Every finding on record at Palms Care Center and Rehab

Based on observation, record review, and interview, the facility failed to provide grooming services for 1 of 21 sampled residents, Resident #42, observed during the screening process. The findings included: Record review revealed Resident #42 was admitted to the facility on [DATE], with diagnoses that included Major Depressive Disorder, Generalized Anxiety Disorder, Blindness Right Eye Category 5, and Blindness Left Eye Category 5. A quarterly assessment dated [DATE] revealed that Resident #42 had a Brief Interview for Mental Status of 15 indicating he was cognitively intact. His care plan dated 01/26/23 documented that he had a self-care deficit with grooming. The goal was for Resident #42 to have a clean, neat appearance daily. One of the interventions listed was for staff to provide hand-on assistance with grooming.An observation on 04/27/25 at approximately 1:30 PM revealed Resident #42 looked unkempt, and his beard extended approximately 8-10 inches below his chin.An interview on 04/27/26 at approximately 1:40 PM with Resident #42 revealed he always kept his face groomed in the past. When asked if he liked the current length of his beard, Resident #42 said he preferred his beard trimmed around his neck and under his chin. When asked why it was so long, the resident said they don't have trimmers on their cart anymore. One of the (unnamed) nurses or CNAs (Certified Nursing Assistant) said he had to go to the shop if he wanted his beard shaved. Resident #42 said that it would have cost about $30 dollars, and he couldn't afford to pay the salon for that service. During another interview on 04/30/2026 at 11:05 AM, Resident #42 said he had requested to be shaved approximately 6 - 8 months ago and he was told that the electric trimmers were missing. Since then, Resident #42 said he asked staff about 3 - 4 more times to be shaved. He said he was told there were no trimmers and more than one staff member told him he had to go to the salon if he wanted that service.An interview on 04/28/26 at 8:55 AM with Staff B, Licensed Practical Nurse (LPN), revealed that grooming was one of the duties that the CNAs were responsible for.An interview with Staff C, CNA, was conducted on 04/30/26 at 11:20 AM. Staff C agreed that Resident #42's beard looked like it needed to be groomed. Staff C said that she had shaved residents before with an electric shaver. She said the electric shaver with shears used to be kept at the nurse's station. The CNA and the surveyor walked to the nurse's station. The. CNA did not find the electric shaver at the nurse's station.An interview with the Directo Of Nursing (DON) on 04/30/26 at 11:05 AM revealed that she kept electric shavers in her office.

Based on observation, interview and record review, the facility failed to provide timely rehabilitative services for 2 of 8 sampled residents reviewed for Physical and Occupational Therapy, Resident #3 and Resident #86. The findings included:1. Record review revealed Resident #3 was admitted to the facility on [DATE]. The medical diagnoses included: Hemiplegia (total loss of movement to one side of the body) and Hemiparesis (partial weakness on one side of the body) following a left side Cerebrovascular Accident (stroke that occurs on the left side of the brain), Silent Myocardial Ischemia (silent heart attack) and Muscle Wasting. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, on a 0-15 scale, indicating the resident was cognitively intact. The MDS also documented Resident #3 had impairment to both upper and lower extremities, which required either moderate assistance from the staff or dependence on the staff to perform the activities of daily living such as dressing, bathing, toileting and personal hygiene.Review of the quarterly Physical Therapy / Occupational Therapy (PT/OT) Screening dated 03/24/26, indicated Resident #3 would benefit from skilled PT/OT services to improve strength, balance and reduce the need for significant care giver assistance.Review of the current care plan dated 04/09/26 documented Resident #3 was to wear a right resting hand splint for 4 to 6 hours as tolerated, with a goal to prevent further contracture. The interventions were to have the resident participate in range of motion exercises 7 days per week, and to refer to PT/OT for therapeutic intervention.Review of the physician's orders dated 04/28/26, instructed OT to evaluate and treat Resident #3, provide services 4 times per week for 4 weeks for therapeutic exercises and activities along with self-care training. Another order dated 04/29/26 instructed PT to evaluate and treat the resident 4 times per week for 30 days.Review of the Occupational Therapy Evaluation and Plan of Treatment indicated the resident started services on 04/28/26, 35 days after the initial screening on 03/24/26. Physical Therapy services started on 04/29/26. During an observation on 04/27/26 at 9:42 AM, 04/28/26 at 8:17 AM and on 04/29/26 at 8:39 AM, Resident #3 was observed in bed with a right-hand splint in place.During an interview with Resident #3 on 04/27/26 9:42 at AM and on 04/28/2026 at 8:17 AM, the resident was asked if she was doing exercises with the staff for her right hand. Resident #3 stated on both occasions that she had not been doing any exercises.During an interview and side by side review of the records on 04/29/26 at 8:44 AM, the Director of Rehabilitation Services, who is a Physical Therapist, explained that the usual time frame for a resident to be screened by PT/OT, evaluated and started on services is within 1 week. Each visit with the resident is documented. She confirmed that Resident #3 was screened on 03/24/26 but did not begin services until 04/28/26. The Director of Rehabilitation Services admitted there was a delay in the care of Resident #3 to improve the resident's functioning, to reduce the need for significant assistance. She attributed this to staffing during that period; having to prioritize between residents who required a higher level of therapy to those less acute, as well as the volume of admissions. She further stated Resident #3 continued to require one person assistance from the time of screening to the start of services. 2. Record review revealed Resident #86 was admitted to the facility on [DATE]. The medical diagnoses included Chronic Obstructive Pulmonary Disease, Contracture (permanent tightening of muscles, tendon or skin) of right and left knee, Muscle Wasting and Atrophy. Review of the quarterly MDS assessment dated [DATE], documented Resident #86 with a BIMS score of 0, indicating the resident had severe cognitive impairment. The MDS also documented the resident required maximum assistance from the staff or was dependent on the staff for transferring and performing activities of daily living (ADLs).Review of the quarterly Physical Therapy / Occupational therapy (PT/OT) screening dated 03/13/26, indicated the resident would benefit from skilled OT services to improve activities of daily living (ADLs) through increased strengthening.Review of the current care plan dated 03/19/26 documented Resident #86 had a self-care deficit with a goal to improve the resident's functioning through staff interventions. The interventions included the resident to have 1-or-2-person assistance for meals, baths and bed mobility, and PT/OT services as required.Review of the physician's orders dated 04/07/26 instructed for OT to evaluate and treat Resident #86, provide services 4 times per week for 30 days for therapeutic exercises and activities along with self-care training. Review of the Occupational Therapy Evaluation and Plan of Treatment indicated the resident started services on 04/07/26, 25 days after the initial screening on 03/13/26.During an interview and side-by-side review of the record on 04/30/26 at 10:38 AM, the Director of Rehabilitation Services was asked again about the lack of intervention between the time of the resident's screening and the start of services. She admitted that the OT services for Resident #86 which were required to strengthen the resident and improve the ADLs, were also delayed.

Based on observations, record reviews, and interview, the facility failed to use appropriate infection control practices with nebulizer equipment for 2 of 3 sampled residents, Resident #32 and Resident #65, reviewed for nebulizer treatments, of 15 residents who had physician's orders for nebulizer treatments. The findings included: Record review of the facility's policy on Administering Medications through a Small (Handheld) Nebulizer, revised 2010, documented to rinse and disinfect the nebulizer equipment, and to allow the equipment to dry on a paper towel. When the equipment was completely dry, it was to be stored in a plastic bag with the resident's name and the date on it. Record review revealed Resident #32 was admitted to the facility on [DATE]. His diagnoses included Interstitial Pulmonary Disease, Unspecified, Chronic Obstructive Pulmonary Disease (COPD), and Acute and Chronic Respiratory Failure with Hypoxia. Review of an assessment dated [DATE] revealed that Resident #32 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that she was cognitively intact. A review of the medical administration record dated 04/27/26 showed that she received Ipratropium-Albuterol Inhalation Solution via nebulizer at 6:00 AM. Her care plan documented she had the potential for complications of respiratory distress related to her history of Asthma and COPD. An observation on 04/27/26 at approximately 10:00 AM revealed Resident #32's nebulizer mask on the 3-drawer dresser next to her bed. The nebulizer mask rested directly on the top surface of the dresser. Small light-colored crumb-like debris was on the top surfacr of the dresser next to the nebulizer mask. The mask was not on top of a paper towel, and it was not in a plastic bag. Photographic Evidence Obtained. Record review revealed Resident #65 was admitted to the facility on [DATE]. His diagnoses included COPD with Acute Exacerbation, and Emphysema, Unspecified. An assessment dated [DATE] revealed that Resident #65 had a Brief Interview for Mental Status (BIMS) of 15, which indicated he was cognitively intact. His care plan last revised 04/12/26 documented he had the potential for complications of respiratory distress related to his medical history that included COPD, Emphysema, Pulmonary Fibrosis, Respiratory Failure , Congestive Heart Failure, and the use of oxygen. The medication administration record documented that Resident #65 was administered Ipratropium-Albuterol Inhalation Solution via nebulizer twice on 04/27/26 and three times on 04/28/26. An observation on 04/27/2026 at approximately 3:00 PM, revealed Resident #65's nebulizer mask on the top surface of the 3-drawer dresser next to his bed. The mask was not on top of a paper towel. It was not covered inside a plastic bag.Photographic Evidence Obtained An observation on 04/28/26 at 4:50 PM revealed Resident #65's nebulizer mask was on top of the dresser. It was not on top of a paper towel. The mask was not covered inside a plastic bag. Photographic Evidence Obtained An observation on 04/29/26 at 3:04 PM revealed Resident #65's nebulizer mask was on top of the dresser. It was not on top of a paper towel. The mask was not covered inside a plastic bag. Photographic Evidence Obtained An interview was conducted with Staff A, (RN Supervisor), on 04/28/2026 at 5:19 PM. Together, Staff A and the surveyor went to the rooms of Resident #32 and Resident #65. Staff A agreed that the nebulizer masks of Resident #32 and Resident #65 were directly on top of the surface of the dressers in each of the resident's rooms. Staff A explained that the facility's policy was to keep the nebulizer mask in a zip lock bag with the resident's name, room number, and date. She said she had no idea why they weren't stored properly. When asked what the possible consequences were from leaving the nebulizer on top of the dresser uncovered, Staff A said it could increase the resident's risk of infection. An interview with the DON on 04/30/26 at 3:30 PM clarified that the nebulizer masks were supposed to be cleaned after each use.

Based on observation, interview and record review, the facility failed to obtain informed consents for use of psychotropic medications for 1 of 5 sampled residents reviewed for unnecessary medications and 2 of 2 sampled residents reviewed for accidents, Residents #41, #42 and #95.The findings included:The facility's policy titled, Informed Consent for Psychotropic Drugs, undated, revealed a psychoactive drug is any drug that affects brain activities associated with mental processes and behavior, including but not limited to antipsychotics (e.g., haloperidol risperidone), antidepressants, anxiolytics, hypnotics, mood stabilizers, anticonvulsants, central nervous system agents, muscle relaxers, anticholinergics, antihistamines, NMDA receptor modulators, and over -the- counter natural/herbal products. Informed consent is disclosure of material information (reasons for use, benefits, risks, including black box warnings, alternatives including non-pharmacological approaches) to the resident or their representative/surrogate allowing them to accept, refuse, or revoke consent. Consent must be obtained prior to initiation or increase. 1. Record review revealed Resident #95 was admitted to the facility on [DATE] with diagnoses that included Wernicke's Encephalopathy, Cirrhosis of Liver, and Open-Angle Glaucoma, Bilateral, Severe Stage. Her Brief Interview for Mental Status (BIMS) score was 12 on the quarterly Minimum Data Set (MDS) dated [DATE]. This indicated the resident had moderate cognitive impairment. A review of the resident's medications revealed a physician's order for Trazodone HCl Oral Tablet 50 MG (milligrams) give 1 tablet by mouth at bedtime for depression. She also was prescribed Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) give 1 tablet by mouth two times a day for mood stabilizer. A review of the Informed Consent for Use of Psychotropic Medication revealed the medication Trazodone is listed and signed by the resident on 04/18/26 as consenting to being given that medication. There was no consent for Depakote. On 04/30/26 at 1:00 PM, the Director of Nursing (DON) was asked about the consent for Depakote, and she stated there was no consent for Depakote because it is an anti-seizure medication. It was discussed with the DON that it is being used as a mood stabilizer, and therefore, it should have an informed consent. 2. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Syncope and Collapse, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Her BIMS score was 6 on the quarterly MDS dated [DATE] indicating she was severely cognitively impaired. A review of the resident's medication revealed a physician's order for Trazodone HCl Oral Tablet 50 MG give 1 tablet by mouth 2 times a day for Major Depressive Disorder. There was an additional order for Trazodone HCL Oral Tablet 100 MG give1 tablet by mouth at bedtime for Major Depressive Disorder. There was also a physician's order for Divalproex Sodium Tablet Delayed Release 125 MG 1 tablet three times a day for Mood. A review of the Informed Consent for Use of Psychotropic Medication revealed the medication Trazodone is listed and signed by the resident on 04/22/26 as consenting to being given that medication. There was no consent for Depakote. On 04/30/26 at 1:00 PM, the Director of Nursing (DON) was asked about the consent for Depakote, and she stated there was no consent for Depakote because it is an anti-seizure medication. It was discussed with the DON that it is being used as a mood stabilizer, and therefore, it should have an informed consent. The DON agreed that there should be a consent for Depakote because it is being used as a mood stabilizer. 3.Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder, Mood Disorders, Anxiety Disorder, Insomnia, and Blindness Right and Left Eyes. Review of the quarterly assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. Review of the care plan dated 01/16/25 stated he had a potential for adverse side effects related to the use of an antidepressant for depression. He had a physician's order dated 01/25/23 for Trazodone HCl 50 milligrams daily, with instructions to give 1 tablet by mouth at bedtime for depression. Record review revealed an Informed Consent for Psychotropic Medication dated 01/26/23, that was verbally signed in person by Resident #42. The box that had a checkmark documented Resident #42 consented to the use of the Trazodone. The consent form said that he understood once the target behavior system was controlled, the dose would be gradually reduced to the lowest possible dosage and frequency or discontinued unless contraindicated by the physician. Photographic Evidence Obtained. Record review revealed Resident #42 had a physician's order for Trazodone HCl oral tablet 150 milligrams dated 08/22/25. The instructions said to give 0.5 tablet by mouth at bedtime related to Major Depressive Disorder. The total amount of Trazodone HCl ordered per day was 75 milligrams. A Psychiatric Encounter note dated 08/25/25 noted during last visit, patient was stable. The date of service for the prior visit was 08/12/25. On 08/12/25 Resident #42 had an order for 75 milligrams of Trazodone per day. A physician's order for Trazodone HCl 100 milligrams oral tablets dated 08/22/25 was active at the time of the survey. The instructions said to give 1 tablet by mouth at bedtime for Major Depressive Disorder. The total number of milligrams per day was 100mgs. An interview was conducted with the DON on 04/29/26 at 5:15 PM. When asked if she had documentation of a more recent Informed Consent for Psychotropics that was dated after the increase in the strength of Trazodone for Resident #42, the DON said no. The DON said that she didn't think it was required to have a consent formed signed after an increase in the dosage of a psychoactive medication.

Based on observation, interview and record review, the facility failed to protect private medical records for 1 of 1 sampled resident reviewed for privacy, Resident #36. The findings included: Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominant Side, and Schizoaffective Disorder, Bipolar Type. Her Brief Interview for Mental Status was 6 on the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicating she was severely cognitively impaired.On 04/29/26 at 2:00 PM, a family member of the resident was interviewed. She stated she was given the wrong envelope when she took her mother to the doctor. She spoke with the Administrator and put in a grievance with the facility.Review of grievance dated 04/28/26 revealed the resident returned from an appointment and reported that the incorrect enveloped was given to the patient. Review of the Action taken documented the new ward clerk was in serviced on HIPPA (Health Insurance Portability and Accountability Act). An interview was conducted with Staff D, Unit Secretary, on 04/30/26 at 10:58 AM who stated this is her 4th day here. Staff D stated they do the envelopes 1 week in advance; the name of the patient and the doctor's address is taped on the outside of the business envelope; and the inside of the envelope is the progress notes, face sheet, physician orders, medication list and consult report that the physician would write on. Staff D stated she gave the resident's daughter the envelope that had the correct name on the outside of the envelope but inside was another resident's information. She was the only resident who went to the doctor that day so there was no other resident involved. The resident whose information was inside of the envelope had his appointment cancelled. She stated that since this occurred, she has a new way of doing this. She puts the name of the patient and the doctor's information on the outside of the envelope and inside of the envelope she puts the progress notes, face sheet, physician orders, medication list and consult report that the physician would write on. Staff D stated she would open the envelope in front of the resident or family member to assure that the resident is receiving the correct information. All of the residents or representatives go to her to pick up the envelopes.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pest (flies and roaches). The findings included: 1. During resident screenings and routine observations conducted on 10/21/24 through 10/24/24, numerous sightings of flying insects were noted by the surveyors that included the following: a. On 10/21/24 - Main Kitchen (7, 9 AM), 300 and 400 Units, and Main Dining Room (12:30 PM). Staff stated that flies and roaches are a common daily occurrence. b. On 10/22/24 - Main Dining Room (8 AM) and in resident Hallways (8 AM - 10 AM). Staff and residents stated that flies are a common daily occurrence. c. On 10/23/24 - Main kitchen (7 AM) and the resident Hallways (300 and 400 Unit). Staff stated that flies are a daily common occurrence. d. On 10/24//24 - Main Dining room [ROOM NUMBER] AM and 12 PM, the resident Common Areas, and the resident Hallways (200, 300, and 400 Units). Photographic Evidence Obtained of above. 2. During the review of facility's Pest Sighting Logs for August 2024, September 2024, and October 2024 (10/02-22/24), numerous sightings were documented by staff that included the following: August 2024: Twenty-six documented sightings that included resident rooms and bathrooms and nourishment rooms. The areas were reported to the pest control company and documented as treated. September 2024 - Twenty-two documented sightings in resident rooms and bathrooms, staff offices, and nurses stations. The areas were reported to the pest control company and were documented as treated. October 2024 (10/01-22/24): Twenty-four documented sightings in resident rooms and bathrooms, nursing food pantry's, staff offices, and nurses stations. The areas were reported to the pest control company and were documented as treated. 3. During the review of the facility's pest control documentation for the months of August 2024, September 2024, and October 2024, it was noted the facility is having Bottle / Flesh Fly activity, standing inside water, accumulation of food products, tree / vegetation touching the building, and door gap/damage. Refer to F584 for additional findings. 4. During an interview conducted by the surveyor with the facility pest control technician on 11/24/24 at 11 AM, it was confirmed that the facility has re-occurring monthly issues with flies and roaches. The pest control technician stated that the facility requires twice monthly treatments and as-needed treatments called in by the facility.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses for 110 of 113 residents. The findings included: 1. During the initial tour of the Main Kitchen on [DATE] at 9:30 AM, and accompanied by the Dietary Director, CDM (Certified Dietary Manager), the following was observed and noted: a. The walk-in refrigerator contained 2 expired items. The Marmalade was dated [DATE]. The Chicken Broth was dated [DATE]. b. The dishwasher was a low temperature dishwasher. The rinse temperature reached 140' F. The sanitization of the dishware depended upon the adequacy of the sanitizing solution. The Dietary Director, CDM, was asked to perform a chlorine sanitizer test to determine if the sanitizing solution was adequate to sanitize the dishware. The first test strip was dipped into the dishwasher solution, and it did not change color. A second test strip trial was performed and again the test strip did not change color. This did not meet the requirement for the concentration of chlorine per the manufacturer's instructions which is ,d+[DATE] ppm. Photographic evidence was obtained. c. A chlorine sanitizer test was performed on bucket #2. It turned blue. This indicated that the concentration of the solution was 400 ppm. The sanitizing solution was too strong. The requirement for the concentration of chlorine per the manufacturer's instructions was between ,d+[DATE] ppm. d. The dietary storage room for emergency supplies had red and brown stains on the floor. e. The gray plastic trays used to store coffee cups had black scuff marks on the exterior corners and on the lower halves of the trays. This was pointed out to the Dietary Director, CDM. She acknowledged that the items looked worn out. f. The electrical outlets on the walls near the spice rack area were soiled with debris. The walls in the surrounding area had many small spots of exposed wall from peeled off paint. g. The bench mounted commercial can opener had worn off metal exterior with metal shavings present. h. The interior of both Vulcan ovens had thick black residue cooked onto the surfaces of the walls, the doors, and the floors of the ovens. i. The silver wall located to the right of the ovens was splattered with white residue markings that looked like drip marks splattered on a large area of the wall. j. The robocoup (small food processor) was stored with the top plastic cover closed tightly and a pool of water remained inside of the plastic container. k. The Arctic Air Commercial reach in freezer had 2 gaskets that showed areas of detachment from the door, where a wet, dark colored, slimy looking substance was observed located along the folds of the gasket. l. The Victory reach-in freezer's gaskets showed areas of detachment from the door where a wet, dark looking, slimy substance was observed located up and down along the gasket. m. The dry storage room floor in the back corner under the food racks had a white chalky looking substance on the floor and up the side of the adjacent wall. 2. The Nourishment rooms were observed on [DATE] at 10:10 AM following the initial tour of the kitchen. The surveyors were accompanied by the Dietary Director, CDM (DD, CDM). The following was observed and noted: A. South wing nourishment room: a. The refrigerator in the South wing nourishment room had a bag of food with a use by date: [DATE]. b. The interior of the microwave had food stains of various colors including red, purple, brown, and yellow. c. The gasket in the refrigerator was ripped and showed areas of detachment from the door. 3. During a follow-up visit to the Main Kitchen on [DATE] at 08:15 AM, accompanied by the Dietary Director, CDM, the following was observed and noted: a. Surveyors observed food service employees placing breakfast foods onto plates and trays for delivery to the dining areas. There were plates and bowls that were stacked on a cart to be used on the breakfast trays. A small, white, plastic bowl had small black markings on it that looked like scuff marks. A plastic white plate was discolored with black marks, yellow splotches, and scratches on it. A plastic white compartment plate was stained with light black marks and 1 very dark black circular mark. These 3 items were given to the Dietary Manager, CDM, who removed them from the cart. Photographic Evidence Obtained of the above findings. The Dietary Director, CDM agreed with these findings.

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable homelike interior for 3 of 3 residential units (200, 300, and 400), the Skilled Therapy Department, the Main Dining Room, the Activity Room, and the Main Lobby. The findings included: During the tour conducted on 10/21-22/24, resident meal observations conducted on 10/21-23/24, routine resident observations conducted on 10/21-23/24, and the environment tours conducted on 10/23-24/24 accompanied with the Corporate Maintenance Director, the Maintenance Director, and the Director of Housekeeping, the following were noted: 200 Resident Unit: room [ROOM NUMBER]: Room windows soiled, and window screens torn and in disrepair. room [ROOM NUMBER]: Room windows soiled, and window screens torn and in disrepair. 300 Resident Unit: room [ROOM NUMBER]/#302/#304: main hallway outside of rooms and inside of rooms noted pervasive and offensive body odor and food / garbage odor. Interviews with staff who requested to not be identified at the time of the observation stated that the resident located within room [ROOM NUMBER] is refusing routine room cleaning, routine linen changes, and ADL (Activities of Daily Living) hygiene. room [ROOM NUMBER]: Room walls damaged and in disrepair. room [ROOM NUMBER]: Room floor soiled and stained, and bathroom water pressure too low. room [ROOM NUMBER]: Room walls damaged and in disrepair, and room widow heavily soiled. room [ROOM NUMBER]: Room floor heavily soiled and stained throughout, exterior of room furniture was peeling. Pervasive room urine odor, room windows heavily soiled, and privacy curtains (2) soiled and stained. room [ROOM NUMBER]: Bathroom toilet required re-caulking to the floor. room [ROOM NUMBER]: Old dialysis tubing required to be removed from the walls of the bathroom and main room. The large black tubing runs from the bathroom sinks onto the bathroom walls, through the bathroom walls and out into the mani bedroom walls all the way around to the beds. The black tubes are about waste high. room [ROOM NUMBER]: Bathroom shower chair seat cushion was torn, wood foot bed-frame heavily worn (D-bed), and call bell on floor (D-bed). room [ROOM NUMBER]: Old dialysis tubing required to be removed from the walls of the bathroom and main room. The large black tubing runs from the bathroom sinks onto the bathroom walls, through the bathroom walls and out into the mani bedroom walls all the way around to the beds. The black tubes are about waste high. room [ROOM NUMBER]: Soiled gloves (2) left on the bathroom floor. room [ROOM NUMBER]: Old dialysis tubing required to be removed from the walls of the bathroom and main room, and room windows soiled. The large black tubing runs from the bathroom sinks onto the bathroom walls, through the bathroom walls and out into the mani bedroom walls all the way around to the beds. The black tubes are about waste high. room [ROOM NUMBER]: Old dialysis tubing required to be removed from the walls of the bathroom and main room, and room windows heavily soiled. The large black tubing runs from the bathroom sinks onto the bathroom walls, through the bathroom walls and out into the mani bedroom walls all the way around to the beds. The black tubes are about waste high. room [ROOM NUMBER]: Room widows (2) soiled, and screens were torn. room [ROOM NUMBER]: Old dialysis tubing required to be removed from the walls of the bathroom and main room. The large black tubing runs from the bathroom sinks onto the bathroom walls, through the bathroom walls and out into the mani bedroom walls all the way around to the beds. The black tubes are about waste high. room [ROOM NUMBER]: Resident toothbrush left on bathroom floor. room [ROOM NUMBER]: Old dialysis tubing required to be removed from the walls of the bathroom and main room, and room widows (6) soiled, and screens were torn. The large black tubing runs from the bathroom sinks onto the bathroom walls, through the bathroom walls and out into the mani bedroom walls all the way around to the beds. The black tubes are about waste high. room [ROOM NUMBER]: Old dialysis tubing required to be removed [NAME] the walls of the bathroom and main room, bathroom mirror had desilverization, and room entry door exterior damaged and in disrepair. The large black tubing runs from the bathroom sinks onto the bathroom walls, through the bathroom walls and out into the mani bedroom walls all the way around to the beds. The black tubes are about waste high. Exit Corridor Doors: Do not shut tight and large space between doors noted. Community Shower Room: Private bathroom / toilet area missing the privacy curtain. 400 Resident Unit: room [ROOM NUMBER]: Exterior of room wall air-conditioner soiled and stained, and air conditioner filters (2) were heavily soiled and dust laden. room [ROOM NUMBER]: Room wall air cover was loose and falling off of the unit, and exterior of room entry door was in disrepair and damaged. room [ROOM NUMBER]: Room air-conditioning filters (2) were heavily soiled and dust laden. room [ROOM NUMBER]: Bathroom toilet tank lid off and not fitting, and Room air-conditioning filters (2) were heavily soiled and dust laden, and exterior of wall air-conditioning unit was stained and soiled. room [ROOM NUMBER]: Room air-conditioning filters (2) were heavily soiled and dust laden, and room walls damaged and in disrepair. room [ROOM NUMBER]: Room floor tiles (4) in disrepair, and old dialysis tubing requires to be removed to walls of the bathroom and main room. room [ROOM NUMBER]: Old dialysis tubing required to be removed from the walls of the bathroom and main room. The large black tubing runs from the bathroom sinks onto the bathroom walls, through the bathroom walls and out into the mani bedroom walls all the way around to the beds. The black tubes are about waste high. room [ROOM NUMBER]: Bathroom toilet required re-caulking to the floor. room [ROOM NUMBER]: Numerous large stains and scraped to room floor. Skilled Therapy Room: Parallel Bars: Bars (2) unstable, loose, and wobble. The floor area heavy soiled, worn, stained, and in need of replacement. Training Stairs: Stairs noted to be heavily soiled, stained, and non-slips taping in disrepair. Room Chairs - exterior cushions torn (2). Main Dining Room: Room windows (18) heavily covered in a green algae matter and residents unable to see outside of the room Room floor noted to have numerous and large black stains throughout the entire room. Numerous flying insects on all observations conducted on 10/21-23/24. Room ceiling tiles (40) noted to be soiled, and brown stained throughout the room. Dining room tables (legs / spindles) noted to have areas of peeling black paint. Activity Room: Room walls (2) in need re-painting, and garbage containers (2) requires a lid covering. Main Lobby Area: Exterior of 3 of 3 sitting chairs heavily worn and in disrepair. Following the environment tours conducted on 10/23-24/24, the examples were again reviewed with the Corporate Maintenance Director, and were again discussed and confirmed with the Administrator.

Based on observation, interview, and record review, the facility failed to ensure that its Cycle menus (#1, #2, #3, and #4) met the nutritional requirements for daily milk / dairy servings and that the approved menu was being followed for potentially 105 of 113 facility's residents. The findings included: 1. During the review of the current Cycle menu in use (Cycle #3) on 10/21/24, it was noted that only 8-ounces on milk / dairy was being served to residents on a daily basis. An interview conducted with the Corporate Dietary Manager (CDM) at the time of the review to review documentation of why the facility menus did not include the required 16-ounces of milk per day to the residents ([AGE] years or older). The surveyor specifically requested the government tool utilized to develop the facility's cycle menu. On 10/22/24, the CDM submitted to the surveyor a nutritional tool utilized for the development of the menus to be nutritionally adequate, and stated that an approved government tool was not utilized. Further interview and review noted an Optima Solutions Menu Template Nutrition Summary that was outsized for the menu development but the CDM explained to the surveyor that the facility menus did not included the required 2-8 ounces (16 ounce total) of milk per day. The CDM could not explain why the minimum milk requirement was not included on the facility's Cycle menus that included Cycles #1, #2, #3, and #4. The CDM additionally indicated that the menus would be revised on 10/22/24. It was noted that the issues with the milk servings potentially affected 105 of the facility's 113 residents. 2. During the review of the approved Cycle #3's menu for the breakfast meal, it was noted that all residents were to be served an 8-ounce portion of milk which would include whole, 2 %, or fat-free. Observation of the breakfast meal in the main dining room of 10/22/24 at 8:30 AM noted that there were 18 resident's in attendance for the meal. Further observation noted that all of the the residents were receiving only 4-ounces of milk in a juice cup. The milk serving issue was brought to the attention of the Minimum Data Set (MDS) Coordinator who was present during the meal service in the main dining room. The coordinator stated that nursing staff were giving only 4-ounce cups for the milk serving and that a 8-ounce carton was utilized for 2 servings per 2 residents. Interview with the Food Service Manger during the meal revealed that the staff should have issued 8-10 ounce large beverage cups for residents' use to ensure that an 8-ounce portion of milk was being served according to the approved breakfast menu.

Based on observations, interviews, facility policies, and record reviews, the facility failed to encourage hand hygiene, provide hand hygiene supplies, and assist residents in performing hand hygiene before meals for 6 of sampled 6 residents, Residents #14, #64, #30, #74, #95, and #27. The findings included: Review of polciy, titled, SNF Clinic Handwashing/ Hand Hygiene - F880; Infection Control, submitted by the Administrator documented, in part, considers hand hygiene the primary means to prevent the spread of healthcare associated infection, and #6 explaining Residents are encouraged to practice hand hygiene. 1. Record review revealed Resident #14 was admitted on [DATE] with diagnoses that included Protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease (lung disease that blocks air flow causing difficulty of breathing), Muscle wasting and Atrophy (thinning of muscle). Record review of Minimum Data Set (MDS) assessment Section C dated 09/19/24,revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating intact mental cognition. Section GG-A revealed Resident #14 needed eating set-up or clean-up assistance, and Section GG-I revealed set-up or clean-up assistance in washing and drying hands. An observation was conducted on 10/21/24 at 9:00 AM of an Enhanced Barrier Precautions (EBP) supply box and signage attached on Resident #14's door. In an interview with Resident #14 on 10/21/24 at 9:24 AM, when asked if Staff C provided wet towel with soap before a meal, she stated no. When asked if Staff C encouraged hand hygiene before eating a meal, Resident #14 stated no. An observation on 10/22/24 at 9:19 AM revealed Staff C, Admission Coordinator, delivered a breakfast tray to Resident#14. Staff C did not encourage hand hygiene and did not provide hand washing supplies to Resident #14. There was no packet of hand sanitizer observed inside Resident # 14's meal tray. There was no wet towel observed next to the meal tray. 2. Record review revealed Resident #64 was admitted on [DATE] with diagnoses that included Hemiplegia and Hemiparesis (paralysis or weakness on one side of the body) and Cerebral infarction (a condition when the brain blood flow is blocked) affecting the left non-dominant side. Review of quarterly MDS section C dated 08/08/24 revealed a BIMS score of 13 indicating an intact cognitive function. MDS Section GG-A dated 08/20/24 revealed Resident #64 needed set-up or clean-up assistance in eating, while Section GG0115 revealed Resident #64 had one-sided functional impairment on both upper and lower extremities. A further MDS review of Section GG-I revealed Resident #64 required set up or clean-up assistance in washing and drying hands. During an observation on 10/22/24 at 9:22 AM, Resident #64 was hand manipulating a bed control, while Staff E, an Administrator-In-Training was setting up the breakfast tray on the table. While Staff E was centering the meal tray on the table, Resident #64 was picking up a juice container without first performing hand hygiene. Staff E did not encourage hand hygiene or provide hand hygiene assistance and supplies to the resident. The surveyor did not observe any packet of hand sanitizer or a wet towel next to the meal tray. In an interview with Resident #64 on 10/22/24 at 9:28 AM, when asked if Staff E encouraged hand hygiene or aided him in sanitizing his hands before eating, he stated no. When asked if Staff E had offered a wet soapy towel, followed by a dry towel before eating, he stated no. When asked if his meal tray has a packet of hand sanitizer, he said none. 3. Record review revealed Resident #30 was admitted on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage (bleeding in or around the brain), affecting right non-dominant side, Essential Primary Hypertension, and Cerebrovascular Disease. Record review of annual MDS Section C dated 07/17/24 revealed a BIMS score of 15 indicating intact mental functioning. Section GG-A revealed Resident #30 required supervision or touching assistance during eating and Section GG-I dated 08/20/24 revealed Resident #30 needed set-up or clean-up assistance in washing and drying hands. During an observation on 10/22/24 at 9:06 AM, Resident # 30 was observed eating breakfast with one hand. He was putting a biscuit with gravy inside his mouth when the surveyor entered the resident's room. When asked if Staff encouraged hand washing before meals, he stated no. Upon closer observation, there was no packet of hand sanitizer inside the meal tray, or a wet towel observed on the table. When asked if staff provided him with a wet soapy towel and a dry towel before eating, he stated no. 4. Record review revealed Resident #74 was admitted on [DATE] with diagnoses that included Benign neoplasm of the brain (non-cancerous mass growing in the brain), and blindness of both eyes. Review of annual MDS Section C dated 09/10/24 revealed a BIMS score of 15 indicating an intact cognitive function. Section B1000 revealed Resident #74's vision is severely impaired, and Section GG-A dated 09/20/24, revealed Resident #74 required set-up and clean-up assistance during eating. During an observation on 10/22/24 at 9:02 AM, Staff M, Medical Records Staff, uncovered the resident's breakfast plate. The resident immediately picked up a fork, then tried to peel a banana. Staff M did not encourage the resident to wash hands or perform hand hygiene. Resident # 74 was observed removing the crusts on her inner eyes and touching hre face before Staff M placed the meal tray on her bedside table. There was no packet of hand sanitizer on the meal tray or a wet towel on the table. In an interview with Resident #74, who was just waking up, on 10/22/24 at 9:05 AM, when asked if Staff M encouraged hand hygiene before breakfast, she stated no. 5. Record review revealed Resident # 95 was admitted on [DATE] with the diagnoses that included Hemiplegia, and Hemiparesis after right cerebral infarction, and Osteoporosis with pathological fracture (broken bone caused by weakness). A review of MDS section C dated 10/10/24 revealed a BIMS score of 04 indicating severe impaired cognition. Section GG revealed Resident #95 had both functional impairments on one upper and one lower extremies. It revealed Resident needs set-up or clean-up assistance during eating, while MDS Section GG-I revealed Resident # 95 requires supervision or touching assistance in washing and drying hands. During an observation on 10/21/24 at 8:45 AM, an EBP (Enhanced Barrier Precautions) supply box and signage was observed attached on Resident 95's door. An observation on10/22/24 at 9:50 AM, Staff F, Certified Nursing Assistant (CNA), went inside the resident's room. Staff F asked the resident if she wanted to eat breakfast. After the resident responded, Staff F left the resident's room and came back with sugar packets. Without performing hand sanitizing, Staff F added the sugar packets contents into Resident #95's oatmeal bowl. Staff F repositioned the resident for breakfast, and without sanitizing Resident #95's hands, allowed her to start eating. Staff F did not encourage the resident to perform hand hygiene before a meal and did not provide hand hygiene supplies to the resident. During interview with Staff F on 10/22/24 at 10:00 AM, she stated that facility staff sanitize hands before entering residents' room with EBP signage. She added the staff were educated to sanitize their hands before getting a meal tray from the meal cart and after delivering the meal tray to the residents' room. When asked if staff encourage the residents to perform hand hygiene before meals, she stated yes. When asked how staff provide hand hygiene to the residents who need mobility assistance, she stated Staff provide residents with towels wet with soap and water then assist the residents in sanitizing hands. 6. Record review revealed Resident #27 was admitted on [DATE] with diagnoses that included Spinal Stenosis of the cervical region (bone disease when neck narrows and puts pressure on the spinal cord and nerves), Chronic Obstructive Pulmonary Disease, Obstructive and Reflux Uropathy (a urinary tract condition that causes urine to flow backwards), and Pyuria (urine containing white blood cells or pus). Review of the quarterly MDS Section C dated 10/02/24 revealed a BIMS score of 15 indicating an intact cognitive response. Section GG0115 of MDS revealed Resident # 27 had impairments on both upper and lower extremities, while Section GG0130A revealed the resident needed supervision or touching assistance during eating. Section GG-I revealed Resident #27 required substantial / maximal assistance in washing and drying hands. Section H dated 10/11/24 revealed a presence of suprapubic catheter, and Section M revealed a presence of Stage 1 pressure ulcer. During observation on 10/21/24 at 8:45 AM, Resident #27's door was observed with an EBP supply box and signage. Observation on 10/22/24 at 9:02 AM reevaled Staff B, [NAME] clerk, placed the breakfast tray on the resident's bedside table. Staff B did not encourage Resident #27 to wash or sanitize hands before eating, and did not provide hand hygiene supplies to the resident. When Resident # 27 was asked if Staff B encouraged her to perform hand hygiene before a meal, she stated no. When asked if Staff B offered her cleaning supplies for her hands, she stated no. There was no wet towel next to the meal tray or a packet of hand sanitizer on the meal tray. In an interview with Staff A, Wound Care Nurse, Licensed Practical Nurse / LPN, on 10/23/24 at 9:30 AM, when asked how staff provides hand hygiene to the residents who required moving and standing assistance, she stated the staff educate residents regarding hand washing before and after meals and activities. Staff A stressed that Staff provide residents who need assistance in getting up, wet towels with soap and water before and after meals. She concluded that staff were educated to encourage and assist residents in hand hygiene, and/or provide hand washing and cleaning supplies to the esidents before and after meals.

Based on observations, interviews, and record review, the facility failed to provide appropriate services to promote and maintain the highest practicable mental and psychosocial well-being for 1 of 1 sampled resident reviewed for Paranoid Schizophrenia (Resident #90). The findings included: Review of the facility's policy, titled, Behavioral Health Services, undated, included the following: Policy Interpretation and Implementation: 2. Residents who exhibit signs of emotional / psychosocial distress receive services and support that address their individual needs and goals for care. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] and re-admission on 06/04/24 with the following diagnoses: Paranoid Personality Disorder, Delusional Disorders, Anxiety Disorder, and Paranoid Schizophrenia. Review of Section C of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Review of section GG of the same MDS revealed Resident #90 was independent for all Activities of Daily Living (ADLs), including toileting and the ability to bath himself (Does not include transferring in/out of tub/shower). Review of the Physician's Orders documented Resident #90 had an order dated 06/04/24 for Haldol Decanoate Intramuscular Solution 100 mg/ml, Inject 2 ml intramuscularly one time a day every 30 day(s) for Paranoid Schizophrenia. Review of the Care Plan dated 08/08/24 documented Resident #90 has the potential for adverse side effects related to the use of psychotropic medications: antipsychotic for treatment of Delusional Behavioral. The goal was for the resident to remain free from adverse side effects due to use of psychotropic medications thru the next review date. The interventions included: Administer psychotropic medications as ordered. Abnormal Involuntary Movement Scale (AIMS) assessment as indicated. Psychotropic review for dose reduction as able. Psychiatry Services or Psychological Services as ordered. Observe for changes in mood/behavior and report to physician if noted. Review of the Care Plan dated 08/08/24 documented that Resident #90 has potential for self-care deficit with dressing, grooming, and bathing as evidenced by needs assistance with set up/supervision with personal care tasks. Resident #90 often refuses assistance with ADL care. The goal for the resident was: will continue to improve toward previous baseline ADL functioning throughout this review period and will allow staff to assist with ADLs as deemed necessary for proper hygiene and safety thru the next review date. The interventions included: Administer medications as ordered. Cue/encourage the resident to participate in ADL tasks. Allow resident ample time to attempt/complete ADL tasks before intervening. Encourage/remind the resident to ask for assistance as needed. Provide hands-on assistance with dressing, grooming, and bathing as needed. Explain actions during cares. Reapproach as needed. During an observation conducted on 10/21/24 at 10:30 AM of Resident #90's room revealed a strong body odor coming from the room which lingered into the hallway. During an interview conducted on 10/23/24 at 4:46 PM with Staff L, Certified Nursing Assistant (CNA), revealed she has been worked at the facility for 3 years and always assigned to the 3PM-11PM shifts in the north hallway (which included Resident #90's room). She stated Resident #90 sometimes requests towels and washclothes from her, but she has never observed the resident going to the shower room. Staff L noted the shower rooms are kept locked and only staff members have the code to unlock the door. She stated Resident #90 has never given her his personal clothing for laundry services. When asked who did his laundry, she stated she does not know, but the facility has not provided laundry services for Resident #90. An interview was conducted on 10/24/24 at 9:08 AM with the Administrator and Director of Nursing (DON). The Administrator stated Resident #90 has been refusing his medications, but has not shown any change in behaviors. In addition, she stated Resident #90 continues to refuse psychiatry visits, but he is reviewed for medications by psychiatry every month. She acknowledged Resident #90 often refuses showers and they do not receive his personal clothing for laundry services. When asked what the plan was to assist Resident #90 with his personal hygiene due to the foul body odor effecting the hallway and other residents, she stated, 'he likes to be left alone and they cannot force him to shower.' An interview was conducted on 10/24/24 at 11:29 AM with Staff J, Psychiatry Nurse Practitioner (Psych NP), who stated he has worked at the facility since November 2023. He stated he is concerned that Resident #90 continues to refuse his medications and is aware the resident has never taken the Haldol injectable as ordered. He agreed that another route of administration and other medications should have been tried. Staff J acknowledged he has not addressed the strong body odor. He stated the interdisciplinary team (IDT) has discussed Resident #90's hygiene practice, but to the management point, they do not see any solution to help with Resident #90's hygiene care because they can not force the resident to shower. He noted that this is something he would redirect to the psychologist therapist. An interview was conducted on 10/24/24 at 1:08 PM with Staff K, Psychologist Therapist, who stated, 'working at the facility Monday through Friday for 3 years'. He stated he has never had a conversation with Resident #90. Staff K acknowledged Resident #90's room has body odor and he tried to communicate with Resident #90. An interview was conducted on 10/24/24 at 1:51 PM with Resident #75's relative (Resident #90's roommate). She was visiting her brother in his room and stated Resident #90 was verbally aggressive the first couple of times she came to visit her brother. She was aware of the strong body odor in the room, but she cleans her brother's area. She stated Resident #75 cannot communicate clearly and does not want to get anyone in trouble. On 10/24/24 at 2:17 PM an interview was conducted with Staff P, Registered Nurse (RN). She has been working at the facility for about 1 year. When asked about Resident #90, she stated he refuses medications, showers, and the resident can be intermediating scary. She is aware of the strong body odor; but she fears him and does not press the resident to take his medication or a shower. There ws no appropriate service to promote a plan or collective effort to provide hygiene care to Resident #90, as well as not providing laundry services and medication administration in attempt to promote and maintain the highest practicable mental and psychosocial well-being for Resident #90.

Based on observation, interview, and record review, the facility failed to prepare food in a pureed form designed to meet the needs of 2 sampled residents of 14 residents with physician ordered pureed diets, Residents #4 and #110. The census at the time of survey was 113 residents. The findings included: Record review of the Nutrition Service Policy and Procedure effective 07/01/23, described the pureed diet as able to be piped, layered, molded if able to retain shape, but should not require chewing if presented in this form. The weekly menus that were labeled Spring / Summer Menus Week 3, from the Optima Solutions Dietary Management System, listed a description of the pureed diet on each menu. It said: Holds shape on spoon; smooth texture; No separated liquid; not firm/sticky. In the dining room on 10/21/24 at 1:04 PM, Resident #4's lunch plate was observed with beef stroganoff that was supposed to be pureed according to the diet listed on the meal ticket. The beef had small lumps in it. The surveyor then went into the kitchen and spoke to the Dietary Manager. Observation revealed that on the tray assembly line at 1:05 PM, a dietary aide placed a plate of pureed Beef Stroganoff on a tray for delivery to the unit. The plate with pureed Beef Stroganoff had a pebbly appearance. A spoonful of pureed Beef Stroganoff was requested and tasted. The texture had small lumps and strings. The Dietary Manager also tasted the pureed beef, and she agreed with this finding. The Dietary Manager removed the pureed Beef Stroganoff from the serving area and gave it to the cook, and asked the cook to puree it to a smooth texture. Photographic Evidence Obtained. In the Dining Room, at 1:25 PM, the pureed chicken on Resident #110's tray appeared to be lumpy. This was brought to the attention of the Dietary Manager in the kitchen. The Dietary Manager requested a taste of the pureed chicken and verified that the pureed chicken was not smooth. The surveyor also tasted the pureed chicken which was not smooth. Photographic Evidence Obtained.

Based on observation, interview and review of policy and procedure, the facility failed to ensure that residents medications were properly stored as evidenced by medications being left on the resident's night stand for 1 of 1 sampled residents, Resident #26; and one opened bottle of Mucus Relief and one opened box of acetaminophen suppositories, over the counter medications (OTC), observed in the medication room cabinet for 1 of 2 medication storage rooms. The findings included: Review of the facility's policy, titled, Medication Labeling and Storage, revised 02/2023, provided by the Regional Nurse, documented, in part, The facility stores all medications .in locked compartments .the nursing staff is responsible for maintaining medications storage .in a clean, safe and sanitary manner medications are stored in an orderly manner in cabinets, drawers, carts each resident's medications are assigned to an individual cubicle, drawer, or other holding area . 1. On 10/21/24 at 11:02 AM, during initial tour to the facility's south wing, an interview was conducted with Resident #26 who stated she had been in the facility for a few years. Observation revealed an opened over the counter (OTC) Antacid chewable bottle on top of the resident's nightstand. The resident stated she takes the antacid when she gets heartburn. The resident was asked if she told the nurse, stated she had not, and added that one nurse knows about it because the bottle was over on the windowsill and she moved it to the night stand. The resident could not remember the nurse's name. On 10/21/24 at 1:15 PM, observation during lunch time revealed Resident #26 in her room sitting at the edge of bed. Further observation revealed the opened bottle of an Antacid continued to be on top of the nightstand. On 10/23/24 at 10:29 AM, observation revealed Resident #26 in her room sitting at the edge of bed. Further observation revealed the opened bottle of an Antacid continued to be on top of the nightstand. Photographic Evidence Obtained. On 10/23/24 at 11:45 AM, an interview was conducted with Staff G, Licensed Practical Nurse (LPN) who stated she did not have any residents with the medications in their room and that residents were not supposed to. Staff G stated resident's OTC medications should be in the medication cart and had not noticed any medications in the residents' room. Staff G was asked to check Resident #26's night stand for OTC medication. Staff G stated she saw a bottle of Tums (antacid) on the resident's nightstand and added she gave the resident's medications this morning and did not notice it. Staff G was apprised the antacid bottle had been on top of the nightstand since Monday when the survey started. A side-by-side review of Resident #26's Tums (antacid) bottle, removed from the nightstand by Staff G, was conducted and revealed an expiration date on 11/2023. Staff G stated the resident did not have a physician order for Tums. 2. On 10/22/24 at 1:21 PM, a side-by-side review of the facility's south wing medication room was conducted with Staff H, LPN and Staff N, LPN. The review revealed the following: -one opened bottle of Mucus Relief - Guaifenesin 400 mg opening date as of 07/12/24. -one box of 12 acetaminophen suppositories. The box had 10 of 12 suppositories left and did not have an opening date. During the review, Staff H, LPN stated once the medication bottle or a box was opened, it had to be dated and removed from the medication room to the medication cart. Staff H and Staff N confirmed the findings. On 10/22/24 at 2:05 PM, the surveyor was approached by the facility's Regional Nurse who stated the medication bottle in the medication room was an extra as it was an extra one in the medication cart; and had been moved to the medication room. The regional nurse was asked if an opened medication bottle was supposed to be in the medication room cabinet and replied No. On 10/24/24 at 2:55 PM, during an interview, the Administrator stated she was aware of the medication storage task findings.

Based on observations, interviews, and record reviews, the facility failed to adequately monitor behaviors for residents receiving psychotropic medications for 3 of 6 sampled residents reviewed for psychotropic medications (Residents #90, #89, and #59). The findings included: Review of the facility's policy, titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, included the following: Policy Statement 1.The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 6.The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Management 1.The interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Monitoring 1.If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. 1. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] and re-admission on 06/04/24 with the diagnoses that included: Paranoid Personality Disorder, Delusional Disorders, Anxiety Disorder, and Paranoid Schizophrenia. Review of Section C of the Quarterly Minimum Data Set (MDS) assessment, dated 08/02/24, revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that he was cognitively intact. Review of Section E of the same MDS revealed Resident #90 was not experiencing hallucinations or delusions; but was experiencing physical behavioral symptoms directed towards others (example: hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and the frequency of these behavior occurred 4 to 6 days. Review of the Physician's Orders showed that Resident #90 had an order dated 06/04/24 for Haldol Decanoate Intramuscular Solution 100 mg/ml, Inject 2 ml intramuscularly one time a day every 30 day(s) for Paranoid Schizophrenia. Review of the Physician's Orders showed that Resident #90 had an order dated 06/04/24 for Medication Management: Diagnosis (Dx) Paranoid Schizophrenia, 0 = no behavior, 1= Combativeness, 2= Verbally inappropriate, 3= Sexually inappropriate, 4= Disrobing, 5= Crying excessively, 6= Calling out constantly, 7= Screaming excessively, 8= Auditory Hallucinations, 9= Delusional, 10= Resists Care, 11= Socially inappropriate, 12= Extreme Pacing, 13= Restlessness, 14= Other, every shift for Monitor. Review of the Behavior Monitoring Record (BMR) for Resident #90 from 10/10/24 to 10/24/24 revealed only a check mark in some of the days for each shift (day and night). The documentation does not indicate a number (0 to 14) as ordered for behavior monitoring. There are nine days where a number was recorded but no interventions documented in the nursing notes on those days. There was no documentation on 10/12/24, 10/17/24, or 10/18/24. Review of the Behavior Monitoring and Interventions Task revealed no behaviors were observed from 10/10/24 to 10/24/24. Review of the Behavior Symptoms Task from 10/10/24 to 10/24/24 revealed no symptoms (14 symptoms listed) were observed during those days except on 10/15/24 but in which Resident #90 exhibit the following symptoms: Repeat movements, yelling/screaming, abusive language, and threatening behaviors. Review of the Care Plan dated 08/08/24 documented Resident #90 had exhibited the following behaviors: Hoarding food items, storing sharp objects, and refusing care; The resident yells and screams at staff when he is being educated or redirected. The goal was for the resident to exhibit a decrease in the number of behavior episodes by the next review date. The interventions included: Continue to monitor and assess resident surroundings as needed for compliance. Reinforce and educate resident on objects that are not permitted. Intervene as needed to protect the rights and safety of resident and others: remove from situation as able. Request psychiatric consult as needed. Review of the Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report dated 06/11/24 included: given the history of Resident #90, care staff should monitor for depressive symptoms, symptoms of anxiety, or symptoms of psychosis, and report any problems to the treatment team. During an observation conducted on 10/21/24 at 10:30 AM of Resident #90's room revealed a strong body odor coming from the room which lingered to the hallway. The resident was in his room with the ceiling-suspended curtains pulled closed and he was speaking with someone, but no one else was in the room. The surveyor attempted to interview Resident #90, but he refused, and then his voice got louder and he continued with his conversation. An interview was conducted on 10/24/24 at 9:35 AM with the Director of Nursing (DON) who has been working at the facility for 3 years. When asked about what does the check marks mean in the BMR since the physician order is to record a number for behaviors, she stated she was not sure and would check the nursing progress notes for documentation. The DON acknowledged there was no documentation in the nursing progress notes. An interview was conducted on 10/24/24 at 11:29 AM with Staff J, Psychologist Nurse Practitioner (Psych NP) who stated he has worked at the facility since November 2023. He stated Resident #90 has not been aggressive towards him or other residents, but Resident #90 had an aggressive episode in June 2024 towards a staff member. Staff J acknowledged that he is concerned that Resident #90 has been refusing his medication and has been exhibiting abnormal thought processes: Paranoid delusions. An interview was conducted on 10/24/24 at 1:45 PM with Staff L, Certified Nursing Assistant (CNA), who stated she has worked at the facility for 3 years. When asked about Resident #90's behavior of aggression towards staff, she stated Resident #90 has never been aggressive towards her, but he has been aggressive towards other staff members. When asked if she would report Resident #90's aggressive behavior to the nurse, she stated not always because he does it all the time and this is his normal behavior. 41837 2 Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on 01/04/24. The resident's diagnoses included in part the following: Major Depressive Disorder. Review of the MDS for Resident #59 dated 07/19/24 documented in Section C a BIMS score of 15 indicating an intact cognitive response. Review of the Physician's Orders for Resident #59 revealed an order dated 01/04/24 for Duloxetine HCl Capsule Delayed Release Particles (a psychotropic medication) 60 MG give 1 capsule by mouth two times a day for Depression. Review of the Physician's Orders for Resident #59 revealed an order dated 01/04/24 Trazodone HCl Oral Tablet (a psychotropic medication) 100 MG give 1 tablet by mouth at bedtime for Depression. Review of the Physician's Orders for Resident #59 revealed an order dated 01/05/24for Medication Management: Diagnosis Depression, 0 = no behavior 1 = Combativeness 2 = Verbally inappropriate 3 = Sexually inappropriate 4 = Disrobing 5 = Crying excessively 6 = Calling out constantly 7 = Screaming excessively 8 = Auditory Hallucinations 9 = Delusional 10 = Resists Care 11 = Socially inappropriate 12 = Extreme Pacing 13 = Restlessness 14 = Other, every shift. Review of the Medication Administration Record (MAR) for Resident #59 from 10/14/24 to 10/20/24 documented for medication management a check for each shift (day and night) but did not indicate if there were any behaviors or no behavior. Review of the nursing progress notes for Resident #59 from 10/14/24 to 10/22/24 revealed no documentation of behavior monitoring. Review of the Care Plan for Resident #59 dated 10/25/23 with a focus on the resident has the potential for adverse side effects related to the use of psychotropic medications: antidepressant for treatment of Depression. The goals were for the resident to remain free from adverse side effects related to use of psychotropic medications and for the resident to receive the lowest effective dose of psychotropic medication to ensure maximum functional ability thru the next review date. The interventions included: Administer psychotropic medications as ordered. Observe for effectiveness of psychotropic medications. Observe for adverse side effects r/t psychotropic med use; report to physician if noted. Educate resident/family on potential risk/benefits of psychotropic medication use. AIMS assessment as indicated. Psychotropic review for dose reduction as able. Psychiatry Services or Psychological Services as ordered. Observe for changes in mood/behavior; report to physician if noted. 3. Record review for Resident #89 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Psychosis Not Due to a Substance Abuse or Known Physiological Condition, Major Depressive Disorder, Brief Psychotic Disorder, Other Specified Persistent Mood Disorders, and Generalized Anxiety Disorder. Review of the MDS for Resident #89 dated 07/19/24 revealed in Section C a BIMS score of 15 indicating an intact cognitive response. Review of the Physician's Orders for Resident #89 revealed an order dated 11/05/23 for Medication Management: Diagnosis Anxiety/insomnia 0 = no behavior 1 = Combativeness 2 = Verbally inappropriate 3 = Sexually inappropriate 4 = Disrobing 5= Crying excessively 6 = Calling out constantly 7 = Screaming excessively 8 = Auditory Hallucinations 9 = Delusional 10 = Resists Care 11= Socially inappropriate 12 = Extreme Pacing 13 = Restlessness 14 = Other, every shift. Review of the Physician's Orders for Resident #89 revealed an order dated 01/25/24 for Trazodone HCl Oral Tablet (a psychotropic medication) 50 MG give 1 tablet by mouth at bedtime for Depression. Review of the Physician's Orders for Resident #89 revealed an order dated 01/26/24 for Ambien CR Oral Tablet Extended Release (a psychotropic medication) 6.25 MG (Zolpidem Tartrate) give 1 tablet by mouth at bedtime for Insomnia. Review of the MAR for Resident #89 from 10/14/24 to 10/20/24 documented medication management documented each shift (day and night) with just a check mark, and no indication of a behavior observed or not behavior observed. Review of the nursing progress notes for Resident #89 from 10/14/24 to 10/20/24 revealed no documentation of behaviors or no behaviors noted for the resident. Review of the Care Plan for Resident #89 dated 08/08/23 with a focus on the resident has the potential for adverse side effects related to the use of psychotropic medications: antianxiety meds for anxiety and Hypnotics for insomnia, and antidepressant for depression. The goals were for the resident to remain free from adverse side effects r/t use of psychotropic medications and to receive the lowest effective dose of psychotropic medication to ensure maximum functional ability thru the next review date. The interventions included: Administer psychotropic medications as ordered. Observe for effectiveness of psychotropic medications. Observe for adverse side effects r/t psychotropic med use; report to physician if noted. Psychotropic review for dose reduction as able. Observe for changes in mood/behavior; report to physician if noted An interview was conducted on 10/24/24 at 1:20 PM with Staff G, Licensed Practical Nurse (LPN), who stated she has been with the facility for [AGE] years. When asked about behavior monitoring for residents receiving psychotropic medication(s), she said they do monitor for behaviors. When asked where this is documented she said on the MAR. An interview was conducted on 10/24/24 at 1:20 PM with Staff H, LPN, who was asked about behavior monitoring for residents receiving psychotropic medications. She said they do monitor for behaviors. When asked where this is documented, she said on the MAR, and you put the code in for the specific behavior or a zero for no behavior.

Based on observation, interview, and record review, the facility failed to provide care and services for 2 of 2 sampled residents, Residents #23 and #97, who were to receive the restorative dining program; and failed to maintain the residents' ability to communicate and to participate in activities of daily living (ADLs) for 1 of 1 sampled resident, Resident #82, The findings included: 1. Review of the clinical record of Resident #23 on 10/22-23/24 noted a readmitted [DATE] with current diagnoses of Alzheimer's Disease and Dementia. Review of the current physician orders included: On 12/04/23, Mechanical Soft Diet / Fortified Foods and Med Pass 2.0 - 120 ml Every Day, and Restorative Dining Program - Breakfast & Lunch Meals 7 days per week. Review of the resident's weight history documented a current weight of 100 pounds, occurring weight loss, and a BMI (Body Mass Index) of 18.5, indicating the resident was underweight / malnourished. Review of the current care plan dated 10/01/24 documented: Nutritional Problem - consuming 25-50% of meals, requires assistance and supervision with meals. Review of the current interventions noted that a Restorative Dining Program with specific interventions were not documented. The ADL (Activities of Daily Living) functioning care plan noted documentation that the resident requires supervision with feeding and Restorative Dining one meal per day. No Restorative Dining Assessment could be located in the medical record of Resident #23. Review of the clinical record of Resident #97 on 10/23-24/24 noted an admitted [DATE] with current diagnoses to include Bipolar Disease, Dysphagia, and Alzheimer's Disease. The current physician orders noted: Plate Guard with meals (06/22/24), and No Added Salt / Mechanical Soft diet (04/16/24). No physician orders for Restorative Dining Program could be located in the medical record. Review of the current Minimum Data Set (MDS) assessment, dated 09/01/24, noted a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognition impairment; and assistance was required with eating. Review of weight history noted the weights were stable. Review of the current care plans revealed no Restorative Dining Program care plans could be located. During observation of the lunch meal in the Main Dining Room (MDR) on 10/21/24 at 12:30 PM, it was noted that Residents #23 and #97 were sitting at separate tables in the very rear of the dining room, away from other resident dining tables. Further observation revealed that the facility's Restorative Dining Program occurs in the rear of the Main Dining Room (MDR) and that Residents #23 and #97 were enrolled into that program. Further observation of the lunch meal noted that Resident #23 had some cognitive impairment and would get up and walk away from the table 4 times during the meal. Each time the resident walked away, she was brought back to her table by staff in the dining room area and was told to eat her meal. At no time [NAME] the 45-minute lunch observation did any staff attempt to sit with Resident #23 and attempt to supervise or assist the resident with the meal intake. It was observed that Resident #23 consumed one 4-ounces of juice during the meal and approximately 5-10 % of the Mechanical Soft / Fortified Foods meal served. It was also observed during the same meal observation that Resident #97 had severe cognitive impairment and had position issues during the meal and would spill foods when attempting self-feeding onto his clothing protector and large amounts of pureed foods remained smeared on the resident's face throughout the meal. It was also noted that Resident #97 did not receive any individual restorative supervision and assistance throughout the 45-minute observation. Continued meal observations of Resident's #23 and #97 in the MDR on 10/22/24 (breakfast & lunch), 10/23/24 (breakfast and lunch) and 10/24/24 (lunch) again noted the residents did not receive any restorative dining service that would include supervision and assistance for meals from the restorative nursing staff. On 10/22/24, an interview was conducted with the facility's Minimum Data Set (MDS) Coordinator concerning the facility's Restorative Dining Program. The surveyor requested a list of residents currently enrolled in the program and the restorative dining policies and procedures, that specifically addressed what restorative programs the facility has, who is in charge of the program, what staff are involved, how are residents are assessed to be enrolled into the programs, are physician orders required, what resident documentation is required on a regular basis, how are resident evaluated to remain on the programs, and evaluation of the restorative program on a regular basis. On 10/22/24, the MSD Cordinator submitted a list of the residents currently enrolled in the nursing restorative dining program. A review of the list noted that 2 of the residents listed were discharged from the facility months ago and the 2 other residents currently enrolled were Resident's #23 and #97. The coordinator also stated that there were no current up-to-date policies and procedures for the Nursing Restorative Dining Program. On 10/23/24, the administrator submitted a policy (1/2 page) for Restorative Nursing Services that did not address the requested policies and procedure for Restorative Nursing Services. During the observation of the lunch meal in the MDR on 10/24/24 at 12:30 PM, it was noted that due to surveyor intervention, both Residents #23 and #97 were receiving hands-on restorative dining interventions. 50895 2. Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, Gastro-esophageal Reflux Disease, Muscle weakness, Muscle wasting and atrophy, Insomnia, Major Depressive Disorder, Anxiety Disorder, and Bipolar Disorder. Review of the Minimum Data Set quarterly assessment, dated 10/10/24, revealed Resident #82's Brief Interview for Mental Status (BIMS) score was 13, which indicated that she was cognitively intact. An interview conducted on 10/21/24 at 11:00 AM, in the resident's language, revealed Resident #82 said that the language was a big barrier. When asked to explain further, Resident #82 said The ladies don't understand me, and I don't understand them. The resident was asked to provide an example of an incident when the language barrier presented a problem. She responded, if I want to request for my feet to be moved into a more comfortable position, or if I need my pillow to be adjusted, the nurses do not understand me. During a second interview, on 10/22/24 at 11:50 AM, the surveyor asked the resident if she participates in activities. Resident #82 said that she participated in the activities that she could understand, like watching TV in her room. When asked if there's an activity that she chose not to participate in because she could not understand English, Resident #82 answered, I can't see the movies because I don't understand them. Record review conducted on 10/24/24 at 9:15 AM revealed that Resident #82s care plan was last revised on 03/29/23. It was noted that no changes were made since its last review. The care plan stated: Resident #82 has a potential for alteration in communication r/t (related to): use of psychotropics, Speech is clear and easily understood and speaks mostly Spanish, patient [sig] uses a communication board. The Goal listed in the care plan said that the resident will continue to voice needs to staff without difficulty through the next review date. One intervention listed in this care plan documented that a Communication Board was provided to the resident along with education on how to use the Board. It also said Resident verbalize to therapist on understanding of the use of communication board. Keep call light within reach; respond to communicated needs. An interview with the Activities Director was conducted on 10/24/24 at 9:33 AM, who said that she knew Resident #82 and that she had worked in this facility for the past four months. When asked if this resident attended activities, the Activities Director responded, not necessarily and doesn't leave her room for activities very often. She added that Resident #82 preferred to stay in her room. The Activities Director said, She joined us 2 days ago in the activity room for coffee. She said Resident #82 preferred to be in her room and watch TV. When the Activities Director was asked if she spoke Spanish, she answered No. In response to how she communicated with Resident #82, the Activities Director said She's able to understand the basics. I ask her simple questions like are you ok and she says yes. The Activities Director informed the surveyor that there were no employees in the Activity Department who spoke Spanish, and she added that she printed out monthly calendars of activities written in Spanish for the seven or eight Spanish speaking residents. The surveyor inquired about showing movies in a group setting and the Activities Director said that showing movies was an activity that she provided to the residents. When asked if she might consider showing a movie in Spanish for her Spanish speaking residents, she answered Yes. That would be great. During an interview with Resident #82 at 10/24/24 at 9:55 AM, the Resident #82 said she wanted to speak more English and that she tries to speak English. She said she knew a few words in English. The surveyor said in Spanish that she would attempt to speak to her in English. The surveyor said, I spoke to the Director of Activities, and the resident shook her head. She did not understand. For that reason, the surveyor continued the interview in Spanish. The resident was asked if she had a communication board. Resident #82 pointed to a communication board posted on the wall next to the window. She said it was too far for her to reach it. She added that it would help her if it was within reach. Photographic Evidence Obtained, showing there was a communication board posted on the wall to the right of the window, that was out of reach for this resident. An interview with the Director of Social Services on 10/25/24 at 11:33 AM revealed that she spoke a few words of Spanish, and that she called Spanish speaking employees when she needed assistance to communicate with Resident #82. She was unaware that Resident #82 had a communication board.

Based on observations, interviews, and record reviews, the facility failed to maintain medications, medication carts and treatment carts in a secure manner and during medication administration opportunities, as evidenced by medications left unattended at the bedside for Resident #100 and 22 and failed to dispose of expired medications and supplements properly on 1 of 2 units (the North Unit). The findings included: Review of the policy, titled, Storage of Medications, dated November 2020, revealed in part, the following: Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access. 1. During tour of the facility conducted on 08/14/23 at 9:24 AM, the surveyor observed an unlocked, unattended treatment cart on the North Hallway of the facility. The treatment cart contained various treatments and ointments. Photographic Evidence Obtained. Upon further observation, there were 2 pairs of scissors observed in the top drawer of the wound care cart. During this observation, multiple staff members were noted in the hallway walking past the treatment cart. An additional observation was conducted on 08/14/23 at 9:30 that revealed this treatment cart had been moved from its initial location by the wound care nurse and was in use at a resident's room door. 2. A medication administration observation pass was conducted on 08/15/23 at 8:50 AM with Staff A, Licensed Practical Nurse (LPN) for Resident #100. While preparing the prescribed medications, Staff A noted she did not have the correct form (tablets) of the prescribed Vitamin D, but rather only had the capsule form in the medication cart. Staff A stated she was going to ask another nurse if she had the tablet form of Vitamin D. Staff A walked to the other end of the hallway, approximately 100 meters away, to talk to another nurse on duty. She left the medication cart unlocked, with other medications (tablets and liquids) already poured into medication cups, on top of the medication cart. Photographic Evidence Obtained. There were multiple staff members in the hallway during this time, distributing and collecting breakfast trays from residents. During this observation, Staff A was away from the unlocked, unattended medication cart and medications for approximately 5 minutes. The facility's Assistant Director of Nursing was in the hallway as well and observed this unlocked, unattended medication cart and medications. She intervened and spoke to Staff A who was returning to the cart. Upon entering Resident #100's room to administer the medications, Staff A placed the medications on the bedside table and entered the bathroom to wash her hands. The medications were not within her line of sight. 3. A medication administration observation was conducted on 08/15/23 at 11:33 AM with Staff C, Registered Nurse (RN) for Resident #22. Upon entering Resident #22's room to administer the medication, Staff C placed the medications on the bedside table and entered the bathroom to wash her hands. The medications were not within her line of sight. The above concerns were reviewed with the facility's Director of Nursing (DON), Assistant Director of Nursing (ADON), and Nursing Educator on 08/17/23. 38349 4. During an observation conducted on 08/16/23 at 9:45 AM of the Central Supply room, with Staff J, Central Supply Clerk, and the DON, it was noted that there was a container of Beneprotein powder supplement with an expiration date of July 2023. Photographic Evidence Obtained. 5. During a observation conducted on 08/16/23 at 10:23 AM, with Staff K, Licensed Practical Nurse (LPN), and the DON, of the South Medication Room, it was observed that there were two (2) expired boxes of over-the-counter (OTC) Mineral Oil Enemas, dated 11/21 and 07/22 respectively. Both were located in a cabinet alongside other active / ready-to-use stock medications. Photographic Evidence Obtained. During an interview conducted on 08/16/23 at 10:35 AM with Staff K and the DON, both acknowledged that the expired protein powder and the OTC Mineral Oil Enemas should all have been promptly discarded.

Based on observations, interviews, and record review, the facility failed to follow the correct tube feeding formulary and rate as per the physicians' orders for 1 of 2 sampled residents reviewed for tube feeding, Resident #100. The findings included: Review of the facility's policy, titled, Enteral Nutrition, revised in 2018, showed, in part, the following: The Nurse confirms that orders for enteral nutrition are complete. Complete orders include a. The enteral nutrition product; b. Delivery site (tip placement); The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.; c. d. Administration method (continuous, bolus, intermittent); e. Volume and rate of administration; f. The volume/rate goals and recommendations for advancement toward these; and g. Instructions for flushing (solution, volume, frequency, timing, and 24-hour volume). Resident #100 was admitted on [DATE] and readmission on 08/08/23 with diagnoses of Hemiplegia and Muscle Wasting. Review of the physician orders dated 08/10/23 showed an order for Renal Novasource (tube feeding formulary type) to run at 60 milliliters (ml) an hour for 18 hours at 4:00 PM and off at 10:00 AM. In an observation conducted on 08/14/23 at 9:50 AM, Resident #100 was noted in the bed with the tube feeding Jevity 1.5 (tube feeding formulary type and not the ordered Renal Novasource) running at 60 milliliters an hour. The tube feeding Jevity 1.5 at 60 ml an hour provides 1620 calories daily. In an observation conducted on 08/15/23 at 8:35 AM, Resident #100 was noted in bed with the tube feeding Jevity 1.5 (tube feeding formulary type and still not the ordered Renal Novasource) running at 60 milliliters an hour. Review of the Nutrition Risk Evaluation dated 08/10/23 showed that Resident #100 currently receives Jevity 1.5 at 80 milliliters an hour for 18 hours. Resident #100 had a significant weight change due to a week of hospitalization . The estimated caloric needs showed 1890 to 2240 calories daily needs. The tube feeding Jevity 1.5 running at 80 ml an hour would have provided 2160 calories daily. The care plan revised on 07/17/23 showed that Resident #100 is at risk for complications associated with enteral feeding; and to administer enteral feeding and flushes as ordered with routine registered dietitian assessment. An observation conducted on 08/15/23 at 4:00 PM of the facility's supply room showed that they had stocked three types of tube feeding formula: Jevity, Nepro, and Glucerna. There was no Renal Novasource and no other types of tube feeding formulas noted. An interview was conducted on 08/16/23 at 11:00 AM with the Registered Dietitian (RD) who stated any order for tube feeding formulary that is not in-house, they (the nurses) should contact her (RD) in person or by phone for an appropriate substitution. She further stated that her phone number was posted in the nurses' station. An interview was conducted on 08/17/23 at 8:33 AM, Staff A, Licensed Practical Nurse (LPN), who stated that if she had an order for tube feeding, she would take the tube feeding bottles from the general supply. Staff A said they have three types of tube feeding in-house, Jevity, Nepro, and Glucerna. When asked what she would do if there were any orders for tube feeding, they do not have in-house, she said she would notify the Director of Nursing (DON). She further said that they did not have orders this year of tube feeding that they did not have in stock. Staff A reported that if she needed to contact the Registered Dietitian, her number is posted in the nurse's station. An interview was conducted on 08/17/23 at 1:00 PM with the Administrator, and she was informed of the findings.

Based on observations, interviews, policy review, and record review, the facility failed to provide proper urinary catheter care, as evidenced by cleaning the catheter tubing from the outside to the insertion site, wiping the buttocks from the top downward into the perinium, lifting the catheter bag above the bladder level, lack of hand hygiene after touching unclean items, and allowing the catheter tubing to be kinked after care, for 1 of 1 sampled resident, Resident #68, reviewed for catheter care. The findings included: Review of the policy, titled, Catheter Care, Urinary, Level III, dated August 2022, revealed, in part, the following: Check the resident to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. Use a washcloth to cleanse the labia-use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth and cleanse around the urethral meatus. With a clean washcloth, rinse using the above technique. Use a clean washcloth to cleanse and rinse the catheter from insertion site to approximately four inches outward. Check the drainage tubing and bag to ensure the catheter is draining properly. A urinary catheter care observation was conducted on 08/17/23 at 7:50 AM with Staff G, Certified Nursing Assistant (CNA) for Resident #68. Staff G began her care on the left side of Resident #68's bed. She opened Resident #68's incontinence brief, which appeared to be clean. Staff G then removed her gloves and washed her hands. Staff G completed perineal care on the right and left sides of the perinium. Staff G then cleaned the catheter tubing from the connection point (outward) toward the insertion site. Staff G realized she had no washcloths to continue the care, so she covered the resident and left the room to retrieve washcloths. Upon returning to the room with the washcloths, Staff G moved to the right side of Resident #68's bed and while moving the bedside table, the package of perineal care wipes fell on to the floor. The CNA changed her gloves but did not wash her hands at this time. Staff G stated she was going to lower the head of the bed so Resident #68 could roll to her left side, but she could not find the bed controller. The surveyor located the bed controller on the floor under the bed. Staff G then retrieved the remote control, reposited the head of the bed and asked Resident #68 to roll onto her left side. Wearing the same gloves, Staff G then prepared a washcloth and wiped Resident #68's bottom from top downward (incorrectly). She verbalized she would wash her hands at this time but did not wash her hands and changed her gloves. Staff G removed Resident #68's incontinence brief and the non-disposable incontinence pad, verbalized she would wash her hands but did not, and changed her gloves. Staff G then wet an additional washcloth and cleaned the remainder of the urinary catheter tubing and catheter bag. She then lifted the catheter bag to her (CNA) height and set the catheter bag onto the bed. She verbalized again she would wash her hands but did not but did change her gloves. She then used a dry washcloth and dried the catheter tubing and bag and then placed the catheter bag onto the side of the bed. Staff G began to cover Resident #68, but the surveyor intervened and showed the resident's catheter tubing was kinked. The surveyor asked Staff G to straighten it. The concerns regarding this urinary catheter care were reviewed with the Director of Nursing, Assistant Director of Nursing, and Nursing Educator on 08/17/23, following the observations.

Based on observations, interviews, and record review, the facility failed to provide the appropriate Activities of Daily Living (ADLs), regarding eating assistance, for 1 of 5 sampled residents reviewed for nutrition, Resident #23. The findings included: Review of the policy, titled, Activities of Daily Living, revised in March 2118, showed, in part, the following: appropriate care and services would be provided for residents who cannot carry out ADLs [Activities of Daily Living] independently by the plan of care, including support and assistance with dining. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. Record review documented Resident #23 was readmitted to the facility on [DATE] with diagnoses to include Heart Disease and Dementia. Resident #23 had been placed under hospice services on 05/31/23. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #23 had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognition impairment. The MDS, dated [DATE], for eating under section G, documented Resident #23 required extensive assistance with one person assist. The MDS dated [DATE], under section G, documented Resident #23 needed supervision and set up only for eating. In an observation conducted on 08/14/23 at 12:35 PM, Resident #23 was noted in her room with her lunch tray. Closer observation showed that no staff were in the room to assist Resident #23 with her lunch meal. At 12:42 PM, there was no staff noted in her room, and at 12:55 PM, Resident #23's lunch meal was barely touched. In an observation conducted on 08/15/23 at 8:40 AM, Resident #23 was in her room with Staff F, Certified Nursing Assistant (CNA), helping the resident with her breakfast meal. The meal was about 30% consumed, and at 8:47 AM, Staff F left the room. At 8:50 AM, Resident #23 was trying to eat independently but stopped and the tray was only 30% consumed. Continued observation showed that at 8:57 AM, the tray was taken out of her room. In an observation conducted on 08/15/23 at 1:08 PM, Resident #23 was noted in her room with no assistance provided from staff. Closer observation showed Resident #23 only ate about 20% of her meal. Review of the care plan revised on 08/16/23 showed that Resident #23 has a self-care deficit related to weakness, limited endurance, and terminal diagnoses and hospice care. Review of the progress note dated 08/02/23 showed that Resident #23 has no family or friends involved in her care. Another progress note dated 08/03/23 showed that Resident #23 was assisted by staff with ADLs extensively. Review of the Nutrition Risk Evaluation dated 08/03/23 showed that Resident #23 was inactive, totally dependent, and needed extensive or complete assistance while eating. An interview was conducted on 08/17/23 at 8:38 AM, Staff D, CNA, who stated Resident #23 can eat independently and usually eats about 50% of her meals. An interview was conducted on 08/17/23 at 1:00 PM with the Administrator, and she was told of the findings.

Based on review of policy and procedure, observation, interview and record review, the facility failed to maintain residents' privacy in a dignified manner for 3 of 24 sampled residents observed, Residents #103, #100, and #68. The findings included: Review of the facility policy and procedure on 08/16/23 at 2:45 PM, titled, Dignity, provided by the Director of Nursing (DON) revised February 2021, documented in part, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times 11. Staff promote, maintain and protect resident privacy, including bodily privacy . 1. Resident #103 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Peripheral Vascular Disease, Diabetes Mellitus Type II, Hypertension, Muscle Wasting and Atrophy, Major Depressive Disorder and Generalized Anxiety Disorder. The Minimum Data Set (MDS) assessment documented a Brief Interview Mental Status (BIM) score of 15 or 15 indicating cognition was intact. On 08/14/23 at 11:20 AM, an observation of Resident # 103, from the main North wing resident's room hallway (bedroom door ajar), revealed the resident with both the left below-the-knee (BKA) amputation old incisional site, as well as her uncovered, loosely worn diaper, visibly exposed to other residents, staff members and visitors, who passed the door, for over an hour. Facility staff members were observed walking by the room and not closing the curtains or the resident's bedroom door. Upon entering the resident's room, there was an increased bodily exposure visibility. The two (2) hanging privacy curtains in the room did not provide a full covering of protection for the resident. Photographic Evidence Obtained. During a subsequent observation conducted on 08/14/23 at 2:30 PM, Resident # 103 was again observed from the main North wing resident room hallway (bedroom door ajar) with both her left BKA amputation old incisional site, as well as her uncovered, loosely worn, diaper both visibly exposed for a time period of at least 30 minutes. Facility staff members were observed walking by the room and not closing the curtains or the resident's bedroom door. An interview ws conducted with Resident #103 on 08/15/23 at 2:17 PM, who when asked if the staff treat you with respect and dignity and keep your person covered, at all times, stated, for the most part they do, but on a few occasions the door and curtain were both left opened and the resident stated that she had to remind the staff to close it. An interview was conducted with Staff H, (CNA), on 08/15/23 at 2:18 PM, regarding the resident's privacy curtains and bedroom door, both being left open, Staff H acknowledged the bedroom door and privacy curtains should not be left open, exposing the resident. An interview was conducted with Staff C, Registered Nurse (RN), on 08/15/23 at 2:26 PM, who acknowledged the resident's bedroom door should not be left open in such a way as to expose the resident and her diaper at any time. An interview was conducted with Staff I, North wing RN, Assistant Director of Nursing (RN/ADON), on 08/16/23 at 3:24 PM, who acknowledged the resident's bedroom door should not be left open in such a way as to expose the resident and her diaper at any time. There were no documented behaviors relative to this observation, for this resident noted in either her care plan, or in the progress notes. The Director Of Nursing (DON) acknowledged that on 08/16/23 at 9:40 AM that the resident's bedroom door should not be left open in such a way as to expose the resident's person and her diaper at any time. 45951 2. A medication administration observation pass was conducted on 08/15/23 at 8:50 AM with Staff A, Licensed Practical Nurse (LPN) for Resident #100. Staff A gathered Resident #100's medications entered Resident #100's room. Staff A entered the resident's bathroom, washed her hands, donned gloves and prepared to administer Resident #100's medications via the gastric tube in Resident #100's abdomen. Staff A neglected to close the room door or the privacy curtain for Resident #100's room. Staff A administered the medications through Resident #100's gastric tube, which left the resident exposed to staff members and residents walking in the main hallway. 3. A catheter care observation was conducted on 08/17/23 at 7:50 AM with Staff G, Certified Nursing Assistant (CNA), for Resident #68. At the end of the catheter care, Staff G realized she did not have an incontinence brief for Resident #68. Staff G stated, I would normally put a 'diaper' on, but I don't have one, so I will get a new 'diaper' and then come back and put the 'diaper' on her. Resident #68 stated she preferred to wear an 'incontinence brief'. Staff G again stated, I will get a new 'diaper' and then come back and put the 'diaper' on her. The above concerns were reviewed with the Director of Nursing, the Assistant Director of Nursing, and the Nursing Educator on 08/17/23.

Based upon interview, observation and record review, the facility failed to provide supervision and a safe environment to prevent 1 of 3 sampled residents assessed for elopement risk, Resident #1, from eloping. The deficient practice allowed Resident #1 to exit the facility undetected on [DATE] between 1:30 AM and 3:20 AM. The facility's system failure, lack of adequate supervision and an exit door not secured and without an alarm, allowed the resident to elope. The family provided directions to his previous residence and Resident #1 was found at approximately 4:30 AM. The Director of Nursing (DON) from the facility determined that the resident would be safest if he went to the hospital for evaluation, to which Resident #1 agreed. Law Enforcement transported Resident #1 to a hospital near his residence. The findings included: The facility policy titled Elopements (revised [DATE]) does not define elopement. Under the Policy Statement section, the policy states: Staff shall investigate and report all cases of missing residents. Under the Policy Interpretation and Implementation section, the policy states the following: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing 2. If an employee observes a resident leaving the premises h/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on authorized leave or pass b. If the resident was not authorized to leave initiate a search of the building(s) and premises c. If the resident is not located, notify the Administrator and the director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squad, etc.) d. Provide search teams with resident identification information and e. Initiates an extensive search of the surrounding area. The Smoking Policy for Residents (Undated) stated, under item 12, Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. The facility smoking policy did not have designated times for smoking prior to [DATE]. Review of the clinical record and documentation revealed Resident #1 was determined to be an independent smoker, which means he was considered not to need supervision. Resident #1 is a [AGE] year-old male who was admitted on [DATE] with a Primary [DIAGNOSES REDACTED]. The resident had the additional [DIAGNOSES REDACTED]. The resident was admitted for rehabilitative services related to the [MEDICAL CONDITION] and [MEDICAL CONDITION] diagnoses. The resident had a 5-day Minimum Data Set (MDS) assessment, dated [DATE]. The resident was evaluated to have a Brief Interview for Mental Status (BIMS) score of 09, which indicates moderate loss in cognitive ability and can be associated with poor decision-making skills. The resident was assessed not to have issues with Mood (MDS Section D) and was assessed as not having the behavior of wandering under the behavior evaluation (MDS Section E).The resident was accessed for Activities of Daily Living (MDS Section G) as independent with no set-up or physical help to from staff for the following Activities of Daily Living (ADLs): Bed Mobility; Walk in the corridor; Locomotion on the unit and Locomotion off the unit; and eating. The resident was identified as requiring Supervision and setup help only for Transfer (moving between surfaces such as bed to chair); Dressing; and Toilet Use. Only under Personal Hygiene, the resident required Supervision with one-person physical assist. Under Section N-medications, Resident #1 was assessed to have been taking an antipsychotic medication for the past 7 days (prior to admission), an anticoagulant for the past 7 days (prior to admission) and a diuretic for the past 7 days (prior to admission). Resident #1 had physician orders, dated [DATE], to include the following medications: [REDACTED] [MEDICATION NAME] 108 mcg/Act (micrograms per activation - 2 inhalations, orally every 6 hour for [MEDICAL CONDITIONS]; [MEDICATION NAME] 200 mg, 1 tablet by mouth one time a day for Systolic (Congestive) Heart Failure ([MEDICAL CONDITION]); Apixaban 5 mg tablet by mouth two times a day for [MEDICAL CONDITION] Fibrillation (A-Fib); Aspirin EC ([MEDICATION NAME] coated) tablet delayed release 81 mg by mouth one time a day related to [MEDICAL CONDITIONS]; Atorvastatin 40 mg tablet give 2 by mouth at bedtime related to [MEDICAL CONDITION]; [MEDICATION NAME] 2mg tablet 1 by mouth in the morning for extrapyramidal symptoms (movement impairing symptoms common with antipsychotic medications); [MEDICATION NAME] 20 mg tablet one tablet by mouth 2 times a day for [MEDICAL CONDITION] Reflux Disease (GERD); [MEDICATION NAME] tablet 20 mg 1 tablet by mouth twice a day for [MEDICAL CONDITION]; [MEDICATION NAME] injectable once every two weeks for [MEDICAL CONDITION]; [MEDICATION NAME] 2mg tablet one tablet 2 times a day for [MEDICAL CONDITION]; Sacubitril-[MEDICATION NAME] (combination medication) tablet ,[DATE] mg - 1 tablet by mouth 2 times a day for [MEDICAL CONDITION]; and [MEDICATION NAME] Aerosol ,[DATE].5 mcg/act, 2 inhalations by mouth two times a day for [MEDICAL CONDITION]. Residents are evaluated for Elopement Risk initially upon entry into the facility and re-evaluated quarterly or if there are changes in mentation or ability. Review of the Comprehensive Nursing evaluation showed there was an elopement evaluation at section 6. This risk assessment is based on the following criteria, numbers followed by parentheses are point values: Cognitive Status: 0) Alert and Oriented x 3 or Comatose 2) Alert and oriented x2 or Lethargic, 4) Alert and oriented x1 or periodic confusion 5) Alert and continuous confusion; History of Elopement/wandering: 0) Does not Wander, has never eloped 2) Wanders, but never eloped 5) has a history of elopement or wanders with a history of exit seeking; Mobility: 0) total or mostly dependent in locomotion 2) independent with wheelchair 3)ambulates independently with walker or cane 4) independent with motorized wheelchair/scooter 5) ambulates independently with no device Adjustment to Facility Placement: 0) content with placement 2)discontent, but agreeable to facility placement 3) Discontent and disagrees with facility placement 4) Expresses desire to leave 5) Actively exit seeking. Review of the Comprehensive Nursing Evaluation, dated [DATE], documented Resident #1 had a cognitive status of (2) Alert and oriented x2 or Lethargic; a History of elopement/wandering of 0) Does not Wander, has never eloped; a Mobility status of 0) total or mostly dependent in locomotion; and an Adjustment to Facility placement status of 0) content with placement. Resident #1 was evaluated with a score of 2 which translates to a Score of ,[DATE], Not at Risk for elopement, and No interventions at this time. On [DATE] at 9:57 AM, an interview was conducted with the Director of Nurses (DON). The DON explained that Resident #1 had left the facility somewhere between 1:30 AM and 3:30 AM on [DATE]. The DON stated that on [DATE], on her way to the facility, she encountered a police roadblock. The DON was informed that there had been a fatal car accident earlier in the evening/early morning hours. The police informed the DON that the accident involved two cars and no pedestrians. On [DATE], from 2:30 PM to 2:51 PM, a walking and driving tour of the surrounding area from the facility to Resident #1's residence and back to the facility was conducted. The observations that follow highlight the potential dangers encountered by Resident #1: The facility is located at the end of a street without an outlet (Dead End) that allows for two-way traffic (no lanes) and forms a T-intersection with a main East-West 6-lane roadway with a speed limit of 45 miles per hour (mph) that has traffic lights and a bridge over the Florida Turnpike (a super highway) in the westerly direction. The facility is bordered on the north and west by condominium complexes that have border fences to limit access to the communities. There is a walkway leading into the complex to the north. There is a sidewalk adjacent to the condominium to the west. There is a sidewalk that is adjacent to the facility. On the same side of the road as the facility, there is a church with a school, with fences surrounding the buildings and along the sidewalk. Both sidewalks lead to the 6-lane roadway described above. In the easterly direction of the main road, there was a canal with a fence in front of it, but the fence would not deter a person from walking down to the canal. The canal is murky with an undetermined depth. The same canal runs behind the facility, but it is protected by a high fence that encloses three sides of the facility. In either direction along the main roadway there are places where the sidewalk ended, did not exist or was broken. During a driving tour of the area and following the path that Resident #1 took, per family interview, Resident #1 encountered several high-speed roadways with dangerous portion without sidewalks and side streets leading into residential areas with unknown dangers. While out of the facility, Resident #1 could have gotten lost, fallen in the canal and drowned, fallen and broken a limb or limbs, been hit by a car and been injured or died . On [DATE] at 3:28 PM, a walking tour of the facility was conducted accompanied by the DON. At that time, the DON explained that immediately after the elopement there were alarms installed on the double doors lead to the lobby and on the front door. The DON explained that at 8:00 PM, when the receptionist leaves for the day and the front door is unobserved, the nursing supervisor would set the alarm on the front door, close the double door and set the alarm on the double door. The DON further explained that the alarms remain activated until the next morning when the person responsible for screening the staff arrives, at around 5:00 AM. The DON stated that the nursing supervisor is responsible for testing the alarm, which was being done nightly by the supervisor setting the alarm and then proceeding through the doors to make the alarm sound. The supervisor then would reset the alarm. The supervisor would repeat this test on the front door. The DON explained that the only people with access to the alarm key were the Administrator, the DON and the Nursing Supervisors, 1 on the North wing and 1 on the South wing. During the walking tour, it was noted that the smoking patio and Resident #1's room were close to the lobby and front entrance. Also, it was observed that the nurses' station was around the corner from the smoking patio and the Resident #1's room, and staff would not see the front door or patio if at the nursing station. On [DATE] at 4:13 PM, interview with Staff-D, the RN-Unit Manager (Registered Nurse), revealed Resident #1 was able to ambulate independently with no device, which does not match to the evaluation tool. This would have changed his score to a 7, which would keep the resident as Not at Risk, but it would make the resident closer to At Risk. A telephone interview was conducted on [DATE] at 10:55 AM with Resident #1's family member. The family member said that Resident #1 walked west over the overpass for the turnpike to the next intersection where he went north. It is unknown if Resident #1 crossed the street first before going north. On the west side of the road, there is a sidewalk on the east side at the beginning of the road there is none. The road that Resident #1 went north on is a split roadway with a concrete barrier dividing north-south traffic. The road at the point where Resident #1 turned right has two large curves and no sidewalk on east side of the road at this point. The speed limit is 40 mph. The roadway north passes by residential neighborhoods on both sides of the street and eventually intersects with a 6-lane high speed roadway with traffic lights and a speed limit of 45 mph. Resident #1 had to cross this roadway on the way to his home. There are sidewalks at this point of the journey. Resident #1 walked to the next intersection, approximately 0.25 mile, where he turned right (east) on a road that is four lanes in either direction with a speed limit of 40 mph. The resident walked approximately 0.25 to 0.5 miles then turned right into the residential area where his home is located. The streets are small one-way and two-way roads usually associated with a small neighborhood. According to the family, Resident #1 stated that he took 2 hours to complete his walk home. The total distance from the facility to the resident's home residence is approximately 4.5 miles. On [DATE] at 2:38 PM, an interview was conducted with Staff A, the Certified Nursing Assistant (CNA) caring for Resident #1 on the night of his elopement, [DATE]. The CNA stated that at 1:30 AM, she saw Resident #1 on the smoking patio. The CNA stated that resident frequently smoked at 1:30 AM. At 3:20 AM, the CNA checked his room and he was not in his room and checked the patio and Resident #1 was not there. Staff A stated at that time, the supervisor had been passing through the South Wing and the CNA informed the supervisor about the missing resident. The supervisor called Code Pink (missing person, now Code White) and the facility was searched. The CNA stated that the resident was not found, and the DON and police were called. Staff A stated that she does not recall exactly what she was doing prior to Resident #1's leaving the facility. The CNA stated that the facility has been having drills regarding elopement every 2 weeks. The CNA said that everyone was provided an in-service. On [DATE] at 3:17 PM, an interview was conducted with Staff B, a Registered Nurse and Nursing Supervisor who was on duty on [DATE]. Staff B stated that she was notified at 3:20 AM by Resident #1's nurse (Staff C) that Resident #1 was missing. She called the missing person code and all staff did an immediate search of the facility. The RN Supervisor stated that the resident was known to go back and forth between his room and the patio to smoke. She further stated that the facility had been having have in-services regarding elopement and responding to alarms but was unsure as to how often the drills occur. Staff B stated that this was after the elopement alarms were added to the doors leading to the lobby and the front door. She stated that she is the supervisor who is responsible for setting the alarms after 8:00 PM when the personnel at the front desk leaves. She stated that she activates both, the ones leading to the lobby and the front door. She stated that she tests the alarms every night as part of the security process. An in-service was done for all employees. On [DATE] at 3:30 PM, an interview was conducted with Staff C, a Registered Nurse (RN) who was the primary nurse for Resident #1 on [DATE]. Staff C stated that she was informed by the CNA that Resident #1 was missing at around 3:16 AM. Staff C stated that at about 1:20 AM, Resident #1 asked her for juice. Staff C stated she provided Resident #1 with the juice and told him to go back to his room. Staff C stated that she was around the corner at the nurses' station writing documentation when she was informed of the missing person. Staff C stated that she had seen last seen the resident in his room at approximately 3:00 AM when she did rounds on her assigned residents. The RN stated that when the CNA told her Resident #1 was missing, a missing person code was called and when the facility search determined that Resident #1 was missing, the DON and 911 was called. An interview with the DON, on [DATE] at 11:47 AM, revealed Resident #1 was not considered a wander/elopement risk. The DON stated that he was a heavy smoker and on the night of the elopement he asked the nurse for juice at approximately 1:30 AM. He had been seen on the smoking patio by the CNA at approximately 1:40 AM. Resident #1 was evaluated to be an independent smoker. Review of a Comprehensive Nursing Evaluation tool, dated [DATE], showed that smoking is evaluated in Section 7. Part of the evaluation is an observation of the resident smoking. In this observation, the resident must demonstrate the following: an ability to light cigarette safely with a lighter; The resident must smoke safely which means no ashes or burning material falling on resident or others; remain alert while smoking; does not forget that they are smoking or fall asleep holding a lit smoking item; does not endanger himself or others; does not burn furniture clothing skin, self or others; turns off oxygen prior to lighting a cigarette; smokes in designated areas only; the resident utilizes ashtray safely and properly; the resident is able to extinguish cigarette safely and completely when finished smoking; the resident is able to communicate reason why oxygen must always be shut off prior to lighting cigarette; and the resident is able to communicate the risks associated with smoking. Review of the same Comprehensive Nursing Evaluation tool, dated [DATE], for Resident #1 revealed the resident was observed and identified as being an independent smoker based upon the above criteria. The DON stated that Resident #1 was believed to have exited through the front door which did not have an alarm on the door. Interview with Resident #1's family member, on [DATE] at 11:47 AM, confirmed that the resident had exited through the front door. Observations on [DATE] at 3:28 PM, in the hallway where Resident #1 had resided, the smoking patio and the lobby at the following times, on [DATE] at approximately 9:00 AM, 1:30 PM and at approximately 3:30 PM; on [DATE] between 12:30 PM and 1:30 PM; on [DATE] at approximately 12:30 PM, 2:30 PM and 3:30 PM; and on [DATE] between 2:00 PM and 3:00 PM, revealed that walking from the smoking patio to the front door without being noticed would have been easy for an independent person who ambulates. The same was true for going to the lobby from the room that Resident #1 resided in. The facility's Immediate Jeopardy Removal Plan included: 1. The patio was closed on [DATE] from 10:00 PM to 7:30 AM, this time was adjusted on [DATE] to 8:00 PM to 7:30 AM. 2. Dual alarms were installed on the Smoke doors in the front lobby and the front exit door on [DATE]. Maintenance staff check the alarms twice daily for proper functioning. These checks are recorded on a physical log sheet. The front exit door alarm was replaced with delayed egress timer on [DATE]. 3. A delayed egress timer was installed on the front exit door in the lobby on [DATE]. The delayed egress timer deactivates in 20 seconds from the time the door is opened. A code is necessary to activate (open and close door). Maintenance staff checks door for proper functioning twice daily and records the checks on a paper log sheet. All exit doors were being checked twice daily beginning on February 21, 2021 by Maintenance staff. 4. The Smoking policy was updated on [DATE] to show the time of patio closing and opening. 5. All staff were in-serviced on Abuse and Neglect from [DATE] to [DATE] and is continuous. 6. All Nursing staff was in-serviced on checking wander guards every shift beginning on [DATE] through [DATE], in-services are continuous. 7. All staff were in-serviced on the alarm system from [DATE] to [DATE]. 8. A Resident Council meeting was convened on to inform the Resident Council President and the six residents present of the changes that were made regarding the closing and opening times of the patio. The six residents present were non-smokers. 9. Residents who smoke were educated on the change in patio closing and opening times on [DATE] by the Director of Nursing. The 'Alarm System on the Exit and Entrance' in-service was conducted from [DATE] to [DATE] and the Elopement in-services was conducted from [DATE] to [DATE] for all staff for all shifts: 7:00 AM to 3:30 PM, 3:00 PM to 11:30 PM and 11:00 PM to 7:30 AM. The following is the breakdown by department: Alarm System on Exit and Entrance In-service was provided from [DATE] to [DATE]: Next Level (contracted) Dietary Staff - 13 Next Level (contracted) Housekeeping - 11 Nursing - Nurses and CNAs - 68 Maintenance - 3 Social Services - 3 Therapy - 20 Dialyzed Direct Employees - 3 Administration - 3 Nursing Administration - 15. This totals to 139 staff members of 139 staff members = 100%. The Elopement In-service was provided from [DATE] to [DATE]: Next Level (contracted) Dietary Staff - 13 Next Level (contracted) Housekeeping - 11 Nursing - Nurses and CNAs - 68 Maintenance - 3 Social Services - 3 Therapy - 20 Dialyzed Direct Employees (RNs and LPNs) - 3 Administration - 3 Nursing Administration - 15. This totals to 139 staff members of 139 staff members = 100%. The Inservice for Abuse/Neglect was conducted from [DATE] to [DATE]: Nursing - Nurses and CNAs - 52 Therapy - 6 Next Level (contracted) Dietary Staff - 6 Next Level (contracted) Housekeeping - 4 Dialyzed Direct Employees (RNs and LPNs) - 1 Maintenance - 1 Social Services - 1 Administration - 2 This totals to 67 staff members of 139 staff members = 48%. The DON explained that due to lower census, there has been staffing cutbacks with many staff being per diem. She explained that she will be calling these staff members to provide the education needed. The DON explained that full-time staff have been educated. The in-service on the New Alarm System at the Front Entrance/Exit was conducted on [DATE] and [DATE]: Activities - 1 Administration - 3 [MEDICAL TREATMENT] - 1 Dietary - 10 Housekeeping - 5 Maintenance - 1 Miscellaneous -1 Nursing (RNs, LPNs, CNAs) - 32 This totals to 54 of 139 staff members = 39%. These in-services will continue until All staff has been educated. On [DATE] between 2:00 PM and 3:00 PM, interviews were conducted with the Resident Council President and 5 residents who smoked in the facility: Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8. Resident #4, Resident #6 and Resident # 8 said they were aware of the changes to the smoking patio closing time of 8:00 PM and reopening at 7:30 AM. Resident #5 was not interviewed because she was sleeping. Resident #7, who suffers from a Traumatic Head and [MEDICAL CONDITION] that could affect memory, denied knowing about the changes. On [DATE] at 4:11 PM, the Administrator, Director of Nursing and the Regional Consultant Registered Nurse were notified that the Immediate Jeopardy was removed. The removal was determined to be as of [DATE]. This date was when the facility was substantially compliant with care based upon the corrective actions that were implemented by [DATE]. The scope and severity of F689, was lowered to a (D) for no actual harm with a potential for more than minimal harm that is not immediate jeopardy as of [DATE]. The scope and severity were lowered as a result of the facility's corrective actions implemented. These corrective actions were verified by the survey team through observation, record review and interview on [DATE]. Photographic Evidence obtained.

Based upon interview, observation and record review, the facility failed to appropriately assess a resident as an elopement risk and failed to provide supervision to prevent 1 of 3 sampled residents, assessed for elopement risk, from eloping, Resident #1. The deficient practice allowed Resident #1 to exit the facility undetected on [DATE] between 1:30 AM and 3:20 AM. The facility's system failure, lack of adequate supervision, an inaccurate risk of elopement assessment and an exit door not secured and without an alarm, allowed the resident to elope. The family provided directions to his previous residence and Resident #1 was found at approximately 4:30 AM. The Director of Nursing (DON) from the facility determined that the resident would be safest if he went to the hospital for evaluation, to which Resident #1 agreed. Law Enforcement transported Resident #1 to a hospital near his previous residence. The findings included: The facility policy titled Elopements (revised [DATE]) does not define elopement. Under the Policy Statement section, the policy states: Staff shall investigate and report all cases of missing residents. Under the Policy Interpretation and Implementation section the policy states the following: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing 2. If an employee observes a resident leaving the premises h/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on authorized leave or pass b. If the resident was not authorized to leave initiate a search of the building(s) and premises c. If the resident is not located, notify the Administrator and the director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squad, etc.) d. Provide search teams with resident identification information and e. Initiates an extensive search of the surrounding area. The Smoking Policy for Residents (Undated) stated, under item 12, Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. The facility smoking policy did not have designated times for smoking prior to [DATE]. Review of the clinical record and documentation revealed the following: Resident #1 was determined to be an independent smoker, which means he was considered not to need supervision. Resident #1 is a [AGE] year-old male who was admitted on [DATE] with a Primary [DIAGNOSES REDACTED]. The resident had the additional [DIAGNOSES REDACTED]. The resident was admitted for rehabilitative services related to the [MEDICAL CONDITION] and [MEDICAL CONDITION] diagnoses. The resident had a 5-day Minimum Data Set (MDS) assessment, dated [DATE]. The resident was evaluated to have a Brief Interview for Mental Status (BIMS) score of 09, which indicates moderate loss in cognitive ability and can be associated with poor decision-making skills. The resident was assessed not to have issues with Mood (MDS Section D) and was assessed as not having the behavior of wandering under the behavior evaluation (MDS Section E). The resident was accessed for Activities of Daily Living (MDS Section G) as independent with no set-up or physical help to from staff for the following Activities of Daily Living (ADLs): Bed Mobility; Walk in the corridor; Locomotion on the unit and Locomotion off the unit; eating. The resident was identified as requiring Supervision and setup help only for Transfer (moving between surfaces such as bed to chair); Dressing; and Toilet Use. Only Personal Hygiene required Supervision with one-person physical assist. Under Section N- medications, Resident #1 was assessed to have been taking an antipsychotic medication for the past 7 days (prior to admission), an anticoagulant for the past 7 days (prior to admission) and a diuretic for the past 7 days (prior to admission). Resident #1 had physician orders, dated [DATE], to include the following medications: [REDACTED] [MEDICATION NAME] 108 mcg/Act (micrograms per activation - 2 inhalations, orally every 6 hour for [MEDICAL CONDITIONS]; [MEDICATION NAME] 200 mg, 1 tablet by mouth one time a day for Systolic (Congestive) Heart Failure ([MEDICAL CONDITION]); Apixaban 5 mg tablet by mouth two times a day for [MEDICAL CONDITION] Fibrillation (A-Fib); Aspirin EC ([MEDICATION NAME] coated) tablet delayed release 81 mg by mouth one time a day related to [MEDICAL CONDITIONS]; Atorvastatin 40 mg tablet give 2 by mouth at bedtime related to [MEDICAL CONDITION]; [MEDICATION NAME] 2mg tablet 1 by mouth in the morning for extrapyramidal symptoms (movement impairing symptoms common with antipsychotic medications); [MEDICATION NAME] 20 mg tablet one tablet by mouth 2 times a day for [MEDICAL CONDITION] Reflux Disease (GERD); [MEDICATION NAME] tablet 20 mg - 1 tablet by mouth twice a day for [MEDICAL CONDITION]; [MEDICATION NAME] injectable once every two weeks for [MEDICAL CONDITION]; [MEDICATION NAME] 2mg tablet one tablet 2 times a day for [MEDICAL CONDITION]; Sacubitril-[MEDICATION NAME] (combination medication) tablet ,[DATE] mg - 1 tablet by mouth 2 times a day for [MEDICAL CONDITION]; and [MEDICATION NAME] Aerosol ,[DATE].5 mcg/act, 2 inhalations by mouth two times a day for [MEDICAL CONDITION]. Residents are evaluated for Elopement Risk initially upon entry into the facility and re-evaluated quarterly or if there are changes in mentation or ability. The Comprehensive Nursing evaluation has an elopement evaluation at section 6. This risk assessment is based on the following criteria, numbers followed by parentheses are point values: Cognitive Status: 0) Alert and Oriented x 3 or Comatose 2) Alert and oriented x2 or Lethargic, 4) Alert and oriented x1 or periodic confusion 5) Alert and continuous confusion History of Elopement/wandering: 0) Does not Wander, has never eloped 2) Wanders, but never eloped 5) has a history of elopement or wanders with a history of exit seeking; Mobility: 0) total or mostly dependent in locomotion 2) independent with wheelchair 3)ambulates independently with walker or cane 4) independent with motorized wheelchair/scooter 5) ambulates independently with no device Adjustment to Facility Placement: 0) content with placement 2)discontent, but agreeable to facility placement 3) Discontent and disagrees with facility placement 4) Expresses desire to leave 5) Actively exit seeking. Review of the Comprehensive Nursing Evaluation, dated [DATE], documented Resident #1 had a cognitive status of (2) Alert and oriented x2 or Lethargic; a History of elopement/wandering of 0) Does not Wander, has never eloped; a Mobility status of 0) total or mostly dependent in locomotion; and an Adjustment to Facility placement status of 0) content with placement. Resident #1 was evaluated with a score of 2 which translates to a Score of ,[DATE], Not at Risk for elopement. No interventions at this time. On [DATE] at 9:57 AM, an interview was conducted with the Director of Nursing (DON). The DON explained that Resident #1 had left the facility somewhere between 1:30 AM and 3:30 AM on [DATE]. The DON stated that on [DATE], on her way to the facility, she encountered a police roadblock. The DON was informed that there had been a fatal car accident earlier in the evening/early morning hours. The police informed the DON that the accident involved two cars and no pedestrians. On [DATE], from 2:30 PM to 2:51PM, a walking and driving tour of the surrounding area from the facility to Resident #1's residence and back to the facility was conducted. The observations that follow highlighted the potential dangers encountered by Resident #1: The facility is located at the end of a street without an outlet (Dead End) that allows for two-way traffic (no lanes) and forms a T intersection with a main East-West 6-lane roadway with a speed limit of 45 miles per hour (mph) that has traffic lights and a bridge over the Florida Turnpike (a super highway) in the westerly direction. The facility is bordered on the north and west by condominium complexes that have border fences to limit access to the communities. There is a walkway leading into the complex to the north. There is a sidewalk adjacent to the condominium to the west. There is a sidewalk that is adjacent to the facility. On the same side of the road as the facility, there is a church with a school, with fences surrounding the buildings and along the sidewalk. Both sidewalks lead to the 6-lane roadway described above. In the easterly direction of the main road, there was a canal with a fence in front of it, but the fence would not deter a person from walking down to the canal. The canal is murky with an undetermined depth. The same canal runs behind the facility, but it is protected by a high fence that encloses three sides of the facility. In either direction along the main roadway, there are places where the sidewalk ended, did not exist or was broken. During a driving tour of the area and following the path that Resident # took, per family interview on [DATE] at 10:55 AM, Resident #1 encountered several high-speed roadways with dangerous portion without sidewalks and side streets leading into residential areas with unknown dangers. While out of the facility, Resident #1 could have gotten lost, fallen in the canal and drowned, fallen and broken a limb or limbs, or been hit by a car and been injured or died . On [DATE] at 4:13 PM, interview with Staff-D, the RN-Unit Manager (Registered Nurse), Resident #1 was able to ambulate independently with no device, which does not match to the evaluation tool. This would have changed his score to a 7, which would keep the resident as Not at Risk, but it would make the resident closer to At Risk. A telephone interview was conducted on [DATE] at 10:55 AM with Resident #1's family member. The family member said that Resident #1 walked west over the overpass for the turnpike to the next intersection where he went north. It is unknown if Resident #1 crossed the street first before going north. On the west side of the road, there is a sidewalk, and on the east side at the beginning of the road, there is none. The road that Resident#1 went north on is a split roadway with a concrete barrier dividing north-south traffic. The road at the point where Resident #1 turned right has two large curves and no sidewalk on east side of the road at this point. The speed limit is 40 mph. The roadway north passes by residential neighborhoods on both sides of the street and eventually intersects with a 6-lane high speed roadway with traffic lights and a speed limit of 45 mph. Resident #1 had to cross this roadway on the way to his home. There are sidewalks at this point of the journey. Resident #1 walked to the next intersection, approximately 0.25 mile, where he turned right (east) on a road that is four lanes in either direction with a speed limit of 40 mph. The resident walked approximately 0.25 to 0.5 miles then turned right into the residential area where his home is located. The streets are small one-way and two-way roads usually associated with a small neighborhood. According to the family, Resident #1 stated that he took 2 hours to complete his walk home. This was a total of approximately 4.5 miles, from the facility to the resident's home-residence. On [DATE] at 3:28 PM, a walking tour of the facility was conducted accompanied by the DON. At that time, the DON explained that immediately after the elopement, there were alarms installed on the double doors leading to the lobby and on the front door. The DON explained that at 8:00 PM, when the receptionist leaves for the day and the front door is unobserved, the nursing supervisor would set the alarm on the front door, close the double door and set the alarm on the double door. The DON further explained that the alarms remain activated until the next morning when the person responsible for screening the staff arrives, at around 5:00 AM. The DON stated that the nursing supervisor is responsible for testing the alarm, which was being done nightly by the supervisor setting the alarm and then proceeding through the doors to make the alarm sound. The supervisor then would reset the alarm. The supervisor would repeat this test on the front door. The DON explained that the only people with access to the alarm key were the Administrator, the DON and the Nursing Supervisors, 1 on the North wing and 1 on the South wing. During the walking tour, it was noted that the smoking patio and Resident #1's room, 202, were close to the lobby and front entrance. Also, it was observed that the nurses' station was around the corner from the smoking patio and the Resident #1's room, and staff would not see the front door or patio if at the nursing station. On [DATE] at 2:38 PM, an interview was conducted with Staff A, the Certified Nursing Assistant (CNA) caring for Resident #1 on the night of his elopement, [DATE]. The CNA stated that at 1:30 AM, she saw Resident #1 on the smoking patio. The CNA stated that the resident frequently smoked at 1:30 AM. At 3:20 AM, the CNA checked his room and he was not in his room and checked the patio and Resident #1 was not there. Staff A stated at that time the supervisor had been passing through the South Wing and the CNA informed the supervisor about the missing resident. The supervisor called Code Pink (missing person, now Code White) and the facility was searched for the resident. The CNA stated that the resident was not found, and the DON and police were called. Staff A stated that she does not recall exactly what she was doing prior to Resident #1's leaving the facility. The CNA stated that the facility has been having drills regarding elopement every 2 weeks. The CNA said that everyone was provided an in-service. On [DATE] at 3:17 PM, an interview was conducted with Staff B, a Registered Nurse and Nursing Supervisor who was on duty on [DATE]. Staff B stated that she was notified at 3:20 AM by Resident #1's nurse (Staff C) that Resident #1 was missing. She called the missing person code and all staff did an immediate search of the facility. The RN Supervisor stated that the resident was known to go back and forth between his room and the patio to smoke. She further stated that the facility had been having in-services regarding elopement and responding to alarms but was unsure as to how often the drills occur. Staff B stated that these were after the elopement alarms were added to the doors leading to the lobby and the front door. She stated that she is the supervisor who is responsible for setting the alarms after 8:00 PM when the personnel at the front desk leaves. She stated that she activates both, the ones leading to the lobby and the front door. She stated that she tests the alarms every night as part of the security process. An in-service was done for all employees. On [DATE] at 3:30 PM, an interview was conducted with Staff C, a Registered Nurse (RN) who was the primary nurse for Resident #1 on [DATE]. Staff C stated that she was informed by the CNA that Resident #1 was missing at around 3:16 AM. Staff C stated that at about 1:20 AM, Resident #1 asked her for juice. Staff C stated she provided Resident #1 with the juice and told him to go back to his room. Staff C stated that she was around the corner at the nurses' station writing documentation when she was informed of the missing person. Staff C stated that she :had seen last seen the resident in his room at approximately 3:00 AM when she did rounds on her assigned residents. The RN stated that when the CNA told her Resident #1 was missing, a missing person code was called and when the facility search determined that Resident #1 was missing, the DON and 911 was called. On [DATE] at 11:47 AM, an interview with the DON revealed Resident #1 was not considered a wander/elopement risk. The DON stated that he was a heavy smoker and on the night of the elopement he asked the nurse for juice at approximately 1:30 AM. He had been seen on the smoking patio by the CNA at approximately 1:40 AM. Resident #1 was evaluated to be an independent smoker. In the Comprehensive Nursing Evaluation tool, smoking is evaluated in Section 7. Part of this evaluation is an observation of the resident smoking. In this observation, the resident must demonstrate the following: an ability to light cigarette safely with a lighter; The resident must smoke safely which means no ashes or burning material falling on resident or others, remain alert while smoking, does not forget that they are smoking or fall asleep holding a lit smoking item, does not endanger himself or others, does not burn furniture clothing skin, self or others, turns off oxygen prior to lighting a cigarette, smokes in designated areas only; The resident utilizes ashtray safely and properly; the resident is able to extinguish cigarette safely and completely when finished smoking; The resident is able to communicate reason why oxygen must always be shut off prior to lighting cigarette; and The resident is able to communicate the risks associated with smoking. Resident #1 was observed and identified as being an independent smoker based upon the above criteria. The DON stated that Resident #1 was believed to have exited through the front door which did not have an alarm on the door. On [DATE] at 10:55 AM, interview with Resident #1's family member confirmed the resident left by the front door. Observations on [DATE] at 3:28 PM, in the hallway where Resident #1 had resided, the smoking patio and the lobby at the following times, on [DATE] at approximately 9:00 AM, 1:30 PM and at approximately 3:30 PM; on [DATE] between 12:30 PM and 1:30 PM; on [DATE] at approximately 12:30 PM, 2:30 PM and 3:30 PM; and on [DATE] between 2:00 PM and 3:00 PM, revealed that walking from the smoking patio to the front door without being noticed would have been easy for an independent person who ambulates. The same was true for going to the lobby from the room that Resident #1 resided in. The facility's Immediate Jeopardy Removal Plan included: 1. The patio was closed on [DATE] from 10:00 PM to 7:30 AM, this time was adjusted on [DATE] to 8:00 PM to 7:30 AM. 2. Dual alarms were installed on the Smoke doors in the front lobby and the front exit door on [DATE]. Maintenance staff check the alarms twice daily for proper functioning. These checks are recorded on a physical log sheet. The front exit door alarm was replaced with delayed egress timer on [DATE]. 3. A delayed egress timer was installed on the front exit door in the lobby on [DATE]. The delayed egress timer deactivates in 20 seconds from the time the door is opened. A code is necessary to activate (open and close door). Maintenance staff checks door for proper functioning twice daily and records the checks on a paper log sheet. All exit doors were being checked twice daily beginning on February 21, 2021 by Maintenance staff. 4. The Smoking policy was updated on [DATE] to show the time of patio closing and opening. 5. All staff were in-serviced on Abuse and Neglect from [DATE] to [DATE] and is continuous. 6. All Nursing staff was in-serviced on checking wander guards every shift beginning on [DATE] through [DATE], in-services are continuous. 7. All staff were in-serviced on the alarm system from [DATE] to [DATE]. 8. A Resident Council meeting was convened on [DATE] to inform the Resident Council President and the six residents present of the changes that were made regarding the closing and opening times of the patio. The six residents present were non-smokers. 9. Residents who smoke were educated on the change in patio closing and opening times on [DATE] by the Director of Nursing. The 'Alarm System on Exit and Entrance' in-service was conducted from [DATE] to [DATE] and the Elopement in-services was conducted from [DATE] to [DATE] for all staff for all shifts 7:00 AM to 3:30 PM, 3:00 PM to 11:30 PM and 11:00 PM to 7:30 AM. The following is the breakdown by department: 'Alarm System on Exit and Entrance' In-service was provided from [DATE] to [DATE]: Next Level (contracted) Dietary Staff - 13 Next Level (contracted) Housekeeping - 11 Nursing - Nurses and CNAs - 68 Maintenance - 3 Social Services - 3 Therapy - 20 Dialyzed Direct Employees - 3 Administration - 3 Nursing Administration - 15. This totals to 139 staff members of 139 staff members = 100%. The Elopement In-service was provided from [DATE] to [DATE]: Next Level (contracted) Dietary Staff - 13 Next Level (contracted) Housekeeping - 11 Nursing - Nurses and CNAs - 68 Maintenance - 3 Social Services - 3 Therapy - 20 Dialyzed Direct Employees (RNs and LPNs) - 3 Administration - 3 Nursing Administration - 15. This totals to 139 staff members of 139 staff members = 100%. The Inservice for Abuse/Neglect was conducted from [DATE] to [DATE]: Nursing - Nurses and CNAs - 52 Therapy - 6 Next Level (contracted) Dietary Staff - 6 Next Level (contracted) Housekeeping - 4 Dialyzed Direct Employees (RNs and LPNs) - 1 Maintenance - 1 Social Services - 1 Administration - 2. This totals to 67 staff members of 139 staff members = 48%. The DON explained that due to lower census, there has been staffing cutbacks with many staff being per diem. She explained that she will be calling these staff members to provide the education needed. The DON explained that full-time staff have been educated. The in-service on the New Alarm System at the Front Entrance/Exit was conducted on [DATE] and [DATE]. These in-services will continue until All staff has been educated. Activities - 1 Administration - 3 [MEDICAL TREATMENT] - 1 Dietary - 10 Housekeeping - 5 Maintenance - 1 Miscellaneous -1 Nursing (RNs, LPNs, CNAs) - 32. This totals to 54 of 139 staff members = 39%. On [DATE] between 2:00 PM and 3:00 PM, interviews were conducted with the Resident Council President and 5 residents who smoked in the facility: Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8. Resident #4, Resident #6 and Resident # 8 said they were aware of the changes to the smoking patio closing time of 8:00 PM and reopening at 7:30 AM. Resident #5 was not interviewed because she was sleeping. Resident #7, who suffers from a Traumatic Head and [MEDICAL CONDITION] that could affect memory, denied knowing about the changes.

Based on interview and record review, the facility failed to monitor a change in condition related to respiratory status that required hospitalization for 1 of 3 sampled residents, Resident #1, as evidenced by no documentation of monitoring or assessment of Resident #1 and when placed on oxygen therapy by nursing without physician orders. The findings included: Review of the facility policy for Change in Resident's Condition or Status states in part, 'Our 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. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician when there has been: A significant change in the resident's physical/emotional/mental condition; A need to alter the resident's medical treatment significantly.' Review of the facility policy for Charting and Documentation states in part, 'All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record .All observations, medications administered, services performed etc., must be documented in the resident's clinical records . All incidents, accidents, or changes in the resident's condition must be recorded .Documentation of procedures and treatments shall include care specific details and shall include at a minimum: The date and time the procedure/treatment was provided; The assessment data and/or any unusual findings obtained during the procedure/treatment; How the resident tolerated the procedure/treatment; Notification of family, physician or other staff if indicated.' Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. The resident was transferred to the hospital on [DATE] for evaluation of abnormal laboratory results. The resident was readmitted to the facility on [DATE] for skilled nursing, wound care and skilled therapy services, with [DIAGNOSES REDACTED]. Review of the record, specifically the Medication Administration Record [REDACTED]. Review of Resident #1's Weights and Vitals Summary sheet, dated 09/16/19 at 9:56 AM, Licensed Practical Nurse (LPN) Staff E, documented a blood pressure of 102/62 and a heart rate of 78. The LPN did not document a respiratory rate, a temperature or oxygen saturation. Review of the Medication Administration Record [REDACTED]. Review of the clinical record revealed no Nursing Progress Notes related to the resident's status from 09/03/19 through 09/16/19. On 11/20/19 at 3:20 PM, an interview was conducted with LPN Staff B', who stated they document on residents daily in the Daily Skilled Note if the resident is receiving skilled services. LPN Staff B stated if there is anything abnormal that arises during your shift, for example abnormal labs or anything that may arise for the resident that is not the usual, they document in the Nursing Progress Notes. An inquiry was made if starting a resident on oxygen would qualify for documentation on the Nursing Progress Notes, to which LPN Staff B stated absolutely because that is something new and a change in condition. A further inquiry was made to LPN Staff B, if the physician should be notified if the resident is requiring oxygen that he/she did not require before, to which she stated the physician needs to be called for any change in condition. Review of a Daily Skilled Note, dated 09/16/19, LPN Staff [NAME] documented at 3:17 PM, at the end of her shift, 'Temperature 97 degrees, respiratory rate of 18, heart rate of 80, and blood pressure of 102/(blank)'. Documented under Additional Comments/Concerns - 'In bed responded to call of name, medicated as order, safety maintained. Mild shortness of breath noted with oxygen saturation at 92% on room air oxygen applied at 2 liters per minute via nasal cannula. MD notify.' Review of the Nursing Progress Notes revealed on the 7 AM to 3 PM day shift on 09/16/19, there was no documentation at what time the oxygen was initiated at 2 liters via nasal cannula, no documentation of an assessment of lung or breath sounds, no documentation of a respiratory rate, if the resident was assessed to have mild shortness of breath and no documentation of the resident's cognitive status. Additionally, there is no documentation what time the physician was notified of this change in condition or if there were any comments or additional orders. Review of Resident #1's (MONTH) 2019 MARs and TARs and (MONTH) 2019 Physician Orders, revealed there was no Physician order for [REDACTED]. Review of Nursing Progress Notes revealed on the 3 PM to 11 PM evening shift on 09/16/19, there was no documentation by Registered Nurse (RN) Staff D of an assessment of Resident #1 when her shift commenced to indicate that Resident #1 was now on oxygen at 2 liters per minute via nasal cannula, and no assessment of his respiratory status or oxygen saturation level. Review of Resident #1's Weights and Vitals Summary sheet, dated 09/16/19, for the start of RN Staff D's 3 PM to 11 PM evening shift, revealed no vital sign assessment and no oxygen saturation assessment. Review of an entry in the clinical record, dated 09/16/19 at 6:35 PM, the Physician Assistant (PA) documented 'Received a call from nurse regarding patient. States family wants to send him out because he doesn't look good. Was told his blood pressure was 90/68 and oxygen saturation was at 92%. Nurse states they were not able to obtain new oxygen saturation at the time. Advised the nurse that if family wants him sent out, to send to hospital. Advised not sure what [DIAGNOSES REDACTED].' Review of the clinical record Nursing Progress Notes for 09/16/19, on the 3 PM to 11 PM evening shift, revealed no documentation by RN Staff D that the PA advised to send the resident out to the hospital for evaluation, or that the resident was sent out to the hospital for evaluation. Review of the Weight and Vital Signs Summary revealed no documentation of a blood pressure of 90/68. Further, the next documentation on the Weight and Vital Signs Summary, dated 09/16/19 from the entry at 9:56 AM, is documented as 8:03 PM documenting the resident's blood pressure was 95/68, heart rate of 120, respiratory rate of 12 and oxygen saturation of 85% on oxygen via nasal cannula. Review of a Communication Form, dated 09/16/19 at 8:23 PM, documents the PA was notified of Resident #1's change in condition at 8:30 PM with vital signs documented as blood pressure 95/68, heart rate of 120, respiratory rate of 12, temperature of 95.6, oxygen saturation of 85% on oxygen with decreased level of consciousness. The Recommendation of Primary Clinician documents 'To hospital for evaluation and treatment.' Review of the Nursing Home to Hospital Transfer Form, dated 09/16/19 at 9:05 PM, completed by RN Staff D, documented Resident #1's vital signs as blood pressure of 93/68, heart rate of 120, respiratory rate of 12, temperature of 95.2 and oxygen saturation of 85% on 2 liters of oxygen. Documentation under Additional Relevant Information stated 'Resident was transferred to (name of hospital) for evaluation and treatment secondary to change in mental status, abnormal vitals, MD notified, staff continue to monitor patient frequently and noted a sudden change in patients mental status. Vitals taken, noted some abnormalities. 911 notified, resident was transferred to (name of hospital).' Review of a Nursing Progress Note, dated 09/16/19 at 8:40 PM, documented as a 'Late Entry', RN Staff D documented 'PA was informed that family wants to send patient to the hospital because he is not looking good. PA stated that patient should be continuously monitored and that his vitals are not enough to send him out. 5:35 PM blood pressure 110/72. Unable to check oxygen saturation patient keep pulling it off. Care provider was also informed about oxygen saturation that was taken on the 7A-3P shift of 92% and that he was placed on oxygen at 2 liters via nasal cannula. 8:00 PM blood pressure 95/68, pulse 120. Unable to respond to verbal stimuli, responded to sternum rub. 911 was called. PA was informed at 8:30.' Review of the Late Entry does not document the time RN Staff D contacted the P[NAME] There is no evidence in the clinical record the resident was continuously monitored. There is no documentation elsewhere in the clinical record that the resident's blood pressure was 110/72 at 5:35 PM with no further assessment of heart rate or respiratory rate. There is no documentation the resident was becoming restless and pulling the oxygen saturation probe off. Review of the Weights and Vital Signs Summary documented the last vital signs obtained at 9:56 AM on 09/16/19, which did not include a respiratory rate or temperature. The next vital signs documented were at 8:03 PM, revealing the blood pressure was 95/58, heart rate 120, respirations of 12, temperature of 95.6 and oxygen saturation of 85% on oxygen via nasal cannula. On 11/25/19 at 1:58 PM, a telephone interview was conducted with Resident #1's P[NAME] She stated, reviewing her phone records, on 09/16/19, the first call she received from the facility was at 6:35 PM from the evening nurse who stated the resident's family member was concerned, he did not look well and wanted the resident to be transferred to the hospital. She stated the nurse told her the vital signs were stable, and his oxygen saturation was 92% and his vital signs were not that bad to warrant a transfer to the hospital, however she told the nurse if the family wants the resident sent to the hospital then send him to the hospital. She stated sometimes family members know the residents better than we do and can sense a change in condition before we can or before it manifests itself. An inquiry was made if she was notified by the day shift nurse that she started the resident on oxygen at 2 liters via nasal cannula for shortness of breath and an oxygen saturation of 92% on room air. The PA stated she was informed the resident was started on oxygen when she received the call at 6:35 PM and not before. She stated she was told at this time he was put on 2 liters of oxygen for a saturation of 92 %, which was not bad, and he probably did not need to be on oxygen. The PA stated she did not give an order for [REDACTED]. She further stated, when she was writing her note in the electronic record, she noticed that RN Staff D was entering a late entry which she had not finished or signed off on yet and she wrote she was told to just monitor the resident and his vital signs were not bad enough to send him out. The PA stated she would never say anything like that and if the family wants the resident sent to the hospital, she sends them to the hospital even if they are only there for an hour and sent back. On 11/25/19 at 2:31 PM, a telephone interview was conducted with RN Staff D, who stated when she started her shift, Resident #1 was stable. She stated the resident's family wanted the resident transferred to the hospital as they felt he did not look good and the PA was called around 5:30 PM but said to just keep monitoring the resident, that the vital signs were not enough to transfer him out. RN Staff D stated she continued to monitor the resident until about 8: 00 PM when there was a sudden change in his condition, his blood pressure was dropping and his oxygen was low so 911 was called, and the PA was recalled and gave an order to send out to the hospital for evaluation. RN Staff D stated the resident was on oxygen when she started her shift and she was not sure what time it was started, and she was not sure if the physician was notified the resident was on oxygen. RN Staff D stated the Nursing Supervisor called the PA around 8:00 PM and the PA said she ordered the resident out 2 hours ago but when RN Staff D talked to the PA, the PA said the vitals were not enough to send him out and to keep monitoring. The PA reiterated during the telephone interview on 11/25/19 at 1:58 PM that she stated she spoke to RN Staff D and asked her why she did not send the resident to the emergency department and RN Staff D said you didn't give me a [DIAGNOSES REDACTED]. The order to send the resident to the hospital for evaluation was not followed. The PA stated if RN Staff D was feeling overwhelmed, she should have requested help from other staff or the Nursing Supervisor. Resident #1 was transferred to the hospital 2 hours after the PA gave a telephone order to transfer the resident out. Further review of the clinical record revealed RN Staff D did not document in the Physician Orders on 09/16/19 at 6:35 PM to send Resident #1 to the hospital for evaluation and treatment. According to the PA, during the telephone interview conducted on 11/25/19 at 1:58 PM, she received a call at 10:00 PM on 09/16/19 from the hospital's emergency physician, who told her Resident #1 passed away in the emergency department with a [DIAGNOSES REDACTED].