Every finding on record at Parklands Care Center and Rehab

Based on observation, interview, and record review, the facility failed to ensure all residents were free from the use of a physical restraints for 1 of 3 residents, Resident #28, reviewed for resident rights.Findings include:During an observation on 04/27/2026 at 10:17 AM, Resident #28 was observed sitting in a wheelchair with a seatbelt buckled; the resident is noted to have bilateral hand contractures.During a subsequent observation on 04/29/2026 at 11:08 AM, Resident #28 was observed sitting in the hallway in her personal wheelchair with a lap belt in place.Review of Resident #28's clinical record documented diagnoses to include unspecified sequelae of cerebrovascular infarction, unspecified dementia, essential hypertension, unspecified protein-calorie malnutrition, multiple contractures, history of falls, and major depressive disorder.Review of the Determination of Capacity form dated 10/28/2020 documented Resident #28 lacks capacity to make medical decisions.Review of the Minimum Data Set (MDS) Quarterly Nursing Comprehensive Evaluation dated 04/06/2026 documented Resident #28 did not have enabler devices or restraints in place. Review of the MDS assessment dated [DATE], Section P, revealed no documentation of restraints.Review of Resident #28's Kardex [a quick reference to provide immediate, updated overview of resident needs] did not have documentation of the resident having a seatbelt or lap belt restraint.Review of Resident #28's medical record progress notes revealed no documentation regarding the use of a seatbelt or lap belt.Review of Resident #28's physician orders did not reveal an order for the use of a seatbelt or lap belt.During an interview on 04/28/2026 at 3:00 PM, Staff L, LPN (Licensed Practical Nurse) stated the wheelchair was a personal wheelchair and that the facility does not utilize the seatbelt.During an interview on 04/29/2026 at 11:54 AM, the [NAME] President of Clinical Operations stated the resident should not have a belt [seatbelt/lap belt].During an interview on 04/29/2026 at 12:00 PM, the Director of Rehabilitation, stated the wheelchair was specifically made for the resident and the belt was part of the manufacturer design. He verified there was no place for a seatbelt, the family had not been contacted regarding use of the belt, and it was not care planned.

Based on record review and interview, the facility failed to ensure Minimum Data Set [MDS} assessments were accurate for 4 of 10 residents, Residents #3, #9, #28, and #62, reviewed for assessments. Findings include: 1) Review of Resident #3's Minimum Date Set (MDS) titled Quarterly dated 3/4/2026 Section I Active Diagnosis did not have psychiatric/mood disorders documented. Review of Resident #3's psychiatry subsequent note dated 1/5/2026 read, Chief Complaint: psychosis, mood, depression, and dementia. Review of Resident #3's psychiatry subsequent note dated 2/19/2026 read, Chief Complaint: Psychosis, mood disorder, depression, and dementia. Review of Resident #3's physician order dated 2/12/2026 read, Depakote [a medication used to treat certain types of psychosis] Oral Tablet delayed release 500 mg [milligrams] (Divalproex Sodium) give 500 mg by mouth two times a day for mood stabilization. During an interview on 4/29/2026 at 10:10 AM Staff F, Registered Nurse Minimum Data Set Coordinator stated, [Resident #3's name] psychiatric diagnoses are not listed in his MDS. It was not captured in the MDS. 2) During an observation on 4/27/2026 at 12:31 PM Resident #9 was eating independently in his room. The meal served had a mechanical soft consistency and thicken juice. During an observation on 4/28/2026 at 8:07 AM Resident #9 was eating in his room independently. The diet served was a mechanically soft meal which included eggs, toast, ground sausage, thicken juice and oatmeal. Review of Resident #9's physician order dated 11/5/2025 read, Consistent Carbohydrate diet. Mechanical Soft texture, nectar consistency for fortified food. Review of Resident #9's MDS titled Quarterly dated 3/3/2026 Section K Swallowing/Nutritional Status did not document the resident was on a mechanically altered therapeutic diet. During an interview on 4/29/2026 at approximately 1:35 PM the Dietary Manager stated, [Resident #9's name] MDS section K needs to be corrected to reflect his current diet. Review of the facility policy and procedure titled MDS Assessments with a last review date of 12/16/2025 read, Policy: It will be the policy of this facility to complete MDS assessments in accordance with the RAI [Resident Assessment Instrument] manual guidelines. 3) During an observation on 4/27/2026 at 10:17 AM Resident #28 was seen sitting in her wheelchair in the hallway with a lap belt clasped over her trunk. During an observation on 4/29/2026 at 11:08 AM Resident #28 was seen sitting in her wheelchair in the hallway with a lap belt clasped over her trunk. Review of Resident #28 Minimum Data Set titled Quarterly dated 4/6/2026 Section P Restraints and Alarms Subsection Physical Restraints there was no documentation of a trunk restraint being used. During an interview on 4/29/2026 at 11:05 AM Staff H, MDS Staff stated Section N should be documented to reflect usage of the lap belt. 4) Review of Resident #62's pertinent medical diagnosis read, Type 2 Diabetes Mellites with autonomic polyneuropathy. Review of Resident #62's physician order dated 1/17/2025 read, Lantus SoloStar, Inject 20 unit subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy. Review of Resident #62's physician order dated 3/18/2026 read, NovoLOG, Inject subcutaneously before meals and at bedtime for diabetes mellitus, per sliding scale (SS). Review of Resident #62 Minimum Data Set (MDS) Quarterly dated 4/11/2026 Section N Medication, Subsection High-risk Drug Classes: Use and Indication did not have hypoglycemic coded [the code used for prescribed insulin use]. During an interview on 4/29/2026 at 11:05 AM Staff H, MDS Staff stated that Section N in the MDS dated [DATE] was coded incorrectly.

Based on record review and interview, the facility failed to ensure residents with newly evident or known diagnosis of serious mental disorders have a coordinated Preadmission Screening and Resident Review (PASRR) for 5 of 10 residents, Residents # 106, #14, #9, #40, and #12, reviewed for PASRR. Findings include: 1) Review of Resident #106's medical record documented diagnosis to include major depressive disorder recurrent mild dated 2/9/2026. Review of Resident #106's Preadmission Screening Resident Review (PASRR) was dated 11/6/2025 did not have a diagnosis of major depressive disorder documented. Review of Psychological evaluation notes dated 2/18/2026 documented DX [diagnosis]: F33.0 Major Depressive Disorder Recurrent Mild. Review of Resident #106's physician order dated 2/10/2026 read, Remeron oral tablet 30 mg [milligrams] (Mirtazapine) give one table at bedtime for major depressive disorder. Review of Resident #106's medication administration record (MAR) dated April 2026 read, Remeron [a medication used to treat major depressive disorder] oral tablet 30 mg (Mirtazapine) give one tablet at bedtime for (Major Depressive Disorder). During an interview on 4/28/2026 at 2:05 PM, the Social Services Director stated, I was not aware that behavior changes had to be updated on the Preadmission Screening and Resident Review. During interview on 4/29/2026 at 2:35 PM, the Clinical Operations and Director of Nursing (DON) stated, Preadmission Screening and Resident Review and care plans should be reviewed and/or completed within 72 hours of admission. Review of the facility policy and procedure titled, P&P [Policy and Procedure] Role of Admissions and Social Services in PASRR with an issue date of 4/1/2022 and last review date of 12/16/2025 read, Policy: The Facility will see each resident in a nursing facility is screened for a mental disorder (MD) or intellectually disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with appropriate state designated authority. The facility will ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate settings when a significate change in their status occurs. 2) Review of Resident #9's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 8/27/2025 did not document mental illness. Review of Resident #9 psychiatry subsequent note dated 2/26/2026 read, Chief Complaint: Depression. Reason for encounter: Today, I saw the patient for medication management as patient has active psychiatric diagnosis, is in the facility setting, and last psychiatric visit was 12 or more weeks ago. History of Presenting Illness: This is a [Resident #9's age] patient with past psychiatric history of depression. Today, I saw the patient for medication management as patient has no symptoms of depression. Patient is eating and sleeping decently. Patient is not on any psych meds. The current diagnoses are being managed by non-pharmacological interventions. Plan of Action: The patient is not on any active psychiatric medications to be continued. Diagnoses Rationale and Justifications: Adjustment disorder with depressed mood: The history suggests that patient's depressed mood is secondary to underlying stressors This appears to be situational, and most likely will improve with time along with ongoing emotional support. Review of Resident #9's Psychosocial Evaluation dated 4/10/2026 read, Dx: Major depressive disorder, recurrent moderate. Reason for referral: Depression, social isolation, staff concern regarding possible decline in mental health. Session Summary: Provider met with [Resident #9's name] to address depressive symptoms as well as social isolation. Review of Resident #9's Supportive Care Psychological Services progress note dated 4/17/2026 read, Dx: Major depressive disorder, recurrent, moderate. Symptoms: Psychological: Depression, helplessness, hopelessness. During an interview on 4/30/2026 at 10:12 AM the Social Services Director stated, I submitted a resident review for him. Psych was not communicating with me when there were changes and new diagnosis added for the patient. I would not be aware that a review of the PASRR needed to be submitted. If psych does not tell me there is a new diagnosis I would not know to add it to the care plan as a focus. Review of Resident #9's Hospital Discharge summary dated [DATE] read, Diagnosis: Developmental delay. Review of Resident #9's provider note dated 9/11/2025 read, History of present illness: This is a [Resident #9's age and gender] with a history of developmental delay and diabetes who is admitted to Parklands Care Center for rehabilitation; skill nursing care. During an interview on 4/30/2026 at 11:20 AM the Psychiatric Mental Health Nurse Practitioner stated, [Resident #9's name] has been seen once before by me and he has more like a temporary adjustment disorder with minimal depression. He was diagnosed with adjustment disorder with depressed mood. He is on no medication at this time. It was a new diagnosis after his admission. I do a post rounding log and email it to the Social Services Director, the Director of Nursing, and MDS [Minimum Data Set]. I might have missed it. During an interview on 4/30/2026 at 11:33 AM the Director of Nursing stated, All the diagnosis should have been updated on the PASSR for [Resident #9's name]. 3) Review of Resident #14's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 8/7/2024 did not document mental illness. Review of Resident #14's pertinent medical diagnosis include adjustment disorder with depressed mood, major depressive disorder and bipolar disorder. Review of Resident #14's psychology subsequent note dated 8/28/2024 read, DX: Major depressive disorder, recurrent, mild. Review of Resident #14's psychology subsequent note dated 10/1/2024 read, DX: Bipolar disorder, current episode mixed, moderate. During an interview on 4/30/2026 at 11:33 AM the Director of Nursing stated, All the diagnosis should have been updated on the PASSR for [Resident #14's name]. Review of Resident #40's PASRR dated 3/18/2026 documented there were no diagnoses checked pertaining to mental illness or suspected mental illness. Review of Resident #40's Psychosocial Evaluation dated 3/20/2026 documented her diagnosis as, major depressive disorder, recurrent, moderate. The reason for the referral was documented as depression. The Session Summary read, Provider met with [Resident #40's name] to complete assessment due to recent admission to facility. Although [Resident #40's name] understood why she was at the facility she had difficulty articulating what had happened. She is alert, but oriented only to self and the town that she lives in. She is delayed in many of her thoughts and does not appear to have capacity of benefit of services. There are no recommendations made at this time. Review of a Balanced Wellbeing Psychiatry Evaluation Note dated 3/18/2026 read, The history of presenting illness: Past psychiatric history of depression and anxiety. 4) Review of Resident #40's Census Data revealed she was admitted on [DATE] with medical diagnoses that included fracture of other parts of pelvis, subsequent encounter for fracture with routine healing; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety; major depressive disorder, recurrent, moderate Review of Resident #40's most recent MDS (Minimum Data Set) Assessment, a Modification of Medicare - 5 Day dated 4/05/2026 documented her BIMS (Brief Inventory of Mental Status) Score as 10 out of 15 which indicated she had some cognitive impairment. She had diagnoses that included Non-Alzheimer's Dementia and Depression (other than bipolar). During an interview on 4/28/2026 at 2:05 PM the Social Services Director confirmed that she had not included any mental health diagnoses on the Level I PASSR for Resident #40. During an interview on 4/30/2026 at 11:33 AM the DON (Director of Nursing) stated, All the diagnoses should have been included on the PASSR for [Resident #40's name]. 5) Review of Resident #12's Documents revealed her Level I PASRR dated 7/30/2025 did not identify any mental illness or suspected mental illness and included negative documentation of dementia being a primary or secondary diagnosis. During an interview on 4/28/2026 at 2:05 PM the Social Services Director stated that Resident #12 had been admitted from home, and her daughter did not provide a lot of information. The Admissions Department was responsible for obtaining previous medical records. She completes the level I PASSARs for residents who are admitted without one. She would review medical records for information on diagnoses and treatments relevant to include in the PASSAR. She confirmed that she had not include any mental health diagnoses for Resident #12. During an interview on 4/29/2026 at approximately 12:30 PM the Admissions and Marketing Director stated that if a resident were admitted from a referral from a community physician, she would contact them for an H&P (History and Physical) and a med (medication) list. The PASSAR would be completed in-house. Resident #12 came from home. She had been at [name of a skilled nursing facility] in [NAME] and had been discharged home from that facility. During an interview on 4/29/2026 at 2:25 PM the DON and VP (Vice President) of Clinical Operations stated that PASRRs and care plans should be screened for accuracy and/or completed within 72 hours of admission. Review of the Progress Note dated 7/09/2025 from Resident #12's PCP (Primary Care Physician) documented diagnoses to include cognitive impairment and dementia. The section titled History of Present Illness, read, The patient is a [AGE] year old Caucasian/White female who is followed for depressive symptoms. The patient's mood has been worsening but the patient denies any suicidal ideation. Review of Resident #12's Progress Note dated 7/17/2025 read, History of present illness: This is a 70 y.o. (year old) female with a history of depression who is admitted to [name of the facility] for rehabilitation; skilled nursing care. Past Medical History: Manic depressive disorder (CMS-HCC: 59). Plan: Diagnoses and all orders for this visit: Cognitive impairment - Comments: Suspect major neurocognitive disorder; Obvious memory deficits; Requires assistance with ADLs/IADLs (Activities of Daily Living/ Instrumental Activities of Daily Living (complex daily tasks necessary for independent community living) Review of the policy and procedure titled Role of Admissions and Social Services in PASRR, with the last review date of 12/16/2025 read, Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated session setting appropriate to their needs by coordinating with the appropriate State-designated authority. The facility will ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs. State Designated Authority: Individuals with serious mental illness, intellectual disability, or a related condition have special protections under state and federal law to ensure that long-term services and supports are provided in the right setting to meet their needs. According to state regulation, nursing facilities and hospitals in Florida are also delegated to complete PASRR Level 1 screenings. Level 1 screeners must be an MSW [Master of Social Work], LCSW [Licensed Clinical Social Worker], LMHC [Licensed Mental Health Counselor], RN [Registered Nurse], ARNP [Advanced Registered Nurse Practitioner], a psychologist, or a physician.

Based on interview and record review the facility failed to develop and implement comprehensive care plans for 3 of 10 residents, Residents #9, #40, and Resident #28 sampled for care plans.Findings include: 1) Review of Resident #9 psychiatry subsequent note dated 2/26/2026 read, Chief Complaint: Depression. Reason for encounter: Today, I saw the patient for medication management as patient has active psychiatric diagnosis, is in the facility setting, and last psychiatric visit was 12 or more weeks ago. History of Presenting Illness: This is a [Resident #9's age] patient with past psychiatric history of depression. Today, I saw the patient for medication management as patient has no symptoms of depression. Patient is eating and sleeping decently. Patient is not on any psych meds. The current diagnoses are being managed by non-pharmacological interventions. Plan of Action: The patient is not on any active psychiatric medications to be continued. Diagnoses Rationale and Justifications: Adjustment disorder with depressed mood: The history suggests that patient's depressed mood is secondary to underlying stressors This appears to be situational, and most likely will improve with time along with ongoing emotional support. Review of Resident #9's Psychosocial Evaluation dated 4/10/2026 read, Dx: Major depressive disorder, recurrent moderate. Reason for referral: Depression, social isolation, staff concern regarding possible decline in mental health. Session Summary: Provider met with [Resident #9's name] to address depressive symptoms as well as social isolation. Review of Resident #9's Supportive Care Psychological Services progress note dated 4/17/2026 read, Dx: Major depressive disorder, recurrent, moderate. Symptoms: Psychological: Depression, helplessness, hopelessness. Review of Resident #9 care plan did not include a focus of adjustment mood disorder or depression. During an interview on 4/30/2026 at 10:12 AM the Social Services Director stated, I submitted a resident review for him. Psych was not communicating with me when there were changes and new diagnosis added for the patient. I would not be aware that a review of the PASRR needed to be submitted. If psych does not tell me there is a new diagnosis I would not know to add it to the care plan as a focus. During an interview on 4/30/2026 at 11:20 AM the Psychiatric Mental Health Nurse Practitioner stated, [Resident #9's name] has been seen once before by me and he has more like a temporary adjustment disorder with minimal depression. He was diagnosed with adjustment disorder with depressed mood. I do a post rounding log and email it to the Social Services Director, the Director of Nursing and MDS [Minimum Data Set]. I might have missed it. They should care plan the resident for depression. During an interview on 4/30/2026 at 11:33 AM with the Director of Nursing stated, All the diagnosis should have been updated for [Resident #9's name] along with his care plan. 2) Review of Resident #40's Census Data revealed she was admitted on [DATE] with medical diagnoses that included fracture of other parts of pelvis, subsequent encounter for fracture with routine healing; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; major depressive disorder, recurrent, moderate Review of Resident #40's most recent MDS (Minimum Data Set) Assessment, a Modification of Medicare - 5 Day dated 4/05/2026 documented her BIMS (Brief Inventory of Mental Status) Score as 10 out of 15 which indicated she had some cognitive impairment. She received antidepressant, opioid, and anticonvulsant medications that were documented as high-risk medications. She had diagnoses that included Non-Alzheimer's Dementia and Depression (other than bipolar). Review of Resident #40's care plan did not include a focus of dementia or major depressive disorder Review of Resident #40's Psychosocial Evaluation dated 3/20/2026 documented her diagnosis as, major depressive disorder, recurrent, moderate. The reason for the referral was documented as depression. The Session Summary read, Provider met with [Resident #40's name] to complete assessment due to recent admission to facility. Although [Resident #40's name] understood why she was at the facility she had difficulty articulating what had happened. She is alert, but oriented only to self and the town that she lives in. She is delayed in many of her thoughts and does not appear to have capacity or benefit of services. There are no recommendations made at this time. Review of a [name of the psychiatric group] Evaluation Note dated 3/18/2026 read, The history of presenting illness: Past psychiatric history of depression and anxiety. During an interview on 4/29/2026 at approximately 2:10 PM the Social Services Director stated that MDS (Minimum Data Set [department/staff]) enters the diagnoses and she reviews them. The development of care plan areas for mental health depended on psych (psychiatry/psychology) notes and behaviors. For Resident #40 with diagnoses of dementia and major depressive disorder on admission, she should have implemented a cognition care plan. She confirmed that Resident #40 did not have a cognition care plan [focus area]. During an interview on 4/29/2026 at 2:25 PM the DON and VP (Vice President) of Clinical Operations stated that PASRRs and care plans should be screened for accuracy and/or completed within 72 hours of admission. Review of the policy and procedure titled, Comprehensive Assessments and Care Plans, last reviewed on 12/16/2025 read, Standard: it will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS (Centers for Medicare and Medicaid Services). The assessment will include at least the following: cognitive patterns; Mood and behavior patterns; Psychological well-being. Guidelines: 7. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care period the baseline care plan will be developed within 48 hours of a resident's admission. 8. The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights set forth at 483.10 (c)(2) and 483.10 (c)(3), that includes measurable objectives and timeframe to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 3) During an observation on 04/27/2026 at 10:17 AM, Resident #28 was observed sitting in a wheelchair with a seatbelt buckled; the resident is noted to have bilateral hand contractures. During a subsequent observation on 04/29/2026 at 11:08 AM, Resident #28 was observed sitting in the hallway in her personal wheelchair with a lap belt in place. Review of Resident #28's clinical record documented diagnoses to include unspecified sequelae of cerebrovascular infarction, unspecified dementia, essential hypertension, unspecified protein-calorie malnutrition, multiple contractures, history of falls, and major depressive disorder. Review of the Determination of Capacity form dated 10/28/2020 documented Resident #28 lacks capacity to make medical decisions. Review of the Minimum Data Set (MDS) Quarterly Nursing Comprehensive Evaluation dated 04/06/2026 documented Resident #28 did not have enabler devices or restraints in place. Review of the MDS assessment dated [DATE], Section P, revealed no documentation of restraints. Review of Resident #28's care plan did not show a focus for the use of a lap belt/seat belt. Review of Resident #28's Kardex [a quick reference to provide immediate, updated overview of resident needs] did not have documentation of the resident having a seatbelt or lap belt restraint. Review of Resident #28's medical record progress notes revealed no documentation regarding the use of a seatbelt or lap belt. Review of Resident #28's physician orders did not reveal an order for the use of a seatbelt or lap belt. During an interview on 04/28/2026 at 3:00 PM, Staff L, LPN (Licensed Practical Nurse) stated the wheelchair was a personal wheelchair and that the facility does not utilize the seatbelt. During an interview on 04/29/2026 at 11:54 AM, the [NAME] President of Clinical Operations stated the resident should not have a belt [seatbelt/lap belt]. During an interview on 04/29/2026 at 12:00 PM, the Director of Rehabilitation, stated the wheelchair was specifically made for the resident and the belt was part of the manufacturer design. He verified there was no place for a seatbelt, the family had not been contacted regarding use of the belt, and it was not care planned.

Based on interview and record review the facility failed to review and revise the comprehensive care plan for 3 of 7 residents, Residents #57, #62, and #93, reviewed for revised care plans. Findings include: 1) Review of Resident #57 Quarterly Nursing Comprehensive Evaluation dated 1/24/2026 read, 7. Smoking Evaluation: resident may smoke independently or with set up. Review of Resident #57 care plan initiated on 3/11/2026 read, [Resident #57's name] desires to smoke. Resident has been assessed as able to smoke: with supervision d/t [do to] poor safety awareness. During an interview on 4/29/2026 at 9:56 AM Staff G, Certified Nursing Assistant (CNA) stated, [Resident #57's name] is consider a safe smoker. He is able to keep materials with him except the lighters. I always light the cigarettes for all residents to be safe, but if he [Resident #57] had a lighter he could light the cigarettes himself. During an interview on 4/29/2026 at 10:15 AM Staff H, Licensed Practical Nurse (LPN) Minimum Data Set Coordinator stated, [Resident #57 's name] care plan needs to be updated, he is considered a safe smoker. During an interview on 4/29/2026 at 10:53 AM the Director of Nursing (DON) stated, Based on last assessment he [Resident #57] is alert and competent. Last one is [smoking assessment] a safe smoker. I would expect them to revise the care plan. Review of the facility policy and procedure titled Comprehensive Assessment and Care Plans with a last review date 12/16/2026 read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. Guidelines:10 The plan of care reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment. 2) Review of Resident #62's physician order dated 11/27/2018 read, Full Code. Review of Resident #62's care plan revealed a focus that read, [Resident #62's name] has expressed the following wishes regarding code status and has the following advanced directives in place: Health Care Surrogate, is capable of making informed consent regarding their health care decisions, is a DNR [Do Not Resuscitate]. Date Initiated: 11/19/2024 Revision on: 11/19/2024. During an interview on 4/29/2026 at 11:00 AM the Social Services Director stated, The care plan is incorrect and will need changes to reflect the accurate code status. 3) Review of Resident #93's Do Not Resistate (DNR) Form dated 9/3/2025 stated the resident was a DNR. Review of Resident #93's care plan revealed a focus that read, [Resident #93's name] has expressed the following wishes regarding code status and has the following advanced directives in place: is Full Code, incapacitated with HCP [health care provider] pending. Date Initiated: 10/04/2021 Revision on: 01/04/2022. During an interview on 4/29/2026 at 1:24 PM the Social Services Director stated, The care plan is incorrect and does not reflect the current code status.

Based on observation, interview and record review, the facility failed to ensure the physician was notified when a skin tear was identified for 1 of 3 residents, Resident #57, a low blood sugar value and physicians' ordered insulin not being administered for 2 of 6 residents, Residents #6 and #102. Findings include:1) During an observation on 04/27/2026 10:13 AM Resident #57 was sitting in bed there was gauze with tape over the resident's right hand with dried dark matter and a band aide with dry blood on the side of outer part of the resident's right hand. There was no date on the dressings.During an interview on 4/27/2026 at 10:13 AM Resident #57 stated, They put the band aide on his Friday [4/24/2026] they need to change it. During an observation on 4/27/2026 at 12:24 PM Resident #57 was in the room. There was a band aide on the outer part of the resident's right hand with dried dark matter.During an observation on 4/28/2026 at 9:13 AM Resident #57 was lying in bed there was a band aide on the outer side of the resident's right had with dried dark matter.During an interview on 4/28/2026 at 9:13 AM Resident #57 stated, They had not changed the band aide. I got a skin tear from the door of the smoking patio.Review of Resident #57 physician ordered did not document wound care orders for the right hand. Review of Resident #57 progress notes did not document information regarding a skin tear located on the right hand. During an interview on 4/28/2026 at 1:30 PM Staff I, Licensed Practical Nurse stated, He [Resident #57] gets skin tears all the time. Normally we will do an incident report, and we will do our part. I am not sure what happened, he told me he cut it with the door. I cannot tell you what it is it had dry blood. He had no orders in place.During an interview on 4/28/2026 at 2:33 PM the Wound Care Nurse stated, I just saw his skin tear and put orders in the system for wound care. An incident report needs to be completed and explain what happened. MD [medical doctor] and family will be notified. There are orders we can use for skin tears. That is what we would put in place until the wound care doctor sees the resident. I ordered xeroform and med honey. There should always be an order for wound care.During an interview on 4/29/2026 at 10:43 AM the Director of Nursing (DON) stated, Once it's been [skin tear] observed and there is a skin impairment there should be a progress note that documents what happened and that the provider was notified. Once you observe the nurses should follow the process. Notify family, MD, obtain treatment and do the incident report. There is a section which populates in the progress note. The incident report was put in place on 4/28 [2026]. Wound care should always have an order.Review of the facility policy and procedure titled Identification of Skin Condition Changes with a last review date of 12/16/2025 read, Policy: It is the policy of this facility that the facility monitors the skin integrity of the residents for changes in condition. Procedure: 3. the nurse should document the newly identified skin area and provide first aid or receive physician orders as are appropriate. 4. Notification of the physician and responsible party should occur when a newly developed skin condition is identified. Residents with minor recurrent skin conditions that are known to the physician, responsible party and staff as a part of their usual condition, do not require recurrent notification provided it is in agreement with the physician's and facility's resident plan of care.2) During an interview on 4/27/2026 at approximately 9:30 AM Resident #6 stated that he refused his long-acting insulin over the weekend because his blood sugar was 21. It had been low a couple times previously, but never that low. Review of Resident #6's Physician Orders dated 3/05/2026 read, Novolog Injection Solution 100 unit/ml [milliliters] (Insulin Aspart) Inject 15 unit subcutaneously with meals for DM [Diabetes Mellites] Give within 15 minutes of eating The physician order did not show parameters for the medication administration.Review of Resident #6's MAR (Medication Administration Record) from 3/01/2026 through 4/28/2026 for Novolog Injection documented 4 - held per parameters on 3/10/26 at 12:00 PM, 3/11/2026 at 12:00 PM and 3/17/2026 at 7:15 AM.During an interview on 4/30/2026 at 9:50 AM Staff E, LPN (Licensed Practical Nurse) stated that she had held Resident #6's insulin on 3/10 and 3/11 [2026] because he was low [low blood sugar] and she didn't want him to bottom out. She should have called the doctor.During an interview on 4/30/2026 at 11:26 AM the Director of Nursing (DON) stated that the expectation was if a nurse held a medication based on the resident's lab values they should follow up with the physician, explain the values and clarify whether to hold the medication.3) During an interview on 4/27/2026 at 4:31 PM Resident #102 stated that she often refused her insulin because she was not taking insulin at home and does not like to have her finger pricked so often for blood sugar checks. Review of Resident #102's physician order on the Medication Administration Record for March 2026 read, Humulin 70/30 KwikPen (70/30) 100 unit/ml suspension pen-injector, inject 15 unit subcutaneously at bedtime for DM documented at 9:00 PM Resident #102 refused the medication on 3/01/2026, 3/07/2026, 3/08/2026, 3/14/2026, 3/16/2026, 3/23/2026, 3/24/2026, 3/25/2026, 3/27/2026, 3/28/2026, 3/29/2026, and 3/30/2026.Review of Resident #102's physician order on the MAR for March 2026 read, Humulin 70/30 KwikPen (70/30) 100 unit/ml suspension pen-injector, inject 20 unit subcutaneously in the morning for DM documented at 6:00 AM Resident #102 refused the medication on 3/1/2026 and 3/5/2026.Review of Resident #102's physician order on the MAR for March 2026 read, Humulin 70/30 KwikPen (70/30) 100 unit/ml suspension pen-injector, inject 23 unit subcutaneously in the morning for DM documented at 6:00 AM Resident #102 refused the medication on 3/7/2026, 3/8/2026, 3/9/2026, 3/11/2026, 3/12/2026, 3/13/2026, 3/15-30/2026.Review of Resident #102's physician order on the Medication Administration Record for April 2026 read, Humulin 70/30 KwikPen (70/30) 100 unit/ml suspension pen-injector, inject 15 unit subcutaneously at bedtime for DM documented at 9:00 PM Resident #102 refused the medication on 4/3/2026, 4/5/2026, 4/7/2026, 4/11-14/2026, and 4/19-21/2026.Review of Resident #102's physician order on the MAR for April 2026 read, Humulin 70/30 KwikPen (70/30) 100 unit/ml suspension pen-injector, inject 23 unit subcutaneously in the morning for DM documented at 6:00 AM Resident #102 refused the medication on 4/1/2026-4/4/2026 and 4/6/2026 - 4/15/2026.Review of Resident #102's Progress Notes from 3/01/2026 through 4/27/2026 there was nothing documented regarding notification to provider of refusal of medications.During an interview on 4/29/2026 at approximately 11:30 AM the DON stated that if a resident refused medications multiple times, she expected the nurse to notify the physician.During an interview on 4/29/2026 at 4:39 PM, Physician #1 stated that he did not recall receiving any calls regarding Resident #102. If he was aware that a resident refused medication multiple times, he would consider changing the medication. With insulin it was difficult unless the resident's blood sugar was well controlled.During an interview on 4/29/2026 at 5:11 PM Staff A, LPN stated that Resident #102 often refused her medications. He should have made a note and documented that he notified the MD (Medical Doctor).During an interview on 4/29/2026 at 5:15 PM the VP (Vice President) of Clinical Operations stated that the expectation was that the nurses should call the MD every time a resident refused medication.

Based on interview and record review the facility failed to ensure residents were free of unnecessary medications for 3 of 6 residents, Residents #8, #28, and #74, reviewed for medications.Findings include: 1) Review of Resident #8's physician orders dated 1/30/2026 read, Cozaar oral tablet 100 mg [milligrams] (Losartan Potassium) Give 1 tablet by mouth one time a day related to essential (primary) hypertension. Hold for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 60 Review of the Resident #8's MAR from 3/01/2026 through 4/28/2026 documented Cozaar oral tablet 100 mg (Losartan Potassium) Give 1 tablet by mouth one time a day related to essential (primary) hypertension. Hold for SBP less than 110 or HR less than 60 -Start Date 01/31/2026 0900 -D/C Date 04/29/2026 2122 (9:22 PM). There was documentation of administration on 3/14/2026 with a heart rate (HR) of 58; administration on 4/06/2026 with a HR of 58; 4/08/2026 with a HR of 53; on 4/16/2026 with a HR of 59; and administration on 4/22/2026 with a HR of 58. During an interview on 4/30/2026 at 12:15 PM Staff D, LPN (Licensed Practical Nurse) stated that if a vital sign for Resident #8 was outside of an ordered parameter she should not have given her the Cozaar. She should have made a note and clarified it with the provider. She did check all of her own vitals and didn't rely on the ones taken by the CNAs (Certified Nursing Assistant). During an interview on 4/30/2026 at 11:26 AM the Director of Nursing (DON) stated that the expectation was for the nurses to follow up with the MD (Medical Doctor) to explain a resident's vital signs and to clarify if a medication was to be given outside of the parameters ordered. During an interview on 4/29/2026 at 4:39 PM Physician #1 stated that he did not remember the nurses reaching out about Resident #8's heart rate being outside of the ordered parameter for administration of her Cozaar. During an interview on 4/29/2026 at 6:09 PM APRN (Advanced Practice Registered Nurse) #1 stated that she did not recall getting a call regarding Resident #8's heart rate or her Cozaar administration parameters. Review of Resident #8's Progress Notes from 3/01/2026 through 4/27/2026 revealed there was no documentation of notification to a provider or confirmation of administration for her Cozaar. 2) Review of Resident #28's physician order dated 8/6/2025 read, Amlodipine Besylate oral tablet 5 mg [milligrams] (Amlodipine Besylate), Give 1 tablet by mouth one time a day for HTN [hypertension] please hold if systolic BP [blood pressure] is less than 120. Hold for diastolic BP less than 60. Review of Resident #28's physician order dated 4/7/2026 read, Metoprolol Tartrate Tablet 100 mg, Give 0.5 tablet by mouth two times a day related to essential (primary) hypertension, please hold if systolic bp less than 120 or if HR [heart rate] is less than 70. Review of Resident #28's Medication Administration Record (MAR) for April 2026 documented Amlodipine Besylate was administered out of parameters at 9:00 AM on 4/7/26 - 113/71, 4/8/26 – 110/67, 4/14/26 – 118/76, 4/22/26 – 119/64, and 4/27/26 – 112.65. Review of Resident #28's Medication Administration Record (MAR) for April 2026 documented Metoprolol Tartrate was administered out of parameters at 9:00 AM on 4/1/26 – HR 60, 4/6/26 – HR 65, 4/7/26 – BP 113/71, 4/8/26 – BP 110/67, 4/12/26 – HR 68, 4/14/26 – BP 118/76, 4/18/26 – HR 69, 4/19/26 – HR 60, 4/22/26 – BP 119/64, and 4/27/26 – BP 112/65. Administered at 5:00 PM on 4/1/26 – HR 64, 4/9/26 – BP 112/69 and HR 68. During an interview on 4/29/2026 at 2:55 PM with Staff E, LPN stated that she did not administer the medications outside parameters what she did was accidently document the wrong blood pressure. She stated that when she administered the medication the blood pressure was within parameters for the order. During an interview on 4/29/2026 at 2:58 PM with DON stated that she would have expected her nursing staff to administer medication according to the physician order. 3) Review of Resident #74's physician orders dated 2/12/2026 read, Insulin Aspart FlexPen 100 unit/ml [milliliters] solution pen-injector Inject as per sliding scale: 151-200 = 2 units, 201-250 = 4 units, 251 – 300 = 6 units, 301 – 350 = 8 units, 351 – 400 = 10 units subcutaneously before meals and at bedtime for DM [diabetes mellitus]. Review of Resident #74's physician orders dated 2/12/2026 read, Insulin Aspart FlexPen 100 Unit/ML [milliliters] Solution pen-injector Inject 9 units subcutaneously before meals for DM [diabetes mellitus] hold for BS [blood sugar] under 151. Review of Resident #74's Medication Administration Record (MAR) for the months of March and April 2026 for Insulin Aspart sliding scale documented the insulin was administered as ordered by the physician. Review of Resident #74's MAR for March 2026 for the physician ordered Insulin Aspart FlexPen inject 9 units before meals for DM Hold for BS under 151 and with review of the Schedule for Mar (March) 2026 blood sugar values documented Insulin Aspart was administered per the initialing of the licensed nurse on 3/7/2026 at 11:30 BS 132, 3/16/2026 at 11:30 BS 121, 3/19/2026 at 11:30 BS was 137, 3/25/2026 at 11:30 BS was 96, 3/26/2026 at 11:30 BS was 96. Review of Resident #74's MAR for April 2026 for the physician ordered Insulin Aspart FlexPen inject 9 units before meals for DM Hold for BS under 151 and with review of the Schedule for April 2026 blood sugar values documented Insulin Aspart was administered per the initialing of the licensed nurse on 4/1/2026 at 1630 [4:30 PM] BS 139, 4/2/2026 at 11:30 BS 110, 4/4/2026 at 11:30 BS 131, 4/9/2026 at 1630 BS 125, 4/11/2026 at 11:30 BS 103, and 4/25/2026 at 11:30 BS 125. During an interview on 4/29/2026 at 11:32 AM with Staff I Licensed Practical Nurse (LPN) stated, I do not really recall, but normally I will hold her [Resident #74's] insulin if it is below her parameters because I know it needs to be held if under the 151. It might have been an error while I was checking off the medications. During an interview on 4/29/2026 at 2:12 PM Staff M, Registered Nurse stated, That was a missed documentation. She [Resident #74] is a brittle diabetic I would not give her insulin if it is [blood sugar value] below the parameter. During an interview on 4/30/2026 at 10:08 AM the Director of Nursing stated, Nurses are to follow orders as written. Review of the facility policy and procedure titled Charting and Documentation with a last review date of 12/16/2025 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as needed. Procedure: 1. Observations, medications administered, services performed, ect., should be documented in the resident's clinical records.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with accepted professional principles for 1 of 4 medication carts and 1 of 4 hallways reviewed for unattended medication and labeling.Findings include: 1) During an observation on 4/27/2026 at 9:37 AM Resident #24 was sitting in his wheelchair, there was a clear plastic medication cup with a white cream that was not labeled at the side from where the resident was sitting. [Photographic evidence obtained] During an interview on 4/27/2026 at 9:37 AM Resident #24 stated, That's for my bottom [pointing at the white cream in the medication cup.] I put it on myself. 2) During an observation on 4/27/2026 at 9:43 AM Resident #15 was sitting up in bed, on her bedside table there was zinc oxide ointment. [Photographic evidence obtained] During an interview on 4/27/2026 at 9:43 AM Resident #15 stated, I buy the cream and the staff put it on for me. 3) During an observation on 4/27/2026 at 10:18 AM Resident #13 was lying in bed. An enteral feeding formula was running at 60 milliliters per minute. The bag containing the enteral feeding formula was dated 4/27 and timed at 0900 (9:00 AM). The enteral feeding bag was not labeled with the name of the formula it contained. [Photographic evidence obtained] During an interview on 4/29/2026 at 11:11 AM the Director of Nursing stated, Medication should not be left unattended and enteral feeding bags should be labeled with the formula's name. During an interview on 4/30/2026 at approximately 9:00 AM the [NAME] President Of Clinical Operations stated, We do not have a policy and procedure for labeling but labeling is a standard of care. Review of the facility policy and procedure titled Medication/Biological Storage with a last review date of 12/16/2025 read, Policy: It will be the policy of this facility to store medications, drugs and biological in a safe, secured and orderly manner. Procedures: 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals. 7. Compartments (Including, but not limited to, drawers, cabinets, rooms, refrigerators carts and boxes) containing medications, drugs and biological shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of nurse's view. 4) During an observation on 4/28/2026 at 5:44 PM the East Long medication cart was reviewed. In one drawer of the cart an open plastic bag was observed. The label on the bag read, [Resident #14's name], Methyl PR Ace Inj 80MG/ML, [Methylprednisolone Acetate Injection 80 milligrams/milliliter]. A potent, steroid medication] and Disp [dispense]: 08/25/2025; Orig [original order date]: 08/25/2025; Stop: 09/01/2025. (Photographic evidence obtained) During an interview on 4/28/2026 at 5:45 PM Staff N, LPN stated that the medication for Resident #14 was not administered by the nurses. It was for the physician to inject for his fingers. She confirmed the medication was past the labeled expiration/discard date and should have been discarded. During an interview on 4/30/2026 at approximately 9:00 AM the [NAME] President of Clinical Operations stated that they did not have a policy for medication labeling, but labeling was a standard of care.

Based on observation, interview, and record review, the facility failed to ensure food is properly and safely stored, labeled, and dated in 2 of 2 nourishment rooms. Findings Include: During an observation on 4/27/26 at 9:25 AM of the [NAME] Wing nourishment room, there was a Salisbury steak frozen meal in the freezer that was not labeled or dated. During interview on 4/27/26 at 9:28 AM with the Certified Dietary Manager, stated that the foods should be labeled and dated.During an observation 4/27/26 at 9:40 AM of the East Wing nourishment room, there were three packages of smoked vegan turkey packaged meats, a frozen falafel, and an open box of frozen cheese pizza not labeled or dated in the freezer.During interview on 4/27/26 at 9:45 AM the Certified Dietary Manager stated that the foods should be labeled and dated.Review of the policy and procedures titled: Foods Brought in From the Outside reviewed 12/16/25, read, It will be the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and beverages brought to residents by family and other visitors. Procedure: Label containers with food item name and date received. Any item noted to be without a label and/or date will be discarded.

Based on observation, interview, and record review the facility to ensure complete and accurate records for 2 of 5 residents, Residents #40 and #62, reviewed for medical record documentation. Findings include: During an observation on 4/27/2026 at approximately 10:00 AM Resident #40 was sitting up in bed dressed in a hospital gown. She was clean and well groomed. A bordered gauze dressing was observed on her left wrist dated 4/24. During an interview on 4/27/2026 at approximately 10:00 AM Resident #40 stated she was unsure of what happened with her wrist, but the nurse had put a dressing on it. Review of Resident #40's physician's order did not show an order for wound care to the resident's left wrist. Review of Resident #40's Progress Notes documented a Health Status Note dated 4/24/2026 that read, Note Text: resident observed sitting in chair directly across from nurses station scratching left forearm, open area was noted. Resident stated its itching, and left forearm cleansed with wound cleanser, xerofoam and border gauze dressing applied. MD (Medical Doctor) notified 1758 (5:38 PM), (daughter's name) notified 1759. Order placed for xerofoam and border gauze dressing During an interview on 4/29/2026 at 8:25 AM Staff B, LPN stated that she had seen Resident #40 scratching her arm. She called the doctor and got an order to clean it and put on a dressing. She also called Resident #40's family to notify them. She knew it was important to put an order in the computer for the wound care, and she thought she had put the order in, but maybe she forgot. During an interview on 4/29/2026 at 12:55 PM the Director of Nursing (DON) stated the expectation would be for the nurse who got the wound care order on Friday would have put it in the system. 2) Review of Resident #62's physician order dated 2/5/2021 read, Systane Gel, Instill 1 drop in both eyes two times a day for dry eyes unsupervised self-administration. Review of Resident #62's Medication Administration Record for April 2026 documented daily documentation of SA (self-administration) for Systane Gel. Review of Resident #62's Quarterly Nursing Comprehensive Evaluation dated 4/11/2026 read, Section:14. Medication administration- 3a. Resident does NOT wish to self-administer medication or treatments. During an interview on 4/29/2026 at 10:00 AM with Resident #62 stated that the eye drops are in the nurses' cart. During an interview on 4/29/2026 at 2:50 PM the Director of Nursing stated that when she reviewed the order that had the resident self-administer the eyedrops it was incorrectly put into the computer the administration area when placing a medication order the clinician administration is right above the self-administration button and it was inadvertently hit instead of the clinician button. Her expectations would be that the nursing staff would have questioned and seek clarification of the order.

Based on observation, interview, and record review the facility failed to ensure a safe, sanitary environment to prevent the possible spread of infection in the handling, storing, and processing of soiled linens and residents' clothing in the laundry room.Findings include:An observation was conducted on 4/29/2026 beginning approximately at 4:55 PM with the Housekeeping Supervisor and the Maintenance Director of the laundry room. During the tour of the laundry room the door separating the soiled utility room and the washing machine area was propped open with two plastic bins. The soiled room contained multiple bags of soiled linen. One bin was observed partially filled; a large volume of soiled linen, including bedding and pillowcases, was noted piled unsecured on top of the containers rather than contained within closed, leak-proof bags or covered receptacles. The door in the washing machine area leading to the dryer room area was open. In the dryer area there was a yellow rolling linen cart, articles of clothing were observed draped over the exterior side of the cart, with portions hanging down the side. A blue piece of clothing on a hanger was directly on the floor in close proximity to the clean linen cart. The clothing on the linen cart was not covered. There was a plastic shelving unit with multiple linens, towels, and clothing items stored in an unorganized manner. Several bags of laundry or linen were on the floor. A large quilted linen item was draped over and not fully contained. A broom was leaning against the shelving unit, with the broom head resting on the floor near the quilted linen. [Photographic evidence obtained]During an interview on 4/29/2026 at 4:58 PM the Housekeeping Supervisor stated, The doors from the soiled room should not be left opened. The technician was sorting the items, and I do not know why she left it [the door to the soiled utility room] open. The clothes and the linen in the soiled room should be covered. We are a bit backed up due to one of our washers being down. The items in the clean area should not be left uncovered and should not be on the floor. They will need to be washed again.During an observation on 4/29/2026 at 5:15 PM with the Administrator of the laundry room, the door to the soiled utility room continued to be open. The soiled linen continued to be not bagged. The door from the washer area to the dryer area was open and the dryer room was observed to have the yellow cart with clothing draped over the exterior of the cart, with portions hanging down the side. The blue clothing item on the hanger continued to be on the floor next to the linen cart. The shelving unit continued to have towels and clothing items stored in an unorganized manner. Several bags of laundry or linen remained on the floor, and the quilted linen continued to be draped near the broom's head.During an interview on 4/29/2026 at 5:16 PM the Administrator verified the areas of concern. Review of the facility policy and procedure titled Laundry Service with a last review date of 12/16/2025 read, Policy: It will be the policy of this facility to provide laundry services in accordance with resident preference while maintaining infection control techniques. Procedure: 3. Staff will maintain infection control techniques while handling both dirty and clean laundry and linen. 4. Dirty and clean laundry will be maintained in separate areas in the laundry room. 5. Facility linens will be bagged and be placed in soiled utility rooms for transport to the laundry room.

Based on observations and interviews, the facility failed to honor resident rights for 5 (Resident #1, #3, #4, #5, #6) of 6 and failed to ensure 2 of 2 hallways were safe, clean, comfortable and homelike environment. Photographic evidence obtained Findings include:Findings include: During an initial tour of the facility on 8/29/2025 at 09:08 AM, east and west wing hallways noted to have buildup of debris on and around the walls. Debris buildup around walls, in the corners, and dust were visually noticeable lying on base boards. Dust and debris could be wiped off with gloved finger on railings within resident rooms and in east and west corridor hallways. During an observation on 8/29/2025 at 09:50 AM, Resident #1's room had brown debris buildup around baseboard and walls in the room and in the bathroom. Winged insect was noted lying on bathroom floor. During an observation on 8/29/2025 at 10:06 AM, Resident #3's room had three live brown bugs running across the floor, and three brown bugs climbing out of Resident #3's shoes when residents' shoe was tapped by the surveyor's foot. The floor in Resident #3's room had unidentified pieces of particles lying loosely on the floor. The wall beside Resident #3's bed had dark particles all over the wall that could be wiped away with a gloved finger. During an interview on 8/29/2025 at 10:06 AM, Resident #3 stated, I told someone about the bugs, and I would like that stuff to be wiped off the walls. During an observation on 8/29/2025 at 10:42 AM, Resident #4's room was cluttered, had live bugs crawling in the room, and a buildup of debris noted around the floor. During an observation on 8/29/2025 at 10:58 AM, Resident #5's room had dry food crumbs on the floor, and a buildup of debris on walls and floors in the room and in the bathroom. During an interview on 8/29/2025 at 10:58 AM, Resident #5 stated, I don't recall if they come in and clean the room daily. I don't think so, but it would be nice to have it cleaned. During an observation on 8/29/2025 at 11:08 AM, Resident #6's room had food particles on the floor and under the bed. Buildup of debris was observed on the walls and on the floors in the room and in the bathroom. During an interview on 8/29/2025 at 11:08 AM, Resident #6 stated, They come in and empty the trash and wipe the floors but that's it. See its dirty and should be cleaned in here. During an observation with the administrator on 8/29/2025 at 11:35 AM, a tour of Resident #1, #3, #4, #5, and #6's rooms were observed with confirmation of dirt and buildup on the baseboards, around the edges of the floors, and with confirmation of live brown bugs crawling in Resident #3's room. During an interview on 8/29/2025 at 9:48 AM, Staff A, Environmental Services Technician stated, The dirt around the floor and baseboards needs to be stripped, it's just dirt that has buildup around the walls throughout the building. During an interview on 8/29/2025 at 2:14 PM, the Administrator stated, The rooms and halls need to be cleaned, and the dirt and debris removed from the halls and resident's rooms. Review of the policy and procedure titled Environment of Care, dated 12/18/2024 read, It will be the policy of this facility to provide the residents with a safe, clean, comfortable and homelike environment. Procedure: 1. The facility staff will provide a safe, clean, comfortable and homelike environment. 2. The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 2 residents reviewed for mood and behavior, Resident #74. Findings include: Review of Resident #74's Quarterly MDS dated [DATE] showed the resident was not taking antiplatelet medication under Section N0415- High Risk Drug Classes Use and Indication. Review of Resident #74's physician orders showed the resident had a current order for Plavix 75 milligrams by mouth once daily ordered on 5/22/2022. During an interview on 11/13/2024 at 10:00 AM, the Minimum Data Set (MDS) Coordinator verified Resident #74 had an order for Plavix 75 milligrams one tablet one time per day ordered on 5/22/2022. The MDS Coordinator stated that it should have been documented in section N of the current MDS.

Based on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 of 4 residents who were diagnosed with serious mental disorder, Resident #24. Findings include: Review of Resident #24's Level I PASRR dated 9/19/2023 showed no mental illness documented in Section I: PASRR Screen Decision-Making. Review of Resident #24's admission record showed the resident was initially admitted on [DATE], with diagnoses that included generalized anxiety disorder (onset date 9/28/2023) and unspecified psychosis not due to a substance or known physiological condition (onset date 9/19/2023). Review of Resident #24's clinical records showed no documentation that Resident #24's diagnoses of generalized anxiety disorder and unspecified psychosis not due to a substance or known physiological condition had been included on an updated Level I PASRR. During an interview on 11/14/2024 at 10:24 AM, the Director of Nursing confirmed Resident #24's mental health diagnoses had not been included on the PASRR completed 9/19/2023. She confirmed that a revised PASRR that documented Resident #24's mental health diagnoses and had not been completed.

Based on observation, interview, and policy and procedure review, the facility failed to ensure staff used proper personal protective equipment (PPE) for administration of medications through subcutaneous injection to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 11/13/2024 at 6:00 AM, Staff A, Licensed Practical Nurse (LPN), began to prepare Resident #13's medications without performing hand hygiene. Staff A entered the resident's room with Tresiba FlexTouch 100 unit/ml Solution Pen Injector. Staff A proceeded to clean injection site with an alcohol pad and administered the medication. Staff A did not don gloves while administering the medication. During an interview on 11/13/2024 at 6:10 AM, Staff A, LPN, stated, I should have worn gloves. During an interview on 11/13/2024 at 7:30 AM, the Director of Nursing (DON) stated, They should perform hand hygiene, don gloves, perform the injection, and then perform hand hygiene. Review of the facility policy and procedure titled Medication Administration via Injection last reviewed on 12/19/2023, read, Procedure . 5. Perform hand hygiene and don gloves prior to administration of medication.

Based on record review and interview, the facility failed to ensure that resident records were complete and accurate for 3 of 3 residents reviewed, Residents #1, #5 and #6. Findings include: 1) Review of Resident #1's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included stage 4 pressure ulcer of right heel, need for assistance with personal care, spastic hemiplegia affecting left nondominant side, lower leg contracture of muscle, left elbow contracture, and dementia. Review of Resident #1's physician order dated 6/26/2024 read, Cleanse open area of the left lateral foot with normal saline, apply piece of Derma Blue foam with silver to open area, and cover with a silicone foam dressing three times per week, every day shift Mon [Monday], Wed [Wednesday], Fri [Friday] for wound healing for 30 days. Review of Resident #1's TAR for July 2024 revealed no entry documented for the left lateral foot wound care on Friday, 7/5/2024. Review of Resident #1's physician order dated 6/26/2024 read, Cleanse open area of the right medial ankle with normal saline, apply piece of Derma Blue with silver to open area, and cover with a foam dressing three times per week, every day shift Mon, Wed, Fri for wound healing for 30 days. Review of Resident #1's TAR for July 2024 revealed no entry documented for the right medial ankle wound care on Friday, 7/5/2024. Review of Resident #1's physician order dated 6/26/2024 read, Cleanse open area of right heel with wound cleanser, apply Derma Blue foam with silver, foam dressing, ABD [abdominal] pad, and wrap with kerlix three times per week, every day shift every Mon, Wed, Fri for wound healing. D/C [Discontinue] Date: 07/11/2024. Review of Resident #1's TAR for July 2024 revealed no entry documented for the right heel wound care on 7/5/2024. Review of Resident #1's physician order dated 7/12/2024 read, Cleanse open area of the left lateral foot with normal saline, apply Anasept gel, and cover with island gauze dressing daily, every day shift for wound healing for 30 days. Review of Resident #1's Treatment Administration Record (TAR) for July 2024 revealed no entry documented for the left lateral foot wound care on 7/12/2024, 7/15/2024, 7/18/2024, 7/20/2024, 7/21/2024, and 7/23/2024. Review of Resident #1's physician order dated 7/12/2024 read, Cleanse open area of the right medial ankle with normal saline, apply Anasept gel, ABD pad, and wrap with kerlix daily, every day shift for wound healing for 30 days. Review of Resident #1's TAR for July 2024 revealed no entry documented for the right medial ankle wound care on 7/12/2024, 7/15/2024, 7/18/2024, 7/20/2024, 7/21/2024 and 7/23/2024. Review of Resident #1's physician order dated 7/12/2024 read, Cleanse open area of the right heel with wound cleanser, apply Anasept gel, ABD pad, and wrap with kerlix daily, every day shift for wound healing for 30 days. Review of Resident #1's TAR for July 2024 revealed no entry documented for the right heel wound care on 7/12/2024, 7/15/2024, 7/18/2024, 7/20/2024, 7/21/2024 and 7/23/2024. 2) Review of Resident #5's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic multifocal osteomyelitis, stage 4 pressure ulcer of sacral region, and type 2 diabetes mellitus. Review of Resident #5's physician order dated 6/17/2024 read, Cleanse depression of sacrum with Vashe, apply collagen sheet with silver (PURACOL) into depression of sacrum, place droplet of Vashe on cotton ball, place cotton ball in depression of sacrum daily and as needed, every day shift for odor control and wound healing for 30 days. Review of Resident #5's TAR for July 2024 revealed no entry documented for sacral wound care on 7/1/2024, 7/3/2024, 7/6/2024, and 7/11/2024. 3) Review of Resident #6's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia, type 2 diabetes mellitus, stage 3 pressure ulcer of left buttock, and stage 4 pressure ulcer of sacral region. Review of Resident #6's physician order dated 7/12/2024 read, Cleanse open area with normal saline, apply Betadine, and cover with an island gauze dressing daily and as needed, every day shift for wound healing of the left third toe. D/C Date: 07/23/2024. Review of Resident #6's TAR for July 2024 revealed no entry documented for the left third toe wound care on 7/20/2024. Review of Resident #6's physician order dated 7/12/2024 read, Cleanse open area with normal saline, apply Derma Blue foam with silver, ABD pad, and secure with retention tape, every day shift for wound healing of the right ischium for 30 days. Review of Resident #6's TAR for July 2024 revealed no entry documented for the right ischium wound care on 7/20/2024. Review of Resident #6's physician order dated 7/12/2024 read, Cleanse open area with normal saline, apply Derma Blue foam with silver, ABD pads, and secure with tape, every day shift for wound healing for 30 days. Apply to Sacrum. Review of Resident #6's TAR for July 2024 revealed no entry documented for sacral wound care on 7/15/2024 and 7/20/2024. Review of Resident #6's physician order dated 7/12/2024 read, Cleanse open area with normal saline, apply Derma Blue foam with silver, pad with ABD, and secure with retention tape, every day shift for wound healing of the left buttock for 30 days. Review of Resident #6's TAR for July 2024 revealed no entry documented for the left buttock wound care on 7/15/2024 and 7/20/2024. Review of Resident #6's physician order dated 7/13/2024 read, Cleanse open area with normal saline, apply oil emulsion and cover with an island gauze daily, every day shift for wound healing of the right, dorsal, lateral, fourth toe, for 30 days. Review of Resident #6's TAR for July 2024 revealed no entry documented for the right, dorsal, lateral, fourth toe wound care on 7/15/2024 and 7/20/2024. During an interview on 7/25/2024 at 1:45 PM, Staff A, Licensed Practical Nurse (LPN), Wound Care Nurse, stated, I completed the wound care as ordered. I just have not been charting all the care that I provided. I do not always have access to a computer. During an interview on 7/25/2025 at 2:38 PM, the Director of Nursing stated that wound care was provided but not documented, and it was her expectation that wound care would be documented when provided. Review of facility policy and procedure titled Charting and Documentation revised in July 2017 read, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation . 2. The Following information is to be documented in the resident medical record . c. Treatments or services performed . 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided. b. The name and title of the individual(s) who provided the care.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional standards for 2 of 4 medication carts and 3 of 4 resident hallways. Findings include: 1. During an observation on [DATE] at 9:37 AM of the East Short Hall Medication Cart, there were five loose circular tablets and one Loperamide tablet packet observed in the cart where the over-the-counter medications are stored. During an interview on [DATE] at 9:44 AM Staff C, License Practical Nurse (LPN) stated, Medication should not be loose in the medication cart they should be discarded. The Loperamide package is not even [supposed to be] stored in the vitamin section. I am not sure why it was up here, but it will fall on me since I had the cart. During an observation on [DATE] at 9:45 AM of the East Long Hall Medication Cart, there were three loose circular tablets observed. There was one open Breo Ellipta ,d+[DATE] inhaler with no open or expiration date, one open Incruse Ellipta inhaler with no open or expiration date, one open artificial tears with no open or expiration date and one expired plastic vial of artificial tears. During an interview on [DATE] at 9:48 AM Staff D, LPN stated, Upon opening medication it should be dated with an open and expiration date. If the medication is expired, it should be discarded and reordered. Loose pills should not be in the medication cart, maybe they fell out. They should have been discarded. During an observation on [DATE] at 10:05 AM Resident #93's room was empty, on top of the night stand draw there was a container of Bio Freeze. During an interview on [DATE] at 10:10 AM Resident #93 stated, I use the ointment for the pain that gets in my arms. The staff will apply it for me. I am not able to do so myself. During an interview on [DATE] at 1:30 PM the Assistant Director of Nursing stated, [Resident #93's name] does not have a self-administration assessment, he is not able to self-administer medication. During an interview on [DATE] at 2:39 PM the Director of Nursing (DON) stated, Medication is labeled once it is open with an open and expire date. Any loose medication should be discarded, not left in the cart. Eye drops should follow manufactures' instructions for expiration after opening. This [the instructions] are located in the binder in the medication cart. Review of the Breo Ellipta manufacturer's instructions read, Safely throw away Breo in the trash 6 weeks after you open the foil tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler. Review of the Incruse Ellipta manufacturer's instructions read, Safely throw away Incruse in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler. 46288 2. During an observation on [DATE] at 10:01 AM of Resident #61's room there was an inhaler on the over the bed table. The medication label read Advair Diskus. (Photographic evidence obtained) During an observation on [DATE] at 8:15 AM of Resident #61's room there was an inhaler on the over the bed table. The medication label read Advair Diskus. During an observation on [DATE] at 10:16 AM of Resident #86's room sitting on the bed side table there was a small medicine cup with a green-colored gelled substance. (Photographic evidence obtained) During an Interview on [DATE] at 10:17 AM Resident #86 stated, That is Bio-Freeze. The CNA [Certified Nursing Assistant] left it here for me. Review of Resident #61's medical record documented a physician order dated [DATE] which read Advair Diskus Aerosol Powder Breath Activated ,d+[DATE] mcg/dose [micrograms] 1 inhalation inhale orally every 12 hours for COPD/Asthma [chronic obstructive pulmonary disease]. Rinse with water after use. Do not swallow. Review of Resident #86's medical record did not provide for documentation of a physician's order for Bio-Freeze. During an interview on [DATE] at 10:18 AM with Staff A, LPN stated, Resident #86 should not have Bio-Freeze at the bedside. During an interview on [DATE] at 10:19 AM Staff A, LPN stated, Resident #61 should not have an inhaler at the bedside. During an interview on [DATE] at 10:26 AM the DON stated, My expectation is that no medications should be left at a resident's bedside. 47275 3. During an observation on [DATE] at 12:38 PM Resident #23 had two bottles of moisture shield skin protectant on the bedside table. (Photographic evidence obtained) During an interview on [DATE] at 12:38 PM Resident #23 stated, The nurse always leaves that there, so she remembers to use it. Review of Resident #23's medical record did not provide for documentation of a physician's order for the resident to self-administer medications. During an observation on [DATE] at 8:17 AM Resident #107 had a large bag of Honey Lemon cough suppressants on the nightstand table. (Photographic evidence obtained) During an interview on [DATE] at 9:55 AM, Resident #107 stated, Those are my cough drops, I keep them there in case I need one. During an interview on [DATE] at 1:17 PM Staff E, CNA stated, I am not sure if residents are supposed to have any medications left in their room. Review of Resident #107's medical record did not provide documentation of a physician's order for the resident to self-administer medications. Review of the facility policy and procedure titled P&P Medication/Biological Storage with a last reviewed date of [DATE] reads, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure: 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer or other holding areas to prevent the possibility of mixing medications of several residents. Review of the facility policy and procedure titled Storage of Medications with a last reviewed date of [DATE] reads, 5a. The nurse shall place a date opened sticker on the medication and record the date open and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacture recommends another date or regulations/guidelines require different dating.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection during medication administration through a peripherally inserted central catheter (PICC) for 1 of 4 residents, Resident #62. Findings include: During an observation on 8/9/2023 at 2:12 PM of Staff B, License Practical Nurse, Staff B primed (placing IV (intravenous) fluid in the IV tubing to remove all air prior to attaching the IV tube to the patient) the IV tubing for Resident #62, cleansed the resident's hep-lock (an IV catheter placed in a vein to administer medication or fluid into the bloodstream), and connected the IV tubing to the resident's hep-lock to administer IV medication. Staff B disconnected the IV tubing from the resident's hep-lock stating she had not flushed the IV hep-lock (flushing is performed before and after administering IV fluids or medications to assess placement and patency). After disconnecting the tubing Staff B released the resident's arm. The hep-lock in the resident's arm was observed to brush across the skin of the right side of the resident's back and come to rest with the hep-lock coming in contact with the resident's incontinence pad (an impermeable multi-layered sheet with high absorbency that is used to soak up urine). Staff B did not cleanse the adaptor to the hep-lock and flushed 5 ml (milliliters) of normal saline into the adaptor using a syringe. Staff B released the resident's arm and the hep-lock was observed to brush across the skin of the resident's right side. Staff B removed the IV tubing from the pole, did not cleanse the IV tubing adaptor or the adaptor to the hep-lock and connected the IV tubing, and started the infusion pump to administer the medication. The IV infusion pump sounded an alarm and had a message displayed on the face of the pump which read, air in line. Staff B disconnected the IV tubing from the hep-lock, primed the IV tubing with normal saline, cleansed the resident's hep-lock, connected the IV tubing to the hep-lock, and started the medication administration. During an interview on 8/9/2023 at 2:29 PM Staff B, LPN stated, I did not notice when the needleless connector came in contact with [Resident #62's name's] skin or pad. I should have definitely cleaned the needleless connector again. During an interview on 8/9/2023 at 2:35 PM the Director of Nursing stated, The needleless connector should have been cleaned every time it touched the resident's skin. Review of Resident the physician order for Resident #62 dated 7/12/2023 read, Cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Solution) use 2 gram intravenously every 8 hours for bacteremia [viable bacteria in the blood] until 8/19/2023 23:59 [11:59 PM]. Review of the physician order for Resident #62 dated 7/13/2023 read, Normal Saline Flush Solution (Sodium Chloride Flush) use 5 cc [cubic centimeter] intravenously every 8 hours for prophylaxis. Flush central venous catheter with 5 ml [milliliters] NS [normal saline] before and after medication administration. Review of the facility policy and procedure titled, P&P IV Infusion with a last review date of 3/21/2023 read, Policy: It is the policy of this facility to provide administration of intravenous fluids, medications and electrolytes for the purpose of hydration and management of infections or other medical conditions. Review of the facility competency titled, Administering Medication Through a Saline Lock Competency read, Cleanse saline lock cap. Cleanse injection cap and properly flush device with saline. Maintain aseptic technique [a set of practices that protects patients from healthcare-associated infections] throughout the procedure.

Based on observation, interview, and record review, the facility failed to ensure foods and beverages were stored in a safe and sanitary manner in 2 of 2 facility nourishment rooms. Findings include: During a tour of the West Hall nourishment room accompanied with the Dietary Manager on 2/5/2023 at 10:00 AM, there were one undated and unlabeled cup of liquid on the counter, one undated pitcher of purple liquid in the refrigerator, one open can of energy drink in the refrigerator, and one undated take-out container of unlabeled and undated food items stored in the West Hall refrigerator. During an interview on 2/5/2023 at 10:00 AM, the Dietary Manager acknowledged that open, undated and unlabeled food items were stored in the West Wing nourishment room refrigerator. During a tour of the East Hall nourishment room accompanied with the Dietary Manager on 2/5/2023 at 10:07 AM, there were two open, undated and unlabeled trays of cookies stored on the countertop in the East Hall nourishment room. During an interview on 2/5/2023 at 10:07 AM, the Dietary Manager acknowledged that open, undated and unlabeled food items were stored in the East Wing nourishment room refrigerator. Review of the facility policy and procedure titled Foods Brought by Family/Visitors reviewed on 12/20/2022, reads, Policy Interpretation and Implementation . 7. Food brought by family/visitors that is left with the resident to consume later will [Sic.] labeled and stored in a manner that is clearly distinguishable from facility-prepared food. a. Non-perishable foods will be stored in re-sealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods must be stored in resealable containers with tight-fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.

Based on observation and interview, the facility failed to ensure garbage and refuse were disposed of properly. Findings include: During an observation of the facility dumpsters and surrounding areas accompanied with the Dietary Manager on 2/5/2023 at 10:08 AM, the dumpster nearest the kitchen exit was overfilled and propped open with cardboard boxes. The lids of the second dumpster were cracked. The lids of the dumpster furthest from the kitchen exit were cracked and bent and did not close flush with the dumpster upper rim. There was garbage and refuse that included take-out food containers, candy wrappers, straws, used gloves, used masks, plastic bags, plastic utensils, used milk carton and plastic forks scattered on the ground surrounding the dumpsters. There was additional garbage and refuse that included an empty milk carton, a plastic grocery bag, clear plastic bags and food wrappers scattered on the ground in the areas surrounding the dumpsters and employee break side of the facility (Photographic evidence obtained) During an interview on 2/5/2023 at 10:08 AM, the Dietary Manager acknowledged that there was garbage and refuse scattered on the grounds around the dumpsters and surrounding areas. She verified the areas should be cleared of garbage and refuse.

Based on observation, interview, and review of the policies and procedures, the facility failed to ensure resident rights to be free from neglect by failing to ensure structures and processes were in place to prevent the likelihood of harm due to respiratory smoke inhalation, [CONDITION(S)] from fire, and death by failure to have a functioning fire alarm system that would alert the monitoring company and the fire department in case of smoke and/or fire, and failed to implement a fire watch for 109 of 109 residents, which consist of two residents who are bedfast, 70 requiring extensive assistance for ambulation, 32 ambulate with assistance or assistive device, and five are independently ambulatory. Findings: During an observation on 8/17/2021 at 11:35 AM, while conducting a tour of the facility, in the Therapy room/fire alarm control panel area the control panel indicated a trouble mode. The control panel trouble light (orange) was illuminated, and the control panel was silent. The control panel was illuminated, but the panel was not sounding an audible noise to indicate the trouble mode. During an observation on 8/17/2021 at 2:05 PM the fire alarm system dialer was tested by unplugging the control panel battery (one of the two ways that the dialer unit can be tested ). After waiting ten minutes for an audible/visual signal on the panel and a phone call from the monitoring company, the audible/visual signal nor the call from the monitoring company happened. During an observation on 8/17/2021 at 2:15 PM of the annunciator panel (secondary fire alarm panel) located in the main lobby showed the trouble light was also illuminated (orange). Review of the [Company's Name] fire alarm system service invoice report dated 9/3/2020 reads: Trouble shot panel and found all of loop 2 in trouble. Panel is bad and needs to be replaced. Review of the [Company's Name] fire alarm system service inspection and testing form dated 1/14/2021 at 8:30 AM reads Discrepancy list: Dialer trouble module 01-017, Loop 2 all devices communication error. Review of the [Company's Name] fire alarm system service inspection and testing form dated 6/10/2021 at 10:00 AM reads Discrepancy List: Dialer unplugged and not working. Loop #2 failed to function. See initiating device sheets for devices that failed to function. Need to be on fire watch. During an interview on 8/20/2021 at 10:15 AM the facility Administrator stated, I knew approximately in September 2020 that the control panel needed to be replaced, but I was not aware that we needed to be on fire watch. We did get a service call back in September 2020, but the Maintenance Director did not tell me that we needed to be on a fire watch. I am responsible for the building. My Maintenance Director spoke to the Fire Marshall, and he told me that he said that the pull station would still work, and we did not need to be on fire watch. I do not know the date he spoke with him. I think it was sometime in June after the 6/10/2021 inspection. I do not think any contact was made with the Fire Marshall prior to that. I do not have that in writing. I do not have any electronic mail from the Fire Marshall, and I do not have any documentation that the Fire Marshall was contacted. We do have a policy that states in the event of the fire system failure we will initiate a fire watch, that we should notify the fire department and the agency [Agency for Health Care Administration]. We did not begin a fire watch and we did not call the fire department or AHCA [Agency for Health Care Administration]. I was supposed to initiate a fire watch according to our policies and procedures. I was supposed to alert the Fire Marshall and notify the agency. I did not reach out to the Fire Marshall and verify the information provided to me by the Maintenance Director. We began training and the fire watch on 8/17/2021. We educated all staff on the fire watch. I'm not sure how many staff were trained. Staff are assigned to complete fire watch on each unit. We did not identify the number of residents that might be affected, we just noted that no residents were affected. During a telephone interview on 08/20/21 at 11:00 AM, the President/CEO (Chief Executive Officer) of the monitoring company stated, The fire system that serves Loop 2 of the building is not functioning and none of the pull stations will dial the fire department and get them to the building. When we were there in January 2021, we recommended they provide a fire watch. We had been to the facility back in September 2020 or October 2020 and recommended a complete replacement of the system as Loop 2 was not functioning then. That would mean that pull stations would not dial the fire department. The dialer itself is not functioning and that would not dial the fire department. During a follow up telephone interview on 08/20/21 at 11:19 AM the service invoice report dated 9/3/2020 was read to the President/CEO of the monitoring company. It read as follows: Trouble shot panel and found all of Loop 2 in trouble. Panel is bad and needs to be replaced. The President/CEO stated, That means that Loop 2 was not working at all and needed to be replaced. The facility was told that they needed to be on fire watch at that time. During an interview on 8/20/2021 at 11:25 AM Staff A, Licensed Practical Nurse (LPN) stated, In case of a fire I would pull the fire alarm and start to evacuate the residents. We wouldn't need to call 911, pulling the alarm gets the fire department here. We are on fire watch, but the alarms still work. I am doing fire watch so every 30 minutes I tour the unit. I am giving residents medications; I am on the medication cart also. During an interview on 8/20/2021 at 11:30 AM Staff R, LPN, stated, If there was a fire, I would pull the fire alarm and start closing doors and if I found the fire, I would rescue the resident, close the door, and get the extinguisher. I would not need to call 911, pulling the fire pull would do that. During an interview on 8/20/2021 at 11:35 AM Staff S, LPN stated, I am on fire watch today. I look in all the rooms every one-half hour. I am also working the medication cart. If I smelled smoke, I would rescue the resident and pull the nearest fire alarm station. I would do the RACE [Rescue, Alarm, Confine, Extinguish] procedure and when I got the fire extinguisher, I would follow PASS [Pull, Aim, Squeeze, Sweep] procedure. I don't need to call 911, pulling the fire alarm does that. I would need to rescue the residents or make sure they are safe. During an interview on 8/20/2021 at 11:40 AM Staff T, Certified Nursing Assistant (CNA), stated, If there was a fire, I would pull the fire alarm and start to close doors after I got the resident out of their room. We have been on fire watch this week. I did not know that the fire alarm doesn't work and didn't know I needed to call 911 to get the fire department. I'm used to calling if the nurses need the ambulance, but I didn't know that. During an interview on 8/20/2021 at 11:45 AM Staff U, CNA stated, We have been on fire watch, the nurses are assigned to do that, I don't. I would pull the fire alarm and start to close doors and get the residents safe. I don't have to call 911; just pull the alarm. I did not know that we needed to call 911 too. During an interview on 8/20/2021 at 11:49 AM Staff V, CNA, stated, We did get training that we are on fire watch, and someone has to go into every room every 30 minutes. I think the nurses are doing that. I would pull the fire alarm and close the doors of the patients' rooms if there was a fire. I don't think that I need to call 911. I just would pull the fire alarm and get the fire extinguisher. During an interview on 8/20/2021 at 11:58 AM Staff W, LPN stated, I am on fire watch, so I am supposed to check the rooms for smells of smoke. If I smell any smoke; I would pull the fire alarm, start the rescue of the residents, close the doors to residents' rooms, and rescue the resident where the fire was. I am on the medication cart today. I am working and doing the fire watch. During an interview on 8/20/2021 at 12:05 PM Staff B, LPN stated, If I smelled smoke, I would pull the fire alarm and start the RACE procedure. We are on fire watch, that means that I have to round every 30 minutes in every room and sign the sheet. I am doing patient care and working the med cart also. I don't have to call 911 unless I want Emergency Medical Services. I did not know that there was any problem with the fire alarms until they started the fire watch. During an interview on 8/20/2021 at 12:15 PM Staff X, Dietary Aide stated, If I smelled smoke, I would pull the fire alarm and let my boss know. We are on fire watch but I'm not doing anything on that. I don't know what to do and I would just take direction from anyone in charge as to what to do. I don't know why we are on fire watch. During an interview on 8/20/2021 at 12:20 PM, Human Resources stated, We are on fire watch. I am not assigned to do that. We were trained that we need to be on fire watch in case of a fire. I would pull the fire alarm and page Code Red overhead. I wouldn't need to call 911. During an interview on 8/20/2021 at 12:25 PM Staff Y, Housekeeper stated, If I saw a fire, I would pull the fire alarm. I have not had any training and I don't know what a fire watch is. During an interview on 8/20/2021 at 12:30 PM Staff Z, Physical Therapy Assistant (PTA), stated, If I smelled smoke, I would find the fire station and pull it and then I would start the RACE/PASS process. I have not had any training that told me the fire alarms weren't working. They did say we are on fire watch, but I am not involved in the fire watch. During an interview on 8/20/2022 at 12:40 PM, the Assistant Director of Nursing, Registered Nurse stated, We are on fire watch currently, so staff are assigned to do it every 30 minutes. They look through every room. They are assigned to other duties, the nurses are assigned to the cart, giving meds and on fire watch. The fire pull stations are working so in the event of a fire we would pull them, and the fire department would come. During an interview on 8/20/2021 at 12:49 PM with Staff Q, CNA stated, In case of a fire I would pull the alarm and start to close doors and get the residents out if I needed to. The fire pull would call the fire department so I would not need to. I think we are on fire watch, but I don't do that, the nurses are. During an interview on 8/20/21 at 1:00 PM, Staff AA, CNA stated Of course I would pull the fire alarm and then I would start to close the doors and do anything else I was told. I don't know why we are on fire watch, but I am not doing it, the nurses are. When you pull the fire alarm it automatically calls the fire department so I would not call 911. During an interview on 8/20/21 at 1:05 PM, Staff E, CNA stated, If I smelled smoked, I would pull the fire alarm then rescue the resident. The fire alarm pull calls the fire department. We are on fire watch, that means rooms are checked every 30 minutes. When we pull the fire alarm, we do not need to call 911. During a follow up interview on 08/20/21 at 2:18 PM the Administrator stated, I was aware that the panel needed to be replaced and I was not sure what the report meant. Residents were possibly at risk for injury while the loop was not functional. Residents were possibly at risk for injury when we did not have the fire alarm system and they are possibly still at risk that is why we are getting a security company. During an interview on 08/20/21 at 3:10 PM, the Director of Nursing (DON) stated, I was not aware of any problems with the fire alarm system until a few days ago. We did not provide any training related to the fire alarms before a few days ago. It is conceivable that residents were at risk since the fire alarm system was broken. I was trained on the fire watch process and the training involved the policy. We should not have staff doing anything more than fire watch if that is what our policy says, so it is conceivable that residents are still at risk of harm. We should have known the seriousness of this before the survey started. This was not brought up in QAPI [Quality Assurance Performance Improvement]. I do not recall ever hearing that the fire pulls did not work and would not get the fire department. In an emergency staff would pull the fire alarm and start RACE [Rescue, Alarm, Confine, Extinguish] and PASS [Pull, Aim, Squeeze, Sweep] procedures. I'm not sure if they would have called 911. I would hope so, but in an emergency of a fire I just can't say. During an interview on 08/20/21 at 3:19 PM, the Maintenance Assistant stated, I did know that we needed to have the fire alarm panel replaced. I have never notified the Fire Marshal about any of this. I have never heard that we had to be on fire watch until you all came in. During an interview on 08/20/21 at 4:08 PM, the Regional Director of Plant Operations stated, We have completed testing of the alarms today and verified that the system was not alerting the fire department. We verified this with the monitoring company that the alarms we tested did not connect to the fire department. I was not aware of the extent of the malfunction and would have started fire watch immediately. All residents, staff, and visitors are at risk of injury if a fire had started, and staff did not understand that they needed to call 911 to get the fire department to respond. I was not aware that staff were doing their normal job duties and being assigned to fire watch. They should not be. Review of the training provided by the facility titled, Fire Watch dated 8/17/21 revealed 32 out of 145 staff attended the training totaling 22% of all staff. Review of the training titled Fire Watch/Call 911 dated 8/20/21 revealed 24 out of 145 staff attended the training totaling 38% of all staff. Sixty three percent (63%) of staff remained untrained in Fire Watch procedures. Review of the policy titled Abuse Protection and Response Policy, undated, last reviewed on 12/28/20, reads, Policy: Abuse, as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardians, friends or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Definitions - Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Policy Number 13.04.07, titled Fire Watch, with an issue date of 3/18, last review on 12/28/2020, reads, Standards: Fire Watch: Guidelines: In the event of a failure of the fire alarm system, sprinkler system, the facility will initiate a fire watch. Guidelines: 1. Notify the local fire department and document instructions. 2. Notify the Agency through the area office. 3. Assess the extent of the condition and effect corrective action, with a documented time frame. If corrective action will take more than 4 hours, do the following: Implement a contingency plan to the facility fire plan containing: a description of the problem, specifically what the system is not doing that it normally does, and the projected correction time frame. All staff on shifts involved shall have documented in-service and drilling for the contingency. Begin a documented fire watch, until the system is restored. Persons used for fire watch will not be assigned to any other duty and must be trained in what to look for, what to do, and be able to expeditiously contact the fire department. 4. Maintenance Director will initiate 'fire watch'. If the maintenance director is not in the facility, the manager on duty or the charge nurse will initiate the 'fire watch'. Until staff (not on duty) or other contracted agency can be called to carry out the 'fire watch'. 5. The fire watch person will conduct a tour of the facility every 15 minutes. This tour will include checking each resident room, offices, closets, storage, common areas and mechanical rooms for signs of smoke, fire smoke, or fire hazards. Smoke from under a door, feel the door and handle for heat, if any exist, they will need to sound the alarm and call fire dept. 6. Announcements will be made to staff reminding them that the fire alarm or sprinkler is not working. 7. In the event if a fire watch person or any person discovers a fire in progress or smoke indicating fire, he/she will contact 911 and then the point of contact person (i.e. maintenance director or manager on duty or charge nurse) and report the fire to him/her. The fire watch person will stay at the scene and try to contain and/or extinguish the fire. 8. The point of contact will immediately call 911 (local fire department) and then announce over the facility intercom CODE RED (area of fire, i.e. RM 53). CODE RED (area of fire, i.e. RM 53), CODE RED (area of fire, i.e. RM 53). The point of contact person will ensure that the RACE procedure is followed. 9. The fire watch will continue until the fire alarm panel or sprinkler system is restored and tested in the presence of the Maintenance Director or Administrator. The fire department and local area office will be notified of the stand down of the fire watch. 10. In the event that there is a phone system failure in the facility, cell phones are available for the employee doing fire watch to be able to dial '911' in case of emergency. Review of the policy titled Fire Watch, revised in August 2018, last reviewed on 12/28/2020, reads, Policy statement: Fire watch procedures will be initiated if the fire alarm system fails. Policy interpretation and Implementation: 1. The purpose of the Fire Watch is to serve as a plan of correction should the fire alarm system fail to work properly to provide continuous facility wide fire detection and alarm capabilities. 2. A fire alarm system should include, but is not limited to, fire alarm panel, smoke or heat detection system, sprinkler system and for department notification system. 3. Fire alarm outages can occur during construction, renovation, electrical [NAME], component/system failure or unplanned events that eliminate a portion of or all of the fire alarm system. Emergency Procedure-Fire Watch. 1. Contact the Administrator, Director of Nursing, and Maintenance Director when any problems are encountered with the fire alarm system. 2. Contact the fire alarm company if the maintenance director or other responsible party is unable to correct the problem. 3. Notify the Fire Department and State Regulatory/Licensure Agency that the fire alarm system is not working correctly and that fire watch procedures are in place until the system is restored. 4. Report to the Incident Command Post for instruction. If warranted, based on the potential severity of the system failure, activate the ICS (Incident Command System) to manage the incident. The most qualified staff member (in regard to the Incident Command system) on duty at the time assumes the Incident Commander position. 5. Initiate fire watch tours throughout the facility. Fire watch tours occur at one-half hour intervals, 24 hours a day and consist of periodic walking tour of the entire facility by one or more assigned and trained staff. a. The fire watch staff monitors the facility through direct observation of all rooms, including resident rooms, mechanical and electrical rooms, kitchen laundry, etc. for all possible signs of fire. b. The fire watch staff documents fire watch tours with findings noting date, time and staff initials. c. The fire watch staff consists of personnel solely dedicated to the fire watch with no other facility related activities or events. 8. Do not terminate the Fire Watch until all fire protection equipment is in normal operating condition and upon authority of the Administrator/Incident commander or designee. Under the section title, Emergency Procedure - Fire reads, Utilize the Fire Procedure in the event of an actual fire, smoke condition, or smell of smoke in the facility. 1. Activate the R-A-C-E response as soon as there is discovery of a fire or potential fire situation with the building. DO NOT PANIC. The documentation for A reads, ALARM: Activate the building's fire alarm system by pulling the nearest manual pull station. Announce CODE RED and the fire location over the loudspeaker-repeat.

Based on interview, record review, and policy and procedure review, the facility Administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility ensuring the safety for the 109 residents when deficiencies were identified of the non-functioning fire alarm system necessary to alert the monitoring company and the fire department in case of fire and not implementing a fire watch. Findings: During an interview on 8/20/2021 at 10:15 AM the facility Administrator stated, I knew approximately in September 2020 that the control panel needed to be replaced, but I was not aware that we needed to be on fire watch. We did get a service call back in September 2020, but the Maintenance Director did not tell me that we needed to be on a fire watch. I am responsible for the building. My Maintenance Director spoke to the Fire Marshall, and he told me that he said that the pull station would still work, and we did not need to be on fire watch. I do not know the date he spoke with him. I think it was sometime in June after the 6/10/2021 inspection. I do not think any contact was made with the Fire Marshall prior to that. I do not have that in writing. I do not have any electronic mail from the Fire Marshall, and I do not have any documentation that the Fire Marshall was contacted. We do have a policy that states in the event of the fire system failure we will initiate a fire watch, that we should notify the fire department and the agency [Agency for Health Care Administration]. We did not begin a fire watch and we did not call the fire department or AHCA [Agency for Health Care Administration]. I was supposed to initiate a fire watch according to our policies and procedures. I was supposed to alert the Fire Marshall and notify the agency. I did not reach out to the Fire Marshall and verify the information provided to me by the Maintenance Director. We began training and the fire watch on 8/17/2021. We educated all staff on the fire watch. I'm not sure how many staff were trained. Staff are assigned to complete fire watch on each unit. We did not identify the number of residents that might be affected, we just noted that no residents were affected. This was not brought to the Quality Assurance and Performance Improvement committee (QAPI) and no plan of action or correction was started. I really just found out the seriousness of this on Tuesday. I have not had a QAPI emergency meeting yet, it is going to happen, but it hasn't yet. We were getting bids for the repairs, I just didn't think that it was this serious. I did not know that the fire alarm pull stations are not working. I did not follow the policy for QAPI and did not call an emergency meeting. Review of the Administrator Job Description dated 2/1/2013 reads Purpose of Your Job Position. The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Delegation of Authority. As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and Responsibilities. Administrative Functions. Plan, develop, organize, implement, evaluate, and direct the Facility's programs and activities in accordance with guidelines issued by the VP [Vice President] of Operations. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Committee Functions. Assist the Quality Assurance And Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Safety and Sanitation. Ensure that all Facility personnel, residents, visitors, etc., follow established safety regulations, to include fire protection and prevention, smoking regulations, infection control, etc. Equipment and Supply Functions. Ensure that the Facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties and services. The job description is signed by the Administrator. Review of the [Company's Name] fire alarm system service invoice report dated 9/3/2020 reads: Trouble shot panel and found all of loop 2 in trouble. Panel is bad and needs to be replaced. Review of the [Company's Name] fire alarm system service inspection and testing form dated 1/14/2021 at 8:30 AM reads Discrepancy list: Dialer trouble module 01-017, Loop 2 all devices communication error. Review of the [Company's Name] fire alarm system service inspection and testing form dated 6/10/2021 at 10:00 AM reads Discrepancy List: Dialer unplugged and not working. Loop #2 failed to function. See initiating device sheets for devices that failed to function. Need to be on fire watch. During a telephone interview on 08/20/21 at 11:00 AM, the President/CEO (Chief Executive Officer) of the monitoring company stated, The fire system that serves Loop 2 of the building is not functioning and none of the pull stations will dial the fire department and get them to the building. When we were there in January 2021, we recommended they provide a fire watch. We had been to the facility back in September 2020 or October 2020 and recommended a complete replacement of the system as Loop 2 was not functioning then. That would mean that pull stations would not dial the fire department. The dialer itself is not functioning and that would not dial the fire department. During a follow up telephone interview on 08/20/21 at 11:19 AM the service invoice report dated 9/3/2020 was read to the President/CEO of the monitoring company. It read as follows: Trouble shot panel and found all of Loop 2 in trouble. Panel is bad and needs to be replaced. The President/CEO stated, That means that Loop 2 was not working at all and needed to be replaced. The facility was told that they needed to be on fire watch at that time. During a follow up interview on 08/20/21 at 02:18 PM the Administrator stated, I was aware that the panel needed to be replaced and I was not sure what the report meant. Residents were possibly at risk for injury while the loop was not functional. Residents were possibly at risk for injury when we did not have the fire alarm system and they are possibly still at risk that is why we are getting a security company. During an interview on 08/20/21 at 3:10 PM, the Director of Nursing (DON) stated, I was not aware of any problems with the fire alarm system until a few days ago. We did not provide any training related to the fire alarms before a few days ago. It is conceivable that residents were at risk since the fire alarm system was broken. I was trained on the fire watch process and the training involved the policy. We should not have staff doing anything more than fire watch if that is what our policy says, so it is conceivable that residents are still at risk of harm. We should have known the seriousness of this before the survey started. This was not brought up in QAPI [Quality Assurance Performance Improvement]. I do not recall ever hearing that the fire pulls did not work and would not get the fire department. In an emergency staff would pull the fire alarm and start RACE [Rescue, Alarm, Confine, Extinguish] and PASS [Pull, Aim, Squeeze, Sweep] procedures. I'm not sure if they would have called 911. I would hope so, but in an emergency of a fire I just can't say. Review of the Director of Nursing Services Job Description dated 12/5/2018 reads Purpose of Your Job Position. The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities. Administrative Functions. Assist in developing and implementing appropriate plans of action to correct identified deficiencies. Safety and Sanitation: Assist in developing safety standards for the nursing service department. Ensure that the department's policy and procedure manuals identify safety precautions and equipment to use when performing tasks that could result in bodily injury. Develop, implement and maintain a procedure for reporting hazardous conditions or equipment. Job description was signed on 1/10/19 by the Director of Nursing Services. During an interview on 08/20/21 at 3:19 PM, the Maintenance Assistant stated, I did know that we needed to have the fire alarm panel replaced. I have never notified the Fire Marshal about any of this. I have never heard that we had to be on fire watch until you all came in. During an interview on 08/20/21 at 4:08 PM, the Regional Director of Plant Operations stated, We have completed testing of the alarms today and verified that the system was not alerting the fire department. We verified this with the monitoring company that the alarms we tested did not connect to the fire department. I was not aware of the extent of the malfunction and would have started fire watch immediately. All residents, staff, and visitors are at risk of injury if a fire had started, and staff did not understand that they needed to call 911 to get the fire department to respond. I was not aware that staff were doing their normal job duties and being assigned to fire watch. They should not be. Review of the Maintenance Supervisor Job Description dated 5/20/2005 reads Purpose of Your Job Position. The primary purpose of your position is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state, and local standards guidelines, and regulations governing our Facility and as may be directed by the Administrator, to assure that out Facility is maintained in a clean, safe, and comfortable manner. Duties and Responsibilities. Plan, develop, organize, implement, evaluate, and direct the Maintenance Department, its programs and activities. Assume the administrative authority, responsibility, and accountability of directing the Maintenance Department. Make written oral reports and recommendations to the Administrator, as necessary or required, concerning the operation of the Maintenance Department. Keep abreast of economic conditions or situations and recommend to the Administrator adjustments in maintenance services that assure the continued ability to provide a clean, safe and comfortable environment. Committee Functions. Serve on various committees of the Facility (i.e. Infection Control, Safety, QA, etc.) and provide written or oral reports of maintenance services and activities as required by the committee's guidelines or direction. Evaluate and implement recommendations from established committees. Safety and Sanitation. Supervise safety and fire protection and prevention programs by inspecting work areas and equipment at least weekly. Ensure that maintenance personnel follow established safety regulations in the use of equipment and supplies at all times. Ensure that all supplies, equipment, etc. are maintained to provide a safe and comfortable environment. Promptly report equipment or Facility damage to the Administrator. Equipment and Supply Functions. Recommend to the Administrator the equipment and supply needs of the department. Make periodic rounds to check equipment and to assure the necessary equipment is available and working properly. Job description was signed on 2/14/15 by the Maintenance Director. Review of the training provided by the facility titled, Fire Watch dated 8/17/21 revealed 32 out of 145 staff attended the training totaling 22% of all staff. Review of the training titled Fire Watch/Call 911 dated 8/20/21 revealed 24 out of 145 staff attended the training totaling 38% of all staff. Sixty three percent (63%) of staff remained untrained in Fire Watch procedures. Review of the policy titled Quality Assurance and Performance Improvement (QAPI) Committee, dated July 2016, last reviewed 12/28/20 reads Policy Statement. This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program. Policy Interpretation and Implementation. 1. The Administrator shall delegate the necessary authority for the QAPI committee to establish, maintain and oversee the QAPI program. 2 . The primary goals of the QAPI Committee are to: 1. Establish, maintain , and oversee facility systems and processes to support the delivery of quality of care and services. Review of the policy titled Abuse Protection and Response Policy, undated, last reviewed on 12/28/20, reads, The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Definitions. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Policy Number 13.04.07, titled Fire Watch, with an issue date of 3/18, last review on 12/28/2020, reads, Standards: Fire Watch: Guidelines: In the event of a failure of the fire alarm system, sprinkler system, the facility will initiate a fire watch. Guidelines: 1. Notify the local fire department and document instructions. 2. Notify the Agency through the area office. 3. Assess the extent of the condition and effect corrective action, with a documented time frame. If corrective action will take more than 4 hours, do the following: Implement a contingency plan to the facility fire plan containing: a description of the problem, specifically what the system is not doing that it normally does, and the projected correction time frame. All staff on shifts involved shall have documented in-service and drilling for the contingency. Begin a documented fire watch, until the system is restored. Persons used for fire watch will not be assigned to any other duty and must be trained in what to look for, what to do, and be able to expeditiously contact the fire department. 4. Maintenance Director will initiate 'fire watch'. If the maintenance director is not in the facility, the manager on duty or the charge nurse will initiate the 'fire watch'. Until staff (not on duty) or other contracted agency can be called to carry out the 'fire watch'. 5. The fire watch person will conduct a tour of the facility every 15 minutes. This tour will include checking each resident room, offices, closets, storage, common areas and mechanical rooms for signs of smoke, fire smoke, or fire hazards. Smoke from under a door, feel the door and handle for heat, if any exist, they will need to sound the alarm and call fire dept. 6. Announcements will be made to staff reminding them that the fire alarm or sprinkler is not working. 7. In the event if a fire watch person or any person discovers a fire in progress or smoke indicating fire, he/she will contact 911 and then the point of contact person (i.e. maintenance director or manager on duty or charge nurse) and report the fire to him/her. The fire watch person will stay at the scene and try to contain and/or extinguish the fire. 8. The point of contact will immediately call 911 (local fire department) and then announce over the facility intercom CODE RED (area of fire, i.e. RM 53). CODE RED (area of fire, i.e. RM 53), CODE RED (area of fire, i.e. RM 53). The point of contact person will ensure that the RACE procedure is followed. 9. The fire watch will continue until the fire alarm panel or sprinkler system is restored and tested in the presence of the Maintenance Director or Administrator. The fire department and local area office will be notified of the stand down of the fire watch. 10. In the event that there is a phone system failure in the facility, cell phones are available for the employee doing fire watch to be able to dial '911' in case of emergency. Review of the policy titled Fire Watch, revised in August 2018, last reviewed on 12/28/2020, reads, Policy statement: Fire watch procedures will be initiated if the fire alarm system fails. Policy interpretation and Implementation: 1. The purpose of the Fire Watch is to serve as a plan of correction should the fire alarm system fail to work properly to provide continuous facility wide fire detection and alarm capabilities. 2. A fire alarm system should include, but is not limited to, fire alarm panel, smoke or heat detection system, sprinkler system and for department notification system. 3. Fire alarm outages can occur during construction, renovation, electrical [NAME], component/system failure or unplanned events that eliminate a portion of or all of the fire alarm system. Emergency Procedure-Fire Watch. 1. Contact the Administrator, Director of Nursing, and Maintenance Director when any problems are encountered with the fire alarm system. 2. Contact the fire alarm company if the maintenance director or other responsible party is unable to correct the problem. 3. Notify the Fire Department and State Regulatory/Licensure Agency that the fire alarm system is not working correctly and that fire watch procedures are in place until the system is restored. 4. Report to the Incident Command Post for instruction. If warranted, based on the potential severity of the system failure, activate the ICS (Incident Command System) to manage the incident. The most qualified staff member (in regard to the Incident Command system) on duty at the time assumes the Incident Commander position. 5. Initiate fire watch tours throughout the facility. Fire watch tours occur at one-half hour intervals, 24 hours a day and consist of periodic walking tour of the entire facility by one or more assigned and trained staff. a. The fire watch staff monitors the facility through direct observation of all rooms, including resident rooms, mechanical and electrical rooms, kitchen laundry, etc. for all possible signs of fire. b. The fire watch staff documents fire watch tours with findings noting date, time and staff initials. c. The fire watch staff consists of personnel solely dedicated to the fire watch with no other facility related activities or events. 8. Do not terminate the Fire Watch until all fire protection equipment is in normal operating condition and upon authority of the Administrator/Incident commander or designee.

Based on observation, staff interview, and policy and procedure review, the quality assessment and assurance committee failed to develop and implement appropriate plans of action to correct the identified quality deficiencies of the nonfunctioning fire alarm system that is necessary to alert the monitoring company and the fire department in case of fire, and failed to implement a fire watch. Findings: During an observation on 8/17/2021 at 11:35 AM, while conducting a tour of the facility, in the Therapy room/fire alarm control panel area the control panel indicated a trouble mode. The control panel trouble light (orange) was illuminated, and the control panel was silent. The control panel was illuminated, but the panel was not sounding an audible noise to indicate the trouble mode. During an observation on 8/17/2021 at 2:05 PM the fire alarm system dialer was tested by unplugging the control panel battery (one of the two ways that the dialer unit can be tested ). After waiting ten minutes for an audible/visual signal on the panel and a phone call from the monitoring company, the audible/visual signal nor the call from the monitoring company happened. During an observation on 8/17/2021 at 2:15 PM of the annunciator panel (secondary fire alarm panel) located in the main lobby showed the trouble light was also illuminated (orange). Review of the [Company's Name] fire alarm system service invoice report dated 9/3/2020 reads: Trouble shot panel and found all of loop 2 in trouble. Panel is bad and needs to be replaced. Review of the [Company's Name] fire alarm system service inspection and testing form dated 1/14/2021 at 8:30 AM reads Discrepancy list: Dialer trouble module 01-017, Loop 2 all devices communication error. Review of the [Company's Name] fire alarm system service inspection and testing form dated 6/10/2021 at 10:00 AM reads Discrepancy List: Dialer unplugged and not working. Loop #2 failed to function. See initiating device sheets for devices that failed to function. Need to be on fire watch. During an interview on 8/20/2021 at 10:15 AM the facility Administrator stated, I knew approximately in September 2020 that the control panel needed to be replaced, but I was not aware that we needed to be on fire watch. We did get a service call back in September 2020, but the Maintenance Director did not tell me that we needed to be on a fire watch. I am responsible for the building. This was not brought to the Quality Assurance and Performance Improvement committee (QAPI) and no plan of action or correction was started. I really just found out the seriousness of this on Tuesday. I have not had a QAPI emergency meeting yet, it is going to happen, but it hasn't yet. We were getting bids for the repairs. I just didn't think that it was this serious. I did not know that the fire alarm pull stations are not working. I did not follow the policy for QAPI and did not call an emergency meeting. During a telephone interview on 08/20/21 at 11:00 AM, the President/CEO (Chief Executive Officer) of the monitoring company stated, The fire system that serves Loop 2 of the building is not functioning and none of the pull stations will dial the fire department and get them to the building. When we were there in January 2021, we recommended they provide a fire watch. We had been to the facility back in September 2020 or October 2020 and recommended a complete replacement of the system as Loop 2 was not functioning then. That would mean that pull stations would not dial the fire department. The dialer itself is not functioning and that would not dial the fire department. During a follow up telephone interview on 08/20/21 at 11:19 AM the service invoice report dated 9/3/2020 was read to the President/CEO of the monitoring company. It read as follows: Trouble shot panel and found all of Loop 2 in trouble. Panel is bad and needs to be replaced. The President/CEO stated, That means that Loop 2 was not working at all and needed to be replaced. The facility was told that they needed to be on fire watch at that time. During an interview on 08/20/21 at 02:47 PM, the Medical Director stated, We meet every quarter and had a QAPI meeting two months ago, we did not talk about fire alarms. I was not aware that there was anything wrong with the fire alarms. When we meet, we get updates related to any problems that there have been and any new concerns there are. I know the maintenance department reports every QAPI meeting, but I do not recall ever being told the fire alarms did not work. That is about all I can tell you. During an interview on 8/20/2021 at 4:08 PM, the Regional Director of Plant Operations stated, We have completed testing of the alarms today and verified that the system was not alerting the fire department. We verified this with the monitoring company that the alarms we tested did not connect to the fire department. I was not aware of the extent of the malfunction and would have started fire watch immediately. All residents, staff, and visitors are at risk of injury if a fire had started, and staff did not understand that they needed to call 911 to get the fire department to respond. I was not aware that staff were doing their normal job duties and being assigned to fire watch. They should not be. During an interview on 8/20/2021 at 3:10 PM, the Director of Nursing (DON) stated, I was not aware of any problems with the fire alarm system until a few days ago. We did not provide any training related to the fire alarms before a few days ago. It is conceivable that residents were at risk since the fire alarm system was broken. I was trained on the fire watch process and the training involved the policy. We should not have staff doing anything more than fire watch if that is what our policy says, so it is conceivable that residents are still at risk of harm. We should have known the seriousness of this before the survey started. I do not recall ever hearing that the fire pulls did not work and would not get the fire department. In an emergency staff would pull the fire alarm and start RACE [Rescue, Alarm, Confine, Extinguish] and PASS [Pull, Aim, Squeeze, Sweep] procedures. I'm not sure if they would have called 911. I would hope so, but in an emergency of a fire, I just can't say. This was not brought up in QAPI. Review of the policy titled Abuse Protection and Response Policy, undated, last reviewed on 12/28/20, reads, The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Policy: Trends of investigative findings will be analyzed and addressed by the QA (Quality Assurance) and Risk Management committee process. Review of the policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, dated July 2016, last reviewed 12/28/20 reads Policy Statement. This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program. Policy Interpretation and Implementation. 1. The Administrator shall delegate the necessary authority for the QAPI committee to establish, maintain and oversee the QAPI program. 2. The committee shall be a standing committee of the facility and shall report to the Administrator and Governing board (body). Goals of the Committee. The primary goals of the QAPI Committee are to: 1. Establish, maintain, and oversee facility systems and processes to support the delivery of quality of care and services. 2. Promote the consistent use of facility systems and processes during provision of care and services. 3. Help identify actual or potential negative outcomes relative to resident care and resolve them appropriately. 4. Support the root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems. 5. Help departments, consultants and ancillary services implement systems to correct potential and actual issues of quality of care. 6. Coordinate the development, implementation, monitoring and evaluation of performance improvement projects to achieve specific goals. 7. Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services and between facility staff, residents, and family members. Committee Authority: 8. The QAPI committee advises the Administrator and owner and/or governing/board (body). Committee meetings. 1. The committee will meet monthly at an appointed time. 2. Special meetings may be called by the coordinator as needed to address issues that cannot be held until the next regularly scheduled meeting. Committee Audit Process. 2. The QAPI committee shall help various departments/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow up. 3. The committee shall track the progress of any active plans of correction.

Based on interview and record review, the facility failed to notify the resident before transfer or discharge and the reasons for the move in writing, with at least 30 days' notice before the resident is transferred or discharged and accurately complete the notice for 1 of 3 residents reviewed. (Resident #1) The facility refused the resident readmission therefore never giving the resident any notice nor appeal rights to an immediate discharge which did not meet criteria for discharge (cross reference F626). Findings: A record review of Resident #1 revealed a Nursing Home Transfer and Discharge Notice on 2/14/19 with an effective date of 2/14/19. The reason for discharge or transfer was blank. A brief explanation on the bottom of the form reads Baker Act. Resident #1 did not receive a 30-day written notice. Resident #1 was not accepted back to the facility. An interview was conducted with Resident #1 on 7/11/19 at 11:17 AM. She stated she never received any notice about her discharge. She stated her emergency contact listed at the facility did not get one either. An interview was conducted with the Administrator on 7/11/19 at 11:33 AM. At the time Resident #1 left, return was anticipated. It was not until we read hospital paperwork that we decided not to accept her back. A review of the facility policy titled Transfer or Discharge Notice (not dated) reads Our facility shall provide a resident and/or the resident's representative with a thirty (30) day written notice of an impending transfer or discharge. It further reads 3. The resident and/or representative will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer or discharge; and 4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on record review and interview, the facility failed to allow a resident to return home to the nursing facility where she resided since 10/13/17 following hospitalization for 1 of 3 residents reviewed. The resident remained in the hospital on the main floor for 43 days. (Resident #1) Findings: Resident #1 lived at the nursing facility since 10/13/17. A record review reveals the resident has [DIAGNOSES REDACTED]. A record review of the facility progress notes revealed that on 2/14/19 Resident #1 read, she wants to tie a sheet around her neck and die, resident is tearful and continues to state she wants to end it all, send resident to Shand's (Hospital) ER (emergency room ) for evaluation. Record Review of the Report of Law Enforcement Officer Initiating Involuntary Examination completed by Gainesville Police Department revealed that on 2/14/19 at 5:52 PM the resident refused voluntary examination and there is substantial likelihood that without care or treatment the resident could cause serious bodily injury to self. The resident suffers from depression due to headaches brought on by her [MEDICAL CONDITION]. She further has issues with the anniversary of the death of her daughter, which is today. She stated that she was suffering from headaches today and told nurses at the facility that she would get a sheet and tie it around her neck. According to both witnesses, the resident is distraught when this occurred, actively crying and in hysterics. Resident #1 was transported to Shand's Hospital emergency room under a Baker Act (BA). Record Review of the Psychiatry Service Consult at Shand's hospital on [DATE] at 6:38 PM revealed Resident #1 was endorsing signs and symptoms of depression with [MEDICAL CONDITION] (SI) and anxiety. Psychiatric Diagnosis: [REDACTED]. Safety Assessment: Resident does meet BA criteria, endorses SI. Record Review of the Hospitalist Note at Shand's hospital on [DATE] at 4:59 AM revealed an assessment and plan for Resident #1 that included: abnormal urinalysis that indicated further work up; [MEDICAL CONDITION], further workup indication; acute [MEDICAL CONDITION], further workup indicated; major [MEDICAL CONDITION] (MDD) uncontrolled, maintain BA, psychiatry on board; and admit to inpatient medical/surgical. Psychiatry was consulted and recommended continuation of BA and plan for discharge to psych receiving facility. Record Review of the Approval for Release of Person on Involuntary Status From a Receiving Facility dated 2/15/19 at 11:33 AM revealed the release of the BA for Resident #1. The release reads I have determined that she does not meet the criteria for involuntary inpatient placement pursuant to 394.467 based upon one or more of the following reasons: Is not likely to suffer from neglect posing a real and present threat of substantial harm nor I there substantial likelihood that in the near future she will inflict serious bodily harm to self or others as evidence by recent behavior causing, attempting or threatening harm. There are less restrictive treatment alternative available offering an opportunity for improvement of her condition. Specify: outpatient mental health follow up. And I have further determined that she does not meet the criteria for involuntary outpatient placement pursuant to 394.4655 based upon one or more of the following reasons: There are available less restrictive treatment alternatives offering an opportunity for improvement of her condition. Observations upon which this determination was made are: Patient was cooperative and calm. TP linear and coherent, no current delusional ideas or hallucinations. She reports she was looking for relief for severe headache but has no wish or intent to kill self. admitted sadness sec. to daughter's death anniversary, denied ongoing depression. No HI Future oriented, motivated to treatment. Denies access to firearms. Record Review of the Psychiatry Service for Baker Act Re-Evaluation at Shand's hospital on [DATE] at 2:32 PM revealed Upon my examination, patient is at no imminent danger to self or others, does not endorse wishes or intent to hurt self or others. History of depression, also likely anxiety disorder, associated to trauma history. Safety Assessment: No criteria for Baker act. Baker act released. I have released her Baker act, as she does not meet criteria for involuntary commitment. Baker act release form was filed and left with her ED chart. Record Review of the Infectious Disease consult dated 2/18/19 at 1:30 PM revealed the resident has a [DIAGNOSES REDACTED]. History of VRE ([MEDICATION NAME]-resistant [MEDICATION NAME] (bacteria resistant to antibiotic [MEDICATION NAME]). Recommendations: I do not think that she has a UTI at this time. I recommend further evaluation for interstitial [MEDICATION NAME] / bladder pai[DIAGNOSES REDACTED] by urology. Record Review of the Psychiatry consult for Baker Act Re-evaluation dated 2/18/19 at 4:35 PM revealed Thought Process: coherent and linear; Thought Content: denies any psychotic process (including paranoia, hallucinations or delusion), SI or HI (homicidal ideations); Response to treatment: Upon my examination, patient is at no imminent danger to self or others, does not endorse wishes or intent to hurt self or others. History of depression, also likely anxiety disorder, associated to trauma history Patient denied depressed mood, no signs of [MEDICAL CONDITION] on exam no SI/HI. Safety assessment: No criteria for Baker Act, Baker act released on 2/15/19. I have released her Baker act, as she does not meet criteria for involuntary commitment. Baker act release form was filed and left with her ED chart. Record review of Progress Notes from Case Management at Shand's Hospital dated 2/18/19 at 5:46 PM reads Parklands report they cannot accept patient to return due to the documentation not clearly reporting the BA to be rescinded at this time. Parklands assured the BA had been rescinded and that further supporting documentations could be provided. Parklands continued to refuse to accept patient for return. Record review of Progress Notes from Case Management at Shand's Hospital dated 2/19/19 at 5:00 PM revealed Parklands who requested clarification on reason for a sitter and isolation. Parklands was notified that the sitter was added due to patients request to return to Parklands and go for walks paired with being a fall risk on isolation. Isolation was started on admission due to a urine VRE positive result 1/28/19 prior to this admission. Parklands updated on these concerns. Waiting on response from Parklands. Record review of Progress Notes from Case Management at Shand's Hospital dated 2/25/19 at 4:29 PM revealed Received update during AM rounds that he covering attending attempted to contact Parklands Medical Director unsuccessfully and requested a direct contact number. Contact number provided to the covering attending who reported contacted the medical director who declined the patient. An interview was conducted with the Administrator on 7/11/19 at 11:33 AM who confirmed at the time the resident left, return was anticipated. It was not until we read hospital paperwork that we decided not to accept her back. An interview was conducted with Resident #1 on 7/11/19 at 11:15 AM. She stated said she had been in the hospital a long time. She does not know why she could not go back home. She stated she never received any notice about her discharge. She stated her emergency contact did not get one either. She stated she does not want to go back to Parklands if the liars are still there. An interview was conducted with the Assistant Director of Nursing Services (ADON) on 7/11/19 at 12:27 PM. The ADON stated the staff is not trained to take care of residents with Major [MEDICAL CONDITION] with [MEDICAL CONDITION]. We do not train our staff on behaviors specific to that diagnosis. An interview was conducted with the Administrator on 7/11/19 at 12:27 PM. He stated that even after receiving Psychiatry exam from Shand's dated 2/19/19, we still felt she was a risk. He felt the resident had the ability and functionality to hang herself with the sheet. He confirmed the facility still would not allow her to return. An interview was conducted with the Director of Case Management at Shand's hospital on [DATE] at 4:16 PM. She confirmed Resident #1 was a patient at Shand's from 2/14/19 to 3/28/19. While at Shand's the resident resided on the main hospital floor. She stated the resident was BA by the facility (Parkland Care Center) to the emergency room of Shand's. The resident was diagnosed with [REDACTED]. The BA was rescinded. She was not in a psych unit while at Shand's. It was hard to find placement for the resident because she was long term care and it is hard to get long term care beds in the area. She stated she called the facility several times to place the resident and sent all information the facility requested. The facility stated they could not meet her needs.

Based on observation, record review, and interview, the facility failed to to provide care and services necessary to avoid physical harm for 1 of 40 sampled residents (resident #25) who exhibited physically aggressive behaviors (kicking) and was known to be at increased risk for fractures. Resident #25 sustained a fracture to his left femur requiring transport to the hospital and surgical repair. Findings: Observation of resident #25 on 4/10/13 at 9:53 AM revealed resident #25 lying in his bed holding his left leg. The resident's 1/4 side rails were raised on each side of the head of the resident's bed. The resident was tearful as Licensed Practical Nurse (LPN) #11 and the Assistant Director of Nursing (ADON) attempted to assess him. Resident #25 yelled at the surveyor to get out of his room. Interview was conducted with Certified Nursing Assistant (CNA) #10 at approximately 9:56 AM on 4/10/13 in the facility's East Hallway. CNA #10 stated he had entered resident #25's room to provide care. The CNA stated he took the resident's " bag of goodies " (bag of tobacco) and placed it on the resident's night stand. At that time, resident #25 began kicking at him while he was attempting to dress the resident. The resident kicked the bed side rail during the episode and was now complaining of pain. The CNA stated he was stepping back from the bed to avoid being kicked when the resident kicked the right bed rail and he heard something pop. The CNA added that the resident is able to assist him with dressing "usually", but has never struck out at the CNA before. CNA #10 also reported he came out of the resident's room and requested assistance from the resident's nurse (LPN #11) and to inform her of the incident. During interview with resident #25 at 10:12 AM on 4/10/13, after being asked what happened to him, the resident yelled: " he grabbed my leg and twisted it, if I'd of had a gun I would have shot him, I don't know why he did it." The resident was observed to be crying, lying on his right side, with both legs pulled up to his chest, and grabbing his left leg. Further interview with CNA #10 and the administrator in the conference room on 4/10/13 at 11:15 AM revealed, during the incident earlier that morning, CNA#10 told resident #25 to stop kicking and the resident accidentally kicked the side rail. CNA #10 stated he did not touch the resident after the resident started kicking and left the room to get assistance from the resident's nurse. CNA #10 denied touching the resident at all. On 04/10/2013 at 12:02 PM, interview with resident #52, the roommate of resident #25, revealed that he witnessed the incident involving CNA #10 and resident #25 which occurred that morning (04/10/13). He stated that CNA #10 was trying to get resident #25 up. CNA #10 took resident #25's tobacco which is when resident #2 started yelling and cussing. Resident #52 explained that he observed CNA#10 catch resident #27's leg when the resident tried to kick the CNA. Resident #52 repeated that he saw CNA #10 holding resident #25's leg. CNA #10 quickly let go of the leg and resident #27 started to yell. Resident #52 explained that it appeared that CNA #10 was only trying to block or prevent resident #25 from continuing to kick. He stated that the nurse came in to check on the resident and resident #27 told her to get out. He stated that resident #25 kept repeating that CNA #10 twisted his leg. He indicated that the resident said this about 10 times. Resident #52 added that resident #25 was always mad, but had never tried to kick anyone prior to this incident. Resident #52 explained that staff usually just leaves resident #25 alone when he begins to cuss and yell. Record review revealed resident #25 has [DIAGNOSES REDACTED]. Further review of resident #25's record revealed two nursing notes regarding the incident on 4/10/13. The nurses note from the East Wing ADON dated 4/10/13 documents that CNA #10 reported resident #25 was kicking at him. CNA #10 reported the resident hit his left knee on the siderail and is in pain. The East Wing ADON added resident #25 was lying in bed holding his left knee crying and stated repeatedly: "it hurt, it hurt, he pulled it." The resident was transported to the hospital due to the injury to his leg. The second nurses note dated 4/10/13 revealed "nurse called into resident's (#25) room and the resident was screaming 'he twisted my leg, he didn't have to do that.' " The nurse added the resident stated his leg hurt too much to move it to assess range of motion, as needed (PRN) pain medication was administered and resident #25 was sent to the hospital for evaluation." Review of the Monthly summary dated 3/11/13 revealed resident is alert, oriented, but confused. Resident #25 "interferes with care" and requires total care for grooming. Review of the Care Area Assessment (CAA) dated 12/07/12 reveals that resident #25 requires extensive assistance with all Activities of Daily Living (ADLs), except eating. Interview with the Director of Nursing (DON) and East Wing ADON on 4/12/13 at 2:04 PM revealed that all staff is trained to deal with aggressive residents. The East Wing ADON stated the CNA's are trained to give the resident space and not be confrontational when residents become aggressive or resist care. Interview with Physical Therapy staff on 4/10/13 at 2:20 PM revealed that CNA #10 called her into resident #25's room at about 10 AM . She observed the resident holding his leg and that there was an "obvious deformity." She added resident #25 pointed to CNA #10 and said "it was him". She stated that when the Emergency Medical Technicians (EMTs) came in to transport resident #25 to the hospital that they indicted the injury was a closed traumatic fracture. She reported that the resident stated he was going to call "the cops" and repeated " 'that man twisted my leg'....every time someone came (sic)" Interview with the risk manager on 4/12/13 at 2:49 PM revealed that she was in the process of her investigation regarding the injury to resident #25 and it was her opinion that "something happened." She added resident #25 could not have kicked the bed rails on the bed due to the rails being at the top of the bed. When asked about the resident claiming his leg was twisted, she stated she thinks resident #25 "is sharp and if he said something happened then it did." Interview with the administrator on 4/12/13 at 3:03 PM, revealed that CNA #10 had been suspended immediately after the incident. He added he had contacted Law Enforcement (LE) about the incident, and that they (LE) stated to him (the administrator) they were unsure "where they are going" with the case. The administrator produced a copy of the hospital report which revealed resident #25 sustained a femoral [MEDICAL CONDITION] leg which required performance of a surgical procedure to repair the injury. Review of the Facility Policy entitled: Abuse, Neglect, Mistreatment of [REDACTED]." Review of the facility's policy entitled: "Training Interventions" with an effective date of July 2012 revealed training for "Interventions To Diffuse Difficult Situations Or Behaviors". The document indicates Staff should: "RESPECT PERSONAL SPACE: Stand at least 1 1/2 to 3 feet from the acting-out person. Invading personal space tends to increase the individual's anxiety and may lead to acting-out behavior." "BE AWARE OF YOUR BODY POSITION: Standing eye-to-eye and toe-to-toe with a person in your charge sends a challenging message. Standing one leg-length away and at an angle off to the side is less likely to escalate the individual. And never lean over the bedside."

Based on record review and interview, the facility failed to promptly notify the physician that 1 (#92) of 32 sampled residents had unrelieved pain. Findings: 1.) In interview with resident #92 on 10/15/12 at 2:50 pm he stated that both of his feet are swollen and the right foot hurt. He stated that he fell at home (August 2012) and his feet have been bothering him every since. He continued to say that the fingernail on the left fore finger was split and the nail would catch on his clothing and it would bring tears to his eyes. The resident stated that he has been asking to see a doctor for sometime now and the doctor has not visited him yet. Interview with the resident's assigned certified nursing assistant (C.N.A.) on 10/16/12 at 4:16 pm revealed that she told the nursing staff about the resident's complaint of right leg pain about 3 weeks ago. She stated that she asked resident #92 every day if the doctor had seen him and the resident would respond no. Interview with the nursing supervisor on 10/16/12 at 4:30 pm revealed that she had not been informed by the nursing staff of the resident's complaint of pain. At this time, the nursing supervisor entered the resident room and asked to assess his feet. When she touched the resident's right foot he hollered out in pain stating that it "hurts." Review of resident #92's chart failed to reveal any documentation that staff had informed the physician that the resident was experiencing pain in his feet prior 10/16/2012. 2.) Review of the facility ' s policy titled " Pain-Clinical Protocol " revised October 2010 and approved by the QA committee on 2/24/11 stated on page one " Assessment and Recognition: #2.) The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening pain. " Also on page one " Cause Identification: #3.) The physician will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain. " On page two " Treatment and Management: #3.) The staff will evaluate and report how much and how often the individual asks for PRN pain medication. "

Based on observations, interview, record review, and review of facility policies, the facility failed to ensure that a comprehensive assessment for pain and continence was conducted for 2 (#92, #166) of 32 residents in the sample. Finding: 1. In interview with resident #92 on 10/15/12 at 2:50 pm ,the resident stated that both of his feet are swollen and the right foot hurt. He said that he fell at home (August 23, 2012) and his feet have been bothering him every since. He continued to say that the fingernail on the left fore finger was split and the nail would catch on his clothing and it would bring tears to his eyes. Review of the resident's minimum (MDS) data set [DATE] revealed that pain was not assessed for the resident after his readmission to the facility on [DATE]. Interview with the resident's assigned certified nursing assistant (C.N.A.) on 10/16/12 at 4:16 pm revealed that she told the nursing staff about the resident's complaint of right leg pain about 3 weeks ago. She stated that she asked resident #92 every day if the doctor had seen him and the resident would respond no. Interview with the nursing supervisor on 10/16/12 at 4:30 pm revealed that she had not been informed by the nursing staff of the resident's complaint of pain. At this time, the nursing supervisor entered the resident room and asked to assess his feet. When she touched the resident's right foot he hollered out in pain stating that it "hurts." On 10/16/12, the facility had the resident's feet x-rayed and the [DIAGNOSES REDACTED]. The right foot [DIAGNOSES REDACTED]. On 10/18/12, the resident was seen by an orthopaedic physician and the second [DIAGNOSES REDACTED]. Review of the facility ' s policy titled " Pain-Clinical Protocol " revised October 2010 and approved by the QA committee on 2/24/11 stated on page one " Assessment and Recognition: #2.) The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening pain. " Also on page one " Cause Identification: #3.) The physician will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain. " On page two " Treatment and Management: #3.) The staff will evaluate and report how much and how often the individual asks for PRN pain medication. " 2. Review of resident #166's initial minimum data set ((MDS) dated [DATE] documented the resident as being continent of bladder. Review of the quarterly MDS dated [DATE] revealed that the resident was documented as incontinent of the bladder. During the interview with the MDS coordinator on 10/18/12 at 9:56 am revealed she used the documentation from the certified nursing assistant (C.N.A.) activities of daily living (ADL) log that documented the resident as continent of bladder on a daily basis for the initial MDS. However, it was not until after she interviewed the resident and husband during the quarterly review of 9/12/12 that she was informed that the resident has been incontinent for several years. Review of the nurses notes revealed that the resident was routinely incontinent of bladder.

Based on observations, interview, record review, and review of facility policies, the facility failed to ensure that 1 (#92) of 32 sampled residents received necessary care and services to alleviate pain. Finding: 1. In interview with resident #92 on 10/15/12 at 2:50 pm, the resident stated that both of his feet were swollen and the right foot hurt. He said that he fell at home (August 2012) and his feet have been bothering him ever since. He continued to say that the fingernail on the left index finger was split and the nail would catch on his clothing and it would bring tears to his eyes. The resident stated that he has been asking to see a doctor for some time, but the doctor has not visited him yet. Observations of the fingernail revealed that it was split across the entire length of the nail and part of the nail was jagged. Interview with the resident's assigned certified nursing assistant (C.N.A.) on 10/16/12 at 4:16 pm revealed that she told the nursing staff about the resident's complaint of right leg pain about 3 weeks ago. She stated that she asked resident #92 every day if the doctor had seen him and the resident would respond no. Interview with the nursing supervisor on the East Wing on 10/16/12 at 4:30 pm revealed that she had not been informed by the nursing staff of the resident's complaint of pain. The nursing supervisor entered the resident's room at this time and asked to assess his feet. When she touched the resident's right foot he hollered out in pain stating that it "hurts". On 10/16/12, the Assistant Director of Nursing (ADON) received an order from the resident's physician for an x-ray of the resident's left and right feet. Review of the clinical record revealed that the x-ray was conducted on 10/16/12 at 6:11 pm, the findings for the left foot revealed a small fragment of metallic needle near the base of the proximal phalanx of the 3rd digit that measured 8mm in length. The findings for the right foot documented an age indeterminate fracture of distal diaphysis of fifth metatarsal bone with mild displacement and angulation. A follow-up interview was conducted with the unit manager on 10/16/12 at 10:00 am. She stated that the resident did not have an order for [REDACTED]. Interview with the licensed practical nurse (LPN) on the East Wing on 10/17/12 at 3:02 pm revealed that the resident complained to her last week about pain in his feet and she wrote a communication sheet for the doctor and put it in his communication book. The LPN then walked over to the communication book, reviewed it, stated that she did not see the communication documentation. Interview with the ADON on 10/17/2012 at 3:05PM revealed that staff is to call resident #92's physician or his on call staff if the resident is experiencing any problems. Continued interview with the LPN on 10/17/12 at 3:07 pm revealed that she did not know that she was supposed to call the doctor for concerns about the resident because she is a new nurse. Review of the physician's follow up notes dated 10/18/12 revealed that the resident had a contusion of the right medial malleolus, Onchomycosis (a deep bruise to the right ankle) 2. Review of the facility ' s policy titled " Pain-Clinical Protocol " revised October 2010 and approved by the QA committee on 2/24/11 stated on page one " Assessment and Recognition: #2.) The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening pain. " Also on page one " Cause Identification: #3.) The physician will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain. " On page two " Treatment and Management: #3.) The staff will evaluate and report how much and how often the individual asks for PRN pain medication. "

Based on observation, interview, record review and review of facility policies, facility administration failed to ensure that the facility was administered in a manner to effectively utilize its' resources to promote the physical health and well-being of residents. Administration failed to identify for 1 of 32 sampled residents (#92) repeated complaints of pain that were not assessed, reported, or acted upon in a timely manner by facility nursing staff, and 1 resident (#92) who was not provided the required physician's visit within 30 days of admission. Failure of administration to ensure the implementation of facility policies for care and to identify failures of staff to assess and provide necessary care resulted in resident #92 experiencing unalleviated pain. Finding: 1. In interview with resident #92 on 10/15/12 at 2:50 pm, the resident stated that both of his feet were swollen and the right foot hurt. He said that he fell at home (August 2012) and his feet have been bothering him ever since. He continued to say that the fingernail on the left index finger was split and the nail would catch on his clothing and it would bring tears to his eyes. The resident stated that he has been asking to see a doctor for some time, but the doctor has not visited him yet. Observations of the fingernail revealed that it was split across the entire length of the nail and part of the nail was jagged. Interview with the resident's assigned certified nursing assistant (C.N.A.) on 10/16/12 at 4:16 pm revealed that she told the nursing staff about the resident's complaint of right leg pain about 3 weeks ago. She stated that she asked resident #92 every day if the doctor had seen him and the resident would respond no. Interview with the nursing supervisor on the East Wing on 10/16/12 at 4:30 pm revealed that she had not been informed by the nursing staff of the resident's complaint of pain. The nursing supervisor entered the resident's room at this time and asked to assess his feet. When she touched the resident's right foot he hollered out in pain stating that it "hurts". On 10/16/12, the Assistant Director of Nursing (ADON) received an order from the resident's physician for an x-ray of the resident's left and right feet. Review of the clinical record revealed that the x-ray was conducted on 10/16/12 at 6:11 pm, the findings for the left foot revealed a small fragment of metallic needle near the base of the proximal phalanx of the 3rd digit that measured 8mm in length. The findings for the right foot documented an age indeterminate fracture of distal diaphysis of fifth metatarsal bone with mild displacement and angulation. A follow-up interview was conducted with the unit manager on 10/16/12 at 10:00 am. She stated that the resident did not have an order for [REDACTED]. Interview with the licensed practical nurse (LPN) on the East Wing on 10/17/12 at 3:02 pm revealed that the resident complained to her last week about pain in his feet and she wrote a communication sheet for the doctor and put it in his communication book. The LPN then walked over to the communication book, reviewed it, stated that she did not see the communication documentation. Interview with the ADON on 10/17/2012 at 3:05PM revealed that staff is to call resident #92's physician or his on call staff if the resident is experiencing any problems. Continued interview with the LPN on 10/17/12 at 3:07 pm revealed that she did not know that she was supposed to call the doctor for concerns about the resident because she is a new nurse. Review of the physician's follow up notes dated 10/18/12 revealed that the resident had a contusion of the right medial malleolus, Onchomycosis (a deep bruise to the right ankle) Continued review of the resident's clinical record revealed that the physician's assistant (PA) visited the resident on 8/26/12, four days after the resident's admission to the facility on [DATE]. However, the physician did not visit resident #92 until 10/18/12. 2. Review of the facility ' s policy titled " Pain-Clinical Protocol " revised October 2010 and approved by the QA committee on 2/24/11 stated on page one " Assessment and Recognition: #2.) The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening pain. " Also on page one " Cause Identification: #3.) The physician will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain. " On page two " Treatment and Management: #3.) The staff will evaluate and report how much and how often the individual asks for PRN pain medication. " 3.) Interview with the Medical Director on 10/18/12 at 2:30 PM revealed that he is responsible for the approval of resident care policies and the staff education program. He stated that he is the physician for Resident #92. He stated that the Director of Nursing (DON) and the Administrator are responsible for notifying him if physicians do not visit their residents in a timely manner. He stated that he is responsible for speaking to those physicians who do not visit their residents in a timely manner. 4.) Interview with the DON, who is also the Risk Manager (RM), on 10/18/12 at 10:00 AM revealed that she has educated the staff concerning assessing the residents for pain. 5.) Interview with the administrator on 10/18/12 at 5:30 PM, revealed that she has became the administrator of the facility one month ago. Since that time, she stated she has hired new staff and that they are training staff to ensure that the residents receive quality of care.

Based on observation, interview, record review and review of facility policies, the medical director failed to ensure the coordination of medical care in the facility to promote the physical, mental and psychosocial well-being of 1 of 32 sampled residents (#92) by failing to ensure staff identified, reported, and acted upon a resident's complaints of pain in a timely manner, and that 1 resident (#92) was provided the required physician's visit within 30 days of admission. Failure of the medical director to ensure facility policies for care were implemented resulted in resident #92 experiencing unalleviated pain. Finding: 1. In interview with resident #92 on 10/15/12 at 2:50 pm, the resident stated that both of his feet were swollen and the right foot hurt. He said that he fell at home (August 2012) and his feet have been bothering him ever since. He continued to say that the fingernail on the left index finger was split and the nail would catch on his clothing and it would bring tears to his eyes. The resident stated that he has been asking to see a doctor for some time, but the doctor has not visited him yet. Observations of the fingernail revealed that it was split across the entire length of the nail and part of the nail was jagged. Interview with the resident's assigned certified nursing assistant (C.N.A.) on 10/16/12 at 4:16 pm revealed that she told the nursing staff about the resident's complaint of right leg pain about 3 weeks ago. She stated that she asked resident #92 every day if the doctor had seen him and the resident would respond no. Interview with the nursing supervisor on the East Wing on 10/16/12 at 4:30 pm revealed that she had not been informed by the nursing staff of the resident's complaint of pain. The nursing supervisor entered the resident's room at this time and asked to assess his feet. When she touched the resident's right foot he hollered out in pain stating that it "hurts". On 10/16/12, the Assistant Director of Nursing (ADON) received an order from the resident's physician for an x-ray of the resident's left and right feet. Review of the clinical record revealed that the x-ray was conducted on 10/16/12 at 6:11 pm, the findings for the left foot revealed a small fragment of metallic needle near the base of the proximal phalanx of the 3rd digit that measured 8mm in length. The findings for the right foot documented an age indeterminate fracture of distal diaphysis of fifth metatarsal bone with mild displacement and angulation. A follow-up interview was conducted with the unit manager on 10/16/12 at 10:00 am. She stated that the resident did not have an order for [REDACTED]. Interview with the licensed practical nurse (LPN) on the East Wing on 10/17/12 at 3:02 pm revealed that the resident complained to her last week about pain in his feet and she wrote a communication sheet for the doctor and put it in his communication book. The LPN then walked over to the communication book, reviewed it, stated that she did not see the communication documentation. Interview with the ADON on 10/17/2012 at 3:05PM revealed that staff is to call resident #92's physician or his on call staff if the resident is experiencing any problems. Continued interview with the LPN on 10/17/12 at 3:07 pm revealed that she did not know that she was supposed to call the doctor for concerns about the resident because she is a new nurse. Review of the physician's follow up notes dated 10/18/12 revealed that the resident had a contusion of the right medial malleolus, Onchomycosis (a deep bruise to the right ankle) Continued review of the resident's clinical record revealed that the physician's assistant (PA) visited the resident on 8/26/12, four days after the resident's admission to the facility on [DATE]. However, the physician did not visit resident #92 until 10/18/12. 2. Review of the facility ' s policy titled " Pain-Clinical Protocol " revised October 2010 and approved by the QA committee on 2/24/11 stated on page one " Assessment and Recognition: #2.) The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening pain. " Also on page one " Cause Identification: #3.) The physician will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain. " On page two " Treatment and Management: #3.) The staff will evaluate and report how much and how often the individual asks for PRN pain medication. " 3.) Interview with the Medical Director on 10/18/12 at 2:30 PM revealed that he is responsible for the approval of resident care policies and the staff education program. He stated that he is the physician for Resident #92. He stated that his PA (physician's assistant) examined Resident #92 on 10/17/12 after notification by facility staff of the resident's complaints of pain. He stated that he also visited the facility and examined Resident #92 on 10/18/12. He stated that resident #92 had x-rays performed on 10/15/12 and that the resident has an upcoming appointment scheduled to see a podiatrist and orthopedic surgeon. He stated that the Director of Nursing (DON) and the Administrator are responsible for notifying him if physicians do not visit their residents in a timely manner. He stated that he is responsible for speaking to those physicians who do not visit their residents in a timely manner. 4.) Interview with the DON, who is also the Risk Manager (RM), on 10/18/12 at 10:00 AM revealed that she has educated the staff concerning assessing the residents for pain.

Based on interview and record review, the facility failed to provide care and services in accordance with the plan of care by failing to consistently document and assess the condition of a resident's skin to treat the noted skin impairment and prevent the development of pressure ulcers for 1 of 4 sampled residents (#4). Resident #4 entered the facility on 01/16/2012 with an excoriated buttocks and no open areas. By 01/25/2012, a Wound Care Specialist consult identified that the resident had developed a Stage 2 pressure ulcer on both the right and left buttocks and a stage 3 pressure ulcer on his sacrum. Findings: 1. A review of the record for resident # 4 reveals he was admitted on [DATE] with [DIAGNOSES REDACTED]. 2. The Nursing Initial Care Plan for resident #4, dated 01/16/2012, identified the resident with the Problem: Self Care Deficit related to Skin Impairment Actual: sacral red buttocks excoriated. The approaches included: assess areas of actual/potential breakdown daily. 3. The Care Plan dated 01/17/2012 identified resident #4 as a total assist with Activities of Daily Living (ADLs) related to the effects of the [MEDICATION NAME] hemorrhage, [MEDICAL CONDITION], limited ROM( range of motion)/impaired mobility and incontinence of bowels which placed him at risk for pressure ulcers. The Interventions included skin assessment at least weekly and as needed/necessary (PRN). 4. Review of the Care Plan dated 01/23/2012 identified a blister on the buttocks, at risk for complications with healing. Goal: Any signs/symptoms of complications with healing will be reported to MD (doctor)upon noting, thru next review. Interventions: Assess decub size; characteristics; presence of drainage; odor; color and document at least weekly and prn. 5. Review of the Resident Data Collection on admission 01/16/2012 revealed the resident's buttocks and groin had redness with no open areas noted, and the nurses note revealed the skin was intact. 6. Review of the daily skilled nurse's note revealed the skin assessment was noted from 01/17/2012 until 01/22/2012 as WNL (within normal limits) although on 01/20/2012 a Nurse's note revealed a therapy member made the nursing staff aware of a filled blister on right area of buttocks. 7. On 01/23/2012, the Daily Skilled Nurse's note revealed the Skin was again within normal limits, but on day shift an open lesion was identified. A note by the day shift on 01/23/2012 revealed the Certified Nursing Assistant (CNA) reported the change in condition of the skin; an open area noted on bottom with no description. The note further stated the treatment nurse assessed the open area. Review of documentation for the evening and night shift on 01/23/2012 note skin was again within normal limits, but no notation of the open area was documented. An additional Nurse's Notes on 01/23/2012 at 1:30 PM revealed the resident had open blisters to right buttocks measuring 4 x 3 x 0.2 cm with a small amount of serosanguineous drainage and open blisters to the left buttocks measuring 4.3 x 2.0 x 0.2 cm. A small amount of serosanguineous drainage present. Areas noted to right and left buttocks full thickness. Deep tissue injury noted to sacrum measuring 12.5 x 11.5 x 0.2 area clustered due to open blisters around sacrum. Periwound excoriation noted. Open blisters 100 % granulated. 8. Review of the assessment written by the Wound Care Specialist (Consult) on 01/25/2012 described the wound to the right buttock as a Stage 2 pressure wound with light serous exudates. The wound size measurements were (L x W x D) 5.0 4.5 x 0.1 cm.The wound to the left buttocks was described as a Stage 2 pressure wound with moderate serous exudates associated with the wound. The wound size measurements were (L x W x D) 9.0 x 4.0 x 0.1 cm.The wound to the sacrum was described as a Stage 3 pressure wound with maceration, moderate serous exudates, and 80 % thick adherent devitalized necrotic tissue with 20% granulation tissue. 9. Review of the Daily Skilled Nurse's Notes from 01/26/2012 until 01/29/2012 either documented skin within normal limits or failed to document any skin assessment at all. 10. On 01/29/2012 at 1:45 PM, the Nurse's Notes documented wound care provided per protocol and described a wound as a 3 cm round area over the coccyx of unblanchable tissue. No further description of the wounds were provided. 11. On 01/31/2012, the Daily skilled nurse's note states the wound care was performed on the Stage II pressure ulcer. No other information was provided detailing the care provided or description of the wound. 12. On 09/07/2012 at 11:00 AM, an interview with the physician's assistant (PA) revealed he had seen the resident and verified that the condition of the resident's skin was not assessed during the history and physical conducted on 01/18/2012 or during the exam on 01/25/2012. 13. On 09/07/2012 at 11:30 AM, an interview with the registered nurse (RN) revealed she charted a weekly note of the dressing change, but does not chart an assessment on the wound.