Every finding on record at Orlando Health and Rehabilitation Center

Based on observation, and interview, the facility failed to ensure residents' call lights were within reach, for 4 of 10 sampled residents, (#5, #6, #7, and #9).Findings: 1.On 4/10/26 at 12:45 PM, resident #5 resided on the D-wing, in bed B by the window. The resident pointed out their call light was behind the bed, hanging on the headboard, out of reach. Resident #5 was awake, and alert, but nonverbal, and communicated with gestures from hand movements only. On 4/10/26 at 12:59 PM, assigned Certified Nursing Assistant (CNA) A, confirmed the call light was behind resident #5's bed, out of reach. The Unit Manager of the D-wing confirmed the call light behind the bed and acknowledged staff should ensure call bells are in reach of residents. 2. On 4/10/26 at 1:09 PM, resident #6 was asleep in bed B, the window bed. Resident #6's call light was behind the bed hanging on the headboard, not within their reach. Within the same room, resident #7 was in the A bed, closest to the door, sitting on the edge of their bed waiting to eat lunch. Resident #7's call light was behind the bed hanging on the headboard, not within reach. Resident #7 stated they did not know where the call light was and staff have never provided instructions on the use of the call light. CNA D was in the room at that time and confirmed the call bells for resident #6 and resident #7 were not within their reach. She acknowledged the call bells should be left by staff within the resident's reach in case they needed to alert staff. 3.On 4/10/26 at 1:30 PM, resident #9 stated he couldn't reach the call light since earlier that morning because it was too high for him to reach with his right hand. The resident explained he previously had a stroke and was unable to move the left side of his body. He conveyed he needed assistance from staff to move around or to get out of bed. The resident indicated the call light attached to the bed sheet on the right upper side by his head and demonstrated he could not reach it with his right arm while sitting up. CNA E was present in the room, and confirmed resident #9 could not reach the call bell where it was attached to the right upper side of the bed sheet. The CNA acknowledged resident #9 was unable to use his left arm and confirmed the call bell should be in reach of the resident's functioning right arm.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a Certified Nursing Assistant (CNA) for 1 of 5 residents reviewed for abuse, of a total sample of 12 residents, (#6). The facility's failure to protect resident #6 resulted in actual harm when the resident sustained injuries to his right hand and left forearm.Findings: Cross Reference F609 Review of resident #6's medical record revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization. His diagnoses included dementia with behavioral disturbances, mood disorder, history of urinary tract infections, weakness, reduced mobility, anxiety, repeated falls, and stroke. Review of the Minimum Data Set (MDS) significant change in status assessment with Assessment Reference Date of 8/02/25 revealed resident#6 had impaired hearing and vision, unclear speech and rarely understood verbal content. A Staff Assessment for Mental Status was completed due to poor comprehension. The MDS assessment noted behavioral physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming, disruptive sounds not directed toward others which occurred one to three days but did not interfere with his care or participation of activities. The MDS assessment showed this behavior did not put others at risk and did not intrude on the privacy of others. The MDS assessment revealed no rejection of evaluation or care necessary to obtain goals for health and well-being and no wandering. The assessment noted he needed substantial assistance from staff with Activities of Daily Living (ADLs) such as eating and oral hygiene. He was dependent on staff for transfers, toileting hygiene, shower/bath, upper & lower body dressing, put on/off footwear, and personal hygiene. Resident #6 had functional limitations in range of motion on his bilateral upper and lower extremities. The MDS assessment revealed resident #6 sustained falls since the prior assessments, two resulting in no injuries and two with injuries.Review of resident #6's medical record revealed a care plan for impaired cognitive function/dementia, revised on 8/06/25. Another care plan for behaviors, revised on 10/07/25 revealed resident #6 was on one to one (1:1) supervision, combative with staff, impulsive and refused care and medications at times. The interventions directed staff to speak softly and clearly when communicating and allow time to communicate effectively.Review of resident #6's Kardex (care plan used by CNAs) revealed interventions such as to observe and report changes including resistance to care.Review of Progress Notes in resident #6's medical record showed the following entries:*9/30/25 at 6:33 AM - Resident alert with confusion, several attempts to get out of the bed; became agitated and combative when redirected. *10/01/25 at 8:25 PM - Resident restless, required PRN (as needed) medications. *10/02/25 - 10/03/25 - Continued 1:1 observation for behavioral concerns; resident resisted care and attempted to strike staff.*10/05/25 at 6:29 AM - Resident combative during the care, attempting to hit staff, and refusing hydration.*10/05/25 at 5:16 PM - At approximately 3:30 PM, resident was observed screaming at other residents and staff, then struck the nursing station plexiglass partition. Nurse notified Supervisors, Physicians, family and 911 was called. The resident was transferred to the hospital for evaluation.*10/05/25 at 8:13 PM - Resident returned to the facility. Hospital records showed bilateral hand x-rays were negative for fractures; a right-hand laceration required no sutures. Resident was restless and reported pain in the right hand. Tramadol was administered. A Transfer Form dated 10/05/25 revealed the reason for transfer to the hospital was behavioral symptoms (e.g. agitation, psychosis). Review of ED (Emergency Department) Provider Notes dated 10/05/25 revealed resident #6 presented to the ED by EMS (Emergency Medical Services) from [facility's name] after they reported he was punching plexiglass and sustained lacerations to both of his hands. The document included, On initial evaluation of the patient he stated that he was locked up and was not allowed to go to the bathroom for an hour and a half. Patient stated that this frustrated him and he hit his hands on the door. He is unable to provide any other meaningful history. Review of the psych provider note dated 10/06/25 read, Patient is a [AGE] year old male . able to make needs known. He is unable to answer some questions during assessment due to cognitive impairment secondary to dementia. Patient was transferred to ER (Emergency Room) last night, returned to facility after a few hours, no change in psychotropics. Patient is unable to recall event, and when prompted denies any negative mental or emotional effect from event. Nursing reports agitation, combativeness, restlessness, and physically aggressive behavior worse at night. Nursing reports frequent attempts to get up independently to urinate at night, agitation with redirection attempts. On 10/13/25 at 8:54 AM, during a telephone interview, Registered Nurse (RN) J stated resident #6 was combative at times but said staff generally managed with redirection and calm communication. She indicated he had been on 1:1 due to falls. She recalled when she started her shift at 7:00 PM on 10/05/25, resident #6 was in the hospital. She stated the day shift nurse reported resident #6 was agitated, broke the plexiglass partition by the nurses station and was sent to the ER. She stated resident #6 returned from the hospital around 8:00 PM and CNA A continued the 1:1 with him until 11:00 PM. RN J stated the hospital paperwork showed resident #6 sustained no fractures and no stitches were required. RN J mentioned when she returned to work the following night, she learned the video footage showed CNA A smashed resident #6's hand with the door and staff in the unit did not intervene. On 10/13/25 at 9:25 AM, during a telephone interview, resident #6's responsible party and Power of Attorney (POA) stated he was informed on Sunday 10/05/25 resident #6 got hurt, was bleeding profusely and was sent to the ER for evaluation. He indicated there were minimal details of how he got hurt during the initial report. He stated he received another call from the facility the following day, when the true story emerged. The POA stated he was asked to press charges against CNA A because the act was deliberate. He said he was hesitant to press charges but was reassured the video footage of the incident was watched several times, including by law enforcement. The POA noted resident #6's hands were swollen with a cut on four fingers of his right hand. On 10/13/25 at 12:10 PM, during a telephone interview, CNA D stated she worked 3:00 to 11:00 PM on 10/05/25 providing 1:1 for a resident in room [ROOM NUMBER]. She reported she observed CNA A close the door to resident #6's room while the resident struggled trying to open it. She indicated she heard the resident yell and later saw the resident exit his room holding a bloody brief. She recalled the nurse telling her it was the assigned 1:1 staff responsibility to deal with the behaviors. She stated the resident she was assigned to care for asked her to close the door because it was too noisy outside. The CNA explained she received a call from the facility the following day asking for details about what happened that Sunday. She stated she received another call on Tuesday when she was informed she was suspended and last night she learned she was terminated. She stated she could not understand their reason as she was not supposed to leave her assigned 1:1 resident and she reported what she saw to the floor nurse. CNA D indicated the Executive Administrator (ENHA) and Executive Director of Nursing (EDON) told her she was supposed to report the incident to them, but she claimed she did not know this was the process. On 10/13/25 at 12:35 PM, RN G confirmed she was one of the weekend supervisors on duty on 10/05/25. She explained she responded to a page for supervisor assistance after the other weekend supervisors had arrived in the unit. She recalled entering resident #6's room and observing two nurses dressing resident's hands. She stated resident #6 was agitated. She explained she was told resident #6 became aggressive and broke the plexiglass partition by the nurses station. She stated she ensured documents were ready for EMS and contacted the weekend's DON. She indicated she gave blank witness statements to the staff in the unit and instructed them to complete them. She stated CNA A was reassigned to sit by the nurses station and monitor the broken plexiglass until maintenance arrived. On 10/13/25 at 12:51 PM, during a telephone interview, RN H validated he was one of the weekend supervisors on duty on 10/05/25. He reported being paged to the unit after the incident and observing the resident anxiously standing in front of the nurse' station with blood on his hand. He was not aware of earlier behavioral escalation or that the resident had been confined in his room. He recalled handing blank witness statements for staff to complete. On 10/13/25 at 1:06 PM, CNA K stated he worked as 1:1 for resident #6 from 7:00 AM to 3:00 PM on 10/05/25. He shared resident #6 needed assistance with most ADLs but could verbalize his needs. He indicated resident #6 became easily frustrated and required patience. CNA K said, Most of his (resident #6) frustrations come in the afternoon. He stated he returned to work two days later and learned CNA A supposedly closed the door on his fingers intentionally, which was caught in camera. CNA K shared he asked resident #6 what happened on his knuckles and the resident told him someone closed the door on him. On 10/14/25 at 10:04 AM, during a telephone interview, resident #11's daughter confirmed she visited her mother on 10/05/25. She stated while looking for her mom, she noticed resident #6 was agitated and bleeding on his hand. She shared resident #6 was trying to open and close a door while repeatedly saying he was bleeding. She shared she walked to the nurses station and told the nurses the resident was bleeding, but the nurses did not react, they are always looking down, like looking at a cell phone. She said that made her angry, and she thought what could have happened. She shared she was nervous. She stated she saw a female employee holding a door and the nurses at the desk ignored the situation. She shared she had to tell them look at him! She shared later that day she noticed the plexiglass was missing at the nurses station. She stated she was asked about her observations during the incident the following day. On 10/14/25 at 5:20 PM, the first floor Administrator (NHA) stated she received a text from RN G a few minutes before 5:00 PM on 10/05/25 asking for maintenance to repair the plexiglass in the secured unit because of an incident. The NHA indicated when she read the message, she called RN G who informed her resident #6 was combative, broke the plexiglass partition, his hand was bleeding, and he was going to the ER for further evaluation. She explained a Maintenance Assistant took care of the broken plexiglass before resident #6 returned to the facility. She explained she was off the Monday after the incident, but the ENHA called her and informed her what they had uncovered in the video. On 10/14/25 at 5:46 PM, during a telephone interview, RN M stated she responded to a page for supervisor assistance in the secure unit. She recalled observing pieces of plexiglass on the floor and at the desk by the nurses station. She indicated resident #6 was sitting in a wheelchair screaming. She stated CNA A told her he was very aggressive. She shared other residents around the nurses station were getting anxious so they [NAME] resident #6 to his room, where he was bleeding profusely, and she performed wound care. RN M mentioned she was confused when she noticed blood in resident #6's room but none on the plexiglass. She stated he had a cut on three fingers of his right hand and a cut on his left forearm. She recalled CNA A standing next to her and resident #6 pointed at them and said, you hit me, you hit me. She stated she told resident #6 she just got there. She noticed everyone in the unit was scared, and resident #6 was anxious and upset. She indicated Licensed Practical Nurse (LPN) B told her he did not know what happened because he was passing medications and she noticed his medication cart down the hallway. On 10/15/25 at 12:44 PM, the Medical Director stated he learned about the incident involving resident #6 on Sunday 10/05/25. He indicated resident #6 was sent to the ER to ensure there was no additional trauma besides the laceration to his bilateral hand and forearm. He shared he evaluated resident #6 the next day and found him at his baseline, severe cognitively impaired. He indicated the ENHA and EDON informed him they were reviewing the video footage because of discrepancies in the staff's statements. He mentioned he asked about the training CNA A had received and was told her education included dementia, redirection, and what to do when a patient was agitated. He stated training was not an issue. He said, this building has it challenges and they were trying to implement a culture of reporting, if you see something say something. He mentioned the culture of not speaking up was one of the missing pieces in this incident as no one who witnessed the incident shared anything. He stated they learned what happened through the cameras. He indicated resident #6 sustained soft tissue trauma but could have sustained fractures. On 10/13/25 at 3:07 PM, during an interview with Risk Manager O and the ENHA, Risk Manager O stated she was reviewing the video to determine how the plexiglass partition broke, when she saw CNA A holding the door of resident #6's room and his hand stuck on the door. She indicated when resident #6 exited his room, he was holding a brief and was bleeding. ENHA stated CNA A had expressed fear of the resident and claimed to close the door for self-protection. The ENHA indicated after reviewing the video, staff actions were inconsistent with facility policy and all staff on the unit that day were first suspended then terminated for failure to intervene. The ENHA added the facility nor the police thought CNA A's life was in danger, hence why she was arrested. Later on 10/15/25 at 1:25 PM, the ENHA stated they recognized how severe this incident was and treated it as such. Review of the facility's security system by the survey team showed the following:*On 10/05/25 at 3:44 PM, resident #6's room door was closed from the inside, unable to see who closed it.*On 10/05/25 at 3:45 PM, LPN B went into the resident's room and exited within 20 seconds. *On 10/05/25 at 3:46 PM, CNA A exited resident #6's room and immediately held the door shut. Resident #6 struggled to get door open. CNA A faced camera, smiling. LPN B went into the nurses' station, across resident #6's room.*On 10/05/25 at 3:47 PM, LPN B returned and stood by the medication cart while CNA A continued to hold the door closed.*On 10/05/25 at 3:47 PM, resident #6's fingers were caught on door while CNA A continued holding the door shut. *On 10/05/25 at 3:47 PM, CNA C walked from the activity room with a bag of linen in her hands toward where CNA A was holding the door handle. CNA C stopped by CNA A who was holding the door handle. CNA C appeared to say something to CNA A.*On 10/05/25 at 3:49 PM, CNA A let go of the door handle, resident #6 opened the door, spots of blood could be seen on the privacy curtain and the door frame. Resident #6 stood by door holding a brief on his bleeding right hand. LPN B brought wheelchair and positioned it in front of resident #6. Resident #6 placed hands on the wheelchair and grabbed Styrofoam cup with water in the wheelchair and threw it on the floor. LPN E and Registered Nurse (RN) F were sitting at the nurses station eating, did not get up to respond or assist.*On 10/05/25 at 3:49 PM, resident #6 walked toward another room without assistive device, unsteadily gait observed.*On 10/05/25 at 3:50 PM, a visitor alerted LPN E and RN F who were still sitting at the nurses' station. RN F stood up from her chair, remained in nurses' station. *On 10/05/25 at 3:51 PM, resident #6 approached nurses station, held on to plexiglass which broke and after a few seconds resident #6 let it drop to the floor. Resident #6 threw brief he was holding onto the nurses station.*On 10/05/25 at 3:52 PM, RN F on the phone while LPN B placed his hands on resident #6's shoulders. CNA L stood by resident #6 and LPN B. *On 10/05/25 at 3:55 PM, resident #6 was assisted to wheelchair by CNA L and LPN B. On 10/05/25 at 3:55 PM, RN M arrived at the unit. A few seconds later, RN H (weekend supervisor) and the Manager on Duty (MOD) arrived at the unit.*On 10/05/25 at 3:56 PM, RN F on the phone. Resident #6 taken wheeled to his room.*On 10/05/25 at 3:56 PM, LPN B entered room with dressing supplies; MOD also entered resident's room. Blood observed on the floor by nurses station.*On 10/05/25 at 3:58 PM, RN G (weekend supervisor) arrived. *On 10/05/25 at 4:05 PM, EMS (paramedics) arrived in the unit.*On 10/05/25 at 4:10 PM, resident #6 was wheeled out of his room, transferred to stretcher by EMS, dressing noted on his right hand and on his left hand extending to the forearm. A few minutes later, resident #6 left the unit with EMS. Review of the job description for the Certified Nursing Assistant (CNA) dated 7/1/19 showed the CNA was responsible for assisting residents with direct care under the supervision and guidance of licensed nurses (RN or LPN). The Essential Duties and Responsibilities included to report all observed or reported incidents of potential abuse, neglect or accidents immediately to their direct supervisor, manage combative residents while maintaining self-esteem and avoid injury to self and residents., respect the rights of each resident according to the Resident [NAME] of Rights, foster and support a culture of compliance and did not engage in abuse or neglect. Review of the job description for the Licensed Practical Nurse (LPN) not dated showed the LPN reported to Unit Manager (RN). The Essential Duties and Responsibilities included to supervise CNA staff, monitor all aspects of residents care, report all observed or reported incidents of potential abuse, neglect or accidents immediately to the direct supervisor, and manage combative residents while maintaining self-esteem and avoiding injury to self and residents. The form revealed LPN had the authority to suspend individuals from work for rule violations. Review of the job description for the Registered Nurse (RN) not dated showed the RN reported to the Unit Manager (RN/DON). The Essential Duties and Responsibilities included to monitor all aspects of residents care, observe the residents and surroundings; identify changes in resident's behavior or conditions, report all observed or reported incidents of potential abuse, neglect or accidents immediately to the direct supervisor, and manage combative residents while maintaining self-esteem and avoiding injury to self and residents. The form revealed the RN supervised LPNs and CNAs, enforced facility policies with authority to issue Disciplinary Action Reports as needed and the authority to suspend individuals from work for rule violations. Review of the Facility assessment dated [DATE] revealed over 30% of residents had cognitive disabilities, including dementia. The form showed 47% residents had psychiatric disorders, and 7% exhibited aggressive behaviors. Review of the Abuse Prevention Program policy and procedure reviewed in September 2025 revealed physical abuse included controlling behavior through corporal punishment or a restraint not required to treat the resident's symptoms. The document showed staff was instructed to report concerns, incidents, and grievances and how to provide protection for residents.

Based on observation, interview and record review, the facility failed to report an allegation of physical abuse to the Agency for Health Care Administration (AHCA) in a timely manner for 1 of 5 residents reviewed for abuse, of a total sample of 12 residents, (#6). The failure to immediately report prevented prompt protective measures to residents and delayed the reporting to state authorities.Findings: Cross Reference F600 Review of resident #6's medical record revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization. His diagnoses included dementia with behavioral disturbances, mood disorder, history of urinary tract infections, weakness, reduced mobility, anxiety, repeated falls, and stroke. Review of the Minimum Data Set (MDS) significant change in status assessment with Assessment Reference Date of 8/02/25 revealed a Brief Interview for Mental Status score was not obtained because resident #6 was rarely or never understood. The MDS assessment noted behavioral symptoms not directed toward others which did not interfere with his care or participation of activities. The MDS assessment showed this behavior did not put others at risk and did not intrude on the privacy of others. The MDS assessment noted resident #6 needed substantial assistance from staff for eating and oral hygiene and was dependent on staff for transfers, toileting hygiene, shower/bath, upper & lower body dressing, put on/off footwear, and personal hygiene. Resident #6 had functional limitation in range of motion on his bilateral upper and lower extremities. Review of resident #6's medical record revealed a care plan for impaired cognitive function/dementia, revised on 8/06/25. Another care plan for behaviors, revised on 10/07/25 revealed resident #6 was on one to one (1:1) supervision, combative with staff, impulsive and refused care and medications at times. The interventions directed staff to speak softly and clearly when communicating and allow time to communicate effectively. Review of resident #6's Kardex (care plan used by Certified Nursing Assistants (CNAs)) revealed interventions such as to observe and report changes including resistance to care. Review of Progress Notes in resident #6's medical record showed the following entries:*10/05/25 at 6:29 AM - Resident combative during the care, attempting to hit staff, and refusing hydration.*10/05/25 at 5:16 PM - At approximately 3:30 PM, resident was observed screaming at other residents and staff, then struck the nursing station plexiglass partition. Nurse notified Supervisors, Physicians, family and 911 was called. The resident was transferred to the hospital for evaluation.*10/05/25 at 8:13 PM - Resident returned to the facility. Hospital records showed bilateral hand x-rays were negative for fractures; a right-hand laceration required no sutures. Resident was restless and reported pain in the right hand. Tramadol was administered. Review of ED (Emergency Department) Provider Notes dated 10/05/25 revealed resident #6 presented to the ED by EMS (Emergency Medical Services) from [facility's name] after they reported he was punching plexiglass and sustained lacerations to both of his hands. The document included, On initial evaluation of the patient he stated that he was locked up and was not allowed to go to the bathroom for an hour and a half. Patient stated that this frustrated him and he hit his hands on the door. He is unable to provide any other meaningful history. On 10/13/25 at 8:54 AM, during a telephone interview, Registered Nurse (RN) J stated resident #6 returned from the hospital around 8:00 PM and CNA A continued the 1:1 with him until 11:00 PM. She stated the hospital paperwork showed resident #6 sustained no fractures and no stitches were required. She mentioned when she returned to work the following night, she learned the video footage reviewed by management showed CNA A smashed resident #6's hand with the door, staff in the unit did not intervene, and someone was arrested. On 10/13/25 at 12:10 PM, during a telephone interview, CNA D confirmed she saw CNA A trying to close the door for resident #6's room from the outside and when she released the door, he came out holding a brief. She recalled the nurse told CNA D to close the door and it was the assigned 1:1 staff to deal with whatever. She stated the resident she was assigned to care for asked her to close the door too because it was too noisy. She explained she received a call from the facility the following day asking for details of what happened on Sunday. She shared on Tuesday she received another call and was informed she was suspended and last night she learned she was terminated. She stated she could not understand their reason as she was not supposed to leave her assigned 1:1 resident and she reported what she saw to the nurse. CNA D indicated the Executive Administrator (ENHA) and Executive Director of Nursing (EDON) told her she was supposed to report what she saw to them, but she claimed she did not know. On 10/13/25 at 12:35 PM, RN G confirmed she was one of the weekend supervisors on duty on 10/05/25. She recalled entering resident #6's room and observing two nurses dressing resident's hands. She stated resident #6 was agitated. She explained she was told resident #6 became aggressive and broke the plexiglass partition by the nurses station. She indicated she gave blank witness statements to the staff in the unit and instructed them to complete them. She stated CNA A was reassigned to sit by the nurses station and monitor the broken plexiglass until maintenance arrived. On 10/13/25 at 12:51 PM, during a telephone interview, RN H validated he was one of the weekend supervisors on duty on 10/05/25. He reported being paged to the unit after the incident and observing the resident anxiously standing in front of the nurse' station with blood on his hand. He was not aware of earlier behavioral escalation or that the resident had been confined in his room. He recalled handing blank witness statements for staff to complete. On 10/14/25 at 10:04 AM, during a telephone interview, resident #11's daughter confirmed she visited her mother on 10/05/25. She stated she noticed resident #6 was agitated and bleeding on his hand. She shared resident #6 was trying to open and close a door while repeatedly saying he was bleeding. She shared she walked to the nurses station and told the nurses the resident was bleeding, but the nurses did not react, they are always looking down, like looking at a cell phone. She said that made her angry, and she thought what could have happened. She shared she was nervous. She stated she saw a female employee holding a door and the nurses at the desk ignored the situation. She shared she had to tell them look at him! On 10/14/25 at 5:46 PM, during a telephone interview, RN M recalled observing pieces of plexiglass on the floor and at the desk by the nurses station when she arrived at the secure unit. She indicated resident #6 was sitting in a wheelchair screaming. She stated CNA A reported resident #6 was very aggressive. RN M mentioned she was confused when she noticed blood in resident #6's room but none on the plexiglass. She recalled CNA A standing next to her and resident #6 pointed at them and said, you hit me, you hit me. She stated she told resident #6 she just got there. She noticed everyone in the unit was scared, and resident #6 was anxious and upset. She indicated Licensed Practical Nurse (LPN) B told her he did not know what happened because he was passing medications and she noticed his medication cart down the hallway. On 10/13/25 at 3:07 PM, during an interview with Risk Manager O and the ENHA, Risk Manager O stated she was reviewing the video to determine how the plexiglass partition broke when she saw CNA A holding the door of resident #6's room and his hand stuck on the door. She indicated when resident #6 exited his room, he was holding a brief and was bleeding. ENHA stated CNA A had expressed fear of the resident and claimed to close the door for self-protection. The ENHA indicated after reviewing the video, staff actions were inconsistent with facility policy and all staff on the unit that day were first suspended then terminated for failure to intervene. The ENHA added the facility, nor the police thought CNA A's life was in danger, hence why she was arrested. The ENHA explained they contacted each employee by telephone and offered the opportunity to make an addendum to their statements, and each was informed the facility had reviewed the video, and all but one declined. Later on 10/15/25 at 1:25 PM, the ENHA stated they recognized how severe this incident was and treated it as such. Review of the facility's investigation revealed the following Witness Statements were collected: *Interview of resident #6 by Risk Manager O on 10/06/25 - She locked me in my room. She did not let me out. She closed the door on my fingers. *CNA A - she did not receive report and did not know what to expect when I went into the room . Resident #6 seemed very anxious and very combative. Resident #6 noticed a resident passing by and walked quickly to say something to her. Once he got up, I knew he was trying to leave the room so I tried to intervene by stopping him. Resident #6 became verbally aggressive toward me, he began hitting me repeatedly and I became afraid for my life. I called for help and ran out of the room to protect myself . tried to open the door and his hand caught in the door he began to bleed. He managed to get out of the room and started yelling. I could not calm him down. resident #6 broke the glass by the nursing station with his bare hands. She included resident #6 was calmed down, his nurse arrived at the scene to stabilize his wound and 911 was contacted while resident was escorted back into his room. *CNA I wrote she was doing a one-on-one (1:1) supervision, was inside a resident's room when she heard a lot of noises. She stepped out of the room and saw a resident standing up by the nursing station and she said call the supervisor. He was agitated. *CNA C wrote she saw CNA A holding resident #6's door. She told CNA A to stop, to open the door, and call for help. CNA C statement read, And I remember I called the nurse for her because she still hold the door. CNA C went into a room and continued providing personal care to one of her assigned residents. Another statement by CNA C, collected on 10/06/25 via phone call by Risk Manager O, read, I was assigned to G Wing back area. As I was passing, I saw [CNA A's name] holding the door, I said, If he's agitated why don't you ask for help. I then went to assist another resident that needed to be changed. *Resident #11's visitor statement, obtained by Risk Manager O on 10/6/25 read, I came in to see my mother and she was not in her room. The nurse stated she was in the dining/activity area. As I was walking toward the dining/activity area, I noticed a resident bleeding and I stated to the nurses in the nurses' station he's bleeding. They did not respond. *LPN B wrote that on 10/05/25 at approximately 3:30 PM, resident #6 was screaming at other residents and staff. The resident punched the plastic protector at the nursing station. Supervisors, physicians, and family were notified, 911 was called, and the resident was to the hospital for evaluation. *RN F wrote that at approximately around 4:00 PM while she was at the desk, it was brought her attention when resident #6 was trying to run out of his room to attack another resident and his CNA, he jammed his fingers in the doorway of his room. She added she went to assess the scene, and resident #6 had quickly ran out of his room and was yelling. Trying to calm him down seemed impossible as he seemed very anxious, was violent and verbally aggressive. I noticed patient was bleeding as he was belligerently hitting the glass at the nursing station until he broke it completely with his bare hands. I called for back up and did my best to calm him but he would not and he did not even notice he was bleeding profusely. I placed a call to 911. By the time I got off the phone with the 911 operator I grabbed dressing supplies to go reinforce the effort being made by the nursing staff to stop [resident #6's name] bleeding and to dress his injured hands. [Resident #6's name] calmed down and was safely transferred to the hospital. *LPN E wrote she was at the nursing station when resident stormed out of his bedroom with bloody hands, and broke the glass at the nursing station and tried to grab (whatever) he could. Supervisor came, restrained him took him back to his room, and took care of the injury. *The EDON interviewed CNA D via phone call on 10/06/25 and wrote, On 10-5-25 I was assigned 1:1 with 1109 I saw the CNA holding the door of 1101 and I told the nurse to go help the CNA. He refused and told me That is why the patient is on one to one. The EDON wrote another statement of her phone conversation with CNA D which read, While speaking with [CNA D's name] I asked her what did she do when she saw the CNA holding the door She stated she told the nurse the CNA needed help and he (the nurse) told me, That is why the patient is on one to one. She also stated that the nurse [LPN B's name] told her to close the door of the resident (1106) because he was making too much noise and she then went into the room with the resident and closed the door. Review of the facility's security system did not show CNA A frightened or resident #6 running or punching the plexiglass partition by the nurses station. The video showed LPN B and CNA C saw CNA A holding resident #6's door closed with resident #6 inside his room, while he was trying to open it and get out. LPN E and RN F were sitting at the nurses station, across resident #6's room, and did not respond or intervene until a visitor alerted them to look at the resident. Review of resident #6's Observation Sheet dated 10/05/25 showed CNAs assigned for 1:1 observation were required to initial and document resident behaviors using codes every 15 minutes. CNA A initialed the form at 3:45 and 4:00 PM and used codes 4 (aggressive toward residents) and 12 (combative). CNA A documented hospital from 4:15 to 7:45 PM. She initialed and documented codes 1 (in room lying in bed) and 2 (calm) from 8:00 to 10:45 PM. Review of the Immediate Nursing Home Federal Report submitted by Risk Manager (RM) O to AHCA on 10/06/25 at 3:02 PM revealed an allegation of physical abuse for resident #6. The report showed the incident occurred on 10/05/25 at 3:46 PM and the ENHA, EDON and RM became aware of the incident on 10/06/25 at 11:33 AM while performing a camera review of the incident. The report read, As I was reviewing, I saw CNA [CNA A's name] holding the door to 1101B closed, I saw the door close on resident's fingers and when he came out of the room, he was bleeding holding a towel. He then walked to the nurse's station and was holding onto the plexiglass to maintain his balance and it came loose. The report mentioned resident #6 sustained no fractures of his hand or fingers but had scratches on his right four fingers from the door and scratches on his forearms from the plexiglass. Review of CNA A's timecard revealed she worked on Sunday 10/05/25 until 11:34 PM. She returned to work on Monday 10/06/25 from 6:57 AM until 1:00 PM. Review of her assignment showed she cared for 10 residents until approximately 11:15 AM when the video footage was reviewed by management and she was removed from the unit. On 10/15/25 at 12:44 PM, the Medical Director stated he questioned who CNA A was and the kind of training she received. He stated he learned she had received required education, so training was not an issue. He mentioned the culture of not speaking up was one of the missing pieces in this incident as none of the staff working in the secured unit that day reported anything. He stated they learned what happened through the cameras. Review of the job descriptions for CNA, LPN, and RN staff revealed each was required to report potential abuse immediately to their supervisor. Review of the Abuse Prevention Program policy and procedure reviewed in September 2025 revealed physical abuse included controlling behavior through corporal punishment or a restraint not required to treat the resident's symptoms. The document showed staff was instructed to report concerns, incidents, and grievances and how to provide protection for residents.

6. On 6/18/25 at 11:15 AM, kitchen staff prepared for the lunch meal and set up of the tray line. At 11:20 AM, there was Dietary Aide ZZ was in the preparation area near an upright refrigerator. He donned his facial hair restraint incorrectly, so that his mustache was exposed. He remained silent when he asked about the correct way to wear a facial hair restraint. Dietary Aide YY was seen washing dishes at the three compartment sink and had donned his facial hair restraint incorrectly, as well. His beard was sticking out and the facial hair restraint was under his chin. Approximately 3-4 minutes later, Dietary Aide XX was assisting with the lunch tray line set up. He was wearing gloves and adjusted his facial hair restraint, touching his face and underneath his nose. Dietary Aide XX then reached for a bin of individually wrapped bread, without performing hand hygiene before donning a new pair of gloves. At that time, the Assistant Dietary Manager confirmed when staff touched their face they needed to re-wash their hands and change gloves. At 11:38 AM, the lunch tray line commenced and staff started plating meals. The Registered Dietician noted the hot food holding temperatures on a piece of paper, however there were not any potentially hazardous cold food holding temperatures. She and the 2nd floor Administrator said the cold food temperatures were taken earlier. The 2nd floor Administrator removed a half pint of milk that was in a bin covered with ice, and the temperature was 44 degrees Fahrenheit (F). They acknowledged potentially hazardous foods such as milk needed to be at a holding temperature of 41 degrees F or below. 7. On 6/18/25 at 2:04 PM, pantry #1 on the H Wing was observed. In the cupboard there were two half pint sized cartons of milk. The cartons of milk were at room temperature. The H Wing Unit Manager felt the milk cartons with his hands and confirmed they were not cold. She could not explain why the cartons of milk were in the cupboard and not in the refrigerator to be maintained at the correct temperature. Based on observation, interview, and record review, the facility failed to store, hold, and serve foods to prevent the potential of foodborne illness; failed to ensure staff donned facial hair restraints; failed to provide 71 ordered resident nourishment/snacks for all six units one afternoon; failed to air-dry dishes; failed to label, date, and discard outdated resident foods brought in from outside sources; and failed to provide evidence the dish machine attained the required temperature over the past three and a half months. These items had the potential to affect all 350 residents who ate their meals at the facility. Findings: 1. On 6/16/25 at 7:40 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), in the main walk-in refrigerator, two cases raw chicken dated 6/12/25 (5 days prior) were noted. There were also three additional raw meat products without any date as to when received or pulled from the freezer to thaw: one package of raw mechanical soft separated turkey, one case of raw pork, and one sleeve of raw ground sausage. In addition, in the walk-in freezer, there was a 1/3 pan of frozen meat; dated 6/23, but not labeled as to what it was. The CDM stated whoever put the meat into the refrigerator was responsible for labeling the date it was put there, which was not done in this case. She added, it was important to date the items so they could keep track of how long food items were kept to make sure they were being utilized within a safe time period, so they did not give the residents any food borne illnesses. The facility's policy entitled Storage, dated June 2024, indicated foods delivered were to have the delivery date written on them. In addition, it detailed prepared items were to be labeled with the product name, preparation date, and use by date. The policy included a Cold Food Storage Chart which indicated raw poultry was to be used within 1-2 days, raw pork within 3-5 days, and raw sausage within 1-2 days. 2. In walk-in refrigerator #1, twelve one-gallon plastic bags filled with labeled individual nourishments (sandwiches, milks, puddings, crackers, etc.), were dated 6/14/25, for resident units A, H, C, G, B, and D . The CDM confirmed these resident snacks were not delivered to the units or distributed to the residents on that afternoon as evidenced by them still being in the refrigerator. She added it was important for snacks to be delivered because it honored the residents' preferences for snacks and because the individual snacks were often needed to help maintain the residents' nutritional status. The facility's policy entitled Nourishment/Snacks, dated June 2024, indicated snacks would be available for residents on request, as a nutrition intervention per dietitian recommendations or by physician orders. The policy continued, individualized evening snacks would be prepared, labeled and dated by the Food and Nutrition Department, and delivered to the nursing units by 7:00 PM. It added, perishable snacks would be distributed as scheduled by the Nursing Department. 3. On 6/18/24 at 11:03 AM, during the follow-up kitchen visit, a cart holding bases used to keep plates of food warm was observed with three bases squeezed into the holder meant for one base, which did not allow space for them to air dry. When the bases were removed from the rack, the sides were touching each other and were still wet. There were approximately 20 additional bases stacked on the side of the tray line on top of each other and were also wet. The Assistant Food Service Manager verified the bases were still wet and said this was wet nesting. She explained it was important to air dry dishes and equipment used for dining because if not, the moist environment could allow germs to grow and could cause illness for those who used them. On 6/19/25 at 2:46 PM, a large cart holding bases was again observed with three bases squeezed into the holder meant for one base which did not allow space for them to air dry. The 2nd floor Assistant Administrator confirmed the findings. On 6/20/25 at 1:20 PM, the CDM and 2nd floor Assistant Administrator acknowledged the facility needed to eliminate the wet-nesting situation. The facility's policy entitled Cleaning and Sanitizing, dated June 2025, indicated cooking utensils and equipment should be allowed to air dry. 4. On 6/19/25 at 9:02 AM, on the A wing, a meal dated 6/12/25 (eight days prior) was noted and thrown away by the Assistance Director of Nursing (ADON)/ Infection Control/ Staff Development nurse who stated it was important to throw away outdated items in a timely manner, so a resident did not eat them and get sick. On 6/19/25 at 9:17 AM, on the G wing, four resident yogurts dated 5/02/25 were noted. Two had an expiration date of 5/09/25 and two had an expiration date of 5/21/25. The G wing Unit Manager (UM) threw them away along with an undated box with leftover pizza. He stated, whoever put the food in the refrigerator was supposed to date it, so the residents didn't get sick from it. The Unit Manager added, he did rounds daily to find and get rid of outdated foods as did the kitchen manager but could not explain why the outdated items had been missed. On 6/19/25 at 9:37 AM, on the B wing, a resident's bag of cheese sticks was without a date, another package with the resident's name had no item name or date, and a resident's package with the date of 6/18, without a resident or item name was noted. The B wing UM verified the findings and stated she checked the refrigerator daily. She acknowledge she didn't check it today as she thought the dietitian checked it. She added, it was important to ensure items brought to the facility for the resident's consumption were labeled and dated for resident's safety as residents could get sick from old food. The UM conveyed, whoever put the food into the refrigerator was responsible to label the food with the name of resident, the item name, and date. She stated she was unsure of the policy for how long resident food could be kept. The facility's policy entitled, Nourishment Rooms/ Pantries, dated June 2024, indicated residents may store personal food items in the refrigerator or freezers when labeled with the resident's name, room number and date the item was placed there. The policy added, items would be discarded after 72 hours of storage if perishable, and 30 days, if non-perishable, or per the expiration date. The document indicated the Food and Nutrition Services and the Nursing departments would inspect food items daily to ensure the guidelines were met and would discard any expired foods. 5. On 6/19/25 at 2:46 PM, the dish machine temperature logs for June 2025 were reviewed with the wash temperatures consistently being recorded at 120 degrees Fahrenheit (F) and the rinse temperatures consistently being recorded at 165 degrees F. In addition, the sanitizer concentration was consistently recorded at 50 parts per million (ppm). The log did not indicate what the minimum temperature should be to ensure the dishes were cleaned and sanitized. The log did not indicate any interventions made by management when the temperatures were not adequate for the high temperature machine. In addition, the logs for March, April and May 2025 indicated similar information. At that time the CDM verified the findings and stated it was her responsibility to check the logs, to make sure the staff were taking and recording the information correctly and to ensure the dish machine worked properly. She said she was sure the dish machine worked properly, and was running at an adequate temperature. The 2nd floor Assistant Administrator was present and stated the dish machine was equipped to run as a low temperature machine if the mechanisms for maintaining its high temperatures ever failed. He acknowledged, the feature was not used over the past several months and therefore the temperature logs were not accurate. He agreed with the CDM that staff education was needed to rectify the inaccurate temperature logs. The facility's policy entitled Cleaning and Sanitizing, dated June 2025, indicated the temperatures needed for a high temperature dish machine were 165 degrees F for the wash and 180 degrees F for the final rinse. In addition, the policy described the chemical sanitizer was not used for high temperature dish machines.

6. Resident #349 was admitted to the facility on [DATE] with diagnoses to include respiratory failure with hypoxia (low O2), pulmonary embolism (clot in lung), encephalopathy (brain disorder), and tracheostomy status. Review of the Medication Review Report (physician orders) revealed the following orders: Tracheostomy size 6 Shiley, tracheostomy care daily and as needed. Clean the inner cannula and replace. Maintain Ambu bag at bedside and replacement tracheostomy of equal size and one size down at bedside every shift for preventative measure, dated 3/13/25. On 8/18/25 at 5:55 PM, resident #349 was in bed; at bedside there was no Ambu bag, and no size 5 or 6 replacement tracheostomy set seen. On 6/18/25 at 5:57 PM, Licensed Practical Nurse (LPN) J verified the Ambu bag and replacement tracheostomy required to be at the bedside for resident #349 was not present. She was unable to say why the equipment was not at the bedside as ordered. At that time, the G Wing UM confirmed the equipment was not available at resident #349's bedside. Resident #349's tracheostomy care plan dated 2/14/25, revealed an intervention to maintain Ambu bag and replacement tracheostomy at bedside per order. 7. Resident #315 was admitted to the facility on [DATE] with diagnoses to include chronic pulmonary insufficiency, encephalopathy, compression of the brain, pulmonary embolism, and tracheostomy status. A physician order dated 4/27/25, revealed maintain Ambu bag at bedside and replacement tracheostomy of equal size and one size down maintained at bedside every shift for preventative measure for respiratory failure requiring a tracheostomy. The tracheostomy care plan dated 7/12/24, revealed an intervention to maintain the Ambu bag and replacement tracheostomy at bedside per order. On 6/18/25 at 6:30 PM, resident #315 was in bed; at bedside there was an Ambu bag and a size 6 tracheostomy inner cannula. There were no smaller sized replacement tracheostomy inner and outer cannula at bedside as ordered. On 6/18/25 at 6:32 PM, the D Wing UM confirmed the emergency equipment was not at bedside but was unsure why it was not at the bedside. 8. Resident #300 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include acute respiratory failure with hypoxia, heart failure, encephalopathy, and tracheostomy status. A physician order dated 3/14/25 indicated maintain Ambu bag at bedside and replacement tracheostomy of equal size and one size down at bedside every shift for preventative measure. The Tracheostomy Care Plan dated 6/07/24 and revised on 3/14/25, revealed an intervention to Maintain Ambu bag and replacement trach at bedside per order. On 6/18/25 at 6:12 PM, there were no replacement tracheostomy cannulas as per order at resident #300's bedside. On 6/18/25 at 6:15 PM, the D Wing UM acknowledged the replacement tracheostomies were not in the emergency bag. She stated her DON told her to get them from the Central Supply Room earlier that morning, but when she went to Central Supply, no one was there. The D Wing UM did not respond to why she didn't try to get them later in the day when someone in Central Supply was available. On 6/19/25 at 1:00 PM, the Director of Central Supply stated she had a difficult time getting size 5 Shiley tracheostomy cannulas. She stated they were frequently on back order and currently did not have any in her Central Supply room. She was not sure when they would be available. On 6/19/25 at 2:00 PM, the Respiratory Therapist (RT) stated she assessed all of the respiratory residents weekly, usually on Tuesday or Thursday. She explained she changed all the tracheostomies monthly and checked all the emergency supplies weekly. The RT was unable to say why most of the residents with tracheostomies did not have all of the ordered emergency equipment available at the time of the survey. 10. Review of the medical record revealed resident #327 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including soft tissue disorders, shortness of breath (SOB), and myositis (a rare autoimmune condition characterized by muscle inflammation with symptoms that often include muscle pain and soreness, fatigue, trouble swallowing, and difficulty breathing). Review of the MDS annual assessment with Assessment Reference Date of 5/02/25 revealed resident #327 had a BIMS score of 15/15 which indicated she was cognitively intact. The MDS assessment indicated the resident did not exhibit behavioral symptoms or reject evaluation or care that was necessary to achieve her goals for health and well-being. The MDS assessment revealed resident #327 had SOB with exertion, when sitting at rest and when lying flat. The assessment noted the resident relied on a manual wheelchair for mobility and received O2 therapy. Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form signed by the hospital's physician on 5/08/25 revealed resident #327 used a BiPAP at night. A bilevel positive airway pressure (BiPAP) machine uses pressure to push air into the lungs, and it is commonly used for people with obstructive sleep apnea. Depending on the settings, it opens the upper airways leading to and increasing the flow into the lungs, improving the level of oxygen in the blood. Breathing difficulties during sleep could impact a person's quality of life. (Retrieved from www.healthline.com on 6/24/25). Review of resident #327's care plan for altered respiratory status for difficulty breathing related to SOB, initiated on 5/10/25, revealed a goal to maintain a normal breathing pattern. The interventions instructed the nurses to apply a BiPAP at bedtime, with settings 12/8. It read, BIPAP as ordered. Review of resident #327's physician orders revealed the following orders: *Apply BiPAP at bedtime (QHS): Settings 12/8 at bedtime for SOB- chronic respiratory insufficiency secondary to muscle contact provider if unable to apply - dated 6/06/25 * Change BiPAP O2 adapter monthly, and as needed (PRN), when O2 filter is changed - dated 5/09/25 * Change BiPAP O2 tubing weekly and PRN - dated 5/09/25 * Fill BiPAP humidifier chamber with distilled or sterile water QHS - dated 5/09/25 * Empty and Rinse BiPAP humidifier chamber every morning (Q AM) and allow to dry every day shift - dated 5/10/25 * Wash BiPAP mask with warm soapy water and wipe dry weekly - dated 5/09/25 * Empty and Rinse BiPAP humidifier chamber Q AM and allow to dry every day shift - dated 5/09/25 Review of resident #327's Progress Notes revealed the following entries: * 6/12/25 - A call was made to the respiratory equipment company to follow up on the resident's BIPAP ordered on Monday, June 9. The representative stated the physician order needed to include the settings. * 5/03/25 - A follow up call was placed to the hospital. Resident was admitted and the nurse reported resident #327 was placed on a BiPAP. * 5/02/25 - Resident experienced respiratory distress and the physician ordered a transfer to the hospital. Review of a physician's Progress Note at the hospital dated 5/07/25 mentioned resident #327 would require the use of BiPAP at night and as needed and an attempt to arrange an Average Volume-Assured Pressure Support (AVAPS) machine upon discharge. (An AVAPS is a type of noninvasive positive pressure ventilation that provides consistent ventilation support for patients with chronic respiratory conditions). The plan noted, Will need to utilize BIPAP at her facility due to facility ventilator constraints. On 6/16/25 at 11:39 AM, resident #327 shared she was supposed to have a BiPAP approximately two months ago. She indicated she went to an outside pulmonologist appointment on 6/04/25 and he again wrote a prescription for the BiPAP. She stated she received the BiPAP this past weekend. She mentioned no one knew how to set it up at night and they were waiting for her pulmonologist appointment this week to ask about it. She shared she had been experiencing SOB, tightness on her chest, a cold, and recently had pneumonia in the past few weeks. On 6/19/25 at 8:06 AM, resident #327 stated she had not used the BiPAP yet, but she saw the pulmonologist that morning and was told the respiratory equipment company needed to adjust the setting. On 6/19/25 at 2:16 PM, the Respiratory Therapist (RT) stated she did not recall seeing or receiving any information regarding a BiPAP order for resident #327. On 6/19/25 at 5:40 PM, the H-Wing UM stated when resident #327 returned from the hospital the discharge documents were reviewed. She indicated admissions handled the orders from the hospital when a resident needed oxygen, BiPAP, or anything else they would need when admitted to the facility. The UM reviewed the 3008 form dated 5/08/25 and confirmed a BiPAP was listed under treatment devices. She indicated admissions or the nurse needed to follow up on getting the BiPAP. She stated the Nurse Practitioner entered an order for the BiPAP in resident #327's medical record on 6/06/25. She mentioned she did not know where that order needed to be sent or who was responsible for getting it done. On 6/19/25 at 6:02 PM, Registered Nurse (RN) P stated resident #327 had an order for the use of a BiPAP when she needed it. She shared she offered resident #327 the BiPAP at night but she refused or had used it for a couple of hours but removed it. When asked if she documented the refusals or resident #327's limited use of the BiPAP, RN P stated she did not recall if she did. She explained she asked the Nurse Practitioner about the BiPAP when resident #327 returned from the hospital, and she mentioned she would order the machine. She recalled she saw the BiPAP in resident #327's room but the resident had not used it. When asked why she documented care to the BiPAP in May and June, prior to the BiPAP's delivery, she indicated she was told she had to click it because nothing could stay red. She explained if the assigned tasks were not marked complete in the medical record, they turned yellow then red. She repeated, I clicked it because I saw the order. She stated she could not recall exactly when she saw the BiPAP in the room, but thought it was approximately two weeks ago. RN P said, If (the task) stays red, I get a call to return and document. She stated she was told nothing could stay red, so I click it off, so it goes away. RN P did not respond when asked if she clicked the tasks off even if the treatment was not performed. Review of the Treatment Administration record (TAR) for the months of May and June 2025 showed RN P signed off the order which read, Fill BiPAP humidifier chamber with distilled or sterile water QHS. at bedtime . dated 5/09/25 as completed 12 times in May 2025, (5/12, 5/13, 5/14, 5/16, 5/17, 5/20, 5/21, 5/22, 5/26, 5/27, 5/28, and 5/31) and 12 times in June 2025 (6/1, 6/3, 6/4, 6/5, 6/9, 6/10, 6/11, 6/14, 6/15, 6/17, 6/18, and 6/19). There was no evidence in the medical record of resident #327's refusal to use the BiPAP. On 6/19/25 at 6:35 PM, RN Q indicated the BiPAP was delivered on 6/12/25 during her shift. RN Q recalled resident #327 was in therapy when the delivery occurred, and when she returned to her room she was informed of the BiPAP delivery she started clapping because she had been waiting a while for it. RN Q stated she was unsure why it took so long for her to get a BiPAP as she was new to the facility. She indicated she filled the humidifier chamber with sterile water that night and gave report to the male nurse from the oncoming shift. She shared resident #327 did not have the BiPAP mask on Monday or today when she started her shift at 7:00 AM. On 6/19/25 at 6:42 PM, the RT stated the BiPAP was delivered sometime last week. She explained a BiPAP was mostly used by patients who suffered from obstructive sleep apnea and needed to maintain their airway open while sleeping. She indicated in resident #327's case, the BiPAP order came from the hospital due to her diagnosis of myosis, which caused her breathing to become compromised. The RT stated resident #327 needed some support throughout the night to keep her airway open. She explained her company received orders from the hospital or the facility. The RT said they received the request for resident #327's BiPAP the same day it was delivered to the facility. She stated she followed up with residents after delivery. The RT mentioned during her visit she ensured the patient was wearing the device, she checked the setting, and that there were no issues with the mask. She stated she saw resident #327 today and the resident shared she attempted to use the BiPAP a couple of nights but felt it was too much. The RT indicated she contacted the Nurse Practitioner today and asked to consider lowering the pressure from 12 over 8 to 12 over 6. She explained when there were issues with a resident not tolerating the new device, she was contacted and she would come to check on it. On 6/20/25 at 12:09 PM, the Executive Director of Nursing (DON) stated admission staff would order the BiPAP when included in the discharge orders, but they did not order it this time. She indicated the UM needed to follow up because the 3008 form did not include the BiPAP settings. Once the UM obtained the required information, it was faxed to the respiratory equipment company. The DON did not provide an answer as to why it took over a month for resident #327 to obtain the ordered BiPAP. She stated the facility did not have a policy for respiratory care, only for oxygen use. Later at 1:40 PM, the DON stated they were unable to obtain a copy of the Pulmonologist progress note for the visit on 6/04/25 or the document sent to the respiratory equipment company when the BiPAP was requested. Review of the policy and procedure titled Physician Orders dated October 2021 read, Clarify unclear written orders by reviewing with the physician and documenting clarification on the Physician's Telephone Orders forms, or in the electronic medical record, as an Clarification Order. The policy included licensed clinicians would confirm the accuracy of the orders and the orders would be reviewed daily during the clinical meetings to confirm accuracy in transcription and identify errors of omission. 9. Resident #26 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Some of her diagnoses included chronic respiratory failure, cardiac arrest, quadriplegia (paralysis), and unspecified tracheostomy complication. A review of the medical record indicated resident #26 tracheostomy type was a Shiley, size 4. The physician orders dated 4/24/25 indicated nurses were to maintain an Ambu/Bag Valve Mask (BVM) bag and replacement tracheostomy of equal size and one size down at the bedside every shift for preventative measure. On 6/18/25 at 11:05 AM, resident #26 was observed with a tracheostomy in bed, eyes closed. The emergency supplies were hung in a clear plastic bag at bedside. Inside the clear plastic bag were an Ambu bag, a few tracheostomy kits, and suction sets. Later that evening, at 5:04 PM, the C Wing UM verified the sizes of emergency kits in the clear bag hanging at resident #26's bedside. There were four kits in the bag, three of the four were size 6 and one of the four was a size 5. The C Wing UM said she was not sure if the sizes were correct and would need to verify with the assigned nurse. A few minutes later at approximately 5:06 PM, assigned nurse LPN K said he believed resident #26 used a size 6 tracheostomy. However, he verified in the physician orders she was a size 4 but could not say if the sizes found in the emergency bag were appropriate. LPN K later acknowledged the sizes kept at the bedside (sizes 5 and 6) for emergency were not appropriate and explained he had not checked this morning to verify the emergency supplies were the appropriate size. On 6/18/25 at 5:15 PM, the Second Floor Staff Development Coordinator said that nurses should verify the size of the kits at shift change. She explained she had educated the nurses that residents should have the same and/or one size under as part of the emergency supplies kept at the bedside. She further acknowledged in the presence of C Wing UM and LPN K that resident #26 should have a size four and a size three replacement tracheostomy at the bedside. On 6/18/25 at 7:00 PM, the Nursing Home Administrator and the Executive DON acknowledged some of the physician ordered emergency supplies were not readily accessible for nine of ten residents with tracheostomies. They confirmed each resident with a tracheostomy required the appropriate emergency supplies at their bedside. The facility's policy regarding Ventilation- Emergency Tracheostomy Tube Changes dated December 2022 indicated, The nurse will perform emergency tracheostomy tube change in the event that a tracheostomy becomes displaced or dislodged. The policy listed the supplies kept at the bedside to be highly visible and included but not limited to, Tracheostomy tubes- one same size and one a size smaller. For Clinical consideration, it described in section 1, In the event you are unable to insert a tracheostomy tube of the same size as the on removed, follow the steps above with a tube one size smaller. Based on observation, interview, and record review, the facility failed to ensure necessary emergency equipment was available at the bedside for tracheostomy care and failed to provide respiratory treatment as ordered by the physician for 10 of 10 residents reviewed for respiratory care, of a total sample of 103 residents, (#25, #79, #158, #171, #300, #315, #327, #336, #349, and #356). Findings: 1. Resident #171 was admitted to the facility on [DATE]. Her diagnoses included anoxic brain damage, not elsewhere classified and persistent vegetative state. Her 5/07/25 Quarterly Minimum Data Set (MDS) assessment indicated she was in a persistent vegetative state with no discernable consciousness. Review of resident #171's medical record revealed the following physician's orders: an order dated 8/22/22 to change suction canister every 72 hours and/or when three quarters full; an order dated 8/22/22 to change the small tubing between the canister and the suction machine monthly, on the night shift on the 28th of each month; an order dated 8/22/22 to change her tracheostomy mask weekly as well as needed; an order dated 1/20/23 to change oxygen (O2) tubing every week, on the night shift on Sunday and label the tubing; an order dated 12/20/23 for a size six tracheostomy to change or replace as needed if displaced or dislodged; and an order dated 11/14/24 to maintain at the bedside a tracheostomy of equal size and one size down every shift. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth, (retrieved on 6/27/25 from www.hopkinsmedicine.org). A Shiley size refers to the specific size of Shiley tracheostomy tube used. On 6/16/25 at 4:25 PM, resident #171 was observed in her bed, the O2 tubing, tracheostomy mask, and suction canister were not labeled. The tubing between the suction canister to the suction machine was not labeled with a date of the last change. On 6/17/25 at 4:43 PM, resident #171's was observed in bed, the O2 tubing, tracheostomy mask, and suction canister were not labeled with the date of the last change, and contained approximately 600 milliliters (ml) of bodily fluid. The tubing between the suction canister to the suction machine was not labeled with a date of change. On 6/18/25 at 8:41 AM, resident #171's O2 tubing, tracheostomy mask, suction canister was not labeled with change date and contained approximately 600 ml of fluid, and the tubing between the suction canister to the suction machine were not labeled with a date of change. On 6/18/25 at 4:16 PM, the A Wing Unit Manager (UM) verified resident #171's respiratory related equipment including the tracheostomy mask; the O2 tubing; the suction canister, containing approximately 600 ml of fluid; the tubing between the suction canister and suction machine were not dated with their date of change as they should have been. Upon review of the emergency tracheostomy supplies kept in a bag at resident #171's beside there was not a tracheostomy kit, containing an inner and outer cannula, size 5, one size down from resident #171's present size 6, as ordered by the physician. She said she was told by the facility's Central Supply Director there were no size 5 cannulas available on 6/16/25. On 6/18/25 at 4:24 PM, the First Floor Director of Nursing (DON) verified the facility did not have any size 5 tracheostomy cannulas. She said she had spoken with the Central Supply Director on 6/17/25 about this issue. The First Floor DON said she did not know how long the facility had not had size 5 tracheostomy cannulas. The First Floor DON went to the B Wing and obtained a tracheostomy inner cannula size 4. The Director of Central Supply said she had not ordered size 5 tracheostomy cannulas in almost one and a half years she had been in her role at the facility. The First Floor DON provided the smaller size 4 inner cannula to the A Wing UM and told her to put it at resident #171's bedside. On 6/18/25 at 4:46 PM, the A Wing UM recognized the DON only provided her with only a size 4 tracheostomy inner cannula, only moments earlier. She then requested of the First Floor DON and the Central Supply Director that resident #171 receive a size 4 inner and outer cannula set for emergency use to maintain resident #171's airway if her present tracheostomy set experienced an emergency. The UM of A Wing said she did not know for how long resident #171 had not had an tracheostomy set, with inner and outer cannula, in a size smaller than size 6 at her bedside. 2. Review of resident #158's medical record revealed an admission date of 1/14/25. Review of resident #158's physician orders dated 1/27/25 included a Shiley size 6 tracheostomy, and a physician order dated 1/29/25 to maintain a replacement tracheostomy of equal size and one a size down at his bedside. On 6/18/25 at 5:03 PM, the A Wing UM observed the contents of resident #158's emergency tracheostomy supplies. There was no size 6 tracheostomy set, including the inner and outer cannulas, in the supplies but there was a smaller size 4 tracheostomy set, not the size 5 tracheostomy set as ordered by the physician. 3. Review of resident #356's medical record revealed an admission date of 4/28/25. His physician orders dated 4/28/25 included a Shiley size 6 tracheostomy, and to maintain a replacement tracheostomy of equal size and one size down at his bedside. On 6/18/25 at 7:12 PM, the B Wing UM reviewed the contents of resident #356's emergency tracheostomy supplies. There was a size 6 with only the inner cannula and a size 4 with only the inner cannula in the supplies, the outer cannulas were not present, and there were no size 5 cannulas as directed by physician order. The B Wing UM said she did not think the supplies were lacking in his emergency tracheostomy supplies, even though there was no size 6 outer cannula nor a set of size 5 inner and outer cannulas as specified in the physician orders. 4. Review of resident #79's medical record revealed an admission date of 5/11/25. His physician orders dated 5/11/25 included a Shiley size 6 tracheostomy, and to maintain a replacement tracheostomy of equal size and one size down at his bedside. On 6/18/25 at 7:15 PM, the B Wing UM reviewed the contents of resident #79's emergency tracheostomy supplies. She verified there was a size 4 inner cannula, but no outer cannula for the size 4, and there was no size 5 tracheostomy set, inner and outer cannulas, as directed by physician order. 5. Review of resident #336 medical record revealed an admission date of 5/30/25. Her physician orders dated 6/2/25 included that she had a Shiley size 6 tracheostomy, and she had a physician order dated 5/30/25 to maintain a replacement tracheostomy of equal size and one size down at her bedside. On 6/18/25 at 7:18 PM, the B Wing UM reviewed the contents of resident #336's emergency tracheostomy supplies. She verified there was a size 4 inner cannula, but no outer cannula for the size 4, and there was no size 5 tracheostomy set, with inner and outer cannulas as directed by physician order. The UM was unsure if the resident needed an outer cannula as well as the inner cannula in the emergency supplies. The B Wing UM confirmed the three residents that had been observed with tracheostomies on the B Wing, residents #356, #79, and #336, should have cannulas of the same size and a size that was smaller. On 6/18/25 at 6:55 PM, the Administrator and the Executive Director of Nursing verified the facility nurses should follow physicians' orders regarding what tracheostomy cannula sizes should be kept at residents' bedsides in the case of an emergency. The Executive DON verified that both outer and inner cannulas comprised the tracheostomy sets, were needed at the beside in case of an emergency for residents who employed that style, not an inner cannula alone.

Based on observation, interview, and record review, the facility failed to follow the menus for portion sizes. The non-compliance found had the potential to affect 263 residents, out of a total resident population of 350 residents that ate meals at the facility. Findings: On 6/18/25 at 12:02 PM, [NAME] F was observed preparing croissant sandwiches with two slices of pre-sliced ham and one of pre-sliced cheese. The Certified Dietary Manager (CDM) weighed these protein sources and found the sandwiches were being prepared with less than half of the three ounce (oz) portion required per the menu and recipe. The CDM provided [NAME] F with the written recipe and had him remake the sandwiches using the correct amount of the protein. On 6/19/25 at 2:21 PM, the CDM stated [NAME] F didn't check the sandwich recipe because he had made these sandwiches in the past and felt he could go by memory. She stated it was important for the cooks to follow the recipes including portion sizes, to ensure all resident's received adequate nutrition and especially when calculating the intake of residents who had difficulty maintaining their nutritional status. On 6/19/25 at 3:16 PM, [NAME] F confirmed he didn't check the recipe for the sandwiches yesterday because he had made these sandwiches before and could remember the recipe called for two slices of ham and one slice of cheese. He stated he didn't realize the pre-sliced ham and cheese did not weigh what the recipe called for and should have made sure they weighed one ounce per slice per the recipe. The facility's policy entitled Standardized Recipes, dated June 2024, indicated standardized recipes were utilized to ensure items prepared were consistent and provided consistent amounts of nutrients per portion. It added, the Food Service Manager was responsible to monitor and check the cooks' use of recipes.

Based on observation, interview, and record review, the facility failed to demonstrate sustained performance improvement with respect to identified Quality Deficiencies and ensure the deficiencies were not repeated. Findings: Review of the facility's last recertification survey from 3/03/24 to 3/08/24 revealed opportunities for improvement, due to non-compliance in the regulatory requirements for Resident Rights, Resident Assessment, Quality of Life, Quality of Care, Dietary and Infection Control. Current concerns identified during the recertification survey revealed continued concerns, leading to repeated non-compliance in the areas of Resident Rights (F550, F553, F554, and F585); Resident Assessments, (F644, and F645); Quality of Care, (F684, F688, and F695); Dietary, (F803, and F812); Quality Assessment Performance Improvement (QAPI), and Infection Control. On 6/20/25 at 12:20 PM, the Food Services Manager (FSM) and the 2nd Floor Administrator were interviewed about actions taken as part of the facility's QAPI committee. They were informed of the concerns that had risen from this years recertification survey, 6/16/25 to 6/20/25, which were Menus/Food to meet resident needs and Kitchen/Pantry sanitation as it related to the storing, and serving of food. They spoke about the dietary staff's cultural and language barriers with the Hispanic and Creole speaking staff. When it was pointed out that native English staff person was in violation of the incorrect donning of facial hair restraints, the staff could not say why the continued non-compliance occurred. The FSM and Administrator spoke about educating the staff but could not provide details of how the QAPI Committee had proactively approached continuous improvements in the Dietary Department to maintain compliance to the regulations as required. On 6/20/25 at 1:07 PM, the Activities Director stated she attended the monthly QAPI Committee meetings, along with the other department heads. She said she was aware of the previous concerns with activities which were cited on the previous years recertification survey. She stated there were no current QAPI projects for activities and could not say how QAPI ensured the improvements made in the past were sustained. The Activities Director explained that during the monthly QAPI meetings she reported the Resident Council activity, Calendar programs and her audits of the 1:1 visits for in room activities with room bound/self isolating residents. However, she did not provide any insight as to why there were repeated, current concerns for activities this year for residents #152, #174, #345, #349, and #359, identified for not having 1:1 in room activities, as noted in the residents' plans of care. On 6/20/25 at 1:35 PM, the Social Worker (SW) indicated that he was the only one from his department who attended the monthly QAPI meetings. He said he was aware of the Resident Assessment issue from last year which was related to Preadmission Resident screening assessments. He said to ensure there were not any repeated deficiencies related to the Preadmission screening assessments, a Performance Improvement Plan (PIP) was implemented after last years recertification survey. The SW did not say what was done to ensure the performance improvement was sustained and added there were not any current PIPs for his department. He explained after last year's revisit survey, he was the only person who reviewed the preadmission screening assessments for 390 residents. The SW conveyed he had not asked for help .but said the team was aware. He was not able to explain why residents #16, #56, #70, and #123 had current concerns identified with issues for Level I and/ or Level II preadmission screenings when these issues were identified and cited during last year's recertification survey. The SW provided no insight as to the QAPI committee's commitment to prevent the repeated non-compliance. On 6/20/25 at 2:38 PM, the Administrator and Director of Nursing (DON) in a joint interview, explained all department heads and the Medical Director attended the monthly QAPI meetings. They said each department discussed audits they were working on and the QAPI team detmined if the audits needed to be extended/continued for monitoring. The Administrator and DON conveyed they were not present for last year's recertification survey, but they were familiar with the survey results. They explained that staff placed a focus on the Abuse/Neglect and Risk Management issues. The Administrator and DON addressed the current issues for Peripherally Inserted Central Catheters (PICC) line, and compared resident #922's issues and whether they differed from last year's identified harm issue for PICC's. They explained resident #922's PICC line was identified on the nursing assessment but the nurse failed to put in batch orders to ensure care and services were provided. The Administrator and DON acknowledged the non-compliance were for the same concerns with nursing care and the service was not provided for the PICC. They did not give any detail as to how QAPI ensured what each department and nursing as a whole, was doing to prevent repeated deficiencies,especially concerns with Quality of Care issues. This facility continues to have concerns/repeated non-compliance in the areas of Resident Rights (F550, F553, F554, F585), Resident Assessment (F644, F645), Quality of Care (F684, F688, F695), Dietary (F803, F812), QAPI and Infection control. This facility continues to have concerns/repeated non-compliance in the areas of Resident Rights (F550, F553, F554, F585), Resident Assessment (F644, F645), Quality of Care (F684, F688, F695), Dietary (F803, F812), QAPI and Infection control. Based on the findings of repeated regulatory non-compliance, and on the interview with the Department Head and the Leadership Team; it was found the facility was reactive to concerns, versus being proactive in their approach to Quality Improvement.

Based on observation, and interview, and record review, the facility failed to ensure residents were afforded dignity during meals for 2 of 20 residents reviewed for dining, of a total sample of 103, (#99, & #206). Findings: 1. Resident #99 was admitted to the facility on [DATE] and had diagnoses that included dementia, anxiety, disorder of the brain, inability to speak and poor muscle coordination after stroke. The annual Minimum Data Set (MDS) dated [DATE] indicated resident #99 was rarely or never understood and her cognitive abilities were severely impaired. Resident #99 had a care plan that indicated she was totally dependent on staff for eating and most other activities of daily living (ADL's). 2. Resident #206 was admitted on [DATE] with diagnoses that included muscle disorders, depression, anxiety, degenerative nerve disease, and trouble swallowing. Her annual MDS assessment dated [DATE] indicated the resident was rarely or never understood, and her cognitive abilities were severely impaired. Resident #206 had a care plan which indicated she was totally dependent on staff for eating and most other ADL's. On 6/16/25 at 5:11 PM, Certified Nursing Assistant (CNA) G was observed standing while assisting resident #206 with her dinner meal. CNA G stated she couldn't find a chair to use while feeding the resident, and acknowledged she was supposed to sit to assist the residents with eating. She explained the room used to have a chair in it, but it was moved about two weeks ago. On 6/17/25 at 12:17 PM, the lunch meal trays were on the bedside tables of both residents #206 and #99. Physical Therapist (PT) I worked with resident #99 on bed stretches/exercises. At 12:25 PM, CNA E entered the room to assist resident #206 with her lunch and stood while she assisted the resident with her meal. At approximately 12:30 PM, PT I finished providing therapy services to resident #99 and began to assist her with her lunch while standing over the resident. On 6/17/25 at 12:43 PM, PT I stated she did not typically provide meal assistance to residents and was not aware she needed to be seated when assisting a resident with dining. She then brought a chair from across the room to the resident's bedside to continue with the meal. A short time later at 12:48 PM, CNA E stated she knew she was supposed to sit in a chair while she assisted resident #206 with her meal, but acknowledged she did not do it today. She explained it was a dignity issue and staff should not be standing over the residents but instead at their eye level to make them feel comfortable and not rushed. On 6/19/25 at 1:52 PM, the Assistant Director of Nursing (ADON)/ Staff Development Nurse stated the CNA's were trained on the importance of sitting when assisting residents with meals. She added if a chair were not available in the room, she would expect the staff member to get one. The facility's policy entitled Dining Program, dated June 2024, indicated nursing staff were to assist residents in need of assistance during mealtimes.

Based on interview, and record review, the facility failed to provide an opportunity to participate in the development and implementation of a person-centered plan of care for 1 of 2 residents reviewed for care planning, of a total sample of 103 residents, (#327). Findings: Review of the medical record revealed resident #327 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses soft tissue disorders, shortness of breath, and myositis (a rare autoimmune condition characterized by muscle inflammation with symptoms that often include muscle pain and soreness, fatigue, trouble swallowing, and difficulty breathing). Review of the Minimum Data Set (MDS) annual assessment with Assessment Reference Date of 5/02/25 revealed resident #249 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. The MDS assessment indicated the resident did not exhibit behavioral symptoms or reject evaluation or care that was necessary to achieve her goals for health and well-being. On 6/16/25 at 11:35 AM, resident #327 stated she had not been invited to participate in care plan meetings. On 6/19/25 at 10:24 AM, the Clinical Reimbursement Director explained the care plan meetings were set approximately a week after the MDS assessment was completed. She indicated invitation letters were sent on Fridays by the receptionist. She explained the invitation letter included the date, but the time was left open to accommodate the availability of the resident or resident representative. She indicated previous care plan meetings for resident #327 were held on 11/14/24 and 2/13/25. She stated the resident was invited but she declined to attend those meetings. She explained an invitation was to be sent on 5/02/25 but the same day resident #327 was transferred to the hospital. She shared the invitation on 5/02/25 showed the meeting was to be held on 5/15/25 but the receptionist returned the invitation with D/C written on it because the resident was not in the facility. Later at 2:46 PM, the Clinical Reimbursement Director confirmed resident #327 actually returned to the facility on 5/08/25, but because the invitation was marked D/C, the May meeting was not held. She said, It was unfortunate because she did return to the facility. Review of the facility Policy & Procedure titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting dated February 2024 revealed the intent to assist residents or their representative, to participate in and understand the assessment and care planning process . holding care planning meetings at the time of day when a resident is functioning best, . Review of the Resident Handbook dated January 2017 read, Your Plan of Care . We take pride in developing a complete plan of care with each resident, to meet the individual's medical, nutritional, and personal needs. Within a few days after you arrive, we will meet with you to gather specific info that will help our staff develop rehabilitation goals for your POC. You and your family (with your permission) are encouraged to attend this planning meeting and give input into your quarterly care planning conference. The staff will review the complete plan of care with you and your family on a regular basis.

2. Resident #332 was admitted on [DATE] for dysphagia (trouble swallowing), sepsis, severe protein-calorie malnutrition, and hypertensive heart disease. The quarterly MDS dated [DATE] indicated resident #332 had a BIMS score of 15/15, which reflected no cognitive impairment. On 6/16/25 at 9:47 AM, three medications including a container of Naproxen, 220 milligram (mg) tablets, a tube of triple antibiotic gel, and a tube of Muscle Rub, were on the resident's bedside table. The resident stated he had these medications in his room since he was admitted and took them for pain as needed. At 9:54 AM, the A wing UM verified the medications on the resident's bedside table. She removed the medications and told the resident the facility would need to administer the medications to him per the physician's orders. Review of physician orders revealed there was no order permitting resident to self-administer any medications. Review of the resident's care plan revealed there was no indication he had been assessed for self-administering of medication. On 6/17/25 at 10:34 AM, the Executive Director of Nursing acknowledged the residents should not self administer medications without an assessment and physician orders. She confirmed residents should have an assessment completed and the care plan should be updated if a resident was to self administer medications. The facility's Policy and Procedure on Medication Administration Self administration by Resident dated November 2017 indicated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team had determined that the practice would be safe and the medications are appropriate and safe for self-administration. Based on observation, interview, and record review, the facility failed to assess residents for self-Adminsitration of medication for 2 of 2 residents reviewed for self-administration, of a total sample of 103 residents, (#71, & #332). Findings: 1. Resident #71 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included other specified disorders of the muscle, type 2 diabetes mellitus, severe sepsis, and chronic obstructive pulmonary disease with acute exacerbation. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 3/19/25 revealed resident #38 had a Brief Interview for Mental Status (BIMS) Score of 15 out of 15, which indicated he was cognitively intact. A review of resident #71' s electronic medical record did not indicate he was assessed to self-administer medications. There were not any physician's orders nor was there a care plan for the self-administration of medications. On 6/17/25 at 9:28 AM, resident #71 entered his room, on his nightstand, there was a medicine cup filled with pills. Resident #71 said that nurse gave the cup of pills to him but he was worried the nurse would be in trouble. A few minutes later, assigned Registered Nurse (RN) L who was outside the room in the hallway, said the care plan or the Medication Administration Record (MAR) would have record of whether a resident was assessed for self administration of medication. She was not sure if resident #71 was assessed or able to self administer his medications. RN L explained there was a list of residents who could self-administer their medications, but said she did not have the list as she was only helping out. She acknowledged she should not have left resident #71 with the medication to self-administer on his own and said she took responsibility. On 6/17/25 at 10:06 AM, in a joint interview with the Staff Development Coordinator and the C Wing Unit Manager (UM), the UM explained it was a safety issue for residents to self-administer medications without an assessment to do so. She acknowledged resident #71 needed a self-administration assessment and a physician's order before he could self administer medications. The Staff Development Coordinator confirmed the assessment needed to be completed and resident #71 had not had an assessment completed. Neither the UM nor the Staff Development Coordinator could provide the list of residents who self-administered medications which RN L spoke about earlier.

Based on interview, and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 20 sampled residents regarding choices, of a total sample of 103 residents, (#120). Findings: Review of resident #120's medical record revealed an admission date of 1/01/24. His diagnoses included quadriplegia (paralysis to all four limbs), contracture of muscle multiple sites, and abnormal posture. Review of resident #120's Quarterly Minimum Data Set, dated [DATE] indicated his cognitive function was intact. On 6/16/25 at 4:33 PM, resident #120 said that he thought his care concerns were not being addressed by staff. He said he had previously made a complaint about long call bell response, for several hours of delay, but it had not been resolved. Review of the Grievance/Concern report dated 4/30/25 detailed two concerns for resident #120. The first concern was about dietary, the next concern detailed resident #120 said it was hard for him to find help from Certified Nursing Assistants and long call bell response times. Dietary department staff was noted as the individual designated to act on this grievance. On 6/19/25 at 8:14 AM, resident #120's Grievance/Concern report dated 4/30/25, was concurrently reviewed with the Social Services Director. He verified that since two topic areas of concerns were expressed by resident #120 they should have been investigated as two separate grievances. He verified there was only documentation that the one grievance involving dietary concerns had been addressed with resident #120. The Social Services Director said it seemed the other concern regarding the long call bell wait time had not been investigated, but should have. The Social Services Director acknowledged it was not clear from the initial report when the long call bell wait times occurred and there was no further clarification completed by staff regarding the questions. Review of the facility's policy and procedure titled, Grievance/Concern Management with an effective date of 2024 indicated it was the Social Services representative/Grievance Official in collaboration with the Nursing Home Administrator who was responsible for assigning the concern to the appropriate department for investigation. The policy revealed that Social Service staff would monitor and document the resident's satisfaction upon completion of the investigation and summary of findings/conclusion.

2. Resident #56 was a long-term care resident who admitted to the facility on [DATE]. Review of the level I PASARR dated 9/20/13, noted section 1A was blank and did not include any diagnoses of potential mental illness or intellectual disability. Review of the resident's current diagnoses included dementia, epilepsy, depression, anxiety and psychotic disorder. Record review revealed during a session with the Psychologist on 4/28/25, the resident was noted with a depressed mood and expressed feelings of being overwhelmed. There was not any evidence in the medical record that the level I PASARR had been updated. On 6/19/25 the Social Service Director was ask to provide a copy of the resident's level I PASARR. On 6/20/25 at 1:35 PM, the Social Service Director provided the requested copy of the PASARR dated 9/20/13 and a copy of a new PASARR which was updated on 6/19/25. He could not explain why the resident's PASARR had not been updated prior to 6/19/25. The Facilty's Policy and Procedure dated February 2021 indicated, During the admission process, Business Development will communicate with the facility regarding prospective admissions. A level I PASARR will be provided prior to admission to the Skilled Nursing Facility (SNF). The facility administration will confirm that a Level I review has been completed prior to transfer to the SNF setting. Based on interview, and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level I and level II evaluation after a new major mental disorder diagnosis for 2 of 5 residents reviewed for PASARR, of a total sample of 103 residents, (#16, & #56). Findings: 1. Review of the medical record revealed resident #16 was initially admitted to the facility on [DATE] and re-admitted on [DATE] from an acute care hospital. Some of her diagnoses included adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, bipolar disorder, disorganized schizophrenia, catatonic schizophrenia, unspecified dementia and weakness. Resident #16's Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 5/09/25 revealed the resident scored 12/15 on the Brief Interview for Mental Status which indicated she had mild cognitive impairment. The assessment revealed resident #16 felt depressed, had no behaviors nor rejection of care and had diagnoses of anxiety disorder, bipolar disorder and schizophrenia listed as active diagnoses. Review of the Plan of Care revealed that resident #16 had behaviors with the potential to demonstrate verbally abusive behaviors related to mental or emotional illness; was often combative during Activities of Daily Living (ADL) care often striking staff; declined care and skin assessments at times; and would appear catatonic or non-responsive. The care plan also addressed the use of psychotropic medications to manage schizophrenia, anxiety, depression, bipolar disorder and insomnia. On 6/16/25 at 4:48 PM, resident #16 was observed sitting in the dining area of the C wing among other residents. At times resident #16 would scream out while using foul language and said, I'll be calm today. On 6/18/25 at 10:50 AM, a review of the Level I PASARR revealed the new major mental illness disorders were not listed on the document dated 2/08/23. The only one of her diagnosis listed was bipolar disorder. On 6/18/25 at 11:32 AM, assigned Certified Nursing Assistant (CNA) M explained resident #16 could be verbally abusive to staff and other residents when having a bad day. She said the resident could be easily redirected or calmed down after speaking with her brother or offered a diversion. On 6/18/25 at 6:07 PM, the Social Services Director said he was responsible for updating the PASARR forms when a resident had a new mental health diagnosis. He was made aware of resident #16's new diagnoses of schizophrenia and adjustment disorder, which he acknowledged the resident should have been re-screened after the new diagnoses were added. The Social Services Director explained that during the Interdisciplinary Team (IDT) meetings, the team would talk about what diagnoses needed to be on the PASARR form and would request the Level II screening, but was not aware of this one.

Based on interview, and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level I and level II evaluation for 2 of 5 residents reviewed for PASARR, of a total sample of 103 residents, (#70, and #123). Findings: 1. Resident #123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, major depressive disorder, adjustment disorder, congestive heart failure, cerebral infarction, and acute respiratory failure with hypoxia. Review of resident #123's Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 4/04/25 revealed the resident was cognitively impaired and listed depression as a psychiatric diagnosis. A review of the electronic medical record revealed a PASARR dated 1/12/23 and no diagnoses were listed in Section 1 A. On 6/19/25 at 1:45 PM, the Social Services Director stated he was responsible for PASARRs. He acknowledged that no diagnoses were listed in section 1 A of resident #123's PASARR and said, guess I missed that one, I will work on it. He continued to explain that the Admissions department looked at the PASARR from the admission packet from the hospital, but he was responsible for ensuring that they were accurate upon admission. The Social Services Director confirmed the level I PASARR was incorrect, therefore the resident's screening was inaccurate, and required a new one. 2. Resident #70 was admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder, bipolar type; anxiety disorder unspecified; major depressive disorder, recurrent, unspecified; and a personal history of other mental and behavioral disorders. Review of resident #70's medical record revealed a level I PASARR signed by the facility's Social Services Director on 4/02/24. The PASARR screening indicated that resident #70 had anxiety disorder, schizoaffective disorder, depressive disorder, and multiple diagnoses related to alcohol abuse. The responses regarding the level I PASARR indicated that a level II PASRR evaluation should be completed. On 6/17/25 at 4:06 PM, the Social Services Director reviewed the level I PASARR which he had electronically signed on 4/02/24 and he verified a level II PASARR evaluation was required, but had no documentation of its completion. He conveyed he had nothing to show regarding the level II screening including that he attempted to follow-up with the contractor completing the screening. The Social Services Director said he would need to resubmit a request for a Level II PASARR for resident #70, which he had not done yet.

Based on observation, interview, and record review, the facility failed to provide a resident centered activities program to meet the needs of residents who required 1:1 in room activities for 5 of 6 residents reviewed for in room activities, of a total sample of 103 residents, ( #152, #174, #345, #349, & #359). Findings: The following residents resided on the locked unit and were observed daily for five days, from 6/16/25-6/20/25, between the hours of 8:15 AM to 9:30 AM, and 11:30 AM to 4:30 PM. During those times no activities for the residents were observed. 1. Resident #152 was admitted to the facility on [DATE] with diagnoses to include dementia, mood disorder, repeated falls. Resident #152's activity care plan indicated, resident requires staff assistance with involvement of activities related to behavioral symptoms that may affect participation. Cognitive deficits .requires staff visits for supplies and assistance with partaking in passive activities in his room, initiated on 2/11/25). The goal was for staff visits completed one to two times per week to offer assistance with active leisure involvement in activities of past interest as tolerated, initiated on 2/11/25. Interventions included in-room activities (reading, staff visits, watching TV. Preferred time afternoons) initiated on 2/11/25. Review of the activity documentation for individual activity and activity participation for the month of June 2025 revealed no documentation of individual activities for resident #152. Resident #152 was not observed taking part in any activity during the survey from 6/16/25 to 6/20/25. Review of the record revealed resident had no documented in-room activities in the past 30 days. 2. Resident #174 was admitted to the facility on [DATE], with diagnoses including encephalopathy (brain disorder), schizophrenia, adjustment disorder, and repeated falls. Resident #174's activity care plan indicated, resident requires staff assistance with involvement of activities related to behavioral symptoms that may affect participation. Cognitive deficits .does not stay for the entire activity, states some enjoyment with watching television, initiated on 12/10/24. The goal was for resident #174 to receive staff visits one to two times per week for participation in activities of interest and sensory stimulation attempts through next review, initiated on 12/10/24. Interventions included in-room reading, television, socializing, and music, initiated on 12/10/24. Review of the activity documentation for individual activity and activity participation for the month of June 2025 revealed no documentation of individual activities. Resident #174 was not observed taking part in any activity during the survey from 6/16/25 to 6/20/25. 3. Resident #345 was admitted to the facility on [DATE] with diagnoses including dementia, encephalopathy, and difficulty walking. The resident's activity care plan detailed, he is capable of pursuing his own activities, is capable of attending activities but prefers to stay in room .Resident's son stated his dad enjoys watching television and listening to music, initiated on 2/20/25. The goal was for resident #345 to receive staff visits one to two times per week to offer assistance in active leisure pursuits and ensure leisure satisfaction until next review, initiated on 2/20/25. Interventions included preference for in-room television, socializing and music, initiated on 2/20/25. Review of the record revealed resident had no documented in-room activities in the past 30 days. Resident #345 was not observed taking part in any activity during the survey from 6/16/25 to 6/20/25. 4. Resident #359 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, encephalopathy, and cerebral infarction. Resident #359's activity care plan indicated the resident required staff assistance with involvement of activities related to behavioral symptoms that may affect participation. Prefers to stay in room, initiated on 4/22/25. The goal was resident #359 would receive staff visits one to two times per week to offer assistance with partaking in activities of past interest as tolerated, initiated on 4/22/25. Interventions included resident prefers in-room reading, television, socializing and music, initiated 4/29/25. The resident had one documented in-room activity in the past 30 days, on 5/26/25. Resident #359 was not observed taking part in any activity during the survey from 6/16/25 to 6/20/25. 5. Resident #349 was admitted to the facility on [DATE] with diagnoses to include respiratory failure, stroke, encephalopathy, tracheostomy (a surgical hole in the throat for breathing) status, and gastrostomy (feeding tube) status. Resident #349's activity care plan detailed, the resident required staff assistance with the involvement of activities related to requires physical assistance to and from activities. Unable to complete interview for daily and activity preference. Requires 1:1 visit for sensory stimulation, initiated 2/23/25. The goal was resident #349 would receive a 1:1 visit for sensory stimulation one to two times per week until next review, initiated 2/23/25. Interventions included resident would benefit from in-room television and music, would benefit from passive/active room activity, preferred activities are television, music, animals, and sitting outside, initiated 2/23/25. Resident #349 had not been seen involved in any activity during the time period from 6/16/25 to 6/20/25. Her television was on only one day of the five. On 6/19/25 at 9:21 AM, the Activity Director stated she provided activities daily in the locked unit beginning at 9:30 AM. She stated she provided different activities throughout the day and in-room activities were performed one to two times per week and documented in the activity task on the computer. The Activity Director was not able to explain why the locked unit staff were not seen participating in activities with residents #152, #174, #345, #349, and #359 throughout the day during the week of the survey.

Based on interview, and record review, the facility failed to timely provide coordination of care for diagnostic imaging/laboratory services and a specialty gastrointestinal (GI) consult for 2 of 2 residents reviewed for coordination of care, (#159 and #22); and failed to obtain physician's wound treatment orders and complete weekly wound measurement assessments for 1 of 5 residents reviewed for non- pressure skin condition concerns, (#120), of a total of 103 sampled residents. Findings: 1. Review of resident #159's medical record revealed an admission date of 5/23/22. Her diagnoses included volvulus (twisting intestines) and abdominal distension-gaseous. Review of resident #159's Quarterly Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status of 13/15, which indicated her cognitive function was intact. On 6/16/25 at 1:34 PM, both resident #159's family member and resident #159 said the size of the resident's abdominal area had increased over time since she had been at the facility. They stated they did not know why. Review of resident #159's medical record revealed a gastrointestinal specialty progress note dated 6/11/25 which indicated resident #159 had a distended abdomen and it was recommended she have a computerized tomography (CT) scan of her abdomen and pelvis to rule out an obstruction. On 6/18/25 at 3:55 PM, the A Wing Unit Manager (UM) stated she obtained a physician's order that day to schedule the recommended CT scan for resident #159. The Um could not explain why it took a week to coordinate with resident #159's physician regarding the GI specialist's recommendation for a follow-up CT scan appointment. 2. Resident #22 was admitted to the facility on [DATE]. His diagnoses included malignant brain cancer, difficulty swallowing, and abnormal weight loss. Review of resident #22's Quarterly MDS assessment dated [DATE] indicated his cognitive function was intact. Review of resident #22's documented eating history from 5/22/25 to 6/18/25 revealed on 20 out of 28 days resident #22 refused a meal or multiple meals; or had 25% or less intake of a meal. Review of resident #22's documented weight history revealed on 6/11/25 he weighed 188.4 pounds (lbs) and on 5/18/25 he weighed 203.8 lbs. This was a 7.37% decrease in less than 30 days. In 45 days his weight decreased 14.08%. On 4/04/25 he weighed 237.2 lbs and a month and a half later on 5/18/25 he weighed 203.8 lbs. Review of resident #22's physician's orders revealed an order to test his stool for occult blood on 4/14/25 with an end date of 4/17/25. The status indicated it was completed. Two days later there was another order to test stool for occult blood on 4/16/25 with an end date of 4/18/25 and the status indicated it was completed. 30 days later, there was again an order to test the stool for occult blood, on 5/23/25 with an end date of 6/08/25. On the same day, 6/08/25, there was a physician's order to test stool for occult blood started on 6/08/25 with an end date of 6/18/25. Resident #22's physician's orders dated 6/12/25 indicated a stool specimen had been collected and was awaiting lab testing. Five days later on 6/17/25, it was noted that a stool specimen had been collected and was awaiting lab testing. Review of resident #22's physician's orders revealed an order for a GI consult dated 4/14/25 with an end date of 6/08/25. On 6/08/25 another physician's order occurred for a GI consult which indicated to discontinue the order when it had been completed; the order appeared as active. On 6/19/25 at 8:57 AM, resident #22's physician's orders from 4/25 to the current date were reviewed with the A Wing UM. She verified there were no results from a fecal occult blood test. She confirmed there was no documentation that a GI consult was made for resident #22, 66 days after it had been ordered by the physician on 4/14/25 and reordered on 6/08/25. The UM could not explain why the consult had not been completed yet. On 6/19/25 at 10:20 AM, resident #22's laboratory results were reviewed with the Advanced Practice Registered Nurse (APRN) W. She said she could not find results for an occult blood stool from April 2025 to present. APRN W thought the resident had one occult blood stool sample result; however, she could not find documentation of it. She said it would be good to have the results of the occult blood stool sample because resident #22 had weight loss, and considered he possibly had an internal mass. APRN W conveyed she did not recall contacting the GI specialty group associated with the facility to request a consultation. On 6/19/25 at 11:23 AM, the Executive Director of Nursing (DON) reviewed resident #22's physician orders for a GI consult from 4/14/25 to 6/08/25 and then the active order from 6/08/25 to present. She was unsure if resident #22 had the ordered GI consult. She acknowledged it should take over two months for a GI consult to be completed. No additional documentation for a completed GI consult for resident #22 was provided by the survey's end. On 6/19/25 at 11:59 AM, APRN X, the GI consult specialist for the facility, said he did not recall having provided a consultation for resident #22. 3. Resident #120 was admitted to the facility on [DATE]. His diagnoses included quadriplegia (paralysis), contracture of muscle multiple sites, and abnormal posture. Review of resident #120's Quarterly MDS assessment dated [DATE] indicated his cognitive function was intact. Review of resident #120's skin evaluations revealed he had an abrasion on his right gluteal area which was measured on 5/20/25, 6/04/25, and 6/19/25. There was no documentation for two weeks from 5/25/25 to 5/31/25 and from 6/08/25 to 6/14/25 in which there was no documentation of his wound measurement during these time frames. Review of the medical record revealed there were no physician's orders regarding the care for this wound area. Review of resident #120's skin evaluation of an abrasion on his left ischial tuberosity documented measurements on 4/30/25, 5/20/20, 6/04/25, and 6/19/25, which revealed two concurrent weeks and two additional weeks that the wound had not been measured within this time frame. Resident #120 had physician orders dated 4/29/25 regarding the left ischial tuberosity to cleanse wound with normal saline, apply Xeroform and cover with dry dressing every night shift. Review of resident #120's skin evaluation of an abrasion on his penis documented measurements on 4/25/25, 5/20/25, 6/04/25, and 6/19/25, which revealed two concurrent weeks and two additional weeks that had no documentation the wound was measured. Review of resident #120's care plan revealed he had a risk for skin integrity with a care plan initiation date of 4/17/23 and a revision date of 5/19/25. One of the interventions dated 4/17/23 was to monitor and document the size and treatments of skin concerns, to report failure to heal and maceration to the doctor. On 6/19/25 at 7:20 AM, Registered Nurse (RN) BB stated the wound care she did for resident #120 during her night shift was to apply a barrier cream to his wounds. She described the wounds on the right gluteus and penis. She could not provide the name of the barrier cream she used, nor could she locate the tube of the cream she used, nor show a sample from the stock of creams of the variety she used for his wounds. On 6/20/25 at 7:55 AM, resident #120's wound orders were reviewed with the A Wing Unit Manager (UM) who verified there were no physician orders for wound treatment regarding the abrasion on his right gluteus. She confirmed the wound should have physician's orders as documentation revealed it had been present since 5/20/25. The A Wing UM verified the physician's treatment orders regarding the left ischial tuberosity were not followed by Registered Nurse BB as she did not indicate she had covered the left ischial tuberosity with a Xeroform dressing. She said she thought the physician's order should be changed. On 6/20/25 at 9:43 AM, the Executive DON confirmed that wounds including lacerations, abrasions, and pressure ulcers should be measured weekly. She said she did not know why weekly measuring was not done for resident #120 regarding his wounds. On 6/20/25 at 9:49 AM, resident #120's right gluteal abrasion, left ischial tuberosity abrasion, and penis abrasion wound measurements were reviewed by the First Floor DON. She stated the wounds should be measured weekly and acknowledged in the case of resident #120's wounds that had not been followed. The First Floor DON verified no refusals from resident #120 were documented regarding taking wound measurements since April 2025 up to the present time. She acknowledged it was the facility's responsibility to obtain weekly wound measurements even if resident #120 was not available in bed when she and the Unit Managers rounded to measure wounds. She explained the value in taking wound measurements was to document any change over time to assess if the wound was improving or declining in regards to healing.

Based on observation, interview, and record review, the facility failed to provide care and services related to management and application of orthotic devices to prevent worsening of contractures and promote skin integrity for 1 of 1 residents reviewed for limited range of motion (ROM) and reduced mobility, of a total sample of 103 residents, (#249). Findings: Review of the medical record revealed resident #249 was admitted to the facility on [DATE] with diagnoses including stroke with left side weakness and paralysis, type 2 diabetes, and cataracts. Review of the Minimum Data Set (MDS) annual assessment with Assessment Reference Date of 3/09/25 revealed resident #249 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. The MDS assessment indicated the resident did not exhibit behavioral symptoms or reject evaluation or care that was necessary to achieve her goals for health and well-being. The MDS assessment revealed resident #249 had functional limitation in range of motion due to impairment of upper and lower extremities on one side. Resident #249 required substantial assistance for bathing and required partial/moderate assistance from staff with oral hygiene, toileting hygiene, dressing, and personal hygiene. The MDS assessment revealed the resident did not receive ROM services or assistance with splints or braces. Review of resident #249's physician orders revealed an order dated 6/03/25 which read, Splint: Apply palm guard split (sp) goal wear time up to 3 hrs (hours) every day shift. Additional orders dated 3/11/23 indicated restorative nursing as needed and physical therapy / occupational therapy / speech therapy to evaluate & treat as needed. A previous order for splinting program dated 6/14/24 was discontinued on 6/03/25 and instructed nurses to don the palm guard splint with a goal wear time up to three hours. Review of resident #249's Care Plan Report revealed a focus for ROM - at risk or actual limitation in ROM as evidenced by requires splinting applications initiated on 6/05/25. Another focus included Activities of Daily Living (ADL), initiated on 3/11/23 - resident has an ADL self-care performance deficit related to left side weakness . decreased mobility . hemiplegia affecting left non-dominant side, right arm contracture, insomnia, need for assistance with personal care, lack of coordination. Review of resident #249's Kardex (Care Plan used by Certified Nursing Assistants (CNAs)) showed a restorative section which read, Assistance with splint or brace apply palm guard splint goal wear time is 3 hours. On 6/17/25 at 8:34 AM, resident #249 was sitting up in bed, her left hand was contracted, and no splint was noted. She stated she had a splint, but her sister took it home to be washed because it was smelly. She shared she was unsure who could wash it in the facility. She indicated she did not use rolled towels or anything on the contracted hand and she was not receiving restorative nursing services. She shared when she had the splint, there were times she had to apply the splint by herself, and it was difficult and painful. Resident #249 mentioned when she wore the splint, it protected her from touching the blanket and feeling pain. She shared when she saw her former Occupational Therapist walking by the hallway, she would call her to assist applying the splint. She indicated she wore the splint and removed it herself. Later on 6/18/25 at 4:36 PM, resident #249 was seen near the receptionist area on the first floor not wearing a splint. On 6/18/25 at 2:02 PM, CNA N stated she had not seen any braces or boots in resident #249's room. She shared resident #249 used to work with therapy but she believed it stopped due to insurance. She indicated the resident had mentioned she would like to work with therapy again. CNA N stated she had not seen resident #249 wearing a splint and the resident had never mentioned a splint to her. Review of resident #249's Treatment Administration Record (TAR) for June 2025 revealed nurses signed off the splinting tasks as completed every day. Review of resident #249's Documentation Survey Report revealed a task initiated on 6/03/25 that read, NURSING REHAB: Assistance with splint or brace apply palm guard splint goal wear time is 3 hours. The report showed CNAs documented not applicable (NA) 16 times out of 18 days. Two days were left blank. Review of resident #249's Progress Notes from May to June 2025 did not reveal documentation of any refusal to wear splints. On 6/19/25 at 1:13 PM, the H-Wing Unit Manager (UM) said it was debatable who was responsible to apply the splint daily. She explained therapy staff handled the information she entered under physician orders for residents who needed splints. She validated nurses were to follow physician orders. She shared they did not have a Restorative Nursing Program (RNP) at the facility. The UM stated resident #249 used her splint whenever she wanted to use it. The UM mentioned a care plan for refusal was just created on 6/16/25 but could not provide evidence in the medical record for the refusals. She recalled therapy donned resident #249's splint occasionally and notified the nurse so the nurse could document it. On 6/19/25 at 1:37 PM, Registered Nurse (RN) O validated she documented resident #249 had the splint on. RN O accompanied surveyor to resident #249's room. RN O confirmed the resident was not wearing her splint. Resident #249 repeated her sister took her splint last week to wash it. After leaving resident #249's room, RN O stated she was not aware the resident's sister took the splint to be washed. RN O validated she documented the splint was applied to the resident twice this week without confirming resident was in fact wearing it. She stated she should have not documented it completed because she did not actually see if the splint was on or not. On 6/19/25 at 3:01 PM, the Rehabilitation Director indicated resident #249 was not currently on therapy caseload. She shared Occupational Therapy (OT) last worked with resident #249 in October 2024. She shared resident #249 was in the RNP for splinting. She explained once therapy discharged a resident with a splint, the program was given to nursing. She mentioned therapy met with RNP at the beginning to show how to don and doff the splint. She stated therapy gave nursing the recommendation for RNP but nursing ran the program. She indicated the RNP was different for each unit. She stated if a resident did not tolerate the splint or refused to use it, nursing informed therapy but she was not aware of any issues with resident #249. On 6/19/25 at 4:18 PM, the Executive Director of Nursing (DON) stated they did not have a Restorative Nurse. She explained the CNAs were responsible for performing the ROM exercises or donning the splints on residents. The DON indicated the splinting showed on the CNAs tasks and the TAR for nurses to perform it. She indicated this was not changed in the year she had worked in the facility. She shared CNAs received training by therapy to handle splints. She recapped CNAs were responsible for splints and the nurse who signed it off was responsible for ensuring the task was completed. Review of resident #249's Therapy Referral form dated 5/22/24 revealed a referral was made to OT and Physical Therapy. It read, left hand contracture wants to be able to toilet herself. Review of resident #249's OT Therapist Progress & Discharge summary dated [DATE] revealed resident improved in orthotic management tolerance using the palm guard to improve joint integrity. Review of resident #249's Therapy Recommendations for Restorative Program form dated 6/20/24 included goals to maintain ability to move upper extremity and wear splint for up to three hours. Review of resident #249's Splinting Program Form with a start date of 6/21/24 read, Gently position left digits in extension and don palm guard. The form was signed by the OT, Charge Nurse and a CNA. Review of resident #249's Nursing Quarterly and PRN (as needed) Data Collection form dated 3/22/25 included the resident was alert and oriented; and cooperative with care and treatment. The question, Does the resident use any splints, braces or orthoses? was answered, Yes. It read, Splinting Program. [NAME] palm guard split (sp) goal wear time up to 3 hrs. Review of the Certified Nursing Assistant (CNA) Job Description dated 7/01/19 revealed the CNA worked under the supervision and guidance of a licensed nurse (RN or License Practical Nurse). The form read, Performs restorative and rehabilitative procedures as instructed.

Based on observation, interview, and record review the facilty failed to provide care and services for a Peripherally Inserted Central Catheter (PICC) intravenous (IV) line for 1 of 1 residents reviewed for central line catheters, of a total sample of 103 residents, (#922). Findings: Resident #922 admitted to the facility from the hospital on 6/10/25. Her diagnoses included type 2 diabetes, heart failure, abdominal hernia, epilepsy and ventricular tachycardia (fast heartbeat). The hospital transfer form did not indicate the resident had an IV line. Staff noted in a progress note dated 6/10/25, the resident had an IV line that was located in the resident's right arm. On 6/16/25 at 2:59 PM, the resident was observed in the therapy gym and said the facilty did not use her PICC line. She conveyed she did not receive antibiotics through the line nor did the facility staff flush it. The PICC dressing had a date of 6/07/25, before she was admitted to the facility, which meant the dressing had not been changed since she had been at the facility. A PICC line is a thin, flexible tube inserted into an upper arm vein and guided into the large vein on the right side of the heart. It is used for intravenous delivery of antibiotics or chemotherapy drugs. The most common complication of a PICC line is infection which can lead to sepsis, shock, and death. The reported patient mortality rate was between 12% and 25% for central line related blood stream infections, Care for the PICC includes, checking the site for redness or bleeding, changing the dressing at least weekly and flushing the IV regularly, (retrieved from www.ncbi.nlm.nih.gov on 7/06/25). Review of the Electronic Medication Administration Record (EMAR) noted a physician order to remove the midline on or about 6/15/25. The EMAR indicated this order was checked off as completed that the PICC line had been removed. Review of the EMAR also noted there was no physician orders for dressing changes, saline flushes, or assessment of the PICC site. On 6/16/25 at 3:03 PM, Registered Nurse A (RN) confirmed resident #922's PICC line dressing was dated 6/07/25. The nurse added resident #922 did not receive any medication via the PICC line and confirmed she did not flush it. RN A did not provide any information as to how the facilty maintained the patency of resident #922's PICC, nor what was done to assess the PICC site for signs of infection, swelling, redness or other symptoms. RN A said IV line dressings were supposed to be changed every 7 days, but did not offer any other steps nurses took to assess, and maintain the central IV line. On 6/19/25 at 3:26 PM, the Executive DON acknowledged the admitting nurse did not put in the batch orders into the computer for the PICC. She was also aware that another nurse checked off the physician's order as completed even though the PICC had not been removed. The DON explained the facility's chart audits for new admissions, confirmed resident #922's medical chart had not been audited and the resident did not have orders for the PICC line dressing change, flushes, or site assessment.

Based on interview, and record review, the facility failed to address a resident's pain timely for 1 of 2 residents reviewed for pain, of a total sample of 103 residents, (#250). Findings: Resident #250 was admitted to the facility on [DATE]. His diagnoses included unspecified polyneuropathy, fusion of the spine thoracic region, fusion of the spine lumbar region, pain in right foot, unspecified fracture of the sacrum sequelae, unspecified fracture of the right and left acetabulum sequelae, unspecified fracture of the the shaft of the right tibia, unspecified fracture of the right and left calcaneous (heel bones), and displaced fracture of the fourth metatarsal bone right foot sequelae. Review of resident #250's annual Minimum Data Set assessment dated [DATE] revealed he had no cognitive deficiencies. Resident #250 had a physician order dated 4/14/24 for the pain medication Lyrica (Pregabalin) 100 milligrams (mg) to be administered every eight hours. On 6/16/25 at 5:19 PM, resident #250 stated he currently was in pain. He described his pain as a nine or a ten out of ten, on the numerical pain rating scale with 10 as the highest value. The resident said his left leg was the most painful area, although both legs had burning pain. He said his pain was so terrible he could not sleep much the previous night because the pain kept him awake. He said the facility had not provided him his Lyrica, a pain medication, during the weekend because the pharmacy had not sent it. He said an alternative or additional pain medication was not offered when the ordered medication had not been available. Review of resident #250's medical record revealed a nursing progress note dated 6/15/25 at 1:45 PM, that nursing was waiting for the pharmacy to deliver the Pregabalin. Later, on 6/15/25 at 10:22 PM, another nursing progress note documented that nursing was waiting for the pharmacy to deliver the Pregabalin. On 6/16/25 at 6:17 PM, resident #250's June 2025 medication administration record (MAR) was reviewed with Registered Nurse (RN) S. She explained she did not administer Pregabalin to resident #250 on 6/16/25 although according to the MAR in the scheduled 6:00 AM administration area for 6/16/25 she had. She said the nursing staff was still waiting to receive the medication from the pharmacy. RN R and the A Wing Unit Manager (UM) who were present, RN R said she was resident #250's assigned nurse on 6/15/25 on the 3:00 PM to 11:00 PM shift. RN R verified that resident #250 had not received his Pregabalin pain medication since the morning of 6/15/25 at approximately 6:00 AM, which was approximately 36 hours ago and included four missed doses. They did not say why they had not called the physician to notify of the missing doses of Pregalbin pain medication or to ask for an alternate medication for resident #250's pain. On 6/18/25 at 10:53 AM, the A Wing UM stated her expectation was that when only several doses were left of a medication a nurse should reorder the medication from the pharmacy so that there was no break in receiving it. The medication should be available to administer according to the physician orders and confirmed this was the situation for resident #250 regarding his pain medication.

Based on observation, interview, and record review, the facility failed to ensure that residents who experienced trauma received trauma-informed care for 1 of 4 residents reviewed for behavioral-emotional concerns, of a total sample of 103 residents, (#251). Findings: Resident #251 was admitted to the facility on [DATE] with diagnoses including heart failure, adjustment disorder with other symptoms, claustrophobia, atrial fibrillation and chronic kidney disease. Diagnoses of post-traumatic stress disorder (PTSD), personal history of physical and sexual abuse in childhood and insomnia due to other mental disorder were added with an onset date of 10/15/24. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 4/02/25 revealed resident #251 had a Brief Interview for Mental Status score of 14/15 which indicated she was cognitively intact. The document revealed resident #251 had an active diagnosis of PTSD and received anti-depressant medications. Review of prior MDS quarterly assessment with ARD of 1/03/25 revealed resident #251 had an active diagnosis of PTSD and received anti-depressant medications. Review of resident #251's Electronic Medical Record (EMR) revealed a care plan for behaviors related to accusations and confabulation about staff and residents, refusal of care, verbally aggressive toward staff which included racial slurs. The EMR did not contain a post trauma care plan. The EMR contained a Psychosocial History and Assessment - V 5 dated 12/30/24 which indicated resident #251 had never been diagnosed with PTSD, had a life altering event or life changing event. A second Psychosocial History and Assessment - V 5 dated 3/30/25 also indicated resident #251 had never been diagnosed with PTSD, had a life altering event or life changing event. Review of psychiatric progress notes revealed resident #251 was seen on 10/14/24. The Psychiatric Advanced Registered Nurse Practitioner (ARNP) noted resident #251 reported continued insomnia with delayed sleep onset and frequent sleep interruptions due to nightmares. Resident #251 recounted significant trauma history of childhood sexual, physical, and verbal abuse. The resident reported witnessing several traumatic events during childhood and abuse during her first marriage. The encounter note indicated resident #251 experienced nightmares, flashbacks and hypervigilance which were worse at night. The resident reported significant emotional distress when triggered by smells or details reminiscent of the traumatic event, had deep shame and difficulty trusting others. On 6/17/25 at 8:45 AM, resident #251 was observed reclined in bed with the door closed and lights off. During interview, resident reported she had PTSD from an incident which occurred when she was a child. Resident #251 stated her mother was not faithful to her father and saw other men behind his back. She recalled one night she was sexually abused by a man her mother was seeing and that her mother was present and aware of the incident. Resident #251 stated the man and his friend had given her peanut butter cups that night prior to the event and she remembered they wore a particular type of cologne. She explained men like the men from that event still made her nervous. She said she hated those candies and the smell of that cologne to this day. Resident #251 acknowledged she received psychological and psychiatric services which were helpful, but was unaware of any other actions the facility staff took to prevent her from being retraumatized. On 6/18/25 at 12:35 PM, the second floor Director of Nursing (DON) and D Wing Unit Manager (UM) were observed at the nursing station. Both stated they were familiar with resident #251 and were aware she had PTSD. The D Wing UM stated she made sure no male Certified Nursing Assistants cared for the resident but could not provide documentation of where nurses were made aware of this intervention to ensure it happened when the UM was not there. The second floor DON and D Wing UM acknowledged neither were aware of all her triggers and verified there was no written communication to staff about the PTSD. In a meeting with the Social Services department on 6/18/25 at 11:49 AM, the the second floor Social Services staff stated she was familiar with resident #251. She explained resident #251 exhibited some behavior problems but was unaware she suffered from PTSD. The second floor Social Services staff stated resident #251 usually preferred to speak with the Social Services Director. The Social Services Director stated he was aware resident #251 had PTSD but was not aware of the specifics of the trauma. The Social Services Director and second floor Social Services staff reviewed the EMR, verified the inaccuracy of the psychosocial assessments and acknowledged that a care plan was not developed or implemented to address trauma informed care. The Social Services Director stated resident #3251 received psychological services He acknowledged that while the psychologist may address the trauma, the staff should be aware of issues and triggers to avoid retraumatizing the resident. On 6/18/25 at 12:39 PM, the Executive Nursing Home Administrator (NHA) was informed of resident #251's PTSD diagnosis and the details relayed by resident #251 regarding the traumatic event. The Executive NHA stated her expectation was that a trauma informed care plan should be developed for any resident identified with PTSD in order to avoid retraumatizing the resident. Review of the facility's policy and procedure for Trauma Informed Care effective June 2025 revealed the purpose of the policy was to ensure that residents who were trauma survivors received culturally sensitive, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The policy and procedure indicated that the Social Services department would attempt to establish a rapport and conduct further psychosocial assessment of the residents' mental or psychosocial adjustment difficulty and/or post-traumatic stress disorder (PTSD) and develop a comprehensive person-centered care plan that addresses specific triggers and appropriate interventions.

Based on interview, and record review, the facility failed to act upon the pharmacist medication recommendations made for one of five residents reviewed for pharmacist recommendations, of a total sample of 103 residents, (#256). Findings: Resident #256 was admitted on [DATE] with the diagnoses of encephalopathy (brain dysfunction), type II diabetes mellitus, history of liver transplant, sepsis, atrial fibrillation, and acute kidney failure. Review of the medical record revealed physician orders included Procrit injection solution 10000 units/milliliter (Epoetin Alfa), one application subcutaneously (under the skin), once a day every Wednesday for prophylaxis until 08/06/25. On 5/23/25, the pharmacist recommended to change the route of administration of the Procrit from intramuscular to subcutaneous and to hold the dose of Procrit for hemoglobin of 10 or more. The physician responded he was in agreement with the recommendation, and that the changes were made to the orders. Upon review of the current physician orders, it was noted the route of administration for the Procrit was changed per the recommendation, but no change was made to address holding the Procrit for a hemoglobin of 10 or more. On 6/19/25 at 4:30 PM, the Executive Director of Nursing (DON) explained she was responsible to ensure the pharmacy recommendations were addressed. She confirmed when doing so, she missed the recommendation to hold the Procrit if the hemoglobin was 10 or more. On 6/20/25 at 2:28 PM, the DON stated it was important to address the pharmacy recommendations accurately to ensure the residents received appropriate and quality care. She added, they didn't want the residents to go back to the hospital if not needed, and oversight of medication orders by the pharmacist was good for the physicians as well, so they had another set of eyes reviewing the residents. The facility's policy entitled Medication Monitoring: Medication Review and Reporting, dated 2007, indicated the purpose of the medication review was to promote positive outcomes and minimize adverse consequences and potential risks associated with medication. The policy detailed, the pharmacist reviewed the medication regimen and medical chart of each resident at least monthly and made recommendations based on findings of irregularities. The nursing care center followed up on the recommendations to ensure appropriate action had been taken within 30 calendar days.

Based on observation, interview and record review, the facility neglected to provide adequate oversight of staff to provide appropriate admission orders and skin assessments; and neglected to provide maintenance care and services for a peripherally inserted central line intravenous catheter (PICC) per standards of care for 1 of 1 resident reviewed for PICC lines, of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency roiagnom on [DATE], but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line. The facility's failure to identify and provide necessary care and services for maintenance and use of a peripherally inserted central line catheter placed resident #72 and all residents who were admitted /readmitted with medical devices including PICCs at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. This failure resulted in Immediate Jeopardy (IJ) starting on 1/10/24. The IJ was removed on 3/06/24. Findings: Cross reference F684 and F726. Resident #72, a [AGE] year-old was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to the stomach, low white blood count, heart failure, skin cancer, lung cancer and tongue cancer. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] for vomiting blood. The Treatment Devices section of the form indicated under type, a double lumen PICC. The form did not indicate when it was inserted, when the device dressing was last changed or where it was located. The time sensitive medications section of the document did not list any antibiotics. A PICC line is a thin, flexible tube inserted into an upper arm vein and guided into the large vein on the right side of the heart. It is used for intravenous delivery of antibiotics or chemotherapy drugs. Delayed complications such as infection and device dysfunction are more gradual in onset and occur over weeks or sometimes months. The most common complication is infection which can lead to sepsis, shock, and death. The reported patient mortality rate was between 12% and 25% for central line related blood stream infections. Device dysfunctions occurred more often in central lines that have been in place for extended times and include catheter fracture and venous clots. Furthermore, cancer patients have amongst the highest risk of thrombosis at 41%. Current research showed no difference between PICCs and standard central lines for rates of complications (retrieved from www.ncbi.nlm.nih.gov on 3/11/24). Review of the Admission/Readmit: Data Collection and Baseline Care Plan with effective date 1/10/24 at 3:45 PM, revealed Licensed Practical Nurse (LPN) BB documented on section 41 Skin Integrity resident #72 was admitted with the following skin issues, right arm- multiple bruises and she incorrectly documented right double lumen instead of left. The box for subsection i3 to Obtain physician orders for care instructions and monitoring, was checked. Section E, Drug Regimen Review detailed the drug regimen was reviewed by the practitioner on admission completed to include medication reconciliation completed upon admission/readmission, order entry warnings and any applicable pharmacy recommendations and found, No clinically significant findings. The subsections for date and time of follow up and follow up information/see new orders were left blank. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC line were seen hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn, white tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung out. He stated he could not recall receiving care for the PICC line while at the facility. On 3/03/24 at 2:34 PM, LPN Z stood at resident #72's bedside, and acknowledged she was aware of the IV in his arm. LPN Z verified the PICC catheter dressing was unlabeled with no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing, but said she was at the end of her shift and had not done that. She stated she had not noticed there was no date on the dressing at all. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. A few minutes later, LPN Z left resident #72's room and looked in the electronic health record to check the physician's orders. She said she could not find any orders for resident #72's PICC line. She said she had never noticed there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. Review of the Abuse Prevention Program policy with most recent date of August 2020 revealed the facility designated and implemented processes which strived to reduce the risk of abuse and neglect. The document described those policies would assist the facility to reduce the risk of abuse and neglect including staff burnout which might increase the likelihood of such events. The definition of neglect was described as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. In interviews on 3/03/24 at 2:53 PM and 3/04/24 at 10:47 AM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. She was unable to say how long he had had the IV, when it was inserted, why he had had it or why it was still in place. She stated she thought resident #72's IV was a midline he received at the hospital but was not sure when. She verified there were no orders to care for the IV, no care plan for it, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with dressing changes and assessment. She described the admission process for the assigned nurse who should do a full body head to toe assessment of the resident and note any devices or skin impairments on the resident. The C wing UM explained the nurse looked at all of the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital papers to determine if there were any changes that happened since the resident went to the hospital. The C wing UM indicated the assigned nurse would call the physician to verify the orders. She stated the next day the UM would perform a chart audit using the admission checklist on all newly admitted or readmitted residents along with performing a second head to toe skin assessment. She described the chart audit would include the UM again checking the paperwork from the hospital for anything pertinent related to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs and other things that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs would hand the audits to the DON and said she assumed they were checking it as well. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine if the line should be discontinued or implement orders for its care and maintenance. She acknowledged the second skin assessment she documented for resident #72 was inaccurate and stated she did not recall seeing his PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated the LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. She stated she also did not catch it when she reviewed the hospital transfer form and therefore did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance at that time. She admitted she notified the on-call physician on 3/03/24 after being made aware by the State Surveyor there was a resident with an IV that she needed orders for. She acknowledged she did not inform the on-call physician of the details that resident #72 had a PICC that had not received care and services since January. The C wing UM instead received approval to put in the batch orders for resident #72's PICC without the physician knowing all of the circumstances concerning his PICC not receiving care. The C wing UM acknowledged she was aware that resident neglect meant not receiving care and services that were required for a resident's health and wellbeing. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the medical record revealed resident #72 had 7 weekly skin assessments from 1/13/24 to 2/28/24. None of the assessments documented the PICC line on his left upper arm nor any actions taken regarding the PICC. The assessments indicated there were no new areas of skin impairment and no mention of the PICC line. One assessment documented a refusal by resident #72. Review of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. During the month of January, 23 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his undated/unlabeled PICC line that had no orders for care or maintenance. In total, 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and failed to notice the PICC line and notify the physician for orders. On 3/03/24 at 3:06 PM, LPN AA stated she had cared for resident #72 since January when he was readmitted to the facility with the PICC line. She could not recall how long he had the PICC line or why he had it but said it had been awhile. LPN AA explained if a resident came to the facility with a PICC line, the nurse needed to obtain orders from the doctor to care for it. She stated she never realized he didn't have orders to care or maintain his PICC. She described a PICC line as needing to be flushed and the site assessed every shift, yet she did not know why she never questioned the lack of physician orders for care of resident #72's PICC line. On 3/04/24 at 12:28 PM, the admitting nurse, LPN BB in a telephone interview stated she was IV certified and recalled caring for resident #72 over the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications and other care needs. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do your own assessment of the resident. She explained if she saw a wound or other skin impairment she would let the physician know, and she would document it in the skin assessment. LPN BB stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. She explained a PICC line needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if she saw that a new or readmitted resident had a PICC line, she would notify the supervisor as they would call the physician for orders. She explained she would also look at a resident from head to toe during weekly skin checks and document if there was an IV and notify the physician. LPN BB could not recall ever discussing the PICC line with his primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them herself. On 3/04/24 at 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in the required batch orders for the PICC line. These orders included flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses had received education on what they were expected to do on admission and there was a class in their electronic learning modules they would take during onboarding. She described the admitting nurse was supposed to admit the resident in the electronic health record, observe the resident, do a hands-on head to toe assessment, then verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the health record. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC line to his upper left arm upon admission or obtain orders. The SDC acknowledged subsequent assigned nurses failed to document the PICC line in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/08/24 at 11:52 AM, the Regional Clinical Reimbursement Specialist stated the facility Clinical Reimbursement Specialists participated in clinical meeting and discussed care plans for new admissions, readmissions and any other residents with changes in their plan of care. She described the Clinical Reimbursement Specialists did an order listing review every morning, and looked at the physician orders. The Regional Clinical Reimbursement Specialist stated when they did the Minimum Data Set Assessment they were supposed to look at the resident for their assessment. She said they should have physically assessed resident #72 and noted he had a PICC line and documented it on the Annual MDS assessment on 1/13/24. The Regional Clinical Reimbursement Specialist explained the facility Clinical Reimbursement Specialist would have looked at him on 1/10/24 and he should have had a care plan for the PICC. The Regional Clinical Reimbursement Specialist said there was obviously some kind of a problem. On 3/08/24 at 8:49 AM, the Risk Manager (RM) stated she was told about the concerns regarding resident #72's PICC line on Monday, 3/04/24. She explained staff usually gave her a call, before they did a risk report. The RM said a risk report was done for any falls, treatment or medication variance, skin impairments, abuse/neglect allegations, unexpected hospitalization s, or deaths. She described the concerns for resident #72 having not received care or services for his PICC as the risk for infection. The RM stated the PICC line should have been removed due to risk it lead to infection or damage to major vessel in the heart. She stated her expectation was the nurse would notify the physician of the PICC not getting treatment when it was discovered and document this in the medical record. On 3/04/24 at 10:24 AM, in a telephone interview APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides his attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it as he did not have antibiotics or any other medication that needed a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have any care for the PICC. She explained the nurses should have called to obtain orders to either discontinue the line or orders for care and maintenance. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. APRN CC then called physician ZZ to clarify what she knew about resident #72's PICC. APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known, they would have discontinued the PICC line. APRN CC indicated nurses should have observed the PICC line during their weekly skin checks and noticed there were no orders for care and notified her or the physician. Review of resident #72's medical record revealed resident #72 was assessed 9 times by the APRN between his admission on 1/10/24 and 3/03/24. The progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 did not mention resident #72's PICC line even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 12:50 PM, in a telephone interview, physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had spoken with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came to the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the resident. She stated none of the facility staff had called to inform her or ask for orders for the PICC. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. She said she had looked at the on call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC not having care since his readmission on 1/10/24. He stated he expected facility nurses to obtain orders for care and notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky that resident #72 did not get a Central line associated infection or other complication due to this lack of care or maintenance for his PICC. The undated job description Unit Manager summary of position detailed the UM was responsible for overseeing direct nursing care to assigned residents by assuming responsibility and accountability for the nursing care and services provided on the unit. The UM was responsible for and adhered to the standards of care for the assigned residents and assisted with monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible to supervise the resident care activity performance by licensed nurses. Essential duties and responsibilities included ensuring proper nursing care was provided, overseeing the assessments of the resident admission process and participation in the clinical admission process. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC line from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous linesite was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on the proper assessment of intravenous lines, including central lines on 3/05/24. The DON educated RNs who participated in the resident assessment referenced in bullet point #2 on the proper assessment of intravenous lines, including central lines. The DON or designee-initiated education on notification of physicians related to obtaining orders for care, maintenance or discontinuance of intravenous lines, including central lines. Education was initiated with licensed nurses related to neglect with obtaining and following physician orders related to intravenous lines including central lines. As of 3/05/24 24 of 114 licensed nurses had received education related to abuse and neglect training. They had a goal to complete an additional 25 nurses by 3/06/24 with the remaining nurses to be completed prior to starting their next work shift. * The DON or designee will compare the admission data collection to the physician order to validate notification to the physician occurred and orders for maintenance or discontinuance of the line were obtained. The DON or designee will visually inspect every resident with an intravenous line including central lines to validate care, maintenance or discontinuance orders were followed. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing of vascular device. Additionally, 76 RNs were educated on PICC catheter removal. Interview with the Nursing Home Administrator on 3/08/24 at 12:32 PM, revealed he was the abuse coordinator and reported the allegation of neglect on 3/05/24 to the State Agency, Department of Children and Families and to local law enforcement. An ad hoc Quality Assurance Performance Improvement (QAPI) was held on 3/06/24 that included the Medical Director. On 3/05/24 a venous doppler of resident #72's left upper arm, an Xray of the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/06/24, 3/07/24 and 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect, assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest.

Based on observation, interview, and record review, the facility failed to provide adequate care and services in accordance with accepted professional standards to identify, obtain and implement physician orders for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, (#72), failed to change intravenous line dressings as per orders for 1 of 6 residents reviewed for medication administration (#435), and failed to monitor blood glucose levels as per physician orders for 1 of 3 residents reviewed for (#584) insulin use out of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency roiagnom on [DATE], but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line The facility's failure to identify and provide necessary care and services for maintenance and use of a peripherally inserted central line catheter placed resident #72 and all residents who were admitted /readmitted with medical devices including PICCs at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. This failure resulted in Immediate Jeopardy (IJ) starting on 1/10/24. The IJ was removed on 3/06/24. Findings: Cross reference to F600 and F726 1. Resident #72, a [AGE] year-old was admitted to the facility on [DATE] with diagnoses of pneumonia of unknown origin, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to his stomach, low white blood cell count, heart failure, skin cancer, lung cancer and tongue cancer. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed resident #72 was cognitively intact, had clear speech, adequate vision, and had clear comprehension of others. The assessment indicated resident #72 required moderate assistance with most transfers and required supervision for bed mobility. The assessment also revealed resident #72 had no refusal of care, no intravenous medications, nor did it indicate any IV access including central lines during the look back period. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC catheter were seen hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn white, tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung out. He stated he could not recall receiving care for the PICC line while at the facility. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] for vomiting blood. The Treatment Devices section of the form indicated for type, a double lumen PICC. The form did not indicate when it was inserted, when the device was last changed or where it was located. There were no antibiotics or IV medications listed on the form. A PICC line is a thin, flexible tube inserted into an upper arm vein and guided into the large vein on the right side of the heart. It is used for intravenous delivery of antibiotics or chemotherapy drugs. Delayed complications such as infection and device dysfunction are more gradual in onset and occur over weeks or sometimes months. The most common complication is infection which can lead to sepsis, shock, and death. The reported patient mortality rate was between 12% and 25% for central line related blood stream infections. Device dysfunctions occurred more often in central lines that have been in place for extended times and include catheter fracture and venous clots. Furthermore, cancer patients have amongst the highest risk of thrombosis at 41%. Current research showed no difference between PICCs and standard central lines for rates of complications (retrieved from www.ncbi.nlm.nih.gov on 3/11/24). On 3/03/24 at 2:34 PM, Licensed Practical Nurse (LPN) Z was at resident #72's bedside, and acknowledged she was aware of the PICC IV in his arm. LPN Z verified the PICC dressing had no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing change, but said she was at the end of her shift and had not done that. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. She reviewed the resident's medical record and stated she could not find any physician orders for resident #72's PICC line. She said she was not aware there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. On 3/03/24 at 2:53 PM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. The C wing UM stated she was not aware of the PICC line. She verified there were no orders to care for the IV, no care plan, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with regular dressing changes and assessments. On 3/03/24 at 3:06 PM, LPN AA stated she had cared for resident #72 since January when he was readmitted to the facility with the PICC line. She could not recall how long he had the PICC line or why he had it but said it had been awhile. LPN AA explained if a resident came to the facility with a PICC line, the nurse needed to obtain orders from the doctor to care for it. She stated she never realized he didn't have orders to care or maintain his PICC. She described a PICC line as needing to be flushed and the site assessed every shift, yet she did not know why she never questioned the lack of physician orders for care of resident #72's PICC line. Review of the Admission/Readmit: Data Collection and Baseline Care Plan dated 1/10/24 at 3:45 PM, revealed LPN BB documented resident #72 was admitted with skin issues of right arm- multiple bruises and incorrectly documented right double lumen instead of left. The box for subsection i3 to Obtain physician orders for care instructions and monitoring, was checked by LPN BB. Section E, Drug Regimen Review detailed the drug regimen was reviewed by the practitioner on admission completed to include medication reconciliation completed upon admission/readmission, PCC order entry warnings and any applicable pharmacy recommendations and found, No clinically significant findings. The subsections for date and time of follow up and follow up information/see new orders were left blank. Review of the Medication Review Report dated 3/03/24 at 3:12 PM, revealed no physician orders for IV medications nor for care or maintenance of resident #72's PICC line. Review of resident #72's medical record revealed no care plan was ever created for his PICC line until 3/04/24, when it was brought to the facility's attention by the State Agency Surveyor. The facility had a policy and procedure for weekly skin check to document the skin condition throughout the resident's stay in the facility. The policy with effective date October 2021 described the nurse would conduct a weekly skin check to identify impairment or suspected impairment timely to reduce the risk for further decline in skin integrity. The policy further described the nurse should document on the weekly skin check and on the appropriate corresponding skin grid any new areas of impairment weekly, as needed and on admission or readmission to the facility. The procedure section described the nurse to document actions taken based on the skin check, to update the care plan as appropriate and to make a notation on the 24-hour report so the Interdisciplinary Team (IDT) would be informed. Review of the medical record revealed resident #72 had 7 weekly skin assessments completed during the 8-week period from 1/13/24 to 2/28/24, none of which documented the PICC line on his left upper arm nor were any actions taken documented on the assessments. Seven different nurses checked resident #72's skin each week and all of the assessments indicated there were no new areas of skin impairment and had no mention of the PICC. Review of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. Twenty three different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line in January 2024. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about the PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his PICC line that had no orders for care or maintenance. In total 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and all of them failed to notice the PICC line and notify the physician for orders. On 3/04/24 at 10:03 AM, the B wing UM stated a clinical meeting was held every weekday morning to discuss all new admissions and readmissions. She stated the UMs discussed the admissions and readmissions to their unit using the information from the hospital paperwork, baseline care plan and the admission audit. She explained the admission audit was completed by the nurse managers after the admission was completed by the assigned nurse. The B wing UM described the process included checks to verify physician orders were in place for devices such as IV lines. She explained this was a check to ensure orders were complete on admission. If orders were incomplete, the UM would contact the physician to obtain the orders. The B wing UM was unsure if the DON or anyone else looked at the audits once they were completed by the managers. On 3/04/24 at 10:47 AM, the C wing UM described the admission process for the assigned nurse. She stated the nurse should do a full body head to toe assessment of the resident and note any devices or skin impairments. She explained the nurse looked at all the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital forms to determine if there were any changes in the resident's care. She explained the assigned nurse would then call the physician to verify the orders. The C wing UM stated the next day, the UM would perform a chart audit using the admission checklist on all newly admitted and readmitted residents along with performing a second head to toe skin assessment. She described the chart audit would include the UM checking the paperwork from the hospital for anything pertinent relating to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs then handed the audits to the DON. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine whether the line should be discontinued or obtain care orders for maintenance. She acknowledged she documented the second skin assessment for resident #72 which was inaccurate and stated she did not recall seeing the PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. The C wing UM stated she also did not catch it on the hospital transfer form therefore she did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance, nor did she document the conversation. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the Admission Checklist (Clinical Leadership) updated December 2023, revealed the hospital transfer form was checked to verify physician orders were complete, confirmed with the physician and matched the orders in the electronic medical record. Another section of the audit detailed for the manager to review the admission nurse chart audit and to read the Admission Data Collection to verify its accuracy. Further in the document a section described a second skin check was completed and compared to the initial skin check along with notification to the physician, documentation and appropriate orders in place. Another section of the audit form detailed IV fluids/meds, dressing (check date), pump, to be checked with the care plan, physician orders, computer and at bedside. On 3/04/24 at 11:23 PM, the Executive DON stated the UMs turned the audits in to either the 1st floor or 2nd floor DON. She explained the DONs only ensured the audits were completed but did not check the information on the audits for accuracy. She stated they discussed the new admissions and readmissions at the clinical meeting by talking about the diagnoses and the plan. She then explained they did not review the audits in the meeting. The Executive DON stated it was her expectation the nurse would call the physician about the PICC line and document the conversation. On 3/04/24 at 12:28 PM, the admitting nurse, LPN BB in a telephone interview stated she was IV certified and recalled caring for resident #72 in the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications, and other care needs. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do an assessment of the resident. She explained if she saw a wound or other skin impairment she would inform the physician, and document the skin assessment. LPN BB stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. She explained a PICC needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if she saw that a new or readmitted resident had a PICC, she would notify the supervisor since they would be the one to call the physician for orders. LPN BB could not recall ever discussing the PICC with the resident's primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them. On 3/04/24 at 10:24 AM, in a telephone interview, APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides the resident's attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it as he did not have antibiotics or any other medication that needed a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have any care for the PICC. She explained the nurses should have called to obtain orders to either discontinue the line or orders for care and maintenance. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. APRN CC then called physician ZZ to clarify what she knew about resident #72's PICC. APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known, they would have discontinued the PICC line. APRN CC indicated nurses should have observed the PICC line during their weekly skin checks and noticed there were no orders for care and notified her or the physician. On 3/04/24 at 12:50 PM, in a telephone interview, physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had spoken with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came to the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the resident. She stated none of the facility staff had called to inform her or ask for orders for the PICC. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. She said she had looked at the on call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. Further review of resident #72's medical record revealed resident #72 was assessed 9 times by APRN CC between his admission on 1/10/24 and 3/03/24. These progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 had no mention of resident #72's PICC even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in the required batch orders for the PICC line. These orders included flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses had received education on what they were expected to do on admission and there was a class in their electronic learning modules they would take during onboarding. She described the admitting nurse was supposed to admit the resident in the electronic health record, observe the resident, do a hands-on head to toe assessment, then verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the health record. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC line to his upper left arm upon admission or obtain orders. The SDC acknowledged subsequent assigned nurses failed to document the PICC line in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/06/24 at 5:32 PM, Registered Nurse (RN) E recalled seeing resident #72 with the PICC in his arm. She described that a PICC line would usually have an order to flush it and to change the dressing. She acknowledged she had documented resident #72's left arm per the physician orders and could only say it slipped her mind to check if the PICC line had any orders for care or maintenance. On 3/06/24 at 5:45 PM, RN B also recalled caring for resident #72 since January. She remembered seeing the PICC in his arm and said in the evenings with two nurses on the unit it was very busy. She explained if she saw an order to do something she would do it but might not notice if there was no order for something. RN B said if the PICC dressing did not have a date on the dressing the nurse should look at the orders and call the physician if there weren't any orders. She was unable to say why she did not notice resident #72 did not have a date on his PICC dressing. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC line with no care orders since his readmission on 1/10/24. He stated he expected nurses to obtain orders for care and to notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky resident #72 did not get a central line associated infection or other complication due to the lack of care or maintenance for his PICC. Review of the Clinical Guidelines Manual- Admission Orders presented by the facility with effective date of October 2021 revealed the policy admission orders would be obtained/approved through the attending physician following or prior to the resident's admission to the facility. The procedure section described the procedure if returned from the hospital to contact the attending physician if the order read to resume all previous orders, and to assure at minimum the orders contained diet, medication, routine care to maintain or improve functional ability, and code status. The return from the hospital procedure did not give direction specifically to review the orders that came with the transfer. The admitted from the hospital/ER section detailed the procedure to review the transfer orders, contact the attending physician immediately upon admission to review the transfer orders and obtain approval and to obtain further orders as appropriate. Review of both the undated job descriptions, Licensed Practical Nurse and Registered Nurse revealed both the LPN and RN were responsible for delivering care to residents using the nursing process of assessment, planning, intervention, implementation, and evaluation to maintain standards of professional nursing. The document further described the responsibilities of the LPN and RN which included assess, plan, direct, and evaluate total nursing care as determined by the resident's needs in accordance with established standards, policies, and procedures. Another responsibility was to monitor, record and report changes in resident's condition in a timely manner, and to perform physical exams to determine the resident's status and develop a treatment plan. Also to complete and review the Admission Data record and to assess the needs of residents to identify potential health or safety problems. The undated job description Unit Manager summary of position detailed the UM was responsible for overseeing direct nursing care to assigned residents by assuming responsibility and accountability for the nursing care and services provided on the unit. The UM was responsible for and adhered to the standards of care for the assigned residents and assisted with monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible to supervise the resident care activity performance by licensed nurses. Essential duties and responsibilities included ensuring proper nursing care was provided, overseeing the assessments of the resident admission process and participation in the clinical admission process. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC line from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous linesite was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on the proper assessment of intravenous lines, including central lines on 3/05/24. The DON educated RNs who participated in the resident assessment referenced in bullet point #2 on the proper assessment of intravenous lines, including central lines. The DON or designee-initiated education on notification of physicians related to obtaining orders for care, maintenance or discontinuance of intravenous lines, including central lines. Education was initiated with licensed nurses related to neglect with obtaining and following physician orders related to intravenous lines including central lines. As of 3/05/24 24 of 114 licensed nurses had received education related to abuse and neglect training. They had a goal to complete an additional 25 nurses by 3/06/24 with the remaining nurses to be completed prior to starting their next work shift. * The DON or designee will compare the admission data collection to the physician order to validate notification to the physician occurred and orders for maintenance or discontinuance of the line were obtained. The DON or designee will visually inspect every resident with an intravenous line including central lines to validate care, maintenance or discontinuance orders were followed. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing of vascular device. Additionally, 76 RNs were educated on PICC catheter removal. Interview with the Nursing Home Administrator on 3/08/24 at 12:32 PM, revealed he was the abuse coordinator and reported the allegation of neglect on 3/05/24 to the State Agency, Department of Children and Families and to local law enforcement. An ad hoc Quality Assurance Performance Improvement (QAPI) was held on 3/06/24 that included the Medical Director. On 3/05/24 a venous doppler of resident #72's left upper arm, an Xray of the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/06/24, 3/07/24 and 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect, assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest. 43192 2. Review of resident #435's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included sepsis (infection of the blood stream), methicillin-resistant Staphylococcus aureus (a bacteria resistant to certain antibiotics), and extended spectrum beta-lactamase (enzymes that break down and destroy some commonly used antibiotics). Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form signed by the hospital's physician on 2/28/24 revealed resident #435 had a Midline IV line inserted on 2/21/24 for administration of IV antibiotics. A midline catheter is a small, thin tube that is inserted into a vein in the upper arm or at the bend in the elbow. A midline catheter is a type of IV access.may be used to: . give medicines. (Retrieved from www.elsevier.com on 3/13/24). Review of resident #435's care plan for IV medications initiated on 2/29/24 included an intervention to check dressing at site daily. Change per facility policy/MD (physician) orders. Review of resident #435's physician orders revealed he received Meropenem (IV antibiotic) three times a day for sepsis until 3/05/24. He had additional orders dated 2/29/24 for nurses to change the IV dressing every 7 days or as needed (PRN) for soiling and/or dislodgement and to document the IV site appearance every shift (2 times per day) and flush every 12 hours. Review of the MAR from February to March 2023 showed the IV dressing was changed on 2/29/ [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services per standards of care for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, out of a total sample of 109 residents (#72) and failed to ensure licensed nurses were competent to follow physician orders for medication parameters, topical ointments and diabetes management for 4 of 102 licensed nurses, (Registered Nurses D, K, E and GG). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency roiagnom on [DATE], but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line. The facility's failure to ensure licensed nurses were knowledgeable and competent to assess central line catheters including PICCs, obtain appropriate admission orders, and provide care and services for peripherally inserted central line catheters placed resident #72 and all residents admitted to the facility with a central line catheter or other intravenous (IV) catheter device at risk. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. These failures resulted in Immediate Jeopardy starting on 1/10/24. The Immediate Jeopardy was removed on 3/06/24. Findings: Cross reference F600 and F684 1. Resident #72, was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to his stomach, low white blood cell count, heart failure, skin cancer, lung cancer and tongue cancer. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] with a double lumen PICC line. The form did not indicate when it was inserted, when the device was last changed or where it was located. The Admission/Readmit: Data Collection and Baseline Care Plan with effective date 1/10/24 at 3:45 PM, indicated Licensed Practical Nurse (LPN) BB documented resident #72 was admitted with the following skin issues, right arm- multiple bruises and she incorrectly documented and failed to identify the type of line. She recorded only, right double lumen instead of indicating the PICC in his left upper arm. LPN BB checked the box which directed the nurse to, Obtain physician orders for care instructions and monitoring, and she later documented the drug regimen was reviewed by the practitioner on admission. She indicated on the form there were no clinically significant findings. Review of the Medication Review Report dated 3/03/24 at 3:12 PM, revealed no current physician orders for IV medications nor for care or maintenance of resident #72's PICC line. Review of resident #72's Medication and Treatment Administration Records for January 2024, February 2024 and March 2024 revealed no physician orders for care, maintenance, or assessment of resident #72's PICC line. Further review of resident #72's medical record revealed no care plan was created for his PICC line until 3/04/24, when concerns about the PICC were brought to the facility's attention by the State Agency Surveyor. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC catheter were hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn white, tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung down. He stated he could not recall receiving care for the PICC line while at the facility. On 3/03/24 at 2:34 PM, Licensed Practical Nurse (LPN) Z was at resident #72's bedside, and acknowledged she was aware of the PICC IV in his arm. LPN Z verified the PICC dressing had no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing change, but said she was at the end of her shift and had not done that. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. She reviewed the resident's medical record and stated she could not find any physician orders for resident #72's PICC line. She said she was not aware there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. During interviews on 3/03/24 at 2:53 PM and 3/04/24 at 10:47 AM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. She was unable to say how long he had had the IV, when it was inserted, why he had had it or why it was still in place. She stated she thought resident #72's IV was a midline he received at the hospital but was not sure when. She verified there were no orders to care for the IV, no care plan for it, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with dressing changes and assessment. She described the admission process for the assigned nurse who should do a full body head to toe assessment of the resident and note any devices or skin impairments on the resident. The C wing UM explained the nurse looked at all of the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital papers to determine if there were any changes that happened since the resident went to the hospital. The C wing UM indicated the assigned nurse would call the physician to verify the orders. She stated the next day the UM would perform a chart audit using the admission checklist on all newly admitted or readmitted residents along with performing a second head to toe skin assessment. She described the chart audit would include the UM again checking the paperwork from the hospital for anything pertinent related to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs and other things that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs would hand the audits to the DON and said she assumed they were checking it as well. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine if the line should be discontinued or implement orders for its care and maintenance. She acknowledged the second skin assessment she documented for resident #72 was inaccurate and stated she did not recall seeing his PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated the LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. She stated she also did not catch it when she reviewed the hospital transfer form and therefore did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance at that time. She admitted she notified the on-call physician on 3/03/24 after being made aware by the State Surveyor there was a resident with an IV that she needed orders for. She acknowledged she did not inform the on-call physician of the details that resident #72 had a PICC that had not received care and services since January. The C wing UM instead received approval to put in the batch orders for resident #72's PICC without the physician knowing all of the circumstances concerning his PICC not receiving care. The C wing UM acknowledged she was aware that resident neglect meant not receiving care and services that were required for a resident's health and wellbeing. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the Job Description- Unit Manager-RN undated, revealed the UM was responsible for overseeing direct nursing care to assigned residents. The UM assumed responsibility and accountability for the nursing care and services provided on the assigned unit. The UM was also responsible for and adhered to the standards of care for assigned residents and assisted with data collection, monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible for supervising the resident care activity performance by licensed nurses. Essential duties and responsibilities included observing staff and visiting residents to ensure proper nursing care was provided and oversaw the assessments of the resident admission process. On 3/04/24 at 10:03 AM, the B wing UM stated a clinical meeting was held every weekday morning to discuss all new admissions and readmissions. She stated the UMs reviewed the admissions and readmissions to their unit using the information from the hospital paperwork, baseline care plan and the admission audit. She explained the admission audit was completed by the nurse managers after the admission was completed by the assigned nurse. The B wing UM described she checked to verify the physician orders for devices such as IV lines were in place. She explained this was to ensure orders were complete on admission and if they were not she would call the physician to obtain the orders. The B wing UM was unsure if the DON or anyone else looked at the audits once they were completed by the managers. In interviews on 3/04/23 at 11:23 AM and 4:55 PM, the Executive DON stated the UMs submitted the audits to either the 1st floor or 2nd floor DON. She explained the DONs only ensured the audits were completed but did not check the information on the audits for accuracy. She stated they discussed the new admissions and readmissions at the clinical meeting by reviewing their diagnoses and the plan of care. The Executive DON stated the facility did not have a policy and procedure for PICC lines and stated only an RN could draw blood by PICC line but acknowledged a physician order was needed. She noted it was her expectation the nurse would call the physician about the PICC line and document the conversation. Review of the Clinical Guidelines Manual- Admission Orders presented by the facility with effective date of October 2021 revealed the policy admission orders would be obtained/approved through the attending physician following or prior to the resident's admission to the facility. The procedure section described the procedure if returned from the hospital to contact the attending physician if the order read to resume all previous orders, and to assure at minimum the orders contained diet, medication, routine care to maintain or improve functional ability, and code status. The return from the hospital procedure did not give direction specifically to review the orders that came with the transfer. The admitted from the hospital/ER section detailed the procedure to review the transfer orders, contact the attending physician immediately upon admission to review the transfer orders and obtain approval and to obtain further orders as appropriate. In a telephone interview on 3/04/24 at 12:28 PM, the admitting nurse, LPN BB stated she was previously certified to care for intravenous lines and recalled caring for resident #72 in the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications and other treatments. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do your own assessment of the resident. She explained if you saw a wound or other skin impairment you would let the physician know, and you would document it in the skin assessment. LPN BB acknowledged she had documented the double lumen was present on resident #72 when she completed the Admission/Readmit: Data Collection and Baseline Care Plan on 1/10/24 but documented incorrectly the location of the line and failed to document what type of line it was. Although she documented the presence of resident #72's IV she also acknowledged she did not obtain orders from the physician per the batch orders available for the PICC. She stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. LPN BB explained a PICC needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if the nurse saw that a new or readmitted resident had a PICC they were supposed to notify the supervisor since they would be the one to call the physician for orders. LPN BB could not recall ever discussing the PICC with his primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them herself as she was aware of what type of care the IV required. LPN BB next explained weekly skin checks were completed by the assigned nurse as it was scheduled. She described the process was to look at the resident head to toe and note any new impairments or anything that did not normally belong on their skin. LPN BB stated the nurse should document what they found and complete an incident report for any newly found impairments. On 3/06/24 at 5:32 PM, Registered Nurse (RN) E recalled seeing resident #72 with the PICC in his arm and she acknowledged she had documented having looked at resident #72's left arm per the physician orders. She described that a PICC line should at the minimum have orders to flush it and to change the dressing but could only say it may have slipped her mind that the PICC did not have any orders for care or maintenance. On 3/06/24 at 5:45 PM, RN B also recalled caring for resident #72 since January. She remembered seeing the PICC in his arm and said in the evenings with two nurses on the unit it was very busy. She explained if she saw an order to do something she would do it but said she might not notice if there was no order for something. RN B said if the PICC dressing did not have a date on the dressing you should look at the orders and call the physician if there weren't any orders. She was unable to say why she did not notice resident #72 did not have a date on his PICC dressing. RN B stated care for the PICC line was important because you would want to treat the resident like you would want someone to care for yourself. Review of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. During the month of January, 23 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his undated/unlabeled PICC line that had no orders for care or maintenance. In total 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and failed to notice the unlabeled PICC line and notify the physician for orders. On 3/08/24 at 11:52 AM, the Regional Clinical Reimbursement Specialist stated that the facility Clinical Reimbursement Specialists go to the clinical meeting and participate in it to discuss the care plans for new admissions, readmissions, and any other residents with changes in their plan of care. She described that the Clinical Reimbursement Specialists did an order listing review every morning, and they should look at the orders. The Regional Clinical Reimbursement Specialist stated when they did the Minimum Data Set Assessment they were supposed to go and look at the resident for their assessment. She said they should have also assessed resident #72 and it should have been on his Annual MDS on 1/13/24 that he had the PICC. The Regional Clinical Reimbursement Specialist explained the facility Clinical Reimbursement Specialist would have looked at him on 1/10/24 and he should have had a care plan for the PICC. She said they should have seen it then and made a care plan for it. Absolutely, she said. The Regional Clinical Reimbursement Specialist said there was obviously some kind of a problem. In interviews on 3/04/24 at 12:23PM and 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in batch orders for the PICC line. These orders would include flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses got education on what they were expected to do on admission and there was a class in their electronic learning modules. She described the admitting nurse was supposed to admit the resident in the computer, look at the resident as they meet them, do a hands-on head to toe assessment, then verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the computer. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC in his upper left arm. The SDC acknowledged nurses had said they had drawn labs from the PICC line without any physician orders. She explained, IV certified nurses could draw blood from a PICC line but confirmed they needed a physician order to do so. The SDC also acknowledged subsequent assigned nurses failed to document the PICC in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/04/24 at 10:24 AM, in a telephone interview APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides his attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility with it on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it because he did not have antibiotics or any other medication that needed to go through a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have had any care for his PICC, and commented facility staff should have called and gotten orders to either discontinue or care for it. She then explained her, and the physician WW were the primary point of contact for the facility staff and said they primarily called her but could text her as well. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. The APRN CC then asked to stop the conversation and call back later until after she could call physician ZZ to clarify what she knew about resident #72's PICC. A few minutes later APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known he had a PICC they would have discontinued it. She stated they were going to discontinue it now. APRN CC explained normally she expected facility nurses to notify the physician of the PICC line. APRN CC stated the nurses also did weekly skin checks and should have noticed the PICC and noticed there were no orders for care and notified her or the physician. Further review of resident #72's medical record revealed resident #72 was assessed 9 times by the APRN between his admission on 1/10/24 and 3/03/24. These progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 had no mention of resident #72's PICC even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 12:50 PM, in a telephone interview physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had talked with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came into the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the residents. She stated none of the facility staff had called to inform her or ask for orders for the PICC and also confirmed a physician order was needed for IV certified nurses to use the PICC for blood draws. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. Physician WW said she had looked at the on-call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC not having care since his readmission on 1/10/24. He stated he expected nurses to obtain orders for care and to notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky that resident #72 did not get a central line associated infection or other complication due to this lack of care or maintenance for his PICC. Review of both the undated job descriptions, Licensed Practical Nurse and Registered Nurse revealed both the LPN and RN were responsible for delivering care to residents using the nursing process of assessment, planning, intervention, implementation, and evaluation to maintain standards of professional nursing. The document further described the responsibilities of the LPN and RN which included assess, plan direct, and evaluate total nursing care as determined by the resident's needs in accordance with established standards, policies, and procedures. Another responsibility was to monitor, record and report changes in resident's condition in a timely manner, and to perform physical exams to determine the resident's status and develop a treatment plan. Also to complete and review the Admission Data record and to assess the needs of residents to identify potential health or safety problems. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous line site was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on 1) clinical care related to intravenous line, including central line, 2) accurately documenting site location, 3) notification to the physician to clarify and obtain orders for the care, maintenance or discontinuance of the line, and 4) initiating the care plan. As of 3/05/24, the DON or designee has provided education to 24 of 114 nurses on 1) clinical care related to intravenous line, including central line, 2) accurately documenting site location, 3) notification to the physician to clarify and obtain orders for the care, maintenance or discontinuance of the line, and 4) initiating the care plan. As of 3/05/24 24 out of 104 registered nurses and LPNs with IV certification have completed competencies related to 1) PICC Catheter removal, 2) Flushing of Vascular Access Device, and 3) Midline/Central Line Dressing Changes. We have a goal of completing education and competencies on an additional 25 nurses by 3/05/24, with the remaining nurses being completed prior to the start of their next shift worked. * The DON or designee will observe each patient with an intravenous line including central line to validate that care, maintenance, or discontinuance has occurred. Any variance identified will result in the immediate reeducation of the licensed nurse. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. Additionally, 76 RNs were educated on PICC catheter removal. An ad hoc QAPI was held on 3/06/24 that included the Medical Director. On 3/05/24 a venous doppler to resident #72's left upper arm, an Xray to the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/05/24 through 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include all 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest. 36489 2. On 3/03/24 at 5:34 PM and 3/05/24 at 10:05 AM, RN K stated there were residents on her assignment who had physician orders for blood glucose checks and insulin administration scheduled at 4:00 PM. She confirmed she had not done the task and she did not always do so before dinner as the residents left the unit to eat in the dining room. RN K stated she checked some residents' blood glucose levels after they returned from dinner in the dining room. On 3/04/24 at 1:07 PM, RN GG confirmed he had not checked scheduled pre-lunch blood glucose levels for his assigned diabetic residents and explained he was busy doing other things. RN GG acknowledged blood glucose monitoring and insulin administration were to be completed prior to meals. When asked if he reported he was running late to the Unit Manager, RN GG stated the manager was aware. On 3/06/24 at 11:01 AM, RN E acknowledged she performed blood glucose monitoring after her assigned resident consumed breakfast. She explained blood glucose could be checked and insulin administered either 20 minutes before or after meals. When asked if there would be a difference in the readings, RN E said, .the after meal reading would be higher, but not a really big difference. She was asked to review the physician order for insulin that read, with meals. RN E confirmed the order meant insulin should be given while eating but she reiterated, I know I can do it 20 minutes before or after meals. I have had him before. On 3/06/24 at 12:31 PM, the B Wing UM stated she expected all nurses to know blood glucose monitoring was to be done before mealtime. She stated if residents ate in the dining room, it was the nurse's responsibility to ensure blood glucose was checked before they left the unit. The B Wing UM explained the nurse could remind the resident to see her before going to the dining room. She stated her office was on the unit and if nurses were running behind, they should ask her for assistance to ensure blood glucose levels were checked before meals as order [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide ongoing evaluation to monitor for decreased range of motion and ensure treatment was provided in a timely manner to prevent complications associated with limited mobility, (#246); and failed to provide care and services related to management and application of orthotic devices to prevent worsening of contractures and promote skin integrity, (#124, #137, #268, #238, #85, and #222), for 7 of 12 residents reviewed for limited range of motion and reduced mobility, out of a total sample of 109 residents. The facility's failure to identify and report a change in joint mobility delayed the initiation of appropriate services and interventions to prevent complications and worsening of the condition, and caused actual harm related to pain and reduced range of motion for resident #246, that was inconsistent with the goals of the resident and his representative. Findings: 1. Review of the medical record revealed resident #246 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including stroke with right side weakness and paralysis, failure to thrive, brain cancer, expressive language disorder, and left eye vision loss. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 1/20/24 revealed resident #246 had short and long-term memory problems and severely impaired skills for daily decision making. The document indicated the resident did not exhibit behavioral symptoms or reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed resident #246 had functional limitation in range of motion due to impairment of upper and lower extremities on one side. Resident #246 was totally dependent on staff for assistance with oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene. The document indicated the resident was totally dependent on staff for transfers and required substantial to maximal assistance for rolling from side to side. The MDS assessment revealed the resident did not receive range of motion services or assistance with splints or braces. Review of the medical record revealed resident #246 had a care plan, initiated on 4/22/22 and revised on 1/23/24, for activities of daily living (ADL) self-care performance deficit related to decreased mobility, weakness, and paralysis. The goals were the resident would have his ADL needs anticipated and met by staff and Occupational Therapy was ordered with goals established according to the Occupational Therapy plan of care. The interventions included assist with ADL as indicated, lubricate skin with routine care, check nail length and trim and clean on bath day and as necessary, offer a sponge bath when not scheduled bath day, and Occupational Therapy evaluation and treatment per physician orders. Review of the Medication Review Report revealed resident #246 had physician orders dated 9/21/23 for Physical Therapy, Occupational Therapy, and Speech Therapy to evaluate and treat as needed, and Restorative Nursing Program (RNP) services as needed. On 3/06/24 at 9:53 AM, Certified Nursing Assistant (CNA) G stated CNAs were responsible for residents' personal hygiene including bathing and nail care. During observation of resident #246's ADL status, the resident's right arm was at his side, elevated on a pillow. When asked to show the fingernails on the right hand, resident #246 shook his head from side to side and used his left hand to lift the right arm a few inches off the pillow. He demonstrated that his right arm was flaccid. Closer observation revealed the resident's right hand was in a cupped position and his fingers were curved towards his palm. CNA G attempted to open the resident's right hand to inspect his fingernails but she was unable to extend his fingers. The resident grimaced and waved his left hand to signal her to stop. CNA G stated she had never seen the resident with a splint and she did not find any orthotic devices when she searched his bedside table and closet. On 3/06/24 at 10:02 AM, the A Wing Unit Manager (UM) stated nurses inspected or assessed residents at least once weekly when whole body skin checks were completed. She explained CNAs provided care every shift and were assigned to give residents at least two showers or baths weekly. The A Wing UM verified nurses and CNAs were responsible for noting and reporting any concerns related to ADL status and changes in condition. On 3/06/24 at 5:12 PM, the Rehab Program Manager stated resident #246 received Occupational Therapy services from 6/05/23 to 7/04/23. She explained while on caseload, his goals were related to wheelchair positioning, and on discharge from therapy, he received an arm support tray for his wheelchair as his right arm was flaccid. The Rehab Manager reviewed the medical record and stated resident #246 did not have discharge recommendations for RNP services or a splint. She was informed of the resident's cupped right hand and pain during an attempt to open his hand. On 3/06/24 at 5:22 PM, the Rehab Program Manager assessed resident #246's range of motion. She described findings of increased tone rather than contractures. The Rehab Program Manager stated the resident had increased tone when she attempted extension of his fingers. She confirmed the resident expressed discomfort and grimaced at approximately 160 degrees of flexion of his shoulder. The Rehab Program Manager explained increased tone could lead to a contracture and skin integrity issues. She said, At this point, he needs to be evaluated right away, before he gets to the point where he can't move it. We need to preserve the joint integrity. This is a significant change over eight months and we need to get in there to make sure he retains full movement. The Rehab Program Manager stated the Therapy department did not conduct periodic screenings of all residents in the facility. She explained the process was the Nursing department would refer residents who exhibited any type of decline in ADLs, mobility, or range of motion via an electronic referral form. She said, We are very heavily reliant on the nursing staff.It would have been appropriate for nursing to refer him when there was a change in tone. The Rehab Program Manager explained based on her assessment of resident #246, she would begin with gentle range of motion and set a goal for use of a resting hand splint. On 3/06/24 at 5:40 PM, Occupational Therapist H stated she was resident #246's therapist when he was last on caseload in July 2023. She stated she ordered a trough for his wheelchair as his arm was so flaccid. She emphasized the resident was able to lay his hand flat in the trough when he was discharged from Occupational Therapy caseload and said, If he had tone at the time we would have ordered a resting hand splint. On 3/06/24 at 6:02 PM, the Executive Director of Nursing (DON) stated her expectation was nursing staff would report any changes or declines appropriately. She explained any staff member could initiate a therapy referral, but nurses and UMs were usually the ones who did so. She validated any assigned staff member should have noticed changes in resident #246's right hand and arm during provision of care. On 3/07/24 at 3:12 PM, Occupational Therapist H explained resident #246's right arm is flaccid and not functional. She stated he could develop contractures over time, but if he received daily range of motion exercises, they might be prevented. Occupational Therapist H said, I would have expected staff to realize he was getting tighter. She confirmed she assessed resident #246 today and developed a plan of care based on her findings. She stated the proximal joints of all digits on the right hand were fixed contractures, but most of the other joints could be stretched, and he had mild pain with the wrist. Occupational Therapist H stated she already ordered a hand roll splint. She stated she was not able to fully open the resident's hand and said, I was not going to push him to fully open as he was in pain, signified by him telling me to stop. Review of an Occupational Therapy Plan of Care dated 3/07/24 revealed Occupational Therapist H noted resident #246 was referred to skilled therapy due to increased tone and developing deformities of the right hand digits. The document indicated the resident had right proximal interphalangeal joint flexion contractures. She determined Skilled [Occupational Therapy] is medically indicated to maximize joint integrity and provide orthotic management. Without immediate intervention, patient is at risk for development of joint deformities. Occupational Therapist H developed short term goals to include wearing a right hand roll and long term goals included functional maintenance program for range of motion and use of a right grip hand splint. On 3/07/24 at 2:57 PM and 3:21 PM, the Executive DON reviewed resident #246's Occupational Therapy Plan of Care and noted the document referred to deformities, increased tone, and contractures, which she acknowledged were negative outcomes that were not identified by nursing staff. The Executive DON stated her expectation was all CNAs would do range of motion exercises during resident care. She explained the facility did not currently have a RNP with designated restorative CNAs. She stated it was concerning that staff had not noted or reported the changes in the resident's right hand and arm. On 3/08/24 at 3:52 PM, the Executive DON provided a copy of the Occupational Therapy Plan of Care dated 3/07/24, with additional documentation by the attending physician to validate the patient has change in tone to right hand and an instruction to remove the word deformities from the document. The Executive DON verbalized understanding that regardless of terminology, resident #246 experienced a decline in range of motion, a change of condition that was not identified and treated by the facility, until discovered by the State Survey Agency surveyor and brought to the facility's attention. 39943 2. Resident #124 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include nontraumatic intracranial hemorrhage, respiratory failure, and other specified disorders of muscle. The quarterly MDS assessment noted resident #124 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) evaluation which indicated the resident was cognitively intact. The MDS assessment did not identify any mood or behavior problems. On 3/05/24 at 10:37 AM, resident #124 was observed lying in bed watching television and his left hand was contracted with no splint. The resident stated he used to have a splint but did not know what happened to it. Review of the resident's care plan for Range of Motion (ROM), dated 5/22/20 and revised 3/19/22 revealed an intervention for Splint type: resting orthotic hand brace. Apply to left hand after breakfast and remove after lunch. Observe and report decline in ROM. On 3/06/24 at 6:09 PM, the Director of Rehab stated resident #124 was on caseload from 10/19/23 to 10/30/23 for Occupational Therapy (OT). She stated his discharge summary included he would have palm guard for 8 hours. When she was informed the resident no longer had his palm guard, the Rehab Director stated the resident would be screened the next day. Review of the Occupational Therapy Screening Form dated 3/07/24 indicated the following: Joint Contracture(s) or is at High Risk for Developing such. Patient has flexor tone in elbow and digits. Occupational Therapy evaluation is recommended. Patient has potential to benefit from orthotic management program to prevent skin breakdown and address hypertonicity. 3. Resident #137 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include traumatic brain injury, acute respiratory failure, and subdural hemorrhage. The MDS Significant Change in Status Assessment noted resident #137 scored rarely or never understood on the BIMS evaluation which indicated the resident had severe cognitive impairment. The MDS assessment did not identify any mood or behavior problems. On 3/04/24 at 6:21 PM, resident #137 was observed lying in bed with both hands contracted with no splints. On 3/06/24 at 5:56 PM, the Director of Rehab stated resident #137 was on physical therapy (PT) caseload from 12/06/23-1/06/24. She stated he had not been on OT caseload since 2021. The Director of Rehab said when he was discharged from OT he was supposed to wear a right-hand resting splint for 2 hours each day and the CNA was educated on the application of the right-hand splint. Resident #137 was screened by OT on 3/07/24 and received the following recommendation: Skilled OT is medically indicated to improve impaired range of motion, tone, cognition, coordination orthotic management. Without immediate intervention, the patient is at risk for further decline in function. 4. Resident #268 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include acute kidney failure, anemia, and other specified muscle disorders. The MDS quarterly assessment noted resident #268 scored 15 out of 15 on the BIMS evaluation which indicated the resident was cognitively intact. The MDS assessment did not identify any mood or behavior problems. On 3/05/24 at 9:39 AM, resident #268 was observed sitting in bed. His left hand was contracted with no splint. The resident stated he did not have a splint and did not receive OT. On 3/06/24 at 6:03 PM, the Director of Rehab stated resident #268 was last on OT caseload from 3/2/23-5/20/23. She explained the discharge summary read for left hand, 4th and 5th finger contracture, resident will wear left resting hand splint for 95 minutes with no signs or symptoms of hand skin breakdown. The Director said, the resident is on the board to be screened because a therapist noticed his hand. She stated he would be screened tomorrow. On 3/07/24 at 6:30 PM, The D Wing Unit Manager stated his expectation was the CNA would apply the splint if it was not done by the therapist. He stated the facility did not have restorative CNAs. On 3/08/24 at approximately 11:00AM, the OT discharge summary and screening were requested for resident #268 but was not received by the end of the survey. On 3/08/24 at 3:45 PM, the Executive DON stated the facility did not have restorative CNA's at this time. She explained the floor CNA's were taught to apply and remove the splints for the residents. She stated her expectation was that residents would get the care that was ordered for them. The Certified Nursing Assistant (CNA) job description dated 7/01/2019 read: Performs restorative and rehabilitative procedures as instructed. and provides range of motion exercises according to the care plan. 32131 5. Resident #85 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, schizoaffective disorder, bipolar disorder, delusional disorders, foot drop right/left foot, and chronic pain. Review of the MDS quarterly assessment with Assessment Reference Date (ARD) of 12/08/23, revealed the resident's cognition was intact, with BIMS score of 14 out of 15. The assessment noted the resident had impairment in functional limitation in ROM on both sides of her upper and lower extremities and was dependent on staff assistance for transfer and personal hygiene. A physician order dated 4/18/22 noted left resting hand splint for 2 hours with skin integrity daily. On 3/04/24 at 10:07 AM, and on 3/05/24 at 9:56 AM, resident #85 was sitting up in bed watching television. Her left hand was contracted, and no splint was noted. The resident said she could not recall when the splint was last placed, and staff forgot to apply the splint. Resident #85 stated therapy told her she should wear the splint daily. On 3/06/24 at 12:19 PM, Licensed Practical Nurse (LPN) A stated the resident used to wear a splint to her left hand, but it had been a while since she saw the splint. LPN A stated the resident had a physician order for left hand splint, and it was usually placed by therapy. On 3/06/24 at 4:04 PM, the Rehab Program Manager stated resident #85 was previously on OT caseload for orthotic management. On 2/02/22 the goal was for the resident to wear a left resting hand splint for approximately 2 hours a day, and the resident was discharged from OT with a left-hand resting splint. On 4/05/22 she was discharged from Physical Therapy and a Functional Maintenance Program for splinting was established. The Rehab Program Manager stated the expectation was for nursing to reach out to therapy if they had any questions or concerns regarding the splint. She stated Therapy had not received any referral from nursing regarding the resident's splinting program until 3/06/24. The Director said, if a resident refused splinting, the assumption was that nursing would send a referral to Therapy to see if the resident's splinting program was still appropriate. The Rehab Program Manager stated splints were worn to increase tone, maintain joint integrity, and decrease contractures. Review of the Therapy Recommendations for Restorative/Functional Maintenance Program revealed the resident's discharge from therapy was 3/31/2022, and the splinting program form directed staff to apply left resting hand splint daily for 2 hours as tolerated. Review of the POC (Point of Care) Response History for the period 2/06/24 to 3/07/24 revealed directions for left resting hand splint daily for up to 2 hours or per patient tolerance. Documentation indicated the resident's left hand resting splint was applied for four days in February, on 2/09/24, 2/10/24, 2/11/24, 2/17/24, and one day in March on 3/02/24. There was no documentation to indicate the resident refused splint application. On 3/06/24 at 5:00 PM, LPN A stated the facility usually had CNAs in the Restorative Nursing Program (RNP), but she did not know how they operated. She said the resident refused to have her splint applied when she offered to place it today, and she placed a referral for her to be screened by therapy. On 3/06/24 at 5:33 PM, the C Wing UM stated the facility used to have an RNP, but no longer had one. She could not recall when the RNP was discontinued. The UM explained that when a resident was discharged from therapy with orthotics, therapy would teach the floor CNAs and nurses to don and doff the orthotic. The UM reviewed the resident's physician orders and acknowledged an order was in place for application of a resting left-hand splint daily. On 3/06/24 at 5:49 PM, the 2nd Floor DON stated the splinting process started with therapy, and after discharge from therapy, nurses followed up on the splinting process. Observation of the resident's contracted left hand without a splint in place was shared with the 2nd Floor DON. She stated resident #85 had a BIMs score of 14 out of 15 and had a care plan in place for refusal of care, and skin checks at times. Review of the ADL care plan initiated 4/23/25 with revision on 3/16/23 revealed no reference to splint application. A care plan for splint application was not identified. On 3/06/24 at 6:07 PM, the Executive DON stated the facility had a RNP, but did not have any specific Restorative CNA. She stated all CNAs performed the task the Restorative CNA would, UMs monitored their units, and the Executive DON had ultimate oversight of the RNP. On 3/08/24 at 10:17 AM, the Rehab Program Manager stated that due to referral from nursing on 3/06/24 regarding refusal of orthotics by resident #85, a therapy screen was conducted on 3/07/24. She stated the left-hand resting splint for the resident was still appropriate, and Therapy had picked her up again. She explained if splint application was not being done, therapy needed to do education of resident and staff. The Rehab Program Manager stated there was no documentation regarding the resident's refusal of splint application when the screen/evaluation was conducted on 3/07/24. 6. Resident #238 was admitted to the facility on [DATE] with diagnoses that included diabetes type II, generalized muscle weakness, transient cerebral ischemic attack, muscle wasting and atrophy, acute cerebrovascular insufficiency, dysphagia following cerebral infarction, and gastrostomy. Review of the MDS quarterly assessment with ARD of 12/11/23 revealed the resident was rarely/never understood. The assessment noted the resident had impairment in functional limitation in ROM to one side of her upper extremity and had dependence on staff assistance for all her activities of daily living. On 3/04/24 at 12:33 PM, 3/05/24 at 10:08 AM, 3/05/24 at 1:00 PM, 3/06/24 at 12:31 PM, and on 3/06/24 at 5:06 PM, resident #238 was observed in her bed. The resident verbalized her name, but was unable to answer any other questions. Her left hand was contracted, and the resident did not have a splint. On 3/06/24 at 12:38 PM, RN B stated resident #238's left hand was contracted, and sometimes her splint was applied by therapy. The RN could not recall the last time she saw the resident with her splint on. On 3/06/24 at 3:39 PM, the Rehab Program Manager stated resident #238 was previously on OT caseload from 6/23/23 and was discharged on [DATE] to wear a left orthotic splint for 5 to 6 hours. The Rehab Program Manager explained that when a resident had a splint, and was no longer on therapy caseload, the resident would be referred to the RNP. She stated that a Restorative program would be given to the Restorative nurse, the Restorative CNA would be educated about donning and doffing the splint/orthotic, and would sign off indicating the education was received, and then nursing would be responsible for the splinting program. The Rehab Program Manager stated she was not aware the resident's splint was discontinued, and therapy had not received any referral from nursing requesting a therapy screen. The Rehab Program Manager verbalized that a review of the resident's therapy documentation, for the last six months, revealed there was no request from nursing for a therapy screen for the resident. She said, if therapy did not receive a referral from nursing, regarding any concerns or issues with the resident's splint, the expectation was the splinting program was ongoing. On 3/07/24 at 11:14 AM, the resident was lying in her bed positioned to her left side. Her left hand was contracted, and a splint was not noted. Review of the OT Progress and Discharge Summary revealed start of care 6/23/23, and end of care 11/29/23. The short-term goal was, patient will wear left palmar guard or appropriate orthotic for 7 hours .to maintain joint integrity and improve ROM. 48878 7. Review of the medical record revealed resident #222 was admitted to the facility on [DATE] from the hospital. Her diagnosis included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, and anxiety disorder. The significant change in status MDS with an assessment reference date of 1/24/24 revealed resident #222 had severely impaired cognitive skills for daily decision making. The MDS assessment also indicated resident #222 had OT from 1/5/24 to 1/18/24 and PT from 1/5/24 to 1/17/24. Review of the Occupational Therapy Discharge and Summary revealed resident #222 was discharged on [DATE] with a splinting functional maintenance program and a left upper extremity palm guard. Resident #222's medical record revealed the restorative task dated 2/9/24-3/8/24 was to perform skin checks before and after application of Orthosis but was documented by the nursing staff as not applicable. On 3/3/24 at 1:27 PM, 3/6/24 at 9:57 AM, and on 3/7/24 at 10:12 AM, observation revealed resident #222 had a left-hand contracture with no palm guard or splint in place. On 3/7/24 at 11:44 AM, the OT Rehab Program Manager stated the resident had OT from 1/5/24 to 1/18/24 with a long-term goal that consisted of a range of motion and splinting functional maintenance program. She confirmed the resident had been discharged from OT on 1/18/24, with directions to wear a left palm guard for 60 minutes each day, intended to prevent further contracture and preserve skin integrity. The OT Rehab Program Manager acknowledged the nursing staff had the responsibility to ensure the resident had a palm guard in place and to notify OT if the palm guard was missing, so a replacement could be arranged. On 3/7/24 at 11:45 AM, OT H verified the resident previously had a palm guard with restorative care to address the orthotic when last discharged from OT on 1/18/24 and the palm guard was currently missing from the resident's room. On 3/7/24 at 12:35 PM, RN U stated she had been working at the facility for [AGE] years. She acknowledged the resident had a left-hand contracture with no palm guard. She did not recall ever seeing a palm guard for the resident. On 3/7/24 at 12:35 PM, RN W stated she was familiar with the resident and could not recall ever observing the resident with a palm guard. On 3/7/24 at 12:34 PM, CNA Y stated she had worked at the facility for 1 year and was familiar with the resident. CNA Y conveyed she had never seen the resident with a palm guard. On 3/8/24 at 11:34 AM, RN X stated she was familiar with the resident. RN X said she was aware resident #222 had a left-hand contracture and she had not seen the resident with an orthotic device or palm guard. She conveyed if she noticed a resident with a contracture, she would notify therapy. She could not give a reason why she did not notify therapy of the resident's contracture. On 3/8/24 at 12:25 PM, the Executive DON explained they did not have a stand-alone restorative program. She said that when OT discharged a resident to restorative nursing services, it was the Unit Manager's responsibility to place the task in the electronic medical record to ensure CNAs were trained appropriately, and the orthotics were applied. On 3/8/24 at 1:32 PM, the D Wing UM accessed the resident's active restorative task and noted resident #222 was to have an orthotic applied and nursing staff were to observe for skin breakdown. He confirmed the restorative task was placed on 1/4/24 and showed it had been documented not applicable for the past 30 days. The UM explained there was not a system in place for him to monitor whether restorative nursing was being carried out and whether the residents had their orthotics applied as ordered. On 3/08/24 4:40 PM the Executive DON said the facility did not have a splint policy. The facility's policy Restorative Nursing Programs and Guidelines with revision date of October 2017 read, The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning . The programs include Contracture Management and Prevention-This program includes the provision of active and, or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength .also involves splint/brace assistance to protect joint and skin integrity.

Based on observation, interview and record review, the facility neglected to provide adequate supervision and a secure environment, neglected to administer scheduled tube feedings and perform regular and change of shift rounds to monitor resident status and activities to prevent resident from exiting the facility unsupervised for 1 of 18 residents reviewed for elopement out of 25 residents identified at risk for elopement, (resident #1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility for 7 hours, unsupervised, there was likelihood he could have become dehydrated, fallen, been accosted by unknown persons, drowned or been hit by a car. On 10/15/22, four days after admission, at approximately 10:45 AM, the facility neglected to prevent a vulnerable, physically impaired resident from exiting the facility unsupervised through the front lobby door. Resident #1 left his room and walked to the lobby of the main entrance door. He was not redirected by staff as he left the resident care areas and was not observed by the receptionist as he passed her desk and exited through the unlocked main entrance doors, unsupervised, wearing socks and no shoes. Once out the main doors, he turned left and headed towards the employee parking lot. The facility's Registered Dietician was in the parking lot at the time but did not recognize the man as a resident and left in her car without notifying any staff of the unknown man wandering the facility property. Once the resident left the parking area, he walked past an elementary school with drainage ditches on both sides of the road. He would have then walked past a retention pond with an open gate that had a steep embankment. The resident had to avoid being hit by motor vehicles as he negotiated his way past entrance/exit ramp of a major highway. The resident was discovered 0.8 miles from the facility at approximately 5:30 PM, along a busy highway by a bystander who called emergency services as he was concerned the resident seemed altered with feces on his pants. The resident was transferred to a nearby hospital's emergency department and did not return to the facility. The total distance the resident traveled was unknown as he was out of the facility for 7 hours and could have traversed the same area multiple times. The resident's assigned Certified Nursing Assistants (CNA) neglected to perform regular and change of shift rounds to ensure the resident's status, activities and well-being were adequately monitored. Resident #1's assigned nurse neglected to check his vital signs and administer scheduled tube feedings and medications throughout the shift. The facility was neither aware of the resident's whereabouts nor that he was missing for 7 hours until the hospital contacted the facility staff to inform the resident was in their emergency department. These failures resulted in Immediate Jeopardy that started on 10/15/22. The Immediate Jeopardy was removed on 10/24/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F689 Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] from an acute care hospital. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Services and Patient Transfer Form dated 10/11/22 indicated the resident was hospitalized on [DATE] for a stroke, hypertension and [CONDITION(S)]. Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a gastrostomy tube (G-tube) and was not to consume any liquid or solid food by mouth. The resident received all his nutrition, hydration, and medications through the G-tube. The hospital therapy notes dated 10/10/22 indicated the resident was oriented to person and his overall cognitive status was impaired. The therapist noted the resident had a delayed response to stimuli and was confused. The therapist reported when the resident attempted to put on socks, he placed them on his hands and the therapist had to cue the resident to put them on his feet. The resident was transferred to the facility on [DATE] to continue his rehabilitation. Review of the resident's facility medical record revealed current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in the medical record to indicate the resident had refused medications, nutrition or hydration. RN B did not notify the resident's physician concerning the resident's refusals as per facility protocol. On 10/22/22 several telephone calls were made to contact RN B, who was suspended from work but the nurse did not answer or return the calls. Review of the resident's Activity of Daily Living (ADL) care plan noted the resident required the assistance of 1 staff for bed mobility, transfers, oral care, personal hygiene, dressing and toilet use. ADL assistance would have been provided by the resident's direct care staff, CNA C. Several telephone calls were made on 10/22/22 to contact CNA C who was suspended from work at the time. The CNA's phone had a busy signal each time she was called and there was no voicemail available. On 10/23/22 at 2:09 PM, CNA D stated resident #1 was part of her assignment on 10/15/22 on the 2:45 PM to 11:15 PM shift. She stated she was not feeling well that day and came to work late. She clocked in at 3:33 PM and the day shift CNA C had already left. CNA D said she did not see resident #1 in his room during rounds and she reported this to RN B. She explained RN B told her the resident always walked around the facility and never stayed in his room. She stated she continued to do rounds until the dinner trays arrived on the unit at 4:30 PM. CNA D recalled she did not see resident #1 at all and that sometime during the shift, RN B informed her the resident had eloped. A review of the resident's elopement assessment dated [DATE] indicated the resident was not at risk for elopement. The assessment form consisted of two questions. Is the resident confused, which was answered no and is the resident ambulatory or mobile which was answered yes. If both questions were answered yes, the resident would be at risk for elopement. The facility's elopement assessment form indicated that only confused residents that were ambulatory/mobile were at risk elopement and the form did not account for any previous history of elopement/wandering or verbalization of elopement or intent to leave the facility. Review of the resident's nursing/progress notes did not show any evidence of previous exit seeking or wandering behaviors. An interview with the receptionist on 10/23/22 at 3:01 PM, revealed the resident had been exit seeking on 10/15/22, before he eloped from the facility. The receptionist recalled 10/15/23 was a Saturday and she arrived at the facility at 7 AM. She stated resident #1 came to the lobby at 9 AM, and he wore shorts, shirt, and blue socks with no shoes. She said he attempted to exit the front entrance as a visitor came in and she brought him back inside the facility. She explained she made resident #1 aware of the facility's leave of absence policy and procedure. He was giving me a difficult time and I was trying to communicate with him, but I was not sure if he understood it. She said she was unable to understand him as his speech was slurred so she called for a supervisor, but no one came. She said she asked the resident to write down his name on a piece of paper and then gave it to the Risk Manager. The Risk Manager told her he would speak to the resident. The receptionist stated resident #1 went out the front entrance again at 9:30 AM, and she had to ask a Certified Nursing Assistant, (CNA) to bring him back inside. She recalled the resident became frustrated and belligerent because he could not go outside. The receptionist recalled the lobby area was very busy that morning with visitors she had to sign in. She stated along with attending to visitors and answering telephone calls, she was responsible for giving money to residents that wanted to make withdrawals from their accounts. She noted residents sometimes lined up to make withdrawls and would get upset if they had to wait long to get their money. She said she made the Executive Director aware that receptionists could not keep a constant eye on the front entrance door during busy times. On 10/23/22 at 1:12 PM, a meeting was held with Risk Manager A, Administrator, and the Director of Nursing. Risk Manager A stated he was the Manager on Duty, on 10/15/22. Risk Manager A explained he was informed by the receptionist of resident #1's attempts to exit. He stated he spoke to resident #1 at approximately 9:30 AM and asked the resident needed to go somewhere and the resident said air. The Risk Manager said he educated the resident to go out to the back patios rather than the front door then did not have any further interactions with the resident. The team was aware the resident had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The team explained RN B tried to give the morning feeding that was scheduled at 9 AM, but the resident refused. They acknowledged there was not any documentation of refusals for either medications or tube feeding in the medical record nor was there any indication RN B had attempted scheduled tube feeds at 1 PM and 5 PM. The Director of Nursing did not explain how the resident was not missed as his scheduled feeds were due at 1 PM and 5 PM. They did not explain how the resident was missing for 7 hours and no facility staff questioned his whereabouts especially during scheduled medication/feeding times, care times or regular and change of shift rounds. When asked what the expectation was of staff to supervise residents, they did not provide an answer as to the supervision needs of the newly admitted resident #1. They stated the resident was not deemed to be at risk for elopement. The Director of Nursing was asked about the questions posed on the elopement risk assessment. She did not explain how the 2 questions on the form were adequate for determining if a resident was at risk for elopement. The staff stated they had reviewed the facility's video recording that showed the resident had come to the front lobby twice. When questioned about resident #1's attempts to go out the front entrance twice that morning indicated elopement behavior, they stated the resident was alert and oriented. It was pointed out that alert and oriented residents did not leave a facility for long periods without their shoes. The Risk Manager acknowledged the resident exited the facility at 10:42 AM wearing socks and no shoes and headed toward the employee parking lot. They verified that facility staff were not aware of the resident's whereabouts or that he was missing from the facility until they received a phone call from the hospital on 10/15/22 at 5:30 PM. Review of the hospital's emergency department notes dated 10/15/22 read, .Paramedics report pt [patient] was sitting on the side of the road and paramedics were called by a bystander due to him being altered and with feces on his pants. Unknown when he was last seen normal . Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: * Resident exited facility on 10-15-22 and was taken to the hospital where he was safe. * A Federal Immediate report was submitted on the allegation of neglect on 10/17/22. * Department of Children and Families and Law Enforcement were notified on 10/17/22. * Front door locking pattern changed on 10/15/22. * Interviews conducted with nurse and CNA directly involved on 10/16/22 and 10/17/22. * Staff educated on 10/17/22 to identify and escalate concerns to a supervisor for identified safety, hazard or risks concerns that may conflict with normal routines, processes, or policies, that may require additional supervision from the facility. * Staff educated on 10/17 to immediately place resident on 1:1 if at risk for elopement. * Nurses educated on 10/17/22 to update care plans with immediate interventions for residents requiring additional supervision. * Staff educated on 10/17/22 regarding shift change walking rounds and knowing where their residents are during each shift-is a priority supervision. * Door Company arrived to check functionality of front door on 10/18/22 * Investigation initiated on 10/15/22 * On 10/17/22 the Regional Nurse Consultant educated Director of Nursing and Administrator on ensuring adequate supervision of residents. * Education on 10/17/22 on walking rounds for shift changes to verify location and condition of residents * Frequent routine rounding by staff 10/15/22 and ongoing to provide supervision on the shift * Therapy will notify nurse when resident is back on the unit or their location of preference (example: smoking patio) on 10/17/22 * On 10/17/22, completed education 353/449 (78%). The remaining 96 employees will receive the education prior to their next working shift. * Use of visitor stickers (started 10/19/22) to identify visitors. * New Admission Binder and Communication Form for receptionist 10/18/22 * Staff Education initiated immediately on the following (10/15/22 and ongoing): -Abuse, neglect, exploitation & misappropriation education -Supervision of residents with a focus on routine rounding -Rounding by staff (CNA and nurses) shift to shift hand off with report - - -Identification of vulnerable residents in the elopement binder -Review of BIMS for accuracy -Review of reportable events -Weekend stand up/down -Stickers for visitors 10/19/22 -Clinical meeting process - 10/18/22 -Review of new admissions by Interdisciplinary Team (IDT) 10/17, 10/18/22 and daily -Social Worker completion of Brief Interview for Mental Status exam-completed A, B and G 10/19/22 -Therapy department providing a list of residents' schedules for therapy for each day to each nurse and Unit Manager and DON -Quality Assurance Meeting Held with IDT and Medical Director 10/18/22 and 10/21/22 included: On 10/24/22 staff interviews were conducted with 7-RN's, 1-LPN, 12-CNAs, 2 housekeepers, 1 receptionist, 2 Therapists, and the Activity director. All staff stated they had received education on Abuse & Neglect, Supervision of residents. The Nurses and the CNAs spoke about the importance of walking rounds at shift change and the supervision of the residents throughout the shift. Activity Director about diversion activities for residents with behaviors/ exit seeking. The staff were aware of the elopement books, that had the information of the residents at risk for elopement. The staff stated that Code Silver would be announced on the public address system for any missing resident and all staff would assist in the search for the missing resident. They spoke about participating in elopement drills. Elopement books were reviewed, and they had been updated with the residents identified by facility to be at risk for elopement. The front lobby was observed and there was control/button on the receptionist desk. The front lobby did not open automatically as persons approached; the receptionist had to open/close the door to let people in/out of the facility. Visitors were observed wearing green sticker as an identification. It was determined that the facility's Immediate Jeopardy at F689 was removed as of 10/24/22 but the non-compliance continued for F689 at a scope and severity of D, no actual harm with potential for more than minimal harm, that is not an Immediate Jeopardy.

Based on observation, interview and record review, the facility failed to maintain a secure environment and failed to provide adequate supervision to prevent a vulnerable, cognitively impaired resident from exiting the facility unsupervised for 1 of 18 residents reviewed for elopement out of 25 residents identified at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility for 7 hours, unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, drowned or been hit by a car. On 10/15/22, four days after admission, at approximately 10:45 AM, resident #1 left his room and walked to the lobby of the main entrance door. He was not redirected by staff as he left the resident care areas and was not observed by the receptionist as he passed her desk and exited through the unlocked main entrance doors, unsupervised, wearing socks and no shoes. Once out the main doors, he turned left and headed towards the employee parking lot. The facility's Registered Dietician was in the parking lot at the time but did not recognize the man as a resident and left in her car without notifying any staff of the unknown man wandering the facility property. Once the resident left the parking area, he walked past an elementary school with drainage ditches on both sides of the road. He would have then walked past a retention pond with an open gate that had a steep embankment. The resident had to avoid being hit by motor vehicles as he negotiated his way past entrance/exit ramp of a major highway. The resident was discovered 0.8 miles from the facility at approximately 5:30 PM, along a busy highway by a bystander who called emergency services as he was concerned the resident seemed altered with feces on his pants. The resident was transferred to a nearby hospital's emergency department and did not return to the facility. The total distance the resident traveled was unknown as he was out of the facility for 7 hours and could have traversed the same area multiple times. The facility was neither aware of the resident's whereabouts nor that he was missing for 7 hours until the hospital contacted the facility staff to inform the resident was in their emergency department. The facility's failure to provide adequate supervision and maintain a secure environment placed all residents who wandered at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy that started on 10/15/22. The Immediate Jeopardy was removed on 10/24/22. the scope and severity of the deficiency was decreased to D, no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600 Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] from an acute care hospital. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Services and Patient Transfer Form dated 10/11/22 indicated the resident was hospitalized on [DATE] for a stroke. Additional diagnoses on the form noted dysphagia, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. The resident had a gastrostomy tube (G-tube) and was not to consume any liquid or solid food by mouth. The resident received all his nutrition, hydration, and medications through the G-tube. The hospital therapy notes dated 10/10/22 indicated the resident was oriented to person and his overall cognitive status was impaired. A review of the facility's elopement assessment dated [DATE] indicated the resident was not at risk for elopement. The assessment form consisted of two questions. Is the resident confused, which was answered no and is the resident ambulatory or mobile which was answered yes. If both questions were answered yes, the resident would be at risk for elopement. The facility's elopement assessment form assumed that only confused residents that were ambulatory/mobile were at risk elopement and the form did not account for any previous history of elopement/wandering or verbalization of elopement or intent to leave the facility. Review of the resident's care plans dated 10/12/22 showed he had nutritional problems and was not to consume any food or fluids by mouth. The interventions directed staff to observe for choking and aspiration. A care plan for [CONDITION(S)] medications noted monitor for side effects that included [CONDITION(S)] activity, confusion and falls. The admission screening noted the resident was incontinent of both bowel and bladder. Review of the resident's nursing/progress notes did not show any evidence of previous exit seeking or wandering behaviors. An interview with the receptionist on 10/23/22 at 3:01 PM, revealed the resident had been exit seeking on 10/15/22, before he eloped from the facility. The receptionist recalled 10/15/23 was a Saturday and she arrived at the facility at 7 AM. She stated resident #1 came to the lobby around 9 AM, and he wore shorts, shirt, and blue socks with no shoes. She said he attempted to exit the front entrance as a visitor came in and she brought him back inside the facility. She explained she made resident #1 aware of the facility's leave of absence policy and procedure. He was giving me a difficult time and I was trying to communicate with him, but I was not sure if he understood it. She said she was unable to understand him as his speech was slurred so she called for a supervisor, but no one came. She said she asked the resident to write down his name on a piece of paper and then gave it to the Risk Manager. The Risk Manager told her he would speak to the resident. The receptionist stated resident #1 went out the front entrance again at 9:30 AM, and she had to ask a Certified Nursing Assistant, (CNA) to bring him back inside. She recalled the resident became frustrated and belligerent because he could not go outside. The receptionist recalled the lobby area was very busy that morning with visitors she had to sign in. She stated along with attending to visitors and answering telephone calls, she was responsible for giving money to residents that wanted to make withdrawals from their accounts. She noted residents sometimes lined up to make withdrawls and would get upset if they had to wait long to get their money. She said she made the Executive Director aware that receptionists could not keep a constant eye on the front entrance door during busy times. Review of the facility's investigation and witness statements revealed the Registered Dietitian left the faciity on [DATE] at 10:37 AM. She was in the employee parking lot by her car when she saw resident #1 but dismissed him as a visitor or transient. There was a border wall, so she was not able see the resident wore only socks and no shoes. The resident tried to engage the dietician but his speech was garbled. As he approached, she felt uncomfortable and got into her car. He indicated by motions about leaving and left the parking lot. The dietician noted he sounded drunk and she was not familiar with the resident as another dietitian had conducted his nutritional assessment. Attempts were made to do a telephone interview with resident #1's direct care Registered Nurse, (RN) B, who was on suspension but the nurse did not return the calls. RN B worked from 7 AM to 7 PM on 10/15/22, the day the resident eloped. Review of RN B's witness statement noted he saw resident #1 in the morning and the resident refused medications and his bolus tube feedings. The statement noted RN B saw the resident again within an hour and the resident still refused medications and feeds. Review of the nursing progress notes and Medication Administration Records (MAR) showed no indication that resident #1 had refused his medications and tube feedings. Attempts were made to contact resident #1's assigned caregiver the day he eloped, 10/15/22 on the 6:45 AM to 3:15 PM shift. CNA C was on suspension from work at the time. Her telephone number had a constant busy signal and no voice mailbox was available. Review of CNA C's witness statement noted she had not worked with resident #1. She indicated she saw resident #1 on the morning of 10/15/22 but she did not note the time. The statement did not indicate whether CNA C provided any care to resident #1 and there was no evidence to support that she had informed the nurse, RN B, that the resident was missing. On 10/23/22 at 2:09 PM, CNA D stated resident #1 was part of her assignment on 10/15/22 on the 2:45 PM to 11:15 PM shift. She stated she was not feeling well that day came to work late. She clocked in at 3:33 PM and the day shift CNA C had already left. CNA D said she did not see resident #1 in his room during rounds and she reported this to RN B. She explained RN B told her the resident always walked around the facility and never stayed in his room. She stated she continued to do rounds until the dinner trays arrived on the unit at 4:30 PM. CNA D recalled she did not see resident #1 at all and that sometime during the shift, RN B informed her the resident had eloped. On 10/23/22 at 1:12 PM, a meeting was held with Risk Manager A, Administrator, and the Director of Nursing. Risk Manager A stated he was the Manager on Duty, on 10/15/22. Risk Manager A explained he was informed by the receptionist of resident #1's attempts to exit. He stated he spoke to resident #1 at approximately 9:30 AM and asked the resident if needed to go somewhere and the resident said air. The Risk Manager said he educated the resident to go out to the back patios rather than the front door then did not have any further interactions with the resident. The Director of Nursing was asked about the questions posed on the elopement risk assessment. She did not explain how the 2 questions on the form were adequate for determining if a resident was at risk for elopement. The team was aware the resident had physician orders for tube feeds, 1 can of formula 4 times per day that indicated RN B would have administered three feeds on the 7 AM to 7 PM shift. The team explained RN B tried to give the morning feeding that was scheduled at 9 AM, but the resident refused. They acknowledged there was not any documentation of refusals for either medications or tube feeding in the medical record nor was there any indication RN B had attempted scheduled tube feeds at 1 PM and 5 PM. The Director of Nursing did not explain how the resident was not missed as his scheduled feeds were due at 1 PM and 5 PM. They did not explain how the resident was missing for 7 hours and no facility staff questioned his whereabouts especially during scheduled medication/feeding times, care times or regular and change of shift rounds. The team acknowledged they reviewed the facility's video recording that showed resident #1 was in the front lobby twice in the morning of 10/15/22 and exited the facility wearing only socks at 10:42 AM and walked toward the employee parking lot. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: * Resident exited facility on 10-15-22 and was taken to the hospital where he was safe. * A Federal Immediate report was submitted on the allegation of neglect on 10/17/22. * Department of Children and Families and Law Enforcement were notified on 10/17/22. * Front door locking pattern changed on 10/15/22. * Interviews conducted with nurse and CNA directly involved on 10/16/22 and 10/17/22. * Staff educated on 10/17/22 to identify and escalate concerns to a supervisor for identified safety, hazard or risks concerns that may conflict with normal routines, processes, or policies, that may require additional supervision from the facility. * Staff educated on 10/17 to immediately place resident on 1:1 if at risk for elopement. * Nurses educated on 10/17/22 to update care plans with immediate interventions for residents requiring additional supervision. * Staff educated on 10/17/22 regarding shift change walking rounds and knowing where their residents are during each shift-is a priority supervision. * Door Company arrived to check functionality of front door on 10/18/22 * Investigation initiated on 10/15/22 * On 10/17/22 the Regional Nurse Consultant educated Director of Nursing and Administrator on ensuring adequate supervision of residents. * Education on 10/17/22 on walking rounds for shift changes to verify location and condition of residents * Frequent routine rounding by staff 10/15/22 and ongoing to provide supervision on the shift * Therapy will notify nurse when resident is back on the unit or their location of preference (example: smoking patio) on 10/17/22 * On 10/17/22, completed education 353/449 (78%). The remaining 96 employees will receive the education prior to their next working shift. * Use of visitor stickers (started 10/19/22) to identify visitors. * New Admission Binder and Communication Form for receptionist 10/18/22 * Staff Education initiated immediately on the following (10/15/22 and ongoing): -Abuse, neglect, exploitation & misappropriation education -Supervision of residents with a focus on routine rounding -Rounding by staff (CNA and nurses) shift to shift hand off with report - - -Identification of vulnerable residents in the elopement binder -Review of BIMS for accuracy -Review of reportable events -Weekend stand up/down -Stickers for visitors 10/19/22 -Clinical meeting process - 10/18/22 -Review of new admissions by Interdisciplinary Team (IDT) 10/17, 10/18/22 and daily -Social Worker completion of Brief Interview for Mental Status exam-completed A, B and G 10/19/22 -Therapy department providing a list of residents' schedules for therapy for each day to each nurse and Unit Manager and DON -Quality Assurance Meeting Held with IDT and Medical Director 10/18/22 and 10/21/22 included: On 10/24/22 staff interviews were conducted with 7-RN's, 1-LPN, 12-CNAs, 2 housekeepers, 1 receptionist, 2 Therapists, and the Activity director. All staff stated they had received education on Abuse & Neglect, Supervision of residents. The Nurses and the CNAs spoke about the importance of walking rounds at shift change and the supervision of the residents throughout the shift. Activity Director about diversion activities for residents with behaviors/ exit seeking. The staff were aware of the elopement books, that had the information of the residents at risk for elopement. The staff stated that Code Silver would be announced on the public address system for any missing resident and all staff would assist in the search for the missing resident. They spoke about participating in elopement drills. Elopement books were reviewed, and they had been updated with the residents identified by facility to be at risk for elopement. The front lobby was observed and there was control/button on the receptionist desk. The front lobby did not open automatically as persons approached; the receptionist had to open/close the door to let people in/out of the facility. Visitors were observed wearing green sticker as an identification. It was determined that the facility's Immediate Jeopardy at F689 was removed as of 10/24/22 but the non-compliance continued for F689 at a scope and severity of D, no actual harm with potential for more than minimal harm, that is not an Immediate Jeopardy.

Based on observation, interview and record review, the facility failed to ensure safe transfers of residents requiring mechanical lifts for 2 of 8 residents sampled for falls. The two residents endured serious injuries when Certified Nursing Assistants (CNAs) did not follow proper transfer techniques when using mechanical lifts, (#94 & #403). This failure resulted in resident #94 sustaining a laceration to her head requiring hospitalization and resident #403 sustaining a fracture of her right femur requiring hospitalization and surgical repair of the fracture. On 5/15/19 at 9:45 PM resident #94 sustained a fall when two CNAs used an improper sling/pad to transfer the resident from her wheelchair to the bed with a mechanical lift. The sling broke causing the resident to fall and hit her right forehead against the lift. The resident sustained [REDACTED]. On 5/25/19 at approximately 8:05 PM resident #403 was being transferred from her wheelchair to the bed with a sit to stand mechanical lift with one CNA. The resident fell and sustained a [MEDICAL CONDITION] femur requiring hospitalization and surgical repair. The facility's failure to provide safe transfers with mechanical lifts resulted in substandard quality of care at Immediate Jeopardy scope and severity of J starting on 5/15/19 and corrected on 5/31/19. The immediate Jeopardy was past non-compliance. Findings: 1. Resident #94 was a [AGE] year-old female initially admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment with a reference date of 2/26/19 identified the resident required total dependence of two staff for bed mobility, transfers, toileting, personal hygiene, and bathing. She was incontinent of bowel and bladder. She required a mechanical lift for all transfers and used a wheelchair for mobility on and off the unit. The Brief Interview for Mental Status (BIMS) score was 15 indicating no cognitive impairment. A review of the resident's plan of care indicated the resident was dependent on 2 staff to assist with bed mobility, turning or repositioning. She used a wheelchair for locomotion and required Total Mechanical Lift for transfers from bed and chair with the assistance of 2 staff using an extra large sling. The resident's weight documented for (MONTH) 2019 was 296.0 lbs. On 6/11/19 at 10:45 AM, resident #94 stated that on 5/15/19 at 9:45 PM, she was brought to her room to be transferred back to bed. She was positioned in her wheelchair inside her room between the foot of her bed and the shower door across from the foot of the bed. She was at a slight angle towards the bed. The CNAs removed the foot pedals from her wheelchair and then connected the mechanical lift to the handles of the pad that was underneath her. The two CNAs used the mechanical lift to transfer her from the chair to the bed. When she was halfway off the seat, (2 feet from the floor, measured with a facility measuring tape and validated by 1st floor Director of nursing (DON)), the handle of the pad broke and she fell to the floor on her right side. She hit her head on the mechanical lift during the fall to the floor which caused a laceration to her forehead. The CNAs called for the nurse who provided first aid for the bleeding from her forehead. The facility staff called 911 and the resident was sent to the hospital for evaluation. On 6/13/19 at 3:40 PM, Licensed Practical Nurse (LPN) staff [NAME] stated, I heard a CNA call me and when I entered the resident's room, I saw both CNAs with resident #94 on the floor on her right side. Her head was bleeding. I applied pressure to her forehead wound. I did not move her. The nursing supervisor staff F came to the room and explained to the resident she was going to the hospital to get checked out and the resident agreed. The CNAs told me they were trying to move her into the bed when the sling broke and she fell to the floor. On 6/13/19 at 4:11 PM, Registered Nurse supervisor (RN) staff F stated, I was down the hall when I saw LPN staff [NAME] run into resident #94's room. I went to the room to see what happened. I saw resident #94 on the floor in the supine position on her right side. There was blood on the mechanical lift cross bar between the two legs of the mechanical lift. I saw about a 9-inch puddle of blood on the floor. LPN staff [NAME] was on the floor next to the resident applying pressure to the resident's forehead. I went around the resident and got on the floor to assess specifically for neck injury and she denied neck pain. She also denied loss of consciousness. She was awake, alert and aware, and we made no attempt to move her. I gave direction to call 911 and followed up with the call. The ambulance arrived in about 10 minutes. I had no idea how she fell , I was focused on the resident and her condition. On 6/13/19 at 12:42 PM, RN staff G said, I was involved in the initial questioning and suspension of the CNA's from the morning and evening shifts. The CNA who had resident #94 on the morning of 5/15/19 said she went to the laundry room to get a mechanical lift sling and was given a pad with loop straps from the laundry aide. She thought it was okay to use. She used this pad/sling to transfer the resident from her bed to the wheelchair. This pad/sling remained on the wheelchair under the resident until the evening. Then the evening shift CNA's tried to transfer resident #94 back to bed for the night. They saw the pad/sling with the loop straps on the pad underneath the resident and thought it was okay to use because that was used to get her into the wheelchair that morning. On 6/11/19 at 3:37 PM, resident #94 said she knew the CNA's were using the wrong sling because her knees were drawn up to her chest when the staff were lifting her with the lift. Normally she was sitting up straight in the sling when being transferred. I told them it was the wrong sling when they lifted me up, but they didn't believe me. They just said don't worry it will be safe. After they lowered me into the wheel chair they said, see I told you it was safe. I forgot to tell the evening CNA's that it was the wrong sling and when they tried to transfer me from the wheelchair to the bed, it broke. I I fell to the floor and hit my head on the lift. On 6/12/19 at 10:00 AM, the executive director stated that, the two newly hired day shift CNA's who used the wrong mechanical lift sling for resident #94 were terminated because they had received training in the past 90 days and should have known to use the proper sling for our mechanical lifts. Our total mechanical lifts only use one type of sling. Resident #94 even told them that they were using the wrong sling but the CNA's didn't listen to her. The two evening shift CNA's that tried to transfer resident #94 back to bed using the mechanical lift with the wrong sling should have known better. They had been with the facility for years and had recent in-services on mechanical lifts, so they were also terminated. A prior in-service for Safe Resident Transfers-Body Mechanics was conducted on 2/12/19 through 2/26/19 for CNA staff was verified. On 6/12/19 at 5:07 PM, the executive director stated we are trying to identify where the transfer pad came from. We believe a resident must have been transported by emergency medical services to the facility using that sling. It was clearly marked, one time use only. It was sent to the laundry to be washed when it should have been discarded. The CNA who went to the laundry to request a mechanical lift sling said she was given the transfer pad. We could not identify the laundry aide who provided the CNA with the transfer pad. Resident #94 did confirm that she told the CNAs that the sling was not correct, but they continued to use it. The transfer pad was underneath her in the chair, and the 3 PM-11PM staff did not identify that it was the wrong sling. The resident at that time did not tell the evening staff about being on the wrong sling. We're not sure how the transfer pad actually got into the building, admissions concierge, and supervisors, suspect it occurred during an admission process. Review of the hospital history and physical dated 5/16/19 revealed grade 1 anterolisthesis C4 on C5 which is nonspecific but likely chronic and [MEDICAL CONDITION] in nature .The patient has a laceration to the right forehead that was repaired while in the ED. It was noted that the non displaced cervical fracture was not related to the resident's fall but was a chronic issue that the resident decided to have repaired while in hospital. A facility nursing progress note dated 5/20/19 indicated incision to right forehead measuring 1.2 centimeters (cm) in length by 2.5 cm in width. On 6/12/19 at 3:30 PM, resident #94 said now she makes sure the staff always use the extra-large sling for her and have been very good about transferring her. She said she feels confident being transferred with the mechanical lift if she makes sure they are using the extra-large dark blue banded sling for her. On 6/11/19 at 2:32 PM, the facility risk management specialist stated resident #94 weighed 296 lbs. and required a total mechanical lift for all transfers. On the morning of 5/15/19 2 CNAs used a non-facility transfer sling/pad to transfer the resident using the total mechanical lift to transfer her from the bed to the wheelchair without incident. EMT's (Emergency Medical Technicians) use these pads to pull residents into their beds from the stretcher and we had some in the building that had been laundered. The CNAs were both new and had started working at the facility in (MONTH) 2019. The two CNAs on the 3-11 shift who attempted to transfer the resident back to bed that evening were not new and should have known that the resident did not have the proper mechanical lift sling under her. They hooked the transfer pad to the total mechanical lift. While they were transferring the resident back in bed, the pad broke and the resident fell on to the floor. The CNAs notified the nurse and the resident was sent to the hospital. The laundry department was notified and shown the transfer pad and instructed to throw them away on sight. We in-serviced the CNAs on the proper slings to be used. We searched the building to look for other transfer pads that may be in the building but had not found any others. All four CNAs were suspended and later terminated. Investigation dates were from 5/16/19 through 5/28/19. 2. Resident #403 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 403's care plan for Activities of Daily Living (ADLs) dated 5/19/ showed staff to transfer the resident using total mechanical lift with 2 staff using a size large sling. A review of the annual Minimum Data Status (MDS) assessment dated [DATE] noted a score of 15 of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required extensive assistance of 2 staff members for transfers and assistance of 1 staff member for toilet use. Resident #403's significant change MDS assessment dated [DATE] showed she required extensive assistance of 2 staff persons for bed mobility, extensive assistance of 1 staff person for eating and she was totally dependent on 1 staff for toilet use. On 6/12/19 at 3:20 PM, resident #403 stated that she was dropped by the Certified Nurse Assistant (CNA) a few weeks ago. She stated there was 1 CNA who transferred her from her wheelchair to the bed when her foot got stuck. She stated her right foot came off the platform of the sit to stand lift during the transfer. She stated she called out to the CNA who was transferring her and operating the sit to stand mechanical lift. I called out, Wait, wait my foot is stuck underneath the lift. She stated the CNA disregarded what she was saying and continued to turn the sit to stand machine. She stated she heard a sound from her leg and she lowered herself to the floor while holding on to the bars with the strap around her upper abdomen. She stated her right knee was in a lot of pain when she was on the floor. A review of the nurse's progress notes dated 5/25/2019 showed the resident was admitted to the hospital with [REDACTED]. The x-ray results done at the facility on 5/25/2019 showed distal femur with a comminuted [MEDICAL CONDITION] shaft of the femur in anatomic position. The x-ray results from the hospital dated 5/26/2019 showed displaced [MEDICAL CONDITION] distal femoral mid diaphysis. On 6/13/2019 at 12:15 PM, Certified Nurse Assistant (CNA) staff M stated she was assigned to resident #403's care on 5/25/2019 during the 3:00 PM to 11:00 PM shift. She stated she was not the regular CNA for the resident. She said she worked mainly weekends throughout the facility on different floors. The CNA staff M stated that on the evening of 5/25/2019, she was assisting resident #403 back to bed from her wheelchair using a sit to stand lift. When she raised the resident up from the wheelchair, resident #403 started to cry out that her leg was bending. She stated she stopped turning the machine and lowered the resident to the floor. When she lowered the resident to the floor she noted the resident's right leg was bent outward. She called out for assistance and Nurse staff N responded. CNA staff M stated she was transferring the resident by herself and she should have had another staff to assist her during the transfer. She said that on 5/25/2019 resident #403 was in a rush to go to bed and she did not call for another staff to assist her as she should have. On 6/13/2019 at 12:15 PM, registered nurse, (RN) staff N stated she was responsible for resident #403 on 5/25/2019 on the 3:00 PM to 11:00 PM shift when she heard CNA staff M called for help from resident # 403's room. The RN staff N stated that when she went to the resident's room, she saw the resident sitting on the floor on the left side of the sit to stand lift. When she asked CNA staff M what happened, CNA staff M stated the resident lost her balance during the transfer and she lowered the resident to the floor. RN staff N said resident #403 was in a lot of pain but she did not want to go to the hospital. She stated that she the called a rapid response and nurse supervisor staff O responded. On 6/13/2019 at 4:29 PM, nurse supervisor staff O stated that on 5/25/2019 she responded to resident #403's room when she saw CNA staff M holding the back of the sit to stand lift and the resident was sitting on the floor on the left side of the machine between the lift and the bed. We assisted the resident to her bed using the total mechanical lift machine. Nurse supervisor staff O stated she told CNA she needed assistance of another staff to transfer resident #403 using the sit to stand lift. She said that CNA staff M did not transfer resident #403 safely on 5/25/2109. On 6/12/2019 at 5:07 PM, the Executive Director of Nursing (EDON) stated it was the facility's practice that 2 staff members must be present at all times to assist residents using any mechanical lift in the facility. She stated CNA staff M should have requested help to transfer the resident on 5/25/2019. On 6/12/2019 at 5:08 PM, the Administrator stated it was the facility's practice that 2 staff persons transfer residents when using a mechanical lift. He stated he did not know why the CNA did not ask for help. He had asked the CNA if there was enough staff and the CNA staff M said yes. She could not give a reason why she did not get assistance from another staff member. He stated he did not have a written policy that explained that 2 staff persons were required when transferring a resident using a mechanical lift. This was the facility practice and process. He stated that all staff received training of safe transfers during orientation and ongoing. He said that this has always been their process and practice to ensure the resident's safety with transfers. On 6/12/2019 at 2:21 PM, Nurse Practitioner P stated he knew resident #403 since she was admitted to the facility and continued to see the resident at least once per month. He said the resident recently reported she was not strong enough and she wanted an electric wheel chair. She complained of knee pain and generalized muscle pain due to [MEDICAL CONDITION]. He stated that the injury she sustained during the unsafe transfer could have been avoided. On 6/12/2019 at 2:21 PM, physical therapy director staff Q stated resident #403 could not pivot during transfers. She explained that the when the resident plants her foot down, she was not able to turn or pick up her foot to turn. This was the reason why the sit to stand mechanical lift was recommended for resident #403. The facility's client /Patient Transfers teaching showed staff to check the resident's care plan. Staff should know how to transfer the resident. It showed that although staff may think he/she was physically able to transfer a resident by him/herself, there may be other reasons why two caregivers were required. One of those conditions listed were severe [MEDICAL CONDITION]. The manufacturer general guidelines for the mechanical lift Using the sling, Standing sling showed the Individuals that use the standing sling must be able to support the majority of their own body weight otherwise injury can occur . Review of the facility's corrective measures revealed the following: An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 5/26/2019 with all department heads including the medical director to discuss resident #403's incident and implementation of corrective measures. The facility's QAA team identified the problem was the resident required to be transferred by mechanical lift and was transferred without the correct number of staff assistance. The goal was that residents requiring mechanical lift will be transferred safely using the lift and with the appropriate number of staff. They determined that the root cause of #403's injuries was that staff did not ensure that resident had the appropriate number of staff during transfer using a sit to stand mechanical lift. They did a full house sweep to validate resident transfer status. They performed a review of all resident transfer status and updated the resident's Kardex, care plans and Minimum Data Set (MDS) assessments. They started education for all staff on identification of patient transfer status and on proper transfer techniques. They initiated weekly audits to ensure compliance for residents with specific mechanical lifts, accurate number of staff member and proper technique and will continue this for 3 months and then monthly for 6 months. QAA meeting will be updated on the results monthly. Interviews conducted with CNAs, RNs, LPNs and laundry aides verified training. On 6/12/19 at 11:30 AM, laundry aide H stated, we had in-service for the mechanical lift slings, we are not supposed use any other sling types that are not from the facility. On 6/12/19 at 11:36 AM, laundry aide J stated, yes we had in-service on how to wash and check mechanical lift slings and not to use any other slings that are not from the facility. We are to throw them away if we see them. On 6/12/19 at 11:40 AM, laundry aide K stated, we have a mechanical lift sling cleaning schedule. We are supposed to throw out any other sling types if they come down to the laundry unless they the facility slings. I have never seen another type of sling come to the laundry. On 6/12/19 at 11:59 AM, the laundry manager stated we just started a numbering system since the incident happened. Sometimes sling/pads come in to the laundry from outside the facility and we throw them out. Review of the in-service education noted, Safe Resident Transfers-Body Mechanics and Mechanical Lifts were conducted for 130 CNA's and Procedure for Laundering of Slings and Heat were completed for the 7 Laundry staff. The education included how to identify the correct lift and sling size by matching the color-coded sticker to the color of the piping on the sling. In-services were conducted on 5/16/19 and 5/17/19 and were verified. On 5/16/19 an audit was completed for all mechanical lifts on each unit to ensure operating condition. The current weight audit was completed for all residents requiring mechanical lift transfers. On 5/16/19 an audit was completed to ensure care plans for residents needing mechanical lift transfers were updated to include size of sling needed. The audit also determined residents that required the use of mechanical lifts for transfers. On 5/22/19 through 6/13/19, audits continued for residents requiring mechanical lifts to include current plan of care and Kardex care plan used by the CNAs for resident transfer status, type of lift used, resident appropriately transferred by staff, and sling size identified on care plan and Kardex.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls with injuries for 2 of 5 sampled residents reviewed for falls (#1 & 5). The facility failure to provide adequate supervision to prevent falls caused actual harm to resident #1 and #5. Resident #1 had 9 falls, each one resulting in more severe injuries. The last fall resident #1 experienced resulted in a fractured right clavicle, hematoma, and laceration to the right parietal region back of the head. Resident #5 experienced 2 falls in which the last one resulted in head injuries requiring hospitalization . Findings: 1. Resident #1 had a history of [REDACTED]. A review of the incident log showed that the resident had 4 falls from July to November 2014. Review of the fall care plan, initiated on 8/24/14 and revised on 11/20/14, included the following: "At risk for fall or fall related injury because of history of fall prior to admission, history of previous fall, cognitive impairment r/t (related to) dx (diagnosis) of dementia....hx (history) of fracture related to previous fall, unsteady gait, impaired balance, poor safety awareness, poor impulse control, muscle weakness....use of antidepressant med (medication)...incontinence attempts to get out of bed without waiting for assistance." Interventions included: "Don't leave bedside when providing care with resident in bed (11/03/14)....Frequent observation (6/18/14)....Anticipate and meet the resident's needs (8/24/14)....Bed maintained in low position while resident in bed (6/18/14)....Report to physician any side effects associated with the resident's medication (11/03/14) A review of the nurse's note showed that on 7/12/14 at 7:45 PM, the resident's bed alarm sounded and the resident was found sitting on the floor mat with her back to the bed. She did not sustain any injuries. Nurse's note on 7/22/14 at 7:45 PM, the resident was found on the floor near her roommate's bed on her right side. She sustained a fractured right clavicle and a hematoma and laceration to the right parietal region, back of the head. The resident sustained [REDACTED]. She was found sitting on the floor next to her wheelchair in the hallway in front of the nursing station with the wheelchair tray on the floor. There were no injuries. On 11/02/14 at 8 AM, the resident fell in her room. Certified nursing assistant (CNA) B was in the room getting ready to wash resident while she was sitting on the edge of the bed. The CNA went to the sink to fill the basin with water. The resident attempted to stand up and fell hitting the right side of her head on the bed rail. The CNA did not witness the fall, but heard the resident fall. The resident sustained [REDACTED]. A review of the falls showed that 3 out of the 4 falls occurred between 7:45 PM-9:05 PM. There was no documentation to reflect that an assessment of the falls had been done. There were no interventions on the care plan regarding any new or revised interventions to prevent falls or to show that the resident should be monitored closely during these times. An interview was conducted with the director of nursing (DON) on 11/20/14 at 4:30 PM. She stated that the resident was on one-to-one (1:1) constant supervision around the clock to prevent falls for more than a year. She said then there was a change in administration, a meeting was held, and the 1:1 supervision was discontinued in January 2014. When asked what lead to the discontinuation of the constant supervision, she could not provide any documentation except to say that it was financial and the facility could no longer pay for it. She said now the resident's room is in front of the nurses' station, so she can be observed more closely. When asked how frequently she is observed by the CNA, she stated about every half hour. An interview was done with the risk manager and DON on 11/20/14 at 2 PM. When asked what was being done to provide adequate supervision to prevent falls, the risk manager said that the resident was being monitored frequently as per care plan. The care plan read "frequent observations" but the risk manager, DON and administrator could not verify what frequent observations meant. The risk manager stated that it could be every 15 minutes or every hour depending on the resident. When asked about resident #1, the risk manager stated that the resident was observed every 15 minutes. When asked about the documentation to verify that the resident was observed every 15 minutes, the risk manager could not provide any. She provided blank forms of close observation records, but these were not implemented for resident #1. In an interview on 11/21/14 at approximately 2:25 p.m., the risk manager revealed that on 11/02/14 at 8 AM, the resident fell in her room. CNA B was in the room getting ready to wash the resident while she was sitting on the edge of the bed. The CNA went to the sink to fill the basin with water. The resident attempted to stand up and fell , hitting the right side of her head on the bed rail. The CNA did not witness the fall, but heard the resident fall. The resident sustained [REDACTED]. Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On initial admission, the resident was placed on one-to-one (1:1) supervision, meaning there was always a staff with the resident to ensure close supervision was provided to prevent falls. There was no record of an interdisciplinary care team (IDT) meeting that determined that she required supervision at all times. This was decided by the former administrator. The 1:1 supervision continued until the end of December 2013, when a new administrator came to the facility and discontinued all 1:1 supervision for residents at risk for falls. There was no IDT meeting that determined the 1:1 for the resident would be discontinued. In an interview on 12/11/14 at 10:35 a.m., the DON stated there was no facility policy to place any resident on 1:1 supervision. Review of the care plans initiated on 8/24/13 assessed the resident as at risk for falls because of history of fall with fracture prior to admission, cognitive impairment, unsteady gait, poor impulse control, muscle weakness, and poor safety awareness. Review of the nurses' notes indicated that as soon as the 1:1 supervision was discontinued, the resident fell several times as follows: On 1/01/14, the resident was found on the floor at 8:30 p.m. there were no injuries sustained. The resident was found on the floor again on the following dates: 1/10/14, 1/14/14, 1/25/14. On 1/25/14, the resident was found on the floor and sustained a small bump on the forehead. The care plans were updated on 1/14/14 to assist the resident to activities, place floor pads to both sides of the bed while in bed, and a scoop mattress with bilateral U shaped bars. On 4/21/14, the resident was found on the floor with no injuries. On 6/08/14, the resident was found on the floor and nurses' notes documented she wanted to go to the bathroom. On 7/12/14 at 7:45 PM, the resident's bed alarm sounded and the resident was found sitting on the floor mat with her back to the bed. She did not sustain any injuries. On 7/22/14 at 7:45 PM, the resident was found on the floor near her roommate's bed on her right side. At that time she sustained a fractured right clavicle, hematoma and laceration to the right parietal region back of the head. The resident was referred to an orthopedic specialist and a sling to the right shoulder was ordered. Nurses' documentation dated 7/24/14 indicated the resident complained of right shoulder pain and bruise was still evident on the right shoulder. She was sent out to the hospital on [DATE] for difficulty of breathing and was wheezing. The resident was readmitted to the facility on [DATE] and was referred to physical therapy for rehabilitation therapy for transfer training and ambulation. Review of the physical therapist's (PT) note dated 8/04/14 read, "Lumbar/ lateral support removed, front anti-tippers readjusted and lap tray fitted for a secure fit. Patient slightly reclined and able to tolerate upright seated posture with no lateral lean to right." On 8/06/14, PT documented, "Patient positioned in wheelchair with tray for safety. Patient required occasional readjustment to correct posture to midline. CNA and nursing unit manager education were provided with instructions for use of wheelchair tray." On 8/05/14 at 2:11 p.m. nurses' notes read, "Spoke with resident's responsible party regarding therapy recommendations of changing from Broda (recliner) chair to special wheelchair with tray; advised that tray is considered a restraint, reviewed risks and benefits. Family consented to change of chair and tray." On 8/07/14, nurse's note at 7:04 p.m. read, "Resident attempted several times to slide out of chair, keep removing lap tray, close supervision provided." On 8/14/14, nurse's note read, "Resident remains non compliant, not easy to redirect. She frequently removed the lap tray and tried to get out from the chair." There was no documentation that the therapist was informed to make adjustments to prevent any future falls. On 8/15/14 at 9:20 p.m., nurse's note indicated that the resident was found sitting on the floor next to her wheelchair in the hallway. The wheelchair tray was off. No injuries were seen. In an interview on 12/11/14 at 2 p.m., the PT stated after the fall on 8/15/14, new orders were to make the right shoulder non-weight bearing. Review of the care plans did not reveal any new updates or revisions to the existing fall interventions, which were not effective to prevent further falls. Nurse's note on 8/22/14 documented that resident continued to take the tray off the wheelchair. The last revision of the care plan was dated on 6/18/14 with interventions to provide environmental adaptations, maintain the bed in the low position while the resident was in bed, and observe frequently. In an interview with the DON on 12/11/14 at 10:45 a.m., she stated the "Frequent Observation Worksheet" was not part of the medical record and therefore was shredded. She validated that the facility did not keep the records but they have been checking on the resident at least every 15 minutes. At around 2 p.m. on 12/11/14, the administrator presented several frequent observations worksheet for resident #1. These worksheets were not consistent and complete. On the dates that the resident fell , there were no records available to review. Review of the nurse's note dated 11/02/14 at 8:49 a.m. read, "Reported by CNA resident had attempted to stand up and lost her balance sliding to floor bumping right side of her head on bed rail. Resident sitting on floor mat resting on side of bed." In an interview on 12/11/14 at 12:47 p.m., CNA B said the resident was lying down flat in a low bed with floor mats and she saw her attempting to get out of bed but was unable to prevent the fall. The resident was impulsive and quick and she was already on the floor mats and had hit her head on the quarter rail of the bed before she could get to her. An observation was conducted at the same time, in the room were the resident had fallen. The sink was approximately 9 feet away from the bed. The CNA demonstrated that she saw the resident attempting to get up but validated she did not drop what she was doing. The CNA had two conflicting versions of the fall, based on information she provided the licensed nurse and was documented in the nurses' progress notes and the personal interview with her on 12/11/14. Review of the last minimum data set (MDS) assessment (annual/comprehensive) dated 8/09/14 indicated the resident required extensive physical assistance of 2 people for bed mobility, toileting, and personal hygiene. The Falls History section was blank, and falls since admission/entry or reentry or the prior assessment was answered "0" or no. The MDS dated [DATE] revealed "0" under the Falls History section and falls since admission/entry or reentry or the prior assessment was answered "0" or no. On 11/02/14, the CNA should have had another staff person with her to assist her during personal hygiene providing a wash in bed since the resident was assessed as requiring 2 persons for bed mobility and personal hygiene The staff was aware and identified the resident with impulsive behavior but did not provide the appropriate staffing numbers. In an interview on 12/11/14 at 1:30 p.m., the risk manager stated that each fall was from a different origin, was investigated and assessed but there were no changes in interventions were made to ensure adequate supervision was provided. There was no documentation in the nurses' progress notes or the medical record to reflect that an assessment of the previous falls were conducted. The resident fell nine times but the care plans were not revised and new interventions were not in place to prevent falls or to show that the resident should be monitored closely during these times. When asked what was being done to provide adequate supervision to prevent falls, the risk manager said that the resident was being monitored frequently as per care plan. 2. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plans dated 10/08/13 assessed the resident as at risk for falls and self- care deficit as evidenced by inability to complete activities of daily living (ADLs) related to impaired cognition. A brief interview of mental status (BIMS) score was 13/15 (15 is alert & oriented), episodes of forgetfulness, glaucoma with gait and balance problems, use of psychotropic and diuretic medications. Interventions included to assist with ADLs as needed, educate resident with assistance prior to ambulation, encourage resident to wear nonskid socks, lock the brakes on the bed and chair before transferring, anticipate and meet the resident's needs, remind the resident and reinforce safety awareness because of impaired mobility and forgetfulness at times, assistance of 1 staff participation with transfers and locomotion, use wheelchair or walker, provide assistance with ADL functions (personal hygiene, transferring, and toileting). The last quarterly MDS assessment dated [DATE] for functional status on ADL self-performance for toileting, coded the resident as a "3", meaning the resident required extensive assistance, staff to provide weight-bearing support. ADL support provided coded the resident as "2" meaning he required one person physical assistance. Review of the nurse's note dated 10/11/14 at 2 a.m. indicated the resident was found on the floor, lying on the left side on floor near bed. The resident stated he was going to the bathroom. There were no documented injuries at that time. Nurse's documentation on 11/13/14 at 8:39 p.m. read, "Called to resident's room at 6:40 p.m. Resident was lying on left side on floor. He stated that he lost his balance while going to the bathroom. He denied loss of consciousness or hitting head. Body audit revealed tiny abrasion to right hand and larger abrasion to right upper side. Measurements 4 cm. (centimeter) x 2 cm. The resident stated that he scratched right side on the head board during fall. Assisted to standing position by 3 persons and returned to bed. MD informed. Order received to skin prep abrasions." The resident was referred to the PT for rehabilitation after the fall on 11/13/14. The start of care by the PT was conducted on 11/18/14, 5 days after the fall. The PT documented on 11/18/14 that the resident was referred to skilled physical therapy services secondary to a fall in his room while ambulating. The resident now presents with new onset of right shoulder pain and weakness that is contributing to the resident's increased need for caregiver assistance, decreased functional mobility and increased risk for falls. On 12/10/14 at 10:30 p.m., the nurse's note indicated the resident was found at 9:30 p.m. sitting on the floor by table lamp holder with a skin tear on the right upper eyelid. "He stated he slipped on the floor while going to the bathroom. Vital signs were obtained B/P 118/77 pulse - 89, resp - 18, and oxygen sat (saturation) 97%. Normal range for B/P = 120 (systolic)/80 (diastolic); pulse = 50-80 per minute; respirations = 16-20 per minute (medscape.com); oxygen saturation = 95%-100% (about.com). Alert and oriented x 3 and extremities checked denies pain and icepack applied to upper eyelid. Neurochecks initiated." The registered nurse documented at 9:45 p.m. that she was called to assess the resident post fall. The resident had a laceration to the right eyelid, the sclera of right inner eye was completely red, and there was red discoloration to right side of forehead, bridge of nose, and left cheek. At 10:30 p.m. on 12/10/14, 911 was called when the B/P dropped to 70/40. The resident was admitted to the hospital. In an interview with the administrator on 12/11/13 at 2:45 p.m., he was informed of the following concerns: The resident had a history of [REDACTED]. Post fall assessment was not conducted after the fall, and care plans were not updated to provide measures to prevent further falls. The resident had fallen twice on the evening shift and had been identified that he was on the way to use the bathroom. There were no measures in place to ensure the resident was provided the services that he needs for toileting. This was not brought up in the facility's meetings, and the facility allowed the resident to continue going to the bathroom unsupervised and unattended. The resident was assessed as requiring supervision/assistance with 1 physical assist with transfers but this service was not provided. There were no interventions/services implemented to prevent the third fall that caused injuries and harm to the resident. The administrator further stated they have stand up meetings "minute meeting Quality Assurance Performance Improvement (QAPI) focus" every shift on each floor to discuss fall risk, recent fall, poor safety awareness. However, the issue with the falls of resident #5 was not discussed, and there were no preventative measures provided until he sustained injuries and was sent out to the hospital. Review of the facility policy for "Fall and Injury Management", effective date January 2006, read in part that the facility "strives to reduce the risk for falls by promoting the implementation of the risk reduction. The IDT works with the resident and family to identify and implement appropriate interventions to reduce risk of falls or injuries while maximizing dignity. Evaluate and review risk factors for falls. Review the plan of care read in part, "adjust/add interventions on the plan of care."