5/26 beginning at 9:05 AM, Resident #12 stated her fingernails needed to be trimmed and clean. During interview on 8/5/2026 beginning at 9:05 AM, Staff A, Licensed Practical Nurse/Unit Manager confirmed Resident #12's fingernails on both hands were discolored with dark and light brown substances. She confirmed Resident #12's fingernails were dirty and needed to be trimmed and cleaned.

Based on observation, interview, and record review the facility failed to ensure an environment that is free from accident hazards for 1 of 3 residents, Resident #63, sampled for accidents and hazards. Findings include: During an observation on 8/5/2026 at 12:45 PM Resident #63 was lying in bed. There was a dark blue disposable razor on top of a towel in his bathroom.During an interview on 8/5/2026 at 12:45 PM with Resident #63 stated, Staff gave me the razor so I can shave myself.Review of Resident #63's Minimum Data Set titled Medicare 5 Day dated 7/24/2026 documented Section GG Functional Abilities: Functional Limitation in Range of Motion: 2. Impairment on both sides upper extremity. Self-Care: Shower/Bathe self: partial /moderate assistance.Review of Resident #63's care plan initiated on 7/20/2026 read, The resident has an ADL [activities of daily living] self-care performance deficit. Resident will improve current level of function in ADLs through the review date. BATHING/SHOWERING: The resident requires min/mod assist by X1 staff with bathing/showering routinely per facility bathing/shower schedule and as necessary. PERSONAL HYGIENE: The resident requires SU [setup] assistance by X1 staff with personal hygiene and oral care.During an interview on 8/5/2026 at 12:47 PM, Staff C Licensed Practical Nurse stated, Residents are not supposed to keep razors in their rooms. During an interview on 8/5/2026 at 2:10 PM the Director of Nursing (DON) stated, We try to have electric razors not disposable. They are not to be left in the room a resident could nick themselves while shaving.During an interview on 8/5/2026 at 2:35 PM with Staff D Certified Nursing Assistant (CNA) stated, He [Resident #63] did not ask me to shave him. I don't normally keep the razors in their rooms. It is removed after using.During an interview on 8/6/2026 at 8:39 AM with the Director of Rehabilitation stated, That is not something we can say he is safe with, we can assess dexterity, but never say it is safe to leave a razor in a resident room. Even though it is not a written policy, we do not leave sharps in a resident's room they always need to be monitored. It was not something we were working on but we can assess to make sure he is safe to do on his own while having a staff with him.During an interview on 8/6/2026 at 8:40 AM with Staff E COTA [Certified Occupational Therapy Assistant] stated, He[ Resident #63] has fine motor skills to hold an object but have not have been working on that area. We are focusing with him on lower body and balancing. If we are doing it together I do not like disposable razors I would prefer an electric razor. Right now I don't know if he would be able to do it on his own, but I don't feel it should be left unattended. I would never sign off on him having that [disposable razor] with him. Any sharp should be monitored. I would do shaving, but not recommend leaving it. The staff should stay with him and dispose of it when done. We have wanderers in the building and anyone can walk into the room.During an interview 8/6/2026 at 10:12 AM with DON stated, He is able to shave himself. I was not in his room to say if the razor was used. Maybe it should have been put away in a drawer and not left out on the sink.During an interview on 8/6/2026 at 10:46 AM DON regarding accidents policy stated she did not have an accidents policy. Review of the facility policy and procedure titled Safe Environment with a last review date of 5/28/2026 read, Policy. In accordance with residents' rights, the facility will provide a safe, clean comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

Based on interview and record review the facility failed to ensure 1 resident's clinical record, Resident #70, of 2 residents reviewed for accidents was completed related to skin conditions. Findings include: During an observation on 08/03/2026 at 10:59 AM, Resident #70 was observed sitting in wheelchair next to her bed. She had significant bruising to the right side of her face, and underneath her right eye was a dark purple area. The back of her right hand also appeared to be bruised. During an interview on 08/03/2026 at 11:00 AM, Resident #70 explained that she had fallen recently and was sent to the hospital. She could not recall when this occurred. During an observation on 08/05/2026 at 12:50 PM, Resident #70 was observed sitting in wheelchair next to her bed, eating her lunch at a bedside table. She was observed to have purple bruising under her right eye, with yellow to green bruising on her left cheek and above her left eye. Review of Resident #70 evaluations revealed a change in condition form dated 07/24/26 that read, Staff notified supervisor and nurse to resident on floor. Resident observed on floor in between beds with gash to right forehead and small cut to right inner thumb. Nurse held pressure to gash on right forehead until paramedics arrived and resident transferred to hospital. Head to toe assessment performed by second nurse and ROM intact for all extremities and hips symmetrical upon assessment. MD aware and orders given to send resident to hospital for treatment and evaluation. Family notified and verbalizes understanding of treatment plan. Review of Resident #70's evaluations revealed a Skin Sweep completed on 07/28/26 that indicated that the resident's skin was impaired with the description Left hand (back) bruising, Right hand (back) bruising; and a note that read scattered discoloration related to recent fall on 7/28.and a Skin Sweep completed on 08/04/26 that indicated that the resident's skin was impaired with Left eye bruise. Review of Resident #70's evaluations revealed 72-Hour Post Fall Monitor 8 HR [hour] reports were completed 4 times on 07/25/26, 2 times on 07/26/26, 1 time on 07/27/26, and 2 times on 07/28/26. During an interview on 08/05/2026 at 12:28 PM, Staff C, Licensed Practical Nurse (LPN) stated that she was aware that the resident suffered a fall, but she was not present when the incident occurred. She explained that when a resident suffers an unwitnessed fall, nursing staff are supposed to assess the resident for injuries like broken bones, head injuries, and take their vitals. If the resident is sent to the hospital, nursing staff assess the resident when they return. She explained that they perform 72hr post-fall reports every shift and regular skin sweeps. She stated that she looks for bruising, swelling, skin tears, or broken bones they might have missed before during these skin sweeps and documents whatever she observes. During an interview on 08/06/2026 at 09:41 AM, Staff O, LPN, stated that he is aware that the resident suffered a fall recently. He stated that she has extensive bruising and discoloration to her face that has been healing. He explained that when a resident suffers an unwitnessed fall, nurses are expected to assess the resident for injuries, test ROM, perform a neuro check, and notify the doctor for further instruction/orders. If the resident goes to the hospital and returns, the nurses are expected to complete a skin assessment on admission, fall sheets, notes and 2-hr checks. He stated that the fall sheets are assigned for 72-hrs after the incident, and the nurse on each shift is supposed to fill out the sheet. He stated that when he completes a skin check, he documents anything that's not supposed to be there, like bruises. During an interview on 08/05/2026 at 02:19 PM, the Director of Nursing stated that she has seen the resident and observed the bruising to the left side of her face, black eye, and gash over the eye that has scabbed over. She explained that when residents return from the hospital after a fall, nursing staff are expected to complete evaluations for the next 72 hours every shift. She stated that the nurses are supposed to complete these evaluations every shift. Review of the facility's Fall Risk Reduction Program policy read, If a resident falls, the following steps should be taken: k) Evaluate the resident's condition and document findings each shift for next 72 hours using the 72 Hour Fall Monitor form.

Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for 2 of 6 residents reviewed for medication management, Residents #351 and #354, and 1 of 3 residents reviewed for gastric tubes, Resident #23. Findings include: 1) Review of Resident #354's physician order dated 3/6/2025 showed it read, Insulin Glargine Subcutaneous Solution 100 UNIT/ML [unit per milliliter] (Insulin Glargine) Inject 40 units subcutaneously in the morning for Hyperglycemia. Review of Resident #354's Medication Administration Record (MAR) for March 2025 showed no entries documented at 6:00 AM on 3/11/2025 and 3/19/2025 for administration of Insulin Glargine. During an interview on 3/24/2025 at 10:11 AM, Resident #354 stated that the staff gave her all her medications. During an interview on 3/26/2025 at 7:10 AM, Staff G, Licensed Practical Nurse (LPN), stated, I got distracted and did not document it. I really do not know what happened. During an interview on 3/27/2025 at 11:24 AM, the Director of Nursing (DON) stated, I expect nurses to document accurately. I do see the blanks on 3/11/2025 and 3/19/2025 for [Resident #354's name]. 2) Review of Resident #23's physician order dated 2/23/2025 showed it read, After meals related to dysphagia, oropharyngeal phase (R13.12); gastrostomy status (Z93.1), Enteral: Hold Bolus Feeding if eats less than 50% of meal. Administer Nepro/CarbSteady Oral Liquid per G-Tube [gastric tube] via bolus. Rate: 237 mL [milliliters] per feeding, 3 times per day. (Enhanced Barrier Precautions). During an interview on 3/26/2025 at 12:25 PM, the Registered Dietician stated, The staff are monitoring [Resident #23's name] intake and has orders for bolus if he eats less than 50% of his meal. During an interview on 3/27/2025 at 8:13 AM, the DON stated, It was a documentation error that needs to be corrected. It should read hold when Resident eats more than 50% not less. I think it got written backwards. During an interview on 3/27/2025 at 3:09 PM, Staff G, Certified Dietary Manager, stated, [Resident #23's name] order should have read if consumed less than 50 percent of the meal to give the bolus. 3) Review of Resident #351's physician order dated 3/3/2025 showed it read, Behavior Monitoring: Monitor for the following: 1. itching, 2. picking at skin, 3. restlessness/agitation, 4. hitting, 5. increase in complaints, 6. biting, 7. kicking, 8. spitting, 9. cursing, 10. racial slurs, 11. elopement, 12. stealing, 13. delusions, 14. hallucinations, 15. psychosis, 16. aggression, 17. refusing care, Document Y if any of the above observed, record code and also document in progress notes. Document N if none of the above occurred. Review of Resident #351's physician order dated 3/3/2025 showed it read, Abilify Oral Tablet 10 mg [milligram] (Aripiprazole), Give 1 tablet by mouth one time a day for depression. Review of Resident #351's physician order dated 3/3/2025 showed it read, Mirtazapine Oral Table 7.5 mg (Mirtazapine), Give 1 tablet by mouth at bedtime related to depression. Review of Resident #351's physician order dated 3/3/2025 showed it read, Paroxetine HCl Oral Tablet 40 mg (Paroxetine HCl), Give 1 tablet by mouth at bedtime related to depression. Review of Resident #351's Treatment Administration Record for March 2025 for behavior monitoring showed staff documented code 0 on 3/16/2025, 3/18/2025, 3/24/2025, 3/25/2025, and 3/26/2025 during 7-3 shift, and NA (Not Applicable) on 3/7/2025, 3/15/2027, 3/16/2025, and 3/25/2025 during 3-1 shift. During an interview on 3/27/2025 at 8:42 AM, Staff L, Licensed Practical Nurse (LPN), stated, When documenting behavior monitoring, you should never put NA. It is a yes or no question. If the resident does have any behaviors, there are numbers to code what behavior they had and what intervention you took to help with the redirection of the behavior. During an interview on 3/27/2025 at 9:07 AM, Staff M, Licensed Practical Nurse (LPN), stated, NA should never be used when documenting behavior monitoring. The staff should answer yes or no. During an interview on 3/27/2025 at 8:17 AM, the DON stated, The staff should be documenting accurately the resident's behavior. They should not document NA. They should answer N for No if the resident does not have any behaviors. It is a user error. Review of the facility policy and procedure titled Documentation, Clinical with the last review date of 2/19/2025 showed it read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. Documentation in the medical record of each resident should provide: A. A complete account of the resident's care treatment and response to the care . 4. An ongoing record of the physical and mental status of the resident.

Based on observation, interview, and record review, the facility failed to ensure residents received their medication as ordered by the physician for 1 of 10 residents reviewed for medication administration, Resident #402. Findings include: During an observation on 3/26/2025 at 9:38 AM, Staff C, Licensed Practical Nurse (LPN), measured 2 grams of Dicoflenac Sodium topical gel (Voltaren) onto the medication ruler. Staff C applied 2 grams of the medication to the medication ruler and applied one gram to the left knee of Resident #402 and then one gram was applied to the right knee. Review of Resident #402 physician order dated 3/14/2025 showed it read, Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium (Topical), Apply to knees topically two times a day for pain. During an interview on 3/26/2025 at 9:36 AM with Staff C, LPN, when asked if Diclofenac gel is 1 gram per knee or 2 grams per knee, Staff C stated, Will need to call the APRN [Advance Practice Registered Nurse] to clarify. During an interview on 3/27/2025 at 10:20 AM, the Director of Nursing (DON) stated, I spoke with [the physician's name] yesterday. I am the person who put the order in the system. Voltaren 2 grams should be given to each knee. I will let the nurse know. Review of the facility policy and procedure titled Administering Medications with the last review date of 2/19/2025 showed it read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required timeframe.

Based on observation, interview, and record review, the facility failed to ensure residents received care and services for central venous access devices in accordance with professional standards of practice for 1 of 3 residents reviewed for intravenous therapy, Resident #95. Findings include: During an observation on 3/24/2025 at 10:17 AM, Resident #95 was sitting at the edge of her bed. Resident #95 had a single lumen PICC (Peripherally Inserted Central Catheter) line on her right arm with a transparent dressing and a gauze underneath the dressing with no date. During an interview on 3/24/2025 at 10:17 AM, Resident #95 stated, The staff changed my dressing last Thursday [3/20/2025]. I am not sure why they did not date the dressing. Review of Resident #95's physician order dated 3/3/2025 showed it read, IV [Intravenous]: Central Line- PICC Line: Change transparent dressing every evening shift every Sat [Saturday] for preventative care. Review of Resident #95's Medication Administration Record (MAR) for March 2025 showed the last transparent dressing change was completed on 3/15/2025. Review of Resident #95's physician order dated 3/13/2025 showed it read, Vancomycin HCl Intravenous Solution (Vancomycin HCl) Use 1250 mg [milligrams] intravenously two times a day for right knee infection. During an interview on 3/27/2025 at 8:09 AM, the Director of Nursing stated, IV dressing should be labeled with the date that the dressing was changed. Dressing changes should be done every 7 days and if they have a gauze under the transparent dressing every 2 days. Review of the facility policy and procedure titled Infusion Devices and Procedures with the last review date of 2/19/2025 showed it read, Policy . Gauze dressings are changed every 2 days. Transparent semipermeable membrane (TSM) dressings are changed every 5-7 days.

Based on interview and record review, the facility failed to ensure residents received restorative services to maintain their mobility for 1 of 3 residents reviewed for restorative services, Resident #16. Findings include: During an interview on 3/25/2025 at 9:20 AM, Resident #16 stated, I am not doing any physical therapy or walking program at this time. I want to start walking again. Review of Resident #16's physician order dated 12/16/2024 showed it read, Restorative Program: Ambulate using 2ww [2 wheeled walker], gait belt, close wc [wheelchair] follow, and close contact assistance up to 100 ft [feet], 3x [3 times] weekly . Order Status: Active. Review of Resident #16's Physical Therapy Discharge Summary dated 12/9/2024 showed it read, Discharge Recommendations and Status . Restorative Programs . Ambulation Program Established/Trained 100' CGA [Contact Guard Assist] using gait belt, close wc follow. During an interview on 3/27/2025 at 12:18 PM, the Director of Nursing confirmed Resident #16 had an order for restorative therapy in December of 2024 and stated, He was not picked up for restorative services in December. During an interview on 3/27/2025 at 1:11 PM, Staff I, Occupational Therapist, stated, They are supposed to follow the goals in the referral to continue their therapy goals. During an interview on 3/27/2025 at 2:00 PM, the Director of Nursing stated, We expect the restorative team to pick up residents who have an order. We do not have a directly related policy.

Based on observation, interview, and record review, the facility failed to provide dietary services as ordered by physician for 3 of 8 residents reviewed for nutrition, Residents #31, #352 and #405. Findings include: 1) During an observation on 3/25/2025 at 12:55 PM, Resident #352 was eating in his room. The meal tray included cranberry juice, dessert, mixed vegetables containing broccoli, carrots, and cauliflower, and an inside out chicken potpie. Review of Resident #352's meal ticket for 3/25/2025 did not show fortified foods listed. During an observation on 3/26/2025 at 7:54 AM, Resident #352 was eating in the room. The meal tray included cold cereal mixed with white milk, scrambled eggs, toast with jelly and juice. Review of Resident #352's meal ticket for 3/26/2025 did not show fortified foods listed. Review of Resident #352's physician order dated 1/14/2025 showed it read, Low Concentrated Sweets diet, Regular Texture, Thin Consistency, for Fortified Foods. During an interview on 3/26/2025 at 12:18 PM, the Registered Dietitian [RD] stated, [Resident #352's name] has orders for fortified foods. For breakfast, oatmeal is the fortified food served, and mashed potatoes would be served for lunch and dinner. Fortified foods add more calories. During an interview on 3/26/2025 at 12:19 PM, Staff G, Certified Dietary Manager, stated, [Resident #352's name] is on fortified foods and should be getting oatmeal for breakfast and mashed potatoes for lunch and dinner. I do not see fortified foods included in his meal ticket. It should be written on the meal ticket. 2) During an observation on 3/24/2025 at 1:30 PM, Resident #31 was lying in bed, receiving Jevity 1.5 via feeding tube at the rate of 80 milliliters per hour. During an observation on 3/25/2025 at 12:39 PM, Resident #31 was lying in bed, receiving Jevity 1.5 via feeding tube at the rate of 80 milliliters per hour. During an observation on 3/26/2025 at 7:10 AM, Resident #31 was lying in bed, receiving Jevity 1.5 via feeding tube at the rate of 80 milliliters per hour. Review of Resident #31's physician order dated 1/24/2025 showed it read, Enteral Feed Order two times a day for (Enhanced Barrier Precautions) Enteral: Pump Feeding: Administer jevity 1.5 per peg [Percutaneous Endoscopic Gastrostomy] tube via pump. Rate: 80 mls/hour for 20 hours/day down at 9 am up at 1 pm. Review of Resident #31's progress note dated 3/12/2025 showed it read, RD Note tolerating TF [Tube Feeding] meeting calorie needs due to wt [weight] decrease will recommend increase TF jevity 1.5 at 85 ml [milliliter] x 20= 1700 cc [cubic centimeter] 2550 cal [calories], monitor wts [weights] weekly thru March review. Review of Resident #31's physician orders showed no order for increasing tube feeding to 85 milliliters. During an interview on 3/26/2025 at 12:04 PM, the Registered Dietician stated, I leave recommendation sheets and we give a copy to the DON [Director of Nursing], CDM [Certified Dietary Manager] and Minimum Data Set nurse and so everyone is aware. I would be careful not to increase too much. Even with the recommendation not followed [Resident #31 name] went up two pounds. I am not sure what happened that it did not get changed. During an interview on 3/26/2025 at 12:15 PM, Staff G, CDM, stated, I received the recommendation and carried it out to all parties including nursing and director of nursing. Nursing or DON are the ones to put in the orders. I was not aware the feeding tube rate was not changed. During an interview on 3/27/2025 at 8:14 AM, the Director of Nursing stated, I do not believe the doctor was notified when the recommendations were made to increase the tube feeding rate. 49846 3) During an observation on 3/26/2025 at 8:00 AM, Resident #405 received her breakfast which included eggs, toast, and coffee. During an observation on 3/26/2025 at 12:45 PM, Resident #405 received her lunch, which included cheese broccoli casserole, roll and soda for a drink. Review of Resident #405's meal ticket for 3/26/2025 showed no fortified foods listed. Review of Resident #405's physician order dated 2/7/2025 showed it read, NAS (No Added Salt) diet Regular texture, Thin consistency, for add Fortified Foods every meal. During an interview on 3/25/2025 at 2:30 PM, Staff G, CDM stated, The fortified foods were oatmeal with cinnamon, cereal and mashed potatoes with gravy. During an interview on 3/27/2025 at 8:16 AM, Staff G, CDM, stated, [Resident #405's name] should have been given oatmeal during breakfast and mashed potatoes during lunch as part of their fortified food order. Review of the facility policy and procedure titled Nutrition Interventions with the last review date of 2/19/2025 showed it read, Policy: Nutritional interventions will be implemented as recommended by the Dietary Manager, dietitian and/or Nutrition and Dietetics Technician Registered (NDTR) to ensure the best possible nutritional status for residents of the facility. Recommendations will be consistent with nutritional best practices and the industry standards of care.

Based on interview and record review, the facility failed to ensure residents were assessed before and after dialysis treatments for 1 of 1 resident receiving dialysis services, Resident #30. Findings include: Review of Resident #30's Dialysis Center-Facility Communication Form dated 2/28/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's Dialysis Center-Facility Communication Form dated 3/3/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's Dialysis Center-Facility Communication Form dated 3/5/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's records showed no Dialysis Center-Facility Communication Form for dialysis visit on 3/10/2025. Review of Resident #30's physician order dated 8/27/2025 showed it read, Dialysis: May go to Dialysis on Monday/[NAME] [Wednesday]/Friday at [Name of dialysis center] on [the dialysis center address and phone number] chair time 11 am pick up after 9a m ([phone number of transportation company]). During an interview on 3/27/2025 at 8:45 AM, Staff L, Licensed Practical Nurse (LPN), stated, There is a dialysis book we have to complete before and after [Resident #30's name] has dialysis. The dialysis book has a communication sheet we have to fill out before resident is sent to dialysis and when they return. During an interview on 3/27/2025 at 9:13 AM, Staff M, LPN, stated, [Resident #30's name] does not have a communication sheet done for 3/10/2025. On 3/3/2205, 3/5/2025 and 2/28/2025, the post dialysis communication sheet has no vitals recorded upon his [Resident #30] return. The dialysis communication form should be completely filled out and vitals should be taken. The form is filled out before sending the resident to dialysis and upon his return. There is no order. It is just an expectation that the staff know they have to complete the communication form for any dialysis resident in the building. During an interview on 3/27/2025 at 11:20 AM, the Director of Nursing (DON) stated, Nurses should do a dialysis communication assessment pre and post dialysis days for [Resident #30's name]. Review of the facility policy and procedure titled Care of the resident receiving Dialysis with the last review date of 2/19/2025 showed it read, Procedure . Pre-dialysis care: a. Nurse will complete top section of Dialysis Communication Form and sign/date . Post-dialysis care . b. Document evaluation by completing bottom section of the Dialysis Communication Form. Sign/date the form. File the completed form in resident's medical record.

Based on observation and interview, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation upon entry to the facility on [DATE] at 9:00 AM, the nurse staffing information posted at the front desk was dated 3/19/2025. During an interview on 3/24/2025 at 9:37 AM, the Administrator stated, Federal posting should be changed daily. The staffing coordinator will change it during the week and the weekend supervisor will be responsible for changing the posting. During an interview on 3/27/2025 at 8:45 AM, the Staffing Coordinator stated, I am responsible for placing the staffing information at the front desk during the week. The weekend supervisors change it on the weekends. The number was correct, but the date wasn't.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 2 of 4 halls. Findings include: 1) During an observation on 3/24/2025 at 10:51 AM, Resident #19 was lying in bed. There was a Ventolin HFA inhaler on top of the resident's nightstand. During an interview on 3/24/2025 at 10:51 AM, Resident #19 stated, I use the inhaler myself. The nurses do not help me with it. During an interview on 3/24/2025 at 8:07 AM, the Director of Nursing stated, There is no resident in the facility at this time that self-administers medication. The nurse will do a self-administration evaluation and it would be recorded in [electronic health record program's name]. Medication should not be left unattended. Even if resident has a self-administration evaluation and is considered safe to administer, the nurse will bring the medication and recollect it and take it back to the cart. During an interview on 3/27/2025 at 10:30 AM, the Director of Nursing stated, [Resident #19's name] does not even have an order for this inhaler [holding the Ventolin HFA inhaler in her hand]. 40559 2) During an observation on 3/25/2025 at 10:56 AM, there was a small clear plastic cup with multiple pills on the overbed table of Resident #91. During an interview on 3/25/2025 at 10:57 AM, Resident #91 stated, These are my medications. I will take them later. Review of Resident #91's medical records did not reveal an evaluation of Resident #91 for self-administration of medications. Review of the facility policy and procedure titled Medication Storage with the last review date of 2/19/2025 showed it read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL Department of Health guidelines. Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart of medication room that is accessible only to authorized personnel as defined by facility policy.

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for 1 of 8 residents reviewed for nutrition, Resident #31, and 1 of 6 residents reviewed for medication management, Resident #81. Findings include: 1) During an observation on 3/25/2025 at 12:39 PM, Resident #31 was lying in bed, receiving Jevity 1.5 via tube feeding at 80 milliliters per hour. During an observation on 3/26/2025 at 7:30 AM, Resident #31 was lying in bed, receiving Jevity 1.5 via tube feeding at 80 milliliters per hour. Review of Resident #31's quarterly Minimum Data Set (MDS) dated [DATE] showed it read, Section K- Swallowing/ Nutritional Status. K0710. Percent Intake by Artificial Route . 3. During Entire 7 Days. A. Proportion of total calories the resident received through parenteral or tube feeding: 1. 25% or less. Review of Resident #31's physician order dated 11/13/2024 showed it read, NPO [Nil Per Os which is a Latin phrase meaning nothing by mouth]-Nothing by Mouth diet, NPO texture, NPO consistency. Review of Resident #31's physician order dated 1/24/2025 showed it read, Enteral Feed Order two times a day for (Enhanced Barrier Precautions) Enteral: Pump Feeding: Administer jevity 1.5 per PEG [Percutaneous Endoscopic Gastrostomy] tube via pump. Rate: 80 mls/hour (80 milliliters per hour) for 20 hours/day down at 9 am up at 1 pm. During an interview on 3/26/2025 at 12:04 PM, the Registered Dietician stated, [Resident #31's name] gets all his caloric intake via the gastric tube feedings. During an interview on 3/26/2025 at 12:15 PM, Staff G, Certified Dietary Manager (CDM), stated, [Resident #31's name] receives all nutrition via the gastric tube. During an interview on 3/26/2025 at 1:59 PM, Staff K, MDS Registered Nurse, stated, After speaking with [the CDM's name] we have to correct the MDS entry because [Resident #31's name] received all caloric intake via the gastric tube. 49777 2) Review of Resident #81's admission record showed the resident was most recently admitted on [DATE], with the diagnosis of pneumonia with onset date of 1/23/2025. Review of Resident #81's physician order dated 1/23/2025 showed read, Levaquin Oral Tablet (Levofloxacin), Give 500 mg by mouth at bedtime for Pneumonia for 7 Days. Review of Resident #81's MDS dated [DATE] showed no infections were documented under Section I- Active Diagnoses. Active Diagnoses in the last 7 days. During an interview on 3/26/2025 at 1:35 PM, Staff K, MDS Registered Nurse, stated that Section I of MDS for Resident #81 was not correct and it should have listed Pneumonia. Review of the facility policy and procedure titled Summit Care Resident Assessment Instrument (RAI) MDS Compliance Policy with the last review date of 2/19/2025 showed it read, Purpose: This policy establishes procedures for completing the Minimum Date Set (MDS) 3.0 to ensure compliance with federal and state requirements, promote accurate resident assessments, and facilitate proper reimbursement under Medicare and Medicaid . Procedure . 3. Accuracy and Completeness: All sections of the MDS must be filled out accurately using input from relevant staff, including nursing, social services, therapy, and dietary departments.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and used proper personal protective equipment during medication administration for 2 of 11 residents reviewed for medication administration, Residents #32 and #56, and while providing care for 2 of 4 residents reviewed for isolation precautions, Residents #302 and #405, to prevent possible spread of infection and communicable diseases. Findings include: 1) During an observation on 3/25/2025 at 8:30 AM, Staff B, Licensed Practical Nurse (LPN), was standing in front of the medication cart. Staff B scratched the side of her head with her right hand. Without performing hand hygiene, Staff B continued to pour medication into a medication cup. Staff B poured the medication into a clear medication sleeve and crushed the medication. Staff B grabbed two capsules from the top of the medication cart, and without donning gloves, opened each capsule and poured the medication into a small bowl. Staff B pushed her medication cart to Resident #32's door, performed hand hygiene before entering the room, and administered the medication to Resident #32. During an interview on 3/26/2025 at 2:50 PM, Staff B, LPN, stated, I know I should use gloves when touching any medication. Medication should not be touched with your hands, but no one has ever told me anything. During an interview on 3/27/2025 at 7:15 AM, the Infection Preventionist stated, Any time the staff touch their face, they should wash her hands and they should not be touching medication with their bare hands. During an interview on 3/27/2025 at 8:06 AM, with the Director of Nursing (DON) stated, Once the staff touched her head, she should have performed hand hygiene and then continued to pour medication. The nursing staff should not touch a capsule with her hand. The nursing staff should wash her hands and don gloves, then she should open the capsule and once she is done and removes her gloves, she should wash her hands again. Review of the facility policy and procedure titled Administering Medications with the last review date of 2/19/2025 showed it read, Policy Statement: Medication are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 25. Staff follows established facility infection control procedures (e.g., hand hygiene, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility policy and procedure titled Handwashing/Hand Hygiene with the last review date of 2/19/2025 showed it read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations . b. After contact with resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile [Clostridium difficile]. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . c. before preparing or handling medications. 49777 2) During an observation on 3/25/2025 at 8:35 AM, Staff D, Registered Nurse (RN), opened Gabapentin and Potassium Chloride capsules with bare hands for Resident #56. Staff D did not have gloves on during medication preparation. During an interview on 3/25/2025 at 9:05 AM, Staff D, RN, stated, I was only touching the outside of the capsule, so I did not think I needed to wear gloves to open the capsule. During an interview on 3/25/2025 at 9:15 AM, 400 Hall Nurse Manager stated, Gloves should be worn when opening capsules during medication pass. 3) During an observation on 3/25/2025 at 9:33 AM, the Wound Care Nurse, RN, provided wound care to Resident #302. The Wound Care Nurse did not have gown while providing wound care. There was an Enhanced Barrier Precautions (EBP) signage outside Resident #302's room. During an interview on 3/25/2025 at 9:40 AM, the Wound Care Nurse stated, I should have worn a gown. During an interview on 3/27/2025 at 3:15 PM, the DON stated, During wound care, staff should wear gown and gloves for a resident on Enhanced Barrier Precautions. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 2/19/2025 showed it read, Policy Statement: Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring the u se of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and g. wound care (any skin opening requiring a dressing). 49846 4) During an observation on 3/26/2025 at 8:31 AM, Staff A, Certified Nursing Assistant (CNA), entered Resident #405's room to pass out the breakfast tray. Staff A did not wear gown before entering the room. There was a contact precaution signage and PPE supplies outside of Resident #405's room. During an interview on 3/26/2025 at 8:40 AM, Staff A, CNA, stated, I just got in a hurry to pass out breakfast trays and didn't even see the bin or the sign outside the door. Review of Resident #405's physician order dated 2/4/2025 showed it read, Contact Isolation: The resident is in isolation due to: C-Diff. The resident is in a room alone, and all items are brought to the resident (food, activities, meditation [Sic.], therapy) because the resident does not leave the room, every shift. During an interview on 3/26/2025 at 8:45 AM, the DON stated, If a resident is on contact isolation for C. Diff., staff is supposed to dress out in appropriate PPE before entering room. Review of the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting last updated in July 2023 showed it read, III.B.1. Contact Precautions . Healthcare personnel caring for patients on Contact Precautions wear gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment.

Based on observation, interview, and record review, the facility failed to ensure comfortable and safe temperature levels were maintained in 4 of 4 facility shower rooms, and failed to ensure a clean and homelike environment in 3 of 5 resident rooms. Finding include: 1. During an interview on 12/11/2023 at 10:06 AM, Resident #106 stated the facility shower rooms were cold and he passed on showers sometimes because the shower room was so cold. During an observation on 12/11/2023 at 10:23 AM, the ambient air temperature was 66.7 degrees Fahrenheit in the B Wing shower room directly across from the nurses' station. During an observation on 12/11/2023 at 10:25 AM, the ambient air temperature was 67.6 degrees Fahrenheit in the B Wing shower room located to the right side across from the nurses' station. During an observation of the A Wing shower room located to the left side across from the nurses' station on 12/11/2023 at 11:02 AM with the Administrator, the ambient air temperature was 66.2 degrees Fahrenheit. During an observation of the A Wing shower room located directly across from the nurses' station on 12/11/2023 at 11:04 AM with the Administrator, the ambient air temperature was 67.8 degrees Fahrenheit. During an interview on 12/13/2023 at 9:30 AM, the Administrator stated that the temperature range of 71 to 81 degrees Fahrenheit is a comfortable and safe temperature range expected to be maintained in the facility. 39371 2. During an observation of Resident #81's room on 12/11/2023 at 2:00 PM, the baseboard was not attached to the wall and was lying face down on the floor. There was a thick substance on the back side of the baseboard and a moderate amount of flakey white debris on the baseboard and the floor surrounding the detached baseboard. The wall where the baseboard had been attached had missing paint and exposed drywall. (Photographic evidence obtained). During an observation of Resident #81 on 12/12/2023 at 1:15 PM, the baseboard was not attached to the wall and was lying face down on the floor. There was a thick substance on the back side of the baseboard and a moderate amount of flakey white debris on the baseboard and the floor surrounding the detached baseboard. The wall where the baseboard had been attached had missing paint and exposed drywall. During an observation of Resident #81 on 12/13/2023 at 12:30 PM, the baseboard was not attached to the wall and was lying face down on the floor. There was a thick substance on the back side of the baseboard and a moderate amount of flakey white debris on the baseboard and the floor surrounding the detached baseboard. The wall where the baseboard had been attached had missing paint and exposed drywall. During an interview on 12/13/2023 at 12:45 PM, the Regional Maintenance Director stated, That should not be like that. It is the responsibility of the maintenance department to fix. 3. During an observation of Resident #57's room on 12/11/2023 at 10:49 AM, there was an outlet on the wall without a cover. (Photographic evidence obtained). During an observation Resident #57's room on 12/13/2023 at 12:19 PM, the outlet on the wall had no cover. 4. During an observation of Resident #75's room on 12/11/2023 at 2:10 PM, there was an outlet on the wall without a cover. (Photographic evidence obtained). During an observation of Resident #75's room on 12/13/2023 at 12:20 PM, the outlet on the wall had no cover. During an interview on 12/13/2023 at 12:45 PM, the Regional Maintenance Director stated, That should not be like that [outlets that are not covered]. That is not safe. It is the responsibility of the Maintenance Department to fix. Review of the facility policy and procedures titled Environmental Services-Safe Environment last reviewed on 1/18/2023, reads, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions . Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes resident's susceptibility to loss of body heat and risk of hypothermia or hyperthermia or and is comfortable for the residents.

Based on record review and interview, the facility failed to ensure residents were referred to the appropriate state designated authority for a Level II evaluation and determination for 1 of 3 residents reviewed for Preadmission Screening and Resident Review (PASRR), Resident #68. Findings include: Review of Resident #68's admission record revealed the resident was diagnosed with bipolar disorder, schizophrenia, and anxiety disorder with onset date of 11/18/2023. Review of Resident #68's Level I PASRR dated 11/1/2023 reads, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #68's hospital progress note dated 10/31/2023 showed history of dementia, schizophrenia, and bipolar disorder. Review of Resident #68's psychiatry subsequent note dated 12/1/2023 showed the resident's chief psychiatric complaints included depression, anxiety, and schizoaffective disorder. During an interview on 12/13/2023 at 8:50 AM, the Social Services Director stated the facility did not have any documentation that indicated Resident #68's Level I PASRR had been revised to show a diagnosis of bipolar disorder, schizophrenia, or dementia and to initiate a Level II PASRR screening.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for notifying the physician of hypoglycemic episodes for 1 of 3 residents reviewed, Resident #82. Findings include: Review of Resident #82's physician order dated 9/11/2023 reads, Insulin Glargine Subcutaneous Solution Pen-Injector 100 unit/ml [milliliter]. Inject 30 unit two times daily related to type II diabetes with diabetic neuropathy. Review of Resident #82's nursing progress note dated 10/30/2023 showed insulin was held due to low BS (blood sugar). Review of Resident #82's nursing progress note dated 11/5/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/6/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/21/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/23/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/25/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/26/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 12/1/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 12/5/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 12/10/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 12/12/9/2023 showed insulin was held due to low BS. Review of Resident #82's care plan dated 7/25/2023 showed the resident had diabetes mellitus. The interventions included administration of diabetes medication as ordered by doctor, and monitoring, documenting and reporting any signs of hypoglycemia. During an interview on 12/11/2023 at 12:30 PM, the Director of Nursing (DON) stated that if there was an occasion that physician orders were not followed for insulin due to a low blood sugar, the physician should be notified for orders to give or to hold the insulin. Review of the facility policy and procedure titled Nursing- Hypoglycemia/ Hyperglycemia last reviewed on 1/18/2023, reads, General Guidelines . 2. Check blood glucose level if signs or symptoms indicate possible hypoglycemia . 5. Notify physician of the hypoglycemic episode and/or effectiveness of treatment and recheck blood sugar as indicated by physician.

Based on record review and interview, the facility failed to ensure the residents were free from medical neglect by not initiating Cardiopulmonary Resuscitation (CPR) subject to the resident's advance directives for 1 of 45 residents with full code status, Resident #1, when Staff A, RN, found the resident with no pulse and no respiration. Resident #1 expired. This deficient practice put 45 residents with full code status out of 98 residents at likelihood of serious harm, serious injury or death due to physical abuse or medical neglect. Findings include: Review of Resident #1' admission records revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical records revealed the resident had full code status acknowledgement signed on [DATE]. Review of the statement written by Staff C, Registered Nurse (RN), on [DATE] revealed shortly after midnight, Staff A, RN, was notified by Staff B, Certified Nursing Assistant (CNA), that Resident #1 was not looking right. Staff A and Staff B walked to Resident #1's room where Staff A noted the resident had expired. Staff A did not honor Resident #1's decision to be resuscitated, did not initiate CPR on Resident #1 or call 911. Staff A instead walked out of Resident 1's room back to nursing station where she proceeded to make telephone notifications of Resident #1's death to resident emergency contact, Advanced Practice Registered Nurse (APRN) and the funeral home. Staff A did not notify any other staff member on shift that Resident #1 was a full code. Review of the nursing progress notes documented by Staff A, RN, on [DATE] at 12:52 AM reads, [Resident #1' name] was found to be without pulse or respiration. Body warm. Pronounced expired 12:15 AM. APRN notified at 12:20 AM. Funeral Home notified at 12:30 AM. Review of the nursing progress notes documented by Staff A, RN, on [DATE] at 1:14 AM reads, [Resident #1's name] emergency contact notified of residents' death. DCF caseworker notified of residents' death. During an interview on [DATE] at 11:40 AM, the Director of Nursing (DON) stated, [Staff A's name] did not let anyone on shift know he [Resident #1] was a full code. There was no excuse for [Staff A's name] not to know if Resident #1's name] is a full code or DNR [Do Not Resuscitate]. When you open the chart, the first page is DNR. If you don't see a DNR, they are a full code. During an interview on [DATE] at 5:51 PM, the Advanced Practice Registered Nurse (APRN), stated, I received a call from [Staff A's name] notifying me of [Resident #1's name] death. I further did not get any notification that there was decline or actively dying prior to receiving notification of [Resident #1' name] death. What was a surprise is that he was not a DNR and that CPR was not initiated. During an interview on [DATE] at 11:01 AM, Staff A, RN, stated, I did not know [Resident #1 name] was a full code. Even though I opened the chart to retrieve face sheet, it did not register there was no DNR. I did not take vitals and when listening to [Resident #1 name's] heart and lungs, he was absent of both. When asked if she noted a decline in Resident# 1's condition, she stated, No, it was early on in my shift. He was so thin and very frail. I had no reason to let anyone else know if I believed he was a DNR. I had not taken care of him for a while. During an interview on [DATE] at 3:30 PM, Staff B, CNA, stated, I cannot pinpoint a time when I alerted [Staff A's name] of patient needing to be looked at. I started my rounds between 11:30 to 11:45 PM and by the time I got back there, it was around midnight. She [Staff A] used the stethoscope and walked out. I stuck around the desk to see if she was going to instruct me to do anything. She just began to call people and let them know patient died . I just returned to room and began to clean him up. His body was removed quickly from facility. In the morning, I heard staff say he was a full code. I think that it was one of the restorative CNAs, not sure. Review of the facility policy titled Emergency Care CPR reads, Policy: The facility will identify each resident's choice for treatment and care, help the resident to develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics decision making policies and procedures and Florida State law. In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's advance directives. Prior to arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences [CONDITION(S)] or respiratory arrest in accordance with the resident's advance directive or Do Not Resuscitate (DNR) order. Review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation reads, Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and The Director of Nursing Definitions: . Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility removed the immediacy on [DATE] and corrected the non-compliance on [DATE] as evidenced by: Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes revealed the facility conducted a meeting attended by the Administrator, Director of Nursing, Medical Director, Social Service Director on [DATE] and implemented a Performance Improvement Plan (PIP) titled Advanced Directive that included audit of all in house resident deaths, audit of employee files for CPR certification status, current background screening, attestation, and education requirements, in service on Code Blue and advanced directives and abuse and neglect, Code Blue drills, and immediate audit of advance directive status of current residents. On [DATE], the facility suspended Staff A; conducted a full in-house audit to verify the code status of all residents; audited in-facility deaths for the past six months to assure that advanced directives were followed; conducted Code Blue drills on all shifts. On [DATE] through [DATE], the facility conducted full audits of employee files to assure that CPR certification status, current background screening, attestation, and education requirements were met; provided in-service training to all facility staff on Code Blue and Advanced Directives and Abuse and Neglect on all shifts. On [DATE], Staff A was terminated, reported to Department of Health and law enforcement. During interviews conducted on [DATE] through [DATE] with Staff F, LPN, Staff G, PCA (Patient Care Assistant), Staff H, RN, Staff I, LPN, Staff J, Staff K, LPN, Staff L, RN, Staff M, CNA, Staff N, LPN, Staff O, RN, Staff P, LPN, and Staff Q, CNA, they were able to express competency to implement the facility's Code Blue, Advance Directive and Abuse/Neglect procedures.

Based on record review and interview, the facility failed to ensure the residents received basic life support including Cardiopulmonary Resuscitation (CPR) subject to the resident's advance directives for 1 of 45 residents with full code status, Resident #1, by not initiating CPR when Staff A, RN, found the resident with no pulse and no respiration. Resident #1 expired. This deficient practice put 45 residents with full code status out of 98 residents at likelihood of serious harm, serious injury or death due to physical abuse or medical neglect. Findings include: Review of Resident #1' admission records revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical records revealed the resident had full code status acknowledgement signed on [DATE]. Review of the statement written by Staff C, Registered Nurse (RN), on [DATE] revealed shortly after midnight, Staff A, RN, was notified by Staff B, Certified Nursing Assistant (CNA), that Resident #1 was not looking right. Staff A and Staff B walked to Resident #1's room where Staff A noted the resident had expired. Staff A did not honor Resident #1's decision to be resuscitated, did not initiate CPR on Resident #1 or call 911. Staff A instead walked out of Resident 1's room back to nursing station where she proceeded to make telephone notifications of Resident #1's death to resident emergency contact, Advanced Practice Registered Nurse (APRN) and the funeral home. Staff A did not notify any other staff member on shift that Resident #1 was a full code. Review of the nursing progress notes documented by Staff A, RN, on [DATE] at 12:52 AM reads, [Resident #1' name] was found to be without pulse or respiration. Body warm. Pronounced expired 12:15 AM. APRN notified at 12:20 AM. Funeral Home notified at 12:30 AM. Review of the nursing progress notes documented by Staff A, RN, on [DATE] at 1:14 AM reads, [Resident #1's name] emergency contact notified of residents' death. DCF caseworker notified of residents' death. During an interview on [DATE] at 11:40 AM, the Director of Nursing (DON) stated, [Staff A's name] did not let anyone on shift know he [Resident #1] was a full code. There was no excuse for [Staff A's name] not to know if Resident #1's name] is a full code or DNR [Do Not Resuscitate]. When you open the chart, the first page is DNR. If you don't see a DNR, they are a full code. During an interview on [DATE] at 5:51 PM, the Advanced Practice Registered Nurse (APRN), stated, I received a call from [Staff A's name] notifying me of [Resident #1's name] death. I further did not get any notification that there was decline or actively dying prior to receiving notification of [Resident #1' name] death. What was a surprise is that he was not a DNR and that CPR was not initiated. During an interview on [DATE] at 11:01 AM, Staff A, RN, stated, I did not know [Resident #1 name] was a full code. Even though I opened the chart to retrieve face sheet, it did not register there was no DNR. I did not take vitals and when listening to [Resident #1 name's] heart and lungs, he was absent of both. When asked if she noted a decline in Resident# 1's condition, she stated, No, it was early on in my shift. He was so thin and very frail. I had no reason to let anyone else know if I believed he was a DNR. I had not taken care of him for a while. During an interview on [DATE] at 3:30 PM, Staff B, CNA, stated, I cannot pinpoint a time when I alerted [Staff A's name] of patient needing to be looked at. I started my rounds between 11:30 to 11:45 PM and by the time I got back there, it was around midnight. She [Staff A] used the stethoscope and walked out. I stuck around the desk to see if she was going to instruct me to do anything. She just began to call people and let them know patient died . I just returned to room and began to clean him up. His body was removed quickly from facility. In the morning, I heard staff say he was a full code. I think that it was one of the restorative CNAs, not sure. Review of the facility policy titled Emergency Care CPR reads, Policy: The facility will identify each resident's choice for treatment and care, help the resident to develop advance directives, as desired, and implement appropriate instructions for care that reflect those choices, all in accordance with the facility's ethics decision making policies and procedures and Florida State law. In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's advance directives. Prior to arrival of emergency medical services (EMS), the facility will provide basic life support, including initiation of CPR, to a resident who experiences [CONDITION(S)] or respiratory arrest in accordance with the resident's advance directive or Do Not Resuscitate (DNR) order. The facility removed the immediacy on [DATE] and corrected the non-compliance on [DATE] as evidenced by: Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes revealed the facility conducted a meeting attended by the Administrator, Director of Nursing, Medical Director, Social Service Director on [DATE] and implemented a Performance Improvement Plan (PIP) titled Advanced Directive that included audit of all in house resident deaths, audit of employee files for CPR certification status, current background screening, attestation, and education requirements, in service on Code Blue and advanced directives and abuse and neglect, Code Blue drills, and immediate audit of advance directive status of current residents. On [DATE], the facility suspended Staff A; conducted a full in-house audit to verify the code status of all residents; audited in-facility deaths for the past six months to assure that advanced directives were followed; conducted Code Blue drills on all shifts. On [DATE] through [DATE], the facility conducted full audits of employee files to assure that CPR certification status, current background screening, attestation, and education requirements were met; provided in-service training to all facility staff on Code Blue and Advanced Directives and Abuse and Neglect on all shifts. On [DATE], Staff A was terminated, reported to Department of Health and law enforcement. During interviews conducted on [DATE] through [DATE] with Staff F, LPN, Staff G, PCA (Patient Care Assistant), Staff H, RN, Staff I, LPN, Staff J, Staff K, LPN, Staff L, RN, Staff M, CNA, Staff N, LPN, Staff O, RN, Staff P, LPN, and Staff Q, CNA, they were able to express competency to implement the facility's Code Blue, Advance Directive and Abuse/Neglect procedures.