Every finding on record at Palatka Center for Rehabilitation and Healing

Based on observation, interview, and record review the facility failed ensure residents' records were complete and accurate for 5 of 7 residents, Residents #49, #58, #132, #161, and #150, reviewed for documentation. Findings include: 1) During an observation on 7/13/2026 at 9:56 AM Resident #161 had a wound dressing on the resident's left ankle. The wound dressing was dated 7/11. [Photographic evidence obtained] During an observation on 7/14/2026 at 9:00 AM Resident #161 had a wound dressing on the resident's left ankle. The wound dressing was dated 7/11. During an interview on 7/14/2026 at 9:00 AM Resident #161, stated, They have not changed my dressing and I need them to change it. Review of Resident #161's physician order dated 7/7/2026 read, Apply betadine to left ankle and cover wth {sic} tegaderm every day shift. Review of Resident Treatment Record for the month of July for dressing changes of to the left ankle documented dressing changes were completed on 7/12/2026, 7/13/2026, and 7/14/2026. During an interview on 7/15/2026 at 9:09 AM Staff E, Licensed Practical Nurse (LPN), stated [Resident #161's name] has orders to change the dressing every day. If the wound doctor rounds, they will do the dressing if not the cart nurse is responsible. I did not change the dressing on Monday [7/13]. I do not remember seeing the dressing order. I do not know why it would have a check mark. During an observation on 7/15/2026 at 9:09 AM with Staff E, LPN, Staff E, LPN confirmed the wound dressing was dated 7/11/2026. During an interview on 7/16/2026 at 10:23 AM Staff F, Registered Nurse (RN) stated, A check mark would mean the treatment was completed. I might have misread what it said or got confused with the area. 2) During an observation on 7/13/2026 at 10:55 AM Resident #132 was lying in bed. There was a wound dressing to the resident's left arm. The wound dressing was not dated and dark dried drainage on the lower right side of the dressing. The dressing was not dated or initialed. [Photographic evidence obtained] During an interview on 7/13/2026 at 10:55 AM Resident #132 stated, I have a skin tear on my arm and had sutures removed from my leg. They did the wound dressing changes on Saturday (7/11/2026). During an observation on 7/14/2026 at 9:06 AM Resident #132 was lying in bed. There was a wound dressing on the resident's left arm that was not dated and had dark dried drainage on the lower right side of the dressing. The dressing was not dated or initialed. [Photographic evidence obtained] During an interview on 7/14/2026 at 9:06 AM Resident #132 stated, The nurses have not changed the dressing on my arm or leg. Review of Resident #132 physician order dated 4/21/2026 read, Cleanse skin tear to left arm with wound wash; pat dry; apply TAO [triple antibiotic ointment] and a dry dressing every day shift. Review of Resident #132 Medication Administration Record for the month of July 2026 documented left arm skin tear wound care was completed on 7/12/2026, 7/13/2026, and 7/14/2026. During an interview on 7/15/2026 at 9:50 AM Staff G, Licensed Practical Nurse stated, Yesterday the wound care team rounded, and they are the ones who do the wound care on Tuesday. I did not do her wound care yesterday it should have been the wound care team or the wound care nurse that was just hired. The dressings should be dated and initialed and the dressing should have been changed. During an observation on 7/15/2026 at 9:50 AM with Staff G, LPN, Staff G, LPN confirmed the wound dressing on the resident's left arm was not dated and was soiled and the wound dressing to the resident's right foot was dated 7/11/2026. [Photographic evidence obtained] During an interview on 7/15/2026at 9:48 AM the Director of Nursing stated, A check mark means the wound dressing was completed. I would expect staff to document accurately. Review of the facility policy and procedure titled, Skin Care and Wound Management with a last review date of 1/20/2026 read, Policy: The facility will manage wound care based upon current standards of practice. Procedure: 3. The treatment order will be documented on the Treatment Administration Record. Review of the facility policy and procedure titled, Clinical Documentation with a last review date of 1/20/2026 read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary the members. 3) During an observation on 7/13/2026 at approximately 11:00 AM, Resident #49 was sitting up in bed. He was dressed in street clothes, and his wife was sitting with him. Resident #49 had a gauze wound dressing on his left wrist with a reddish-brown substance observed. The dressing had a date of 7/11. During an interview on 7/13/2026 at approximately 11:00 AM, Resident #49 stated that he had asked to have his nails trimmed and that he scratched himself. Resident #49's wife confirmed that he had scratched himself, and said his bandage was changed Saturday. Review of Resident #49's care plan documented Focus – [Resident #49's name] is at Risk for Impaired Skin Integrity. Interventions included - Evaluate skin; Provide skin care per facility guidelines and PRN (as needed). Focus - The resident has a Skin Tear/potential for skin tear of the right arm above wrist. Focus – [Resident #49's name] has potential/actual impairment to skin integrity r/t (related to) peripheral vascular disease, chronic kidney disease, Stage 3. Interventions included – Treatment as ordered (see MD (medical doctor) order for most current order) Review of Resident #49's physician orders dated 7/08/2026 read, Cleanse lower right forearm with wound cleanser, pat dry, apply dry dressing. Cleanse right hand (between thumb and index finger) with wound cleanser, pat dry, apply dry dressing every shift for skin tears Review of Resident #49's MAR/TAR (Medication Administration Record/Treatment Administration Record) from 7/07/2026 through 7/15/2026 read, Cleanse lower right forearm with wound cleanser, pat dry, apply dry dressing. Cleans right hand (between thumb and index finger) with wound cleanser, pat dry, apply dry dressing. every shift for skin tears. There was documentation of wound care and dressing changes each shift, three times daily, on 7/11/2026, 7/12/2026, and 7/13/2026. During an observation on 7/13/2026 at approximately 3:00 PM Resident #49 was lying in bed with his eyes closed. He had a gauze wound dressing on his left lower forearm/wrist that was dated 7/11. During an interview on 7/16/2026 at 1:08 PM Staff B, LPN stated that she had worked with Resident #49 on the night shift on 7/12/2026. She was not sure whether she provided wound care or a new dressing for him. If a medication or treatment was signed off on the MAR/TAR, it meant that I did it. During an interview on 7/16/2026 at 3:00 PM Staff C, LPN stated that she had worked with Resident #49 over the past weekend. She believed she had provided wound care and applied a dressing on Saturday night but not on Sunday. She did not use plain gauze for a dressing on the wrist. 4) During an observation on 7/13/2026 at 10:29 AM, Resident #58 had a wound dressing on to the left upper arm. The wound dressing was dated 7/11/2026. During an interview on 7/13/2026 at 10:29 AM, Resident #58 stated that they were changing the dressing every 2 days. Review of Resident #58's care plan read, Focus: for Impaired Skin Integrity. Interventions included – Provide skin care per facility guidelines and PRN (as needed). Focus – The resident has a skin tear of left upper arm. Interventions included - Treatment as ordered (See MD order for most current order) Review of Resident #58's physician orders dated 6/23/2026 read, Skin tear to left upper arm: Cleanse with wound cleanser, pat dry, apply Medi honey, cover with silicone bordered foam dressing until healed every day shift Review of Resident #58's MAR/TAR from 6/01/2026 documented an entry that read, Skin tear to left upper arm: Cleanse with wound cleanser, pat dry, apply Medi honey, cover with silicone bordered foam dressing until healed every day shift. There was documentation of daily treatment as ordered from 6/24/2026 through 7/14/2026, with the exception of documentation of resident refusal on 7/02/2026. 5) During an observation on 7/13/2026 at approximately 10:30 AM Resident #150 was sitting in his wheelchair beside his bed with the television on. He was dressed in street clothes and was wearing non-slip socks. During an interview on 7/13/2026 at approximately 10:30 AM Resident #150 stated, I can't get anyone to put on my compression socks. It's been about three days. My cardiologist told me I should wear them [the compression socks] every day. Review of Resident #150's MDS, a quarterly assessment dated [DATE] documented his BIMS Score as 12 out of 15 which indicated he had some mild cognitive impairment. He required partial to moderate assistance for bathing and putting on/taking off footwear. Review of Resident #150's care plan documented Focus - Risk for Impaired Skin Integrity. Interventions - Apply knee high compression socks during day. Remove at night. Focus - The resident is on diuretic therapy r/t (related to) edema/swelling. Review of Resident #150's physician order read, Apply knee high compression socks during day. Remove at night one time a day for circulation remove at night. Review of Resident #150's physician order read, Remove knee high compression socking {sp.} at night in the evening for edema. Review of Resident #150's MAR/TAR from 7/01/2026 through 7/16/2026 read, Apply knee high compression socks during day. Remove at night one time a day for circulation remove at night. There was documentation of application of the compression socks daily. During an observation on 7/14/2026 at 4:39 PM Resident #150 was sitting in his wheelchair. He was dressed in street clothes and wearing non-slip socks. During an interview on 7/15/2026 at approximately 10:00 AM the Director of Nursing stated that a check mark on a resident's MAR/TAR indicated the medication or treatment was administered. The expectation was that nurses accurately document what they did. If there was a question about the order, the nurse is expected to get clarification from the provider. During an interview on 7/15/2026 at 2:35 PM Staff G, LPN stated, a check mark on the MAR or TAR meant completed (medication or treatment administered). If there was an error or could not be completed after it was documented, the nurse has to go back in and strike it (the check mark) out. If there was a question about an order, the nurse is supposed to contact the DON and confirm the order with the doctor. Based on what the doctor said, the nurse would change or leave the order. During an observation on 7/16/2026 at 12:15 PM Resident #150 was assisted out of his bed into his wheelchair. He was dressed in street clothes and non-slip socks. A pair of knee-high compression socks/stockings were laying on the dresser in Resident #150's room. (Photographic evidence obtained) During an interview on 7/16/2026 at 12:20 PM Resident #150 stated that it had been days since anyone had assisted him to put on his compression socks. He was not able to put them on or take them off by himself. During an interview on 7/16/2026 at 12:25 PM Staff H, CNA stated that she regularly worked with Resident #150. She had not put his compression socks on today. She did not remove the compression socks, and he could not remove them himself. 6) Review of Resident #7's physician order dated 5/01/2026 read, Novolog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart): Inject subcutaneously three times a day for Diabetes - Inject as per sliding scale: if 0 - 150 = 0 units if blood sugar reads less than 70, initiate hypoglycemic protocol and notify MD [Medical Doctor]; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 8units; 301 - 350 = 10 units if blood sugar reads greater than 350 give 10 units and notify MD, subcutaneously three times a day for Diabetes Review of Resident #7's MAR/TAR from 5/01/2026 through 5/31/2026 read, NovoLog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML Inject as per sliding scale: if 0 - 150 = 0 units if blood sugar reads less than 70, initiate hypoglycemic protocol and notify MD; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 8units; 301 - 350 = 10 units if blood sugar read greater than 350 give 10 units and notify MD, subcutaneously three times a day for Diabetes. Dated 5/16/2026, 5/18/2026, 5/22/2026, 5/27/2026 5/31/2026 at 0600 [6:00 AM] and 5/12/2026, 5/13/2026, 5/16-18/2026, 5/21/2026, 5/22/2026, 5/26/2026, and 5/27/2026 at 2200 [10:00 PM] blood sugar results were in the range requiring insulin coverage per the physician. Documented for the administration was a 9 (Other/See Nurse Note). Review of Resident #7's nurse progress notes from 5/01/2026 through 5/31/2026 showed there were no notes documenting why the physician order was not followed for the administration of insulin. Review of Resident #7's MAR/TAR from 6/01/2026 through 6/30/2026 read, NovoLog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML Inject as per sliding scale: if 0 - 150 = 0 units if blood sugar reads less than 70, initiate hypoglycemic protocol and notify MD; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 8units; 301 - 350 = 10 units if blood sugar read greater than 350 give 10 units and notify MD, subcutaneously three times a day for Diabetes. Dated 6/6/2026, 6/7/2026 at 0600 and 6/1/2026, 6/6/2026, and 6/7/2026 at 2200 blood sugar results were in the range requiring insulin coverage per the physician. Documented for the administration was a 9 (Other/See Nurse Note). Review of Resident #7's Progress Notes from 6/01/2026 through 6/30/2026 showed there were no notes documenting why the physician order was not followed for the administration of insulin. During an interview on 7/15/2026 at approximately 10:00 AM the Director of Nursing stated the expectation is ordered treatments are to be administered. For residents with sliding scale insulin, the dosage of insulin needs to be documented on the MAR. If the resident did not require insulin coverage, a numeric chart code could be documented to indicate that no coverage was needed or administered. During an interview on 7/15/2026 at approximately 3:00 PM the Director of Nursing stated after reviewing Resident #7's chart, she could not determine what doses of insulin, if any, were administered for the 19 occurrences of a chart code of 9 between 5/01/2026 and 6/30/2026. During an interview on 7/16/2026 at approximately 12:00 PM Staff K, LPN stated, there was not a reason to use the numeric code 9, but if it was used, a note should be written. During an interview on 7/16/2026 at 3:00 PM Staff C, LPN stated that during May and June she had not been following proper documentation procedures when documenting on Resident #7's sliding scale insulin order. Review of the policy and procedure titled, Medication Administration General Guidelines with the last review date of 1/20/2026 read, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedure: A. Preparation 4) Five Rights - Right resident, right drug, right dose, right route and the right time, are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. D. Documentation (including electronic) 1) The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. Review of the policy and procedure titled, Wound Care and Dressings Change, Dry/Clean, with the last review date of 1/20/2026 read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. The name and title (or initials) of the individual changing the dressing. 5. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. Reporting. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview and record review the facility failed to ensure wound care dressing changes were provided per physicians' orders for 4 of 7 residents, Resident #49, #58, #132, and #161 reviewed for skin conditions and failed to apply compression stockings per they physician order for 1 of 3 residents, Resident #150 reviewed for edema.Findings include: 1) During an observation on 7/13/2026 at 9:56 AM Resident #161 was lying in bed. There was a wound dressing on the resident's left ankle. The wound dressing was dated 7/11. [photographic evidence obtained] During an observation on 7/14/2026 at 9:00 AM Resident #161 was lying in bed. The resident had a wound dressing to the left ankle that was dated 7/11/2026. During an interview on 7/14/2026 at 9:00 AM Resident #161, stated, They have not changed my dressing, and I need them to change it. Review of Resident #161's physician order dated 7/7/2026 read, Apply betadine to left ankle and cover wth [sic] Tegaderm every day shift. During an interview on 7/15/2026 at 9:09 AM Staff E, Licensed Practical Nurse (LPN), stated [Resident #161's name] has orders to change the dressing every day. If the wound doctor rounds, they will do the dressing if not the cart nurse is responsible. I did not change the dressing on Monday [7/13]. I do not remember seeing the dressing order. During an observation on 7/15/2026 at 9:09 AM with Staff E, LPN, Staff E, confirm the wound dressing was dated 7/11/2026. 2) During an observation on 7/13/2026 at 10:55 AM Resident #132 was lying in bed. There was a wound dressing to the resident's left arm. The wound dressing was not dated and had dark dried drainage on the lower right side of the dressing. The dressing was not dated or initial. [Photographic evidence obtained] During an interview on 7/13/2026 at 10:55 AM Resident #132 stated, I have a skin tear on my arm and had sutures removed from my leg. They did dressing changes on Saturday [7/11/2026]. During an observation on 7/14/2026 at 9:06 AM Resident #132 was lying in bed. A wound dressing was observed to the resident's left arm. The wound dressing was not dated and had dark dried drainage on the lower right side of the dressing. The dressing was not dated or initial. [Photographic evidence obtained] During an interview on 7/14/2026 at 9:06 AM Resident #132 stated, The nurses have not changed the dressing on my arm or leg. Review of Resident #132's physician order dated 4/21/2026 read, Cleanse skin tear to left arm with wound wash; pat dry; apply TAO [triple antibiotic ointment] and a dry dressing every day shift. Review of Resident #132's progress note dated 7/11/2026 read, 14 sutures removed from right lower leg. No bleeding or discharge observed. Skin is dry and intact. Covered with dry absorbent dressing and rolled gauze. Review of Resident #132's physician order did not document an order for dressing changes from 7/11/2026 to 7/13/2026 for the resident's lower right leg. During an interview on 7/15/2026 at 9:50 AM Staff G, Licensed Practical Nurse stated, Yesterday the wound care team round and they are the ones who do the wound care on Tuesday. I did not do her wound care yesterday it should have been the wound care team or wound care nurse that was just hired. The dressings should be dated and initialed and the dressing should have been changed. During an observation on 7/15/2026 at 9:50 AM with Staff G, LPN, Staff G, confirmed the wound dressing on the resident's left arm was not dated and was soiled and the wound dressing on the resident's right foot was dated 7/11/2026. [Photographic evidence obtained] During an interview on 7/15/2026at 9:48 AM the Director of Nursing stated, Dressing orders should be done as ordered. There should always be an order in place for wound care. The dressing should be dated and initialed. Review of the facility policy and procedure titled, Skin Care and Wound Management with a last review date of 1/20/2026 read, Policy: The facility will manage wound care based upon current standards of practice. Procedure: 2. Physician order will be obtained based on the selected protocol. 3) During an observation on 7/13/2026 at approximately 11:00 AM, Resident #49 was sitting up in bed. He was dressed in street clothes, and his wife was sitting with him. He had a gauze wound dressing on his left wrist with a reddish-brown substance observed. The wound dressing had a date of 7/11. During an interview on 7/13/2026 at approximately 11:00 AM, Resident #49 stated that he had asked to have his nails trimmed and that he scratched himself. Resident #49's wife confirmed that he had scratched himself, and said his bandage was changed Saturday. Review of Resident #49's medal record documented the resident was admitted on [DATE] with a readmission on [DATE] with medical diagnoses that included nondisplaced zone II fracture of sacrum, subsequent encounter for fracture with routine healing (primary); repeated falls; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; need for assistance with personal care; peripheral vascular disease, unspecified Review of Resident #49's Minimum Data Set (MDS), Medicare 5-day assessment dated [DATE] documented the resident has a BIMS (Brief Inventory of Mental Status) Score of 5 out of 15 which indicated he had significant cognitive impairment. Review of Resident #49's Care Plan documented Focus – [Resident #49's name] is at Risk for Impaired Skin integrity. Interventions included: Evaluate skin; Provide skin care per facility guidelines and PRN (a needed). Focus - The resident has a Skin Tear/potential for skin tear of the right arm above wrist. Interventions included - 7/6/26 Offer nail care as needed to reduce risk of scratching or injury from picking at skin. Focus – [Resident #49's name] has potential/actual impairment to skin integrity r/t (related to) peripheral vascular disease, chronic kidney disease, State 3. Interventions included – Treatment as ordered (see MD [medical doctor] order for most current order). Review of Resident #49's physician orders dated 7/08/2026 read, Cleanse lower right forearm with wound cleanser, pat dry, apply dry dressing. Cleans right hand (between thumb and index finger) with wound cleanser, pat dry, apply dry dressing every shift for Skin tears. During an interview on 7/15/2026 at approximately 10:00 AM the DON (Director of Nursing) stated that the expectation was that ordered treatments were to be administered, which included wound care, dressing changes, and treatments or procedures. During an interview on 7/16/2026 at 1:08 PM Staff B, LPN stated that she had worked with Resident #49 on the night shift on 7/12/2026. She was not sure whether she provided wound care or a new dressing for him. During an interview on 7/16/2026 at 3:00 PM Staff C, LPN stated that she had worked with Resident #49 over the past weekend. She believed she had provided wound care and applied a dressing on Saturday night but not on Sunday. She did not use plain gauze, she always used Coban and it would have been purple or blue. 4) During an observation on 7/13/2026 at 10:29 AM, Resident #58 had a wound dressing on the resident's left upper arm. The wound dressing was dated 7/11/2026. During an interview on 7/13/2026 at 10:29 AM, Resident #58 stated that they had left the tape on her arm too long and it had pulled her skin off. They were changing the dressing every 2 days. Review of Resident #58's medical record documented the resident was admitted on [DATE] with medical diagnoses that included fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing (primary) Review of Resident #58's most recent quarterly assessment dated [DATE] documented her BIMS Score as 13 out of 15 which indicated she was cognitively intact. Review of Resident #58's care plan documented: Focus - Risk for Impaired Skin Integrity. Interventions included – Provide skin care per facility guidelines and PRN (as needed). Focus – The resident has a skin tear of left upper arm. Interventions included - Treatment as ordered (See MD order for most current order). Review of Resident #58's physician orders dated 6/23/2026 read, Skin tear to left upper arm: Cleanse with wound cleanser, pat dry, apply Medi honey, cover with silicone bordered foam dressing until healed every day shift. 5) During an observation on 7/13/2026 at approximately 10:30 AM Resident #150 was sitting in his wheelchair beside the bed with the television on. The resident was dressed in street clothes and was wearing non-slip socks. During an interview on 7/13/2026 at approximately 10:30 AM Resident #150 stated, I can't get anyone to put on my compression socks on. It's been about three days. My cardiologist told me I should wear them every day. Review of Resident #150's medical record documented the resident was admitted on [DATE] with a readmission on [DATE] with medical diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris (primary); Parkinson's disease with dyskinesia, without mention of fluctuations; essential (primary) hypertension; acute kidney failure, unspecified; difficulty in walking, not elsewhere classified Review of Resident #150's physician orders read, Apply knee high compression socks during the day. Remove at night one time a day for circulation remove at night Review of Resident #150's physician orders read, Remove knee high compression socking {sp.} at night in the evening for edema. During an observation on 7/14/2026 at 4:39 PM Resident #150 was sitting in his wheelchair. The resident was dressed in street clothes and wearing non-slip socks. During an interview on 7/15/2026 at 2:35 PM Staff G, LPN stated that Resident #150 was supposed to have his compression socks on during the day and they were removed at night. During an interview on 7/16/2026 at 11:45 AM Staff I, Certified Nursing Assistant (CNA) stated that she occasionally worked with Resident #150. His compression socks were supposed to be on during the day and be removed at night. During an observation on 7/16/2026 at 12:15 PM Resident #150 was assisted out of bed into his wheelchair. The resident was dressed in street clothes and non-slip socks. A pair of knee-high compression socks/stockings were laying on the dresser in Resident #150's room. (photographic evidence obtained) During an interview on 7/16/2026 at 12:20 PM Resident #150 stated that it had been days since anyone had assisted him to put on his compression socks. He was not able to put them on or take them off by himself. During an interview on 7/16/2026 at 12:25 PM Staff H, CNA stated she regularly works with Resident #150. Sometimes he asked her to put on his compression socks; she had not put them on today. She did not remove the compression socks, and he could not remove them himself. Review of Resident #150's MDS, quarterly assessment dated [DATE] documented the resident has a BIMS Score of 12 out of 15 which indicates some mild cognitive impairment. Review of Resident #150's care plan documented: Focus - Risk for Impaired Skin Integrity. Interventions included - Apply knee high compression socks during day. Remove at night. Focus - The resident is on diuretic therapy r/t edema/swelling Review of the policy and procedure titled, ADL's [Activities of Daily Living] Assistance (Bathing, Dressing, and Grooming) with the last review date of 1/20/2026 read, Policy: The facility will assist residents in in attaining and maintaining the highest practical level of function. Procedure: Functional limitations regarding ADL ability may be identified by a variety of sources such as nurses, CNA's, therapist or physicians. Determine the specific tasks and areas of ADL's requiring skill practice and/or training. The ADL's may include but are not limited to: b) Dressing: May include selecting and obtaining clothes, putting clothes on, fastening buttons or snaps, taking off all items of clothing, applying or removing braces and artificial limbs, or use of adaptive equipment. Review of the policy and procedure titled, Wound Care and Dressings Change, Dry/Clean, with the last review date of 1/20/2026 read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. 3. Check the treatment record. Steps in the procedure: 10. Label tape or dressing with date, time and initials. Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. The name and title (or initials) of the individual changing the dressing. 5. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. Reporting. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for 8 of 15 residents, Residents #2, #3, #8, #9, #112, #73, #139, and #153, reviewed Minimum Data Set assessments.Findings include: 1) Review of Resident #2's physician order dated 4/2/2026 read, Olanzapine Oral Tablet 5 MG [Milligram] (Olanzapine) give 1 tablet by mouth at bedtime for schizophrenia. Review of Resident #2 Medication Administration Record for the month of April 2026 documented the resident was administered Olanzapine for schizophrenia for the look back period of 4/2/2026 through 4/8/2026. Review of Resident #2's MDS titled Medicare 5 Day dated 4/8/2026, under Section I – Active Diagnoses, schizophrenia was not documented. During an interview on 7/15/2026 at 11:03 AM the MDS Registered Nurse (RN) Lead stated, [Resident #2's name] assessment is missing the diagnosis of schizophrenia. 2) Review of Resident #8 physician order dated 6/23/2026 read, Amoxicillin-Pot Clavulanate 875-125 MG [milligrams] give 1 tablet by mouth every 12 hours for bacterial infection for 7 Days. Review of Resident #8's Medication Administration Record (MAR) for the month of June 2026 documented resident was administered Amoxicillin-Pot Clavulanate for the look back period of 6/23/2026 through 6/27/2026. Review of Resident #8's physician order dated 6/25/2026 read, Sulfamethoxazole Trimethoprim Tablet 800-160 MG give 1 tablet by mouth every 12 hours for UTI [urinary tract infection] for 7 days Review of Resident #8 Medication Administration Record for the month of June 2026 documented the resident was administered Sulfamethoxazole Trimethoprim for the look back period of 6/25/2026 through 6/27/2026. Review of Resident #8's lab results for Urinalysis w/Micro, Reflex to Urine Culture/Urine Culture documented a collection date of 6/19/2026 and a reported date of 6/25/2026. The report read, Result: Klebsiella pneumoniae, Escherichia coli, and Acinetobacter baumannii [bacterial infections]. Review of Resident #8's MDS titled Quarterly dated 7/5/2026 under Section I - Active Diagnoses UTI was not documented in the last 30 day look back. During an interview on 7/15/2026 at 10:22 AM the MDS RN (Registered Nurse) Lead, stated, The UTI diagnosis was not put in [coded in the assessment]. 3) Review of Resident #139's (Name of psychiatry provider) note dated 4/9/2026 read, Chief Complaint: Mood disorder, PTSD [post-traumatic stress disorder], depression, anxiety, TD [Tardive dyskinesia] and opioid abuse. Diagnoses Rationale and Justifications: PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology. Review of Resident #139's MDS titled Annual dated 4/15/2026 under Section I - Active Diagnoses, PTSD was not documented as an active diagnosis. During an interview on 7/15/2026 at 10:37 AM the MDS Coordinator stated the diagnosis should have been documented. Review of the facility policy and procedure titled Accuracy of Resident Assessment Policy with a last review date of 1/20/2026 read, Policy Statement: The facility ensures that all resident assessments, including the Minimum Data Set (MDS) are accurate, complete and reflective of the resident's status in accordance with federal regulations under F641. 4) Review of Resident #153's physician orders as documented on the Medication Administration Record (MAR) for the month of April 2026 showed the resident was administered Remeron (used to treat major depressive disorders), Eliquis (use to stop dangerous blood clots from forming), and Lasix (used to treat fluid retention). Review of Resident #153's MDS dated [DATE] documented under Section N, High-Risk Drug Classes for antidepressant was coded as No, for anticoagulant (used to stop blood from clotting) was coded as No, and diuretic (used to treat fluid retention), was coded as No. During an interview on 07/15/2026 at 3:40 PM, the MDS Coordinator reviewed the MDS assessment dated [DATE] and acknowledged the identified sections had been coded incorrectly. 5) Review of the physician's orders for Resident #73 dated 06/19/2026 documented an order for Metoprolol Succinate Extended-Release 25 mg by mouth daily for hypertension and an order for Atorvastatin 40 mg by mouth at bedtime for hyperlipidemia. Review of Resident #73's history and physical dated 06/23/2026 documented a past medical history significant for hyperlipidemia. Review of Resident #73's nursing progress notes dated 06/29/2026 and 06/30/2026 documented blood pressure monitoring and administration of metoprolol succinate for hypertension. Review of Resident #73's MDS 5-Day assessment dated [DATE] documented under Section I - Active Diagnoses I0700 Hypertension as No and under I2300 Hyperlipidemia as No. During an interview on 07/15/2026 at 10:10 AM, the MDS Coordinator reviewed the 06/26/2026 MDS assessment and acknowledged that Section I had been coded incorrectly and should have reflected Yes for both Hypertension (I0700) and Hyperlipidemia (I2300). 6) Review of Resident #9's most recent MDS (Minimum Data Set) Assessment, dated 7/01/2026 documented that her active diagnoses included a multi-drug-resistant organism and pneumonia. Review of Resident #9's medical record documented the resident was admitted on [DATE] with a readmission date of 3/27/2026 with medical diagnoses that included metabolic encephalopathy (primary), and acute respiratory failure with hypoxia During an interview on 7/15/2026 at 10:56 AM the MDS Lead stated Resident #9's under Section I, It's [multi-drug-organism] from the hospital paperwork from 3/27/2026, it should have come off. The pneumonia should have come off because she wasn't being treated [for pneumonia]. 7) Review of Resident #3 physician's order dated 11/12/2025 read, Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) - Give 1 tablet by mouth three times a day for non-acute pain hold for lethargy. Review of Resident #3's Medication Administration Record for the months of April 2026 and May 2026 documented the resident was administered Hydrocodone-Acetaminophen Oral Tablet medication for the look back period of 04/26/2026 to 05/03/2026. Review of Resident #3's care plan with a focus date of 01/27/2025 read, Pain Medication- [Name of Resident #3] is on pain medication therapy. Review of Resident #3's MDS titled Medicare 5 Day dated 05/03/2026 under Section J - Health Conditions did not document the resident was being administered a scheduled pain medication. During an interview on 07/15/2026 at 10:43 AM, the MDS Coordinator stated that Resident #3 was taking scheduled hydrocodone and that the pain medication regimen should have been marked Yes in Section J. Review of Resident #3 MDS titled Medicare 5 Day dated 05/03/2026 under Section N - Medications documented the resident is being administered anticoagulant medications. Review of Resident #3 Medication Administration Record for the months of April 2026 and May 2026 documented the resident was not administered anticoagulant medication for the look back period of 04/26/2026 to 05/03/2026. During an interview on 07/15/2026 at 10:43 AM, the MDS Coordinator stated, I don't see anticoagulant medication for [name of Resident #3] in the lookback period. 8) Review of Resident #112's [Name of the psychiatric provider] note dated 06/01/2026 read, History of Presenting Illness: This is a [age of Resident #112] patient with a past psychiatric history of mood disorder, depression, anxiety, dementia and insomnia, and Dementia with behavioral disturbance: History suggests that the patient had a gradual decline in memory, executive function, language, concentration, and fund of knowledge. These symptoms have caused distress and have affected the quality of life and activities of daily living. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug abuse, a medication) or another medical condition. The memory loss has been followed by significant behavioral disturbance as well. Review of Resident #112's care plan focus dated 12/22/2025 read, Cognition: [Name of Resident #112] has impaired cognitive function/dementia or impaired thought processes r/t [related to] dementia. Review of Resident #112's MDS titled Medicare 5 Day dated 06/03/2026 under Section I - Active Diagnoses, Non-Alzheimer's Dementia was not documented. During an interview on 07/15/26 at 10:52 AM, the MDS Lead stated, The MDS is incorrect, the diagnosis for dementia should be there.

Based on observation, interview, and record review the facility failed to ensure medications were securely stored when unattended for 2 of 4 hallways.Findings include: 1) During an observation on 7/13/2026 at 9:31 AM Resident #53 was sitting in her room. On top of the resident's nightstand there was a medication cup with a white cream. During an interview on 7/13/2026 at 9:31 AM Resident #53 stated, The nurses give me that cream so I can apply it to my hands and feet it has lidocaine. I use it for my neuropathy pain. During an interview on 7/13/2026 at 1:23 PM Staff E, Licensed Practical Nurse (LPN) stated, [Resident #53's name] is not able to self-administer medication. Normally she will rub the cream herself, but the nurse has to be there with her. 2) During an observation on 7/13/2026 at 10:20 AM Resident #8 was lying in bed with eyes closed. There was an antibiotic ointment on top of the cabinet in the room. During an interview on 7/13/2026 at 1:25 PM Staff J, Unit Manger Registered Nurse (RN) stated, [Resident #8's name] is not able to self-administer the ointment, it is for his wound. The ointment should not be left in his room. 3) During an observation on 7/14/2026 at 8:08 AM Resident #50 was sitting up in bed there was a clear medication cup containing medications on top of the bedside table. During an interview on 7/14/2026 at 8:08 AM Resident #50 stated, I normally drink my medications with coffee. I am waiting for breakfast. During an interview on 7/14/2026 at 8:11 AM Staff D, LPN, stated, [Resident #50's name] is not able to self-administer medication. I thought he had taken all his medications before leaving the room. During an interview on 7/15/2026 at 9:40 AM the Director of Nursing stated, Nurses should ensure residents consume medications, no medication should be left unattended. Review of the policy and procedure titled, Medication Storage with a last review date of 1/20/2026 read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL [Florida] Department of Health guidelines. Procedure: A. With the exception of Emergency Drug Kits, all medication will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. 4) During an observation of Resident #159's room on 07/13/2026 at 9:13AM a bottle of Equate eye drops was on the bedside table. During an observation of Resident #159's room on 07/14/2026 at 2:23PM, the resident was sitting in wheelchair in the room. On the bedside table was a bottle of Equate Eye Drops. (Photographic evidence obtained) During interview with Resident #159 on 07/15/2026 at 12:55 PM, the resident stated, The eyedrops. I have used them for a long time. I used to have the name brand ones, but they got too expensive and I use the generic now. They work just as well. I want them in my room I never know when I am going to need them for my dry eyes. During an interview with the Director of Nursing (DON) on 07/14/2026 at 2:30PM, the DON stated an evaluation for self-administration must be done for a resident to be able to have medications available at bedside. Review of Resident #159's physician orders did not show an order the resident was safe to self-administer medications. Review of Resident #159's medical record showed the record did not contain an evaluation for the self-administration of medications. 5) During an observation of Resident #162's room on 07/14/2026 at 8:30 AM, in the shared bathroom were medicine cups of unidentified creams and powder on the counter and in a grey basin placed on the counter. (Photographic evidence obtained) During an interview with Resident #162 on 07/14/2026 at 8:31AM, the resident stated they have been treating me for a fungal infection, and the cream is applied when I am getting cleaned up in the bathroom or I can put it on myself where and when my rash is bothering me. Review of Resident #162's physician orders dated 07/01/2026 read, Nystatin Cream 100000 UNIT/GM Apply to abdominal area bilateral topically every shift for fungal rash for 14 days, Nystatin External Cream 100000 UNIT/GM apply to bilateral breast topically every shift for rash for 14 days, and Nystatin Cream 100000 UNIT/GM apply to bilateral under arms topically every shift for fungal rash for 14 days.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection during wound care and the administration of gastrointestinal tube feeding. Findings include: 1) During an observation of wound care on 07/15/2026 at 2:30 PM, Staff A, Licensed Practical Nurse (LPN) performed hand hygiene, and donned a gown and clean gloves. The LPN set up wound care supplies on a sheet of tin foil and placed supplies on Resident #6's bedside table, doffed the gloves, performed hand hygiene, and applied clean gloves. The LPN cleansed the resident's coccyx wound with wound cleanser, patted the area dry with gauze, did not remove the soiled gloves, did not perform hand hygiene, or don clean gloves, and packed the wound with mupirocin, Santyl, and calcium alginate, placed a silicone foam dressing over the wound, then completed hand hygiene. During an interview on 07/15/2026 at 2:45 PM, Staff A, LPN stated that she was not aware that she needed to wash her hands and change her gloves between cleaning the wound and applying the new wound dressings. During an interview on 07/15/2026 at 3:15 PM, the Director of Nursing stated that the nurse should have washed her hands and changed her gloves after cleaning the resident's wound, before applying a new dressing. Review of policy and procedure titled, Handwashing/Hand Hygiene reviewed 01/20/2026 read, The facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care. 2) During an observation on 7/15/2026 at 12:04 PM Staff G, Licensed Practical Nurse, entered Resident #136's room. Staff G donned gloves but did not don a gown. Resident #136's room door had an enhanced barrier sign. Staff G administered 50 ml [milliliters] of water to flush the gastric tube followed by 250 ML of Glucerna 1.5. Staff G finished the administration and did not flush the tubing after administering the bolus feed. During an interview on 7/15/2026 at 1:36 PM the Director of Nursing stated, Staff should have donned a gown to provide a bolus feeding via the feeding tube. During an interview on 7/15/2026 at 3:02 PM the Assistant Director of Nursing/Infection Preventionist stated, When a resident is on enhanced barrier precautions staff should don gloves and a gown to provide direct care. During an interview on 7/15/2026 at 4:29 PM with Staff G, LPN, stated, I should have donned a gown to provide care to [Resident #136's name]. Review of the policy and procedure titled, Enhanced Barrier Precautions with a last review date of 1/20/2026 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs). Policy Interpretation and Implementation 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, ect).

Based on interview and record review the facility failed to develop and implement a comprehensive care plan for 1 of 3 residents, Resident #139, reviewed for behavioral management.Findings include:Review of Resident #139's [Name of psychiatric provider] note dated 4/9/2026 read, Chief Complaint: Mood disorder, PTSD [Post Traumatic Stress Disorder], depression, anxiety, TD [Tardive dyskinesia] and opioid abuse. Diagnoses Rationale and Justifications: PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology.Review of Resident #139's [Name of psychiatric provider] note dated 7/9/2026 read, Chief Complaint: Mood disorder, PTSD, depression, anxiety, TD and opioid abuse. Diagnoses Rationale and Justifications: PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology. Triggers: Perceived helplessness.Review of Resident #139's care plan did not have a focus area for PTSD.During an interview on 7/15/2026 at 10:26 AM the Minimum Data Set (MDS) Registered Nurse Lead stated, [Resident #139's name] care plan does not include PTSD, just depression and anxiety.During an interview on 7/16/2026 at 1:21 PM the Director of Nursing stated, [Resident #139's name] care plan does not include PTSD and in should have been included.Review of the policy and procedure titled, Resident Assessment Instrument [RAI] Comprehensive Care Plan Policy with a last review date of 1/20/2026 read, Purpose: To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI), and to comply with state and federal regulations. Policy Statement: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care. This process will involve interdisciplinary team members and be revised to reflect resident condition changes.

Based on interview and record review the facility failed to ensure laboratory specimens as ordered by the physician were collected for 2 of 4 residents, Resident #3 and #48, reviewed for laboratory services.Findings include: Review of Resident #48's physician order dated 7/7/2026 read, Ferritin, Folate, Iron, TIBC [Total Iron-Binding Capacity], and % SAT [saturation] waiting to be sent one time only related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Review of Resident #48's medical record for lab results the record did not contain lab results for the physician ordered labs dated 7/7/2026. During an interview on 7/16/2026 at 9:07 AM the Director of Nursing stated, [Resident #48's name] labs did not get drawn. The facility did not do a requisition form. Review of Resident #3's physician's order dated 06/30/2026 read, Urinalysis w/Micro [with microscopic], Reflx {sic} to Urine Culture - ** SCHEDULED 6/30/2026; Auto-Send 6/30/2026 12:00 AM ** one time only. Review of Resident #3's medical record for labs results the record did not contain lab results for the physician ordered labs dated 06/30/2026. During an interview on 7/16/2026 at 1:21 PM the Director of Nursing stated, [Resident #3's name] urinalysis was not completed. During an interview on 7/16/2026 at 11:50 the [Name of lab providing services to the facility] representative stated, [Resident #48's name] did not have labs drawn on 7/7/2026. Last labs are on 6/6/2026 which was a CBC [Complete Blood Count], CMP [Comprehensive Metabolic Panel], TSH [Thyroid-stimulating hormone], B12 [vitamin B12], and Vitamin D. [Resident #3's name] does not have a urinalysis collected. The last labs for [Resident #3's name] were on 6/29/2026 which were CBC and CMP. Review of the facility policy and procedure titled, Laboratory Test/Diagnostic Procedures: Communicating the results with a last review date of 1/20/2026 read, Procedure: 2. All other lab or diagnostic procedure orders received are documented in PCC when received. The designated nurse is responsible for completing the lab requisition or verifying the diagnostic procedure appointment has been made as part of noting the order. The order lab is logged on the lab log sheet found in front of each date in the binder.

Based on interview and record review, the facility failed to ensure physician orders were followed related to the pharmacy Psychoactive Medication Use Recommendations for the monthly drug regimen review for 1 of 5 residents, Resident #49, reviewed for unnecessary medications.Findings include: Review of the Psychoactive Medication Use Recommendations document for Resident #49 dated 6/23/2026 read, Currently receiving Trazodone which can increase risk of drowsiness and falls. Per clinical record, with recent falls. Please evaluate, consider tapering dose or implementing alternative treatment, if necessary. The physician response was documented as Agree; Will do; D/ C [discontinue]. Review of Resident #49's physician orders dated 6/22/2026 read, Trazodone HCl Oral Tablet 50 MG [milligrams] (Trazodone HCl): Give 25 mg by mouth at bedtime related to major depressive disorder, recurrent, moderate (F33.1) Review of Resident #49's MAR (Medication Administration Record) from 6/23/2026 through 7/15/2026 documented that Trazadone was administered daily at bedtime per the initialing of the MAR by the licensed nurse. During an interview on 7/16/2026 at 9:50 AM the DON (Director of Nursing) stated the Medication Regimen Review (MRR) process was that the pharmacist's recommendations were presented to the providers and were reviewed by the MD or NP (Medical Doctor of Nurse Practitioner). Any changes or orders were then entered [into the electronic medical record (EMR)] by the Unit Managers. The expectation was that the providers' orders would be entered and followed. During an interview on 7/16/2026 at 11:15 AM Physician #1 stated he and the nurse practitioners were routinely addressing the recommendations made by the pharmacists. The expectation was that when he or a nurse practitioner wrote a medication order, it was to be followed. Review of the policy and procedure titled, [Name of Pharmacy] - Drug Regimen Review, with the last review date of 1/20/2026 read, Policy: In accordance with State and Federal regulations, the consultant pharmacist will review each resident's clinical chart monthly. Apparent irregularities will be reported in writing to the Director of Nursing, Medical Director, Attending Physician and Administrator. The facility shall follow up of {sp.} Consultant Pharmacist recommendations to ensure all residents maintain the highest practical level of functioning. Purpose: To ensure drug and medication regimen reviews are completed, received and reviewed by appropriate personnel in a timely manner. Procedure: 2. Recommendations and apparent irregularities will be reported timely to ensure the safe and appropriate medication utilization to meet the individual needs of the residents.

Based on observation, interview, and record review the facility failed to ensure respiratory care for oxygen administration and/or humidification per physician orders for 2 of 6, Resident #48 and #147, and failed to obtain a physician order for the use of a continuous positive airway pressure machine for 1 of 3 residents, Resident #84, reviewed for respiratory services.Findings include: 1) During an observation on 07/13/2026 at 9:28 AM Resident #48 was lying in bed oxygen was administered at 4 liters with humification attached. During an observation on 7/14/2026 at 9:01 AM Resident #48 was lying in bed with eyes closed oxygen was administered via nasal cannula at 2 liters per minute with humidification. [Photographic evidence obtained] Review of Resident #48 physician order dated 6/15/2026 read, Oxygen @ 4 L/Min [at 4 liters per minute] continuous inhalation via NC [nasal cannula] every shift. There was no order documented in the record for the use of humidification. During an interview on 7/15/2026 at 9:13 AM Staff E, Licensed Practical Nurse (LPN) stated, [Resident #48's name] does not a humidifier ordered. I am not sure if it should be part of the order. Her [Resident #48's] order is for 4 liters we should be checking the flow rate every shift. During an interview on 7/15/2026 at 9:53 AM the Director of Nursing stated, Nurses are to check the flow rate throughout the shift to make sure it is accurate. I will have to review the policy to see if a humidifier needs to have orders. During an interview on 7/16/2026 at 10:19 AM Staff F, Registered Nurse stated, [Resident #48's name] has never changed her flow rate. If a resident's oxygen is making her nose dry or having nose bleeds, we will do oxygen with humidification. We would call the provider to let them know and make a note in the system. During an interview on 7/16/2026 at 1:21 PM the Director of Nursing stated, If a resident has a dry nose or has discomfort, I would expect the nurses to notify the provider of need for treatment and document it. Review of the facility policy and procedure titled Oxygen Administration with a last review date of 1/20/2026 read, Purpose: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: 9. Turn on the oxygen. Start the flow of oxygen at the prescribed rate. 2) During an observation on 07/13/2026 at 9:45 AM Resident #147 was lying in bed with oxygen being administered via nasal cannula at 3 liters per minute. During an observation on 07/13/2026 at 2:29 PM Resident #147 was lying in bed with oxygen being administered via nasal cannula at 3 liters per minute. [Photographic evidence obtained]. During an observation on 07/14/2026 at 8:50 AM Resident #147 was lying in bed with oxygen being administered via nasal cannula at 3 liters per minute. [Photographic evidence obtained]. During an observation on 07/14/2026 at 9:10 AM Resident #147 was lying in bed with oxygen being administered via nasal cannula at 3 liters per minute. [Photographic evidence obtained]. Review of Resident #147 physician's order dated 06/26/26 read, Oxygen @ 2L [liters]/Min [minute] continuous inhalation via NC [nasal cannula] every shift. During an interview on 7/15/2026 at 9:08 AM, Staff E, Licensed Practical Nurse (LPN), confirmed Resident #147's active oxygen order is for a 2 liter per minute flow rate. She stated, We're supposed to check oxygen flow rate every day for accuracy. During an observation on 7/15/2026 at 9:08 AM with Staff E, LPN, Staff E observed Resident #147's flow rate and confirmed the flow rate was at 3 liters per minute and stated, The flow rate is wrong. During an interview on 07/15/26 at 09:53 AM, the Director of Nursing stated, Nurses are to check the flow rate throughout the shift to make sure it is accurate. Review of the policy and procedure titled, Oxygen Administration with a last review date of 1/20/2026 read, Purpose: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: 9. Turn on the oxygen. Start the flow of oxygen at the prescribed rate. 3) During an observation of Resident #84's room on 07/13/2026 at 10:43 AM, the Resident had an oxygen concentrator not in use in the corner of the room. There was a white nebulizer treatment machine and a black Continuous Positive Airway Pressure(C-PAP) machine on the bedside table. The mask was stored and dated in a patient belongings bag. During an observation on 07/15/2026 11:37 AM of Resident #84's room a C-PAP and a nebulizer machine were on the nightstand with the tubing in a bag. During an interview on 7/15/2026 at 11:37 AM Resident #84 stated I have used a C-Pap for so long I can't even remember when I started. I have had that one here with me since day one. It came from my house. During an interview on 07/15/2026 at 12:43 PM Staff L, Licensed Practical Nurse (LPN stated, An order is needed for a C-PAP, If there is no order, we would go to the medical records from admission and see if the hospital has information on the setting and see when the last sleep study was done. We do supply C-PAP machines. During an interview on 07/15/2026 at 2:45 PM the Director of Nursing stated, If the Resident needs a C-PAP machine the nurse should call the Doctor for an order. Review of Resident #84's medical record documented diagnosis to include: COPD (Chronic Obstructive Pulmonary Disease) and heart failure. Review of Resident #84's physician order dated 07/05/2026 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML [milligram/milliliter] 1 vial inhale orally every 8 hours as needed for wheezing related to chronic obstructive pulmonary disease, unspecified. There was no physician order in the record for a C-PAP machine. Review of Resident #84's Nursing Progress Notes Daily Medicare/Managed Care Note on 7/11/26 by Staff K, LPN read, Respiratory Devices: None of the above. Review of Resident #84's MDS (Minimum Data Set) Medicare 5 Day dated 06/30/2026 under Section O, did not have documentation for the use of a C-PAP machine. Review of Resident #84's care plan read, Focus: [Resident #84's name] has COPD. Goal: The resident will be free of s/sx [signs/symptoms] of respiratory infections through review date. Intervention: Encourage to elevate head of bed while in bed to assist with breathing and prevent episodes of shortness of breath when lying flat. CPAP on at HS [hour of sleep], setting as ordered. Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Head of bed elevated as tolerated to prevent SOB [shortness of breath] while lying flat. Observe for s/s of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis, Somnolence. Review of the policy and procedure titled, Skilled Nursing-Use of CPAP/BIPAP/APAP [continuous positive airway pressure/ bilevel positive airway pressure, automatic positive airway pressure] last revision date 01/20/2026. Guidelines for use: MD [Medical Doctor] Orders: Obtain MD order that includes the following: Specifies what type of machine is required (CPAP, BIPAP, APAP). Contains the specific pressure. If machine is from home (May continue home settings). Diagnosis. For cleaning mask and tubing instructions. Care and Maintenance: All machines have at least one filter, located at the back of the machine at the air intake. Washable foam filters should be cleaned as soon as they are discolored or at least weekly.

Based on observation, interview, and record review the facility failed to ensure the flushing of a gastric tube after the administration of a bolus feeding for 1of 4 residents, Resident #136, reviewed for enteral tube management.Findings include:During an observation on 7/15/2026 at 12:04 PM Staff G, Licensed Practical Nurse (LPN) entered Resident #136's room. Staff G donned gloves but did not don a gown. Staff G administered 50 ml [milliliters] of water to flush Resident #136's gastric tube followed by 250 ml of Glucerna 1.5. Staff G finished the administration of the bolus feeding and did not flush the gastric tube after administering the bolus feed.During an interview on 7/15/2026 at 12:12 PM Staff G, LPN stated, Usually I only flush before to clean out the gastric tube not after. The order did not say to flush after.Review of Resident #136's physician orders dated 7/8/2026 read, Enteral Feed Order every 8 hours Enteral: Bolus Feeding - Glucerna 1.5 per G-TUBE [gastrostomy tube] via bolus. 250 mL every 8hrs, FLUSH with 50ML of H20 [water] BEFORE AND AFTER EVERY BOLUS to provide 1125 KCALS [kilocalorie]/ [per] 24 hours.During an interview on 7/15/2026 at 1:36 PM the Director of Nursing stated, Nursing staff should review orders and flush gastric tubes before and after the administration of a bolus feeding.During an interview on 7/16/2926 at 9:26 AM the Registered Dietitian when ask if Resident #136 was at risk of dehydration stated, Not necessarily, [Resident #136's name] is on a oral diet. The nurses should flush before and after the bolus it is the protocol to do it.Review of the policy and procedure titled, Feeding Tube with a last review date of 1/20/2026 read, Purpose. The purpose of this procedure is to provide guidelines for the safe administration of tube feeding. Procedure: Feeding Administration: i. Draw up thirty (30) to sixty (60) cc tap water. Flush feeding tube with water.

Based on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) and Level II PASRR were completed when a mental illness was identified for 2 of 3 residents, Resident #2 and #136, review for PASRR screening.Findings include:1) Review of Resident #2's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 4/2/2026 read, Section I: PASSR Screen Decision-Making. A. MI [Mental Illness] or Suspected MI: Schizophrenia and substance abuse. Section III: PASSR Screen Provisional admission or Hospital Discharge Exemption: Individual may be admitted to an Nursing Facility (check one of the following): Hospital Discharge Exemption. The individual is being admitted under 30 day discharge exemption. If the individual's stay is anticipated to exceed 30 days, the NF must notify the Level I screener on the 25th day of stay and the Level II evaluation must be completed no later than the 40th day of admission on or before (date): [blank]. The resident continues to reside in the facility.Review of Resident #2's medical record did not document a PASRR Level II screening having been completed.Review of Resident #2 Discharge summary dated [DATE] read, Hospital Course to date: significant history of schizophrenia.During an interview on 7/15/2026 at 12:26 PM with the Director of Social Services stated, [Resident #2's name] PASSR was not clear and we did not have the history. We got the history later on. We told psych and they were going to let me know and I never got told and life went on. We should have looked at it better. A Level II PASSR was not completed and needed to be completed.2) Review of Resident #136's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review dated 5/5/2026 did no document depression. Review of Resident #136's admission record documented the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis including but not limited to major depression disorder [onset date 6/4/2026].Review of Resident #136's [Name of psychiatric provider] note dated 5/7/2026 read, Chief Complaint: Depression. History of Presenting Illness: As per collected information, new admission psychiatric assessment completed with patient presenting for evaluation following report of cancer diagnosis. Patient appeared withdrawn during encounter, frequently avoiding eye contact and turning away when spoken to, with affect appearing, mildly depressed and constricted. Patient is not on any psych meds. Diagnoses Rationale and Justifications: Adjustment disorder with depressed mood: The history suggest that the patient's depressed mood is secondary to the underlying stressors.Review of Resident #136's [Name of psychiatric provider] note dated 6/18/2026 read, Chief Complaint: Depression and insomnia. Patient reports benefiting from medication. Current dose of Mirtazapine [used to treat major depressive disorder] is managing depression. Diagnoses Rationale and Justifications: MDD [major depressive disorder], Recurrent: The history suggests that this patient has suffered from episode of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient, and they have occurred without any underlying substance use or organic brain pathology.Review of Resident #136's physician order dated 7/8/2026 read, Mirtazapine Tablet 7.5 MG [milligram] give 1 tablet by mouth at bedtime for mmd.During an interview on 7/15/2026 at 12:35 PM the Director of Social Services stated, MDS [Minimum Data Set] nor Psych notified us of a change in diagnosis. [Resident #136's name] PASSR should have been reviewed due to the new diagnosis given of depression.During an interview on 7/16/2026 at 12:00 PM the Administrator stated, We had a change in social services and two newer people in admissions in the past six months. What we had in place prior was our admission Director and our Social Services Director both looked at PASSRs. I think the system broke when we had the change in admission, social service department, the Director of Nursing and psych.Review of the facility policy and procedure titled Pre-admission Screening and Resident Review (PASRR) with a last review date of 1/20/2026 read, Overview: The purpose of PASRR is to ensure individuals who are being considered for placement in Nursing Facility are evaluated for serious mental illness and/or intellectual disability and are offered the most integrated setting appropriate for their long term care needs (including determining whether a Nursing Facility is appropriate).

Based on interview and record review the facility failed to ensure the residents' health record showed the residents either received the pneumococcal immunization for 1 of 5 residents, Resident #43 reviewed for immunization.Findings include:Review of Resident #43's vaccination records showed a pneumococcal immunization consent signed on 8/25/2025 accepting to receive the pneumococcal vaccine.Review of Resident #43's immunization report did not document Resident #43 was administered a pneumococcal vaccine.During an interview on 7/16/2026 at 1:21 PM the Director of Nursing stated, [Resident #43's name] did not receive the pneumococcal vaccination.Review of the policy and procedure titled, Pneumococcal Vaccine with a last review date of 1/20/2026 read, Policy Statement. All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation. 4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol.

Based on record review and interview, the facility failed to ensure resident records were complete and accurately documented for wound care treatments 1 of 5 residents, Resident #1, reviewed for wound care. Findings includedReview of Resident #1's physician order dated 01/17/2026 read, WOUND CARE: Cleanse abdominal staples with NSS [normal saline solution], pat dry, apply dry dressing every day shift. End date 01/26/2026.Review of Resident #1's Treatment Administration Record, the record did not contain documentation wound care was completed as ordered by the physician for the abdominal wound on 01/18/2026, 01/19/2026, or 1/23/2026.During an interview on 02/27/2026 at 12:40 PM, Staff A, LPN (Licensed Practical Nurse) stated, I changed [Resident #1's name]'s abdominal dressing every time I took care of her, so I must have just forgotten to document that I changed it on January 18th and 23rd.During an interview on 02/27/2026 at 1:13 PM, Staff B, LPN stated, I cannot recall whether I changed [Resident #1's name]'s dressing on January 19th or not.Review of the policy and procedure titled, Documentation, Clinical read, The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. Documentation in the medical record of each resident should provide: 1. A complete account of the resident's care treatment and response to the care.

Based on observation and interview, the facility failed to ensure Peripherally Inserted Central Catheter (PICC) dressing changes were performed in accordance with professional standards of practice for 1 of 5 residents, Resident #2, reviewed for intravenous therapy.Findings include:During an observation on 02/27/2026 at 10:22 AM of Resident #2, the resident had a PICC (peripherally inserted central catheter) line inserted into the right upper arm. The PICC line was covered with a transparent dressing dated 2/11.During an interview on 02/27/2026 at 10:25 AM, Staff A, LPN (Licensed Practical Nurse) stated, It says 2/11 [the date on the PICC line dressing]. They are supposed to be changed weekly, I believe on Saturdays.During an interview on 02/27/2026 at 10:37 AM, Staff C, LPN stated, I think the RN [Registered Nurse] supervisor changes all the PICC line dressings. She works Monday through Friday, but she's not here today.During an interview on 02/27/2026 at 10:41 AM, the Director of Nursing stated, The PICC dressings should be changed every week, it is the responsibility of the nurse on the cart. [Resident #2's name]'s dressing should have been changed. There is no order for PICC dressing changes.Review of the policy and procedure titled, Skin and Wound Management - Manage Wound Care read, The facility will manage wound care based upon current standards of practice. 1. When skin impairment is identified, the nurse will review and select the appropriate treatment protocol for the wound. 2. A physician order will be documented on the Treatment Administration Record.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection for not implementing enhanced barrier precautions for 1 of 3 residents, Resident #2, reviewed for intravenous therapy care.Findings included:During an observation on 02/27/2026 at 10:32 AM, Staff A, LPN (Licensed Practical Nurse) was observed changing Resident #2's PICC (peripherally inserted central catheter) line dressing. The LPN was not wearing a gown.During an interview on 02/27/2026 at 10:43 AM the Director of Nursing stated, [Resident #2's name] should be on enhanced barrier precautions due to her IV (intravenous) and her wound. [Staff A's name] should have worn a gown. [Resident #2's name] doesn't have an order for enhanced barrier precautions.During an interview on 02/27/2026 at 10:48 AM, Staff A, LPN stated, I didn't think I needed to wear a gown to change a PICC line dressing.Review of Resident #2's care plan dated 02/02/2026 read, [Resident #2's name] is on IV Antibiotic Medications r/t [related to] Wound Infection. Interventions: Provide enhanced barrier precautions per facility policy.Review of the policy and procedure titled, Enhanced Barrier Precautions read, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.; and h. wound care (any skin opening requiring a dressing).

Based on record review and interview the facility failed to provide a rationale when actions were not taken for pharmacy recommendations for 3 (Resident #7, #84, and #99) of 5 residents review for unnecessary medication. Findings include: 1)Review of Resident #7 Drug Regimen Review dated 7/10/2024 read, Consultant Pharmacist Recommendations. Currently receiving Oxybutynin (Ditropan) three times daily for urinary incontinence. Oxybutynin (Ditropan) can increase risk of dizziness and falls. Per clinical record, with recent falls. Periodic discontinuation recommended to determine current need and minimize resistance to the drug. Please evaluate, consider trail taper to two times daily with eventual discontinue, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #7 Drug Regimen Review dated 11/27/2024 read, Consultant Pharmacist Recommendations. Currently with active order for Hydrocodone/APAP which can increase risk of falls with recent documented falls per clinical record. Please evaluate possible casual relationship, Consider tapering dose or implementing alternative treatment, if appropriate .Physician Response: Disagree with no rationale included. Review of Resident #7 progress note did not document a rational for recommendations on 7/10/2024 and 11/27/2024 pharmacy recommendations. During an interview on 2/20/2025 at 9:15 AM with the Administrator stated, I am not sure if the provider have to provide a reason why, I will have to check with the Director of nursing. During an interview on 2/20/2025 at 9:20 AM with the Director of Nursing stated, The provider should write a reason why they are in disagreement with the pharmacist recommendations The provider reviewed the medication but I do not see a rationale. Review of the facility policy and procedure titled Pharmacy Services-Drug Regimen Free from Unnecessary Drugs with a last review date of 12/10/2024 read, Intent: The intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing . 49656 2. Review of Resident #84 Drug Regimen Review dated 7/10/2024 read, Consultant Pharmacist Recommendations. Currently receiving Gabapentin which has potential for dizziness and drowsiness, increasing the risk of falls. Per clinical record, with recent falls. Please evaluate possible causal relationship . Consider trial taper Gabapentin to 100mg three times daily, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #84 Drug Regimen Review dated 8/13/2024 read, Consultant Pharmacist Recommendations. Currently receiving Guaifenesin LA tabs (Mucinex) without a stop date. Please evaluate current need. Consider add stop date, if appropriate . Physician Response: Disagree with no rationale included. During an interview on 2/20/2025 at 11:00 AM with the Director of Nursing stated, The provider should write a reason why they are in disagreement with the pharmacist recommendations. In the progress notes he writes that the recommendations have been reviewed but does not write a rationale. Review of the facility policy and procedure titled Pharmacy Services-Drug Regimen Free from Unnecessary Drugs with a last review date of 12/10/2024 read, Intent: The intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing . 3. Review of Resident #99 Drug Regimen Review dated 7/23/2024 read, Consultant Pharmacist Recommendations. Currently with order for Rivaroxaban (Xarelto) once daily in the morning with start date: 08/11/24. Recommended to be given once daily after dinner to improve absorption. Please consider switching to once daily after dinner, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #99 Drug Regimen Review dated 7/23/2024 read, Consultant Pharmacist Recommendations. Currently receiving Methotrexate Injection 50mg once a week. Please evaluate need for high dose. Consider taper to 25mg once a week, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #99 Drug Regimen Review dated 7/23/2024 read, Consultant Pharmacist Recommendations. Currently has an active order for Lorazepam prn without a specified stop date. Please note that CMS guidelines do not allow maintaining open ended orders for PRN psychotropics on medication profiles. Please evaluate and consider discontinue Lorazepam prn, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #99 Drug Regimen Review dated 10/9/2024 read, Consultant Pharmacist Recommendations. Currently receiving Duloxetine (Cymbalta) with estimated CrCl below 30ml/min. Use not recommended when CrCl is below 30ml/min due increased incidence of nausea and/or diarrhea. Please evaluate risk versus benefit and switch to alternate therapy, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #99 Drug Regimen Review dated 10/9/2024 read, Consultant Pharmacist Recommendations. Currently receiving Lorazepam which can increase risk of falls. Per clinical record, with recent falls. Please evaluate, consider tapering dose or implementing alternative treatment, if appropriate . Physician Response: Disagree with no rationale included. During an interview on 2/20/2025 at 11:00 AM with the Director of Nursing stated, The provider should write a reason why they are in disagreement with the pharmacist recommendations. In the progress notes he writes that the recommendations have been reviewed but does not write a rationale. Review of the facility policy and procedure titled Pharmacy Services-Drug Regimen Free from Unnecessary Drugs with a last review date of 12/10/2024 read, Intent: The intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing .

Based on an interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #44) of 3 residents reviewed for urinary tract infections (UTI) , and for 1 resident (Resident #21) of 4 residents reviewed for mood and behaviors. Findings include: Review of Resident #21's medical record documented diagnoses that included depression. Review of Resident #21's physician progress note dated 1/31/2025 read, Chief Complaint: Depression, dementia and insomnia. Reason for Today's Encounter: Today, I saw the patient for medication management as patient has active psychiatric diagnosis, is on psych( psychiatric) meds(medications), is in the facility setting, and the last psychiatric visit was 4 or more weeks ago and as it was reported to me that patient is unstable requiring psychiatric assessment. History of Present Illness: This is a [AGE] year old patient with a past psychiatric history of depression, dementia and insomnia. Review of Resident #21's progress note dated 11/09/2024 read, resident refused shower for nurse and certified nursing aide. Resident began to get upset once staff was consistently kept encouraging him to do so. Resident refused x 3. Review of Resident #21's progress note dated 1/06/2025 read, Resident refused shower today. Review of Resident #21's progress note dated 1/09/2025 read, resident refused labs, MD(Medical Doctor) in facility and made aware, no new orders received. Review of Resident #21's care plan did not reveal a care plan focus related to a focus on potential of behavior related to diagnosis of depression or being unstable. During an interview conducted on 2/19/2025 at 7:45 AM the Director of Nursing (DON) stated The interdisciplinary team (IDT) should have initiated a care plan for [Resident #21's name] with a focus for behaviors, refusing care, or being on an anti-depressant with interventions and goals and this was not done. 2) Review of Resident #44's medical record documented diagnoses that included a diagnosis of urinary tract infection(UTI). Review of Resident #44's physician order dated 2/12/2025 read, Macrobid 100MG, give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 7 days. Review of Resident #44's care plan did not show a care plan for a UTI or antibiotic therapy. During an interview on 2/18/2025 at 8:15 AM the Administrator stated , The IDT (interdisciplinary team) is responsible for identifying and care planning and failed to do so for [Resident #44's name]for a UTI (urinary tract infection) or for antibiotic therapy and the team should have done so.

Based on interview and record review the facility failed to administer blood pressure medication following parameters for 2 (Resident #103 and 143) out of 8 residents reviewed for medication administration and failed to follow professional standards of practice during medication administration to 1 resident, Resident #456. Findings include: 1.) Review of Resident #103 physician order dated 9/7/2023 read, Metoprolol Tartrate Oral Tablet 25 MG (milligram) (Metoprolol Tartrate) Give 12.5 mg by mouth two times a day for hypertension hold for SBP<120 (systolic blood pressure less than 120). Review of Resident #103's Medication Administration Record (MAR) for the month of January 2025 documented Metoprolol Tartrate 12.5 mg was given at 0900 [9:00 AM] on 1/16/2025 with a systolic blood pressure (SBP) of 108, 1/18/2025 with a systolic blood pressure of 118, 1/19/2025 with a SBP of 115, 1/21/2025 with a SBP of 114, 1/30/2025 with a SBP of 118 and at 2100 [ 9:00 PM] on 1/5/2025 with a SBP of 113, 1/15/2025 with a SBP of 117, 1/19/2025 with a SBP of110, 1/23/2024 with a SBP of 118, 1/28/2025 with a SBP of 110 and on 1/29/2025 with a SBP of 113. Review of Resident #103's Medication Administration Record (MAR) for the month of February 2025 documented Metoprolol Tartrate 12.5 mg was given at 0900 [9:00 AM] 2/6/2025 with a SBP of 116, 2/14/2025 with a SBP of 111, 2/17/2025 with a SBP of 114, 2/18/2025 with a SBP of 116, on 2/19/2025 with a SBP of 114 and at 2100 on 2/4/2025 with a SBP of 118, 2/5/2025 with a SBP of 112, 2/12/2025 with a SBP of 110, 2/15/2025 with a SBP 118, 2/16/2025 with a SBP of 112, 2/17/2025 with a SBP of 116 and on 2/18/2025 with a SBP of 114. Review of Resident #103 admission record resident was admitted on [DATE] with diagnosis including but not limited to atrial fibrillation, essential hypertension, fatigue, dysuria. During an interview on 2/19/2025 at 10:40 AM with the Director of Nursing stated, [Resident #103's name] blood pressure medication was given out of parameters. Staff should follow the provider's parameters. The nurses should follow the parameters and get clarification from the provider if they are unsure of an order. During an interview on 2/19/2025 at 4:17 PM with Medical Director stated, Staff are expected to follow parameters and call if they gave any questions regarding the medication order. [Resident #103's name and Resident #143 name] have not had any adverse medical issues due to her blood pressure medication administration. [Resident #143 name] medication order was a transcription error it should have been hold for systolic blood pressure greater than 130. Review of the facility policy and procedure titled Administration of Drugs with a last review date of 12/10/2024 read, Policy: Residents shall receive their medication on a timely basis and in accordance with our established policies. Procedure: .Should there be an doubt concerning the administering of medication(s), the physician's order must be verified before the medication is administered. 51447 2.) Review of Resident #143 physician order dated 2/4/2025 read, Midodrine 5 MG (milligrams), give 1 table by mouth three times a day, hold for systolic greater than 110, hold for SBP>110 (systolic blood pressure greater than 110). Review of Resident #143's Medication Administration Record (MAR) for the month of January 2025 documented administration of Midodrine 5 MG .hold for systolic greater than 110 was given on the following dates, times and blood pressure readings on 1/3/2025 6:00 AM, Blood Pressure (BP) 135/77, 1/6/2025 10:00 PM, BP 148/87, 1/7/2025 6:00 AM, BP 164/92, 1/7/2024 10:00 PM, BP 126/88, 1/8/2025 6:00 AM, BP 134/78, 1/10/2025 6:00 AM, BP 117/68, 1/10/2025 2:00 PM, BP 111/66, 1/11/2025 6:00 AM, BP 130/69, 1/11/2025 10:00 PM, BP 130/63, 1/12/2025 6:00 AM, BP 132/75, 1/14/2025 10:00 PM, BP 112/71, 1/17/2025 10:00 PM, BP 111/ 78, 1/18/2025 6:00 AM, BP 111/78, 1/20/2025 2:00 PM, BP 111/69, 1/22/2025 2:00 PM, BP 114/64, 1/23/2025 10:00 PM, BP 99/54, not administered, 1/29/2025 2:00 PM, BP 131/70, 1/31/2025 2:00 PM, BP 131/87, and 1/31/2025 10:00 PM, BP 121/74. Review of Resident #143's Medication Administration Record (MAR) for the month of February 2025 documented administration of Midodrine 5 MG .hold for systolic greater than 110 was given on the following dates, times and blood pressure readings on 2/1/2025 6:00 AM, BP 122/74 and 2/2/2025 2:00 PM, BP 127/76. Review of Resident #143 progress note dated 1/2/2025, His past medical history is significant for . hypotension. During an interview on 2/20/2025 at 10:05 AM with the Director of Nursing stated, I would expect that if a resident has a medication order with parameters that the nurse administering the medication would administer the medication according to the parameters ordered and if the nurse needed any clarification about the order or parameters, that prior to administration they would notify the physician. 15234 3.) On 2/18/2025 at 8:21 AM, Resident #456 was sitting semi reclined in her bed in her room. Resident #456 was holding a medication cup in her hand. There were 3 tablets and 1 capsule in the medication cup that Resident #456 was holding. There was no nurse in Resident #456's room. A nurse was standing outside of Resident #456's room at a medication cart attending to a computer screen. During an interview on 2/18/2025 beginning at 8:21 AM, Resident #456 stated the tablets and the capsule in the medication cup were her medicine. She pointed at the capsule and stated this one is for my head. Review of Resident #456's care plan, date initiated 2/6/2025, failed to reveal documentation Resident #456 had been assessed as capable of self-administration of her medications. Review of Resident #456's medication administration records, dated 2/1/2025 through 2/28/2025, documented Resident #456 had been administered Metoprolol Succinate ER [Extended Release] 24 Hour 100 milligrams for hypertension; Meloxicam oral tablet 7.5 milligrams 1 tablet by mouth one time a day for muscle spasms; Lisinopril oral tablet 5 milligrams 1 tablet by mouth one time a day for hypertension; and Cephalexin capsule 500 milligrams 1 capsule three times a day for abscess on scalp for 10 days on 2/18/2025 at 9:00 AM. During interview on 2/19/2025 at 9:44 AM, Staff A, Registered Nurse, stated the nurse administering medications was supposed to watch residents swallow medications during medication administration. During interview on 2/19/2025 at 11:56 AM, the Director of Nursing stated her expectation was the nurse should stay in the resident's room until the resident had taken the administered medications.

Based on observation, interview and record review the facility failed to ensure that residents were treated with dignity and respect and were free from physical restraint use when 1 resident had a splint on one hand and a nonskid sock covering the other hand for 1 resident (Resident #116) of 2 residents observed for positioning and mobility. Findings include: Review of the admission record documented that Resident #116 was admitted to the facility on [DATE], with medical diagnoses including hemiplegia [the complete loss of movement of one side of the body] and hemiparesis [weakness and partial loss of movement of one side of the body] following cerebral infarction affecting right dominant side [a stroke affecting the right side of the body],cognitive communication deficit[ difficulty communicating], and contracture, left hand [ a tightening of muscles and ligaments that prevents normal movement of the affected part]. During an observation on 02/17/2025 at 1:53 PM, Resident #116 was wearing a splint on her left hand and a non-skid sock on her right hand. During an observation on 2/1820/25 at 9:28 AM Resident #116 was observed lying in bed with her eyes closed. There was a splint on her left hand, and a non-skid sock on her right hand. During an observation on 2/18/2025 at 12:58 PM Resident #116 was dressed in street clothes, her hair had been combed. She had a splint on her left hand, and a non-skid sock on her right hand. During an observation on 2/1920/25 at 8:51 AM, Resident #116 could be heard from outside of her room calling out,hollering. Upon entering her room, she was observed lying in bed with her eyes open. She was wearing a blue sock on her right hand and a splint on her left hand. During an interview on 2/19/2025 at 8:50 AM, Staff C, Licensed Practical Nurse (LPN) stated, Her [Resident #116] daughter either requested the sock or approved it. During an interview on 2/19/25 at 9:53 AM, the Administrator stated, She [Resident #116] should not have a sock on her hand. Review of Resident #116's physician orders from 12/01/2024 through 2/17/2025 revealed no orders for gloves, mittens, or Geri-sleeves (sleeves used to protect the skin on arms and legs from damage caused by friction and shearing). Review of Resident #116's Consent forms revealed no consent for gloves, mittens or any form of restrictive or restraining devices for her hand. Review of the policy and procedure, titled, Restorative - Physical Restraint Program, last reviewed of 12/10/2024, read, Policy: The facility will not impose the use of any physical restraint on any resident for discipline or convenience . Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . Devices that may meet the definition of physical restraints are leg or hand restraints, hand mitts .

Based on record review and interview, the facility failed to ensure accuracy of minimum data set assessments for 1 (Resident #4) of 6 residents reviewed for respiratory services and 1 (Resident #143) of 5 reviewed for unnecessary medications. Findings include: 1)Resident #4 physician order dated 7/5/2024 read, Oxygen @ 3 L/Min (at 3 liters per minute) continuous inhalation via nc (nasal cannula) every shift for sob (shortness of breath). Review of Resident #4 Minimum Data Set (MDS) titled Quarterly dated 12/24/2024 read, Section O Special Treatments, Procedures and Programs: Oxygen therapy was coded No. Review of Resident #4 Admission Record resident was admitted on [DATE] with diagnosis including but not limited to acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and acute posthemorrhagic anemia. During an interview on 2/19/2025 at 3:40 PM with the Regional MDS Consultant stated, [Resident #4's MDS appears to need to be corrected. I will modify Section O and correct the oxygen section. 2)Review of Resident #143 no physician order for insulin. Review of Resident #143 Medication Administration Record (MAR) for the month of November 2024 there was no insulin administered for the month. Review of Resident #143 diagnosis did not include Diabetes Mellitus. Review of Resident #143 MDS titled Quarterly dated 11/25/2024 read, Section N-Medication documented resident received insulin injections for last 7 days. During an interview on 2/19/2025 at 3:42 PM with the Regional MDS Consultant stated, [Resident #143's MDS appears to need to be corrected, insulin was not administered. I will modify the section. We follow the RAI (Resident Assessment Instrument).

Based on observation, interview, record review, and CDC (Centers for Disease Control and Prevention) guidelines review, the facility administration failed to implement an infection prevention and control program to prevent four residents (Residents #1, 3, 4, and 12) who were infected with [DIAGNOSES REDACTED]-CoV-2, a highly contagious and potentially deadly virus for people over [AGE] years of age, from exposing 12 other residents living on the same unit by failing to isolate and implement transmission-based precautions for residents who were confirmed with COVID-19. The facility failed to quarantine residents exposed to COVID-19 in the Memory Care Unit. The facility failed to follow the policies and procedures to ensure staff contained PPE (Personal Protective Equipment) used for residents in trash receptacles to prevent possible environmental exposure and failed to ensure staff performed hand hygiene before and after resident care. Individuals who are [AGE] years and older, those with chronic underlying medical conditions, and those living in nursing homes are at high risk for developing serious complications from COVID-19 illness. Individuals who are infected could develop serious disease with difficulty breathing and might require intensive care for the treatment of [REDACTED]. COVID-19 infection can lead to death. COVID-19 is a new disease, caused by a new coronavirus that has not previously been seen in humans. Currently, there is no vaccine and no approved treatment for [REDACTED]. As a result of the deficient practice related to transmission-based precautions, 12 residents living in the Memory Care Unit and the deficient practice related to general infection control practices, 127 residents living in the general units of the facility, 138 out of 142 total residents, are at risk for developing a communicable disease (COVID-19). Findings include: Review of the Job Description: Centers Position Title: Administrator, Effective Date: 03/2018, Job description/performance appraisal read: Cooperates with department personnel, as well as other healthcare personnel to ensure that services can be adequately maintained to meet the needs of residents. Meets with supervisors on a regular basis to assist in identifying and correcting problem areas and/or improving services. Follows established infection control policies and procedures. Attends and participates in in-service training programs as mandated by regulatory agencies and company policy. Attends and participates in doing what's right classes. Review of the Job Description: Centers Position Title: Director of Nursing Services. Effective Date: 04/11/2018. Job description/performance appraisal. Cooperates with department personnel, as well as other healthcare personnel to ensure that services can be adequately maintained to meet the needs of residents. Meets with supervisors on a regular basis to assist in identifying and correcting problem areas and/or improving services. Follows established infection control policies and procedures. Attends and participates in doing what's right classes. Utilizes reports, CMS (Center for Medicare and Medicaid Services) reports, current survey status and clinical outcomes to monitor clinical progress. Understands federal and state survey enforcement practices. Makes daily rounds and spot check documentation accuracy and completeness on new admissions, residents with change in condition. Creates an environment that encourages excellence. Review of the Job Description: Centers Position Title: Assistant Director of Nursing Services. Effective Date: 06/08/2018. Job description/performance appraisal. Cooperates with department personnel, as well as other healthcare personnel to ensure that services can be adequately maintained to meet the needs of residents. Meets with supervisors on a regular basis to assist in identifying and correcting problem areas and/or improving services. Follows established infection control policies and procedures. Attends and participates in doing what's right classes. Utilizes reports, CMS reports, current survey status and clinical outcomes to monitor clinical progress. Understands federal and state survey enforcement practices. Makes daily rounds and spot check documentation accuracy and completeness on new admissions, residents with change in condition. Creates an environment that encourages excellence. Review of the Medical Director Agreement Dated: 09/5/2019 reads, Services of the physician: As medical director of facility, physician shall have the responsibilities and perform the duties set forth in the section (the services). 3.7 - Physician shall be responsible for the coordination of medical care in the facility. Physician shall help the facility obtain and maintain timely and appropriate medical care that supports the healthcare needs of the residents, is consistent with current standards of practice, and helps the facility meet its regulatory requirements. As required by Florida Regulation concerning medical directors, physician shall meet at least quarterly with the risk management and quality assurance committee at the facility. Physician shall address issues related to the coordination of medical care identified through the facility's quality assessment and assurance committee and quality assurance program, and other activities related to the coordination of care, which may include, but is not limited to helping the facility: 3.7.2 assist in developing systems to monitor the performance of health care practitioners, including mechanism for communicating and resolving issues related to medical care and ensure that other licensed practitioners (e.g.,) nurse practitioners) which may perform physician-delegated tasks act within the regulatory requirements and within the scope of practice as defined by Florida law. Review of the local department of health assessment plan dated May 14, 2020 reads, General facility recommendations; recommend discontinuation of communal dining and activities. Maintain social distancing. Ensure residents are offered masks in communal areas. If residents are noncompliant, ensure all staff members are wearing masks at all times. Ensure staff are changing gloves after contact with each resident care task. Clean high touch surfaces frequently and create documentation system. Sanitize communal activity equipment after each use. Solaris specific recommendations: Enclose open utensils on medication cart or replace with prepackaged plastic wear. Create designated ward for COVID positive residents that is blocked off to the rest of the facility. Create designated ward for 14-day monitoring of COVID suspected or precautionary residents. Designate one entrance/exit for personnel working on COVID positive ward. Place signage on doors alerting staff that the resident is a contact precaution i.e.: droplet precaution, airborne precaution, etc. Assign designated staff members to work on the on the designated COVID ward and promote continuity of care. Avoid housekeeping from accessing COVID positive ward and promote designated staff to perform environmental cleaning. Engage staff members in continuation of environmental cleaning of high touch surfaces during scheduled shift and after housekeeping scheduled hours and create a documented log. Memory care residents should remain spaced 6 feet apart if non-compliant with staying in their room. Chairs should be moved to ensure 6-foot distance is met. Continue to educate residents on the rationale for social distancing if noncompliant. Face mask should always be offered to memory care residents in congregate areas. Even if they refuse wearing a mask each time or take mask off. If gown supplies are not available, notify the health department or emergency management as soon as possible. Keep logs of supplies and frequency of supplies needed to stay ahead of supply availability. Reusing one PPE gown per (1) staff, per (1) resident per (1) day is the CDC recommendation if gown availability is critically low. Ensure that used gowns are hung inside of the resident rooms and not on the door. Recommend keeping contact precaution resident room doors closed at all times. Conduct more frequent rounding on residents with higher safety risks (i.e.: falls risks, aspiration risk) when doors are closed. Review of the facility policy and procedure titled, Guidance for Limiting the Transmission of COVID-19, effective date 3/16/2020, revision date 7/29/2020, reads, Solaris Healthcare will implement measures to control the spread of COVID-19 in our skilled nursing facilities, in accordance with recommendations form the CDC, the Florida department of health, the Centers for Medicare and Medicaid Services, State of Florida Division of Emergency Management and other applicable regulatory entities . 12 c. Facilities without an airborne infection isolation room (AIIR) are not required to transfer the resident as long as: i. The resident does not require a higher level of care and, ii. The facility can adhere to the rest of the infection prevention and control practices recommended for caring for a resident with COVID-19. Review of the facility policy and procedure titled Isolation-Categories of Transmission based Precautions, revision date 1/8/2020, reads, 1. Transmission based precautions will be used whenever measures more stringent than Standard precautions are needed to prevent or control the spread of infection . Droplet precautions: 1. In addition to standard precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particles droplets (larger than 5 microns in size) that can be generated by the individual coughing, sneezing, talking or by the performance of procedures such as suctioning . 3. Resident placement: a. Place the resident in a private room if possible, b. When a private room is not available, Residents with the same infection with the same microorganism but with no other infection may be cohorted, c. When a private room is not available and cohorting is not achievable use a curtain to maintain at least 3 feet space between the infected resident and other residents and visitors . 5. Resident transport: a. Limit movement of resident from the room to essential purposes only, b. If transport or movement is necessary, place a mask on the infected individual and encourage resident to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets . 8. The facility will also ensure that the residents care plan and care specialist communication system indicate the type of precautions implemented. Review of the facility policy and procedure titled Handwashing/Hand Hygiene revised 4/20/2020, reads, The facility considers hand hygiene the primary means to prevent the spread of infection. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors . 7. Use an alcohol based hand rub containing at least 60% alcohol: or alternatively soap and water for the following situations: . b. Before donning gloves, . m. after removing gloves. Review of CDC guideline titled Responding to Coronavirus (COVID-19) in Nursing Homes, updated 04/30/2020, read, Resident Cohorting: Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19: - Ideally the unit should be physical separated from other rooms or units housing residents without confirmed COVID-19 . Considerations for new admissions or readmissions to the facility: - Newly admitted and readmitted residents with confirmed COVID-19 who have not met criteria for discontinuation of Transmission-Based Precautions should go to the designated COVID-19 care unit . Resident with new- onset suspected or confirmed COVID-19: - Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g. (for example), residents who have fever, for example, due to a non-COVID10 illness could be put at risk if moved to a COVID-19 unit.). Review of CDC guideline titled Transmission-Based Precautions, read, Droplet Precautions: . Ensure appropriate patient placement in a single room if possible . in long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. Review of CDC guideline titled, Preparing for COVID-19 in Nursing Homes, updated 06/25/2020, reads, Core Practices, . Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices . Personal Protective Equipment (PPE): - Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room. 1. On 08/05/2020 at 10:45 AM, droplet precautions PPE box was observed at the entry of Resident #1 and Resident #2's room in the Memory Care Unit. Review of the list titled Solaris Palatka COVID Positive Last 6 months revealed Resident #1 was identified as COVID-19 positive resident. Review of Resident #1's clinical records revealed she was a [AGE] year-old resident who was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of the nursing progress note for Resident #1 dated 07/27/2020 at 12:01 PM reads, Resident complained she couldn't breathe. Stated clothes were tight. Nurse assisted resident with loosening her clothing around her back and abdomen. Resident stated she felt better. Resident called out again that she could not breathe again. Vital signs were obtained oxygen level 97% on oxygen at 2 liters via nasal cannula. Blood pressure 155/80, pulse 67, and respirations 17. Temperature 97.6. No labored breathing noted. No accessory muscle usage noted. Resident was complaining of pain in unspecified area. The physician was called. The facility was awaiting a return call from the physician. Review of the physician's orders for Resident #1 dated 07/29/2020 reads, COVID-19 test one time related to concern of complaint of (c/o) problems with breathing and low oxygen level. Review of the nursing progress note for Resident #1 dated 07/29/2020 at 10:01 AM for Resident #1 reads, Resident stated she could not breathe. Vital signs: Temperature 97.2, respirations 16, Oxygen level 92% on room air, blood pressure 126/62, and pulse of 76. Attempts to put O2 via nasal cannula on resident were met with resistance. The Advanced Registered Nurse Practitioner (ARNP) notified of the situation and vital signs. At 12:07 PM reads, Received orders from the physician via telephone to swab resident for COVID-19 r/t (related to) episodes of shortness of breath and low oxygen saturation. At 4:30 PM read, Received orders from the physician to send to ER (emergency room ) at local hospital. Review of the facility physician progress notes [REDACTED]. Resident was becoming more lethargic and shorter of breath, chest x-ray shows both lung pleural effusions (buildup of fluid between the tissues that line the lungs and the chest) and [MEDICAL CONDITIONS]. Findings; blood pressure is 148/96, pulse 82, respirations 16, temperature 97.1, oxygen saturation on room air 91%. Lung sounds clear, but breath sounds are diminished in both lungs. Assessment: likely becoming dehydrated and developing symptoms of coronavirus in light of multiple exposures [MEDICAL CONDITION] positive patients. Plan: send her to the hospital for further evaluation and possible admission. Review of the nurse's progress note for Resident #1 dated 07/29/2020 at 8:10 PM reads, The resident returned from (local hospital's name) ER. COVID test positive. Droplet isolation precautions started. Review of Resident Census for Resident #1 revealed the resident was admitted to her room in the Memory Care Unit on 01/30/2019 and she remained in the same room until 08/04/2020. Review of MDS (Minimum Data Set) quarterly review for Resident #1 dated 06/02/2020 read, Section C. Cognitive Patterns: C0100. Should Brief Interview for Mental Status (BIMS) be Conducted? No . C0700. Short-term Memory Ok: 1. Memory problem. C0800. Long-term memory Ok: 1. Memory problem. C0900. Memory/Recall Ability: None of the above were recalled (A. current season, B. Location of own room, C. Staff names and faces, D. That he or she is in a nursing home/hospital swing bed). C1000. Cognitive Skills for Daily Decision Making: 3. Severely impaired- never/rarely made decisions. Review of Resident #2's clinical records revealed she was [AGE] year-old resident, who was admitted to the facility on [DATE] at 11:30 AM, with [DIAGNOSES REDACTED]. Review of the physician's progress note for Resident #2 dated 07/29/2020 at 7:09 PM reads, follow-up of resident that is surrounded by coronavirus positive residents. Resident is at risk for developing symptoms of coronavirus infection because of the exposure to other people. Review of the list titled Solaris Palatka COVID Positive Last 6 Months revealed Residents #15, #3, #7, #17 were identified as COVID-19 positive residents on 07/28/2020, 07/27/2020, 07/25/2020, and 07/25/2020, respectively. Review of the Midnight Census Report dated 07/29/2020 and the Midnight Census Report dated 08/04/2020 revealed Residents #15, #3, #7, #17 were residing in the Memory Care Unit. Review of the physician progress notes [REDACTED]. History: this resident was seen last week and showed no evidence of having [MEDICAL CONDITION] however, other people around her were testing positive. She was moved to room and was deemed to be more safe. She still has not shown any symptoms of headache fever or shortness of breath or chest pain. Assessment: patient remains at risk for exposure to coronavirus positive populations, however at this time she has given no indication of infection. Follow-up of patient that is surrounded by coronavirus positive patients. Recently the resident was reported to be somewhat lethargic today. Review of the MDS quarterly review for Resident #2 dated 06/02/2020 read, Section C. Cognitive Patterns: C0100. Should Brief Interview for Mental Status (BIMS) be Conducted? No . C0700. Short-term Memory Ok: 1. Memory problem. C0800. Long-term memory Ok: 1. Memory problem. C0900. Memory/Recall Ability: None of the above were recalled (A. current season, B. Location of own room, C. Staff names and faces, D. That he or she is in a nursing home/hospital swing bed). C1000. Cognitive Skills for Daily Decision Making: 3. Severely impaired- never/rarely made decisions. Review of the resident census dated 07/19/2020 and a review of the census dated 08/04/2020 midnight revealed Resident #1 and Resident #2 were roommates before 07/29/2020 when Resident #1 tested positive and after Resident #1 tested positive for COVID-19. During an interview on 08/05/2020 at 10:55 AM, Staff A, LPN (Licensed Practical Nurse), stated, I do not know why the resident that tested positive (Resident #1) and the resident that had not been a confirmed positive (Resident #2) are housed in the same room. The two ladies (Resident #1 and Resident #2) have been roommates for a while. During an interview on 08/05/2020 at 11:00 AM, the Director of Nursing (DON) stated, The facility currently has two residents, (Resident #1's name), who tested positive for COVID-19 at the hospital on [DATE], and (Resident #2's name), who has not been identified as having tested positive for COVID-19, in the same room. (Resident #1 and Resident #2's names) were not separated when (Resident #1's name) tested positive on 07/29/2020 because the local health department informed the facility that it was okay not to separate a COVID-19 positive resident from a COVID-19 negative resident in the same room. The health department told the facility to treat everyone in the Memory Care Unit as if they were persons under investigation (PUI) for COVID-19. 2. On 08/05/2020 at 10:45 AM, droplet precautions PPE box was observed at the entry of Resident #3 and Resident #4's room in the Memory Care Unit. Resident #3 and Resident #4 were not in the room at the time of observation. Review of the list titled Solaris Palatka COVID Positive Last 6 months revealed Residents #3, #4 were identified as COVID-19 positive residents on 07/27/2020 and 08/03/2020, respectively. Review of Resident #3's clinical records revealed she was a [AGE] year-old resident, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nurse's progress note for Resident #3 dated 07/27/2020 at 12:00 PM reads, The nurse received a call from the hospital. Resident is COVID positive. Director of Nursing (DON), family and physician were notified. The only concern that the family had was that resident maybe moved. Nurse assured her that resident would not be moved to another unit due to test (Positive) results. Review of the physician's progress note for Resident #3 dated 08/05/2020 at 10:16 PM reads, Reason for visit: follow-up of custodial care resident care patient with known coronavirus infection. History: At the time of the last visit the resident seemed to be becoming more lethargic. She is already on hospice care. Review of the MDS annual review for Resident #3 dated 06/02/2020 read, Section C. Cognitive Patterns: C0100. Should Brief Interview for Mental Status (BIMS) be Conducted? No . C0700. Short-term Memory Ok: 1. Memory problem. C0800. Long-term memory Ok: 1. Memory problem. C0900. Memory/Recall Ability: None of the above were recalled (A. current season, B. Location of own room, C. Staff names and faces, D. That he or she is in a nursing home/hospital swing bed). C1000. Cognitive Skills for Daily Decision Making: 3. Severely impaired- never/rarely made decisions. Review of Resident #4's clinical records revealed she was [AGE] year-old resident, who was admitted to the facility on [DATE] at 5:16 PM, with [DIAGNOSES REDACTED]. Review of the nurse's progress note for Resident #4 dated 08/01/2020 at 2:16 AM read, At 12 midnight, resident temperature at 101.8 via infrared. Tylenol 650 MG (milligram) given as per doctor's orders. 2 AM, recheck of temperature now at 99.4, no signs symptoms of chills, cough or body aches. Will continue to monitor. 4 AM, temperature now at 97.1, resident seems more comfortable and is sleeping soundly. Review of the physician progress notes [REDACTED]. History: at time the resident was seen last week, she appeared to be deteriorating later tested positive for [MEDICAL CONDITION]. Review of the MDS quarterly review for Resident #4 dated 07/17/2020 read, Section C. Cognitive Patterns: C0100. Should Brief Interview for Mental Status (BIMS) be Conducted? No . C0700. Short-term Memory Ok: 1. Memory problem. C0800. Long-term memory Ok: 1. Memory problem. C0900. Memory/Recall Ability: None of the above were recalled (A. current season, B. Location of own room, C. Staff names and faces, D. That he or she is in a nursing home/hospital swing bed). C1000. Cognitive Skills for Daily Decision Making: 3. Severely impaired- never/rarely made decisions. During an interview on 08/05/2020 at 10:55 AM, when asked why Resident #3 and Resident #4 were not in their rooms on isolation precautions, Staff A, LPN, stated, I don't know, but they will not stay in her rooms. When asked why Resident #3 and Resident #4 seated in the common/dining area in the Memory Care Unit were not wearing masks and not seated 6 feet apart, Staff A stated, The residents refuse to wear their mask and it is difficult to keep them 6 feet apart. During an interview on 08/05/2020 at 11:00 AM, the Director of Nursing, stated, It is very difficult to keep the residents in their rooms on isolation. It is difficult to keep face coverings on the residents and difficult to keep them six feet apart. On 08/05/2020 at 11:53 AM, Resident #3 and Resident #4 were observed in the dining/common area in the Memory Care Unit, seated back to back. The residents were not seated 6 feet apart. Staff was not observed to encourage the residents to don masks or to assist and/or encourage the residents to be seated six feet apart. Review of Resident #4's care plan last revised 08/06/2020 at 9:41 AM reads, I have tested positive for COVID-19 and am currently on droplet precautions. I have cognitive loss and do not understand the protocol for my isolation of isolating to room, wearing a mask, hand hygiene, and social distancing. Approach: please encourage and remind me of good hand hygiene with hand washing/use of hand sanitizer, use of mask, and distancing myself from other residents. Staff will wear assigned PPE (gloves, isolation gown, face shield, N95 mask, and surgical/cloth mask) while assisting with my care. 3. Review of Resident #12's clinical records revealed the resident was an [AGE] year-old resident, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's notes dated 08/05/2020 at 9:48 PM for Resident #12, reads, Reason for visit: follow-up of custodial care patient who has recently tested positive for the coronavirus. The resident is possibly more sluggish than last week but again he seems to be in not acute distress. Review of the nurse's progress note dated 07/14/2020 at 1:40 PM for Resident #12 reads, The resident was sent to the hospital for being nonresponsive. The resident was admitted to the hospital for febrile illness. Review of the nursing progress note dated 07/31/2020 at 7:00 PM for Resident #12 reads, Resident arrived via non-ER transport stretcher from (local hospital's name), escorted by 2 attendants - alert with confusion - currently resident on LTC Dementia unit - resident tested + (positive) for COVID while at the (local facility's name) - Upon readmit, resident was afebrile with no symptoms - place on Droplet isolation precautions as facility protocol. Review of the COVID-19 positive residents list for residents identified as being positive for COVID-19 revealed Resident #12 was not identified as being COVID positive. Review of Resident #12's care plan last revised 08/06/2020 at 9:51 AM reads, I am currently on droplet isolation as a precaution related to current positive COVID-19 on the unit where I live. Due to my cognitive loss I do not understand the protocol for my isolation of isolating to room, wearing a mask, hand hygiene, and social distancing. Goal: I want to remain symptom free from COVID-19. Approach: please encourage and remind me of good hand hygiene with hand washing/use of hand sanitizer, use of mask, and distancing myself from other residents. Staff will wear assigned PPE (gloves, isolation gown, face shield, N95 mask, and surgical/cloth mask) while assisting with my care. Review of Resident #12's progress note dated 07/31/2020 revealed the resident returned from the local hospital on [DATE] being COVID-19 positive. During an interview on 08/05/2020 at 11:00 AM, the Director of Nursing (DON), stated, I was not aware that (Resident #12's name) had tested positive for COVID-19 on 07/31/2020 at the hospital. (Resident #12's name) was not placed on isolation. On 08/06/2020 beginning at 8:55 AM, observation revealed no isolation signage and no PPE supply box outside Resident #12's Room in the Memory Care Unit. 4. On 08/05/2020 at 10:44 AM, while approaching the facility's Memory Care Unit, two trash receptacles with blue bags and lid were observed outside of the unit in the 300 Hallway. During an interview on 08/05/2020 at 10:55 AM, Staff A, LPN, stated, The staff that work in the Memory Care Unit remove their soiled PPE just outside of the Memory Care Unit in the 300 Hallway. When asked where the staff that work in the Memory Care Unit enter and exit the facility, Staff A stated, The staff that work in the Memory Care Unit enter and exit the building with staff not working in the memory care unit. On 08/05/2020 at 11:53 AM, Staff A, LPN (Licensed Practical Nurse), was observed to remove her PPE (gloves) and place them in the trash receptacles with blue bags outside the Memory Care Unit in the 300 Hallway. On 08/06/2020 at 8:00 AM, two trash receptacles were observed outside of the Memory Care Unit in the 300 Hallway. Staff C, CNA (Certified Nursing Assistant), was observed exiting the Memory Care Unit and doffing PPE (gown and gloves) in the 300 Hallway. On 08/06/2020 at 9:35 AM, PPE trash receptacles for doffing PPE was observed to have been moved from the 300 Hallway to the Memory Care Unit. The trash receptacles remain in a common area in the memory care unit. During an interview on 08/06/2020 at 09:25 AM, the Wound Care Nurse/Infection Control Nurse stated, We moved the isolation doffing trash receptacles inside the Memory Care Unit. I guess we didn't consider that this would expose all the residents to potentially infected things with COVID-19. I expect all staff to adhere to the standard precautions of hand washing and sanitizing. Full PPE of a gown, gloves, N95 mask and goggles or faceshield should be used whenever caring for a resident with COVID-19. We have gotten guidance from the health department on COVID-19 on what we need to do. I do not think that DOH (Department of Health) has been here and seen trash receptacles in the hallways, and I don't think that we actually spoke to them about where the doffing of PPE would happen. Review of Solaris Healthcare Palatka PPE Inventory 07/31/2020 revealed the facility had 910 N95 masks, 1360 KN95 masks, 5300 surgical masks, 463 fluid shields, 98 goggles, 2490 disposable gowns, 510 washable gowns, 0 gloves, 42 hand soap refills, 48 bleach wipe containers, 73 hand sanitizer refills. During an interview in the 300 Hallway on 08/06/2020 at 9:47AM, Staff I, CNA, stated, I am not sure why the trash receptacles for the Memory Care Unit are outside the Memory Care Unit in the 300 Hallway. The trash receptacles have been in the 300 Hallway since the Memory Care Unit admitted the first COVID-19 positive resident. The Memory Care Unit nurses place their PPE in the trash receptacles. During an interview on 08/06/2020 at 10:00 AM, Staff C, CNA, stated, We remove our PPE when we leave the unit in the trash receptacles just outside the Memory Care Unit door. There isn't any special area that we take off our PPE. We do it right in the 300 Hallway. That is how we were trained to do it. We have not been making the COVID-19 positive residents stay in their rooms. The Director of Nursing has told us that they don't have to. We have received training and education related to how to use PPE, putting it on and taking it off. We put on our N 95 when we come in and before we enter the memory care unit we put on our gowns. We take our gowns off right outside of the doors in the hallway. There isn't any special area that we take off our PPE, we do it right in the hallway that is how we were trained to do it. During an interview on 08/06/2020 at 10:15 AM, Staff D, CNA, stated, We stay in the same gown all day. We don't change them. Right now, we have three residents who have [MEDICAL CONDITION]. We don't do anything different for them than anyone else that is in here in the Memory Care Unit. We use the same gown all day and when we are taking care of those residents that are COVID-19 positive.<br (TRUNCATED)

Based on observation, interview, record review, and CDC (Centers for Disease Control and Prevention) guidelines review, the facility failed to implement an infection prevention and control program to prevent four residents (Residents #1, 3, 4, and 12) who were infected with [DIAGNOSES REDACTED]-CoV-2, a highly contagious and potentially deadly virus for people over [AGE] years of age, from exposing 12 other residents living on the same unit by failing to isolate and implement transmission-based precautions for residents who were confirmed with COVID-19. The facility failed to quarantine residents exposed to COVID-19 in the Memory Care Unit. The facility failed to follow the policies and procedures to ensure staff contained PPE (Personal Protective Equipment) used for residents in trash receptacles to prevent possible environmental exposure and failed to ensure staff performed hand hygiene before and after resident care. Individuals who are [AGE] years and older, those with chronic underlying medical conditions, and those living in nursing homes are at high risk for developing serious complications from COVID-19 illness. Individuals who are infected could develop serious disease with difficulty breathing and might require intensive care for the treatment of [REDACTED]. COVID-19 infection can lead to death. COVID-19 is a new disease, caused by a new coronavirus that has not previously been seen in humans. Currently, there is no vaccine and no approved treatment for [REDACTED]. As a result of the deficient practice related to transmission-based precautions, 12 residents living in the Memory Care Unit and the deficient practice related to general infection control practices, 127 residents living in the general units of the facility, 138 out of 142 total residents, are at risk for developing a communicable disease (COVID-19). Findings include: 1. On 08/05/2020 at 10:45 AM, droplet precautions PPE box was observed at the entry of Resident #1 and Resident #2's room in the Memory Care Unit. Review of the list titled Solaris Palatka COVID Positive Last 6 months revealed Resident #1 was identified as COVID-19 positive resident. Review of Resident #1's clinical records revealed she was a [AGE] year-old resident who was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of the nursing progress note for Resident #1 dated 07/27/2020 at 12:01 PM reads, Resident complained she couldn't breathe. Stated clothes were tight. Nurse assisted resident with loosening her clothing around her back and abdomen. Resident stated she felt better. Resident called out again that she could not breathe again. Vital signs were obtained oxygen level 97% on oxygen at 2 liters via nasal cannula. Blood pressure 155/80, pulse 67, and respirations 17. Temperature 97.6. No labored breathing noted. No accessory muscle usage noted. Resident was complaining of pain in unspecified area. The physician was called. The facility was awaiting a return call from the physician. Review of the physician's orders [REDACTED]. Review of the nursing progress note for Resident #1 dated 07/29/2020 at 10:01 AM for Resident #1 reads, Resident stated she could not breathe. Vital signs: Temperature 97.2, respirations 16, Oxygen level 92% on room air, blood pressure 126/62, and pulse of 76. Attempts to put O2 via nasal cannula on resident were met with resistance. The Advanced Registered Nurse Practitioner (ARNP) notified of the situation and vital signs. At 12:07 PM reads, Received orders from the physician via telephone to swab resident for COVID-19 r/t (related to) episodes of shortness of breath and low oxygen saturation. At 4:30 PM read, Received orders from the physician to send to ER (emergency room ) at local hospital. Review of the facility physician progress notes [REDACTED]. Resident was becoming more lethargic and shorter of breath, chest x-ray shows both lung pleural effusions (buildup of fluid between the tissues that line the lungs and the chest) and [MEDICAL CONDITIONS]. Findings; blood pressure is 148/96, pulse 82, respirations 16, temperature 97.1, oxygen saturation on room air 91%. Lung sounds clear, but breath sounds are diminished in both lungs. Assessment: likely becoming dehydrated and developing symptoms of coronavirus in light of multiple exposures [MEDICAL CONDITION] positive patients. Plan: send her to the hospital for further evaluation and possible admission. Review of the nurse's progress note for Resident #1 dated 07/29/2020 at 8:10 PM reads, The resident returned from (local hospital's name) ER. COVID test positive. Droplet isolation precautions started. Review of Resident Census for Resident #1 revealed the resident was admitted to her room in the Memory Care Unit on 01/30/2019 and she remained in the same room until 08/04/2020. Review of MDS (Minimum Data Set) quarterly review for Resident #1 dated 06/02/2020 read, Section C. Cognitive Patterns: C0100. Should Brief Interview for Mental Status (BIMS) be Conducted? No . C0700. Short-term Memory Ok: 1. Memory problem. C0800. Long-term memory Ok: 1. Memory problem. C0900. Memory/Recall Ability: None of the above were recalled (A. current season, B. Location of own room, C. Staff names and faces, D. That he or she is in a nursing home/hospital swing bed). C1000. Cognitive Skills for Daily Decision Making: 3. Severely impaired- never/rarely made decisions. Review of Resident #2's clinical records revealed she was [AGE] year-old resident, who was admitted to the facility on [DATE] at 11:30 AM, with [DIAGNOSES REDACTED]. Review of the physician's progress note for Resident #2 dated 07/29/2020 at 7:09 PM reads, follow-up of resident that is surrounded by coronavirus positive residents. Resident is at risk for developing symptoms of coronavirus infection because of the exposure to other people. Review of the list titled Solaris Palatka COVID Positive Last 6 Months revealed Residents #15, #3, #7, #17 were identified as COVID-19 positive residents on 07/28/2020, 07/27/2020, 07/25/2020, and 07/25/2020, respectively. Review of the Midnight Census Report dated 07/29/2020 and the Midnight Census Report dated 08/04/2020 revealed Residents #15, #3, #7, #17 were residing in the Memory Care Unit. Review of the physician progress notes [REDACTED]. History: this resident was seen last week and showed no evidence of having [MEDICAL CONDITION] however, other people around her were testing positive. She was moved to room and was deemed to be more safe. She still has not shown any symptoms of headache fever or shortness of breath or chest pain. Assessment: patient remains at risk for exposure to coronavirus positive populations, however at this time she has given no indication of infection. Follow-up of patient that is surrounded by coronavirus positive patients. Recently the resident was reported to be somewhat lethargic today. Review of the MDS quarterly review for Resident #2 dated 06/02/2020 read, Section C. Cognitive Patterns: C0100. Should Brief Interview for Mental Status (BIMS) be Conducted? No . C0700. Short-term Memory Ok: 1. Memory problem. C0800. Long-term memory Ok: 1. Memory problem. C0900. Memory/Recall Ability: None of the above were recalled (A. current season, B. Location of own room, C. Staff names and faces, D. That he or she is in a nursing home/hospital swing bed). C1000. Cognitive Skills for Daily Decision Making: 3. Severely impaired- never/rarely made decisions. Review of the resident census dated 07/19/2020 and a review of the census dated 08/04/2020 midnight revealed Resident #1 and Resident #2 were roommates before 07/29/2020 when Resident #1 tested positive and after Resident #1 tested positive for COVID-19. During an interview on 08/05/2020 at 10:55 AM, Staff A, LPN (Licensed Practical Nurse), stated, I do not know why the resident that tested positive (Resident #1) and the resident that had not been a confirmed positive (Resident #2) are housed in the same room. The two ladies (Resident #1 and Resident #2) have been roommates for a while. During an interview on 08/05/2020 at 11:00 AM, the Director of Nursing (DON) stated, The facility currently has two residents, (Resident #1's name), who tested positive for COVID-19 at the hospital on [DATE], and (Resident #2's name), who has not been identified as having tested positive for COVID-19, in the same room. (Resident #1 and Resident #2's names) were not separated when (Resident #1's name) tested positive on 07/29/2020 because the local health department informed the facility that it was okay not to separate a COVID-19 positive resident from a COVID-19 negative resident in the same room. The health department told the facility to treat everyone in the Memory Care Unit as if they were persons under investigation (PUI) for COVID-19. 2. On 08/05/2020 at 10:45 AM, droplet precautions PPE box was observed at the entry of Resident #3 and Resident #4's room in the Memory Care Unit. Resident #3 and Resident #4 were not in the room at the time of observation. Review of the list titled Solaris Palatka COVID Positive Last 6 months revealed Residents #3, #4 were identified as COVID-19 positive residents on 07/27/2020 and 08/03/2020, respectively. Review of Resident #3's clinical records revealed she was a [AGE] year-old resident, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nurse's progress note for Resident #3 dated 07/27/2020 at 12:00 PM reads, The nurse received a call from the hospital. Resident is COVID positive. Director of Nursing (DON), family and physician were notified. The only concern that the family had was that resident maybe moved. Nurse assured her that resident would not be moved to another unit due to test (Positive) results. Review of the physician's progress note for Resident #3 dated 08/05/2020 at 10:16 PM reads, Reason for visit: follow-up of custodial care resident care patient with known coronavirus infection. History: At the time of the last visit the resident seemed to be becoming more lethargic. She is already on hospice care. Review of the MDS annual review for Resident #3 dated 06/02/2020 read, Section C. Cognitive Patterns: C0100. Should Brief Interview for Mental Status (BIMS) be Conducted? No . C0700. Short-term Memory Ok: 1. Memory problem. C0800. Long-term memory Ok: 1. Memory problem. C0900. Memory/Recall Ability: None of the above were recalled (A. current season, B. Location of own room, C. Staff names and faces, D. That he or she is in a nursing home/hospital swing bed). C1000. Cognitive Skills for Daily Decision Making: 3. Severely impaired- never/rarely made decisions. Review of Resident #4's clinical records revealed she was [AGE] year-old resident, who was admitted to the facility on [DATE] at 5:16 PM, with [DIAGNOSES REDACTED]. Review of the nurse's progress note for Resident #4 dated 08/01/2020 at 2:16 AM read, At 12 midnight, resident temperature at 101.8 via infrared. Tylenol 650 MG (milligram) given as per doctor's orders. 2 AM, recheck of temperature now at 99.4, no signs symptoms of chills, cough or body aches. Will continue to monitor. 4 AM, temperature now at 97.1, resident seems more comfortable and is sleeping soundly. Review of the physician progress notes [REDACTED]. History: at time the resident was seen last week, she appeared to be deteriorating later tested positive for [MEDICAL CONDITION]. Review of the MDS quarterly review for Resident #4 dated 07/17/2020 read, Section C. Cognitive Patterns: C0100. Should Brief Interview for Mental Status (BIMS) be Conducted? No . C0700. Short-term Memory Ok: 1. Memory problem. C0800. Long-term memory Ok: 1. Memory problem. C0900. Memory/Recall Ability: None of the above were recalled (A. current season, B. Location of own room, C. Staff names and faces, D. That he or she is in a nursing home/hospital swing bed). C1000. Cognitive Skills for Daily Decision Making: 3. Severely impaired- never/rarely made decisions. During an interview on 08/05/2020 at 10:55 AM, when asked why Resident #3 and Resident #4 were not in their rooms on isolation precautions, Staff A, LPN, stated, I don't know, but they will not stay in her rooms. When asked why Resident #3 and Resident #4 seated in the common/dining area in the Memory Care Unit were not wearing masks and not seated 6 feet apart, Staff A stated, The residents refuse to wear their mask and it is difficult to keep them 6 feet apart. During an interview on 08/05/2020 at 11:00 AM, the Director of Nursing, stated, It is very difficult to keep the residents in their rooms on isolation. It is difficult to keep face coverings on the residents and difficult to keep them six feet apart. On 08/05/2020 at 11:53 AM, Resident #3 and Resident #4 were observed in the dining/common area in the Memory Care Unit, seated back to back. The residents were not seated 6 feet apart. Staff was not observed to encourage the residents to don masks or to assist and/or encourage the residents to be seated six feet apart. Review of Resident #4's care plan last revised 08/06/2020 at 9:41 AM reads, I have tested positive for COVID-19 and am currently on droplet precautions. I have cognitive loss and do not understand the protocol for my isolation of isolating to room, wearing a mask, hand hygiene, and social distancing. Approach: please encourage and remind me of good hand hygiene with hand washing/use of hand sanitizer, use of mask, and distancing myself from other residents. Staff will wear assigned PPE (gloves, isolation gown, face shield, N95 mask, and surgical/cloth mask) while assisting with my care. 3. Review of Resident #12's clinical records revealed the resident was an [AGE] year-old resident, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's notes dated 08/05/2020 at 9:48 PM for Resident #12, reads, Reason for visit: follow-up of custodial care patient who has recently tested positive for the coronavirus. The resident is possibly more sluggish than last week but again he seems to be in not acute distress. Review of the nurse's progress note dated 07/14/2020 at 1:40 PM for Resident #12 reads, The resident was sent to the hospital for being nonresponsive. The resident was admitted to the hospital for febrile illness. Review of the nursing progress note dated 07/31/2020 at 7:00 PM for Resident #12 reads, Resident arrived via non-ER transport stretcher from (local hospital's name), escorted by 2 attendants - alert with confusion - currently resident on LTC Dementia unit - resident tested + (positive) for COVID while at the (local facility's name) - Upon readmit, resident was afebrile with no symptoms - place on Droplet isolation precautions as facility protocol. Review of the COVID-19 positive residents list for residents identified as being positive for COVID-19 revealed Resident #12 was not identified as being COVID positive. Review of Resident #12's care plan last revised 08/06/2020 at 9:51 AM reads, I am currently on droplet isolation as a precaution related to current positive COVID-19 on the unit where I live. Due to my cognitive loss I do not understand the protocol for my isolation of isolating to room, wearing a mask, hand hygiene, and social distancing. Goal: I want to remain symptom free from COVID-19. Approach: please encourage and remind me of good hand hygiene with hand washing/use of hand sanitizer, use of mask, and distancing myself from other residents. Staff will wear assigned PPE (gloves, isolation gown, face shield, N95 mask, and surgical/cloth mask) while assisting with my care. Review of Resident #12's progress note dated 07/31/2020 revealed the resident returned from the local hospital on [DATE] being COVID-19 positive. During an interview on 08/05/2020 at 11:00 AM, the Director of Nursing (DON), stated, I was not aware that (Resident #12's name) had tested positive for COVID-19 on 07/31/2020 at the hospital. (Resident #12's name) was not placed on isolation. On 08/06/2020 beginning at 8:55 AM, observation revealed no isolation signage and no PPE supply box outside Resident #12's Room in the Memory Care Unit. 4. On 08/05/2020 at 10:44 AM, while approaching the facility's Memory Care Unit, two trash receptacles with blue bags and lid were observed outside of the unit in the 300 Hallway. During an interview on 08/05/2020 at 10:55 AM, Staff A, LPN, stated, The staff that work in the Memory Care Unit remove their soiled PPE just outside of the Memory Care Unit in the 300 Hallway. When asked where the staff that work in the Memory Care Unit enter and exit the facility, Staff A stated, The staff that work in the Memory Care Unit enter and exit the building with staff not working in the memory care unit. On 08/05/2020 at 11:53 AM, Staff A, LPN (Licensed Practical Nurse), was observed to remove her PPE (gloves) and place them in the trash receptacles with blue bags outside the Memory Care Unit in the 300 Hallway. On 08/06/2020 at 8:00 AM, two trash receptacles were observed outside of the Memory Care Unit in the 300 Hallway. Staff C, CNA (Certified Nursing Assistant), was observed exiting the Memory Care Unit and doffing PPE (gown and gloves) in the 300 Hallway. On 08/06/2020 at 9:35 AM, PPE trash receptacles for doffing PPE was observed to have been moved from the 300 Hallway to the Memory Care Unit. The trash receptacles remain in a common area in the memory care unit. During an interview on 08/06/2020 at 09:25 AM, the Wound Care Nurse/Infection Control Nurse stated, We moved the isolation doffing trash receptacles inside the Memory Care Unit. I guess we didn't consider that this would expose all the residents to potentially infected things with COVID-19. I expect all staff to adhere to the standard precautions of hand washing and sanitizing. Full PPE of a gown, gloves, N95 mask and goggles or faceshield should be used whenever caring for a resident with COVID-19. We have gotten guidance from the health department on COVID-19 on what we need to do. I do not think that DOH (Department of Health) has been here and seen trash receptacles in the hallways, and I don't think that we actually spoke to them about where the doffing of PPE would happen. Review of Solaris Healthcare Palatka PPE Inventory 07/31/2020 revealed the facility had 910 N95 masks, 1360 KN95 masks, 5300 surgical masks, 463 fluid shields, 98 goggles, 2490 disposable gowns, 510 washable gowns, 0 gloves, 42 hand soap refills, 48 bleach wipe containers, 73 hand sanitizer refills. During an interview in the 300 Hallway on 08/06/2020 at 9:47AM, Staff I, CNA, stated, I am not sure why the trash receptacles for the Memory Care Unit are outside the Memory Care Unit in the 300 Hallway. The trash receptacles have been in the 300 Hallway since the Memory Care Unit admitted the first COVID-19 positive resident. The Memory Care Unit nurses place their PPE in the trash receptacles. During an interview on 08/06/2020 at 10:00 AM, Staff C, CNA, stated, We remove our PPE when we leave the unit in the trash receptacles just outside the Memory Care Unit door. There isn't any special area that we take off our PPE. We do it right in the 300 Hallway. That is how we were trained to do it. We have not been making the COVID-19 positive residents stay in their rooms. The Director of Nursing has told us that they don't have to. We have received training and education related to how to use PPE, putting it on and taking it off. We put on our N 95 when we come in and before we enter the memory care unit we put on our gowns. We take our gowns off right outside of the doors in the hallway. There isn't any special area that we take off our PPE, we do it right in the hallway that is how we were trained to do it. During an interview on 08/06/2020 at 10:15 AM, Staff D, CNA, stated, We stay in the same gown all day. We don't change them. Right now, we have three residents who have [MEDICAL CONDITION]. We don't do anything different for them than anyone else that is in here in the Memory Care Unit. We use the same gown all day and when we are taking care of those residents that are COVID-19 positive. During an interview on 08/06/2020 at 10:30 AM, Staff E, RN (Registered Nurse), stated, When we remove our PPE, it is outside the unit doors in the trash receptacles outside the doors. During an interview on 08/06/2020 at 4:15 PM, Staff H, CNA, stated, When we come into the Memory Care Unit, we put on our gowns and face shield. We keep those on all day. I don't put on any gowns over this gown. I do not wash my face shield after I take care of the COVID-19 positive residents. The positive residents are not kept inside their rooms. They come out in the common area. We usually took our gowns off right outside the door. They just told us that today. We have been taking our gowns off in the hallway up until today. We have been doing that since the first resident in the Memory Care Unit was positive. I can't remember how long it been, maybe a few weeks now. During an interview on 08/07/2020 at 7:40 AM, Staff G, LPN, stated, We haven't isolated residents in the Memory Care Unit. We were told that we treated them all like they might have COVID-19. The residents all come out to the lounge area and mingle. It is kind of hard to stop some of them from leaving their rooms. We have three residents with [MEDICAL CONDITION] in the Memory Care Unit. We did not have them all in private rooms until you all from the state showed up. We were told that the department of health said this is how we should be doing things. We have had residents in the same room that were negative and positive until you showed up and then they separated them. I have not used but one gown each night while I'm on shift for all the residents whether they were positive or negative. I don't put a disposable gown over this one no one has ever told me that I needed to. I keep my face shield on all night, I don't clean it at all between residents, should I, because no one has ever told me that I should. 5. On 08/06/2020 at 8:55 AM, during a tour of the Memory Care Unit, Resident #1 was observed in the common area within approximately three feet of other residents. Six residents, who were observed in the common areas, did not have masks on. On 08/06/2020 at 9:20 AM, Staff D, CNA, was observed repositioning Resident #1 in her chair. Staff D did not have gloves on. Staff D then got a pair of gloves and donned gloves without performing hand hygiene and returned to assist Resident #1. During an interview on 08/06/2020 at 10:15 AM, Staff D, CNA, stated, I did not have gloves on when I repositioned (Resident #1's name). When I realized I didn't have them on, I got them and put them on. I did not sanitize my hands before putting the gloves on. I should have. We stay in the same gown all day. We don't change them. Right now, we have three residents who have [MEDICAL CONDITION]. We don't do anything different for them than anyone else that is in here in the Memory Care Unit. We use the same gown all day and when we are taking care of those residents that are COVID-19 positive. On 08/06/2020 at 9:35 AM, Staff E, RN, was observed at the medication cart in the Memory Care Unit. She was observed entering Resident #14's Room with a cup of medications. She did not perform hand hygiene upon entry to Resident #14's Room. She was observed leaving the room at 09:45 AM. She did not perform hand hygiene after exiting the room before and after resident contact. During an interview on 08/06/2020 at 10:30 AM, Staff E, RN, stated, I didn't realize that I didn't wash or sanitize my hands. I should have, and I should have put on gloves. We have three residents who are COVID-19 positive right now. We have not really isolated the residents that are COVID-19 positive. They still are out in the lounge area. I have not redirected them to go back in their rooms. We were told we didn't have to because the department of health said we should treat them all like they might be positive. We should put anyone who is in droplet isolation in a private room and maintain a closed door. On 08/06/2020 at 12:30 PM, Staff D, CNA, was observed delivering meals in the Memory Care Unit to residents. Resident #1 was observed in the common area/dining room being assisted for lunch by Staff D, CNA, who was feeding Resident #1 without gloves on. During an interview on 08/06/2020 at approximately 12:40 PM, Staff D, CNA, stated, I did not have gloves on when I was feeding resident #1. During an interview on 08/06/2020 at 8:36 AM, with the Administrator when asked why the staff working in the Memory Care Unit, housing COVID-19 positive residents, are entering and exiting using the same entrance and exit with the staff not working in the Memory Care Unit, the Administrator stated, The nursing staff is under the Director of Nursing. I will refer that question to her. I do rely on the Director of Nursing's expertise in the matter of infection control practices and how they are implemented. When asked why the linen barrels for discarding the PPE used in the Memory Care Unit was outside the Memory Care Unit on the 300 Hallway, the Administrator stated, I don't know why the barrels are in the 300 Hallway except to collect what they are supposed to collect. I will again refer to the DON. When asked what the facility was doing to minimize infection control related to COVID-19 positive residents, the Administrator stated, I will refer to the DON. When asked if he was aware that the facility was cohorting COVID-19 positive residents with non-COVID-19 positive residents, the Administrator stated, I am aware that the facility is cohorting COVID-19 positive and negative residents. I do not recall being on a phone call from the health department regarding cohorting residents. I am ultimately responsible for the care the residents receive in the facility. During an interview on 08/06/2020 at 09:25 AM, the Wound Care Nurse/Infection Control Nurse stated, I am the wound care nurse and I took over infection control in April. (Resident #1's name) is positive for COVID-19. I guess she should not be in the common areas. She was just finishing breakfast. She really should not have been so close to the other resident. We moved the isolation doffing trash bins inside the Memory Care Unit. I guess we didn't consider that this would expose all the residents to potentially infected things with COVID-19. We have treated the Memory Care Unit as if everyone might have COVID-19. We were told by the health department to treat everyone in there the same. We didn't think about moving positive residents when one tested positive and their roommate was negative. It is in our infection control policies that we put droplet precaution residents in a private room. We have had private rooms and we could have done that. I expect all staff to adhere to the standard precautions of hand washing and sanitizing. Full PPE of a gown, gloves, N95 mask and goggles and faceshield should be used whenever caring for a resident with COVID-19. We have gotten guidance from the health department on COVID-19 on what we need to do. I do not think that DOH (Department of Health) has been here and seen trash receptacles in the hallways, and I don't think that we actually spoke to them about where the doffing of PPE would happen. During an interview via telephone on 08/06/2020 at 1:05 PM, the Medical Director stated, I have been Medical Director for about [AGE] years. I am aware that the Memory Care Unit is now a COVID-19 unit. I haven't been happy about that or having to accept COVID-19 residents. The facility has been in constant contact with the local health department and they have been doing things according to what the health department has directed them to. It was their understanding that the Memory Care Unit has exceptions for memory care unit residents. I was not aware that the facility was not following the recommendations of the CDC. But the guidance is not clear and the facility was following the DOH recommendations. I am aware that infection control practice standards call for isolation of patients with droplet borne infections. Review of the census for the Memory Care Unit dated 08/05/2020 revealed a current census of 15 residents. During an interview on 08/07/2020 at 8:41 AM, the DON stated, If we had a resident outside of the Memory Care Unit tested positive, we would not place them in the Memory Care Unit. We would set up a dedicated COVID-19 area with dedicated staff. We presume all Memory Care Unit residents may have coronavirus, but they are not all on isolation because they are not all positive. All staff wear full PPE at this time. We thought when the DOH guided us to treat everyone in the Memory Care Unit as if they might be positive that we did not have to isolate or separate the residents who were positive from those that were negative. We do have transmission-based policies for droplet isolation. We have not followed them in the Memory Care Unit because the department of health told us to treat everyone in there as if they might be positive. We did place the three residents in Memory Care Unit on isolation. We still have allowed them out of their rooms, and we have not moved any residents if one is positive and one is negative. I didn't realize that there was any problem with having the trash bins for removing PPE in the hallway outside the Memory Care Unit. Review of the local department of health assessment plan dated May 14, 2020 reads, General facility recommendations; recommend discontinuation of communal dining and activities. Maintain social distancing. Ensure residents are offered masks in communal areas. If residents are noncompliant, ensure all staff members are wearing masks at all times. Ensure staff are changing gloves after contact with each resident care task. Clean high touch surfaces frequently and create documentation system. Sanitize communal activity equipment after each use. Solaris specific recommendations: Enclose open utensils on medication cart or replace with prepackaged plastic wear. Create designated ward for COVID positive residents that is blocked off to the rest of the facility. Create designated ward for 14-day monitoring of COVID suspected or precautionary residents. Designate one entrance/exit for personnel working on COVID positive ward. Place signage on doors alerting staff that the resident is a contact precaution i.e.: droplet precaution, airborne precaution, etc. Assign designated staff members to work on the on the designated COVID ward and promote continuity of care. Avoid housekeeping from accessing COVID positive ward and promote designated staff to perform environmental cleaning. Engage staff members in continuation of environmental cleaning of high touch surfaces during scheduled shift and after housekeeping scheduled hours and create a documented log. Memory care residents should remain spaced 6 feet apart if non-compliant with staying in their room. Chairs should be moved to ensure 6-foot distance is met. Continue to educate residents on the rationale for social distancing if noncompliant. Face mask should always be offered to memory care re (TRUNCATED)