Every finding on record at Palm Garden of Tampa

Based on observations, interviews, and record review the facility did not ensure medications were stored in accordance with current professional standards for 4 of 6 medication carts and 1 of 2 medication storage rooms.Findings included:1. An observation on 5/5/2026 at 2:31 P.M. of the C Wing Medication Room revealed:1 box of bisacodyl suppositories in the cabinet above the sink that expired 2/20261 syringe of Aplisol Tuberculin in the refrigerator that expired 5/2/20262. An observation on 5/5/2026 at 2:37 P.M. of the C Wing Team 2 Medication Cart revealed: 1 medication card for hydrochlorothiazide that expired 4/30/20261 medication card for hydrochlorothiazide that expired 3/31/20261 medication card for ondansetron that expired 2/28/20263. An observation on 5/5/2026 at 3:00 P.M. of the A Wing Team 3 Medication Cart revealed: 8 expired insulin pens6 boxes of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution opened and did not have an expiration date.2 boxes of bisacodyl suppositories that expired on 4/2025 and 2/20261 Trelegy inhaler opened on 3/21/2026 and did not have an expiration date1 Trelegy inhaler opened and did not have an expiration date1 medication card for Tamsulosin HCL that expired 3/31/20261 medication card for tizanidine that expired 9/30/20251 medication card for tizanidine that expired 4/30/20261 medication card for ondansetron that expired 3/31/20264. An observation on 5/6/2026 at 2:05 P.M. of the A Wing Team 1 Medication Cart revealed:1 medication card for ondansetron that expired 4/30/20265. An observation on 5/6/2026 at 3:40 P.M. of the A Wing Team 2 Medication Cart revealed:2 boxes of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution opened and did not have an expiration date.1 box of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution opened on 12/5/2025 and did not have an expiration date.1 box of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution opened on 1/22/2026 and did not have an expiration date.An interview on 5/5/2026 at 2:40 P.M. regarding C Wing Team 2 Medication Cart with Staff M, Registered Nurse (RN) was conducted. Staff M, RN said the unit managers are responsible for maintaining the medication carts. Staff M, RN said the medications had expired and should have been discarded.An interview on 5/5/2026 at 3:15 P.M. regarding A Wing Team 3 Medication Cart with Staff N, Licensed Practical Nurse (LPN) was conducted. Staff N, LPN said the floor nurses are responsible for maintaining the medication carts. Staff N, LPN said she was not aware the insulin pens were expired. Staff N, LPN said the boxes of inhaled solutions should have been dated when opened and have an expiration date. Staff N, LPN said the medications cards should have been removed when the medication was discontinued.An interview on 5/7/2026 at 1:35 P.M. with the Director of Nursing (DON) was conducted. The DON said he could not understand why A Wing Team 3 Medication Cart contained so many expired medications. The DON said the expired insulins found were unacceptable. The DON said the residents medications were discontinued or expired should have been removed and sent back to the pharmacy. The DON said the nurses and unit managers are responsible for cleaning out the medication carts. The DON said all the medications found should have been discarded; there should not have been any expired medications found in any of the medication carts.A review of a policy effective 12/01/2007, titled, Storage and Expiration Dating of Medications revealed the procedure of the facility was: 5: Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened; 5.1: Facility staff may record the calculated expiration date based on date opening on the primary medication container; 5.3: If a multi-dose injectable medication has been opened.the vial should be dated and discarded within 28 days.

The facility did not ensure one (Resident #11) was provided with adequate pain management out of three residents sampled for pain management.On 5/04/26 at 2:09 p.m., an interview was conducted with Resident #11. Resident #11 stated she had a Leave of Absence (LOA) from the facility the morning of 4/24/26 and returned to the facility on the morning of 4/26/26. On 4/24/26, Resident #11 stated she was provided one Oxycodone tablet when she left on LOA. She stated her nurse told her there was only one tablet remaining in her prescription. She stated she experienced pain while on LOA, and one tablet was not enough to address the pain. Resident #11 stated a family member provided her with Tylenol, but it was not enough for her pain. Resident #11 stated she was not offered an option to delay her LOA until her prescription was refilled.Review of Resident #11's admission record revealed the resident was admitted on [DATE]. The record includes diagnoses not limited to unspecified abnormalities of gait and mobility, ulcerative colitis, hydronephrosis with renal and ureteral calculous obstruction, and chronic obstructive pulmonary disease.Review of Resident #11's active orders revealed the following:-Oxycodone hydrochloride (HCL) oral tablet 5 milligrams: Give 1 tablet by mouth every 4 hours as needed for pain immediate release tablet.-May leave with the resident representative or escort.Review of Resident #11's care plan dated 3/25/26 revealed the following:-Resident has potential for pain related to history of back pain with sciatica, with an intervention to Administer and monitor for effectiveness and for possible side effects of pain medication.Review of Resident #11's Medication Administration Record (MAR) dated April 2026 revealed Oxycodone HCL Oral Tablet was administered as needed when the resident's pain levels were marked as a 5 or higher, which indicates moderate to severe pain. On 4/24/26, Resident #11's pain level was a 6, which indicates moderate pain.On 5/06/26 at 2:00 p.m., an interview was conducted with Staff I, Licensed Practical Nurse (LPN). She stated when Resident #11 went on LOA on 4/24/26, there was only one oxycodone tablet remaining in her order. She stated if the resident ran out of medication while on LOA, the resident's family is expected to manage the resident's pain until the resident returns to the facility.On 5/06/26 at 4:12 p.m., an interview was conducted with Staff L, Registered Nurse (RN). She stated when a resident goes on LOA, she would review the resident's orders to confirm how many medications the resident will need. If she identified a resident was running low on a medication, she stated she would recommend that the Resident delays the LOA until the medications are received.On 5/07/26 at 8:51 a.m., during an interview was conducted with Staff J, LPN. She stated when a resident goes on LOA, she checks their medication administration record (MAR) and orders to determine how much medication the resident will need while they are away from the facility. She stated if she determined a resident would not have enough medications while on LOA, she would check the medication storage system. She would also contact the pharmacy and stat the medication order. She stated she would speak with the resident and their family and encourage them to delay leaving the facility until the medication arrived.On 5/07/26 at 9:20 a.m., an interview was conducted with Staff K, Unit Manager, LPN. She stated if a resident is going on LOA, she would check their MAR to determine if they have enough medication for the month and send the resident the medications they need while on LOA. She stated she would make a copy of the medication list for the family. She stated if she determined a resident would not have enough medication while on LOA, she would check the medication storage system to see if the medication was in stock. If the medication is not available, she would contact the pharmacy and ask if they could stat the medication order.On 5/7/26 at 12:15 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated he was not aware that the resident did not have enough pain medication when she went on LOA. If a resident who is going on LOA does not have enough medication, he stated his expectation would be for the nurse to ask the resident/resident representative if they could delay going on LOA or call the physician to see if there is an alternative medication that could be provided. He stated the facility has an Emergency Drug Kit (EDK) that could also be checked for additional medications if needed.A review of the facility's policy titled Resident's Leave of absence effective date March 2018 with a revision date of August 2024, revealed: Procedure 5. The center will provide the resident/ resident representative the number of doses of the resident's physician ordered medication to cover the period of time that the resident will be absent from the center.

Based on observations, record review and interviews, the facility failed to ensure one of two residents (#105) who were diagnosed with Post Traumatic Stress Disorder (PTSD), were assessed and monitored for specific trauma related behaviors and failed to ensure care staff were aware of resident #105 having PTSD, and having knowledge of what specific trauma based behaviors to look out for. Findings included: On 5/6/2026 at 9:15 a.m. and multiple other observations Resident 105's room was approached and entered after knocking. During all times observed, Resident #105 was observed in her room lying flat under the covers and presenting with her eyes closed. The call light was placed within her reach. Resident was noted sleeping most to all of the days observed and did not appear to be up out from her bed. Interviews with passing staff members had confirmed Resident #105 likes to stay in her room but did not know the reasons of why she did not spend time out from her room much. Resident #105 did resident in a room with a roommate and there did not appear to be any concerns between them. On 5/6/2026 at 10:00 a.m. the facility's Nursing Home Administrator (NHA) and the Director of Nursing (DON) provided a facility matrix document, which was created for completion on 5/6/2026, for review. The facility matrix document revealed Resident #105 was checked as having Post Traumatic Stress Disorder (PTSD).On 5/6/2026 at 11:30 a.m. an interview with Staff F, Licensed Practical Nurse/Unit Manager (LPN/UM), confirmed he was not aware of Resident #105 having any types of behaviors and was unaware if she had a diagnosis of Post Traumatic Stress Disorder (PTSD). A review of Resident #105's medical record revealed she was admitted to the facility on [DATE] and with a readmission from the hospital on [DATE]. Review of the advance directives revealed Resident #105 had a responsible party for making her medical decisions. Further review of medical record to include the diagnosis sheet, revealed diagnoses to include but not limited to: Alzheimer's, Seizures, and PTSD (order date 7/25/2024).Review of the current month (5/2026) physician's order sheet, revealed Resident #105 had orders to receive general psychiatric services with an order date 11/5/2024.Review of the most current Quarterly Minimum Data Set (MDS) assessment, dated 4/12/2026 revealed; (Cognition/Brief Interview Mental Status or BIMS score of 00 - 15, which indicated Resident #105 could not speak related to her medical care and services); (Behaviors - none documented as exhibited during timeframe reviewed); (Active diagnosis - Traumatic Brain Injury - YES, Post Traumatic Stress Disorder - YES). Review of the nurse progress notes dated from 3/1/2026 through to 5/7/2026 did not have any documentation revealing Resident #105 presenting with PTSD, nor were there any documentation to support what types of specific trauma behaviors Resident #105 presents or presented with. Review of the last psychological care visits/assessments, revealed;-Psychological care visit 3/23/2026 revealed Resident #105 was seen as a follow up visit. Pt. admitted to this facility on 11/5/2024. She has a past medical history of PTSD, anxiety, Alzheimer's, and long term resident at facility. Assessment plan: Post Traumatic Stress Disorder, chronic, monitoring for PTSD symptoms, assessing their severity, and tracking the individual's progress over time. Check for the following signs: intrusive thoughts, avoidance, hyperarousal, changes in behavior, need for medicinal therapy.-Psychological care visit 4/20/2026 revealed Resident #105 was seen as a follow up visit. Pt. admitted to this facility on 11/5/2024. She has a past medical history of PTSD, anxiety, Alzheimer's, and long term resident at facility. Assessment plan: . monitoring for PTSD symptoms, assessing their severity, and tracking the individual's progress over time. Check for the following signs: intrusive thoughts, avoidance, hyperarousal, changes in behavior, need for medicinal therapy.Review of the current care plans with a next review date 7/19/2026 revealed the following but not limited to:Seizure Disorder related to close head injury, with interventions in place as reviewed. It was determined through review of the entire care plan care plan problem areas, there were no problem areas with goals and interventions related to Resident #105 with diagnosis of PTSD.It was also determined there was no additional documentation within Resident #105's medical record to support what type of trauma/PTSD she had, nor did the record indicate what types of specific triggered behaviors to monitor for in order to reduce those specific behaviors. On 5/6/2026 at 12:20 p.m. an interview with Resident #105's assigned Certified Nursing Assistant (CNA) Staff A, revealed she has provide care for Resident #105 and she normally likes to stay in her room and does have family visit her often. Staff A was unaware if Resident #105 received psychiatrc services but did confirm Resident #105 had not presented with any type of behaviors other then from time to time declining care and services. Staff A stated she did not believe Resident #105 had any type of behaviors, or at least she had not shown any. Staff further confirmed she was not aware Resident #105 had a past history of trauma/PTSD, nor was she ever trained/inserviced on how to handle residents with trauma/PTSD. Staff A confirmed she would not know what specific trauma/PTSD behaviors to monitor for. Staff A continued to state if residents on her assignment had behaviors, she would know by review of the care plan KARDEX, and the nurses would tell her of those specific behaviors. Staff A again confirmed nursing had not made her aware of Resident having trauma/PTSD, nor were those types of diagnoses listed on her care plan KARDEX. On 5/6/2026 at 12:55 p.m. an interview with Resident #105's 7-3 shift assigned Licensed Practical Nurse Staff D, stated she normally works the 100 unit, but has worked the 200 unit with Resident #105 enough times to know her and what her care needs were. Staff D confirmed Resident #105 had not presented with any types of behaviors in the past other than the occasional swatting away when not wanting care, and routinely wanting to stay in her room and in bed. Staff D stated the few times Resident #105 had swatted away, she (Staff D) will leave and give her space and come back another time to try again. Staff D stated she was not aware of any other types of behaviors from Resident #105. Staff D was unaware of Resident #105 having any type of past trauma/PTSD and if she had those types of behaviors/diagnoses, she would find them on the care plans and within her medical record. Staff D was unaware Resident #105 did have a diagnosis of PTD, and it was also listed in her MDS assessments. Staff D stated that during daily stand up meetings, and shift pass down meetings, this diagnosis and trauma behaviors should have then been passed down to her for her knowledge and to further monitor and assess for. Staff D confirmed she would not know what types of specific trauma related behaviors to look out for as par of her PTSD diagnosis. Further, Staff D revealed she had not been trained or inserviced with specific training on how to identify and handle residents who present with PTSD. Staff D was unaware if there were any psych. assessments/visits that spoke to Resident #105 having past trauma/PTSD.On 5/7/2026 at 9:45 a.m. an interview with the Care Plan Coordinators, Staff H and G both revealed they assess residents and implement care plan problem areas with specific goals and interventions based on quarterly Interdisciplinary Team IDT assessments, as well as their own assessments. Staff H and G were both aware of Resident #105 and her general care and diagnoses. Staff H and G were at first not aware Resident #105 had diagnosis of past trauma/PTSD and then reviewed the medical record to then confirm she did, based on the diagnoses sheet and the most current MDS assessment dated [DATE]. Staff H and G stated they then remembered when Resident #105's son was present as part of care plan meetings, he had mentioned Resident #105 had been in a war, but was not sure which war, nor when. Staff H and G confirmed they had documented past diagnoses of trauma/PTSD in the MDS assessments, and then confirmed the past Psychological care visits/assessments did mention Resident #105 had PTSD, but they never developed a care plan with that problem area to show goals and interventions. Staff H and G confirmed they both missed it and that Resident #105 should have been care planned with specific trauma behaviors for PTSD, and what to look out for so staff can deescalate and continue to reduce triggers for those types of specific behaviors. Staff H and G both confirmed at this time there were no assessments, behavior monitoring plans to support Resident #105's possible behaviors to past trauma/PTSD. Staff H and G were not sure how staff are or were trained on what things (behaviors) to look out for when it comes to residents who present with past trauma/PTSD. On 5/7/2026 at 8:20 a.m. an interview with the Social Service Director revealed she was aware of Resident #105's care and services and that her family do visit routinely and are part of care plan meetings. The Social Service Director was not aware Resident #105 had trauma/PTSD and after reviewing the medical record she did confirm there was a medical diagnosis of PTSD. The Social Service Director was not aware Resident #105 was presenting with any type of behaviors that would be triggered from trauma/PTSD. The Social Service Director confirmed Resident #105 was being seen by psych. services but was not aware if psych. services was monitoring/assessing for trauma/PTSD. The Social Service Director further confirmed during the admission process, the facility should evaluate and go over past diagnoses with family, decision makers to make sure they appropriately develop care plans with problem areas, goals and interventions to reduce specific triggers that create trauma/PTSD behaviors. She further confirmed this was not done with regards to Resident #105.It was found through observations on 5/4/2026 through to 5/7/2026 and interviews with direct care staff who care for Resident #105, staff were not aware Resident #105 had any past trauma/PTSD and further did not know of what types of specific triggers to look out for to reduce the risk for trauma/PTSD behaviors. On 5/7/2026 at 12:00 p.m., Nursing Home Administrator provided the Trauma-Informed Care Comprehensive Care Plans policy and procedure, with an effective date of 10/20222 for review. The policy stated; It is the practice of the center to develop and implement a comprehensive person-centered care plan to ensure each guest/resident receives care and services that account for experiences and address the needs of trauma survivors by minimizing triggers and /or re - traumatization while helping them to attain and maintain the highest practicable psycho-social well-being. The interventions in the guest/resident's care plan will reflect the individual guest/resident's needs and preferences and align with the guest/resident's personal experiences and circumstances including previous traumatic events. The Process section of the policy stated; The center will use a multi-prong approach to identify each guest/resident's history of trauma including the Minimum Date Set (MDS), guest/resident interview, family/responsible party information, the physician's history & physical, and other interdisciplinary assessment tools.The interdisciplinary team will work collaboratively with the guest/resident, responsible party and/or family members if appropriate other mental health professionals to develop a comprehensive person - centered care plan that identifies previous trauma, and potential triggers which could re-traumatize the guest/resident and individualized interventions to reduce or eliminate re-traumatization. Definitions:Trauma - Results from an event, or serious of events or a set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, emotional, or spiritual well-being. Trauma-informed care - is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma- informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in guests/residents and incorporates knowledge about trauma into care plans to avoid re-traumatization.Post Traumatic Stress Disorder (PTSD - is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.Triggers - is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. Examples of Trauma (not an all-inclusive list): Military Veterans, Survivors of natural or man-made disasters, Holocaust survivors, Individuals with a history of physical, sexual, or emotional abuse, Victims of violent crimes, Homelessness, Traumatic loss of a loved one, Previous imprisonment, Sexual abuse/rape, Ethic/Racial genocide.Examples of common triggers (most triggers are very individualized): Feeling confined or claustrophobic - fear of small confined spaces, Loud noises/Alarms/Loud voices, Bright light and/or flashing lights, [NAME] of privacy, Sounds, smells, and even physical touch, Certain sights or objects associated with previous abuse.Care Planning to Address Past Trauma:The interdisciplinary team will attempt to identify triggers which may re-traumatize the guest/resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the guest/resident.Trigger specific interventions will identify ways to decrease the guest/resident's exposure to triggers.Trigger specific interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, anxiety and/or behaviors.Trigger specific interventions will be developed to recognize the guest/resident's need for respect, independence with making their own decisions, access to information, and their involvement in the development of the comprehensive plan of care.Individualized interventions will include appropriate mental health services and/or support groups if guest/resident express a desire to participate in such groups.

Based on observations, interviews and record review, the facility failed to develop care plans with goals and interventions for two residents (#52 and #105) of 2 residents reviewed for care plans, related to: 1. Not developing care plan to reflect Resident #105 who had a diagnosis of Post Traumatic Stress Disorder (PTSD); 2. Facility and Resident #52 having a video camera facing from the hallway into the room and the need for two or more staff members to enter the resident's room for any reason to include care and services.Findings included:1.On 5/4/2026 during a record review for Resident #105, it was found she was admitted with a diagnosis of Post Traumatic Stress Disorder (PTSD) with an onset date of 7/25/2024, Alzheimer's, and seizures.Review of Resident #105's medical record revealed she was admitted to the facility on [DATE] and with a readmission from the hospital on [DATE]. Review of the advance directives revealed Resident #105 had a responsible party for making her medical decisions. Review of the current month (5/2026) physician's order sheet revealed Resident #105 had orders to receive general psychiatric services with an order date 11/5/2024.Review of the most current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status or BIMS score of 00/15, which indicated Resident #105 was not cognitively intact; (Behaviors - none documented as exhibited during timeframe reviewed); (Active diagnosis - Traumatic Brain Injury - YES, Post Traumatic Stress Disorder - YES). Review of the nurse progress notes dated from 3/1/2026 through to 5/7/2026 did not have any documentation revealing Resident #105 presenting with PTSD, nor were there any documentation to support what types of specific trauma behaviors Resident #105 presents or presented with.Review of the last psychological care visits/assessments revealed;Psychological care visit 3/23/2026 revealed Resident #105 was seen as a follow up visit. Pt. admitted to this facility on 11/5/2024. She has a past medical history of PTSD, anxiety, Alzheimer's, and long term resident at facility. Assessment plan: Post Traumatic Stress Disorder, chronic, monitoring for PTSD symptoms, assessing their severity, and tracking the individual's progress over time. Check for the following signs: intrusive thoughts, avoidance, hyperarousal, changes in behavior, need for medicinal therapy.Psychological care visit 4/20/2026 revealed Resident #105 was seen as a follow up visit. Pt. admitted to this facility on 11/5/2024. She has a past medical history of PTSD, anxiety, Alzheimer's, and long term resident at facility. Assessment plan: . monitoring for PTSD symptoms, assessing their severity, and tracking the individual's progress over time. Check for the following signs: intrusive thoughts, avoidance, hyperarousal, changes in behavior, need for medicinal therapy.Review of the current care plans with a next review date 7/19/2026 revealed the following but not limited to:Seizure Disorder related to close head injury, with interventions in place as reviewed.It was determined through review of the entire care plan care plan problem areas, there were no problem areas with goals and interventions related to Resident #105 with diagnosis of PTSD.On 5/6/2026 at 12:55 p.m. an interview with Resident #105's 7-3 shift assigned nurse Staff D, Licensed Practical Nurse (LPN), stated she normally works the 100 unit, but has worked the 200 unit with Resident #105 enough times to know her and what her care needs were. Staff D was not aware Resident #105 had any past trauma/PTSD, nor knew if she had been presenting with any type of behaviors to support any past trauma. Staff D confirmed there were no current care plans that reflected problem areas with goals and interventions related to trauma/PTSD. She confirmed after reviewing the chart, there was a documented diagnosis of PTSD.On 5/7/2026 at 9:45 a.m. an interview with the Care Plan Coordinators, Staff H, LPN and Staff G, Registered Nurse (RN) both revealed they assess residents and implement care plan problem areas with specific goals and interventions based on quarterly Interdisciplinary Team (IDT) assessments, as well as their own assessments. Staff H and Staff G were both aware of Resident #105 and her general care and diagnoses. Staff H and Staff G were at first not aware Resident #105 had diagnosis of past trauma/PTSD and then reviewed the medical record to then confirm she did, based on the diagnoses sheet and the most current MDS assessment dated [DATE]. Staff H and Staff G stated they then remembered when Resident #105's son was present as part of care plan meetings, he had mentioned Resident #105 had been in a war, but was not sure which war, nor when. Staff H and Staff G confirmed they had documented past diagnoses of trauma/PTSD in the MDS assessments and then confirmed the past Psychological care visits/assessments did mention Resident #105 had PTSD, but they never developed a care plan with that problem area to show goals and interventions. Staff H and Staff G confirmed they both missed it and that Resident #105 should have been care planned with specific trauma behaviors for PTSD, and what to look out for so staff can de-escalate and continue to reduce triggers for those types of specific behaviors. Staff H and Staff G both confirmed at this time there were no assessments, and no behavior monitoring plans to support Resident #105's possible behaviors to past trauma/PTSD. Staff H and Staff G were not sure how staff are or were trained on what things (behaviors) to look out for when it comes to residents who present with past trauma/PTSD. On 5/7/2026 at 8:20 a.m. an interview with the Social Service Director revealed she was aware of Resident #105's care and services and that her family do visit routinely and are part of care plan meetings. The Social Service Director was not aware Resident #105 had trauma/PTSD and after reviewing the medical record she did confirm there was a medical diagnosis of PTSD. The Social Service Director was not aware Resident #105 was presenting with any type of behaviors that would be triggered from trauma/PTSD. The Social Service Director confirmed Resident #105 was being seen by psych. services but was not aware if psych. services was monitoring/assessing for trauma/PTSD. The Social Service Director further confirmed during the admission process, the facility should evaluate and go over past diagnoses with family, decision makers to make sure they appropriately develop care plans with problem areas, goals and interventions to reduce specific triggers that create trauma/PTSD behaviors. She further confirmed this was not done with regards to Resident #105. 2.On 5/4/2026 at 10:40 a.m. Resident #52 was lying in bed , bed in low position , resident appears to be clean and free of odors . Resident #52 was not presenting with any behavior's pains or discomfort; resident resides in private room .On 5/4/2026 at 1:15 p.m. an interview with Resident #52's Power of Attorney (POA) reports the only issue she has had in the past is them doing oral care with a pink sponge and she wanted oral care done with special wipes. She advised she wanted a camera in the room so that she can verify the care Resident #52 is getting.On 5/4/2026 at 2:00 p.m. an observation was made of a wall mounted video camera in the main hallway on the wall across from Resident #52's room. Further observations revealed the camera was pointed directly into Resident #52's room and the resident would be within view of that camera. Resident #52's POA had stated she and the Nursing Home Administrator agreed on the use of the video cameraOn 5/6/2026 at 8:45 a.m. Resident #52 appears to be asleep in bed, the camera has now been repositioned to face end of the hall.A review of resident # 52's medical record revealed she was admitted to the facility 11/26/2025 with diagnoses to include but not limited to , adult failure to thrive, dementia in other diseases classified elsewhere, moderate, with mood disturbance.Review of the most current annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status or BIMS score 99 /15, indicating resident #52 is not cognitively intact.Review of the most current Care plans with a next review date 6/27/2026 did not have a problem area with goals and interventions related to video monitoring.On 5/6/2026 at 12:21 p.m. an interview with Staff A, Certified Nursing Assistant (CNA) was conducted. Staff A stated Resident #52 has not been combative with others, is a total care resident and always needs 2 staff members to go in the room. Staff A stated they put up a [NAME] in front of the room about 6 months ago and does not know why the [NAME] was moved on 5/6/2026. Staff A stated she has not received any education on the video camera.On 5/6/2026 at 1:00 p.m. an interview with Staff D, LPN, was conducted. She stated they always go in with 2 staff members and has never been informed of camera/video system within the facility. Staff D stated no education was provided.On 5/6/2026 at 2:46 p.m. an interview with Staff E , assistant social worker was conducted. Staff E stated during Resident #52's care plan meeting they have not discussed the video camera.On 5/7/2026 at 9:45 a.m. an interview with MDS care plan team Staff G, RN and Staff H, LPN was conducted. Staff G and Staff H both stated they were not told about the video monitoring being used for Resident #52; if they had known, they would have updated the resident's care plan to include the new safety measures and interventions. Staff G and Staff H both reported they did not know staff were expected to always enter the resident's room in pairs (2 staff members) and if they had known about this expectation, they would have updated the resident's care plan to reflect that two staff members should always be present when entering the room.On 5/7/2026 at 10:51 a.m. an interview with Nursing Home Administrator was conducted. The NHA stated that the resident's family is very involved in her care and visits almost every day. The NHA stated that staff often provide care with two staff members present. She stated the resident was not formally care planned to always require two staff members during care. The NHA also reported the care plan team did not know the camera was being used.Review of the policy, Person center comprehensive care plan, with an effective date October 2022 for review revealed the following: Policy: Overview: The guideline outlines the practice of developing and implementing a person-centered comprehensive care plan that addresses the guest/resident's nursing, medical, physical, mental, and psychosocial needs. The plan is designed to include measurable objectives and timeframes to meet individual preferences and goals. Key Points: The interdisciplinary team reviews and revises the care plan after each assessment, including both comprehensive and quarterly reviews, and when there are significant changes in the guest/resident's condition. Collaboration between the interdisciplinary team, guest/resident, responsible party, and/or family members is essential to ensure the care plan reflects personal preferences, goals, and objectives. The care plan is based on the Minimum Data Set (MDS) to assess clinical condition, cognitive and functional status, and use of services. Care Plan Must Address: Services to attain or maintain the guest/resident's highest practicable physical, mental, and psychosocial well-being. Trauma-informed care/interventions/potential triggers. The center will invite the guest/resident and representative to attend the care planning meetings and participate in the care planning process. The center will offer care plan meetings based on the preference of the guest/resident and representative. Attendance will be documented in the medical record.

Based on observations, interviews, and record review the facility did not ensure specialized call light was within reach for one (Resident #3) of four residents sampled for call lights.Findings included:An observation on 5/4/2026 at 10:58 A.M. of Resident #3 revealed she was lying in bed; a red call light with a press pad was on the right side of the residents bed; not resting on Resident #3's pillow next to her head. Upon request Resident #3 could not reach her call light and press the pad.An observation on 5/6/2026 at 10:36 A.M. of Resident #3 revealed the call light was on the right side of the residents bed; not resting on Resident #3's pillow next to her head. Upon request Resident #3 could not reach her call light and press the pad.An observation and interview on 5/6/2026 at 3:58 P.M. of Resident #3 revealed the call light lying on the right side of the mattress and out of reach. Resident #3 said she was uncomfortable and wanted the fan placed on her.A record review of Resident #3's admission record showed he was admitted to the facility on [DATE] with diagnoses including but not limited hemiplegia and hemiparesis following cerebral infarction, quadriplegia, contractures of right and left hand. A review of Resident #3's minimum data set (MDS), section C, dated 4/11/2026 revealed a brief interview for mental status (BIMS) score of 13 indicating cognitively intact. A review of Resident #3's MDS section GG, dated 4/11/2026 revealed her functional limitation in range of motion included impairments on both sides of her upper and lower extremities, and dependent with all self-care needs as well as mobility. A review of Resident #3's care plan initiated on 12/30/2025 contained a focus of potential for pain r/t (related to) contractures with an intervention that included wedge call light within reach of head.An interview on 5/6/2026 at 4:02 P.M. with Staff O, Certified Nursing Assistant (CNA) was conducted. Staff O, CNA said Resident #3 usually had the call light next to her head so she could press it with her cheek. Staff O, CNA said if Resident #3's call light was not within reach he does not know Resident #3 would ask for assistance.An interview on 5/6/2026 at 4:06 P.M. with Staff P, CNA, was conducted. Staff P, CNA said the call light should be by Resident #3's head for her to utilize.An interview on 5/6/2026 at 5:25 P.M. with the Executive Director (ED) was conducted. The ED said the expectation is the call light should be within the resident's reach at all time. The ED said the facility does not have a policy regarding call lights, but the staff should adhere to the call light policy.

Based on observations, interviews, and record review the facility did not provide therapy services needed for one (Resident #38) of one resident sampled for specialized rehabilitative services .Findings included:An observation on 5/4/2026 at 9:15 A.M., Resident #38 was sleeping; her breakfast tray was on the bedside table and was not eatenAn observation on 5/4/2026 at 1:00 P.M., Resident #38 was sleeping: her lunch tray was on the bedside table and was not eaten.A record review of Resident #38's evaluations revealed a referral to therapy was made on 4/30/2026 related to a decline in self-feeding.A review of Resident #38's quarterly minimum data set (MDS) dated [DATE] and 1/27/2026 revealed Resident #38 required supervision or touching assistance with eating.A review of Resident #38's annual MDS dated [DATE] revealed Resident #38 required supervision or touching assistance with eating.A review of Resident #38's culinary profile valuation dated 4/30/2026 revealed Resident #38's average meal intake was 25% and her eating assistance was independent.A review of Resident #38's progress notes revealed a communication note dated 4/30/2026, Note Text: Family is reporting resident having a difficult time self-feeding and requests a ST referral. Referral submitted on resident's behalf.A review of Resident #38's weight history revealed the following weights with a weight loss of 7.23% in thirty-four days:5/6/2026 124.4 pounds 4/2/2026 134.1 pounds An interview on 5/6/2026 at 10:55 A.M. with the Speech Language Pathologist (SLP) was conducted. The SLP said Resident #38 was eating and she had not had a decline in self-feeding. The SLP said Resident #38 requires full setup from the staff. The SLP said Resident #38 had not experienced weight loss and she was not seeing Resident #38 for therapy services. The SLP said the Director of Rehab (DOR) would receive notification of a therapy referral and then notify the SLP.An interview on 5/6/2026 at 11:43 A.M. with the DOR was conducted. The DOR said Resident #38 was recently discharged from physical therapy on 2/11/2026 and speech therapy on 3/23/2026. The DOR said nursing staff would send a speech therapy referral to the therapy department through point click care and then the therapy department would evaluate Resident #38 within 24-48 hours after the referral was received. The DOR said there had been a therapy referral for weight loss by the Director of Nursing (DON) completed on 5/6/2026. The DOR said there had been another therapy referral placed on 4/30/2026 for a decline in self-feeding. The DOR stated, apparently there is one on 4/30/2026 that I did not see, she was not screened because I am just seeing it now.An interview on 5/7/2026 at 1:57 P.M. with the DON was conducted. The DON said the therapy department should have evaluated Resident #38 within 24-48 hours of receiving the referral. The DON said that when nursing staff requests a referral from therapy, the nursing staff should have also notified the therapy department.A review of a policy revised on 10/13/2023 titled, Therapy Screening Process indicates the procedure was: .Therapists will perform screening: Upon request or referral by any individual (member of the nursing team, resident's family, facility staff member, or physician) and upon any changes in the resident's condition.the following are some examples of the type of changes that should be monitored for appropriate therapy referrals: g. decreased ability to perform activity of daily living (ADL): eating, dressing, and/or bathing.

Based on interviews and record review, the facility did not ensure medication recommendations were reviewed for one (Resident #4) of five residents sampled for unnecessary medications.Findings included:A review of Resident #4's pharmacy recommendations revealed:3/12/2026-3/13/2026 - Not signed by attending physician or medical directorHydrocodone-Acetaminophen tablet 10-325mg - Give 1 tablet by mouth every 6 hours as needed for pain. Recommendation: Please reduce PRN (as needed) analgesic therapy until the lowest effective dose is achieved.A review of Resident #4's active physician orders as of 5/6/2026 revealed:Hydrocodone-Acetaminophen Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for PainA review of Resident #4's pharmacy recommendations revealed:2/13/2026-2/14/2026 - Not signed by attending physician or medical directorInsulin Glargine Solostar SQ (subcutaneously) - Inject 10-unit SQ in the morning. Recommendations: Please adjust the diabetes regimen by initiating Metformin 250mg BID (twice a day) with food and increasing insulin glargine to 15 units SQ in the morning.A review of Resident #4's active physician orders as of 5/6/2026 revealed:Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously in the morning for DM (diabetes mellulitis)No order (discontinued or active) for Metformin foundAn interview on 5/7/2026 at 9:27 A.M. with the Pharmacist was conducted. The Pharmacist said the pain medication frequency should have been changed. The Pharmacist said he would expect Resident #4's attending physician to call him if there were any questions regarding his recommendations.An interview on 5/7/2026 at 9:39 A.M. with Resident #4's Attending Physician (AP) was conducted. The AP said if the pharmacy recommendations are not placed in his folder for review, then the recommendations would not get reviewed. The AP said he expects the facility to place pharmacy recommendations for him in the folder at each nursing station. The AP said he did not remember speaking with any staff member about the above recommendations.An interview on 5/7/2026 at 1:43 P.M. with the Director of Nursing (DON) was conducted. The DON said he signs the pharmacy recommendations and does not check any of the boxes indicating if Resident #4's physician approved or denied the recommendation. The DON said he did not know if the recommendations were approved or denied. The DON said the AP had folders at each nursing station and does not know if the recommendations were placed in the folders for the AP.A review of a policy effective 11/28/2016, titled: Medication Regimen Review revealed: 7.1: For those issues that require physician/prescriber intervention, facility should encourage the physician/prescriber to either accept and act upon the recommendations contained within the MMR (medication regimen review), or reject the recommendations contained in the MMR and provide an explanation as to why the recommendation was rejected. 7.2.1: If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record.

Based on interviews and record review the facility failed to allow one (Resident #2) to return after hospitalization of three residents reviewed for readmission. Findings included: On 3/2/26 at 5:02 PM an interview was conducted with Resident #2's family member. The family member said Resident #2 was in the hospital from Tuesday, 2/24/26 to Saturday, 2/28/26. Resident #2 was supposed to be discharged on Friday 2/27/26 back to the [facility]. Resident #2 had to stay an additional day in the hospital as [facility] refused to take Resident #2 back at the last moment. Resident #2 was discharged to another nursing facility on Saturday, 2/28/26. Resident #2's family member stated the discharge delay was stressful for Resident #2. The family member stated they had to scramble the morning of 2/28/26 to find another facility for Resident #2. Resident #2 was anxious and now didn't know where she was going to go. The family member said [facility] was unhappy with them as we were vocal and advocating for Resident #2. The facility provided a letter to Resident #2 dated 2/24/26 from the Nursing Home Administrator (NHA) revealed: You/your loved one had recently transferred to the hospital. Although we expect your return, we are required to issue you the attached notice detailing the reason for transfer and your right to repeal. No further action is required currently, unless you wish to appeal this transfer. Attached was the Nursing Home Transfer and Discharge Notice, AHCA Form number 3120-0003.A review of Resident #2 hospital case manager note dated 2/27/26 at 8:42 AM stated: [facility] Skilled Nursing Facility (SNF) has indicated that they are now unable to take patient back. Case Manager (CM) to discuss with patient and family and provide choice list/options CM informed nurse/charge nurse with the update. Family member upset that [facility] SNF not taking Resident #2 back. CM coordinating with patient and son to find another SNF. On 3/2/26 at 2:10 PM an interview with the Social Services Assistant (SSA) revealed it is the admission department who talks to resident/families about a return from the hospital. On 3/2/26 at 2:16 PM an interview with the Admissions Director Assistant (ADA) was conducted. The ADA stated they had gotten a referral for Resident #2 to come back but was told Resident #2 could not come back due to the resident's diet and the family member making concerns about the resident's provided diet. The ADA stated the family was not happy with how the facility was accommodating Resident #2's diet. The facility told the Hospital Case Manager (HCM) the facility could not accommodate the specific diet. The ADA stated that the family member had attempted to reach out to the administrator after the denial. On 3/2/26 at 3:49 PM an interview was conducted with the Director of Nursing (DON), the Certified Dietary Manager (CDM), and the ADA. The ADA stated they only spoke with the hospital case manager, and Resident #2 was being denied due to clinical accommodations but could not define what the clinical accommodations were and what was not able to be provided. The DON stated clinical concerns goes to him, and Resident #2's family member made planning the resident's day difficult as the family member was bringing up the residents' preferences on waking up and when to go to therapy. The DON stated he is not sure if it is a cultural thing for the family member to take control over the resident's planning and speaking for Resident #2, but the family member made it difficult for the facility. The DON stated despite Resident #2's family member advocating for the resident's preferences, it did not intervene with Resident #2's plan of care as the resident was still attending all services ordered by the physician and did not miss anything. The DON stated the denial was marked as clinical services due to the family member demanding the resident's preferences be followed. The ADA stated when the case manager asked the reasoning for denial, it was explained Resident #2 had a lot of limitations, but the ADA does not remember what those limitations were, and does not remember what was said as they spoke a few days ago and they speak to a lot of people all the time. On 3/2/26 at 4:45 PM an interview was conducted with the facility's physician. The physician stated the resident came from the hospital for physical and occupational therapy due to having a stroke, and that there is no medical reason as to why Resident #2 could not be admitted back to the facility. The physician stated to their knowledge there would be no reason as far as diet needs or preferences that a resident would not be accepted back to the facility.A review of Resident #2's admission record revealed an admission date of 2/20/2026 with diagnoses to include cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery, paroxysmal atrial fibrillation, cognitive communication deficit, and type 2 diabetes mellitus with hyperglycemia. A review of Resident #2's Medical Certification for Medicaid Long-Term Care Services and Patent Transfer Form (AHCA Form 3008) dated 2/19/26 revealed: Mental/Cognitive Status at transfer Resident #2 was Alert, disoriented, but can follow simple instructions and no special instructions for dietary were marked. A review of Resident #2's physician orders dated 2/20/26 revealed: Vegetarian diet, regular texture, thin consistency liquids. A review of Resident #2's physician orders dated 2/24/26 revealed: regular diet, regular texture, thin consistency liquids. Eats cheese, peanut butter for vegetarian choice. A review of the Facility Assessment revealed the following: The facility provides person-centered, competent care that helps each person served to live their life as they wish. The services and care provided assist people to reach their highest level of practicable potential and maintain their ability to participate in life activities as long as they are able. Religious Factors (activities, food and nutrition) add deliveries of ither services-- Food and Nutrition services- we accommodate religious holidays and any dietary restrictions that are practiced by our residents. Services and care offered are based on our residents' needs and are adjusted as needed based on the resident population. Nutrition- Individualized dietary requirements, liberal diets, specialized diets, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions.A review of the facility's admission Agreement revealed the following: This Admissions Agreement ( Agreement) gives us permission to provide nursing care and other services while you are a resident of Palm Garden. You may discharge yourself from the center at any time, however we require a two (2) day notice of your wish to be discharged . We will assist you as necessary in arranging for your voluntary transfer or discharge. As a minimum, your written notice will: Specify the reason(s) for the impeding transfer or discharge. A review of the facility's Social Services- Policy and Procedures revealed the following: Facility Initiated transfer or discharge- This is when the resident/resident representative objects to or did not initiate the request for transfer or discharge themselves or is not in line with their stated goals for care and preferences. The Social Services Directed/designee will coordinate all resident discharges and transfers and be responsible for documenting interventions and plans in the progress notes and appropriate forms. Involuntary discharge or transfer of the resident will need 30-day advance notice and must be given to the resident/resident representative/family member. Notice may be given as soon as practicable before the discharge or transfer if: Discharge or transfer is necessary for the resident's welfare and the resident's needs cannot be met in the center. The reason must be documented in the medical record by the physician.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program as evidenced by small gnat like flies observed in the kitchen at the hand washing station, inside the dry storage area, inside the freezer, the dish cleaning area, around a cart outside of the freezer, and flies were observed over the tray/cook line for two days (11/13/23 and 11/15/23) out of four days of survey. Findings included: On 11/13/2023 at 7:20 a.m. during the initial kitchen tour the trash can at the hand washing station was observed to be overflowing with trash and the entire area had gnat like flies flying around. In addition, inside the dry storage area dead gnat like flies were observed on several plates. An observation of the inside of the freezer revealed dead gnat like flies in the corner on the floor behind milk crates. Outside of the freezer gnat like flies were observed flying around a cart that had several containers with tops that appeared dirty and smeared with a brown pasty substance. Also observed during this time was the dish cleaning area which had a stack of dirty dishes on the shelf with gnat like flies flying around. The catch tray/drain pan under the dishwasher had old food present and observed gnat like flies in this area (Photographic Evidence Obtained) During an interview on 11/13/2023 at 7:20 a.m. the Assistant Certified Dietary Manager (ACDM) stated the dishes from the night before are cleaned up by the staff that come in the next morning, they also clean the catch tray/drain pan. On 11/13/2023 at 9:30 a.m. a second tour of the kitchen was conducted, and the trash can in the hand washing area was observed to not have a trash bag and was full of gnat like flies when opened. A staff member was cleaning a food cart lying on its side in the middle of the kitchen and gnat like flies could be seen flying around the area. During an interview on 11/13/2023 at 9 30 a.m. the Certified Dietary Manager (CDM) stated the cart was being cleaned as a plate had broken inside. The CDM stated he pours bleach down the drains for the gnat like flies weekly. He stated he put a work order in the Electronic work order system two weeks ago. The food buildup was observed in the drain pain under the dish machine, and gnat like flies were observed flying throughout the kitchen area. On 11/15/2023 at 11:45 a.m. an observation of the tray/cook line for lunch revealed gnat like flies in the kitchen area and larger flies over the tray/cook line during the food service. During an interview on 11/16/2023 at 9:50 a.m. with the Nursing Home Administrator (NHA) and Dietician photographic evidence was shared regarding the gnat like flies observed in the kitchen. The NHA stated a bug zapper was installed in the kitchen. A request was made to have a copy of the work order for the bug zapper. On 11/16/2023 at approximately 1:00 p.m. an observation of the kitchen revealed no bug zapper was seen. Interview with the ACDM at this time confirmed he was not aware of a bug zapper. Review of the pest control company's service report revealed: 1. Dated 10/10/2023 - revealed the areas serviced for pests were exterior, courtyards, dumpster areas, rodent bait stations, Rm #161, and nurse's station. No kitchen areas were serviced. 2. Dated 10/17/2023 - revealed areas serviced for pests included dietary kitchen, dry storage, juice station, tray line/cook line, and dish room. 3. Dated 11/3/2023 - revealed the areas serviced for pests were exterior, court yards, dumpster area, rodent bait stations and maintenance building. No kitchen areas were serviced. 4. Dated 11/14/2023 - revealed areas serviced for pests included dry storage, kitchen, tray line/cook line, and the dish washing room. Review of the policy titled, Maintenance-Pest (Insect) Control, revised October 11, 2022, revealed: Policy: The facility will maintain an ongoing pest control program. Pest control services are provided by a licensed pest exterminator on a no less than monthly basis and as needed. The contracted Pest Control Services will include both interior and exterior pest control. Procedure: 1. Food items in resident rooms should be kept in air-tight containers. 2. Garbage and trash are to be removed from the facility daily. 3. Staff will report any evidence of insects in resident's rooms or common areas to the maintenance/housekeeping staff. During regular hours, the report can be logged into the maintenance request log and/or the log provided by the pest control company, if applicable. 4. Live insects in resident rooms or care areas should be reported as soon as possible to the maintenance or housekeeping supervisor and the administrator. 5. Maintenance/housekeeping will investigate any reports of insects and will ensure adequate control measures are provided. Maintenance/housekeeping will notify the licensed pest exterminator. 6. Residents will be removed from the area where live insects are noted until control measures are provided. Only pest control measures that are approved by the licensed pest exterminator will be used. 7. If insects are detected on a resident, the resident will be assessed by nursing staff and the resident's physician will be notified of any insect bites. The Director of Nursing and resident's family will also be notified. A work order for the bug zapper was not provided to the survey team as of the survey teams exit on 11/16/2023.

Based on observations, interviews, and record reviews the facility failed to ensure medications were stored in a safe manner in regards to 1) leaving one of two treatment carts unlocked while unattended (C-wing), 2) unopened eye drops requiring refrigeration stored in one (100-hall team #2) out of six medication carts, 3) one (C-wing team #3) out of six medication carts held medication tablets in a medication cup and a loose tablet, 4) three (C-wing, A-wing team #2, C-wing team #1) out of six medications carts left unlocked while unattended, 5) medications left on top of two unattended medication carts (100 team #2 and A-wing) out of 6 carts, 6) allowing a visitor unattended access to an unlocked medication cart (A-wing team #2 and C-wing team #1) out of six carts, and 7) allowed one resident (#85) to have a prescribed Albuterol inhaler at bedside. Findings included: 1. On 11/13/23 at 7:27 a.m., an observation was made of an unlocked treatment cart parked inside the C-wing nursing station. The observation identified a intravenous (IV) bag of normal saline with IV supplies on top of the treatment cart. The cart contained wound care supplies including creams/ointments. An unknown housekeeper was observed in the office next to the unlocked treatment cart. Staff B, Licensed Practical Nurse (LPN), arrived to the station and stated the cart should be locked at all times. The staff member locked the treatment cart leaving the IV bag and supplies sitting on top of the cart. The nursing station did not have a door prohibiting entrance into the area behind the desk. (Photographic evidence was obtained) 2. On 11/15/23 at 7:18 a.m., the review of the 100-hall, team #2 medication cart was conducted with Staff Q, LPN, identified an unopened bottle of Latanoprost ophthalmic drops. The bottle was labeled to refrigerate. The staff member walked away from the open medication cart to the nursing station while writer was inspecting the cart and the bottle of Latanoprost was sitting on top of it, which was parked across from the station. Staff Q was observed speaking with Staff P, LPN, behind the nursing station and not looking in direction of the medication cart. The staff member returned to cart and agreed this writer was not authorized to have unattended access to the medication cart, I guess not. The staff member confirmed the bottle of Latanoprost was unopened, should be refrigerated, and stated the medication had not been delivered from pharmacy during the shift of 11 p.m. to 7 a.m. (Photographic evidence was obtained) 3. On 11/15/23 at 7:37 a.m., an observation was conducted with Staff B, LPN, of team #3 medication cart. The staff member opened the top drawer of the cart and removed a medication cup with 3 tablets, 2 white and 1 blue, in it. Staff B identified one of the tablets as an antidepressant. The staff member stated the tablets were not morning medications, had taken over the cart so did not know the resident they were prescribed. One round white tablet was found in the bottom of the second drawer which Staff B identified as an antihypertensive. 4. During an observation of medication administration for Resident #211 on C-wing, on 11/15/23 at 7:46 a.m., the medication cart was parked slightly to the side of a resident's door and in the hallway allowing people to pass in between the door and cart. Staff D, Registered Nurse (RN), left the cart unlocked and out of vision when administering medications to a resident. 5. During an observation of medication administration, on 11/15/23 at 9:20 a.m., of Resident #25, medication blister-packaging cards were left on top of an unlocked med cart. The nurse was observed standing behind the resident's privacy curtain administering the medication. On 11/15/23 at 9:39 a.m., the Director of Nursing (DON) walked in between the cart and rooms door, leaving medications on top of it and unlocked. Immediately following the medication administration, on 11/15/23 at 9:48 a.m., Staff P confirmed 5 blister-packaging medication cards containing tablets/capsules were left on top of the cart and the cart was unlocked. (Photographic evidence was obtained) 6. An observation was conducted with Staff O, LPN, on 11/16/23 at 1:36 p.m. of C-wing team #1 medication cart. The medication cart was parked between room [ROOM NUMBER] and 203, approximately halfway down the hallway and around the corner from the nursing station. Staff O unlocked the cart and as this writer opened the top drawer of the cart the staff member walked away standing at the nursing station then disappeared from sight. The observation identified the Director of Education (DOE) was seen standing at the nursing station and after a few minutes the DOE arrived to the cart and confirmed Staff O should not have unlocked the cart and walked away. The DOE went to the nursing station and returned with the staff member. Staff O confirmed being responsible for the medication cart and was watching from afar. (Photographic evidence was obtained) 7. An observation was made, on 11/13/23 at 9:38 a.m., of a handheld red/gray inhaler in a manufacturer box on Resident #85's over-bed table. The inhaler was dated 9/22. Resident #85 reported, on 11/13/23 at 9:59 a.m., of using the inhaler twice a day, 2 puffs in the morning and 2 at night, They trust me with it. An interview was conducted on 11/14/23 at 8:30 a.m., with the Director of Nursing (DON). The DON reported no resident in the facility was self-administering medications and stated hope that doesn't mean you found meds at bedside. During an observation and interview on 11/15/23 at 12:24 p.m. with Staff O, LPN, and Resident #85. The resident stated to the staff member that he was not upset that she had taken the inhaler but he was able to take it (administer) it by himself. The staff member reported she had taken the inhaler from the resident today after informing him that it would be easier to reorder it. During an interview, on 11/16/23 at 2:53 p.m., the DON did not ask any questions or commented on findings. The policy - Storage and Expiration Dating of Medications, Biologicals, last revised 7/21/22, revealed, This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. The policy included the following: - Facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. - Store all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. - Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. - Facility should ensure that medications of biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. - Facilities should store bedside medications or biologicals in a locked compartment within the resident's room.

Based on observations, interviews, and record reviews the facility failed to resolve grievances related to dietary concerns in a timely manner for two residents (#4 and #85) out of the two sampled residents for grievances. Findings included: 1. On 11/14/23 at 10:12 a.m., Resident #4 reported he was the Resident Council President. He stated the number one concern in the facility was food. The food was cold, did not taste good, and was always late. He reported these concerns have been voiced over and over during the Resident Council Meetings and nothing changes. The response from staff related to the food concerns was always something about the budget. If they are served hotdogs, then they probably won't get mustard and ketchup. Administration took away cokes and they are only served ginger ale and diet ginger ale. They were told this was for nutritional reasons. The administration took away vending machines for residents. They have one in the staff break room but if they want something they have to ask a staff member to get it. Resident #4 stated, For some of them, food is the only thing they have to look forward to. He stated the concerns have been discussed with the Administration and they always say they will look into it. A review of the Admission Record for Resident #4 showed he was initially admitted to the facility on [DATE] with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Review of the Food Committee Meeting Minutes, dated 05/10/23, revealed there would be cutbacks on certain drinks due to cost. There were eighteen residents in attendance. Review of the Resident Council Meeting Minutes, dated 08/09/23, revealed during food council, the council voiced concerns regarding dissatisfaction about the meals. There were ten residents in attendance. There was new business discussed about the facility providing a survey for food times likes/dislikes, dinner starts promptly at 4:45 p.m., and the menu for the week including alternatives would be at the nurses' station. Review of the Food Committee Meeting Minutes, dated 08/09/23, showed the council voiced concerns regarding dissatisfaction with meals. The facility would provide a survey for food items likes and dislikes. Menus for the week, including alternatives, will be at the nurses' station. Review of the Food Committee Notes, dated 11/09/23, indicated guests requested to get regular sodas back. Soda will be ordered as available through the vendor. A review of the Grievance/Complaint Log from July 2023 to November 2023 did not show any grievances for the dietary concerns voiced by the resident council. On 11/16/23 at 11:11 a.m., the Life Enrichment Manager reported she assisted with putting together the Resident Council Meetings. She stated the residents complained mostly about food. She stated, One time the whole meeting was about food. She stated, the residents complained about running out of syrup and other small items that they should not have run out of, and the residents were upset about not being able to have sodas. The Life Enrichment Manager stated anytime they have a concern, she writes a grievance and puts it on the grievance log. On 11/15/23 at 11:15 a.m., the Registered Dietitian (RD) stated they only have ginger ale or diet ginger ale available, and she was not sure why they stopped ordering cokes. On 11/16/23 at 12:26 p.m., an interview with the Administrator and the RD was conducted. The Administrator reported about fifty residents completed surveys related to food to get an idea of what were the concerns the residents had. On 11/16/23 at 10:12 a.m., the Administrator reported she attended the Food Committee Meetings. At the time a new menu was rolling out and she wanted to see if any additional concerns would come up. The residents spoke about preferences through the dietitian and the Certified Dietary Manager (CDM). The Administrator stated they have not found a particular pattern for any specific items. The residents are aware that alternatives are available. The Administrator stated soda was removed, but they have ginger ale and diet ginger ale. They are readdressing the concern with the sodas. Some of the residents have family members bringing sodas to them. On 11/16/23 at 11:19 a.m., the Social Services Director (SSD) stated a grievance was usually resolved within three days after she receives it. She confirmed she did not see any grievances from the Resident Council and the Grievance/Complaint Log. 37999 2) On 11/13/23 at 9:39 a.m., Resident #85 reported, Food is terrible, chicken looked like it was dragged across the floor, the food tastes terrible. The resident stated the kitchen was not very efficient and reported telling the kitchen manager if working in a public restaurant Would be closed in a week. A review of Resident #85's Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14, indicating an intact cognition. Review of a grievance filed by Resident #85 on 11/7/23 included the following concerns voiced by the resident: - Chicken looks like its been drug on floor; - Quality of food is not good; - Chicken still pink on plate; - Chicken rib cage on plate; - Quiche is burnt and terrible; - Oatmeal is like clay, too thick. The grievance revealed the resident desired Manager to be more efficient and pay attention to what goes on and for efficiency and quality. The steps taken to investigate the grievance included the resident showing photos of food that the investigator identified as Most of the meals were dated months to even a year ago. The food in the pictures also looked fully cooked. The investigators findings revealed Resident #85 had been spoken with and Tried my best to resolve his concerns and explained to him that we temp and document our food before serving it. I followed up to the cook that cooked the quiche on the 23 rd of October. That cook has been spoken with on numerous occasions about food quality and preparation. The corrective action revealed the investigator had Verbally expressed the concerns and needs of how the food is to be cooked and prepared. Also will follow up with a written in-service on food temps. The grievance identified the resident was notified and the response was Satisfied/understood on 11/7/23. On 11/15/23 at 3:31 p.m., Resident #85 reported sending a note on his food tray two days ago (11/13/23) then the Certified Dietary Manager (CDM) came to speak with him. The resident reported sending a note yesterday and the CDM came to speak with him again. Resident #85 stated after filing a grievance last week the Certified Dietary Manager (CDM) spoke with him 2 days ago. The resident reported after speaking with the CDM felt the grievance had been taking care (7 days after the grievance was resolved) of satisfactorily and would continue to send notes. The policy provided by the facility Grievance Policy and Procedures, undated, revealed the following: This facility will assist residents and their representatives in filing grievances when such requests are made and/or complaints are voiced. The facility will promptly and responsibly investigate these grievances to initiate timely resolution and determine if the facility has areas that need corrections to achieve our desire or providing quality care and a safe environment. Procedure 5. The Social Service Director will make every attempt to resolve the grievance in a timely manner and will keep the resident and their representative aware of the progress towards resolution. 6. The Social Service Director will keep a summary log of all grievances, which will be brought to the monthly QAPI meeting for review and further action, if necessary. The log will be signed by the Medical Director.

Based on observations, interviews, and record review, the facility failed to reassess the need for an appropriate use of bed rails for one resident (#80) of three residents sampled for bed rails. Findings included: On 11/15/23 at 4:09 p.m. Resident #80 stated the facility just came in and took the rails off the bed. The resident reported using the rail/enabler to assist with getting into bed and moving up in the bed. The resident stated he knew what a trapeze was and had not been assessed for one. The observation revealed Resident #80 had a left upper arm contracture which was held in front of the chest. An observation of the resident bed revealed no assistance devices were attached to the bed. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #80 had a Brief Interview of Mental Status score of 13, indicative of an intact cognition. Section GG of the MDS identified the resident had Range of Motion limitations on one side of the upper and lower extremities. The MDS revealed the resident required substantial/maximal assistance with toileting hygiene, bathing, and lower body dressing, and required partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The assessment identified the resident was independent with rolling left to right, sit to lying, and lying to sitting on side of bed. Review of Resident #80's Admission Record revealed the resident was admitted on [DATE] and was the responsible party. The record included the diagnoses of unspecified encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, generalized muscle weakness, other abnormalities of gait and mobility, and Type 2 Diabetes Mellitus without complications. The clinical record for Resident #80 included an Adaptive Rails Informed Consent and Release form signed by Resident #80 on 4/7/23. The consent revealed the resident had been informed of the benefits and risks associated with the use of adaptive rails, including possible entrapment and accidental skin bruising, cuts, or scrapes. The consent identified the benefits to using the adaptive rails were: 1. Improved mobility in bed: I will be able to reposition myself or assist my caregivers to reposition me. 2. Improved mobility getting in and out of bed. I will be able to transfer myself into and out of bed or to assist my caregivers with transferring me into and out of bed. I understand that the adaptive rails are to be used as a mobility aid and not as a physical restraint. I can withdraw this consent at any time. If I become unable to use the adaptive rails, the adaptive rails will be removed from my bed, so they are not an unintended physical restraint or possible entrapment hazard. Included with the consent was a description of adaptive rails approved by the center: quarter-length adaptive rail and an adaptive transfer bar. A review of Resident #80's care plan identified the resident was at risk for falls related to impaired mobility, balance, status post (s/p) Cardiovascular accident (CVA) with left (lt) hemiplegia (hemi), atrial fibilation (Afib), hypertension (HTN), Diabetes Mellitus (DM), (and) need for assistance with transfer. The interventions included but not limited to Keep adaptive equipment within reach. The care plan identified the resident had the need for setup to complete assistance from staff with Activities of Daily Living (ADL) self-care and/or mobility deficit with potential for further decline due to diagnosis. The interventions instructed staff to encourage and assist to turn and reposition, shifting weight to enhance circulation. During an interview on 11/13/23 at 1:34 p.m., Staff O, Licensed Practical Nurse (LPN) reported a couple of months ago the facility removed side rails and enablers due to the new state law. The staff member stated if residents insisted on having side rails they have to be evaluated for them. An interview on 11/15/23 at 12:24 p.m., was conducted with Staff O, LPN. The staff member reported side rails were taken out in stages and if a resident or family requested side rails or if she felt the resident needed them for safety, a therapy request would be initiated who would assess for a trapeze and if the resident continued to want rails, she would have to ask again for them and have a consent signed. Review of Resident #80's Adaptive Rail Screen revealed it was completed on 4/11/23. The screening identified the use of adaptive rail(s) were being considered due to Resident requested for safety/security and the resident had requested rails states it provides a sense of security. The screening revealed adaptive rails will assist the resident in turning side to side/holding self to one side or up and down in bed, pulling self from laying to a sitting position, will assist the resident in improving balance or trunk control, assist in supporting self, and assist the resident in entering/exiting (the) bed or transferring more easily. The documentation revealed the use of adaptive rails would not create a possible accidental hazard or barrier to the resident or have any negative physical or psychosocial outcomes, and no prior interventions such as a low bed, restorative care, frequent staff monitoring, assisted toileting, or reminders to use call bell had been implemented. The recommendation identified adaptive rails on both sides were recommended due to resident request and the risks, benefits and alternatives had been discussed with the resident. The therapy screens for Resident #80 included: - 6/8/23 Quarterly evaluation identified Physical therapy (PT) was indicated without occupational therapy (OT). The evaluation did not reveal the resident was screened for the discontinuation of adaptive rails or the evaluation of alternatives. - 6/23/23 Referral evaluation indicated no PT, OT, or speech therapy (ST) was indicated. Patient (Pt) currently on caseload for PT. - 7/31/23 Referral evaluation identified PT was indicated as resident had decline in lower extremity (LE) strength and was no longer ambulatory. The screening did not address the discontinuation of adaptive rails or the evaluation of alternatives. - 9/8/23 Quarterly speech therapy evaluation revealed no change or concerns and speech therapy was not indicated at that time. - 9/12/23 Quarterly evaluation for PT and OT revealed neither was indicated at that time. The screening did not address the discontinuation of adaptive rails or the evaluation of alternatives. The evaluation did identify the resident was recently discharged from PT services. - 9/19/23 Referral for speech therapy to assess swallowing function. - 10/24/23 Referral to OT for assessment of left hand contracture development. Review of Resident #80's PT Discharge Summary for the date of services of 6/16/23 through 7/10/23 identified the short-term goal of Patient will safely perform bed mobility task with standby assistance without use of side rails and 5% verbal cues for safety awareness, for proper sequencing, for task segmentation, for correct hand/foot placement, and for initiation/termination of tasks in order to decrease risk for skin breakdown, participate in EOB activities, get in/out of bed, participate in activities of daily living, enhance safe functional mobility, and reduce risk for falls. The summary identified the resident's baseline on 6/16/23 for this goal was contact guard assist (CGA) and was unchanged at the time of discharge on 7/10/23. A long-term goal for the resident was Patient will safely perform bed mobility tasks with Supervised (A) without use of side rails and 5% verbal cues for safety awareness, for proper sequencing, for task segmentation, for correct hand/foot placement, and for initiation/termination of tasks in order to decrease risk for skin breakdown, participate in EOB activities, get in/out of bed, participate in activities of daily living, enhance safe functional mobility, and reduce risk for falls. The summary identified the resident's baseline (6/16/23) and discharge (7/10/23) was contact guard assist (CGA) for bed mobility. The summary revealed the patient demonstrated fair progress and had plateau' d and the recommendation to continue with restorative nursing program (RNP). A review of the facility Admission Agreement identified The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility provided a letter dated 2/7/23 (2 months prior to Resident #80's admission) sent to families and residents. The letter identified the facility would be working to eliminate the use of all adaptive rails/mobility bars unless they are proven to be medically necessary for each individual guest/resident. The letter revealed as part of an ongoing performance improvement program each individual guest/resident would be assessed for the use of adaptive rails/mobility bars with the input from the interdisciplinary team and all recommendations would be reviewed with the individual guest/resident and/or responsible party. A facility letter, dated 5/30/23, revealed the facility was working towards eliminating the use of all adaptive rails/mobility bars unless proven medically necessary. The assessment for the use of rails/bars would include input from the interdisciplinary team (IDT) and the recommendations would be reviewed with the individual guest/resident and/or responsible party. The continued use would be routinely monitored and the IDT would make recommendations if a guest's/resident's circumstances changed. The facility plan for removal of adaptive rails, dated 6/18/23, identified Adaptive rails to only be utilized when the center has tried alternatives, IDT (includes therapy) assessment recommends one or tow for mobility and transfer and physician's order has been obtained, family/resident consents, and is care planned. - 1. letter to sent to all families/residents two weeks prior to removal explaining regulation and new protocols. - 2. center will obtain and have a par level of concave/perimeter mattresses, fall mats, motion sensor lights, and night lights, identify facility bed frames that are able to extend to wider beds with wider mattresses available. - 3. all adaptive rails and bed rails will be removed from all beds and stored in an inaccessible storage area for anyone but maintenance/environmental services to ensure that none make it back to the floor without the process being followed. - 4. Alternatives to adaptive rails will be attempted and documented. Should multiple alternatives fail, an adaptive rail review will be performed, and a therapy referral will be made. Therapy interventions, i.c. slide boards will be utilized. Should the therapy alternatives fail, the IDT will discuss and if need be, the possible use of one or two adaptive rails for transfers, the IDT recommendations will be discussed physician and resident/family. Should a recommendation be made for one or two adaptive rails and physician and family/resident agree, a consent would be obtained, scanned into the medical record, and care planned. The adaptive rail review will be performed quarterly and as needed with change of condition (COC). During an interview on 11/16/23 at 2:56 p.m., the Director of Nursing (DON) reported the facility looked at adaptive rails in June and removed them. He stated when someone requests an adaptive rail the facility asks for an alterative such as a scoop mattresses, trapeze, or furniture placement, therapy would screen them, nursing would meet, a side rail evaluation, physician order, consent and the rails would be added to the care plan. The DON stated the facility looked at the rails, explained to residents, sent out letters to residents and family members, and met in resident council in June or July. The facility also held a team talk with staff. He reported all residents were informed the facility was to try something different and all residents were screened. The policy - Siderails/Adaptive Rails Guideline, revised January 2023, identified It is the standard of the center to attempt to use alternatives prior to installing an adaptive rail (bed mobility assistive device). If an adaptive rail(s) is used the center will ensure correct installation, use and maintenance of the adaptive rail. The center only utilizes adaptive rails to aid with bed mobility. The center only utilizes adaptive rails based on individual guest/resident assessment - no full side rails, half rails or quarter rails will be installed. 1. Adaptive rails are used to assist with mobility and transfer of guests/residents. 2. Prior to the use of adaptive rails, alternatives will be attempted and documented. 3. Alternatives to be considered prior to installing adaptive rail include but are not limited to - a. Low bed - b. Concave mattress - c. Furniture placement - d. mechanical lift - e. therapy recommended bed mobility devices such as slide boards - f. One adaptive rail instead of two for guests/residents with limitations related to medical conditions on a specific side of their body. - g. fall mats - h. Overbed trapezes - i. motion sensor lights - j. night lights - k. Other resident specific interventions with supporting documentation. 11. If guest/resident condition improves and adaptive side rail use is no longer indicated the adaptive rails will be reviewed by the interdisciplinary team and discontinued after reviewing with guest/resident and/or responsible party.

Based on observations, interviews and record review, the facility failed to inform the resident/resident representative of a change in status and change in medication for two residents (#99 and #314) of two residents sampled for change of status. Findings included: 1) Review of the Admission Record revealed Resident #99 was admitted to the facility on [DATE], with diagnoses to include surgical aftercare following surgery on the digestive system, difficulty in walking, malignant neoplasm of the pancreas, and other co-morbidities. An Admission Minimum Data Set (MDS), dated [DATE], for Resident #99 showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 11/13/2023 at 8:18 AM, Resident #99 stated, My discharge medication list from the hospital and my surgeon showed Lovenox to be given to prevent thrombosis, which I have had in the past. I received two injections from here, then the nurses stopped administering. I wasn't receiving the medication. I kept asking the nurses for it. I know how important this medication is to prevent me from having a stroke. I did not hear anything from them, they just said I was being difficult. I even showed them the discharge paperwork the hospital had given to me. The paperwork clearly indicates continue the Lovenox. I had to get my family involved. When my family checked, they were told, the Advanced Practice Registered Nurse (APRN) from the facility discontinued the Lovenox. No one discussed this change with me or my surgeon. My surgeon called and the medication was restarted. This should not have occurred without my knowledge or my surgeons. Review of the Medication Administration Record (MAR) for the month of October 2023, showed Resident #99 received Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG (milligram)/0.4 ml (milliliter) (Enoxaparin Sodium) generic for Lovenox, inject 0.4 ml subcutaneously in the evening for prophylaxis, on 10/14/2023 and 10/15/2023. The order was discontinued on 10/16/2023 at 1636. An order was started on 10/18/2023 for Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4 ml (Enoxaparin Sodium) generic for Lovenox, inject 0.4 ml subcutaneously in the evening for Deep Vein Thrombosis (DVT) upper extremity and was given for the remainder of Resident #99's stay. 2) Review of the Admission Record revealed Resident #314 was admitted to the facility on [DATE], with diagnoses to include Rhabdomyolysis (skeletal muscle breaks down rapidly), centrilobular emphysema, history of falls and other co-morbidities. On the Admission Record under contacts the resident is listed as responsible party. Resident #314's Clinical Admission Assessment marked the resident as alert & oriented x 3, communicated verbally, speech is clear, can understand and be understood when speaking. During an interview on 11/13/23 8:13 AM, with Resident #314 and a family member, who is his health care surrogate and primary care giver, the family member stated, I guess he fell the other day; they did not call me when the fall occurred. They told me when I got here today. Review of Resident #314's Progress Notes with an effective date of 11/12/2023, 7:41 AM showed the following: Resident was observed on the ground by the CNA. CNA reported the incident to the nurse. Comprehensive assessment completed and no abnormal findings and will continue to monitor for any pertinent changes. Review of Resident #314's Therapy Screen Form - V4 with an effective date of 11/12/2023 at 5:06 PM. showed the following: Resident #314 was referred to therapy due to a fall on 11/12/2023. A Physical Therapy Assistant denied completing the screen as Resident #314 was already being seen by physical and occupational therapy. An interview was conducted with the Director of Nurses (DON) on 11/15/2023 at 3:51 PM. The DON stated he was not aware of Resident #314's fall and would have to ask the Unit Manager. The DON stated the expectation for notification of changes would be shortly after the incident or changes to the medications. Review of a facility policy titled, Nursing - Change in Residents Condition or Status, effective date: October 2014, showed the following: 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 of care, billing/payments, resident rights, etc.). Procedure: . 3. Unless otherwise instructed by the resident, the nurse supervisor/charge nurse/designee will notify the resident's family or representative when: * The resident is involved in any accident or incident that may or may not have resulted in an injury, including injuries of an unknown source; *There is a significant change in the resident's physical, mental, or psychosocial status; . 4. Regardless of the resident's current mental or physical condition, the nursing supervisor/charge nurse will inform the resident of any changes in his/her medical care or nursing treatments. 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observations, interviews, and record review, the facility failed to provide treatment and care according to physician orders for non-pressure related skin conditions for two residents (#314 and #316) of two residents sampled for skin conditions. Findings included: 1) On 11/13/23 at 08:13 AM, Resident #314 was observed laying in the bed, sheet up to waist with arms on top of the sheet. Resident had a soiled dressing, with dried blood visible to his left forearm dated 11/12/2023. Directly above the left forearm was a soiled folded gauze with medical tape wrapped around the arm, undated. A soiled dressing to left elbow, the dressing was peeling off and undated. The dressing to the right elbow was soiled with red and brown bloody drainage and starting to peel off the skin dated 11/12/2023. (Photographic Evidence Obtained). During an interview on 11/13/23 at 12:00 PM, the family member of Resident #314 stated the resident had several skin areas that needed bandages, the ones you can see on his arms and on both of his legs. The family member stated the bandages on his legs look just as bad as the ones on his arms. The family member stated you should have seen the bandages yesterday, all the bandages were so saturated the bed was wet from the leakage. The family member stated, I kept asking for someone to come and change them. I could not get anyone to come change the bandages until I stood in front of them. Resident #314 confirmed this was an issue. Review of the Admission Record revealed Resident #314 was admitted to the facility on [DATE], with diagnoses to include Rhabdomyolysis (skeletal muscle breaks down rapidly), centrilobular emphysema, history of falls and other co-morbidities. On the Admission Record under contacts the resident was listed as responsible party. Resident #314's Clinical Admission Assessment marked the resident as alert & oriented x 3, communicated verbally, speech is clear, can understand and be understood when speaking. Review of Resident #314's N Adv - Clinical Admission evaluation, dated 11/10/2023 at 7:53 PM, revealed the resident was admitted with skin impairments to the right and left anterior elbow, the right lower leg, and right knee. Review of Resident #314's hospital history and physical revealed the resident had dressings on in the hospital and an order to change dressings daily. Review of Resident #314's Physician Order Summary Report showed no orders for treatments to the left elbow, left wrist, right elbow, and right knee until 11/13/2023 at 2:44 PM. Review of Resident #314's Physician Order Summary Report showed an order dated 11/13/2023 at 2:44 PM Cleanse Left elbow with normal saline, pat dry, apply Xeroform, cover with abdominal pad then wrap with Kerlix every two days and as needed (PRN) if soilage or dislodgment. Order was discontinued on 11/15/2023. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was provided on 11/14/2023. Review of Resident #314's Physician Order Summary Report showed an order dated 11/13/2023 at 2:44 PM Cleanse Left wrist with normal saline, pat dry, apply Xeroform, cover with abdominal pad then wrap with Kerlix every two days and PRN if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was provided on 11/14/2023 and 11/16/2023. Review of Resident #314's Physician Order Summary Report showed an order dated 11/13/2023 at 2:40 PM Cleanse Right elbow with normal saline, pat dry, apply Xeroform, cover with abdominal pad then wrap with Kerlix every two days and PRN if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was provided on 11/14/2023, 11/15/2023 and 11/16/2023. Review of Resident #314's Physician Order Summary Report showed an order dated 11/13/2023 at 2:44 PM Cleanse Right knee with normal saline, pat dry, apply Xeroform, cover with bordered gauze island dressing every two days and PRN if soilage or dislodgment. As needed for skin tear. Order discontinued on 11/15/2023. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was not provided. During an interview on 11/13/2023 at 3:00 PM, Staff B, Licensed Practical Nurse (LPN) confirmed the resident did not have orders for treatments until 11/13/2023. Staff B, LPN stated orders should have been requested at the time of admission. 2) On 11/13/23 at 08:18 AM, Resident #316 was observed, dressed, and lying on top of the bed. Resident's left foot was observed with a bandage that was not secured to itself or the resident. The bandage was barely covering the resident's recent surgical incision (amputation of the toes). The bandage was loosely wrapped from the top of the foot to the heel and around the ankle. The bandage had no visualized drainage or discoloration. The incision site had no discoloration, ointments, or cream observed. (Photographic Evidence Obtained). During an interview on 11/13/23 at 8:18 AM, Resident #316 stated she had requested all weekend for the nurses to fix the bandage as it was falling off. No one would listen or help. The resident stated knowledge of the treatment needed, and said there should be an orange medicine applied to the incision and this not being done. Resident #316 stated the physician had said to keep the incision clean and not to put pressure on it. Review of the Admission Record revealed Resident #316 was admitted to the facility on [DATE], with diagnoses to include dehiscence of amputation stump; left foot amputation partial, open wound to the left foot, Peripheral Vascular Disease, muscle weakness, dysphagia, cognition, need for assistance, hypertension, and other co-morbidities. On the Admission Record under contacts the resident was listed as responsible party. Review of Resident #316's Brief Interview for Mental Status (BIMS) reveals a score of 13 out of 15, indicating the resident is cognitively intact. Review of Resident #316's Physician Order Summary Report showed an order dated 10/30/2023. Cleanse left lower extremity with normal saline, pat dry, apply Betadine then wrap with Kerlix daily and as needed (PRN) if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was document completed from November 1st to 15th. Review of Resident #316's Physician Order Summary Report showed an order dated 10/30/2023. Cleanse left foot with normal saline, pat dry, apply Betadine then wrap with Kerlix daily and as needed (PRN) if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was document completed from November 1st to 15th. Review of Resident #316's Physician Order Summary Report showed an order dated 10/30/2023. Cleanse left heel with normal saline, pat dry, apply Betadine then wrap with Kerlix daily and as needed (PRN) if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was document completed from November 1st to 15th. During an interview on 11/16/2023 at 8:00 AM with Staff H, LPN, a review of the photographs of Resident #314's left and right arms was conducted. Staff H, LPN stated a recollection of 11/13/2023 when a family member requested dressing changes, and confirmed the dressings should have been changed when soiled and dated when completed. Reviewed the photographs of Resident #316's bandage on 11/13/2023. Staff H, LPN stated a recollection of that dressing as well and confirmed the bandage should have been changed, secured with tape and dated. Staff H, LPN stated the bandage did not appear to have the Betadine applied but Staff H, LPN was not here and could not confirm. During an interview on 11/16/23 at 1:26 PM with the Director of Nursing (DON) a review of the photographs for Resident #314 and #316's bandages was conducted. The DON stated the bandages should have been changed. The DON stated the expectation is for the physician's order to be followed and the bandages should be dated when placed. Review of the Policy and Procedure titled, NURSING PROCEDURE MANUAL Clean Dressing Change (Wound/Surgical Site), dated 07/2023 showed: Purpose: * To prevent contamination of the wound. * To protect adjacent skin surfaces from irritation due to wound drainage. *To promote wound healing. Procedure: 1. Verify physician's order for dressing change and pain medication. 4. Identify a guest/resident, explain procedure, and provide privacy. 8. Observe the amount, color, and odor of drainage and condition of wound bed or incision. 18. Document date, time dressing changed, and initials on a piece of tape and place on dressing. 23. Document the following in the electronic medical record: Date and time of dressing change; Amount of drainage, color, and odor; Any unusual appearance of wound or peri-wound area; Complaints of pain or discomfort; Guest/resident response to procedure

Based on observations, interviews, and record review the facility failed to ensure the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed and nine errors were identified for two residents (#211 and #25) of four residents observed. These errors constituted a 24.32% medication error rate. Findings included: 1) On 11/15/23 at 7:46 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #211. The staff member dispensed the following medications: - Levofloxacin 500 milligram (mg) tablet - Lisinopril 10 mg tablet - Mucinex DM 600 mg Guaifenesin/30 mg Dextromethopran over-the-counter (otc) tablet - Aspirin 81 mg chewable otc tablet - Nifedipine Extended Release (ER) XL 60 mg tablet - Polyethylene glycol 3350 - 17 grams (gm), mixed with 4 ounce (oz) of water - Vitamin D 25 microgram (mcg) - 2 otc tablets Staff D confirmed 7 tablets and one liquid medication. The staff member administered oral medications and identified the resident was to receive short and long-acting insulin. Staff D obtained a blood glucose level of 91 from the resident. The staff member stated and documented the dosage of Insulin Lispro (short-acting) would not be administered due to glucose level of 91. An unknown Certified Nursing Assistant (CNA) informed Staff D the breakfast trays were on the unit and the nurse left the area, returning with a breakfast tray placing it in front of the resident, and reported being told by a doctor to ensure a resident ate before administering insulin. Staff D returned to the medication cart, dialed a Insulin Glargine pen to 2 units, pressing the dosage selector to it reached zero, then applied a needle to the pen, dialed it to 25 units, entered the resident room and injected the insulin into the right upper arm of Resident #211. A review of Resident #211's physician orders included the following: - Guaifenesin ER 12 hour 600 mg tablet - Give one tablet by mouth two times a day for indigestion for 14 days, dated 11/10/23. - Insulin Lispro 100 unit/milliliter (mL) - Give 6 unit sublingually three times a day for Diabetes Mellitus (DM). - Insulin Glargine 100 unit/3 mL - Inject 25 unit subcutaneously two times a day for DM. The review of Resident #211's physician orders did not identify the resident was to receive Mucinex DM that is a combination medication containing 600 mg of Guaifenesin and 30 mg of Dextromethopran and the morning dose of Insulin Lispro did not include parameters to hold. The manufacturer instructions for Lantus (Insulin Glargine), located at https://products.sanofi.us/Lantus/Lantus.html., included the following education for insulin pen users: Step 2. Attach the needle Do not re-use needles. Always use a new sterile needle for each injection. This helps prevent contamination and potential needle blocks. A. Wipe the Rubber Seal with alcohol. B. Remove the protective seal from a new needle. C. Line up the needle with the pen, and keep it straight as you attach it (screw or push on, depending on the needle type). - If the needle is not kept straight while you attach it, it can damage the rubber seal and cause leakage, or break the needle. Step 3. Perform a Safety test. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: - ensuring that pen and needle work properly - removing air bubbles A. Select a dose of 2 units by turning the dosage selector. B. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards. D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the injection button all the way in. Check if insulin comes out of the needle tip. - You may have to perform the safety test several times before insulin is seen. - If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. - If still no insulin comes out, the needle may be blocked. Change the needle and try again. - If no insulin comes out after changing the needle, your SoloStar may be damaged. Do not use this SoloStar. 2) On 11/15/23 at 9:20 a.m., an observation of medication administration with Staff P, Licensed Practical Nurse (LPN), was conducted with Resident #25. Staff P obtained a blood pressure of 105/78 from the resident and dispensed the following medications: - Thiamine Vitamin B1 100 milligram (mg) over-the-counter (otc) tablet - Cetirizine 10 mg otc tablet - Artificial tears eye drops - Creon Delayed Release (DR) 6000 unit capsule - Dicyclomine 10 mg capsule - Folic Acid 400 microgram (mcg) otc tablet - Gabapentin 300 mg capsule - Mesalamine ER 500 mg capsule - Senna 8.6 mg otc tablet - Vitamin D3 125 mcg otc tablet - Klor-Con 10 milliequivalents (meq) tablet - Polyethylene glycol 17 gram (gm) - mixed with 4 ounces (oz) of water - Aspercreme with 4% Lidocaine Max Strength topical patch Staff P confirmed dispensing 10 tablets/capsules, acknowledging the resident was scheduled to receive Lactulose but it had to be re-ordered, and was holding Amlodipine due to the blood pressure parameters. The staff member crushed tablets together and added to applesauce. The staff member administered the medications and placed the topical patch to the lower- mid back of the resident. The physician orders for Resident #25 included an order reading May crush medications unless contraindicated, the orders were further reviewed and the following issues were observed: - Lidocaine 5% patch - apply topically daily, apply in a.m. and remove at bedtime (hs) for chronic pain. Staff P applied a topical patch of Aspercreme with 4% Lidocaine. - Amlodipine Besylate 5 mg tablet by mouth in the morning for hypertension (HTN). The order did not include blood pressure parameters to hold. - Lactulose solution 10 gm/15 milliliter (mL) - give 15 mL by mouth one time a day for constipation. The medication was not administered due to unavailability of it for the resident and the medication profile was colored red revealing the medication was late. The Medication Administration Record (MAR) identified the medication was scheduled for 8:00 a.m. - Thiamine B1 was scheduled for 8:00 a.m., medication profile colored red revealing the medication was late. - Creon DR 6000 unit capsule - observation identified the breakfast trays on the unit have been removed from resident rooms. No meal tray was observed in Resident #25's room. According to creoninfo.com, Creon needs to be taken with every meal and snack to work as expected. The digestive enzymes in Creon need to mix with food and enter the stomach and the small intestine at the same time. - Klor-Con 10 milliequivalent (meq) tablet - crushed with other oral medications. Physician order - Potassium Chloride Extended Release 10 meq - Give 1 tablet by mouth in the morning for hypokalemia. Do Not Crush. The website, mayoclinic.org identified Potassium Supplement, Do not crush or chew the capsule. Swallow the capsule whole with a full (8-ounce) glass of water. Some capsules may be opened and the contents sprinkled on applesauce or other soft food. On 11/5/23 at 9:48 a.m., Staff P confirmed crushing Potassium, We need to change that. A request was made to the Director of Nursing (DON), on 11/15/23 at 4:46 p.m. for a Do Not Crush medication list. The DON reported This is about the potassium. On 11/15/23 at 5:25 p.m., the DON stated the facility does not have a Do Not Crush medication list. An interview was conducted on 11/16/23 at 11:22 a.m. with the Consultant Pharmacist. The issues observed during medication administration were reviewed and discussed with the consultant. In regards to Staff D not applying a needle when priming the Insulin Glargine pen for Resident #211, he stated How did it get out? and the facility should have followed the orders for Insulin Lispro. The pharmacist reported Klor-Con was extended release and should not be crushed, Creon Dr should be administered with meals, there was no reason for Thiamine and Lactulose to scheduled at a different time than the other observed medications, and Mucinex DM was not the same as Guaifenesin ER as it contained the additional medication Dextromethopran. The consultant agreed with the findings and stated it looked like the facilty would need extensive education with medication administration. During an interview on 11/16/23 at 2:50 p.m., the Director of Nursing (DON) stated he had spoken with the Consultant Pharmacist regarding the findings during medication administration and did not have any questions. The policy - Medication Administration, dated 7/2023, included the following instructions: - Compare the medication with the Medication Administration Record (MAR). - Verify physician's order to crush medication. - Verify medication can be crushed. Examples of medication that should not be crushed includes, but are not limited to: enteric coated tablets, sustained or extended-release tablets, effervescent tablets, (and) sublingual or buccal tablets. The policy regarding Insulin Injection did not instruct the use of an insulin pen.

Based on observations, interviews, and record review, the facility failed to provide access to activities for one resident (#74) out of one resident sampled for activities. Findings included: On 11/13/2023 at 8:25 AM, Resident #74 was observed sleeping in bed. Floor mats were observed on each side of the bed. On 11/13/2023 at 11:45 AM, Resident #74 was observed in bed. The roommates television (TV) was on. On 11/13/2023 at 2:30 PM, Resident #74 was observed in bed. The resident was observed with the head of the bed slightly raised, utilizing the left hand, and tapping on the overbed table. Resident #74's TV was not on, but the roommate's TV could be heard. On 11/14/2023 at 9:05 AM, Resident #74 was observed in bed, with the head of the bed at a 90-degree angle, being assisted with breakfast. Resident #74 stated breakfast was good. Resident was utilizing left hand to tap on the over bed table. On 11/15/2023 at 3:30 PM, Resident #74 was observed in bed with the head of the bed raised. Resident #74's TV was on, and was facing bed A, not toward the resident. An interview was conducted with Resident #74's family member on 11/14/2023 at 10:30 AM. The family member stated she insisted the facility get Resident #74 up for lunch. She stated she took the resident to the dining room across from the nurses' station, and was told the area was not really a dining room, so she could not assist the resident to eat in the area. She stated, I was very perplexed as other residents are permitted to eat in the room. I was told [Resident #74] would be getting up for lunch and going to the dining room on the other side of the facility, which was fine with me. The facility got [Resident #74] up for one or two days and then stopped. I had to insist they get [Resident #74] up so we can go outside. The facility told me [Resident #74] was only permitted to be up for two hours due to her wound, of course I don't want anything to impede healing. The rest of the time [Resident #74] just lays in the bed looking at the walls. [Resident #74] has a TV but needs to get out of the room or have something in the room to do. Every time I come [Resident #74] says, 'bored'. [Resident #74] has started a habit of tapping on the over bed table. I think [Resident #74[ started this behavior due to boredom and anxiety, with nothing to do. The only activities offered are the ones I offer her. No one from activities comes to the room to offer something different to do. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 11/15/23 at 9:50 AM. Staff B, LPN stated Resident #74 does not get up for breakfast and does not normally get up for lunch until recently, as the family member comes to assist the resident. An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 11/15/23 at 10:00 AM. Staff A, CNA stated regularly working with Resident #74. Staff A, CNA stated the resident is assisted to eat in her bed for breakfast and only recently gets up for lunch. She stated, I don't see anyone doing anything with Resident #74, only the [family member]. I only provide care not activities. An interview was conducted with Staff G, Registered Nurse (RN) on 11/15/23 at 3:45 PM. Staff G, RN stated Resident #74 does not get up for dinner. An interview was conducted with Staff R, CNA on 11/15/23 at 4:05 PM. Staff R, CNA stated Resident #74 does not get up for dinner. An interview was conducted with the Activity Director (AD) on 11/16/2023 at 8:11 AM. The AD stated the activities department goes room to room and asks residents if they would like to attend the activities for the day. She stated they try to go back and bring the residents to the group activities. The AD stated the facility does complete 1:1 visits with some of the residents who cannot get out of their rooms. The AD stated Resident #74 was not one of those residents. The AD stated residents on the rehabilitation side do not usually want to go to activities and they do not really have to provide much support to the rehabilitation side. An interview was conducted with the Registered Dietitian (RD) and the Nursing Home Administrator (NHA) on 11/16/2023 at 9:35 AM. The NHA stated Resident #74 was admitted with numerous wounds and poor nutritional status with protein deficiency. They stated they had been working with the family member on providing a dining experience that would reduce the distractions for the resident, and permit Resident #74 to focus on eating. They stated they had assigned Resident #74 to sit in a smaller dining room to accomplish this goal for the last two weeks. They stated, the staff know to get Resident #74 up for lunch and dinner and to take Resident #74 to the smaller dining room on the other side of the building. They stated they verbally told the nurse on floor, the Unit Manager (UM), the evening supervisor, and the weekend supervisor. A review of Resident #74's Admission Record showed Resident #74 was admitted on [DATE] with the following diagnoses: Pressure Ulcer of sacral region, stage 4; atrial fibrillation; necrotizing fasciitis; dementia, anxiety plus other co-morbidities. A review of Resident #74's Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 6 out of 15, indicating severe cognitive impairment. Section G: Functional Abilities revealed the resident was dependent on the facility staff for bed mobility, toileting, showering, eating, and dressing. A review of Resident #74's PG Life Enrichment Assessment - V 2, dated 9/30/2023, revealed the following: 4. Daily routine-prefers to spend free time in room, prefers to participate in leisure activities mostly in morning, and preferred activity setting in own room. 5. Leisure interest-several interests marked very important included computer/games, clothes/fashion, crafts, exercise, music, gardening/plants, snacking, pet therapy, spiritual and family/visitors. Interests marked somewhat important included reading, TV, talking/conversation, and group activities. A review of Resident #74's Care Plan, dated 10/17/2023, revealed the following: Focus: Resident #74 prefers being involved in self-directed activities, no interest in group activities. Listen to Music, spend time outside weather permitting, spend time with visitors, watching/listening to TV. Goal: Resident #74 will show no signs and symptoms of social isolation/sadness through next review. As evidenced by: no longer engages in self-directed activities of expressed interest, increased refusal for care or therapy, not engaging with visitors and staff. Interventions: Address Resident by preferred name, encourage Resident #74 to be active daily, give pastoral visits for opportunities for Resident #74 to exercise her spirituality, invite and escort to activities as resident elects/chooses of choice, provide daily meet and greet visits and give Resident the daily chronicle with the activities for the day listed, and provide materials needed for in-room activities as needed. A review of the policy titled Live Enrichment Manual, dated 11/22, revealed the following: -Life enrichment programming can enhance quality of life for guests/residents by integrating meaningful and enjoyable activities into daily experiences. Facility team members plans, coordinates, encourages, and supports a variety of recreational and therapeutic activities for all guests/residents based on individually identified needs, interests, culture, and background. -Life enrichment programs are developed and implemented to meet the individualized physical, mental, spiritual, and psychosocial/emotional needs of the guest/resident as well as promoting self-expression and choice. Activities refer to an endeavor, other than routine activities of daily living, in which a guest/resident participates in activities that enhances his/her sense of well-being and that promotes or enhances physical, cognitive, and emotional health. -Guest/residents are encouraged, but not required, to attend and participate in recreational and therapeutic activities in a group setting, one-on-one, or self-directed activities. . Procedure: 3. Share with guest/resident and family the center schedule of life enrichment activities and assist in identifying areas programs of interest *If there are no scheduled programs of interest to the guest/resident, discuss plan to schedule desired activities. 10. Assist and support other life enrichment programs as needed.

Based on observations, interviews, and record reviews, the facility failed to allow two residents (#64 and #62) out of 40 sampled residents to exercise their autonomy related to the individual preference of having a personal refrigerator in their room. Findings included: 1) The review of Resident #64's Admission Record identified the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to cervical spina bifida with hydrocephalus, moderate protein-calorie malnutrition, and unspecified paraplegia. On 11/14/23 at 9:24 a.m., Resident #64 reported having a personal refrigerator and the facility had removed it about 3-4 weeks before his birthday in June. The resident stated the facility informed him the removal was due to health and safety. The resident reported being able to maintain the refrigerator and it had contained cans of soda. Resident #64 reported it was a new refrigerator bought by a family member. During the interview, a refrigerator was not observed in the resident's room. On 11/15/23 at 3:25 p.m., Resident #64 stopped writer in hallway and again reported the facility had removed a personal refrigerator from his room. The resident reported being informed of the removal right before they took it, it had a 6 pack of cola in it, and he could clean it by himself. The resident stated the Nursing Home Administrator (NHA) informed him the refrigerator was in storage. An observation, on 11/16/23 at 1:36 p.m., identified Resident #64 propelling self in wheelchair in the hallway and was able to maintain control of it using both hands. Review of Resident #64's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating an intact cognition. The MDS revealed the resident required extensive assistance from one person for bed mobility, dressing, and toileting, was independent with locomotion on and off unit, and required limited assistance from one person for personal hygiene. On 11/15/23 at 1:52 p.m., Staff N, Certified Nursing Assistant (CNA), stated Resident #64 had a refrigerator and about 2-3 months ago they (management) came around and took them all out saying it was because of health and safety issues. The Executive Director (ED) provided, on 11/16/23, a copy of a handwritten list of thirteen resident names, which included Resident #64's. The list was dated June 2023, Resident #64's name had a X next to name with Sat - Birthday. Resident #64 was the only name with a X next to it, others had notations with bullet points in front of the name. A handwritten list of refrigerators, dated July 2023, did not include Resident #64's name and included 11 other resident names. The resident names had x after the name, with no indication of what x meant. A handwritten list of Refrigerators, dated 8/15/23, included 10 resident names - 3 with ok, 1 identified I did, 6 noted no. Additional information listed was two additional resident names, one of which was Resident #64's, dated 8/21/23, both of the names were followed by no. The list for August 2023 did not identify what no, ok, or I did meant. The lists provided by the ED did not identify the staff member or members who had noted the refrigerators, revealing multiple staff had been involved. On 11/16/23 at 3:15 p.m., the ED stated residents were assessed on their ability to clean the personal refrigerators and maintain temperature logs, and as a team the personal refrigerators were determined to be a safety issue as well. The ED reported residents were notified by memo and representatives received a robo-call to inform them of the removal. On 11/16/23 at 3:34 p.m., the ED stated Resident #64's refrigerator had not been managed appropriately and no resident and/or representative had been able to maintain the personal refrigerators so all had to be removed. The NHA stated during a resident council meeting the residents were notified that they or their representatives would have to maintain the refrigerators. She reported there were nutrition refrigerators on the units that residents could use. The NHA was unable to provide documentation that determined Resident #64 had not maintained his personal refrigerator. She reported she had the documentation in sooooo many areas, not knowing she would have to have access to it, and sent the Director of Nursing (DON) to the unit to look for the documentation. The NHA stated the Ombudsman was notified of the refrigerators removal and did not have an issue with the decision. A review of the Resident Council meeting notes from May 2023 identified the council was informed on 5/10/23 that all residents having refrigerators in their rooms must be able to maintain/clean them and no coffee machines were allowed in resident rooms. The meeting notes, from 5/10/23, revealed Resident #64 had not attended the meeting. The review of Resident #64's progress notes did not reveal the resident was notified of the need to maintain or had been educated on maintaining the personal refrigerator in accordance with the standards of food safety. A letter provided by the ED and addressed to Resident #64, dated October 26, 2023, identified the facility was storing the residents refrigerator and it needed to be removed from our center to a permanent location. 48823 2. On 11/13/2023 at 7:30 a.m. Resident #62 was observed sitting at his bedside getting ready for breakfast. He stated that he was concerned regarding his refrigerator being taken away without notice, and he wanted to have it back in his room. On 11/13/2023 at 11:00 a.m. review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses to include Type II Diabetes Mellitus, obesity, adult failure to thrive, hypertension and insomnia. Review of the Admission Minimum Data Set, October 2022, revealed in Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. An interview with Resident #62 on 11/15/2023 at 11:45 a.m. confirmed he had a refrigerator, and it was removed several months ago. He stated the Nursing Home Administrator (NHA) was removing all the refrigerators because residents were not following the facility policy to keep them clean. Resident # 62 stated he asked the NHA to look at his refrigerator and she stated to him she wished hers was as clean at her home. Resident #62 stated at no time was he informed he did not follow facility policy for the care of the refrigerator. Resident #62 stated he keeps his extra milk from dietary in the refrigerator, he keeps his soda his family brings to him in the refrigerator as well. He stated using the refrigerators on the nursing unit is an inconvenience and he has to get someone to unlock the door to the nourishment room. Review of the care plan, dated 11/2/2022, revealed the following: Focus: Resident will remain in long term care at the facility, and the goal will be to adjust to facility living without difficulties, and the intervention will be to provide services in an effort to enhance well-being. Focus: Resident prefers self-directed activities with a goal of being involved in activities of his choosing, and an intervention of in room activities of his choice. Focus: Resident is at risk for malnutrition related to adult failure to thrive, a goal of no weight loss and with an intervention of honoring preferences and diet as ordered. Review of a progress note dated 7/18/2023, and signed by the facility psychiatric service provider, revealed, [Resident #62] is being seen for depression and insomnia follow-up. Resident is in good spirits he reports his appetite is fair and that depends on the food. He admits that he orders take out with other residents. During an interview on 11/16/2023 at 9:50 a.m., with the Nursing Home Administrator (NHA) and the Dietician, the NHA stated a meeting was held with the resident regarding his request for a refrigerator in his room. The meeting was held with the resident and his family member. The NHA stated the resident's family member stated she does not feel Resident #62 is capable of following the facility policy to maintain the refrigerator and she is not able to help Resident #62 maintain the refrigerator. The NHA stated facility notes went out to the residents with refrigerators on August 21, 2023, regarding the removal of refrigerators, and on August 26, 2023, regarding storage of any refrigerators. Review of a progress note dated 5/31/2023, by the NHA revealed the meeting with the resident and family member acknowledged and agreed to the facility terms to have a personal refrigerator within the resident's room. Resident #62 and family member agreed to clean the refrigerator, temperature check the refrigerator, and keep the refrigerator in good repair for the resident's and facility's safety. There were no further progress notes related to denial of Resident #62 having a refrigerator in his room and no notes related to him not following facility policy for maintaining the refrigerator. During an interview with Resident # 62 on 11/16/2023 at 11:45 a.m. the resident stated the NHA told him the refrigerator had to be removed as there were other residents that did not keep their refrigerators clean and so all of the refrigerators in the facility had to be removed. He stated he was not given any letter regarding the removal. He stated that his family members help him with whatever he needs, and they bring him any items that he needs. He stated that his family members visit him weekly. He stated that when the NHA came to see him about the refrigerator and told him it was because residents are not keeping the refrigerators as per facility policy, he asked her to look at his and he stated that she told him she wished hers at home was as clean as his was. Resident #62 stated that he has not received any written notices and that no one spoke with a family member as far as he knows regarding care of the refrigerator. Interview with Staff K, Certified Nursing Assistant/Unit Clerk/Transport Driver (CNA/UC/TD) stated Resident #62's family members visit several times a week and they come in the evenings as they work during the day. Review of a facility memo, dated August 21, 2023, revealed the following: As of today, Palm Garden of [NAME] will no longer permit use of personal refrigerators in resident/guest rooms due to health and safety concerns. All personal refrigerators need to be removed by the end of day on August 24, 2023. If you are unable to arrange for the removal, the facility will place the refrigerator in resident/guest storage for a short period of time while arrangements are made for picking up the personal item. Please call [phone number] if you have any questions. The facility has nourishment rooms on each unit for storage of food items. We ask that your personal items be labeled for identification purposes. Review of the policy titled, Culinary Services - Resident Personal Food, December 2018, 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. Procedure: Personal refrigerators will be allowed in resident rooms at the discretion of the Executive Director. Resident or designee will be responsible for monitoring and maintaining the refrigerator in accordance with standards of food safety. Review of the policy titled, Resident [NAME] of Rights - A Guide To Your Rights As A Resident, revised July 2021, revealed the following: B. Notes of Rights and Services: The center must inform the resident, both orally and in writing, in a language that the resident understands of his or her rights and all the rules and regulations governing resident conduct and responsibilities during the stay in the center. The center must also provide the resident with notice (if any) of the state plan developed under section 1919 (e)6 of the act such notification must be made prior to or upon admission, and as appropriate during the resident stay, and when the centers rules change. The resident has the right to be informed of his/her rights and of all rules and regulations governing resident conduct and responsibilities during his/her stay in the center, anytime state or federal laws relating to the residents right or center rules change during the resident stay in the center he/she must be promptly informed of those changes N. Personal Property: The right to retain and use personal possessions including some furnishings, and appropriate clothing as space permits, unless to do so would infringe upon the rights or health and safety of other residents. The center shall exercise reasonable care for the protection of the resident's property from loss or theft.

Based on record review and interview, the facility failed to issue a written discharge notice when the decision was made to not accept one (#1) of three sampled residents back from the hospital, and the facility failed to provide timely written notice of transfers to the resident and their responsible party for one of three (#2) residents sampled for admission, transfer, and discharge requirements. Findings included: 1. Review of Resident #1's admission record revealed that she was admitted to the facility on [DATE]. Review of the transfer form indicated the resident was sent to the hospital on Saturday, 9/25/21, and the reason for the transfer was chest pain. Review of the Nursing Home Transfer and Discharge Notice with an effective date of 9/25/21 revealed the date the notice was given to the Resident/Representative was documented as 9/29/21 (Wednesday/4 days after the effective date). The form indicated that your needs cannot be met in this facility. On 11/23/21 at 3:03 PM, the Director of Guest Relations (DGR) revealed that Resident #1 was originally accepted back to the facility, but the resident tested positive for COVID prior to discharge from the hospital. This facility does not accept positive COVID residents, and the family was offered placement at another facility owned by the same corporation (sister facility). The DGR reported that all communication with the family was verbal, and no additional written notification of discharge was issued to the resident or the responsible party. On 11/23/21 at 3:20 PM, the Nursing Home Administrator (NHA) reported that if a resident goes out to the hospital they will take them back, but if the resident was COVID positive they would send the resident to their sister facility. She reported that Resident #1 was not accepted back to the facility for this reason. The resident was offered the opportunity to go to their sister facility but somehow ended up at another facility, and she did not know why. The NHA confirmed that Resident #1 was not issued written notification when the decision was made to not accept her back due to a COVID diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #2's record revealed that she was admitted to the facility on [DATE]. Review of the record indicated the resident was transferred to the hospital on Thursday, 11/4/21. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Home Transfer and Discharge Notice with an effective date of 11/4/21 revealed the date the notice was given to the Resident/Representative was documented as 11/14/21 (Sunday/10 days after the effective date). The form indicated that your needs cannot be met in this facility. Interview with the Nursing Home Administrator (NHA) on 11/23/21 at 2:48 PM revealed that she or the receptionist were the ones who completed the Nursing Home Transfer and Discharge notice form. She reported that if the resident was alert at the time of the transfer, then the form will go out with them. She reported that typically the form was not sent out if the resident goes to the hospital on the weekends as she or the receptionist were not there on the weekends, but the notice will go out on Mondays. She reported the forms were sent out to the address on file, and that she was not aware if the representative/resident received it. She reported the date reflected on the notice given to section of the form was the date the form was mailed out. On 11/23/21 at 3:03 PM, the Director of Transitional Services and the DGR reported that Resident #2 did not return to the facility as the resident/family chose to go to a rehab hospital. The resident had a limited amount of skilled days left and the rehab hospital could bill differently allowing the resident more time for rehabilitation services. A policy related to written transfer/discharge notice was requested, but not provided.

Based on interviews and record review, the facility failed to document in the medical record the specific needs that could not be met by the facility, the facility's attempts to meet the needs, and the services available at the receiving facility to meet the needs for one (#1) of three residents sampled for admission, transfer, and discharge requirements. Findings included: Review of the Admission Record for Resident #1 revealed an admitted [DATE] and a primary payer source of Medicare. Continued review of the medical record for Resident #1 revealed an Interdisciplinary Discharge Summary with a discharge date of [DATE]. The reason for discharge was documented as chest pain. Review of a resident transfer form revealed Resident #1 was transferred to the local hospital on 9/25/21 due to chest pain. A Nursing Home Transfer and Discharge Notice with an effective date of 09/25/21 and a 09/29/21 date the notice was provided revealed the resident was discharged from the facility to the local hospital because Your needs cannot be met in this facility. It was also noted on this transfer notification to see the attached orders. Review of the attached orders revealed a 09/26/21 verbal physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional information could be found in the resident's medical record by the resident's physician or other facility personnel relating to a request for Resident #1 to return to the facility from the hospital, documentation that the facility was not accepting the resident back and why, any attempts to meet the needs of the resident so that she could return to the facility, and any accommodations/services available at another facility which would meet the needs of this resident. On 11/23/21 at 3:03 p.m., the Director of Guest Relations (DGR) stated that Resident #1 was originally accepted to come back to the facility following the 9/25/21 hospitalization , but while she was in the hospital, she tested positive for COVID-19. The DGR reported that this facility does not accept COVID patients, but they offered the resident a bed at their sister facility (another facility within the same corporation). The DGR indicated that she had several conversations with the resident's daughter about not being able to accept the resident back due to her having COVID-19 and offering her a bed at the sister facility. The DGR revealed that no documentation of these discussions was maintained. The DGR reported that Resident #1 did not go to the sister facility but instead went to another facility owned by a different corporation. The DGR thought that the family selected the other facility due to distance. Review of Google maps (https://www.google.com/maps/dir/) revealed the approximate distance from this facility to the sister facility was 33 miles and the other facility was approximately 17 miles. On 11/23/21 at 3:20 PM, the Nursing Home Administrator (NHA) reported that she gets communication from the hospital when residents are ready for discharge and if people go out to the hospital they will take them back. However, if the resident was COVID positive they would send the resident to their sister facility. She reported that Resident #1 was offered the opportunity to go to their sister facility but could not show any of this documentation in the clinical record.

Based on observation, record review, and interviews the facility failed to ensure one resident (#30) was assessed for self-administration of a medication and that the medication was not stored at bedside out of five residents sampled for unnecessary medications. Findings included: An observation was made at 3:18 p.m. on 9/22/21 of a box labeled, [MEDICATION(S)] Spray on the over-bed-table of Resident #30. (Photographic Evidence Obtained) The resident stated that she had brought the nasal spray from home and used it every couple of days. She reported that staff were aware she had it and that she did not try to hide it. A review of Resident #30's September 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/21 at 4:01 p.m., the Director of Nursing (DON) stated Resident #30 was not allowed to self-administer medications. An observation was conducted with the DON, who viewed the box of [MEDICATION(S)] on the resident's table and stated that she would take care of it. A review of the Admission Record for Resident #30 showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy titled, Self-Administration of Medications, effective 12/1/07 and revised 5/10/10 and 11/28/16, indicated: - 3. To ensure safe and appropriate Self-Administration, Facility should educate residents to ensure that a resident is able to: .correctly store his/her medications in a locked compartment .5. Facilty should ensure that orders for Self-Administration list the specific medication(s) the resident may Self-Administer. The policy: Storage and Expiration Dating of Medications, Biological's, Syringes, and Needles, effective 12/1/07 and later revised on 10/28/19, identified the following: - Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. - When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle. - Bedside Medication Storage: Facility should not administer/provide bedside mediations or biological's without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. Facility should store bedside medications or biological's in a locked compartment within the resident's room.