Every finding on record at Palm Garden of Pinellas

Based on interviews and record review, the facility failed to provide care and treatment in accordance with professional standards and failed to send the resident to higher level of care, upon request for one (Resident #2) of two residents sampled. Resident #2 experienced a change of condition on [DATE] with a delay treatment according to professional standard of practice. Cross-reference F580. Findings included:Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] and expired on [DATE]. Resident #2 had a primary diagnosis of heart failure, unspecified and additional diagnoses included type 2 diabetes mellitus with diabetic neuropathy, unspecified; essential (primary) hypertension; and hyperlipidemia, unspecified. Resident #2 had intact cognition and primary physician was listed as Medical Director. Review of Resident #2's progress notes from [DATE] to [DATE] revealed: - [DATE] at 5:35 p.m., Staff A, Registered Nurse (RN), wrote, Patient c/o [complained of] middle back pain and became anxious. Patient had previously asked day nurse for [antacid] and antifungal cream while ambulating in her wheelchair. Assessed patient. Lungs were clear bilaterally. Vitals BP [blood pressure] of 152/69, P [pulse] of 86, SPO2 [oxygen level] of 97%, and a T [temperature] 97.7 [degrees Fahrenheit]. Per nursing supervisor, patient vomited prior to alerting me that patient was feeling unwell. Patient did not vomit in my presence. Repositioned patient with pillow under her back facing R [right] with R side down. Patient expressed she no longer felt pain andwanted [sic] to rest at this time. 30 minute follow up, patient was resting in bed with no signs or symptoms of pain. Will provide report to next shift as well. - [DATE] at 9:30 a.m., Staff B, RN, wrote, Resident c/o chest pain that's radiating to her back. Upon assessment resident appeared clammy and sweating. APRN [Advanced Practice Registered Nurse] [Name] notified, and n/o [new orders] placed for STAT [immediately] EKG [electrocardiogram], CXR [chest x-ray], & blood work to be collected. - [DATE] at 10:00 a.m., Staff B, RN, wrote, Called [EKG/lab provider] and explained to the residents [sic] state and APRN wanted STAT EKG. Per [EKG/lab provider] 'unable to do STAT EKG and it could only be done and ordered routine and that they will reach out to dispatch and see where the field tech was and call back.' APRN [name] notified. - [DATE] at 11:15 a.m., Staff B, RN, wrote, APRN [name] returned from assessing the resident and stated she wanted to potentially give resident something for her anxiety to 'calm her down' however no n/o were placed at this time. - [DATE] at 12:00 p.m., Staff B, RN, wrote, Resident called out to staff stating she is really wanting to go to ER [emergency room] and she wasn't feeling good at all. Nurse writing this went into residents [sic] room and once again resident appearing [sic] sweaty, pale and clammy to touch. Resident stated, 'I really want to go to the Hospital [sic] I don't feel good.' Reported this to the APRN again and no n/o were placed. No call back from [EKG/lab provider] regarding ETA [estimated time of arrival] for STAT EKG/CXR. - [DATE] at 2:15 p.m., Staff B, RN, wrote, Nurse writing this went into DON [Director of Nursing] office and expressed grave concerns that resident needed to be sent to ER due to her c/o chest pain that was radiating to her back. DON discussed this with APRN [name] and n/o was put in to give resident 0.4 mg [milligrams] nitro [nitroglycerin] SL [sublingual] [administered under the tongue]. Verbalized these orders to the assigned nurse. On [DATE] at 2:30 p.m., Staff C, Licensed Practical Nurse (LPN), wrote, Resident stated medication helped BP [blood pressure] 145/81, PRN (as needed) Administration was: Effective. On [DATE] at 2:40 p.m., Staff B, RN, wrote, Resident stated that SL nitro was helping with her chest pain. VSS [vital signs stable]. Contacted [EKG/lab provider] again to expedite the EKG. Per [EKG/lab provider] they were going to contact the field team. [Name APRN] provider present. Ok to hold off on ER transport. On [DATE] at 2:40 p.m., Staff B, RN, wrote, SL Nitro given and went in to reassess resident. VSS stable see VSS documented. On [DATE] at 3:10 p.m., APRN wrote, Notified by unit manager at 0930 that pt [patient] was requesting to go to the hospital for pain. Pt found in her room (0935), sitting up in bed and at her baseline. No distress noted; calm and cooperative. She complained about having a throbbing pain in her chest area that started a day or so ago. Stated that when she burps the pain goes away for a while. Denies any changes to her diet. No radiating to her arms, back or jaw, no diaphoresis or SOB [shortness of breath] noted. VSS at this time; slightly hypertensive 145/81 and O2 [oxygen sat [saturation] on RA [room air] is 98%. Agreeable to having labs and diagnostics performed at SNF [skilled nursing facility]. Orders for STAT CBC [complete blood count], CMP [comprehensive metabolic panel], UA w/C&S [urine analysis with culture and specificity], CXR, EKG placed. Notified by unit manager that pt wanted to speak to APC (advanced practice clinician) (1100) as she was anxious and wanting to go to the hospital. Approx 1400-1415, DON approached APC about pt and c/o chest pain. Ordered for NTG [nitroglycerine SL] PRN and to give dose now w/VS prior to and after administration. Also ordered for her to have O2 NC [nasal canula] place for comfort and prophylaxis. Notified by unit manager approx 15-20 mins later that relief w/NTG and pt refused to have O2 NC placed. Nurse on other cart approached APC and stated that pt is c/o wanting to go to the hospital. Verbal order given to send pt out to the ED [emergency department]. Notified approx 15 mins after that pt was unresponsive up in her w/c in her room. APC entered room and pt unresponsive in w/c, slumped over w/agonal breathing. Staff moved pt back to her bed and cyanosis noted around her lips. She is a DNR (do not resuscitate) code status; EMS (emergency medical services) was called and no carotid or radial pulse felt, no heart sounds w/auscultation noted. EMS arrived and placed on monitor, PEA (pulseless electrical activity) on monitor. Pronounced at 1504. On [DATE] at 3:40 p.m., Staff B, RN, wrote, At approximately 1500 [3:00 p.m.], the DON entered my office and reported that the resident was unresponsive in her wheelchair. I immediately proceeded to the resident's room and found her in the wheelchair with agonal respirations and cyanotic lips. I attempted to sternal rub, but the resident demonstrated only minimal response to painful stimuli. Myself [sic] and three other nursing staff members assisted in transferring the resident back to her bed. APRN [NAME] at bedside and assessed the resident, after checking for one minute, determined that the resident was pulseless. Time of death was pronounced at that time. EMS arrived shortly thereafter and confirmed the absence of a heartbeat. Review of Resident #2's electronic record from [DATE] to [DATE] revealed no change of condition documented, one set of vitals, and no diagnostics were completed. Review of Resident #2's physician orders revealed the following:-[DATE] at 9:50 a.m., 2v [two view] CXR to be done for chest pain, STAT for chest pain, ordered by APRN, confirmed by Staff B, RN, on [DATE] at 1:03 p.m. -[DATE] at 9:51 a.m., 12 lead EKG for chest pain vs GERD (gastroesophageal reflux disease) w/interpretation, STAT for chest pain vs. GERD, ordered by APRN, confirmed by Staff B, RN, on [DATE] at 1:02 p.m. -[DATE] at 9:52 a.m., CBC and CMP STAT for chest pain vs. GERD, STAT for chest pain vs GERD, ordered by APRN, confirmed by Staff B, RN, on [DATE] at 1:02 p.m. -[DATE] at 2:21 p.m., Nitroglycerin Tablet Sublingual 0.4 mg, Give 1 tablet sublingually every 15 minutes as needed for Chest Pain x 3 doses. If no relief, call MD., ordered by APRN, confirmed by Former DON, on [DATE] at 2:21 p.m. -[DATE] at 2:29 p.m., OK to transfer to ER, one time only for resident insist for 1 Day, created and confirmed by Staff C, LPN. An interview was conducted with Staff B, RN, on [DATE] at 2:36 p.m. Staff B confirmed Resident #2 was having chest pain. Staff B reported the facility had educated staff that they are only to call the nurse practitioner, We can't send them out, we can only go to them. Staff B verified that Medical Director was Resident #2's physician. Staff B described seeing Resident #2 at 8:30 a.m. as [NAME] as a ghost, she did not look good, she was sweating and clammy and complaining of chest pain. Staff B assessed again at 9:30 a.m. and reported Resident #2 stated she was not feeling good and kept saying she wanted to go out. Staff B reported expressing Resident #2 needed emergent care the whole day to Former DON and APRN and their response was to schedule an in-house cardiology consult. Staff B verified speaking with [EKG/lab provider] and was informed they could not perform STAT EKGs. She reported that she expressed concerns six to eight times and was never informed that she could send Resident #2 directly to the emergency department. Staff B reported that approximately around 2:45 p.m., Former DON stated, Just [derogatory term] send her (Resident #2) out. Staff B, RN, described Resident #2 was stable prior to the incident. She reported the facility recommended she change her documentation and that if the State was to look at the documentation, they would ask why she or anyone else did not send her (Resident #2) to the ER. She reported the event as traumatic. An interview was conducted with the APRN on [DATE] at 3:08 p.m. She verified that she arrived at the facility on [DATE] between approximately 9:00 to 9:30 a.m. She ordered STAT labs, EKG, and CXR for Resident #2 around 9:30 a.m. She confirmed facility staff had informed her that Resident #2 was reporting chest pain and wanted to go to the hospital. She denied that these concerns were assessed by her or communicated by Resident #2 to her. She confirmed she ordered nitroglycerin around 2:30 p.m. for chest pain, and the next thing I head she was unresponsive in her w/c. She reported that the death was not expected and said, I did not know her [Resident #2] very well. She also stated, I should have collaborated with the primary, unfortunately I did not. I was busy charting and handling other concerns. An interview was conducted on [DATE] at 3:37 p.m. with Interim DON. He confirmed the expectations for a change of condition and staff should have completed one for Resident #2. He reviewed that a change of condition would consist of an assessment, notification to the provider for further treatment and instructions, and documented in the charting system. He reviewed Resident #2's record and stated, If the resident was asking to go to the hospital, they have the right to do so. Looking at those symptoms, they are signs of a cardiac issue, they should have been sent out. An interview was conducted on [DATE] at 3:58 p.m. with Nursing Home Administrator (NHA). NHA stated that the nurse practitioner is the one to communicate with the physician. She reviewed Resident #2's record and determined a change of condition should have been completed and was not. She verified that Resident #2's family was not notified prior to expiration. NHA agreed Resident #2 reported chest and back pain to staff, reported wanting to go to the ER to staff, and was not sent to the ER. An interview was conducted on [DATE] at 4:23 p.m. with Former DON. She reported that Resident #2 was stable prior to [DATE]. She reported she was the one who found Resident #2 in the doorway of her room unresponsive and called 911. She reported that APRN was in the facility all day and she was handling it. She stated that if Resident #2 wanted to go to the ER, they should be sent as residents have the right to seek medical care outside of the facility. She stated APRN wanted Resident #2 to stay for treatment. She reported that if a change of condition was completed on [DATE] when Resident #2 first reported symptoms it would trigger for review during the [DATE] clinical meeting and for the nurse to call the physician and family. An interview was conducted on [DATE] at 10:08 a.m. with Staff C, LPN. Staff C, LPN, was Resident #2's assigned nurse on [DATE]. He reported that Resident #2 stated she was not feeling well during morning medication administration. He stated, She did not know what was bothering her.she was a little bit restless.a little paler than usual. He stated that he checked on Resident #2, unable to specify a time, and she remained restless. He denied any conversation with Staff B, RN, or APRN until approximately 2:30 to 2:45 p.m. on [DATE]. He stated they told him that everything was going to be done in-house for Resident #2 and that was normal procedure. Staff C, LPN, stated Resident #2's death was unexpected and that he did not know she passed until [DATE]. An interview was conducted on [DATE] at 11:43 a.m. with Director of Quality Assurance and Risk Management. She reported she did not complete a complete an investigation of Resident #2's death. She reported that corporate completed an investigation. She agreed on the expectation for staff completing a change of condition after reading the progress note for Resident #2 on [DATE] and confirmed no change of condition was documented. She reported she is not aware that the facility has the capability to perform a STAT EKG and confirmed an EKG was not completed. She verified the facility provided education to the staff regarding resident rights and regarding calling 911 for emergent situations. An interview was conducted on [DATE] at 12:18 p.m. with Medical Director. She confirmed Resident #2 was her patient. She stated she was not notified of Resident #2's condition and Resident #2 was very stable prior to [DATE]. She stated, We always listen to the patient, if they want to be sent out, we send them right away. She denied being aware that a STAT EKG was ordered and not completed. She stated Resident #2 should have been sent right away to the hospital and that suspected cardiac concerns could not be monitored in the nursing home setting. Medical Director expressed frustration for not being notified of Resident #2's change in condition and if she was notified, she would have sent Resident #2 to the hospital right away. She reported that she does not supervise or provide oversight to the APRN. She stated she was in the process of identifying the physician that supervises the APRN The Medical Director stated the Former DON or a nurse could have called 911 and stated that they are also responsible for the residents. An interview was conducted on [DATE] at 2:16 p.m. with Staff D, Certified Nursing Assistant (CNA). She worked with Resident #2 often and described that she had become more independent. She described Resident #2 as loving to attend activities and had planned to go on leave of absence for a shopping trip the following day. She reported that around 7:30 a.m. on [DATE], Resident #2 had put on her call light that she was having chest pain and that she wanted to go to the hospital. Staff D, CNA, confirmed reporting this finding to Staff B, RN, and Staff C, LPN. Staff D, CNA, described Resident #2 as In distress and not comfortable. She reported that Resident #2's death was unexpected. Staff D, CNA, reported being affected by the sudden death and being upset that the Resident did not go to the hospital when she requested. Review of Mayo Clinic's heart attack symptoms for women showed: Chest pain is the most common symptom of heart attack in men and women. But women are more likely than men to have symptoms that may seem unrelated to a heart attack, such as nausea and brief pain in the neck or back.Women often describe heart attack chest pain as pressure or tightness. But it's possible to have a heart attack without chest pain.Women are more likely than men to have these symptoms of a heart attack: Neck, jaw, shoulder, upper back or upper stomach pain. Shortness of breath. Pain in one or both arms. Nausea or vomiting. Sweating. Lightheadedness or dizziness. Unusual fatigue. Heartburn, also called indigestion.These symptoms may be vague but more noticeable than chest pain. Review of the facility's policy and procedure titled Nursing - Change in a Residents Condition or Status dated [DATE] showed:Policy: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level ofcare, billing/payments, resident rights, etc.). In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's advance directives.Procedure: 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . A significant change in the resident's physical/emotional/mental condition which includes discovery of the loss of vital bodily functions (loss of responsiveness to stimuli and loss of blood pressure, pulse, and respirations). A need to transfer the resident to a hospital/treatment center; . 2. Should the Attending Physician be unavailable and the change in condition is of an urgent nature, the facility will contact the Medical Director for guidance. 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse/designee will notify the resident's family or representative when: . There is a significant change in the resident's physical, mental, or psychosocial status; . Review of the facility's job description for Registered Nurse, dated [DATE], included: Essential Functions:- Assesses, plans and evaluates clinical care delivered to guests requiring long-term or rehabilitative care.- Delivers clinical care to guests requiring long-term or rehabilitative care.- Initiates emergency support measures (i.e., CPR (Cardiopulmonary Resuscitation), protects guest from injury).Marginal Functions:- Information is relayed to other members of the health care team (i.e. physicians, respiratory therapy, physical therapy, social services, etc.).- Decisions are made that reflect knowledge and good judgment and demonstrate an awareness of guests/family/physician needs.- Assessment identifies changes in the guests physical or psychological condition (i.e. changes in lab data, vital signs, mental status).Specific Requirements:- Must possess the ability to make independent decisions when necessary.- Communicates with the medical and clinical team members and other department supervisors. Review of the Medical Director Services Agreement, dated [DATE] between Facility and Medical Director, included:- 3.8 Direct and coordinate:- 3.8.4 resident care in emergency situations, upon Operator requests, or when attending physicians are unavailable- 3.9 Provide guidance and oversight for attending physicians and other health care practitioners regarding:- 3.9.1 appropriate resident care;- 3.9.3 their individual performance and practices; and- 3.9.4 clinical issues, as necessary.- 3.10 Establish and ensure:- 3.10.3 all health care professionals' practice within the scope of their licenses- 3.11 Address and resolve:- 3.11.2 medical care that is inconsistent with applicable standards of care- 3.13 Help Operator identify, evaluate, address, and resolved medical and clinical concerns and issues that:- 3.13.1 affect resident care, medical care, or quality of life; or- 3.13.2 are related to the provision of services by physicians or other licensed health care practitioners- 16. Regulatory Requirements: Operator and Group will provide services at all times in compliance with federal, state, and local law, rules, and regulations, as well as the policies, rules, and regulations of Facility, and all currently accepted and approved methods and practices of Physician's specialty.

Based on interviews and record review, the facility failed to ensure the residents' family and physician was notified of a significant change in condition for one (Resident #2) of two residents sampled. Cross-reference F684. Findings included:Review of Resident #2's medical record showed that her primary physician was listed as Medical Director. Review of Resident #2's progress notes from 4/7/26 to 4/8/26 revealed: - On 4/7/26 at 5:35 p.m., Staff A, Registered Nurse (RN), wrote, Patient c/o [complained of] middle back pain and became anxious. and Per nursing supervisor, patient vomited prior to alerting me that patient was feeling unwell. - On 4/8/26 at 9:30 a.m., Staff B, RN, wrote, Resident c/o chest pain that's radiating to her back. Upon assessment resident appeared clammy and sweating. - On 4/8/26 at 12:00 p.m., Staff B, RN, wrote, Resident called out to staff stating she is really wanting to go to ER [emergency room] and she wasn't feeling good at all. Nurse writing this went into residents [sic] room and once again resident appearing sweaty, pale and clammy to touch. Resident stated, 'I really want to go to the Hospital [sic] I don't feel good.' . - On 4/8/26 at 2:15 p.m., Staff B, RN, wrote, Nurse writing this went into DON [Director of Nursing] office and expressed grave concerns that resident needed to be sent to ER due to her c/o chest pain that was radiating to her back. An interview was conducted with Staff B, RN, on 5/11/26 at 2:36 p.m. Staff B confirmed Resident #2 was having chest pain. Staff B reported the facility had educated staff that they are only to call the nurse practitioner (APRN), We can't send them out, we can only go to them. Staff B verified that Medical Director was Resident #2's physician. Staff B described seeing Resident #2 at 8:30 a.m. as [NAME] as a ghost, she did not look good, she was sweating and clammy and complaining of chest pain. Staff B stated assessed again at 9:30 a.m. and reported Resident #2 stated not feeling good and kept saying she wanted to go out. Staff B reported expressing Resident #2 needed emergent care the whole day to the Former DON and APRN and their response was to schedule an in-house cardiology consult. Staff B reported expressing concerns six to eight times and was never informed that she could send Resident #2 directly to the emergency department. Staff B reported that the facility leadership recommended changing her documentation and stated that if the State was to look at the documentation, they would ask why she or anyone else did not send her (Resident #2) to the ER per her request. An interview was conducted with the APRN on 5/11/26 at 3:08 p.m. The APRN stated, I should have collaborated with the primary, unfortunately I did not. I was busy charting and handling other concerns. An interview was conducted on 5/11/26 at 3:37 p.m. with the Interim DON. He confirmed the expectations for a change of condition and stated staff should have completed one for Resident #2. He reviewed that a change of condition would include notification to the provider for further treatment and instructions. He stated the notification would have included notifying the family as well. An interview was conducted on 5/11/26 at 3:58 p.m. with Nursing Home Administrator (NHA). The NHA stated that the nurse practitioner is the one to communicate with the physician when needed. She reviewed Resident #2's record and determined a change of condition should have been completed and confirmed it was not. The NHA verified the physician and Resident #2's family were not notified of her change effective 4/7/26 and throughout the day on 4/8/26 up until the resident's expiration. An interview was conducted on 5/11/26 at 4:23 p.m. with the Former DON. She reported that when a change of condition is completed it would trigger the nurse to call the physician and family. She confirmed Resident #2's physician and family should have been notified by staff from 4/7/26 to 4/8/26. An interview was conducted on 5/12/26 at 11:43 a.m. with Director of Quality Assurance and Risk Management. She confirmed the expectation would have been for staff to complete a change of condition, and after reading the progress note for Resident #2 on 4/7/26, confirmed that a change of condition was not documented which would have triggered further follow-up. She reported that she was not aware that facility staff did not notify the physician or family of Resident #2's change of condition from 4/7/26 to 4/8/26. She verified the family and physician should have been notified per facility procedure and expectation. An interview was conducted on 5/12/26 at 12:18 p.m. with Medical Director. She confirmed Resident #2 was her patient. She stated she was not notified of Resident #2's condition and stated the resident was very stable prior to 4/8/26. The Medical Director expressed frustration for not being notified of Resident #2 complaining of chest pain through the 24 - hour period. The Medical Director confirmed neither the APRN, nor the facility staff called her. The Medical Director stated she would have sent Resident #2 to the hospital right away, following the reported symptoms. Review of Facility policy titled, Nursing - Change in a Residents Condition or Status, effective October 2014, included:Policy: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status.Procedure:1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:- A significant change in the resident's physical/emotional/mental condition which includes discovery of the loss of vital bodily functions (loss of responsiveness to stimuli and loss of blood pressure, pulse, and respirations).- Instructions to notify the physician of changes in the resident's condition.2. Should the Attending Physician be unavailable and the change of condition is of an urgent nature, the facility will contact the Medical Director for guidance.3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse/designee will notify the resident's family or representative when:- There is a significant change in the resident's physical, mental, or psychosocial status

Based on observations and interviews, the facility did not ensure food safety standards were followed, in the kitchen and two of two nourishment rooms, as evidenced by improper infection control practices including hand hygiene, ice buildup in the walk-in freezer, the dish machine and dumpster areas not maintained in a clean sanitary condition, and resident food items were not labeled/dated. Findings included: On 5/12/25 at 9:28 a.m., an initial tour of the kitchen was conducted. An interview and observation of Staff Q, Culinary Assistant was conducted while he was utilizing the dish machine. An observation of the top of the dish machine revealed a plastic water bottle. An observation of Staff Q, Culinary Assistant revealed he grabbed the plastic water bottle, drank from it, and placed it back on top of the dish machine. He said he was thirsty as the dish machine area was hot. Observations of the interior and bottom edges of the dish machine hood revealed multiple areas of brown and red discoloration. Further observation of the dish machine area revealed a white rag with light yellow-colored stains, on the top shelf of a utility rack, with clean kitchen items. The rag was in close proximity to clean items intended to hold beverages. Further observations of the dish machine area revealed Staff R, Culinary Assistant touched the rim of the garbage can, then went to the rack with clean items to retrieve kitchenware. An observation of Staff R, Culinary Assistant revealed he moved on to another task and did not perform hand hygiene after touching the garbage can. On 5/12/25 at 9:43 a.m. an observation of the walk-in freezer revealed a box of plant-based chicken tenders with ice buildup, approximately 3-4 inches in height on top of the food item. On 5/12/25 at 10:03 a.m. an observation of the dumpster revealed the right-side door was open. An interview with the Certified Dietary Manager (CDM) revealed all staff are responsible for cleanliness and closing the doors of the dumpster, but it mainly falls on the kitchen staff and maintenance. On 5/12/25 at 10:08 a.m. an observation of the refrigerator in the nourishment room, on the a-wing, revealed a carton of Ensure clear and two 32-ounce tubs of yogurt that were not labeled with a resident's information. He said the Ensure clear is not a nutritional supplement the facility provides, as he is the one who orders them. Further observation of the freezer in the a-wing nourishment room revealed a, Hot Pocket, with no resident information, as well as no date of expiration or when the original packaging was opened. On 5/12/25 at 10:17 a.m., an observation of the refrigerator in the nourishment room, on the c-wing, revealed a large bottle of juice that was not labeled with a resident's information. The CDM said he toured the nourishment rooms every morning, to include labeling and dating of items in the refrigerators and freezers. On 5/14/25 at 11:41 a.m., an observation was conducted of the lunch meal tray line in the kitchen. An observation of Staff T, Culinary Assistant revealed she was washing her hands with water without soap in the hand washing sink. She said she was allergic to soap and usually uses hot water to wash her hands. She said she could use sanitizer instead of soap and pointed to the 3-compartment sink and stated, There's sanitizer there. She was observed going to the area with the 3-compartment sink. An interview with Staff T, Culinary Assistant revealed she used the sanitizing solution in the 3-compartment sink to wash her hands. She said there wasn't a gel hand sanitizer available but thinks that it would be okay to use. At 11:44 a.m., an observation of Staff T, Culinary Assistant revealed she was on the tray line and scratched her neck, touched her glasses and was leaning over clean trays and the bottom part of insulated lids. Staff T, Culinary Assistant did not wash her hands. On 5/14/25 at 11:54 a.m Staff S, [NAME] was observed in the kitchen tray line plating food for the lunch meal service. She started plating food without conducting hand hygiene prior to this task. Staff S, [NAME] was observed touching the beverage and dessert cart in between plating the resident's food. At 11:56 a.m., an observation of Staff S, [NAME] revealed she was touching her pockets. Hand hygiene was not observed between these tasks. On 5/15/25 at 12:34 p.m., an interview with the CDM was conducted. He said the hood of dish machine has not been cleaned by kitchen staff and isn't part of their cleaning schedule. He stated, It might be under the maintenance cleaning schedule. The CDM stated the brown looking substance on the surface was rust, and confirmed it is not a cleanable surface. The CDM said maintenance completed a monthly inspection of the dish machine which included a, Touch up, cleaning of the hood. The CDM said staff are not supposed to have personal items or beverages while they are utilizing the dish machine. The CDM said the expectation was for staff not to have personal food or drinks in the kitchen area. He said there was a refrigerator in his office for personal items. He said in February 2025 staff were provided an in-service about cross contamination in work areas. The CDM said staff should be performing hand hygiene before starting new tasks. He said staff should be washing their hands after touching their face, hair, or any part of their body while handling food. The CDM said if staff are touching garbage cans, dirty dishes, or anything potentially soiled, they should be washing their hands. The CDM said he was not aware of a dietary staff member that could not use soap. He said all of this kitchen staff, including Staff T, Culinary Assistant, performed hand hygiene with soap during the demonstration in-services. He stated he would not expect dietary staff to wash their hands with the sanitizing solution in the 3-compartment sink. He stated, It would be potential cross contamination and an infection control issue. He stated, I'm not sure if that soap is approved for hand washing. The CDM said dumpster doors should be closed at all times to prevent pests and rodents. He stated, All departments have access to it and should be aware of closing the doors. He said he reviewed the nourishment rooms at least once or twice a day. The CDM confirmed resident items need to be labeled with their name and room number on them. The CDM said in orientation staff are educated about labeling and dating items in the nourishment refrigerators and freezers. A review of the facility's policy titled Handwashing - Culinary and Glove Use, dated 4/15/24, revealed the following, Purpose: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Culinary team members shall clean their hands in a handwashing sink or approved automatic hand washing center and may not clean hands in a sink used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. Further review of the policy revealed the following, . 6. Frequency of Handwashing: a. Culinary team members shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: . ii. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. iii. Hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). iv. After coughing, sneezing, or blowing your nose, using tobacco, eating or drinking.x. After engaging in any activity that may contaminate the hands. A review of the facility's policy titled 3 Compartment Sink- Manual Warewashing Policy, dated 4/15/24, revealed the following under policy and compliance guidelines, . Warewashing sinks may not be used for handwashing. A review of the facility's policy titled Nourishment and Life Enrichment Refrigerator and Freezer Store, dated 11/1/24, revealed the following, Purpose: It is the right of the Residents/Guests of the center to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the Resident/Guest. Further review of the policy revealed the following: -Guidelines: 1. Foods in the nourishment and life enrichment refrigerators can be kept for up to 3 days or per manufacturer guidelines (see #4 and# 7 for further information). Freezer foods once opened can be kept up to 90 days (3 months). 3. All food items that are prepared by the family members or visitors must be stored in the following manner: a Stored in an airtight container or Ziploc bag b. Labeled with the Resident/Guest name and room number c. Labeled with date of storage. 4. All food items that are pre-packed and sealed from the manufacturer must be labeled with Resident/Guest name and room number. These items will be held until the manufacturer's expiration date. A. After the manufacturer sealed food item is opened it may be resealed, labeled, dated and held for 3 days. b. Freezer foods after opening may be sealed, labeled, dated and held for 90 days. 5. Foods that are not easily identifiable without removing a cover, such as a bowl of applesauce with a lid with a lid; must also be labeled with content. A review of the facility's policy titled Resident personal food, dated 10/2024, revealed the following, Policy: All residents have the right for family members and visitors to provide preferred or requested foods and fluids from outside of the facility, except where the health and safety of the individual or other residents would be endangered. Items brought into the facility will be stored under sanitary conditions. Further review of the policy revealed the following, Procedure . 2. Labeled and dated perishable items may be stored under refrigeration in the nursing unit consistent with standards of food storage. (Photographic Evidence Obtained)

Based on observations interviews, and policy reviews the facility failed to ensure, 1. Respiratory equipment and supplies were dated and stored in a sanitary manner in seven rooms (134, 133, 143, 137,113, 120 and 126) of 65 rooms toured, and did not ensure Hand Hygiene was performed during two medication administration observations and 3. failed to ensure hand hygiene was performed during dining and kitchen tours during two (5/12/25 and 5/14/25) of four days of survey and 4. did not ensure clean linen was handled in a manner to prevent cross contamination during one of one laundry facility tours. Findings Included: 1. During a tour on 5/12/25 at 9:29 A.M. in room [ROOM NUMBER], a nebulizer mask was observed uncovered laying in the top drawer of the resident's bedside table and the in use nasal canula was not dated. During a tour on 5/13/25 at 9:43 A.M. in room [ROOM NUMBER], a nebulizer treatment mask was observed lying on top of a see through a plastic bag. During a tour on 5/13/25 at approximately 10:00 A.M. in room [ROOM NUMBER], a Continuous Positive Airway Pressure (CPAP) mask was observed lying uncovered on top of the bedside table with a back scratcher lying on top. An uncovered nebulizer mask was placed on the countertop located near the foot of the bed. During a tour on 5/13/25 at 9:58 A.M. in room [ROOM NUMBER] an uncovered CPAP mask was observed lying on top of the bedside table and the opening to the mask was exposed. The prefilled bubble humidifier plastic bottle was placed directly on the floor. (Photographic evidence obtained) During an interview on 5/14/25 at 2:30 P.M. Staff B, Licensed Practical Nurse (LPN) , Unit Manager (UM) said the nebulizer mask should be rinsed after each use, dried and placed in a bag. Staff B stated each week a vendor changes and labels oxygen supplies. She said nasal canula's should be labeled with the date it was changed. Staff B, LPN, UM said staff are expected to date oxygen supplies. During a review of a facility grievance form, dated 5/8/25 showed an unidentified resident's family member reported nebulizer masks uncovered. During breakfast and lunch observations on 5/12/24 and 5/13/24, Staff J, Certified Nursing Assistant (CNA) delivered trays to residents on Unit C and did not offer hand hygiene prior to or during delivery of the meal trays. During an interview on 5/14/25 at 8:54 AM, Staff J, CNA said she always offer residents hand hygiene with meal tray delivery. She did not say why she did not offer hand hygiene during these encounters. During medication administration observation on 5/14/25 at 8:05 A.M. on Unit C with Staff M, Registered Nurse (RN). Staff M, RN missed five opportunities for hand hygiene, prior to and after using the thermometer, a wrist blood pressure cuff and a finger pulse oximeter and placing the items on top of the medication cart. Staff M, RN did not perform hand hygiene prior to administering medications, while holding a medication cup with medications for Resident #214, and prior to placing sugar packets from a different resident on their bedside table. Staff M, RN did not perform hand hygiene before touching another resident's medication cup. During an interview on 5/14/25 at 12:50 P.M Staff M, RN, confirmed she did not perform hand hygiene according to the facility policy during medication administration. On 5/14/25 at 10:56 A.M. Medication administration observation was condcuted with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN did not perform HH prior to entering and after leaving Resident #41's room. He placed gloves prior to obtaining finger stick blood glucose and removed gloves after the test was completed without performing hand hygiene. While wearing gloves Staff F, LPN cleaned and disinfected the glucometer machine without performing hand hygiene. Staff F, LPN prepped medications without gloves. Staff F, LPN then placed and removed gloves prior to administering insulin without performing hand hygiene. Staff F , LPN performed HH did not perform HH before and after glove use while obtaining blood glucose level, cleaning the glucometer and administering insulin. During an interview on 5/14/25 at approximately 11:26 A.M Staff F, LPN confirmed he did not perform hand hygiene and stated, should have. An interview was condcuted on 5/14/25 at 2:06 P.M. with Staff M, LPN, UM. Staff M, LPN,UM said, Staff should wash hands before and after leaving the room when all else fails wash your hands. 50570 2. On 5/12/25 at 9:28 AM an interview and observation of Staff Q, Culinary Assistant was conducted as he was utilizing the dish machine. An observation of the top of the dish machine revealed a plastic water bottle. An observation of Staff Q, Culinary Assistant revealed he grabbed the plastic water bottle, drank water from it, and placed it back on top of the dish machine. He said he was thirsty as the dish machine area was hot. Further observations of the dish machine area revealed Staff R, Culinary Assistant touched the rim of the garbage can, then went to the rack with clean items to retrieve kitchenware. An observation of Staff R, Culinary Assistant revealed he moved on to another task and did not perform hand hygiene after touching the garbage can, (Photographic Evidence Obtained). On 5/12/25 at 11:56 AM an observation of the dining room during the lunch meal was conducted. An observation of the Human Resources (HR) Director revealed he was assisting with providing coffee to residents. He was not observed performing hand hygiene before providing the beverages. Further observations of the HR Director revealed he provided coffee to one resident, then put a sugar substitute in another resident's cup and stirred the beverage. Observations of the HR Director revealed he touched the outside of the garbage can when throwing a food item away. Further observations of the HR Director, during the lunch meal service in the dining room, revealed he touched the arm rests and handles of resident's wheelchairs, as well as his belt, face and eye. Throughout these observations hand hygiene was not observed. On 5/12/25 at 12:50 AM an observation of the Staffing Coordinator/Certified Nursing Assistant (CNA), in the dining room during the lunch meal, revealed he sat down next to a resident to assist with feeding. An observation of the Staffing Coordinator/CNA revealed he did not perform hand hygiene prior to assisting with feeding the resident. He was observed touching the handle of the resident's wheelchair, their plate and assisting with providing them a beverage. Further observation of the Staffing Coordinator/CNA revealed he touched and wiped his eyes, with the collar of his shirt, while assisting with feeding the resident. On 5/14/25 at 11:41 AM an observation was conducted of the lunch meal tray line in the kitchen. An observation of Staff T, Culinary Assistant revealed she was washing her hands with water in the hand washing sink. She said she was allergic to soap and usually uses hot water to wash her hands. She said she could use sanitizer instead of soap, pointed to the 3-compartment sink and stated, There's sanitizer there. She was observed going to the area with the 3-compartment sink. An interview with Staff T, Culinary Assistant revealed she used the sanitizing solution in the 3-compartment sink to wash her hands. She said there wasn't a gel hand sanitizer available but thinks that it would be okay to use. At 11:44 a.m., an observation of Staff T, Culinary Assistant revealed she was on the tray line and scratched her neck, touched her glasses and was leaning over clean trays and the bottom part of insulated lids. On 5/14/25 at 11:54 AM an observation was conducted in the kitchen where Staff S, [NAME] was plating food for the lunch meal service. She started plating food without conducting hand hygiene prior to this task. Staff S, [NAME] was observed touching the beverage and dessert cart in between plating the resident's food. At 11:56 a.m., an observation of Staff S, [NAME] revealed she was touching her pockets. Hand hygiene was not observed between these tasks. On 5/15/25 at 11:41 AM an interview with the Director of Nursing (DON) was conducted. She said staff are educated on using hand gel during the meal service. She said upon hire staff are educated on hand hygiene. The DON stated, They are re-educated on hand hygiene all the time. She said staff should be performing hand hygiene between residents when serving meals. The DON said if staff are setting the tray down and not touching residents, they don't have to use hand gel. She said she conducts observations every day during dining and confirmed there are opportunities for improvement related to hand hygiene. On 5/15/25 at 1:04 AM an interview was conducted with the Certified Dietary Manager (CDM). He said staff are not supposed to have personal items or beverages while they are utilizing the dish machine. The CDM said the expectation is staff should not have personal food or drinks in the kitchen area. He said there is a refrigerator in his office for personal items. He said in February 2025 staff were provided an in-service about cross contamination in working areas. He stated, They should be well versed in infection control because they've completed quizzes and videos. He said his expectations for the dietary staff related to hand hygiene are the following, put their hair restraint first, wash their hands when they come in the kitchen, start one task, finish that task then remove the gloves, and wash their hands. The CDM said staff should be performing hand hygiene before starting new tasks. He said staff should be washing their hands after touching their face, hair, or any part of their body while handling food. The CDM said if staff are touching garbage cans, dirty dishes, or anything potentially soiled, they should be washing their hands. He stated wearing gloves is, Preferable if you're grabbing utensils, plates, anything that is going to the residents' mouth. The CDM said in February 2025 he provided an in-service/re-education to 13 kitchen staff about hand washing. He said he demonstrated, staff did a return demonstration, and he provided them a quiz to complete. The CDM said he is not aware of a dietary staff member that can't use soap. He said all of this kitchen staff, including Staff T, Culinary Assistant, performed hand hygiene with soap during the demonstration in-services. He said he would not expect dietary staff to wash their hands with the sanitizing solution in the 3-compartment sink. He stated, It would be potential cross contamination and an infection control issue. He stated, I'm not sure if that soap is approved for hand washing. On 5/13/25 at 9:19 AM an observation was conducted in room [ROOM NUMBER]. A nebulizer mask and machine was observed on the seat of the resident's recliner. The mask and machine were not stored in a bag, (Photographic Evidence Obtained). 48223 3. On 05/12/25 at 09:43 AM and 05/13/25 at 12:57 PM in room [ROOM NUMBER] bed by the window was observed with a nebulizer mask sitting on top of the nightstand unbagged next to the resident's bed. On 05/12/25 at 10:15 AM in room [ROOM NUMBER] bed by the window was observed with a nebulizer mask sitting on top of the nightstand unbagged next to the resident's bed. 34768 4. On 05/15/2025 at 12:07 PM Staff U, Laundry Aide was observed placing clean laundry under his chin during laundry folding. Staff U let a sheet touch the floor while he was folding. Staff U stated he should not place the laundry under his chin. He stated he was trying to remember not to do that. He stated he did that at home when he folded his personal laundry. During an interview on 05/15/2025 at 1:21 PM the Infection Control Preventionist (ICP) stated hand sanitizing was to be used between each resident contact. He stated hand sanitizing was to be performed between each resident they pass a tray to. ICP stated they encourage the residents to hand sanitize also. The ICP stated the staff was to hand sanitize between each resident. The ICP stated the staff was to have their own hand sanitizer or use the machines on the wall. The ICP stated the staff had been educated regarding cleaning of multi-use equipment such as blood pressure cuffs, thermometers, pulse oximeters. The ICP stated the expectation was to clean the equipment between resident use. The ICP stated he educated the staff yesterday (05/14/2025) on how to use the manual or tower blood pressure cuffs because the wrist blood pressure cuffs if the cuffs cannot be cleaned adequately. The ICP stated the nebulizer was to be stored in a plastic bag at the bedside when not in use. The ICP stated the oxygen tubing should be dated. The ICP stated the tubing was changed weekly by a respiratory company and they were to date the tubing when they changed it. He stated the tubing was good for 7 days. The ICP stated the nurse can change the tubing as needed also. The ICP stated he was not aware of anyone being allergic to soap. The ICP stated he should be made aware of anyone being allergic to soap so we can make accommodations. The ICP stated anyone allergic to soap can use hand sanitizer. The ICP stated he gave an in-service in the kitchen in March 2025 at the sink, and no one stated they were allergic to soap. The ICP stated the kitchen manager should be watching his employees sanitizing their hands. The ICP stated it was not acceptable to put their hands into the 3-in-1 sink for sanitizing their hands. The ICP stated the nurses should be hand sanitizing during medication pass. The hand sanitizing should occur before preparing medicines, once the medications are ready, and before entering the resident room and upon exiting the resident room Review of the facility's policy titled Infection Prevention and Control Manual - Infection Surveillance - Overview dated December 2020 revealed: Purpose Infection prevention begins with routine and ongoing surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility or have the potential to cause, an outbreak. This facility has established a system, based upon national standards of practice and the facility assessment to closely monitor all residents who exhibit signs/symptoms of infection through ongoing surveillance including a systematic method for collecting, analyzing and interpretation of data, followed by dissemination of that information to identify infections, infection risks and outbreaks to those who can improve the outcomes for quality. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, Surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in-service education, and identify individual resident problems in need of intervention. Two types of surveillance (process and outcome) implemented in healthcare facilities. I. Process Surveillance Process surveillance reviews practices directly related to resident care in order to identify whether the practices comply with facility infection prevention and control procedures and policies based on recognized guidelines. Examples of this type of surveillance include but are not limited to: *Monitoring of compliance with transmission-based precautions, * Proper hand hygiene, * The proper use and disposal of personal protective equipment, * Injection safety, * Point-of-care testing, * Urinary catheter care, * Wound care, * Invasive treatments, * Incontinent care, * Dialysis care, *Management of bloodborne pathogen exposure, * Cleaning and disinfection of products, equipment or environmental surfaces, * Handling, storing, processing and transporting linens according to procedure II. Outcome Surveillance The outcome surveillance process consists of collecting/documenting data on individual comparing the collected data to standard written definitions (criteria) ofinfections 1. The Infection Preventionist or other designated staff reviews data (including residents with fever or purulent drainage, and cultures or other diagnostic test results consistent with potential infections) to detect clusters and trends and to be able to identify and report evidence of a suspected or confirmed HAI or communicable disease. The facility's program should choose to either track the prevalence of infections (existing/current cases both old and new) at a specific point or focus on regularly identifying new cases during defined time periods. When conducting outcome surveillance, the facility may choose to use one or more of the automated systems and authoritative resources that are available, and include definitions. Monitoring the implementation of the program, its effectiveness, the condition of any resident with an infection, and the resolution of the infection are considered an integral part of the healthcare facility surveillance. The healthcare facility monitors adherence to facility policies and procedures (e.g., dressing changes and transmission-based precaution procedures) to ensure consistent utilization of practice standards. Quality Assessment and Assurance Committee (QAA) 1. The designated IP or at least one of the individuals if there are more than one IP will regularly attend and report on the Infection Prevention and Control Program at the facility's quality assessment and assurance committee. 2. The responsibilities include active implementation and reporting on current Quality Assurance and Performance Improvement projects. A review of the facility's policy titled Handwashing - Culinary and Glove Use, dated April 15, 2024, revealed the following, Purpose: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Culinary team members shall clean their hands in a handwashing sink or approved automatic hand washing center and may not clean hands in a sink used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. Further review of the policy revealed the following, . 6. Frequency of Handwashing: a. Culinary team members shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: . ii. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. iii. Hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). iv. After coughing, sneezing, or blowing your nose, using tobacco, eating or drinking.x. After engaging in any activity that may contaminate the hands. A review of the facility's policy titled, 3 Compartment Sink- Manual Warewashing Policy, dated April 15, 2024, revealed the following under policy and compliance guidelines, . Warewashing sinks may not be used for handwashing.

Based on interview and record review, the facility failed to file and act upon grievances voiced during resident council meetings for 6 meetings on (4/30/25, 3/26/25, 2/26/25, 1/29/25, 12/31/24 and 11/29/24) of six Resident Council Meetings Minutes reviewed, with a potential to affect a census of 107. Findings included: During a Resident Council meeting conducted on 05/13/25 at 02:02 PM with seven participants, who regularly attend the Resident Council Meetings. The group confirmed on-going complaints related to the following: - Call light response time during mealtimes. Certified Nursing Assistants (CNAs) are removed to assist in the dining room. We have to wait for them to return to have our light answered. This is embarrassing at times, due to incontinent care needed. The CNAs are punished if they are late, we can hear them being paged to the dining room. One of the residents stated one time a CNA was in the middle of providing care and someone came looking for the CNA and told the CNA that she was in trouble for not being in the dining room. The resident said, You would think while providing care, I would take priority. - Missing laundry - they tell us we have to complete a grievance ourselves. This issue has been going on for months. - The facility changes the rules without informing us or asking us how the rule change affects us. The group shared about not being able to go outside on a regular basis. - Food likes/dislikes are not resolved. - Not being offered snacks after dinner. The residents stated they used to be offered but are not any longer. Review of the Resident Council meeting minutes revealed: - On 4/30/25 at 2:00 PM laundry is not returned timely or missing; maintenance takes a long time to fulfill requests; dietary likes/dislikes; and not being able to go outside. No documentation of follow-up was found. - On 3/26/25 at 2:00 PM laundry is not returned timely or missing; and dietary likes/dislikes. No documentation of follow-up was found. - On 2/26/25 at 2:00 PM laundry is not being returned timely or missing; dietary likes/dislikes; and residents would like to go outside if the weather permits. No documentation of follow-up was found. - On 1/29/25 at 2:00 PM laundry is not being returned timely or missing; and dietary likes/dislikes. No documentation of follow-up was found. - On 12/31/24 at 2:00 PM staffing during mealtimes; laundry not being returned timely or missing; and dietary likes/dislikes. No documentation of follow-up was found. - On 11/29/24 at 3:30 PM staffing during mealtimes; laundry not being returned timely or missing; maintenance taking a long time to fulfill requests; and dietary likes/dislikes. No documentation of follow-up was found. Review of the Grievance Log for May 2024 to May 2025 did not reveal any concerns from Resident Council. During an interview on 05/13/25 at 4:39 PM the Activity Director (AD) stated the resident council minutes are completed by the Resident Council President (RCP). The RCP invites me to attend their meetings and I do. If the RCP has concern then I take the concern to the Social Service or the Nursing Home Administrator (NHA). I do not complete a grievance form on behalf of the resident council group, I was told they need to complete individually. The RCP completes the minutes and brings them to me a few days after the meeting. I read the minutes and if there is a concern written I go back to the RCP and ask if a grievance form needed to be submitted. The AD stated, I do notice there are some consistent concerns from the group,such as staffing, laundry, and food. During a follow up interview on 05/13/25 at 05:26 PM the RCP stated staffing concerns are not discussed in minutes as we don't feel this would be necessary as no action is ever taken and doesn't do any good. The RCP stated the facility always said they staff over the minimum staffing requirements. During an interview on 05/14/25 at 03:15 PM the Social Service Director (SSD) said there had been no resident council grievances in the last 3 months. The SSD stated she didn't look back any further. During an interview on 05/15/25 at 4:42 PM the NHA stated not being aware the resident council concerns. The NHA had not asked to be in attendance to the resident council meetings in a long time, and has not received a request from the RCP to attend. Review of the facility's policy titled Life Enrichment Manual Services - Resident Council Meeting, dated 11/22 revealed: Guests/Residents will be provided the opportunity to meet together at least monthly in an organized group setting to discuss current issues/topics of their choice. These topics may include events, activities, resident rights, care, and service and concerns. In addition, a review of old business, problem resolution, and development of action plans may be discussed. The Life Enrichment Department staff will serve as facilitators for the meetings and will document minutes. The Resident Council will elect officers who will serve a term of one year. Procedure - 4. Record minutes and provide a copy to the Administrator for review. Record minutes on the Resident Council/ Minutes. Utilize the Resident Grievance Form for any issues requiring a follow up response. Ensure all concerns/grievances have resolution prior to the next meeting and share resolution with the Resident Council. 5. Distribute Resident Grievance form to the appropriate department. 7. Review Resident Council information at the QAPI meeting monthly for opportunities for improvement and to address any concerns/grievances.

Based on record review and interviews, the facility failed to ensure residents reviewed for Beneficiary Protection Notification received the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form prior to the end of Medicare part A services for two (#64 and #159) of three residents reviewed. Findings Included: Review of record revealed Resident #64 had Medicare A days remaining in the benefit period. The facility informed Resident #64 of Medicare part A services would be terminated on 4/24/25. Resident #64 was choosing to remain in the facility. The facility did not complete form SNF-ABN as required. Review of record revealed Resident #159 had Medicare part A days remaining in the benefit period. The facility informed Resident #159 Medicare part A services would be terminated on 5/6/25. Resident #159 was choosing to remain in the facility. The facility did not complete form SNF-ABN as required. During an interview on 05/15/25 at 02:42 PM the Social Service Director (SSD) stated being familiar with the Notice of Medicare Non-coverage (NOMNC) and the SNF-ABN. The SSD stated when the facility Interdisciplinary Team (IDT) determines a resident has met the desired goals and the resident is in need of continuing to remain in the facility, a NOMNC is issued by the social service department. Any other forms or conversations are issued by the business office. During an interview on 05/15/25 at 02:48 PM the Assistant Business Office Manager (ABOM) stated not being responsible for any forms related to Medicare. During an interview on 05/15/25 at 02:56 PM the Business Office Manager (BOM) stated not being responsible for any of the Medicare forms, and stated Social Services completed them. During an interview on 05/15/25 at 04:35 PM the Nursing Home Administrator (NHA) stated not being responsible for any of the Medicare forms and that social services or the business office completes them. Review of the facility's policy and procedure titled Business Office Manual MDS (Minimum Data Set)/Medicare Points and Guidelines - Denial notices Part A - Original Fee for Service Medicare & Medicare C Managed Care Plans Section 1000 with a revision date of Feb. 2, 2018 revealed: Policy: It is the policy of this Center to comply with Medicare guidelines upon admission and throughout the resident's stay as defined by the Centers for Medicare and Medicaid Services and our Medicare Administrative Contractor. The denial letters serve as the primary communication tool to communicate eligibility, reduction of services or discharge of Medicare covered services. Beneficiaries will be issued the proper notice(s), as mandated. The notices provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. Procedures: 2. Part A Denial Letters issued at the end of All Skilled Services - There are two notices that are required to be issued when skilled services are ending and benefits are not exhausted for residents with traditional Medicare (also known as original fee for service Medicare). The 2 forms are the SNFABN (Form CMS 10055 (2018)) Skilled Nursing Facility Advance Beneficiary Notice and the Notice of Medicare Provider Non-Coverage Generic Notice (Form CMS 10123). The form CMS-10055 (2018) SNFABN applies to beneficiaries covered by original fee for service Medicare only.Three (3) to Five (5) days prior to the discharge of ALL skilled services for a beneficiary enrolled in Traditional Medicare, the SNFABN (Form CMS-10055 (2018)) must be discussed at the A.M. meeting and presented to Social Services Director or designee for signature & completion. The MDS Coordinator will present the partially completed SNFABN (Form CMS-10055 (2018)) to Social Services. The Social Service Director or designee will deliver and explain the notice to the patient or authorized representative, and obtain the patient or authorized representative's signature. This form is delivered at the same time the NOMNC (Form CMS-10123) is delivered. The original SNFABN (Form CMS-10055 (2018)) and the original Notice of Medicare Provider Non-Coverage (Form CMS 10123) must be filed in the business office financial folder. The Social Service Director, or designee, will keep a copy in a binder in the Social Service Office. Entries in the blanks may be typed or legibly hand-written and should be large enough for easy reading (approximately 12 point font).

Based on interviews and record review, the facility failed to follow its policy related to documentation and resolution of grievances for two residents (#35 and #92) of 51 sampled residents. Findings included: 1. On 5/12/25 at 10:57 a.m., an interview was conducted with Resident #35. She said she has a physician ordered diet of no salt added (NAS). Resident #35 said she had concerns with the food being, Salty, specifically the meat. She stated, They are cooking with salt again. She said she was disappointed with the mother's day lunch as it was not appealing, appetizing, and not recognizable. She said she received food in a Styrofoam box yesterday morning. She stated it is, Every weekend. Resident #35 said the meal tray consistently doesn't come with condiments. She said when she talked to the kitchen manager about her concerns he says they are hiring. She feels like her grievances related to food are not resolved. A review of Resident #35's admission record revealed an original admitted [DATE] and a re-admitted [DATE] with diagnoses to include heart failure, unspecified, pulmonary hypertension, unspecified, morbid (severe) obesity due to excess calories, essential (primary) hypertension, and chronic kidney disease, stage 2 (mild). A review of Resident #35's quarterly Minimum Data Set (MDS), Section C - Cognitive Patterns, dated 3/28/25, revealed a Brief Interview for Mental Status (BIMS) of 15, indicating cognitively intact. A review of the facility's food committee minutes, dated 4/30/25, revealed the following, . Discussed the past 4 weeks of new menu -- likes & [and] dislikes. Soups need more flavor, more ingredients -- . Special food requests can be discussed with [Kitchen Manager] or the in-house dietician (here Weds [Wednesdays] & Thurs [Thursdays] in AM [morning]). Beef costs have gone up - New staff has been hired for kitchen. - 2 new chefs - 1 for AM & 1 for PM [afternoon]. - Gravies are salty -- Please send brown sugar with oatmeal . A review of the grievances revealed a documented grievance for Resident #35 dated 1/30/25 related to food and nutrition. The grievance revealed the resident's meal choices were not honored. The grievance showed the resident requested a grilled cheese sandwich but instead was given an egg salad sandwich that was two days old. Under summary of findings or conclusions, the grievance form showed Ticket had no specification on whether to give sub (substiotute) for chicken tenders. The greivance was marked confirmed and satisfied. No other grievances were documented for Resident #35 related to food concerns. Further review of grievances from 5/2024 to 5/2025 revealed no grievances documented from resident council or the facility's food committee. On 5/14/25 at 12:55 p.m., an interview was conducted with the Certified Dietary Manager (CDM). He said the facility's food committee takes place once a month. He said they discuss different topics including food concerns. The CDM said he tries to make it about the group, but if there are individual concerns he meets with them. He said most of the concerns presented at the food committee meetings are individualized issues. He said he speaks to Resident #35 frequently, especially at activities, where they discuss food concerns and, Dig into those issues. He said they have discussed she doesn't like some of the food and has provided feedback that the meat was tough or bland. He said he's informed Resident #35 that the menus are standardized based on the food program and dietitian's input. He said for residents on a NAS diet the kitchen uses salt free seasoning. The CDM said he follows up with Resident #35 about her food related concerns and encourages her to document a grievance on them. He said the common complaint from residents has been about condiments. The CDM said he has observed the kitchen staff on the tray line and pays attention to them putting condiments on the meal tray. He said he attended care plan meetings, and addresses likes/dislikes, as well as, discussing issues with food. He said he conducts customer service rounds that occur a few times a week which includes a set of residents he talks to. The CDM said during morning meetings food concerns are also discussed. He said food related grievances are brought to the Social Services Director (SSD) and then given to him. The CDM said in a day or two, he tries to return the resolved grievance back to the SSD. On 5/14/25 at 2:45 p.m., an interview was conducted with the SSD and the Social Services (SS) Assistant to review Resident #35's food related grievance. The SS assistant said the Business Manager had Resident #35 in their room rounds. She said the grievance was received in January 2025 at dinner. She said she didn't receive her documented preferences/alternate that day and instead receive a sandwich she didn't want. She said Resident #35 also didn't receive condiments on her tray. The SS assistant said the Business Manager asked Resident #35 how her grievance could be resolved, and her response was, I'd like there to be major improvement in food choices and quality. The SSD said grievances are reviewed in morning meetings and would have been given to the CDM. The SSD said steps were taken to update Resident #35's meal ticket to reflect her preferences and likes/dislikes. The SSD said the CDM spoke with the kitchen staff about condiments on the trays and ticket accuracy. The SSD said the grievance was resolved on 2/3/25, and Resident #35 signed on 2/4/25. The SSD said if there are additional grievances from Resident #35 they would, Open up a new grievance and follow the process all over again. The SSD and SS Assistant said they haven't received any more food concerns from Resident #35. The SSD said they have ambassador rounds, where all department managers have assigned residents. 48223 2. During interviews on 5/12/25 at 1:46 PM and 05/13/25 at 09:46 AM Resident #92 stated speaking with multiple staff members, including the dietary manager regarding his preferences not being followed. Resident #92 stated nothing changes and no follow up occurs, they don't listen. Review of the clinical record for Resident #92 shows resident was admitted on [DATE]. The resident's most recent quarterly Minimum Data Set, dated dated dated [DATE] shows resident is cognitively intact. A review of the Grievance Logs from February to May 2025, revealed a grievance for Resident #92 related to dietary/culinary preferences dated 2/13/25. The grievance reveals Resident #92 unhappy with dietary/culinary preferences, receiving cold food all meals, burnt toast, what he receives doesn't match what he requests. Has asked not to receive these items several times. The response on the form revealed: updated preferences - ticket now match dislikes, new toaster needed. In-serviced staff on following tickets. Resolution/Final Disposition: Toaster replaced on 3/20/25. The form shows the grievance was confirmed and grievant was satisfied with the resolution. The Resident signed the form on 2/21/25, the Nursing Home Administrator (NHA) signed on 2/24/25 and the grievance official signature on 2/21/25. No other follow up or grievances were found related to Resident #92's concerns. Review of the Grievance Log for May 2024 to May 2025 did not reveal any concerns from Resident Council. During an interview on 05/13/25 at 4:39 PM the Activity Director (AD) stated, I do notice there are some consistent concerns from the group, like staffing, laundry, and food. Review of the facility's policy titled Grievance Policy and Procedure with a revision date of March 2024 revealed: Purpose: F585 - The center recognizes the guest/resident/legal representative/family has the right to voice grievances to the center without discrimination and without fear of reprisal. The center team members are responsible for making prompt efforts to resolve a grievance and to keep the guest/resident appropriately updated on the progress being made toward resolution. Definitions: Prompt effort to resolve includes the center's acknowledgment of a grievance and to actively work toward a documented resolution of that grievance. Policy: The Grievance Official and Social Services personnel will serve as guest/resident liaisons/advocates in the concern grievance procedure. 1. The center will support the right of the guests/residents to file a grievance anonymously. 2. The center will make information available on how to file a grievance to the guest/resident/legal representative/family. This can be done by providing the information directly to the guest/resident and/or by posting the procedure in prominent locations throughout the center. 3. The name and contact information (business address and email address and business phone number) for the Grievance Official will be posted in prominent locations throughout the center. The Grievance Official is the Social Service Director/designee of the center. 4. The guest/resident has the right to file a grievance orally or in written format. 5. The center will make a prompt effort to resolve any grievance received. Grievances will be reviewed, investigated, resolved and documented in five days. 6. The center team members will immediately report all alleged violations involving neglect, abuse, injury of unknown origin, and/or misappropriation of guest/resident property following the center abuse prohibition policy. 7. The center will review with the guest/resident/legal representative/family the final resolution of the grievance. 8. The guest/resident/legal representative/family have the right to obtain a written decision regarding the grievance. 9. The center will maintain the grievance and any supportive documentation for a period of not less than 3 years. Procedure: The Grievance Official and Social Services personnel will serve as resident liaisons/advocates in the concern grievance procedure. 1. A grievance is defined as any formal expression (verbally or in writing) of interest regarding the well-being of a guest/resident. 2. Upon admission, the guest/resident/legal representative/ and family are informed of the right to voice grievances free from discrimination and/or reprisal. a. This information will include the mechanism for voicing concerns/grievances and will be provided with a copy of the center's grievance policy, upon request. 3. A description of the grievance procedure for voicing concerns/grievances, either individually or anonymously, will be prominently posted throughout the center informing of the right to file a grievance either orally (spoken) or in writing. 4. The center will designate a Grievance Official with whom the grievance can be filed and will post his or her name, business address (mailing and email) and business phone number. Any team member can write, or assist in the writing of a grievance. 5. The Grievance Official is the Social Service Director/designee. a. The Grievance Official is responsible for the following items: l . Overseeing the grievance process to include receiving and tracking grievances through to their conclusions to include the investigation, documentation of the summary and the follow up. 2. Leading any necessary investigations (including investigating responsibility for lost or damaged personal property to include dentures and eyeglasses). 3. Maintaining the confidentiality of all information associated with the grievance. 4. Coordinate with the center's Director of Quality Assurance, if the grievance meets criteria as an immediate reporting of alleged violation(s) involving abuse, neglect and/or misappropriation of guest/resident property. 5. The Grievance Official will close the grievance and reflect the conclusion/outcome of the grievance investigation or abuse investigation. 6. The Grievance Official will provide the guest/resident/legal representative with a written decision about the filed grievance upon request. 7. The grievances will be brought to the morning stand up meeting daily. They will be reviewed out loud with all the leadership team members. The grievance forms will come to the stand-up meeting daily until resolved. 8. The Grievance Official/designee will bring the Grievance Log monthly to the Quality Assurance and Performance Improvement (QAPI) meeting. 6. The center will make a prompt effort to resolve any grievance received. Grievances will be reviewed, investigated, documented and resolved within 5 business days. Every effort will be made to bring a resolution to the grievance. 7. The contact information of independent entities with whom a grievance may be filed such as: State Survey Agency, State Long-[NAME] Care Ombudsman program, or the Abuse hotline, will be posted in a prominent area of the center. 8. A designated area within the center for grievance collection will be identified so that each guest/resident/legal representative/family member may voice a concern anonymously or directly to the Grievance Official. a. Grievance forms will be available in the Social Service Department and may be returned to that office. They will also be available in other prominent areas of the center. (Social Service team members will maintain the stock in these areas). b. A grievance may be registered by telephone, mail, a visit to a team member's office, visit or direct outreach to any team members. Guests/Residents who are unable to prepare a written grievance without assistance, may elect to receive support from any center team members or third party chosen by the guest/resident. 9. Below is a list of items that the investigating team member will include on the grievance form and the Grievance Official will be responsible to assure is completed when a written decision is requested. A written decision will only be provided by the Grievance Official/designee. a.The date the grievance was received. b. The guest/resident name that is involved in the grievance. c. A summary of the guest/resident/legal representative/family grievance. (What is the grievance)? d. The steps that were taken to investigate the grievance. e. A summary of the pertinent findings or conclusions of the investigation regarding the grievance. f.A statement as to whether the grievance was confirmed or not confirmed. g. Documentation of any corrective action taken or to be taken by the center. 10. Upon receipt of the grievance, documentation on the grievance form will be initiated by the Grievance Official/designee or whichever professional team member receives the concern. Instructions for completion are outlined on the Addendum. a. The Grievance Official/designee will document the date the grievance is received on the Grievance Log and copies are made and distributed to the Executive Director and the referenced department representative. b. The Department Manager will initiate an investigation and complete the applicable portion of the grievance form to record the investigative process and actions taken. C. After the Department Manager completes the grievance form the signature and date areas must be completed. d. The grievance reports will be reviewed by the Executive Director, the Grievance Official/designee to assure that the guest/resident's interests are addressed and the final disposition is identified, including the guest/resident/legal representative/family are satisfied with the outcome. e. The Executive Director signs the form in the designated area after the Final Deposition is recorded. All grievances forms will be reviewed and maintained by the Executive Director/designee. 11. The signature of the person initiating the grievance is not required. A guest/resident will not be subject to retaliation by any center team members because of the grievance or a recommendation for change. 12. The person filing the grievance has the right to expect the center will make prompt efforts to resolve grievances and, upon request, have the right to obtain a written decision regarding the grievance. a. Upon request for a written decision regarding the grievance, the Grievance Official/ designee will complete the Grievance Decision Notification of Guest/Resident/Legal Representative/Family Grievance/Complaint/Concem and provide a copy to the person initiating the grievance. 13. In the event that the grievance is not resolved to the satisfaction of all parties involved, the following options may be employed after an IDT/IPOC meeting is held: a. Contact Center Executive Director, Nursing and Social Service Directors meet and discuss possible further resolutions. b. Contact Regional Director and/or Consultants. c.Contact Ombudsman. d. Contact area AHCA Agency Office. 14. The Social Service Director/designee will record each Concern/Grievance Report on the Concern/Grievance Log for each month and submit it to the Executive Director. a. The Concern/Grievance reports will be kept together with the monthly log. Group Grievances: 15. Group grievances generated in Resident Counsel meetings, or any other venue will be documented on the grievance form by the guests/residents or their designee. The grievance will be provided to the Grievance Official and the grievance process described in this policy will be initiated. The Grievance Official will assist Life Enrichment in resolving group grievances that resulted from the resident counsel.

Based on observation, interview and record review, the facility failed to revise patient-centered care plans for four (#81, #37, #33 and #76) out of twenty-nine residents reviewed. Findings included: 1. During an interview on 5/13/25 at 1:44 P.M. Resident #81 stated loud noises were a trigger for him and he completes self-calming exercises. The resident stated he went to a quiet place when he felt anxious. A review of Resident #81's admission record showed an admitted [DATE] with diagnoses to include bipolar disorder and Post Traumatic Stress Disorder (PTSD). A review of Resident's # 81's Medication Administration Record, dated May 2025, showed orders for Bupropion twice daily for depression, Lamotrigine twice daily for mood. A review of Resident #81's Trauma Informed Care Questionnaire (TICQ) dated 4/17/25, showed the resident had served in a war zone, thought his life was in danger and was seriously injured. A review of care plan showed Resident #81 initiated on 4/17/25 showed the resident has a significant trauma exposure related to history of prior service in war zone/exposure to war-related casualties and history of a serious car accident. The goal showed Resident # 81 will state feeling safe in the facility environment through the next review date, revised on 4/30/25. The interventions included: address resident in a calm, quiet and respectful manner, offer resident information and encourage active participation in the development of the resident care plan, psychiatry, and psychological services consultation will be requested as needed and staff will attempt to ensure a consistent and predictable routine for resident care and minimize unexpected changes. A review of Resident # 81's admission Minimum Data Set (MDS) dated [DATE], showed Section C, cognitive patterns Brief Interview for Mental Status Score (BIMS) of 15, indicating intact cognation. Review Section D, mood showed feeling down, depressed, or hopeless occurred 2 to 6 days. A review of Resident# 81's psychological evaluation dated 5/8/25 showed the resident's emotional functioning is sufficient to alter his baseline functioning and therefore, treatment is medically necessary. The resident may benefit from individual therapy to help reduce symptoms of depression. A review of Resident #81's visual/bedside Kardex (a document used by staff with care instructions specific to each resident) Report as of 5/15/25, sections related to safety, monitor, resident care, did not include trauma related care interventions. During an interview on 5/14/25 at 8:05 A.M. Staff M, Registered Nurse (RN) assigned to Resident #81 said she did not know if any of her residents had a PTSD diagnosis. During an interview on 5/14/25 at 2:35 P.M. with the Social Services Director (SSD) and the Social Service Assistant (SSA), the SSD said she completed Resident #81's TICQ on admission and does not recall what was on the form. The SSD stated the care plan including the interventions are initiated based on the residents' response to the questions. During an interview on 5/15/25 at 8:50 A.M. with Resident #81 and the SSD. Resident #81 said when he woke up in the mornings his anxiety level is at a 5. The SSD said, he does not have any triggers. The review of the care plan dated 4/17/25 and interview with SSD revealed Resident #81 was not assessed or care planned for triggers or retraumatization. 50570 2. On 5/12/25 at 2:34 p.m., Resident #37 was observed lying down in bed. An observation of her hands, over the blanket, revealed her nails were approximately 1-1.5 inches long. She said she did not like them like that. Resident #37 was observed attempting to hide her hands and stated, I'm sorry they are like that. If they would give me something to cut or file them I would do it. On 5/14/25 at 9:48 a.m., an observation of Resident #37 revealed the same concerns observed on 5/12/25. On 5/14/25 at 9:49 a.m., an interview was conducted with Staff V, Certified Nursing Assistant (CNA). He confirmed Resident #37 was one of his assigned residents. He said nail care was provided on Sundays or on the residents' shower days. Staff V, CNA said there was a book at the nurse's station with resident's shower times and assigned days. A review of Resident #37's admission record revealed an admitted [DATE]. Further review of the admission record revealed diagnoses to include anxiety disorder, unspecified, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, recurrent, unspecified, repeated falls, adult failure to thrive, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. A review of Resident #37's progress notes from 12/2024 to 5/15/25 revealed there was no documentation related to nail care to including cutting, trimming,filing or refusals. A review of Resident #37's tasks related to shower and bath days in the last 30 days revealed the following, Shower: Tuesday and Friday 3-11. A review of documented tasks revealed she received a shower on 4/22/25 and 4/29/25. A review of documented tasks revealed she received a bed bath on 4/18/25, 5/2/25, 5/6/25, 5/9/25, and 5/13/25. The review did not show the resident was offered nail care. A review of Resident #37's care plan revealed the following: - [Resident name] has ADL [activities of daily living] Self-Care and mobility deficit. She needs assistance with bathing, dressing, transfers and toileting related to weakness Date Initiated: 03/02/2022, Revision on: 06/12/2023, with interventions to include, Bathing preference shower and/or bed bath, BATHING- Total ASSIST x1 [1 person] GROOMING- Total Assist x1. Further review of the care plan revealed no documentation related to refusing nail care or preferring long nails. On 5/15/25 at 10:20 a.m., an interview was conducted with Staff O, CNA. She said she provided nail care including washing and cutting residents' nails. She said nail care is provided every day or as needed. Staff O, CNA said she followed the resident's care plan regarding nail care, such as preferences for their nails being cut. On 5/15/25 at 2:40 p.m., an interview with Staff P, Registered Nurse (RN)/Unit Manager (UM) was conducted. She stated nailcare is provided, Whenever it's needed. You can do nailcare if you walk by a resident whose nails are long and during their shower. She said a couple of weeks ago she started implementing that staff should look at the residents' nails after dining, such as cleaning them, when they put the resident in bed. She stated, It's on-going education and reminders. Staff P, RN/UM said Resident #37 was very picky and, It's a hit or miss, with nail care. She said, She likes them long as it's part of who she is. Staff P, RN/UM confirmed Resident #37's refusals for trimming her nails/preference for long nails is not in her care plan and stated, It should probably be documented. 48223 3. On 05/12/25 at 09:53 AM Resident #33 was observed lying in bed in a facility gown, just above resident elbow on the right upper extremity red circular spots were noted. Resident stated having a rash that was extremely itchy. Resident continued this is much better, the physician visited and prescribed a cream the facility has been applying. Review of the Admission Record showed Resident #33 was admitted to the facility on [DATE] with diagnoses that included but not limited to Generalized Anxiety Disorder, and Major Depressive Disorder. Review of Resident #33's Minimum Data Set (MDS) most recent quarterly assessment dated [DATE] revealed resident is cognitively intact, with a Brief Interview for Mental Status (BIMS) of 15/15. Review of Resident #33's Dermatology Provider Note dated 04/24/2025 revealed new resident to be seen per administration to rule out contagion. Diagnoses included but not limited to: Rash and other nonspecific skin eruption; Pruritus, unspecified; Xerosis cutis; Atrophic disorder of skin, unspecified. Assessment: . on examination, the patient is noted with a rash to the right chest, a scrape biopsy was performed to the right chest, patient tolerated well. Wound care is managing the patient's buttocks. Patient presents for evaluation of rash the rash is described as erythematous and patient reports pruritus. Medications order: Triamcinolone Acetonide 0.1% External Cream start 4/24/2025. Review of Resident #33's Care Plan showed: Focus - At risk for alteration and skin integrity related to: Edema, Fragile skin, Use of blood thinning medications and incontinence. revised 01/01/2025. The Goal: * intact skin will remain intact through next review, revised 2/17/2025; * lateral lower extremity dyskeratosis will be managed with treatment in place for 30 days date initiated 2/13/2025; * MASD [Moisture-Associated Skin Damage] to bilateral buttocks will improve with treatment in place date initiated 3/20/2025;* left inner thigh will resolve with treatment in place they initiated 5/9/2025; * wound to sacrum will improve with treatment in place date initiated 5/12/2025; * left breast fold will resolve with treatment in place 5/14/25 treatment updated for 10 days revised on 5/15/2025. The care plan did not show any interventions related to the the new rash on the resident's arm and chest on 4/24/2025. 4. During an interview on 5/12/25 at 2:35 PM Resident #76's responsible party (RP) stated not seeing hydration in Resident #76's room when visiting, especially in the evening. The RP stated being concerned that going from dinner to breakfast with no liquids was concerning. The RP stated bringing the concern to the facility on multiple occasions but the concern continues. During multiple observations of Resident #76's room on 05/12/25 at 2:03 PM, 05/13/25 at 5:36 PM, and on 05/14/25 at 1:09 PM there were no cups or liquids in room. Review of Resident #76's admission record showed Resident #76 was admitted to the facility on [DATE] with a diagnosis that included but not limited to Cerebral Infarction (stroke), hypertension, and other comorbidities. Review of Resident #76's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive deficits and resident is dependent on staff for Activity of Daily Living (eating and drinking). Review of Resident #76's Order Summary Report with active physician orders as of 05/15/25 showed: REGULAR diet, Pureed texture, Honey Thickened Fluids consistency 10/16/24 - revised 12/17/24. Review of Resident #76's Speech Therapy (SLP) Discharge Summary dated 4/5/2025 revealed diagnosis of Dysphagia and Recommendations not limited to: Nectar thick liquids (NTL), drink from cup only, check mouth for pocketing or residue after intake; alternate solids and liquids during meals, and close supervision. Review of Resident #76's Care Plan showed: Focus - Resident is at nutritional risk related to CVA [stroke], hypertension on mechanically altered diet 12% loss x 60 days. BMI [body mass index] greater than 19. 6.2% gain x 10 days BMI 19.6, within normal limits. BMI 18.7, within normal limits, -5.7% x 30, intake 76 to 100% most meals. Add large portions meat/meat alternate at meals. revised on 12/11/2024. The goal Resident will tolerate food/liquid consistency and have no significant weight change through review period, revised on 2/19/2025. Interventions: fortified foods with meals revised on 3/5/2024; monitor labs as ordered initiated 1/30/2024; Provide adaptive equipment as ordered scoop plate with meals revised on 5/28/2024; serve diet as ordered date initiated 1/30/2024; Weight per facility protocol revised on 2/19/2024. Review of this care plan revealed there were no interventions for swallowing or swallowing precautions. During an interview on 05/15/25 at 11:09 AM the MDS Coordinator confirmed the resident #33's care plan was not updated to reveal the treatment for the rash. The MDS Coordinator continued to state Resident #76's care plan did not reveal a swallowing issue the only care plan was related to nutrition and showed to follow the physician orders. During an interview on 05/15/25 at 11:53 AM the Director of Nursing (DON) stated the expectation is for the care plan to be updated when new issues are treated/updated. The DON continued to review the care plan for Resident #76 and confirmed the care plan did not specifically indicate what the problem is for Resident #76 related to the swallowing. Review of an undated facility policy titled Person-centered Comprehensive Care Plan revealed: Guideline: It is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and timeframes to meet their preferences and goals, and address the guest/resident's nursing, medical, physical, mental, and psychosocial needs. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest/resident's condition. The interdisciplinary team will work collaboratively with the guest/resident, responsible party and/or family members to develop a comprehensive person-centered care plan that encompasses each guest/resident's personal preferences, goals, and objectives. The comprehensive person-centered care plan will be developed based on the Minimum Data Set (MDS) to assess the guest/resident's clinical condition, cognitive and functional status, and use of services. The comprehensive care plan will address the following: -Services to be furnished to attain or maintain the guest/resident's highest practicable physical, mental, and psychosocial well-being. -Needs and Strengths of the guest/resident. -Culturally Competent Care and Services/Preferences . -Guest/resident's refusal of care or services and center's action to provide education to guest/resident and/or representative.

Based on observation interview and record review the facility failed to provide an environment free from falls and failed to ensure documentation of assessments and neurological checks post fall, for three (#93 #11 and #10) of three residents sampled. Findings included: 1. On 05/14/2025 at 8:41 a.m. Resident #93 was observed sitting at her bedside. She was not eating her breakfast. When greeted, she stated, not good. She turned her back and would not engage in conversation. Resident #93 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to pneumonia, End Stage Renal Disease (ESRD), gastrostomy, adult failure to thrive, diabetes, dependent on renal dialysis, muscle weakness, difficulty in walking, anemia, Cerebrovascular Accident (CVA), hypertension, cardiac pacemaker, depression, atrial fibrillation, generalized anxiety disorder. Review of the admission, Minimum Data Set (MDS) dated [DATE] showed Brief Interview for Mental Status (BIMS) score of 15 or cognitively intact. Section GG, Functional Abilities showed resident required partial to moderate assistance with toileting and showering. Section O, Special Treatments, Procedures, and Programs showed resident was on dialysis. Review of the progress notes revealed the following: On 05/13/25 at 11:42 a.m. Interdisciplinary Note (IDT) note showed Resident was discussed with IDT team post incident (fall). Resident verbalized she was trying to self-transfer to wheelchair with ultimate goal of using restroom. Right shin abrasion noted, resident denied impact to head during event or delayed pain/discomfort. Resident education provided post event was regarding call light utilization, resident's physical limitations, and the importance of using the Wheelchair (w/c) brakes. Return demonstration shows effectiveness as well as verbal understanding. Resident was own responsible party and verbalized no call out needed at this time. On 05/13/2025, Fall Risk Evaluation showed a score of 17.0 meaning the resident was at risk for falls. On 05/12/2025, a Change in Condition (CIC) / SBAR (Situation, Background, Assessment, Recommendation), showed Falls, Nursing/observations, evaluation, and recommendations are: Heard someone calling out help me. Discovered resident laying on floor on her back with w/c (wheelchair) behind her, noted w/c brakes were not on, asked resident what happened stated I was trying to go to the bathroom, and I forgot to put my brakes on and fell . Primary Care Provider Feedback: none at this time. Reminders given to resident to ask for assistance. Review of the care plans showed Resident #93 was at risk for falls related to unsteady gait/balance as of 04/16/2025. Interventions included but not limited to encourage appropriate footwear as of 04/16/2025; place items used in easy reach and PT and OT to screen prn (as needed). Review of resident #93's electronic medical record (EMR) revealed neurological checks were not documented. Post fall neurological checks were requested and they were not provided. During an interview on 05/14/2025 at 4:08 p.m. Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) reviewed Resident #93's medical record for the 05/02/2025 fall. Staff B verified there was not a progress note regarding the fall including a description of the fall, and the assessment of the resident in the medical record. Staff B stated only a facility form was filled out. Staff B was unable to locate the neurological checks. 2. On 05/14/2025 at 8:42 a.m. and at 3:49 p.m. Resident #11 was observed sleeping in her bed. The bed was in low position. Review of the Admission Record for Resident #11 revealed and admitted [DATE] and readmitted on [DATE] with diagnoses included but not limited to atrial fibrillation, Chronic Obstructive Pulmonary Disease (COPD), pulmonary fibrosis, diabetes, muscle weakness, difficulty in walking, unsteadiness on feet, heart failure, cognitive communication deficit, osteoporosis, pathological fracture, myasthenia gravis without exacerbation, Altered Mental Status, cardiac pacemaker, dementia, hypertension, and cardiomegaly. Review of the MDS dated [DATE] showed resident #11 had a BIMS score of 13, meaning cognitively intact. Section GG, Functional abilities showed she required partial/moderate assistance for toileting and showering. Review of progress notes revealed the following: On 04/18/2025 at 7:29 p.m. spoke with resident's [family member] regarding an unwitnessed fall. Vital signs stable. Small cut on right side of face. No complaints of pain. Doctor paged and made aware. On 04/20/2025 at 3:52 p.m. a Fall Risk Evaluation was performed revealing a score of 12 meaning the resident was at risk for falls. Review of an Advanced Registered Nurse Practitioner (ARNP) note dated 04/23/2025 showed facility staff requesting evaluation as resident had an unwitnessed fall at the end of last week. Resident does not appear to have injured herself, but they are stating that she was experiencing some increased back pain. Resident has a history of chronic pain as well as multiple old compression fractures to her lumbar and thoracic spine. Resident was seen and examined sitting up in the common area eating lunch, no other distress. Stated she started to feel better today. She denied specific complaints of chest pain, shortness of breath, nausea/vomiting, fever. She stated that her pain has been managed with her current pain medications. A progress note on 05/08/2025 at 2:30 a.m. showed - Resident got up into wheelchair with assist of one person. She complained of severe pain in her back and hard to breathe. Resident said, It's hurting so bad, 8 on a scale of 1 to 10. Her blood pressure was 130/94, pulse 75. Administered Morphine Sulfate 0.25 ml and Lorazepam 0.25 ml as per doctor's orders. Resident did not want ice on her back. Staff did massage back for10 minutes with minimal relief. Will continue to monitor for pain meds to work. On 05/08/2025 at 6:59 a.m. nurse called and spoke to [family member] and also notified hospice that resident had been transported to hospital for fall. On 05/08/2025 at 7:13 a.m., Change in Condition / SBAR for fall occurred in the morning, blood pressure showed 150/74 at 3:11 a.m., pulse 76 for 05/06/2025 at 3:07 p.m., respirations 19 on 05/08/2025 at 3:11 a.m. oxygen saturation 95% on 05/06/2025 at 3:07 p.m. Primary Notification on 05/08/2025 at 6:30 a.m. Recommendation to send resident out per request. Resident / Representative Notification of [family member] hospice and doctor on 05/08/2025 at 6:31 a.m. The Change in Condition / SBAR documented for 05/08/2025 fall did not include a description of the fall event and/an accurate assessment of the resident's status. On 05/08/2025 at 11:22 a.m. Resident returned to facility. Discoloration noted to bilateral lower extremities as well as bilateral upper extremities. CT (Computed Tomography) scans of head and c-spine were negative. Chest and pelvic x-ray negative for acute injury as well. [family member] at bedside upon return. Resident expresses discomfort. Floor nurse made aware and will follow. Call light placed within reach and bed placed in lowest position. On 05/09/2025 physician note showed the resident seen today for medication management, CHF, multiple ecchymosis and right head hematoma. Resident was seen in bed and appeared comfortable. Chart reviewed and resident had a fall on 05/08/2025. She was sent to the hospital ER (emergency room ) for evaluation per her request. Resident returned later the same day to facility where she resides for long term care. Nurse reports resident was refusing pills (medications). No other concerns per nurse and plan of care was reviewed. An IDT progress note dated 05/09/2025 at 9:59 a.m. showed - Resident discussed with IDT team post incident. Resident recently admitted to Hospice care with diagnoses of ASHD (Atherosclerotic Heart Disease). Overall decline was noted. Resident appeared to be trying to get ready for the day. Care plan updated for during last rounds on 11 p.m. -7 a.m., staff to offer assistance with a.m. ADL care to prevent resident from self-ambulating for a.m. set up. Notify nurse for documentation if resident refuses at that time and continue to re-offer throughout a.m. Referral to therapy placed. [Family member] made aware of care plan changes. No delayed injury noted. Imaging in ER negative for acute injury. Review of the record showed on 05/09/2025 at 10:47 a.m., a Fall Risk Evaluation showed resident had a score of 14.0 meaning the resident was at risk for falls. Review of resident #11's electronic medical record (EMR) revealed neurological checks were not documented. Post fall neurological checks were requested and were not provided for the 04/18/2025 fall. There was no Change in Condition/SBAR documented for the fall on 04/18/2025. There was no assessment of the fall including description of event and assessment of the resident's status. Review of the care plans showed Resident #11 was at risk for falls related to weakness and unsteady gait as of 01/19/2023 and revised on 05/08/2023. Interventions included but not limited to during last rounds on 11 p.m. -7 a.m., staff to offer assistance with a.m. Activities of Daily Living (ADL) care to prevent resident from self-ambulating for a.m. set up as of 05/09/2025; 11 p.m. -7 a.m. shift to offer toileting throughout the overnight hour to discourage self-transfers as of 11/18/2024; encourage appropriate foot wear as of 01/19/2023; Place items within easy reach as of 01/19/2023. During an interview on 05/14/2025 at 3:54 p.m. Staff A, RN reviewed the documentation for Resident #11 RN verified there was no documentation or complete documentation regarding the 04/18/2025 fall nor 05/08/2025 fall in the medical record. During an interview on 05/14/2025 at 4:08 p.m. Staff B, LPN, UM stated she reviewed the medical record for Resident #11 regarding the 04/18/2025 fall. Staff B stated there was not a progress note regarding the fall. Staff B stated the staff did a Fall Risk Evaluation only. Staff B stated they referred the resident to therapy. Staff B stated there was no description of the fall in the medical record. She stated neurological checks are required for an unwitnessed fall. Staff B,LPN stated they perform neurological checks on paper. Staff B stated related to the 05/08/2025 fall, they sent the resident to the hospital. She stated the Change In Condition / SBAR just documents fall. Staff B, LPN confirmed there was no description of the fall in the Change in Condition nor was there a progress note. 3. On 05/14/2025 at 8:3 a.m. Resident #10 was lying in bed with the head of the bed elevated. Floor mats were in place. Her bed was in a low position. Resident #10 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to COPD, cognitive communication deficit, muscle weakness, difficulty in walking, history of falling. Review of the MDS dated [DATE] showed BIMs score of 08 or moderately impaired. Section GG Functional Abilities showed Resident #10 required maximum assistance for toileting and showering. Review of the progress notes showed the following: On 04/02/2025 at 8:53 p.m. Fall Risk Evaluation was performed with a score of 4.0 meaning the resident was at not at risk for falls. On 04/02/2025 at 10:18 p.m. resident found on floor in sitting position next to bed. Normal Range of Motion. No injuries or complaints of pain. Vitals within normal limits. Doctor and family notified. Change in Condition / SBAR performed. On 04/02/2025 at 10:23 p.m. a Change in Condition / SBAR for fall was documented. On 04/03/2025 at 7:45 a.m. a Fall Risk Evaluation was performed with a score of 23 meaning the resident was at risk for falls. A Change in Condition / SBAR for fall dated 04/08/2025 at 7:15 p.m. showed - Aide notified this nurse resident was sitting on floor beside bed. Resident alert and oriented x 3. Vitals within normal limits. Resident denied injury. No notable injuries. Resident stated she was trying to get up to take self to bathroom and slid off bed onto floor. Bed was in low position, call light within reach, but call light was not on. Resident assessed, no injury, assisted up on to bed and then to wheelchair and assisted to bathroom. Resident educated to use call light for assistance. Primary Care Provider responded with the following feedback: no new orders. On 04/09/2025 Resident discussed with IDT team post incident. Resident trying to ambulate to restroom without assistance. It was noted she was toileted less than 2 hours prior. Resident verbalizes no delayed pain/discomfort. Care plan reviewed and updated for Palm Program and low bed while in bed. Attempt to call out to family in regards. Line disconnected. Social services made aware. An IDT progress note dated 04/11/2025 showed Resident #10 was discussed with IDT team post fall. No delayed injury noted, and resident verbalizes no pain/discomfort. Resident noted to have been toileted within an hour prior to incident. Discovered sitting on floor against bathroom door with brief off. Resident verbalized she is aware she did not use her call light. Resident education provided regarding call light usage as well as severity of falling and risk for major injury. Understanding noted and returned demonstration appears effective. Per resident [family member] has been called enough and she preferred no call out in regard to education. Per nurse [family member] also has been giving resident verbal encouragement regarding call light usage. Referral to therapy placed as well. A Change in Condition / SBAR for fall dated 04/16/2025 at 12:45 a.m. showed - Blood pressure on 04/16/2025 at 1:15 a.m. 119/81; pulse 106 04/16/2025 at 1:15 a.m.; respiration 18 on 04/16/2025 at 1:15 a.m. Resident was found by aide on floor next to bed in a prone position trying to crawl. When this nurse asked the resident what she was doing she stated she was trying to go to the bathroom. Call light was not on but in resident's reach. Bed was in low position. Notified doctor that resident had behaviors earlier showing aggression toward staff and difficult to re-direct. Also notified this was third fall in two weeks. Doctor ordered resident to be sent to the ER for further evaluation and CT scan. Primary Care Provider responded with the following feedback: Send to ER for CT scan and evaluation. Further review of progress notes revealed the following:- On 04/16/2025 at 6:38 a.m. Resident returned from hospital with a sprained right ankle. Splint on ankle. Follow up with orthopedic. On 04/16/2025 at 6:42 a.m. doctor and family notified of resident returning. On 04/16/2025 at 11:02 a.m. Fall Risk Evaluation was performed with a score of 26.0 meaning the resident was at risk for falls. An IDT progress note dated 04/16/2025 at 11:12 a.m. showed - Resident discussed with IDT team post incident (fall). Resident returned from ER with diagnosis of right ankle sprain. Splint/brace in place. Resident verbalizes no discomfort this a.m. Per investigation, resident toileted less than 2 hours prior during 1st rounds of 11 p.m. -7 a.m. shift. Resident verbalized trying to go to closet to get clothes. Confusion noted. Care plan reviewed and updated for bilateral floor mats while in bed. Referral to therapy placed. Nurse Practitioner in house and reviewing medications for possible adjustment. Risk Manager called family in regards to fall. Family verbalized understanding regarding care plan changes and interventions with thanks given and no concerns noted. Verbalized understanding. A progress note dated 04/16/2025 at 6:49 p.m. revealed Resident #10 was sent to ER last night for fall. That was her 3rd fall in two weeks. Resident was returned back with a sprained right ankle. Resident has been very confused and called 911 herself demanding to go to ER. Review of the EMR revealed no Change in Condition/SBAR documented for transfer to hospital on 04/16/2025. There was no documentation to indicate the doctor was notified. Review of the progress notes showed the following: On 04/16/2025 at 7:25 p.m. the nurse called family and left message to call back to notify of resident going out to the hospital. On 04/17/2025 at 12:24 a.m. facility called hospital for an update. Resident was admitted for encephalopathy. On 04/22/2025 at 10:45 p.m. Resident readmitted from hospital via stretcher. Spoke with family, notified of arrival. Notified doctor of return. Gave orders to continue with hospital discharge orders and labs. On 04/22/2025, Fall Risk Evaluation, score of 11.0. On 04/25/2025 at 2:13 p.m. Change in Condition/SBAR for fall showed blood pressure 127/77 on 04/25/205 at 10:94 a.m.; pulse 79 at 04/25/205 at 10:94 a.m.; respirations 18 on 04/25/2025 at 10:04 a.m. All other areas blank. A progress note dated 04/25/2025 at 2:16 p.m. showed during routine round this resident (#10) was found sitting on the floor next to her wheelchair, apparently reaching for an object. Resident stated, I was trying to reach for my dentures. Resident also stated, I did not hit my head. No injuries noted during assessment. Will continue to monitor. No distress noted. All parties were notified. Review of a Change in Condition / SBAR for a fall on 04/26/2025 at 4:55 p.m. revealed Resident #10 was found sitting on the floor. Blood pressure 108/75 on 04/26/2025 at 6:51 p.m., pulse 97 04/26/2025 at 6:51 p.m. respirations 18 04/26/2025 at 6:51 p.m. Range of motion within normal limits. No blood. No complaint of pain. She stated that she was trying to reach the garbage can. She did not use the call light. Sitting back on her chair at the nursing station for safety. Started neuro checks. She was alert but confused. Doctor notified. Family notified. Primary Care Provider responded with the following feedback: none. On 04/26/2025 at 10;59 p.m. Fall Risk Evaluation was performed with a score of 13.0 meaning the resident was at risk for falls. On 04/27/2025, 2:05 p.m. Change in Condition/ SBAR for fall revealed . Nursing observations, evaluation, and recommendations are Resident was found sitting on the floor in sitting position. Range of Motion within normal limits. No blood. No complaint of pain. She stated that her foot got caught in wheelchair. She did not use the call light. She was sitting back in her chair at the nursing station for safety. Start neuro checks. She was alert but confused. Doctor notified. Family notified. Primary Care Provider responded with the following feedback: none. A Change in Condition/SBAR and progress note for fall dated 05/03/2025 at 5:40 p.m. showed the Resident was found sitting on the floor. Range of motion was within normal limits. No bruises, no blood. Resident denies any pain. Doctor notified. Family notified. Primary Care Provider responded with the following feedback: Range of Motion within normal limits, start neurological checks. On 05/03/2025 Fall Risk Evaluation was performed with a score of 15 meaning the resident was at risk for falls. An IDT progress note dated 5/052025 at 12:29 p.m. showed Resident #10 was discussed with IDT team post fall. Resident noted to have been brought back to nurse's stations moments prior to fall per weekend supervisor. Noted slightly soiled. Care plan reviewed and updated for staff to offer resident toileting prior to leaving dining room in dining room bathroom. Family made aware of care plan change day of event. Referral to therapy placed. Review of a Therapy Screen for change in condition dated 05/062025 at 9:11 a.m., showed initiated Therapy, please review and address screen. Referral to therapy completed. Review of Neurological checks provided for 04/08/2025, 04/09, 04/10, 04/11, 04/12, 04/13, 04/26, 04/27, 04/28, and 04/29/2025 revealed Neuro check assessments were conducted on these dates. The review showed Neurological checks were not documented on 04/02, 04/03, 04/04, 04/25,05/03, 05/04/2025 and on 05/05/2025. Review of the care plans showed Resident #10 was at risk for fall related to unsteady gait and weakness as of 04/02/205. Interventions included but not limited to resident education regarding call light usage and asking for assistance with ambulation, transfers, toileting etc. as of 04/11/2025. Bilateral floor mats while in bed as of 04/22/2025. Encourage appropriate foot wear as of 04/02/2025. Ensure trash can is within residents reach at bedside prior to leaving room. Staff to also offer to throw away any excess trash/clutter prior to leaving the room post patient care as of 04/28/2025. Low bed while in bed as of 04/22/2025. Palm Program as of 04/09/2025. Place items used in easy reach i.e. water, telephone, call lights as of 04/02/2025. PT and OT to screen prn as of 04/02/2025. Every 15-minute checks due to fall risk Ensure observation log is completed and returned to management as of 04/27/2025. Staff to offer resident assistance with denture application. If resident refuses, ensure that dentures are within reach as of 04/25/2025. Staff to offer resident usage of dining room bathroom prior to leaving lunch and dinner as of 05/05/2025. Staff to offer toileting assistance upon rising, before and after meals and every night as of 04/22/2025. During an interview on 05/14/2025 at 4:08 p.m. Staff B, LPN, UM stated the resident has had multiple falls. She was very impulsive. Staff B stated psych was working with the resident regarding medications. Staff B, LPN stated they had increased her medications. Staff B stated Resident #10's last fall was on 05/03/202 and they updated her care plans with interventions. During an interview on 05/15/2025 at 9:17 a.m. Director of Quality Assurance / Risk Manager (RM), The RM stated when a resident falls the nurses fill out a change in Condition / SBAR which includes a description of the fall and the assessment. The RM stated for Resident #93 they documented in the facility forms but that was not part of the medical record. The RM stated the nurse was to pass the neurological form during nurse to nurse and then it was to go to the UM and then to her or medical records clerk for scanning in the medical record. The RM stated for all unwitnessed falls a neurological check was to be performed. The RM stated they had initiated QAPI (Quality Assurance and Performance Improvement) on falls. The RM stated they have discovered the nurses are not documenting the falls in the medical record and are not performing the neurological checks. The RM stated the QAPI was only for preventing falls it did not include the documentation of the falls. The RM stated the possible negative outcome for not performing neurological checks was an injury to the brain or a subdural hematoma. The RM stated if the resident goes to the hospital they still have to do neurological checks when they get back, if the hospital did not perform a CT scan on the resident. The RM stated they were not required to do a progress note if they describe the fall in the Change in Condition/SBAR. The RM stated they have to document current vital signs on the Change in Condition / SBAR. The RM verified Resident #10 did not have neurological checks on the chart for the 04/16/2025, 04/25/2025, 05/03/2025 falls. The RM verified the 04/16/2025 SBAR for Resident #10 did not have accurate vital signs documented, they were from hours after the fall. The RM verified there was no documentation regarding the fall for Resident #11 on 04/18/2025, 04/20/2025 nor 05/08/2025. The RM stated the fall document for Resident #11 was in the facility forms only. The RM stated there was no documentation regarding the description of the fall, the assessment, which should include recent vital signs, skin impairments for Resident #11. The RM verified there were no neurological checks for Resident #93 for the fall on 05/12/2025. During an interview on 05/15/2025 at 11:20 a.m. the Director of Nursing (DON) stated the falls should be documented post and should include any pain, range of motion, current vital signs, (specific to the fall), and note if any skin tears. The DON stated the neurological checks were to be done for all unwitnessed falls. The DON stated they were to be done for 72 hours. The DON stated the nurses do neurological checks on paper. The DON stated the neurological form was kept at the desk. The DON stated the form was to be given to the RM. The DON stated the fall was to be documented in initially into the facility form and then the nurse should be filling out the Change in Condition/SBAR and should include most of the information about the fall. The DON stated the IDT met every morning, Monday through Friday and the supervisors monitor on weekends. The DON stated the care plans are to be updated after the fall. The DON stated the care plans are reviewed once the team gets together for any needed adjustments. Review of a facility policy titled Nursing/Risk Management - Risk Evaluation for Falls, revised July 2017, revealed a purpose to identify and address risk factors associated with resident falls, to determine the need for any special care, assistive device or equipment needs, assist with resident care planning needs and to confirm the continued accuracy of the evaluation. Post Fall - 1. Post fall a team meeting of all available should occur. The goal is to huddle, discuss and assess the area of the fall and surroundings prior to the end of shift. This meeting initiates the investigation process. The team should be comprised of the fall ambassador or therapist on duty that shift, nursing team members and housekeeping. The post fall evaluation should be completed by the nurse 2. Therapy should screen for every post fall event 3. Interdisciplinary team (IDT) note will be utilized for documentation of repeat fall review and new fall related interventions.

Based on interviews and record reviews the facility failed to ensure two residents (#81 and #33) out of three reviewed for mood and behavior received culturally competent trauma-informed care related to identifying triggers that may cause re-traumatization. Findings included: 1. During an interview on 5/13/25 at 1:44 P.M. Resident #81 stated loud noises were a trigger for him and he completes self-calming exercises. The resident stated when he felt anxious he would go to a quiet place. A review of Resident #81's admission record showed an admitted [DATE] with diagnoses to include bipolar disorder and Post Traumatic Stress Disorder (PTSD). A review of Resident's # 81's Medication Administration Record (MAR), dated May 2025, showed orders for Bupropion twice daily for depression, Lamotrigine twice daily for mood. A review of Resident #81's Trauma Informed Care Questionnaire (TICQ) dated 4/17/25, showed the resident had served in a war zone, thought his life was in danger and was seriously injured. A review of care plan showed Resident #81 initiated on 4/17/25 showed the resident has a significant trauma exposure related to history of prior service in war zone/exposure to war-related casualties and history of a serious car accident. The goal showed Resident # 81 will state feeling safe in the facility environment through the next review date, revised on 4/30/25. The interventions included: address resident in a calm, quiet and respectful manner, offer resident information and encourage active participation in the development of the resident care plan, psychiatry, and psychological services consultation will be requested as needed and staff will attempt to ensure a consistent and predictable routine for resident care and minimize unexpected changes. A review of Resident #81's admission Minimum Data Set (MDS) dated [DATE], showed Section C, cognitive patterns Brief Interview for Mental Status Score (BIMS) of 15, indicating intact cognation. Review of section D, mood - showed feeling down, depressed, or hopeless occurred 2 to 6 days. A review of Resident# 81's psychological evaluation dated 5/8/25 showed the resident's emotional functioning is sufficient to alter his baseline functioning and therefore, treatment is medically necessary. The resident may benefit from individual therapy to help reduce symptoms of depression. A review of Resident #81's visual/bedside Kardex (a document used by staff with care instructions specific to each resident) Report as of 5/15/25, sections related to safety, monitor, resident care, did not include trauma related care interventions. During an interview on 5/14/25 at 8:05 A.M. Staff M, Registered Nurse (RN) assigned to Resident #81 said she did not know if any of her residents had a PTSD diagnosis. During an interview on 5/14/25 at 2:35 P.M. with the Social Services Director (SSD) and the Social Service Assistant (SSA), the SSD said she completed Resident #81's TICQ on admission and does not recall what was on the form. The SSD stated the care plan including the interventions are initiated based on the residents' response to the questions. During an interview on 5/15/25 at 8:50 A.M. with Resident #81 and the SSD. Resident #81 said when he woke up in the mornings his anxiety level is at a 5. The SSD said, he does not have any triggers. The review of the care plan dated 4/17/25 and interview with SSD revealed Resident #81 was not assessed or care planned for triggers or retraumatization. 48223 2. During an interview and observation on 05/12/25 at 09:53 AM, Resident #33 was teary eyed and emotionally upset as she discussed her prior nursing home experience. Resident #33 stated she was abused and treated badly at the previous nursing home. Resident #33 stated since being admitted to the facility no one had discussed the diagnosis of PTSD or any triggers that would cause her re-traumatization. Resident #33 stated being seen by psychology/psychiatrist at the facility. Review of the Admission Record showed Resident #33 was admitted to the facility on [DATE] with diagnoses that included but not limited to Generalized Anxiety Disorder, and Major Depressive Disorder, and other comorbidities. Review of Resident #33's Minimum Data Set (MDS) most recent quarterly assessment dated [DATE] revealed resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15/15. Review of Resident #33's Psychiatric Nurse Practitioner note dated 2/27/2025 revealed: Follow-up visit at SNF. A new problem has emerged Resident #33 made an allegation of abuse towards a staff member. She states that the staff member punched her multiple times in the head while adjusting the [total lift]. Resident #33 states the staff member did apologize to her after the incident. Resident #33 states she has had to use the [total lift] for over a year and had never had an incident with anyone like this while using the lift. The resident states the pain was enough that she asked for a pain pill after it happened. She is feeling better today but is scared to be in the care of that particular staff member otherwise resident is feeling safe in facility. Resident #33 has history of trauma in her previous facility and had another incident with staff member in this facility a few weeks ago. She is tearful when discussing these incidents. Review of Resident #33's Psychiatric Nurse Practitioner note dated 2/7/2025 revealed: Staff reported Resident #33 was recently harassed by another staff member that is currently being investigated. Resident #33 states a CNA (Certified Nursing Assistant) was very rough ., was harsh while providing care, and made Resident #33 feels scared while being provided personal care. Resident #33 reports that the same CNA was also very rude saying things like why are you wearing a wig you know you aren't going anywhere. Resident #33 so states that at a previous SNF (Skilled Nursing Facility) was horrible and she was abused while there. Resident #33 is anxious that the same thing will happen here. Review of Resident #33's Trauma Informed Care Questionnaire (TICQ) dated 3/3/25, 2/12/25, and 2/5/25 revealed all answers to the trauma questionnaire was documented as no. Review of Resident #33's record did not reveal a Brief Trauma Questionnaire (BTQ) or TICQ dated 3/5/2025 or after. Review of Resident #33's care plan showed a focus area dated 3/5/2025, Resident has a history of significant trauma exposure related to - reported history of abuse at prior nursing facility. The goal showed Resident #33 will state feeling of safety in the facility environment through the next review date. The interventions all dated 3/5/2025 showed psychiatry consult will be requested as needed, psychology services consult will be requested as needed, social services staff will complete the Brief Trauma Questionnaire (BTQ) with the resident. There were no triggers identified in the care plan. During an interview on 05/14/25 at 3:15 PM, Staff D, Certified Nursing Assistant (CNA) stated not being aware of any Residents in the facility with the diagnosis of PTSD or with a history of trauma. During an interview on 05/14/25 at 3:18 PM, Staff H, CNA stated being aware Resident #33 had a bad experience prior to this facility. Staff H, CNA stated did not know if Resident had any triggers. During an interview on 05/14/25 at 5:47 PM, Staff I, Licensed Practical Nurse (LPN) stated not being aware of Resident #33's past experiences or if any triggers were known. During an interview on 05/15/25 at 09:10 AM, Staff E, CNA stated being aware of Resident #33 had something but doesn't know exactly what and is not aware of any triggers. During an interview on 05/15/25 at 09:23 AM, Staff F, LPN stated being aware of Resident #33 past experience from speaking with resident. Staff F, LPN stated not being aware of any triggers. During an interview on 05/15/25 at 10:21 AM, Social Services Director (SSD) stated Resident #33 trauma evaluations were all with 'no' responses after the allegations. The SSD stated if during the questionnaire a 'yes' response was given, then we would discuss the event in detail and develop a care plan with triggers. During an interview on 05/15/25 at 11:53 AM the Director of Nursing (DON) stated the facility should try to identify triggers, if they could. The DON stated the care plan interventions will then flow over to the plan of care documentation the CNAs can view. Review of an undated facility policy titled Person-centered Comprehensive Care Plan revealed under guideline: It is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and timeframes to meet their preferences and goals, and address the guest/resident's nursing, medical, physical, mental, and psychosocial needs. The comprehensive person-centered care plan will be developed based on the Minimum Data Set (MDS) to assess the guest/resident's clinical condition, cognitive and functional status, and use of services. The comprehensive care plan will address the following: . Trauma-informed Care, Interventions, and Potential Triggers.

Based on interviews and record reviews the facility failed to monitor antibiotic prescribing practice to reduce antibiotic resistance in two (#38 and #85) of two residents reviewed for long term antibiotic use. Findings included: 1. Review of Resident # 85's admission record showed 5/13/24 initial admitted and 2/17/25 readmitted with diagnoses to include sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA) and Extended Spectrum Beta Lactamase (ESBL) resistance. Review of Resident #85's order summary report, active orders as of 5/15/25 showed Cephalexin 500mg give 1 capsule three times a day for infection until 4/2/26. Review of Resident #85's care plan, revised on 4/3/25 showed the following focus: resident is at risk for side effects of antibiotic therapy related to sepsis, 4/2/25 now on prophylaxis PO (oral) treatment for one year Goal: Resident # 85 will tolerate antibiotic therapy without complications. Interventions to include medications as ordered, monitor for signs and symptoms of intolerance of antibiotic, observe for diarrhea, rash, stomach issues, etc. and report any issues associated with the use of antibiotic. Review of a Resident #85's progress note from a local hospital, dated 2/9/25 showed Infectious Disease recommends .oral suppressive antibiotics with Keflex 500 4 times daily for 1 year. During an interview on 5/15/25 at 4:13 P.M. with the Director of Education (DOE)/ Infection Preventionist (IP) said on 2/17/25 Resident # 85 was added to the facility's antibiotic surveillance log and was removed from the log when intravenous antibiotic was discontinued. The DOE, IP said Resident #85 will receive antibiotics indefinitely for chronic immunosuppressive therapy. During an interview on 5/15/25 a 4:49 P.M. the Director of Nursing (DON) said the duration of antibiotic it is up to the physician if (the antibiotic) deemed to need long term. 34768 2. On 05/14/2025 at 8:34 a.m. Resident #38 was observed dozing in bed. Her breakfast was on her overbed table. The head of the bed was elevated. Resident #38 was admitted on [DATE]Review of the Admission Record showed diagnoses included but not limited to after care following a total knee replacement, sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA), infection and inflammatory reaction due to internal left knee prosthesis, intraspinal abscess and granuloma, enterocolitis due to clostridium difficile, difficulty in walking, heart failure, Rheumatoid arthritis. Review of the Minimum Data Set, dated dated dated [DATE] showed Section C, Cognitive Patterns, Brief Interview for Mental Status of 12, cognitively intact. Review of physician orders showed Cephalexin (Keflex) 500 mg twice day for MRSA left knee, suppressive therapy for life, no stop date as of 03/03/2025. Review of the Antibiotic Time Out dated 02/24/2025 showed Cephalexin 500 mg twice day. admitted on [DATE] with diagnosis of MRSA chronic to left knee wound. Evaluated the antibiotic with resident's medical provider. Continue with current antibiotic therapy. Discussed with provider the present Keflex antibiotic therapy with MRSA of left knee wound. Per hospital infectious disease physician, resident to remain on antibiotic therapy for chronic immunosuppression due to history of MRSA in past. Review of the care plans showed Antibiotics lifetime immunosuppression for history of MRSA as of 03/25/2025. Interventions included enhanced barrier precautions for history of MRSA as of 03/25/2025. Medication per order, notify MD for any concerns as of 03/25/2025. Review of the Hospitalist Progress Note dated 02/23/2025 showed Keflex 500 mg twice a daily, chronic suppressive therapy for life. Call Infectious Disease Doctor for refills. During an interview on 05/15/2025 at 11:20 a.m. the Director of Nursing (DON) stated that Resident #38 was on Keflex for MRSA, suppressive therapy for life. The DON stated the ID doctor put her on it. The DON stated the resident came from the hospital on that medication. The DON stated the Infection Control Preventionist (ICP) was following her, because of on the antibiotic. The DON stated she did not know if it was appropriate to be on long term antibiotic or not they were just following the ID doctors orders. During an interview on 05/15/2025 at 1:21 p.m. ICP stated Resident #38 came from the hospital with the antibiotic order from the ID doctor. ICP state they did not want us to take her off of the medication. The ICP stated he did not call the ID doctor personally to verify the orders. The ICP stated there were extensive notes from the hospital. The ICP stated he had heard of some cases in the past, where residents were left on long term antibiotics. The ICP stated Resident #38 did not have c-diff issues or was immune compromised. The ICP stated they had her on Enhanced Barrier Precautions (EBP) but was not following her on Antibiotic Stewardship. The ICP stated we have not been following her, we would only follow her if she had symptoms. The ICP stated she was on EBP due to the MRSA, she was compromised. The ICP stated we followed her initially, February 24, 2025. The ICP stated when she was admitted in February she had c-diff and MRSA in her surgical incision of the left knee. The ICP stated the c-diff resolved. The ICP stated the initial MRSA infection colonized and resolved. The ICP stated the Keflex was for the MRSA of the left knee and the chronic suppression for life came from the ID doctor. The ICP stated she was treated for a Urinary Tract Infection on 04/15/2025 and we followed her in Antibiotic Stewardship. The ICP stated the process was the resident to come off the Antibiotic Stewardship tracking when the resident finishes the antibiotic and not symptomatic anymore. The ICP stated if the resident was symptomatic we would be monitoring her again. The ICP stated he would be alerted to her having symptoms through the morning report which includes elevated temperature, change in condition, adverse vital signs, or other symptoms she may be having. The ICP stated we would then go through the Antibiotic Stewardship using the evidence-based surveillance criteria system. During an interview on 05/15/2025 at 4:39 p.m. the DON, verified order for Keflex 500 mg bid for life. The DON stated the ID doctor ordered it. The DON stated the new hospital record showed the resident was to be on Keflex 500 mg twice a day and to call the ID doctor for refills. The DON stated she did not call the ID doctor regarding the order. The DON stated they have seen the same order before from these ID doctors. The DON stated verified the hospitalist wrote the order on the hospital record. The DON stated the purpose of Antibiotic Stewardship was to try to ensure not to over utilize antibiotics. The DON stated the Medical Director was also the resident's medical provider in the facility. The DON stated the medical provider was writing the resident's orders for the Keflex now. The DON stated it would be up to her ID doctor or the medical doctor to review the antibiotic orders. The DON stated it was up to the medical provider, and they deem it (antibiotic) was for life. The DON stated it was up to the ID or the medical doctor to review. 3. Review of the facility's policy, Infection Prevention and Control Manual Antibiotic Stewardship & MDROs, effective 2020 showed it is the policy of this facility to provide efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. Antibiotic Stewardship will include an assessment process, use of evidence based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rational for use appropriate use dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed procedure 6. Prophylactic medication used in the facility will be limited based on practitioner documentation of rationale, risk, and benefits for use. Review of the facility's policy, Infection Prevention and Control Manual Antibiotic Stewardship & MDROs, effective 2020 showed antibiotic stewardship refers to systematic efforts to optimize the use of antibiotics - not just reduce the total volume used - to maximize their benefits to patients, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. The CDC indicates that antibiotics are among the most frequently prescribed medications in nursing homes with up to 70% of residents receiving at least one antibiotic when followed for over one year. The CDC defines Antibiotic Stewardship as a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Stewardship involves identifying the like microbe responsible for disease, utilizing evidence based definitions when indicated; selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed. There are 7 core elements for Antibiotic Stewardship and nursing homes outlined by the CDC: Leadership Commitment Accountability Drug expertise Action Tracking Reporting Education Leadership Commitment: a well-defined leadership commitment to include: Policies and Procedures including evidence-based standards of practice promoting a judicious process for antibiotic use in the organization A solid communication system including nursing staff and prescribing practitioners including their organization system (policies, procedures, and protocols) for the use of antibiotics. This communication includes a system to identify any potential prescribing concerns to the infection preventionist, DON, Pharmacy Consultant and Medical Director for appropriate follow up timely. Culture change - the entire organization through education and support that promotes compliance with the organization's commitment to appropriate antibiotic use, monitoring, surveillance, tracking and correction of any identified concerns timely in an effort to provide quality care based on standards of practice. Accountability: The organization will identify positions that will have the authority to hold others accountable for compliance with the facility antibiotic stewardship program. Medical Director: Responsible for ensuring standards of antibiotic prescribing for quality are set and followed for the care of residents in the facility. DON: Responsible for ensuring proper Policies, Procedures and Protocols for care are in place to include the entire nursing process (assessment, plan, implementation, and follow up) for use of antibiotics in the care of the residents. The role of the DON will include adequate education and monitoring, to ensure the process is implemented, proper communication, evidence-based standards of practice vs. perceptions and expectations of all staff and their respective roles. Infection Preventionist: The IP will be responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the DON, Medical and Consultant Pharmacists and ongoing system review. Drug Expertise: Organizations will want to ensure facility staff has the ability to consult and receive support from experts (Pharmacy Consultant, Physicians, etc.) that have received specialized training in infectious diseases and / or antibiotic stewardship. Tracking and Reporting: Tracking and reporting of antibiotic use and outcomes will be completed in the facility to identify adherence to facility policies and procedures, use and outcomes. Tracking will allow the facility to identify patterns, prevalence of antibiotic use as well as specific ordering data. Outcomes (i.e. adverse drug events, antibiotic resistant organisms, C- difficile infections, etc.) will be tracked by the Infection Preventionist and discussed with the Quality Assurance Committee for action planning. Education: Education on antibiotic stewardship will be provided to facility staff, practitioners, residents, and families / responsible parties. Educational programs provided to families can assist with understanding and work towards reduction in perceptions and misconceptions on the use of antibiotics in nursing homes.

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS) was accurate related to discharge reason for one (#106) of 50 sampled residents. Findings included: Resident # 106 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the Admission Record showed the diagnoses included but not limited to fracture of right femur. Review of the discharge MDS dated [DATE] showed Section A, Identification Information showed discharge status to 04. Short-Term General Hospital. Review of the progress notes dated 3/25/25 showed discharged to assisted living facility (ALF). Transported by ALF, sent with discharge instructions. During an interview on 05/14/2025 at 5:47 p.m. the MDS RN, (Registered Nurse) stated the MDS showed the resident was transferred to an acute hospital. She verified the progress note showed the resident was discharged to an ALF. The MDS RN stated the resident went to an ALF. The MDS RN stated the MDS had an error and needed to be modified. Requested and did not receive a facility policy on MDS accuracy expectations.

Based on record review and staff interview, the facility failed to complete and or update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for two (#12 and #6) of six residents reviewed for PASARRs. Findings included: 1. Review of the admission record for Resident #12 showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with primary diagnosis of dementia dated 9/22/24, and secondary diagnoses to include unspecified psychosis dated 9/21/20 and an adjustment disorder with depressed mood dated 6/17/21. Review of a level I PASARR for Resident #12 dated 5/8/24 revealed the primary diagnosis of Dementia was not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. 50570 2. A review of Resident #6's admission record revealed an initial admitted [DATE] and a re-admitted [DATE] with diagnoses to include an adjustment disorder with depressed mood. A review of Resident #6's Preadmission Screening and Resident Review (PASARR), dated 8/31/2020, revealed there were no diagnoses marked under section I, mental illness (MI) or suspected MI. On 5/13/25 at 2:13 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She confirmed the level 1 PASARR for Resident #6 was not updated. She provided documentation showing the previous Director of Nursing (DON) attempted to update the level 1 PASARR, but did not submit it in the state vendor system. She said herself, the Director of Nursing (DON) and their corporate registered nurse (RN) are reviewing and updating PASARRs. She said all residents are screened for PASARRs upon admission to the facility. She said for those who are current residents they are reviewed during monthly psychiatry meetings. She said they review medications, new behaviors and/or diagnoses, then the PASARR is updated. The NHA stated the facility did not have a PASARR policy. The NHA stated they follow federal and state vendor guidelines.

Based on observation, interview and record review, the facility failed to ensure personal hygiene needs were provided to one (#76) of two dependent residents sampled for Activities of Daily Living (ADL). Findings included: 1. On 05/12/25 at 02:03 PM Resident #76 was observed sitting in his specialty wheelchair with whiskers (long stiff hairs) growing on his face and food particles on his face and down his shirt. During an interview on 05/12/25 at 02:36 PM Resident #76's Responsible Party (RP) stated frequently finding Resident #76 unshaven and has informed the facility on multiple occasions of resident's preference to be shaved. The RP confirmed Rsident #76 was dependent on staff to complete ADLs. On 05/13/25 at 05:36 PM Resident #76 was observed lying in bed with whiskers growing on his face. Review of Resident #76 clinical record revealed the resident was a long term care resident with diagnosis that included cerebral infarction (stroke) and contracture of right wrist/hand. Review of the Resident #76's most recent quarterly Minimum Data Set (MDS) Assessment, dated 05/02/2025, revealed the resident was coded as a '00' for the Brief Interview for Mental Status, indicating the resident had severe cognitive impairment. The resident was coded as being dependent on staff for personal hygiene needs, which included facial grooming and cleaning. Review of the resident's care plan dated 01/26/2024 revealed a problem of ADL - Activities of Daily Living - Self Care and Mobility Deficit. Resident needs assistance with ADL's and is at risk of developing complications associated with decreased ADL self-performance related to right sided weakness. During an interview on 05/13/25 at 11:42 AM with Staff G, Certified Nursing Assistant (CNA) stated residents are provided facial grooming on shower days only and yes residents can develop whiskers in between showers. Staff G, CNA stat Resident #76 did not have any behaviors and did not have concerns when providing care for the resident. Staff G confirmed Resident #76 had significant whiskers. During an interview on 05/15/25 at 09:41 AM with Staff P, Registered Nurse (RN)/Unit Manager (UM) stated CNAs should provide facial grooming related to shaving everyday. Staff P, RN/UM stated ithe resident had a clean shave preference. Staff P stated the resident should be assisted with cleaning of the face and hands after all meals and as needed throughout the day. A policy related to ADLs for dependent residents was not received.

Based on observation, interview, and record review the facility failed to ensure devices for contracture prevention were provided as ordered for two (#76 and #82) of two residents sampled. Findings included: 1. Multiple observations were conducted of Resident #76 without splints and braces. On 05/12/25 at 2:03 PM Resident #76 was observed in room seated in a wheelchair without any splints or braces on upper extremities. On 05/13/25 at 5:36 PM, Resident #76 was observed in bed without any splints or braces on upper extremities. On 05/14/25 at 9:15 AM, Resident #76 was observed in the day room seated in a wheelchair without any splints on. On 05/14/25 at 1:09 PM, Resident #76 was observed in his room seated in a wheelchair without any splints on. On 05/14/25 at 3:15 PM, Resident #76 was observed in bed sleeping without any splints on. On 05/14/25 at 5:32 PM, Resident #76 was observed in bed awake, without any splints on. During an interview on 5/12/25 at 2:35 PM Resident #76's family member stated they had not seen Resident #76 with splints on right hand. The family member stated visiting at various times and days. Family member stated mentioning this several times to the facility and they do not do anything. The family memeber said, Recently, I gave them a list of concerns at the care plan meeting related to Resident #76, and worsening of right wrist contracture was one of the concerns. Review of Resident #76's admission record showed Resident #76 was admitted to the facility on [DATE] with a diagnosis that included but not limited to Cerebral Infarction (stroke), hypertension, and other comorbidities. Review of Resident #76's quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive deficits. Section E Behaviors shows resident does not exhibit any behaviors. Section GG Functional Abilities showed the resident was totally dependent on staff for all Activities of Daily Living (ADLs), had impairments to one side, both upper and lower extremities. Section O Special Treatments, Procedures, and Programs showed the resident does not have a splint or brace. Review of Resident #76's Order Summary Report with active physician orders as of 05/15/25 showed: Order start date 6/13/24, Passive range of motion (ROM) to right hand/gentle stretching to right hand and wrist. Apply right [brand name] resting hand splint. Wear as tolerated, may be removed for care and laundering. Review of Resident #76's Occupational Therapy (OT) Discharge Summary dated 4/5/24 showed the following discharge recommendations: Contracture management program as written. Resident #76 made consistent progress throughout treatment plan of wearing splint. Review of Resident #76's care plan initiated on 1/26/24 revealed the resident did not have a care plan in place related to contracture management. The care plan showed an ADL Self-Care and mobility deficit. Resident needs assistance with ADL's and is at risk of developing complications associated with decreased ADL self performance related to right sided weakness Date Initiated: 01/26/2024 Revision on: 01/26/2024 with the following interventions: Daily after a.m. (morning) care, passive ROM to right hand/gentle stretching to right hand and wrist. Apply right [brand name] resting hand splint. Wear as tolerated, may be removed for care and laundering. Date Initiated: 04/05/2024. If Resident #76 is noted to remove splint attempt to reapply Date Initiated: 08/28/2024. Review of the care plan showed Resident #76 did not have a care plan in place related to behaviors or refusing care. Review of Resident #76's nursing progress notes from January 2025 to May 2025 confirmed there were no documented behaviors or refusal of care. During mulptiple interviews related to Resdient #76 conducted on 05/14/25, Staff G, Certified Nursing Assistant (CNA), Staff D, CNA, and Staff H, CNA all confirmed caring for Resident #76 regularly and stated the resident was cooperative and did not wear any splints. They stated the resident did not have behaviors. Staff H, CNA stated if a resident needed splints it would be in the computer or the resident would just request the splint. During an interview on 05/14/25 at 05:47 PM Staff I, Licensed Practical Nurse (LPN) stated being familiar with Resident #76. Staff I, LPN stated the resident did not have behaviors, did not refuse care and stated they were not aware of splint usage. Staff L could not recall seeing the resident with splint on. Staff I, LPN stated if a resident had orders for splint or ROM the nurse is responsible to check the box and the CNAs should complete this task During an interview on 05/15/25 at 09:10 AM Staff E, CNA stated Resident #76 does not wear a splint. During staff interviews on 05/15/25 09:23 AM Staff F, LPN stated they were not aware of Resident #76 having a splint order. Staff F, LPN stated if resident had an order the CNAs carry this order out and the nurse checks the box. 2. During an interview and observation on 05/12/25 at 2:03 PM, Resident #82 was lying in bed no splint observed on hand stated no one has put on my splint since being discharged from OT, it sits in a box on the dresser. During an interview on 05/13/25 at 9:22 AM Resident #82 stated the splint was not offered or applied last night. Review of Resident #82's admission record showed Resident #82 was admitted to the facility on [DATE] with diagnoses to include atrial fibrillation and contracture of the right hand. Review of Resident #82's admission Minimum Data Set (MDS) dated [DATE] indicated the resident had a BIMS score of 15 out of 15 which indicated no cognitive deficits. Review of Resident #82's Order Summary Report with active physician orders as of 05/15/25 showed: Order start date 4/24/2025, Apply right hand splint at hours of sleep. Remove in AM for ADL's as tolerated. Check skin for integrity with application and removal Review of Resident #82's care plan showed an ADL Self-Care and mobility deficit - Resdient needs assistance with ADLs and is at risk of developing complications associated with decreased ADL self-performance related to disease process/condition, recent surgery, Weakness Date Initiated: 6/27/2024 with the following interventions, apply right hand splint at hours of sleep. Remove in a.m. Skin checks when applying and removing. To be worn as tolerated. Resident is able to remove independently. Date initiated 4/25/2025 Review of Resident #82's Splinting and Wheelchair Positioning Program dated 4/14/2025 revealed: the therapist's name who completed form, trained nursing and wrote: precautions - Check skin before and after application and notify therapy with any issues. Under the section Instructions and Adaptive Equipment: 1. Place hand splint into hand. 2. Wrap wrist strap and secure Velcro. 3. Gently straighten the ring and little finger within patients' tolerance. 4. Strap finger to Velcro. Note: Patient is able to remove himself and its okay if he does. To be worn as tolerated. Remove for care. A picture of the device on the resident is shown. Physicians Order to Say: Apply right hand splint at hours sleep. Remove in am for ADLs as tolerated. Provide skin checks. During an interview on 05/15/25 at 09413 AM Staff P, Registered Nurse (RN)/Unit Manager (UM) stated the CNAs put the splints on and they have instructions in the room. The Treatment Administration Record (TAR) has the order. The nurse check mark would indicate the nurse completed the task. If the resident refused the splint or ROM, then the nurse would need to indicate that in the TAR and document. Staff P, RN stated Resident #76 and Resident #82 both had hand splints. Staff P stated Resident #82 needed assistance with placing the hand splint on and does not know why it was not being put on the resident. During an interview on 05/15/25 at 11:53 AM the Director of Nursing (DON) stated the expectation is for the CNAs to place the resident splints on. The DON stated the nurse is responsible for completing the ROM. Review of an undated facility policy titled SPLINT and BRACE Program showed: Splints are to be worn according to the schedule outlined in the referral from therapy that then placed in tasks and the Kardex. Therapy will train the CNAs and nursing team members how to put the device on and off with the specifics on the splinting program form. Each guest or resident with a splint will have a splint box or designated splint storage container when it is not in use. It should be labeled with the resident/guest's name and located in their room. The splinting program form will be stored in the top of the splint box for reference and any other place deemed appropriate by the center IDT (Interdisciplinary Team). Cleaning of the splint should be done according to manufacturer's guidelines. Always examine the resident/guest for red areas, pain, change in skin integrity, rash, ill fit, etc. Should something be observed when applying or removing the splint, notify the nurse and therapy immediately and do not put it on until directed to do so. Review of the facility's policy titled Restorative Functional Maintenance Nursing Program with a revision date of May, 2022 showed: The therapy department plays an important role in the Nursing Restorative/Functional Maintenance programming by providing resident screening for needs and assisting with the development of the restorative plan as needed. Follow up review of progress may also be provided by the therapist at regular intervals as needed. Should the resident experience lack of anticipated progress toward restorative goals or have a significant change in functional ability, the Restorative Nurse may refer the resident back to the therapist. Nursing restorative/functional programming may include, but is not limited to: Active and/or passive Range of Motion, Splint or brace assistance.

Based on observation, interview and record review the facility failed to ensure medications were administered prior to dialysis appointments for one (#93) of one sampled resident. Findings included: On 05/14/2025 at 8:41 a.m. Resident #93 was observed sitting at her bedside. She was not eating her breakfast. She stated, not good to greetings, turned her back and would not engage in conversation. Resident #93 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to pneumonia, End Stage Renal Disease (ESRD), gastrostomy, adult failure to thrive, diabetes, dependent on renal dialysis, muscle weakness, difficulty in walking, anemia, Cerebrovascular Accident (CVA), hypertension, cardiac pacemaker, depression, atrial fibrillation, generalized anxiety disorder. Review of the admission, Minimum Data Set (MDS) dated [DATE] showed Brief Interview for Mental Status (BIMS) score of 15 or cognitively intact. Section GG, Functional Abilities showed resident required partial to moderate assistance with toileting and showering. Section O, Special Treatments, Procedures, and Programs showed resident was on dialysis. Review of current physician orders for Resident #93 showed orders for dialysis on Monday, Wednesday and Friday. Amlodipine besylate 5 mg give 2 tablets in the morning for hypertension [HTN] ASA [Aspirin] 81 mg [milligrams] in the morning for coronary artery disease [CAD] Candesartan Cilexetil 32 MG [milligrams] Give 1 tablet by mouth in the morning for HTN Labetalol HCl 100 MG Give 3 tablet by mouth 3 times a day for HTN Review of the Medication Administration Record (MAR) for April 2025 showed: Amlodipine besylate 5 mg give 2 tablets in the morning for HTN was not given on 4/18, 4/21, 4/23, and 4/28/25 in the a.m. (morning), due to absent from center. ASA 81 mg in the morning for CAD was not given on 4/18, 4/21, 4/23, and 4/28/25, in the a.m., due to absent from center. Candesartan Cilexetil 32 MG Give 1 tablet by mouth in the morning for HTN was not given on 4/18, 4/21, 4/23, and 4/28/25 in the a.m. due to absent from center. Labetalol HCl 100 MG Give 3 tablet by mouth 3 times a day for HTN, was not given 4/18, 4/21, 4/23, 4/28, and 4/30/25 in the afternoon, due to absent from center. Augmentin 500-125 mg twice a day for pneumonia for 3 days as of 4/17/25, was not given on 4/19/25 in the a.m., due to absent from center. Ciprofloxacin HCL 500 mg twice a day for pneumonia for three days as of 04/16/2025, was not given on 4/19/25 in the a.m. due to absent from center. Review of the Medication Administration Record (MAR) for May 2025 showed: Amlodipine besylate 5 mg give 2 tablets in the morning for HTN was not given on 05/02, 05/05, 05/07, and 05/12/25 in the a.m. due to absent from center. ASA 81 mg in the morning for CAD was not given on 05/02, 05/05, 05/07, and 05/12/25, in the a.m., due to absent from center. Candesartan Cilexetil 32 MG Give 1 tablet by mouth in the morning for HTN was not given on 05/02, 05/05, 05/07, and 05/12/25, in the a.m. due to absent from center. Labetalol HCl 100 MG Give 3 tablet by mouth 3 times a day for HTN, was not given 05/02, 05/05, 05/07, 05/09, and 05/12/25 in the afternoon, due to absent from center. Review of the progress notes for resident #93 revealed On 05/14/25 at 9:47 a.m. (during survey), this writer spoke with the dialysis center which communicated it was recommended for blood pressure medication to be administer 3-4 hours before dialysis. Review of the care plans showed the resident had potential for complications related to dialysis for ESRD and required dialysis as of 04/16/2025. Interventions included but not limited to administer and monitor effectiveness of medications as ordered as of 04/16/2025; Communicate with dialysis center regarding medication, diet, and lab results as of 04/16/2025. Coordinate resident's care in collaboration with dialysis center as of 04/16/2025. Resident was antiplatelet therapy related to diagnosis of CAD as of 04/16/2025. Interventions included but not limited to administer medication as ordered as of 04/16/2025. During an interview on 05/14/2025 at 3:54 p.m. Staff A, Registered Nurse (RN) stated Resident #93 went to dialysis in the a.m., around 10 a.m. Staff A stated that if a resident misses their medication, they are to inform the medical provider for missed medications. During an interview on 05/14/2025 at 4:08 p.m. Staff B, Licensed Practical Nurse Unit Manager (LPN, UM) stated Resident #93 goes out to dialysis around 9:40 a.m. Staff B stated the nurse should let the doctor know right away about any medications not taken. Staff B stated they discussed today about changing the time of the medications for Resident #93. Staff B stated the nurse was talking to the dialysis center and the doctor about her medications and moving the medication times. Staff B, LPN, UM verified Resident #93 had not been getting her morning medications prior to dialysis. Staff B stated there was no reason why Resident #93 was not getting her medications before she left because she does not leave until 9:40 a.m. Staff B stated the nurses should have discussed with the doctor before today about the resident not getting her morning medication. During an interview on 05/15/2025 at 11:20 a.m. the Director of Nursing (DON) stated residents were to receive the medications as ordered by the doctor. The DON stated the nurse should be calling the doctor about not giving medications, for any reason. The DON stated the nurse should find out what the doctor would like the nurse to do. The DON verified there was no documentation regarding the medications not given for Resident #93. The DON reviewed the progress notes for Resident #93 and found no documentation regarding notifying the doctor of missing medications. The DON verified there was only documentation showing she was on a LOA (Leave of Absence). The DON stated she would expect to see the doctor notified. The DON stated there was a window for medication administration times in the morning. The DON stated she was not sure why Resident #93 did not get the medications before she left for dialysis. The DON stated it would depend on what the doctor said if the nurses were to give the medications before dialysis or not. The DON stated that the issue of medications not administered before dialysis had not come up before. Review of the facility's policy, Medication Administration, dated 07/2023 showed to administer the following according to the principles of medication administration, including the right medication, to the right guest / resident at the right time, and in the right dose and route. Procedure 1. Verify physician's orders for medications to be administered. 10. Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time. Verify / clarify orders as needed prior to administration 13. Verify the following, again, by comparing medication to MAR prior to administering: Correct guest / resident, correct medication, expiration date, dose and dosage form, route and time. Review of the facility's policy, Change in a Resident's Condition or Status, dated October 2014 showed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Procedure: 1. The Nurse Supervisor / Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been among others, a reaction to medication and / or medication error, a need to alter the resident's medical treatment significantly and refusal of treatment, medications or meals (i.e. two (2) or more consecutive times).

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Thirty-three medication opportunities were observed, and two errors were identified for Resident #1 resulting in an error rate of 6.06% Findings included: On 5/14/25 at 8:23 A.M. Staff M, Registered Nurse (RN) was observed administering medication to Resident #1. Prior to the medication administration, Staff M, RN obtained the following vital signs: pulse 95 and blood pressure 115/83. Staff M, RN administered the following medications: -Vitamin D 1000 Units -Tizanidine 2mg, 3 tablets -Oxycodone 10 mg -Methimazole 5 mg -Midodrine HCl 5 mg -Aspirin low dose 81 mg -Omeprazole 20 mg, 2 capsules -Quetiapine 400 mg -Duloxetine HCl 60 mg, 2 capsules -Bupropion SR 100 mg -Pregabalin 150 mg Following the medication administration observation, a review of the physician's orders for Resident #1 revealed Aspirin 325 MG Give 1 tablet by mouth in the morning for anticoagulant and Midodrine HCl 5 mg Give 1 tablet by mouth three times a day for hypotension hold for systolic blood pressure greater than 110. During an interview on 5/14/25 at 12:50 PM, Staff M, RN said, after administering Aspirin 81mg to Resident #1 she realized the wrong dose was given and the Midodrine 5 MG should not have been administered. During an interview on 5/14/25 at 12:50 PM with the Director of Nursing (DON) said nurses are expected to administer medications as ordered. Review of the facility's policy titled, General Dose Preparation and Medication, revised on 11/15/24 showed the following: Applicability procedures relating to general dose preparation and medication administration. Procedure: .Only prepare medications for one resident at a time, using a 3-way-check (i.e., comparing the medication to the MAR [Medication Administration Record] and to the prescription label) .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident If necessary, obtain vital signs During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: . Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record.

Based on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of six residents at risk for elopement with a known history of exit seeking behaviors, and an expressed desire to leave the facility, was provided supervision and services to prevent elopement. Resident #1, on 3/25/2024 at approximately 4:15 p.m., exited the facility without being seen by staff members. Resident #1 exited through an ambulance side (C-Wing) entrance door of the facility, which was equipped with an electromagnetic locking device (a magnetic lock that was unlocked when de-energized and required power to remain locked). Resident #1 was able open the door by punching the security code into the keypad beside the door. She walked out of the door and around the outside of the facility for approximately 13 minutes. She traveled approximately 0.3 miles, along a 2-lane road, across this busy road and continued walking 0.5 miles down a well-traveled 6-lane road for 16 minutes. The staff at the facility did not know Resident #1 was missing. The facility staff neglected to ensure supervision or safety of Resident #1. Resident #1 was seen by a staff member who was on her way back to the facility from escorting another resident to an appointment at approximately 4:40 p.m. Resident #1 was picked up by the facility van with staff members and returned to the facility at 4:45 p.m. on 3/25/2024. The resident was not located for approximately 30 minutes. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 3/25/2024. The findings of Immediate Jeopardy were determined to be removed on 4/10/2024 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: Review of the facility's policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation, dated September 2023 a 15-page document shows: Policy: The center recognizes each resident's right to be free from abuse, neglect, and exploitation (ANE), misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, voluntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. This includes the center's identification of resident's whose personal histories render them at risk for abusing other residents, and development of interventions strategies to prevent occurrences, observing for changes that would trigger abusive behavior, reassessment of the interventions on a regular basis. On page 7, under the section titled Definitions - Neglect is defined in statute 483.5 is the failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This occurs when the center was aware of or should have been aware of, goods or services that the resident(s) required but the center failed to provide them resulting in or may result in physical harm, pain, mental anguish, or emotional distress. This does not mean that all services must be provided by the center but that the center is responsible to ensure that the resident receives the necessary/required services. Goods and services fall into categories. Those categories are structures and processes and individual. On page 9, under the section titled Procedures for Prevention reveals: . The center identifies, correct, and intervenes in situations of alleged abuse, neglect, and exploitation (ANE) and misappropriation of resident property and focuses on the following areas for prevention: . e. supervision of staff . On page 14, under 7. Investigation: A thorough investigation will be conducted, as the center has a zero tolerance for abuse of any form. The DQA/designee will initiate procedures for conducting the investigation. The investigation shall include the following but is not limited to this list: a. The type of allegation (as defined previously in this policy and procedure) may include the following: o Confiscating photographs and/or recordings of residents, with any type of equipment (e.g., cameras, smartphones, and other electronic devices) that contain inappropriate images or record situations such as a resident dressing or undressing, bathing, using the bathroom, having intimate relations, or any situation which breaches the resident's right to privacy. Additionally, under no circumstances should these images or recordings be kept, shared, or disseminated via any type of text, e-mail, image sharing, or social media application. o Confiscating photographs or recordings of a resident that were obtained without the explicit written consent from the resident and/or their family. b. What occurred, when, where and to whom? By whom? Get a physical description or identify the alleged suspect if possible. c. Describe the injury and any treatment. d. Interview witnesses separately; interview caregivers, roommates; get statements; observe/document demeanor; include names, and addresses, emails, and phone numbers of actual witnesses. e. Document cognitive status of victim, resident witnesses; document if credible/believable. f. Obtain signed statement from alleged suspect, if possible. g. Review alleged suspects' past performance and reputation. h. Describe action taken to protect resident. i. Note any bias between alleged suspect and witness. j. If agency personnel, obtain information from agency. k. Use observation of your own and others that may be identified during interviews. l. If sexual abuse is alleged, document regarding physical examination; obtain copy or statement from examiner. m. If neglect is alleged, identify team members, length of time, and outcome to resident. n. If exploitation is alleged, identify items and value. o. Review schedules and assignments. p. Review any medications that may cause the resident to bruise easily or be related to the nature of the injury. q. Review center Policy and Procedures for unsafe techniques used by the team members. r. Review training logs to ensure abuse prevention training. s. Review the nurse's notes and other records for information about the incident. t. Secure all physical evidence. It is important to complete an investigation that allows for decision making that is strongly supported. 8. Corrective Action If an investigation verifies an allegation the center must take appropriate corrective action to protect the residents. The implementation of the corrective action should have oversight and be evaluated for effectiveness. The center Quality Assessment and Assurance Committee shall monitor the reporting and investigation of the alleged violations. All corrective actions will be documented. Acts of abuse directed towards residents are absolutely prohibited. Such acts are cause for disciplinary action, including up to termination of employment, reporting to licensing boards and possible criminal prosecution. Review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 2/25/2024, showed under Section C: Decision Making Capacity, Resident #1 required a surrogate for medical decision making. The transfer form showed under Section S: Physical Function, Resident #1 ambulated with assistance and required no assistive devices to ambulate. The transfer form showed under Section U: Mental/Cognitive Status at Transfer, Resident #1 was alert and disoriented but could follow simple instructions. Review of Resident #1's Admission record showed Resident #1 was admitted to the facility on [DATE] with diagnoses of presence of left artificial shoulder joint, aftercare following joint replacement surgery; presence of cardiac pacemaker; hypertension; anxiety disorder; atherosclerotic heart disease without angina; muscle weakness; and cognitive communication deficit. Review of Resident #1's progress notes dated 2/26/2024 at 1:20 p.m., authored by Staff G, Licensed Practical Nurse (LPN) showed a note under Type: Clinical Admission, under the section titled: Mental Status: Resident #1's level of cognitive impairment: Mild impairment (some confusion). The evaluation showed under Mood and Behavior: Resident is agitated. Resident is anxious. Anxious - Unknown if change in mood. Agitated - Unknown if change in mood. Resident is currently experiencing unwanted behavior(s). Review of Resident #1's progress notes dated 2/26/24 at 4:13 p.m., the Social Service Director wrote, Spoke with case manager from the senior apartments where she lives. The case manager reported that she has been off her medications for a while and is not well mentally. Resident has been confused for a while. Review of Resident #1's Elopement Evaluation dated 2/27/2024 at 7:31 a.m., showed a Score of 6. A score value of 1 or higher indicated at Risk of Elopement. Review of Resident #1's care plan showed a problem area date initiated 2/27/2024, Resident #1 is at risk for elopement related to wandering/desire to go home. Goal: Will not have any unsafe elopement episodes through review, date initiated: 2/28/2024. The resident will not leave facility unattended, date initiated 2/27/2024. The resident's safety will be maintained, date initiated 2/27/2024. Interventions included: Engage resident with purposeful activities date initiated: 2/27/2024. Provide reorientation to surroundings, environment, date initiated 2/27/2024. Resident added to elopement book, date initiated 2/27/2024. 1:1 due to high elopement risk, date initiated 3/25/2024. Review of the Initial Plan of Care Summary dated 2/28/2024, on admission showed under the section titled, Summary of Care Plan Goals, Resident is an Elopement risk of 6 (add to elopement). A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/3/2024, showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 8/15, which indicated moderate impaired cognition. Review of Resident #1's progress notes dated 3/22/2024 at 2:38 p.m., authored by Staff N, Registered Nurse (RN) showed a note Type: COMMUNICATION - with Physician. A telephone call with the Advanced Practiced Registered Nurse (APRN) revealed that resident has had an increase in wandering since her fall on this week. Resident has started wandering into other resident rooms over the past couple of days and today repeatedly got into other residents' beds. Resident is usually easy to redirect but has become belligerent over the course of the day. CNA reports that resident is urinating more frequently today. New order received for UA C&S (urinalysis with a culture and sensitivity) to rule out UTI (urinary tract infection). Review of Resident #1's progress notes dated 3/25/2024 at 5:00 p.m. and authored by the Director of Nursing (DON), showed LATE ENTRY, notified by staff that resident was observed off the property and on the sidewalk that runs in front of the church across the street. A Certified Nursing Assistant (CNA) that was on an escort was returning from an appointment with another resident and observed the resident. CNA immediately came into the facility to notify staff and staff went to bring resident back. Resident was on the sidewalk with her cell phone and her bowl of ice cream she got from Life Enrichment (activities). When asked where she was going, she said to get more ice cream because hers was melted. She was placed on 1:1. When she spoke to another staff member, she reported she was out looking at apartments. Resident #1 was not noted to be in any distress. CNA provided her with a shower. CNA and resident sitting together and conversing. Review of Resident #1's progress notes dated 3/26/2024 at 6:29 p.m., and authored by Staff P, LPN showed Resident discharged with meds and belongings to another Skilled Nursing Facility at 6 pm. Transferred via wheelchair van with one attendant. Vital signs stable. No skin issues noted at this time. Resident has no complaints and is looking forward to transfer. An interview was conducted on 4/8/2024 at 2:37 p.m., with Staff F, CNA. Staff F stated, I was not [Resident #1's] assigned CNA; I am the one who found [Resident #1]. I routinely work on the front hall, so I don't see exit doors, unless I go over to them. I recall [Resident #1] wandering consistently throughout the building. I do not recall her going into the lobby, those are the only doors I can see on my assignment. [Resident #1] would wander the facility, go into other resident rooms, lay down and sleep in other's beds. On the day of the event, 3/25/2024 at approximately 4:45 p.m., I was coming back with another resident from an appointment, in a non-facility van. I just happened to look out the van window and saw a person with a red shirt on. I said to the van driver, 'I think that is our residents'. The van driver refused to stop. As soon as we pulled up to the facility, I ran out of the van to the receptionist and asked her if Resident #1 was here. The receptionist called 'Code Green' which is a missing resident. The business office manager (BOM) overheard me with the receptionist and came out of the office. The BOM and I ran out of the facility to where I had seen the resident. I saw the resident on Seminole Boulevard past the church. When we got to the resident, we waited for the [facility] van to pick us up. Resident #1 was fine, asked us for more ice cream. The van arrived shortly after we reached the resident. We all got in the van and the van driver returned us to the facility. Resident #1 was wearing a short sleeve red t-shirt, shorts, socks, and sneakers. An interview was conducted on 4/8/2024 at 2:08 p.m., with Staff G, LPN who was Resident #1's routine nurse for the 7:00 a.m. to 3:00 p.m. shift. Staff G recalled Resident #1 and stated [she] was very confused, argumentative, always exit seeking. [Resident #1] continuously stated desire to go home and carried a purse. [Resident #1] walked around the whole building, not just this unit. Staff G continued, [Resident #1] would go up to (exit) doors, push on the door. The door would be locked, and [Resident #1] would turn around and continue walking another way. An interview was conducted on 4/8/2024 at 2:15 p.m., with Staff H, CNA. Staff H recalled Resident #1. Staff H stated, [Resident #1] would walk around a lot. I've seen [Resident #1] at the doors trying to exit and would become upset when I would tell her that she should not be there (near the door) and to come over to where I am and go to activities. [Resident #1] would shout at me, 'no one is going to tell me what to do.' An interview was conducted on 4/8/2024 at 2:30 p.m., with Staff I, CNA. Staff I regularly worked with Resident #1 and stated [Resident #1] was very sociable and liked to go to activities. [Resident #1] wandered around the facility on a regular basis, always going into other resident rooms, would lay down in their beds, always carried her purse. [Resident #1] would not stop talking about going home, she definitely did not want to be here. An interview was conducted on 4/9/2024 at 10:30 a.m. with Staff L, CNA. Staff L confirmed being assigned to Resident #1 regularly and was assigned to Resident #1 the evening of the elopement. Staff L stated, she recalled seeing Resident #1 the evening of 3/25/2024 when she came on shift. Staff L stated I thought [Resident #1] was in activities. I did not realize she was gone until after the 'Code Green' was called. An interview was conducted on 4/9/2024 at 3:30 p.m. with Staff E, LPN. Staff E stated [Resident #1] continuously walked around the building. I usually worked here (A Wing), and she lived on the other (C Wing). I would redirect her to go back to her wing. The evening of the elopement, I remember seeing [Resident #1] here on A wing and redirected her over to C wing. I did not know she was missing until the 'Code Green'. I don't recall any door alarms sounding that evening until after [Resident #1] had returned. A telephone interview was conducted on 4/9/2024 at 3:10 p.m., with Resident #1's primary care Advanced Practice Registered Nurse (APRN). The APRN stated he was quite familiar with Resident #1, as he had seen her several times. The APRN stated [Resident #1] was admitted to the hospital for a shoulder replacement, with expectation of discharge to home the same day. The resident had no record of dementia or cognition issues in the medical records prior to the surgery. The anesthesia affected her cognition and caused a decline, as well as an infection developed in the incision. [Resident #1] showed an improvement in the hospital and was discharged to this facility for short term rehabilitation. During the course of treatment, [Resident #1's] cognition was improving 'quite a bit'. Although, she still lacked the safety awareness to make an informed decision regarding her surroundings. The facility did call me regarding the resident's increase in behaviors. The APRN continued to state, an order for a UA was ordered on 3/22/24 and resulted on 3/26/24. He said the results were not of concern, and he suggested the facility follow up with the physician at the new facility. The APRN stated, I was made aware of the situation (elopement) upon my visit the following day, actually they could have told the answering service the night before. A telephone interview was conducted on 4/9/24 at 4:12 p.m. with the Resident Representative (RR) of Resident #1. The RR stated the facility told him Resident #1 went outside. He found out later through the resident's good friend, that Resident #1 walked about a 1/4 mile down the road. The facility did not tell the RR any specifics of the incident. The RR stated he had no problems until he found that out. The RR stated Resident #1 lived on her own prior to admission to the hospital for surgery. The RR stated Resident #1's memory problems had been getting worse prior to entering the facility over the past couple of months. The RR stated Resident #1 had a little case of dementia going on but was not sure if she had been diagnosed with dementia. The RR stated Resident #1 was great when on her meds but 'just isn't right' when she doesn't take them. The RR did not know what medications Resident #1 was routinely on. The facility did not communicate any sort of increase in behaviors. Just stated your mother walked out of the building, and we need to find her a new place within the next 12 hours. A telephone interview was attempted on 4/9/2024 at 3:30 p.m., with Resident #1's friend (RF) who visited her daily. RF did not answer the phone call and a message was left. On 4/11/2024 at 3:02 p.m., the RF returned the call. The RF stated, She visited her friend every day. She stated [Resident #1] went to the hospital for an elective shoulder replacement. The RF stated, [Resident #1] was fine with just a little memory issue prior to surgery. She was supposed to come home right after surgery. Although, she had some sort of reaction to the anesthesia and was in recovery for a while. When [Resident #1] woke up from anesthesia her memory was awful and had not come back yet. She is doing better but not great. The facility really was good to us. [Resident #1] really improved while at the facility. We even went to lunch but that turned out to instigate her desire to go home. She became fixated on going home. After that experience, I did not take her out of the facility. One day I went home and when I returned the next, [Resident #1] was on 1:1. She had a staff companion that did not leave her. The staff member told me she got out. [Resident #1] admitted to me that she left because she wanted to go home. Later that night, [Resident #1's] (family member) called and told me she had eloped. The facility told him [Resident #1] is not safe in their facility and had to find another. The RF stated the facility had found [Resident #1] another place that had a better environment where Resident #1 would be safer. An interview was conducted on 4/8/2024 at 12:20 p.m. with the Director of Quality Assurance (DQA) and DON. The DON and DQA stated, Resident #1 eloped from the facility on 3/25/2024. During the investigation into Resident #1's elopement, the facility developed the following timeline of events through staff interviews and indoor and outdoor video camera observations. The DQA and DON said they determined Resident #1's most likely route determined was: Resident #1 exited the facility via the C wing ambulance entrance. Resident #1 walked around the facility and crossed the road out front of the facility and down the sidewalk of the main road near the facility. They stated, We picked her up with the facility van at the Assisted Living Facility just past the church. The DON stated [Resident #1] refused to tell us how she exited. [Resident #1] stated, I wouldn't be able to get out again if I told you. We (the facility) had a couple of staff ask [Resident #1] the question. [Resident #1] never did tell us. [Name of another state oversight agency] investigator told us [Resident #1] told him she had the code. We (facility) determined [Resident #1] heard the code given to Staff D, CNA when she exited the facility. Review of the facility's investigation showed interviews were conducted with numerous staff members. None of the interviews showed a staff member observed Resident #1 leave the facility. Nor did the interviews reveal a staff member heard the door alarm. Review of the facility's interview with Staff D, Agency CNA showed she was new to the facility and did not know where staff were supposed to enter/exit. Staff D added that there were several codes given to her to get into the different areas of the facility. The interview showed: When Staff D was asked how she was able to leave through the C-Wing side door, she said someone gave her the code when she was leaving. A telephone interview was attempted on 4/9/2024 at 1:20 p.m., 4/10/2024 at 9:05 a.m. and 3:00 p.m. with Staff D, CNA. Staff D, CNA was the agency staff member who exited the facility via the C wing ambulance entrance/exit on 3/25/2024 at 4:11 p.m. The phone call was not returned by Staff D, CNA. During review of the facility's staff interviews the Regional Maintenance Assistant's (RMA) interview showed, the RMA saw Resident #1 in the back of the building but was under the impression Resident #1 was a guest. The facility conducted a root cause analysis of the elopement and determined Resident #1 was able to leave the facility due to unauthorized use of C wing ambulance entry/exit by door, codes being shared with non-staff individuals, and staff failing to recognize signs of elopement as evidence by Resident #1's increased elopement seeking behavior prior to the event. The Regional Maintenance Assistant was unavailable for interview during the time of the survey. On 4/9/2024 at 2:25 p.m., an observation of the route traveled by Resident #1 from the facility to the Assisted Living Facility down the road, showed Resident #1 walked approximately 1 mile away from the facility: Resident #1 exited the C wing entrance/exit door. - Turned right and continued to walk on the sidewalk around the facility passing the Outpatient Therapy entrance. The sidewalk continued toward the back of the facility, passing the back of the Therapy Department. Located here were therapy steps with handrail on each side. - The sidewalk brought you to the back of the facility, near a small building structure and parking lot to the left and the facility to the right. The resident continued to walk off the sidewalk, on broken pavers to the parking lot behind the building near the kitchen entrance/exit and dumpsters. The parking lot was uneven and cracked. - Resident #1 exited the facility property onto the 2-lane road with a speed limit of 35 mph (miles per hour). - She turned right onto a 4-lane road with a large median in the middle, the road enters a large apartment complex, speed limit 35 mph and walks 0.2 miles. - She turned right onto a busy 2-lane subdivision road with a speed limit of 35 mph and Resident #1 was then seen at the A wing ambulance entrance/exit (via camera) sidewalk proceeding to main driveway of the facility. Resident #1 exited the facility parking lot. - She turned right back onto a busy 2-lane subdivision road with a speed limit of 35 mph and walked 0.3 miles, crossed the subdivision street, speed limit of 35 mph (numerous apartments/business'/homes, located on this busy street). - She turned left onto the main highway near the facility for 0.5 miles. This main highway was a heavily traveled road, 6-lanes of traffic (3 each way with a median separating the lanes, plus turn lanes) Speed limit 45 mph. (Photographic Evidence Obtained) On 4/8/24 at 4:05 p.m., an observation was conducted of the main road and the road where the facility was located. The traffic was heavy. Numerous cars were seen on both sides of the main road. Three cars on the main road were waiting to turn onto the road the facility was on. Two cars were waiting to turn onto the main road from the road the facility was located on. (Photographic Evidence Obtained) On 4/9/2024 at 4:00 p.m., an observation was conducted of all the roads Resident #1 had traveled. The roads were highly traveled with busy traffic, uneven terrain, and obstacles like curbs and parking bumpers. (Photographic Evidence Obtained) The weather in [NAME], Florida according to localconditions.com on 3/25/2024 was clear with a temperature range between 78- and 80-degrees F when Resident #1 eloped. An interview was conducted on 4/8/2024 at 12:20 p.m. with the DQA and DON. The DQA stated Resident #1's return to the facility, a skin assessment was performed, and Resident #1 had no injuries from the elopement. The DON stated Resident #1 was in good spirits and requested more ice cream. An interview was conducted on 4/9/2024 at 2:30 p.m. with the NHA. The NHA stated a third-party vendor was contacted on 3/26/2024 to inspect all exit/entry doors for proper function. The third-party vendor completed inspection on 3/29/2024 noting all doors work as they should at this time. During an interview with the DON and the DQA on 4/8/2024 at 12:20 p.m. The DON stated the facility had changed all the door codes. Only staff members being permitted to have the exit codes for the facility. The DON stated all facility staff had in-service education related to elopement and the elopement policy, abuse, neglect, and exploitation, the leave of absence (LOA) policy, and identification of wandering/elopement behaviors, which was started on 3/26/2024 and continue. Facility's immediate actions to remove the Immediate Jeopardy included: - 3/25/2024, Resident #1 was returned to the facility and a body audit was completed with no new findings. Resident #1's PCP was notified, and no new orders were given. - 3/25/2024, Resident #1 was placed on 1:1. - 3/25/2024, an updated elopement risk evaluation was completed for Resident #1 by DON. - 3/25/2024 Resident #1's care plan and Kardex (CNAs key resident information from the care plan) reviewed to include 1:1 supervision. - 3/25/2024 facility wide resident count occurred; all residents were accounted for. - 3/26/24: DON/designee initiated 100% audit of all residents to identify for at risk for wandering. All assessments were completed, one resident was added to the log. Orders, care plans, Kardex, and elopement binders were updated for all identified residents. - 3/26/24: Maintenace completed 100% audit of all entrance/exit doors in the facility to ensure all doors were locked and functioning properly for delayed egress. - 3/26/24: Education initiated for CNA staff related to exit seeking behaviors, place resident on 1:1 then call supervisor. - 3/26/24: Education initiated for all staff related to elopement policy and elopement drill, Elopement risk, utilization of what door staff are to use and no sharing codes with non-staff. - 3/26/24: Education initiated for all staff related to abuse, neglect, and exploitation. - 3/25/2024 Quality Assurance & Performance Improvement (QAPI) implanted. - 3/26/2024 Ad Hoc QAPI, meeting held to review plan. - 4/3/2024 Ad Hoc QAPI, meeting held to review plan and progress. Changes made to plan (codes). - 4/8/2024 Ad Hoc QAPI, meeting held to review plan and progress. Verification of the facility's removal actions was conducted by the survey team on 4/10/2024. Review of facility education was conducted. Staff roster provided by NHA and DON. 142 total staff members. All staff members were educated related to abuse, neglect, and exploitation, elopement policy and protocols (focus on supervision), LOA policy, and elopement risk/exit seeking behaviors and notification, place resident with new/increased exit seeking behaviors on 1:1 notify supervisor, which was completed on 4/3/2024. A sample of two residents at risk for elopement were reviewed for verification of elopement evaluations, care plans/Kardex and pictures present in the elopement books at all locations. Review of the two residents showed elopement evaluations were completed, care plans/Kardex updated, and pictures were present in the electronic medical record and elopement risk books. A sample of seven of the entry/exit doors were reviewed to verify functioning of electronic Mag Lock devices. Review of the seven doors showed proper placement and functioning of electronic Mag Lock devices and code keypads at time of visit. Interviews were conducted with 68 staff members, including 13 Licensed Nurses, 23 CNAs, 6 dietary staff, 7 therapy staff, 6 housekeeping staff, and 13 other staff members. The staff members were able to state that they had been trained and were knowledgeable about the policies and procedures. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 4/10/2024 and the non-compliance was reduced to a scope and severity of D.

Based on observations, interviews, and record review, the facility failed to ensure one resident (#1) of six residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits, lack of safety awareness, and confusion before admission to the facility. The facility staff failed to ensure the supervision and safety of Resident #1 on 3/25/2024 at approximately 4:15 p.m. Resident #1 exited the facility through an ambulance side (C Wing) entrance door that was equipped with an electromagnetic locking device (a magnetic lock that unlocked when de-energized and required power to remain locked). Resident #1 was able open the door by punching the security code into the keypad beside the door. She walked out of the door and around the outside of the facility for approximately 13 minutes and then traveled approximately 0.3 miles along a 2-lane road, crossed this busy road and continued walking 0.5 miles down a well-traveled 6-lane road for 16 minutes. Resident #1 was seen by another staff member who was on the way back to the facility from escorting another resident to an appointment at approximately 4:40 p.m. Resident #1 was picked up by the facility van by staff members and returned to the facility at 4:45 p.m. on 3/25/2024. The resident was not located for approximately 30 minutes. The facility failed to take action to prevent the resident from exiting the facility by not determining and providing the necessary level of supervision, and not distinguishing the resident from visitors of the facility. This failure created a situation that resulted in the likelihood of a worsened condition, serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 3/25/2024. The findings of Immediate Jeopardy were determined to be removed on 4/10/2024 and the severity and scope was reduced to a D after verification of removal of the immediacy. Findings included: An interview was conducted on 4/8/2024 at 2:37 p.m., with Staff F, Certified Nursing Assistant (CNA). Staff F stated, I was not [Resident #1's] assigned CNA; I am the one who found [Resident #1]. I routinely work on the front hall, so I don't see exit doors, unless I go over to them. I recall [Resident #1] wandering consistently throughout the building. I do not recall her going into the lobby, those are the only doors I can see on my assignment. [Resident #1] would wander the facility, go into other resident rooms, lay down and sleep in other's beds. On the day of the event, 3/25/2024 at approximately 4:45 p.m., I was coming back with another resident from an appointment, in a non-facility van. I just happened to look out the van window and saw a person with a red shirt on. I said to the van driver, 'I think that is our resident'. The van driver refused to stop. As soon as we pulled up to the facility, I ran out of the van to the receptionist and asked her if [Resident #1] was here. The receptionist called Code Green, which is a missing resident. The business office manager (BOM) overheard me with the receptionist and came out of the office. The BOM and I ran out of the facility to where I had seen the resident. I saw the resident on Seminole Boulevard past the church. When we got to the resident, we waited for the facility van to pick us up. [Resident #1] was fine, asked us for more ice cream. The van arrived shortly after we reached the resident. We all got on the van and the van returned us to the facility. [Resident #1] was wearing a short sleeve red t-shirt, shorts, socks, and sneakers. Review of Resident #1's progress note, dated 3/25/2024 at 5:00 p.m. and authored by the Director of Nursing (DON), showed: LATE ENTRY, notified by staff that resident was observed off the property and on the sidewalk that runs in front of the church across the street. A Certified Nursing Assistant (CNA) that was on an escort was returning from an appointment with another resident and observed the resident. CNA immediately came into the facility to notify staff and staff went to bring resident back. Resident was on the sidewalk with her cell phone and her bowl of ice cream she got from Life Enrichment [Activities]. When asked where she was going, she said to get more ice cream because hers was melted. She was placed on 1:1. When she spoke to another staff member, she reported she was out looking at apartments. [Resident #1] was not noted to be in any distress. CNA provided her with a shower. CNA and resident sitting together and conversing. On 4/8/24 at 4:05 p.m., an observation was conducted of the main road and the road where the facility was located. The traffic was heavy. Numerous cars were seen on both sides of the main road. Three cars on the main road were waiting to turn onto the road the facility was on. Two cars were waiting to turn onto the main road from the road the facility was located on. (Photographic Evidence Obtained) On 4/9/2024 at 4:00 p.m., an observation was conducted of all the roads Resident #1 had traveled. The roads were highly traveled with busy traffic, uneven terrain, and obstacles like curbs and parking bumpers. (Photographic Evidence Obtained) The weather in [NAME], Florida according to localconditions.com on 3/25/2024 was clear with a temperature range between 78- and 80-degrees F when Resident #1 eloped. Review of Resident #1's progress note, dated 3/22/2024 at 2:38 p.m. and authored by Staff N, Registered Nurse (RN), showed: Type: COMMUNICATION - with Physician. A telephone call with the Advanced Practiced Registered Nurse (APRN) revealed that resident has had an increase in wandering since her fall on this week. Resident has started wandering into other resident rooms over the past couple of days and today repeatedly got into other residents' beds. Resident is usually easy to redirect but has become belligerent over the course of the day. CNA reports that resident is urinating more frequently today. New order received for UA C&S (urinalysis with a culture and sensitivity) to rule out UTI (urinary tract infection). Review of Resident #1's progress note, dated 3/26/2024 at 5:17 p.m. and authored by Staff O, Licensed Practical Nurse (LPN), showed: spoke with APRN, ok to collect urine via straight catheter and send it to lab stat for analysis, this writer was able to obtain urine via straight catheter, no distress to resident, lab called and stat pick up for urine given to technician, lab will be out within 2 hours to pick up specimen. Review of Resident #1's care plan showed a Problem, initiated 2/27/2024, as (Resident #1) is at risk for elopement related to wandering/desire to go home. Goal: Will not have any unsafe elopement episodes through review, initiated: 2/28/2024. The resident will not leave facility unattended, initiated 2/27/2024. The resident's safety will be maintained, initiated 2/27/2024. Interventions included: Engage resident with purposeful activities initiated: 2/27/2024. Provide reorientation to surroundings, environment, initiated 2/27/2024. Resident added to elopement book, initiated 2/27/2024. 1:1 due to high elopement risk, initiated 3/25/2024. Review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 2/25/2024, showed under Section C: Decision Making Capacity, Resident #1 required a surrogate for medical decision making. The transfer form showed under Section S: Physical Function, Resident #1 ambulated with assistance and required no assistive devices to ambulate. The transfer form showed under Section U: Mental/Cognitive Status at Transfer, Resident #1 was alert and disoriented but could follow simple instructions. Review of Resident #1's Admission Record showed Resident #1 was admitted to the facility on [DATE] with diagnoses of presence of left artificial shoulder joint, aftercare following joint replacement surgery; presence of cardiac pacemaker; hypertension; anxiety disorder; atherosclerotic heart disease without angina; muscle weakness; and cognitive communication deficit. Review of Resident #1's progress note, dated 2/26/2024 at 1:20 p.m. and authored by Staff G, LPN, showed a note under Type: Clinical Admission, under the section titled: Mental Status: Resident #1's level of cognitive impairment: Mild impairment (some confusion). The evaluation showed under Mood and Behavior: Resident is agitated. Resident is anxious. Anxious - Unknown if change in mood. Agitated - Unknown if change in mood. Resident is currently experiencing unwanted behavior(s). Review of the Social Service Director's progress note, dated 2/26/24 at 4:13 p.m., revealed, Spoke with case manager from the senior apartments where she lives. The case manager reported that she has been off her medications for a while and is not well mentally. Resident has been confused for a while. Review of Resident #1's Elopement Evaluation, dated 2/27/2024 at 7:31 a.m., showed a score of 6. A score value of 1 or higher indicated at Risk of Elopement. Review of Resident #1's progress note, dated 3/26/2024 at 6:29 p.m. and authored by Staff P, LPN showed: Resident discharged with meds and belongings to another Skilled Nursing Facility at 6 pm. Transferred via wheelchair van with one attendant. Vital signs stable. No skin issues noted at this time. Resident has no complaints and is looking forward to transfer. A review of Resident #1's physician's orders showed the following: - An order dated 2/26/2024 for Buspirone 10 mg (milligrams) by mouth twice a day for diagnosis of anxiety. - An order dated 2/26/2024 for Paroxetine 20 mg by mouth at night for diagnosis of depression. - An order dated 2/27/2024 for Hydroxyzine 25 mg by mouth once daily as needed for diagnosis of anxiety. - An order dated 2/26/2024 for Trihexyphenidyl 5 mg by mouth twice a day for diagnosis of Parkinson's. Review of the Initial Plan of Care Summary, dated 2/28/2024, showed under the section titled, Summary of Care Plan Goals, Resident is an Elopement risk of 6 (add to elopement). A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/3/2024, showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 8/15, which indicated moderate impaired cognition. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the people with Dementia. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in people with dementia. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD.) An interview was conducted on 4/8/2024 at 2:08 p.m. with Staff G, LPN, who was Resident #1's routine nurse for the 7:00 a.m. to 3:00 p.m. shift. Staff G recalled Resident #1 and stated, [she] was very confused, argumentative, always exit seeking. [Resident #1] continuously stated desire to go home and carried a purse. [Resident #1] walked around the whole building, not just this unit. Staff G continued, [Resident #1] would go up to (exit) doors, push on the door. The door would be locked, and [Resident #1] would turn around and continue walking another way. An interview was conducted on 4/8/2024 at 2:15 p.m. with Staff H, CNA. Staff H recalled Resident #1. Staff H stated, [Resident #1] would walk around a lot. I've seen [Resident #1] at the doors trying to exit and would become upset when I would tell her that she should not be there (near the door) and to come over to where I am and go to activities. [Resident #1] would shout at me, 'no one is going to tell me what to do.' An interview was conducted on 4/8/2024 at 2:30 p.m. with Staff I, CNA. Staff I regularly worked with Resident #1 and stated [Resident #1] was very sociable and liked to go to activities. [Resident #1] wandered around the facility on a regular basis, always going into other resident rooms, would lay down in their beds, always carried her purse. [Resident #1] would not stop talking about going home, she definitely did not want to be here. An interview was conducted on 4/8/2024 at 2:50 p.m. with Staff M, CNA. Staff M stated, I remember [Resident #1], mostly nice, always carried her purse, would go in others' (residents) rooms, and was frequently found in their beds. [Resident #1] would try to get out the door but would just walk around when she noticed it would not open. I was not assigned to [Resident #1], but we all would redirect her. An interview was conducted on 4/8/2024 at 3:20 p.m. with Staff K, CNA. Staff K stated, .took care of her sometimes, I was not responsible for her on the day she eloped. I remember working that day. I did not even know [Resident #1] was missing until the Code Green was called. I don't recall hearing an alarm going off, until after the resident's return. Then they (management) started testing the doors. An interview was conducted on 4/9/2024 at 10:30 a.m. with Staff L, CNA. Staff L confirmed being assigned to Resident #1 regularly and was assigned to Resident #1 the evening of the elopement. Staff L stated, she recalled seeing Resident #1 the evening of 3/25/2024 when she came on shift. Staff L stated, I thought [Resident #1] was in activities. I did not realize she was gone until after the Code Green was called. An interview was conducted on 4/9/2024 at 3:30 p.m. with Staff E, LPN. Staff E stated, [Resident #1] continuously walked around the building. I usually worked here (A Wing), and she lived on the other (C Wing). I would redirect her to go back to her wing. The evening of the elopement, I remember seeing [Resident #1] here on A Wing and redirected her over to C Wing. I did not know she was missing until the Code Green. I don't recall any door alarms sounding that evening until after [Resident #1] had returned. A telephone interview was conducted on 4/9/2024 at 3:10 p.m. with Resident #1's primary care APRN. The APRN stated he was quite familiar with Resident #1, as he had seen her several times. The APRN stated, [Resident #1] was admitted to the hospital for a shoulder replacement, with expectation of discharge to home the same day. The resident had no record of dementia or cognition issues in the medical records prior to the surgery. The anesthesia affected her cognition and caused a decline, as well as an infection developed in the incision. [Resident #1] showed an improvement in the hospital and was discharged to this facility for short term rehabilitation. During the course of treatment, [Resident #1's] cognition was improving 'quite a bit'. Although, she still lacked the safety awareness to make an informed decision regarding her surroundings. The facility did call me regarding the resident's increase in behaviors. The APRN continued to state, an order for a UA was ordered on 3/22/24 and resulted on 3/26/24. He said the results were not of concern, and he suggested the facility follow up with the physician at the new facility. The APRN stated, I was made aware of the situation (elopement) upon my visit the following day, actually they could have told the answering service the night before. A telephone interview was conducted on 4/9/24 at 4:12 p.m. with the Resident Representative (RR) of Resident #1. The RR stated the facility told him Resident #1 went outside. He found out later, through the resident's good friend, that Resident #1 walked about a 1/4 mile down the road. The facility did not tell the RR any specifics of the incident. The RR stated he had no problems until he found that out. The RR stated Resident #1 lived on her own prior to admission to the hospital for surgery. The RR stated Resident #1's memory problems had been getting worse prior to entering the facility over the past couple of months. The RR stated Resident #1 had a little case of dementia going on but was not sure if she had been diagnosed with dementia. The RR stated Resident #1 was great when on her meds but just isn't right when she doesn't take them. The RR did not know what medications Resident #1 was routinely on. The facility did not communicate any sort of increase in behaviors. Just stated your mother walked out of the building, and we need to find her a new place within the next 12 hours. A telephone interview was attempted on 4/9/2024 at 3:30 p.m. with Resident #1's friend (RF) who visited her daily. RF did not answer the phone call and a message was left. On 4/11/2024 at 3:02 p.m. the RF returned the call. The RF stated, She visited her friend [Resident #1] every day. She stated [Resident #1] went to the hospital for an elective shoulder replacement. The RF stated, [Resident #1] was fine with just a little memory issue prior to surgery. She was supposed to come home right after surgery. Although, she had some sort of reaction to the anesthesia and was in recovery for a while. When [Resident #1] woke up from anesthesia her memory was awful and had not come back yet. She is doing better, but not great. The facility really was good to us. [Resident #1] really improved while at the facility. We even went to lunch, but that turned out to instigate her desire to go home. She became fixated on going home. After that experience, I did not take her out of the facility. One day I went home and when I returned the next (day), [Resident #1] was on 1:1. She had a staff companion that did not leave her. The staff member told me she got out. [Resident #1] admitted to me that she left because she wanted to go home. Later that night, [Resident #1's] (family member) called and told me she had eloped. The facility told him [Resident #1] is not safe in their facility and had to find another. The RF stated the facility found Resident #1 another place that had a better environment where Resident #1 would be safer. An interview was conducted on 4/8/2024 at 12:20 p.m. with the Director of Quality Assurance (DQA) and DON. The DON and DQA stated, Resident #1 eloped from the facility on 3/25/2024. During the investigation into Resident #1's elopement, the facility developed the following timeline of events through staff interviews and review of the indoor and outdoor video camera observations: - 4:08 p.m. via interview with Staff E, LPN Resident #1 seen inside facility on A Wing and was redirected back to C Wing. - 4:11 p.m. Staff D, CNA was captured by camera footage outside the C Wing camera (ambulance entrance) walking toward parking lot, this is in the front of building. Staff D, CNA was leaving the facility at the end of her shift. - 4:11 p.m. Resident #1 was captured by camera footage inside the building on C Wing by the nurse's station facing the C Wing hall. At the end of this hallway is the exit door to the parking lot (C Wing ambulance entrance/exit). - 4:14 p.m. Resident #1 was captured by camera footage outside the C Wing ambulance entrance facing the parking lot. - 4:16 p.m. Resident #1 was captured by camera footage outside the therapy department's back door, near the outside therapy steps (rear of facility). - 4:18 p.m. Resident #1 was captured by camera footage by the kitchen, near the construction area, witnessed by the Regional Maintenance Director. - 4:19 p.m. Resident #1 was captured by camera footage outside by the dumpster walking toward the rear of the building. - 4:27 p.m. Resident #1 was captured by camera footage outside the A Wing ambulance entrance/exit walking away from the building toward the front parking lot. - 4:27 p.m. Resident #1 was captured by camera footage outside the A Wing ambulance entrance/exit walking on the sidewalk toward the main entrance of the front parking lot. - 4:37 p.m. Staff F, CNA observed Resident #1 on the sidewalk of the main road, past the church on the corner. - 4:40 p.m. Staff F, CNA was captured by camera footage in the portico of the front lobby entrance. - 4:43 p.m. the facility van was captured by camera footage driving away from the facility on 16th Ave. - 4:45 p.m. the facility van was captured by camera footage in the portion of the front lobby entrance. - 4:45 p.m. Resident #1 was back in the facility. The DQA and DON continued to state they determined Resident #1's most likely route determined was: Resident #1 exited the facility via the C Wing ambulance entrance. Resident #1 walked around the facility and crossed the road out front of the facility and down the sidewalk of the main road near the facility. They stated, We picked her up with the facility van at the assisted living facility just past the church. The DON stated, [Resident #1] refused to tell us how she exited. [Resident #1] stated, I wouldn't be able to get out again if I told you. We (the facility) had a couple of staff ask [Resident #1] the question. [Resident #1] never did tell us. The [name of another regulatory agency] investigator told us [Resident #1] told him she had the code. We (facility) determined [Resident #1] heard the code given to [Staff D, CNA] when she exited the facility. During the continued interview with the DQA and DON, the DQA stated Resident #1's return to the facility, a skin assessment was performed, and Resident #1 had no injuries from the elopement. The DON stated Resident #1 was in good spirits and requested more ice cream. The DON stated the facility had changed all the door codes. Only staff members were permitted to have the exit codes for the facility. The DON stated all facility staff had in-service education related to elopement and the elopement policy, abuse, neglect, and exploitation, the leave of absence (LOA) policy, and identification of wandering/elopement behaviors, which was started on 3/26/2024 and continues. On 4/9/2024 at 2:25 p.m. an observation of the route traveled by Resident #1 from the facility to the assisted living facility down the road, showed Resident #1 walked approximately 1 mile away from the facility: - Resident #1 exited the C Wing entrance/exit door. - Turned right and continued to walk on the sidewalk around the facility passing the Outpatient Therapy entrance. The sidewalk continued toward the back of the facility, passing the back of the Therapy Department. Located here were therapy steps with handrail on each side. - The sidewalk brought you to the back of the facility, near a small building structure and parking lot to the left and the facility to the right. The resident continued to walk off the sidewalk, on broken pavers to the parking lot behind the building near the kitchen entrance/exit and dumpsters. The parking lot was uneven and cracked. - Resident #1 exited the facility property onto the 2-lane road with a speed limit of 35 mph (miles per hour). - She turned right onto a 4-lane road with a large median in the middle, the road enters a large apartment complex, speed limit of 35 mph, and walked 0.2 miles. - She turned right onto a busy 2-lane subdivision road with a speed limit of 35 mph and Resident #1 was then seen at the A Wing ambulance entrance/exit (via camera) sidewalk proceeding to the main driveway of the facility. Resident #1 exited the facility parking lot. - She turned right back onto a busy 2-lane subdivision road with a speed limit of 35 mph and walked 0.3 miles, crossed the subdivision street, speed limit of 35 mph (numerous apartments/business'/homes, located on this busy street). - She turned left onto the main highway near the facility for 0.5 miles. This main highway was a heavily traveled road, 6-lanes of traffic (3 each way with a median separating the lanes, plus turn lanes), speed limit of 45 mph. (Photographic Evidence Obtained) Review of the facility's investigation showed interviews were conducted with numerous staff members. None of the interviews showed a staff member observed Resident #1 leave the facility. Nor did the interviews reveal a staff member heard the door alarm. Review of the facility's interview with Staff D, CNA showed she was new to the facility and did not know where staff were supposed to enter/exit. Staff D, CNA added that there were several codes that were given to her to get into the different areas of the facility. The interview showed: When [Staff D, CNA] asked how she was able leave through the C-Wing side door, she said someone gave her the code when she was leaving. The interview reviewed showed Staff D, CNA was not able to tell the name of the person given her the code nor if she was a center's staff member. During review of the facility's staff interviews the Regional Maintenance Assistant's (RMA) interview showed, the RMA saw Resident #1 in the back of the building but was under the impression Resident #1 was a guest. The facility conducted a root cause analysis of the elopement and determined Resident #1 was able to leave the facility due to unauthorized use of C Wing ambulance entry/exit by door, codes being shared with non-staff individuals, and staff failing to recognize signs of elopement as evidence by Resident #1's increased elopement seeking behavior prior to the event. A telephone interview was attempted on 4/9/2024 at 1:20 p.m., 4/10/2024 at 9:05 a.m. and 3:00 p.m. with Staff D, CNA. Staff D, CNA was the agency staff member who exited the facility via the C wing ambulance entrance/exit on 3/25/2024 at 4:11 p.m. The phone call was not returned by Staff D, CNA. The Regional Maintenance Director was unavailable for interview during the time of the survey. An interview was conducted on 4/9/2024 at 2:30 p.m. with the Nursing Home Administrator (NHA). The NHA stated a third-party vendor was contacted on 3/26/2024 to inspect all exit/entry doors to check for proper function. The third-party vendor completed the inspection on 3/29/2024, noting all doors work as they should at this time. Review of the facility's policy and procedure titled, Risk Management - Elopement, dated November 2022, showed: Policy: It is the policy of this center that an elopement risk evaluation is completed upon admission. All guest/residents will be evaluated for elopement risk upon admission, quarterly, and with the change in condition or significant event. An elopement risk identification notebook will be maintained at key locations in the center to alert team members of those guests/residents deemed at risk for elopement. Procedure: 1. If the guest/resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Center team members will provide supervision and engage the guest/resident as needed to minimize wandering or exit seeking behavior according to the plan of care. 2. Guests/residents identified at risk for elopement will have a Resident Identification Sheet completed, and a copy of a recent color photograph of the guest/resident will be attached. a. The photo should be taken when the guest/resident is awake and dressed for the day. b. Pertinent information will be included to assist the search activities. 3. The completed Resident Identification Sheet will be added to the Elopement Risk notebooks located at each Nurse's Station and at the front desk. The DQA will be responsible for maintaining and updating the Elopement Risk Notebooks. Review of the facility's policy and procedure titled, Risk Management - Missing Guest/Resident, dated November 2022, showed: Policy: The purpose of this policy is to clearly define guest/resident elopement and to provide guidance and management of all reports of missing guest/residents. Definition of Elopement: Elopement occurs when a guest/resident leaves the premises or a safe area without the center's knowledge and supervision, if necessary. If any guest/resident should leave the premises at any time without following the center's procedures for a voluntary leave, the missing guest/resident procedure should begin immediately. If a guest/resident attempts to leave the center or a safe area and a team member is aware of the occurrence/visualizes the guest/resident and immediately accompanies the guest/resident and returns the guest/resident to the center, it will not be considered an elopement, as the guest/resident in this case was always under a team member supervision. If an alert guest/resident leaves the property without signing out, they will be encouraged to return to the center and will be reeducated on the center's Leave of Absence (LOA) process. Repeated failures to follow the center's process for LOA may lead to formal discharge notice. Procedure: 1. It is the responsibility of all team members to report any guest/resident attempting to leave the premises, or suspected of being missing, to the Charged Nurse immediately who will then notify others (see below). 2. Should a team member observe a guest/resident leaving the premises without authorization, he/she should: a. Attempt to prevent the departure. b. Obtain assistance from other team members in the immediate vicinity, if necessary. c. Instruct other team members to inform Charge Nurse or Director of Clinical Services that a guest/resident is attempting to leave or has left the premises. d. Be courteous in preventing the departure and in returning the guest/resident to the center. e. If possible, the team member should stay with the guest/resident until additional help responds if the guest/resident is refusing to return to the center. 3. Upon return of the guest/resident to the center, the director of Clinical Services or Charge Nurse should: a. Examine the guest/resident for injuries. b. Contact the attending physician and report what happened. c. Contact the guest/resident's legal representative and inform them of the incident. d. Make appropriate notification in the resident's medical record. 4. Should a team member discover the guest/resident is missing from the center he/she should: a. Determine if the guest/resident is out on an authorized leave or pass. If not: b. Make center announcement designating missing guest/resident. c. Begin timeline to document pertinent information. d. Make a thorough search of the building(s) and premises. Including all closed doors, bathrooms, common spaces, offices, and outdoor areas. If not located: e. Notify the Executive Director and Director of Clinical Services. f. Notify the Police Department. g. Notify the guest/resident's legal representative. h. Notify the attending physician. i. If necessary, notify volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). j. Provide search teams with guest/resident identification information, including photo. k. Make extension extensive search of surrounding area. l. Conduct head count to ensure all other guest/residents are accounted for in the center. m. Attempt to identify exit door to assist with search and to identify if door/alarm were functioning properly. n. Check all other exit doors to ensure proper functioning alarms. 5. Upon return of the guest/resident to the center, the Director of Clinical Services and Charge Nurse should: a. Examine the gas resident for injuries. b. Contact the attending physician and report findings and conditions of the guest/resid [TRUNCATED]

Based on observation, interview, and medical record review, the facility failed to ensure that two (#24 and #66) out of two sampled residents had a Preadmission Screening and Resident Review (PASRR) that reflected an accurate screen decision-making for mental illness or suspected mental illness. Findings included: 1. On 03/28/2023 at 9:49 a.m. Resident # 24 was observed from her door way sitting up in her bed eating her breakfast. She looked at the open door and stated outloud help me. Resident #24 waved her hand that gestured to come here, and as she was approached she stated move me over it hurts to sit on my bottom. A nurse was in the hallway and was informed of the resident need, he stated she will say that over and over, she does it all the time. The nurse and a certified nursing assistant assisted the resident. Resident #24 thanked staff over and over again, as she stated she was no longer in pain. Medical record review of the Admission Record form revealed Resident #24 had resided at the facility for over five years and is geriatric in age. The form contained diagnosis information that listed schizoaffecive disorder, bipolar type and major depressive disorder. Review of Psychiatric Nurse Practitioner Progress note dated 04/06/2022 revealed Problem (Prob.): Her condition today does not allow (Resident #24 name) to describe her symptoms. EXAM: (resident #24 name) condition today does not allow cognition to be formally tested . DIAGNOSES: The following Diagnoses are based on currently available information and may change as additional information becomes available: Unspecified dementia without behavioral disturbance, Psychotic disorder with delusions due to known physiological condition. Review of Preadmission Screening and Resident Review (PASRR) dated 02/19/2018 revealed Section I: PASRR Screen Decision-Making A. MI or suspected MI (check all that apply) areas checked: Anxiety Disorder, and other: Depression. Findings are based on: Documented History and Medications. Areas that were not checked as medical record reflected included Bipolar Disorder, Psychotic Disorder and Schizoaffective disorder. On 03/29/23 at 1:20 p.m. and interview was conducted with the Social Worker Assistant (SWA) and Social Worker Director (SWD). They revealed they were unaware if a resident is diagnosed after admission with a new serious mental illness (SMI) the current PASRR screen would reviewed for accuracy. The SWD stated I would need to look at the facility policy. On 03/29/2023 at 1:30 p.m. an interview was conducted with the Regional Director of Clinical Services who confirmed she was aware of the focus on PASRR accuracy, and said the company has already started to look into them. At 2:00 p.m. the Regional Director of Clinical Services said the facility did not have a policy or procedure in place for PASRR. She stated we follow what is regulated by the state. 41773 2. Review of Resident #66's medical record was conducted. The admission record revealed an initial admitted [DATE] and diagnoses that included, dementia and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed active diagnoses that included non-Alzheimer's dementia and anxiety disorder. Review of active physician orders revealed Resident #66 was prescribed Alprazolam for anxiety/agitation two times a day, Remeron at bedtime for depression, and Mirtazapine at bedtime for depression. The PASRR Level I document for Resident #66's admission, dated 11/25/22, had no diagnoses documented in Section I, all questions in Section II were documented as no, and section IV was documented as No diagnosis or suspicion of SMI (serious mental illness) or ID (intellectual disability) indicated. Level II PASRR evaluation not required. There were no additional PASARR documents in Resident #66's medical record. Interview with the facility Administrator (NHA) on 3/30/23 at 10:04 a.m. confirmed there was no facility policy related PASRR and no procedure in place for ensuring PASRRs were update. She reported that with the changes of who was qualified to complete PASRRs, they had a break in their system and need for updates wasn't getting triggered since their Social Services staff did not have the required qualifications to complete them.

Based on record review, observation, interviews, manufacturer's instructions, and policy review the facility did not ensure insulin orders were clarified to ensure correct dosage administration for two (#1, #3) of five sampled residents and the facility failed to ensure insulin was given correctly by priming the needle prior to administering insulin for one (#4) of four residents observed during medication administration. Resident #3 was admitted on [DATE] with orders for 0.3 ml of insulin subcutaneously (SC) twice a day. The order was not clarified by facility nurses and the resident was administered 3 units of insulin twice a day instead of the correct dose of 30 units twice a day. On 2/28/19, Resident #3 was sent to the hospital with a blood sugar of 567. Findings included: 1. Resident #3 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of the hospital orders listed on the Discharge Summary of Care, dated 2/26/19, revealed insulin (NPH) [MEDICATION NAME] 0.3 ml SC twice a day to be continued after discharge from the hospital A review of the facility's physician's orders [REDACTED]. Continue with meds from hospital. This nurse let ARNP know that resident is on insulin twice a day 3 ml at the time. This nurse told ARNP that accuchecks were put in to be done before giving insulin so we would know if insulin had to be adjusted. ARNP was fine with that. Further record review revealed a physician order, dated 2/27/19, for [MEDICATION NAME] N suspension 100 unit/ml inject 3 unit subcutaneously two times a day. A review of the (MONTH) 2019 MAR (medication administration record) showed the nurses signed the PM dose for the 0.3 ml order on 2/26/19 and on 2/27/19 at 6:00 AM. The PM dose on 2/27/19 was signed for 3 units, and the 2/28/19 AM and PM dose were also signed for 3 units. The resident's blood sugars were running in the low 100s to low 300s during this time. A nurse's note dated 2/28/19 at 19:03 (7:03 PM) showed: Patient blood sugar was 358 at 5 pm and at this time blood sugar is 567. Called MD and wife called Nurses station and wants patient to go to hospital. Spoke with .ARNP new order to send to hospital to EVAL/TX (evaluation/treatment). The next Nursing Note dated 2/28/19 at 21:40 (9:40 PM) revealed: EMS arrived and patient left facility at 730 pm via stretcher . During an interview, on 4/4/19 at 1:24 p.m., the Consultant Pharmacist stated she would not comment on the order because she had only been working with the contracted pharmacy and the facility for a month. An interview was attempted with the ARNP, who verified the original insulin order, but she could not be reached. On 4/4/19 at 2:03 p.m., a telephone interview was conducted with the attending physician. He stated he was covering for the ARNP because she was on vacation. He also would not comment on the order stating that he was driving and didn't have access to the resident's record. He said he recalled the circumstance but not much more. He could not say if he was the one notified about the insulin error since he didn't have access to the chart. The physician did not call back to provide any additional information. On 4/4/19 at 2:10 p.m., a telephone interview was conducted with Staff F, the Licensed Practical Nurse (LPN) who verified Resident #3's orders upon admission on 2/26/19. She said she was the supervisor the night the resident was sent to the hospital. She said she also admitted Resident #3, and she called the ARNP and told her he had orders. She did not ask for clarification of the insulin order. She said the Director of Nursing (DON) called the pharmacy and asked what the conversion was, and she said it was 3 units. The DON told her to change the order to 3 units. She said it was unusual to have orders from the hospital written in milliliters rather than units. She said the next time she came to work, the DON told her the pharmacy made a mistake and his order should have been 30 units. She said no one called the doctor to clarify the order. She said she was terminated and was told it was because she didn't follow facility policy. On 4/4/19 at 2:59 p.m., a telephone interview was conducted with Staff H, an agency LPN, who administered the 6 PM dose of 3 units on 2/28/19. She said Resident #3's blood sugar was high so she called the doctor to get him sent out. She said the resident's family was very upset. She was not aware of the discrepancy with his insulin order. She said she gave him what was ordered. 2. Resident #1 was admitted to the facility with a relevant [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. A review of the MAR (medication administration record) for the month of (MONTH) 2019 showed the order was signed on the 9th, 10th, and 11th for [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) Inject 5 ml subcutaneously one time a day related to Type 2 Diabetes mellitus (DM2) without complications. Review of written orders in the medical record showed an order dated 3/8/2019 for [MEDICATION NAME] 5 mg (milligrams) SQ (subcutaneous) once daily in AM. The order was signed by a nurse and the ARNP (Advanced Registered Nurse Practitioner). Additional review of the physician's orders [REDACTED]. A review of a nurse's note signed by Staff A, LPN, dated 3/11/2019, showed MD called to clarify [MEDICATION NAME] order that was written for 5 mg, entered 5 ml, BID (two times a day) for DM2. MD clarified 5 units BID subcutaneously. 5 units given this am. Order clarified in PCC (electronic medical record). In an interview with Staff B, LPN agency on 4/5/2019 at 12:15 p.m. he said the doctor put the order in for 5 mg. The doctor put the order in and she doesn't know how to use PCC. He said he called her about it. It was after 11:00 p.m. He said he told the the 11-7 p.m. supervisor the order was wrong. She used his computer and put the order in for 5 ml under his name. He was working the 3-11 shift and he had asked for her help because he was behind. He said the the Risk Manager called him and said they took his name off the order and the issue was resolved. The supervisor set him up by using his computer. He was concerned for Resident #1's high blood sugar. He said he does not feel comfortable working there. He was trying to leave, and it was his first time in the facility. The supervisor was very unhelpful. He said he didn't take the order from the physician, the supervisor did. He said he was not going to put in an order he didn't take. In a follow up interview with the Consultant Pharmacist at 3:16 p.m. on 4/4/2019, she said the process for order entry in the electronic medical record is the nurse would type in the new order and then send it to the pharmacy through PCC. The pharmacy would double check the order and address any changes that need to be made. At that point pharmacy sends it back to the facility through PCC. She said that Physicians orders for insulin are in units per dose. She confirmed that if the order comes in milliliters it should be clarified. She said you wouldn't see insulin ordered in milliliters. She said she doesn't know what happens inside the pharmacy. They accept the order, make the correction, and send it back through PCC. There is always a pharmacist on duty. She also said she was looking at the orders and for Resident #1 she didn't do the review until the 17th. Resident #1's order came on the 9th. The nurse contacted the physician and changed it. So it was already corrected by the time she did her review on the 17th of March. On 4/4/2019 at 3:54 p.m., an interview was conducted with the Director of Nursing (DON) . She said as nurses we are all taught to give insulin in units, not milliliters. She said they did education with staff. She said they did an audit of all the people that were on insulin, and educated the staff that we only take insulin orders in units. If there's any question we verify the order with the physician. On 4/5/2019 at 8:53 a.m., another follow up interview was conducted with the Consultant Pharmacist. She said Resident #1's insulin order was a transcription error. At 12:40 p.m. on 4/5/2019, a follow up interview was conducted with the DON. She said in the standup meeting they review new residents. We looked at the order and saw it was not in units. She said she asked Staff A if she clarified Resident #1's orders and she said she did. The order was written on the 8th. It was on a weekend. She said they reviewed it Monday morning. That's when Staff A said she clarified it. Review of internal facility documentation showed a document in large, bold, black font which read INSULIN ORDERS: URGENT AND MANDATORY. 1. Never take an insulin order in ML's or MGs or anything other than units 2. Read all orders to Dr. line by line upon admission or readmission from hospital 3. If there is an insulin order in anything except units call doctor immediately for clarification, no matter what time of day or night 4. Do not leave this for the next person, you saw it you own it and will be held accountable for it The in-service/training session/team meeting attendance form attached to it, dated 3/11/2019 contained only 14 nurse signatures. A review of the active employee roster revealed a total of 30 licensed nurses. At 11:47 a.m. on 4/5/2019. an interview was conducted with Staff C, LPN. She said she received an in-service this morning. She said you have to notify the physician of incorrect insulin orders, and get verification for the order. At 11:49 a.m. on 4/5/2019, an interview was conducted with Staff D, RN. She said she doesn't recall getting any inservicing for entering insulin orders. She said she was self taught on order entry. She said you have to call the doctor and go over the orders. They come from the hospital with their medication orders and we confirm them with the physician. On 4/5/2019 at 11:58 a.m., in an interview with Staff E, LPN he said he did not have any inservicing on insulin orders. He said he would have to verify the order with the doctor, whether its through the doctor's visit or by phone. A review of the in-service training session dated 3/11/19 revealed no signatures of training on INSULIN ORDERS: URGENT AND MANDATORY by Staff C, D, and E. A review of the Policy and Procedure titled physician's orders [REDACTED]. Procedure: Routine orders: A nurse may accept a telephone order from the physician, physician assistant, or nurse practitioner (as per state statute). The order shall be repeated back to the physician, PA, or ARNP for his/her verbal confirmation. The order is transcribed to all appropriate areas (MAR, TAR, etc.) or electronic equivalent. The nurse shall sign off the orders on completion or verification of transcription. The clinical nurse will notify the pharmacy per pharmacy policy by telephoning, faxing, or completing the order electronically. 3. Resident #4 was admitted to the facility with a relevant [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED].>On 4/4/2019 at 1:03 p.m. an observation was conducted with Staff A, LPN during insulin administration. Staff A removed a Humalog Mix 75/25 insulin pen from the medication cart and turned the dial to 20 units. She did not prime the insulin with 2 units. She placed the insulin pen along with a new needle and alcohol preps on a foam plate. She knocked on Resident #4's door, entered her bedroom and placed the foam plate with supplies on the bedside table. Then Staff A went to the bathroom and washed her hands in the sink. Next she put on a pair of gloves. Then she removed the cap from the insulin pen and cleaned the top with an alcohol prep pad, after she identified Resident #4. Next Staff A removed the seal form the needle and attached the needle to the end of the insulin pen. After that she cleaned Resident #4's left lower abdomen with an alcohol prep. Then she placed the needle against the area and pushed the injection button at the end. Then she removed the needle from the insulin pen, recapped the pen, and disposed of the needle in a Sharps container. Then she returned the insulin pen to a bag and placed it in the medication cart. On 4/4/2019 at 1:24 p.m. an interview was conducted with the Consultant Pharmacist. She said insulin pens don't need to be primed every time. She said they can prime it for a new pen but as far as she has read it's not a requirement. In a follow up interview with the Consultant Pharmacist at 3:16 p.m. on 4/4/2019, she said she looked up the [MEDICATION NAME]pen and anytime they change the needle the pen does need to be primed with 2 units. On 4/5/2019 at 8:53 a.m. another follow up interview was conducted with the Consultant Pharmacist. She stated the insulin pens are more of an education issue. Nurses need to be more educated. She said it (referring to priming) was not written clearly in the manufacturer's own literature. She stated, it does not make a significant difference in the dose they are getting. On 4/5/2019 at 12:40 p.m., the DON stated she was not aware the [MEDICATION NAME] had to be primed. Review of the manufacturer's instruction for [MEDICATION NAME], undated, showed the following information: (page 2) A Guide to using your [MEDICATION NAME] Remove the cap Pull off the pen cap and wipe the rubber [MEDICATION NAME] with an alcohol swab. Attach the new needle Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps. Prime your pen Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Select your dose. Turn the dose selector to select the number of units you need to inject.

Based on observation of the resident at meals, review of the medical record, and interview with facility staff, the facility failed to ensure that weight changes were monitored and interventions implemented for two (#39, #150 ) of four residents identified in Stage II for investigation of significant weight loss, out of a total facility census of 105 residents receiving oral intake and at risk for weight loss.. When weight changes or planned interventions are not monitored, significant weight losses can occur, which can impact resident's overall status. Findings include: 1. Observation of resident # 39 at breakfast on 07/25/13 at 8:15 a.m. revealed a small man in an electric wheelchair in the unit's day room. His right arm and hand were noted to be contracted, bent at the elbow and at the wrist, with the wrist brought up to the resident's chin and the hand curled into itself. He received his breakfast on a divided dish (to assist with self feeding). It consisted of scrambled eggs with ham and cheese and a piece of coffee cake. He had hot cereal in a separate bowl. There was an eight ounce carton of 2% milk, and a four ounce cup of orange juice, both of which had straws. Even though the aides verbally encouraged him to eat his breakfast, by 8:45 a.m. he had left the room with only consuming approximately 50% of his eggs and none of the coffee cake or hot cereal. He had consumed all of the juice but none of the milk. At lunch on 07/25/13 at 12:30 p.m. the resident was observed in the main dining room. He was eating independently with his left hand, from a divided dish. He had been served meat loaf, macaroni and cheese, broccoli, and chocolate pudding for dessert. By the end of the meal he had eaten almost all of the meat loaf and half of the macaroni and cheese and the chocolate pudding, and none of broccoli. He had consumed both of his beverages - a six ounce cup of water and a cup of coffee. Review of the resident's diet slips revealed the use of 2% milk, rather than the higher calorie whole milk - should the resident choose to drink the milk. There was no indication of the use of fortified foods, which would add calorie dense foods to his meals. Review of the nursing aides documentation of meal intakes for the month of June 2013 revealed for the thirty days of three meals each (90 opportunities to document intake) 27 opportunities either had no documentation of intake or documentation indicating the resident had eaten 25% or less of the meal. Review of the nursing aides documentation of meal intakes for the month of July 2013 revealed for the twenty five days of three meals each reviewed (75 opportunities to document intake), 30 opportunities either had no documentation of intake or documentation indicating the resident had eaten 25% or less of the meal. Review of the June and July 2013 physician order [REDACTED]. Review of his Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of quarterly Nutrition Follow up notes written by the Dietary Manager, dated 11/26/12, 04/15/13, and 05/24/13, revealed the resident's diet order, including supplement remained the same since November 2012. These three notes documented the resident's weight at 105.1, 105.9, and 106.2 pounds. The 05/24/13 note documented that the resident was at 82% of ideal body weight. Labs were documented for all three notes and indicated low hemoglobin, hematocrit, and [MEDICATION NAME]. The notes also documented the need for assist at meals and in May 2013, it was documented that the resident's ability to feed himself had declined. The Registered Dietitian (RD) had written a follow up note on 11/07/12. Interview with the RD on 07/26/13 at approximately 9:15 a.m., confirmed that the November note was the last note she had written for resident #39. On 06/13/13 an Interdisciplinary Care Plan Conference was held for this resident. Comments written by the team included a weight from 06/04/13 of 102.5 (even though there was a weight on the weight record from 06/11/13 of 98.2) and a BMI of 18. (A BMI - body mass index of 18.5 or less is considered underweight.) Review of the document Standards of Care Meetings revealed monthly weights had been documented for resident #39 and listed the weight on 05/15/13 as 106.2 lbs, on 06/12/13 as 96.6 lbs and on 07/17/13 as 94.6. There was no oversight to this documentation of a 10 lb weight loss from May to June and then an additional 2 lb weight loss from June to July, 2013, as neither the Dietary Manager or Registered Dietitian had been made aware or had acted on this downward weight trend and significant weight loss. Review of the care plan for the problem of Altered Nutrition revealed the facility identified inadequate intake, a mechanically altered diet and a history of abnormal labs as all playing a role. Goals were planned to include consuming 75% of meals, with no weight loss. Interventions included weights until stable. Review of the care plan for the problem of Resident has ADL (activities of daily living) Self Care Deficit did not identify the resident's level of self performance or staff assistance with eating. Identified as a problem for this resident was 'at risk of developing complications associated with decreased ADL self performance.' An approach was listed to 'screen and provide treatments as ordered.' Review of the medical record revealed a screen conducted by the Occupational Therapy department on 06/03/13. Review of the screening form revealed nursing had referred the resident related to a change in ability to feed self, as 'patient needs more assist with self feeding per aide interviews and documentation.' The therapist documented that he had observed the resident using the standard equipment for feeding with the left hand, that the resident had done well and that he had educated the staff not to assist until the resident had tried himself. The therapist concluded that additional therapy was not warranted as the resident demonstrated the ability to self feed. Neither the Altered Nutrition or ADL Self Care Deficit care plan was updated with this information. Review of the Annual Weight and Vital Sign Record for resident #39 revealed on 01/04/13 the resident weighed 106.3 and on 01/16/13 the resident weighed 107.5 lbs. On 02/05/13 the resident weighed 106.6, on 03/05/13 the resident weighed 101.6 and on 03/12/13 the resident weighed 101.8 lbs. On 04/07/13 the resident weighed 105.9 lbs and on 04/17/13 106.4 lbs. On 05/02/13 the resident weighed 106.2 lbs and on 06/04/13 the resident weighed 102.5 lbs. Weekly weights were taken in June and on 06/11/13 the resident weighed 98.2, on 06/18/13 the resident weighed 96.6 lbs, and on 06/25/13 the resident weighed 94.2 lbs. On 07/02/13 the resident weighed 94.6 lbs and on 07/10/13 the resident weighed 94.8 lbs. Resident #39 lost 11.7 lbs in six months, from January until July 2013, which is 11%. Resident #39 lost 7.9 lbs in one month, from June to July 2013, which is 7.7%. (Significant weight loss is determined at 5% in one month and 10% in six months - resident #39 had sustained significant weight loss at one and six months.) Interviews with the Director of Nurses (DON), the dietary manager and the RD on 07/26/13 beginning at 9:00 a.m. revealed the process for monitoring the residents' weights. The DON reported that the restorative aides weigh the residents every month or every week as determined by the interdisciplinary team. The DON reported that having the same staff member weigh residents provides for more consistency in the weights. It was reported that the DON reviews all weights and documents them on the weight forms located in the resident's medical records. The DON reported that she provides the weights to the dietary manager and the RD for review as well. The Dietary Manager (DM) reported that he inputs the weights into a computer software program which calculates the percentage lost or gained, and he provides that report to the RD. The DM reported that he would refer residents to the RD if he noted a weight change or the RD could identify the change in weight and follow the resident, as she received the report as well. Resident #39's weight changes were reviewed during this interview and it was agreed that the resident had had very stable weights from January through May, but then lost weight and remained for one month at the lower weight. The DON confirmed that she had not identified and referred the significant weight loss to either the DM or the RD, having thought by the consistent July weights of more than 10 lbs below his usual weight of 106 lbs, one of them would have picked up on the weight loss trend exhibited by this resident. Review of the resident's medical record during this interview revealed that the resident had been sent to the hospital on [DATE] for a few hours due to 'no urine output' and returned on antibiotics. Labs that had been drawn while at the hospital on [DATE] were reviewed during the meeting and noted to be within normal limits. Both the DM and RD confirmed that they had not reviewed those labs prior to the meeting on 07/26/13. Both the DM and RD confirmed, through medical record review during the meeting, that neither of them had identified and then assessed resident #39 as having had a significant weight loss. They also confirmed that the resident's diet order had remained the same since November 2012, without new interventions to assist with the resident's downward weight trend. 2. Resident #150 was observed during lunch on 07/23/13 and 07/25/13. Review of her diet slip indicated the resident was to receive a magic cup at lunch and dinner. Observation of her served meal did not include the magic cup at either of the observed meals. Interview with aide L, who was assisting the resident with the meal, reported that the resident liked sweets. She said that the resident would probably eat most of the pudding that the resident had received for dessert. The aide shook her head no when asked if the resident usually received a magic cup with her meals. Review of this resident's medical record revealed a Nutrition Evaluation dated 05/13/13 which identified the diet order as Pureed diet with Nectar thick liquids. The resident was at 85% of her ideal body weight for height per the evaluation and a high calorie, high protein supplement appropriate for a resident on thickened liquids had begun on 05/09/13, per the Evaluation. The supplement, Menu Magic Cup (MMC) would be provided to the resident at lunch and dinner with her meal. Review of follow up notes by the Registered Dietitian, dated 06/12/13 and 07/17/13, included the use of the MMC twice a day which the resident was documented as "tolerating". Review of the resident's care plan, with dates for review of 05/13/13, 05/27/13, and 06/04/13, for "Altered Nutrition - at risk for unavoidable weight changes with a history of weight loss." The intervention of an additional supplement, identified as the MMC BID (twice a day) was listed. Review of the Medication and Treatment Administration Records for July 2013 did not reveal that intake of the magic cup was documented. The nursing aides documentation also did not allow for documenting whether the resident consumed the planned intervention for the resident's significant weight loss.