Every finding on record at Pines Nursing Home

Based on observations, record reviews and interviews, the facility failed to ensure the medication administration error rate was below 5% as evidenced by a medication rate of 6.45 % out of 31 opportunities observed. As evidenced by staff omitted a prescribed vitamin, a wrong medication dosage and a wrong form of medication. Forty-five residents resided in the facility at the time of the survey. The findings included:Record review of the facility's policy and procedure titled, Physician Services/Orders dated: February 1, 2024, Revision date: January 2, 2026, revealed INTENT: It is the policy of the facility to ensure Physician Services are in accordance with State and Federal regulations. It is the policy of the facility to ensure that physician orders are followed accurately and timely.Record review of the facility's policy and procedure titled, Administering Medications Revised April 2019 revealed: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 6.Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Record review of the facility's policy and procedure titled, Medication Administration Error Revision date: January 2, 2026, POLICY: The facility will provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident.POLICY INTERPRETATION AND IMPLEMENTATIONIn the event of medication error occurring the nurse will notify the Director of Nursing or designee immediately for appropriate action.The DON or designee will notify the doctor of the error.The responsible party of the resident will be notified.Pharmacy consult will also be contacted regarding the error.The medication error form will be completed by DON or designee.DON or designee will conduct an investigation to find the root cause of the medication error.Appropriate action will be taken based on the nature of the error and outcome of the investigation, including re-training and education with the involved nurse.A review of medication errors will be performed during QAPI. On 06/22/2026 at 8:29 AM, Staff J, Licensed Practical Nurse (LPN), was observed administering medications to Resident #35. Staff J prepared five medications: one tablet of Memantine hydrochloride 10 milligrams (mg), one tablet of Symtuza-800-150-200-10 mg, one tablet of Ferrous Sulfate 325 mg oral tablet, one tablet of Vitamin C 500 mg, and two tablets of Haloperidol 5 mg (0.5 tablet). The surveyor noted that the Haloperidol bingo card label stated, give 1 tablet, to which Staff J responded, There is a new order. Staff J confirmed there were five pills in the medication cup, verified the resident's identity, and administered the medications. Record review and medication reconciliation revealed Resident #35 had physician orders dated 11/18/2025 for Folic Acid Tablet 1 mg directions: Give 1 tablet by mouth one time a day for Supplement and order dated 06/10/2026 for Haloperidol Tablet 5 mg directions: Give 0.5 tablet by mouth two times a day for Schizophrenia.The ordered Folic Acid 1 mg Tablet was not administered, and the incorrect dosage of Haloperidol Tablet 5 mg was given during the medication administration observation.On 06/22/2026 at 2:41 PM, Staff J, LPN, was informed of the identified concerns and asked to review Resident #35's haloperidol order in the EMAR. Staff J, LPN, acknowledged the error, noting, I misread the order and administered an incorrect dose of Haloperidol. Staff J, LPN also explained that folic acid was unavailable in the facility. On 06/23/2026 at 9:04 AM, Staff K, a Licensed Practical Nurse (LPN), was observed administering medications to Resident #11. Staff K prepared 14 medications: 1 tablet each of Apixaban 2.5 mg [Eliquis], aspirin 81 mg chewable, benztropine mesylate 2 mg, ferrous fumarate 325 mg, folic acid 1 mg, furosemide 40 mg, Metformin Hydrochloride 500 mg, Potassium Chloride ER Tablet Extended Release 20 meq(Milliequivalent), prednisone 10 mg, sertraline 25 mg, spironolactone 25 mg, aripiprazole 5 mg, divalproex sodium 500 mg Delayed Release [Depakote], and Metoprolol tartrate 25 mg Oral Tablet retrieved from the Emergency Kit double checked the 14 tablets, verified the resident's identity, explained the medications, and administered them to Resident #11. A Medication reconciliation revealed Resident #11 had physician orders dated: 05/21/2026 for Toprol XL Oral Tablet Extended-Release 24 Hour 25 mg (Metoprolol Succinate) Give 1 tablet by mouth one time a day for HTN. The ordered Toprol XL Oral Tablet Extended-Release 24 Hour 25 mg was not given during the medication administration observation. On 06/23/2026 at 3:00 PM Staff K, LPN was notified of the identified concern and asked to verify Resident # 11's Metoprolol order in the EMAR again and Staff acknowledged the incorrect form of the medication was given. During an interview on 06/23/2026 at 3:17 PM, the Consultant Pharmacist revealed the extended-release form of Metoprolol is longer acting. The Tartrate and Extended release are the same medication, but the release is different. On 06/23/2026 at 3:20 PM Staff K, LPN stated: I thought both forms of Metoprolol were the same, but when I looked it up, I realize it is two different types. The Extended Release is one time a day and the Tartrate is to given multiple times due to the release in the body. On 6/25/26 at 11:07 AM, the Director of Nursing stated: Medications are to be administered according to the physician's orders. Staff are expected to verify what is in the order and the medications and triple checked.

Based on observations, interviews and record review, the facility failed to securely store medications in one of its two medication carts (Cart A); Medication Cart A was left unattended and unlocked. This oversight raised the risk of residents accessing and consuming the medications, which could result in an overdose or serious side effects. There were forty-five residents residing in the facility during the survey.The findings included: On 06/22/2026 at 08:51 AM, an unlocked and unattended medication cart was observed in the East hallway.On 06/22/2026 at 8:52 AM, Staff F, Registered Nurse was notified about the identified concern.On 06/22/2026 at 8:55 AM, Staff F, a Registered Nurse, stated that, according to the facility's medication storage policy, staff were required to lock the medication cart whenever no one was present to watch it, in order to prevent anyone from removing medications from the cart. During an interview on June 25, 2926, at 11:07 AM, the Director of Nursing (DON) was notified of the concern. The DON stated: Staff are supposed to lock the cart when they move away from the cart so that no one can enter the cart and remove medications.Record review of the facility's policy titled, Medication Storage undated indicated: Purpose:The Purpose of this procedure is to ensure that medications are stored in a safe, secure manner.General Guidelines:Medications are stored in containers until they are ready to be used.Any medications having soiled, ineligible, incomplete, damaged, or missing labels are returned to the vendor/pharmacy.No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are to be disposed as per state guidelines.Medications are to be stored in an orderly manner in cabinets, drawers, or carts. These compartments are of sufficient size to prevent crowding.

Based on observations, interview and record review, the facility's Quality Assurance and Assessment (QAA)/QAPI) committee failed to demonstrate an effective plan of action was implemented to correct identified quality deficiencies in the problem area related to repeated deficient practice for F880-Infection Prevention and Control. There were 44 residents residing in the facility at the time of the survey.Record review of the facility's survey history revealed that, during a recertification survey conducted from April 27, 2025, through April 30, 2025, at the facility, F880 - Infection Prevention and Control was cited due to the facility's failure to dispose of used blood glucose monitoring supplies in the sharps container, failure to clean the insulin vial before extracting medications via needle syringe for one (1) resident, and failure to wear personal protective equipment during catheter care for one (1) resident.Review of the facility policy and procedure titled Quality Assurance and Performance Improvement, revision date 01/2026, states: The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to foster an environment where people are welcomed, valued, and respected. To do this, all employees will participate in ongoing QAPI efforts which support our mission by always staying true to our core values and mission of services.The Administrator is designated as the QAPI Coordinator for the facility. Every department reports issues, activities, progress, and outcomes monthly to the Performance Improvement/Risk Manager/Safety Committee. All information is discussed and collaborated on with the administrative team and staff.Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign in Sheets dated 03/26/2026, 04/30/2026, and 05/28/2026 documented that the facility held QAA Committee meetings monthly. Attendees included the Medical Director, Administrator, Director of Nursing (DON), Infection Preventionist, and all interdisciplinary team members.During an interview with the Administrator on 06/25/2026 at 5:07 PM, he stated that the QAA Committee meets every month; the last meeting was held on 05/28/2026. The QAPI committee consists of the Medical Director, Administrator, Director of Nursing (DON), Infection Preventionist, and all interdisciplinary team members. The purpose of QAPI is to identify and carry out interventions that improve residents' quality of care while ensuring their safety. QAPI is an ongoing, practical program in which multiple team members work together to analyze problems and develop solutions.

Based on observations, record reviews, and interviews, the facility staff did not adhere to infection control protocols for three of five sampled residents (Resident #52, Resident #35, and Resident #54). As evidenced by staff failed to disinfect a blood pressure cuff used between Resident #52 and Resident #35 and placed Resident # 54's urinary collection bag on the floor during wound care. These deficient practices potentially increased the risk of infection transmission. The findings included:

Based on observations, interviews and record reviews the facility failed to implement adequate pharmaceutical services to ensure accuracy in administering routine medications for two residents (Resident #35 and Resident #11) out of four reviewed for medication administration observation. Staff omitted Folic Acid vitamin and administered double the prescribed amount of Haloperidol to Resident #35. Facility staff also administered the incorrect form of Metoprolol, a blood pressure medication, to Resident #11. Forty-five residents resided in the facility at the time of the survey. The findings included: Resident #35On 06/22/2026 at 8:29 AM, Staff J, Licensed Practical Nurse (LPN), was observed during medication administration for Resident #35 . After performing hand hygiene and verifying the physicians' orders, Staff J, LPN, prepared five medications: 1 tablet of Memantine hydrochloride 10 Milligrams (mg), 1 Tablet Symtuza-800-150-200-10 mg, 1 Tablet Ferrous Sulfate 325 MG Oral Tablet, 1 Tablet Vitamin C 500 mg, and 2 tablets of Haloperidol Tablet 5 mg (0.5 tablet). The surveyor pointed out that the Haloperidol bingo card label read give 1 tablet, and Staff J, LPN, replied, There is a new order. Staff J, LPN, verified there were 5 pills in the medication cup, verified the resident's identity, and administered the pills to Resident #35 in the hallway.Record review of Resident # 35's clinical records revealed the resident was admitted on [DATE] with diagnosis that included Immunodeficiency and Schizophrenia. Record review and medication reconciliation revealed Resident #35 had physician orders dated 11/18/2025 for Folic Acid Tablet 1 MG directions: Give 1 tablet by mouth one time a day for Supplement and order dated 06/10/2026 for Haloperidol Tablet 5 MG directions: Give 0.5 tablet by mouth two times a day for Schizophrenia.The ordered Folic Acid 1 MG Tablet was not administered, and the incorrect dosage of Haloperidol Tablet 5 MG was given during the medication administration observation. Further review of Resident # 36's clinical record revealed no notes pertaining to medication error being reported to the Director of Nursing or Medical Doctor. Resident # 11Observation on 06/23/2026 at 9:04 AM of medication administration for Resident # 11 being performed by Staff K, Licensed Practical Nurse (LPN) revealed after performing hand hygiene and verifying the physicians' orders Staff K, LPN prepared 14 medications: 1 tablet of Apixaban 2.5 mg Oral Tablet [Eliquis], aspirin 81 mg. Oral Tablet chewable, benztropine mesylate 2 mg. Oral Tablet, ferrous fumarate 325 mg Oral Tablet, folic acid 1 mg, furosemide 40 mg Oral Tablet, Metformin Hydrochloride 500 mg, Potassium Chloride ER Tablet Extended Release 20 Milliequivalent, prednisone 10 mg Oral Tablet, sertraline 25 mg Oral Tablet, spironolactone 25 mg Oral Tablet, aripiprazole 5 mg Oral Tablet, divalproex sodium 500 mg Delayed Release Oral Tablet [Depakote] and Metoprolol tartrate 25 mg Oral Tablet which was retrieved from Emergency kit. Staff J, LPN verified 14 tablets. obtained permission to enter the room, verified the resident's identity, explained medications and administered tablets to Resident # 11.Record review of the clinical record revealed Resident # 11 was admitted to the facility on [DATE] with diagnosis that included: Essential Hypertension (HTN.A Medication reconciliation revealed Resident #11 had physician orders dated: 05/21/2026 for Toprol XL Oral Tablet Extended Release 24 Hour 25 mg (Metoprolol Succinate) Give 1 tablet by mouth one time a day for HTN.The ordered Toprol XL Oral Tablet Extended Release 24 Hour 25 mg was not given during the medication administration observation.Further review of Resident 11's clinical records revealed no notes pertaining to the medication error being reported to the Director of Nursing or Medical Doctor.During an interview on 06/22/2026 at 2:41 PM Staff J, LPN stated, For med pass I verify the resident by name and the verify physician orders and ensure the correct dosage by comparing the order on the EMAR (Electronic Medication Administration Records) to the label on the bingo card. The Surveyor notified Staff J, LPN about the identified concern and asked Staff J, LPN to verify order for haloperidol for Resident # 35 in the EMAR again. At that time Staff J, LPN admitted the mistake and stated: I misread the order and administered the wrong dose of Haloperidol, and the folic acid was not available in the facility.On 06/23/2026 at 3:00 PM Staff K, LPN stated, I ensure I am giving the correct medication by comparing the label to the physician order and EMAR in the computer. The Surveyor notified Staff K, LPN about the identified concern and asked Staff K, LPN to verify Resident # 11's Metoprolol order in the EMAR again and Staff admitted the incorrect form was given.During an interview on 06/23/2026 at 3:17 PM, the Consultant Pharmacist revealed the extended-release form of Metoprolol is longer acting. The Tartrate and Extended release are the same medication, but the release is different. On 06/23/2026 at 3:20 PM Staff K, LPN stated: I thought both forms of Metoprolol were the same, but when I looked it up I realize it is two different types. The Extended Release is one time a day and the Tartrate is to given multiple times due to the release in the body. On 6/25/26 at 11:07 AM, the Director of Nursing stated: Medications are to be administered according to the physician's orders. Staff are expected to verify what is in the order and the medications and triple checked.

Based on observations, record reviews and interviews, the facility failed to provide an environment free of accident hazards as evidenced by observation of a bottle of bleach left unattended and easily accessible on the housekeeping cart in the East hallway. The facility had four housekeeping carts at the time of survey. This practice had the potential to affect the forty five residents residing in the facility at the time of survey, The findings included On 06/22/2026 at 07:04 AM, a bottle of bleach was observed on the unattended housekeeping cart in the East hallway.On 06/22/2026, at 07:05 AM, Staff F, Registered Nurse (RN), was notified of the concern. Staff F, RN, stated that the bottle of bleach should not be left in the hallway, as it presents a potential risk to resident safety.On 06/25/2026, at 8:20 AM, during an interview, the Maintenance/Housekeeping Director and Staff G from Housekeeping explained that all chemicals must be securely locked inside the cart to protect the residents. This precaution is necessary because some residents wander through the facility and might accidentally ingest the chemicals. Record review of the facility's policy titled Incidents and Accidents Date Reviewed/Revised: 1/2/2020 revealed Policy: It is the policy of this facility for staff to utilize (specify risk management system/tools used) to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.

Based on observations, records reviewed and interviews it was determined that the facility did not provide proper care and treatment according to professional standards for two out of four sampled residents (Resident #54 and Resident #2). Resident #54 did not receive dressing changes as prescribed, and Resident #2-the only resident at the facility undergoing hemodialysis did not receive phosphorus-binding medications as ordered by the physician. At the time of the survey, forty-five residents lived in the facility.The findings included:Record review of the facility's policy and procedure titled, Quality of Care, General dated February 1, 2024. Revision date: January 2, 2026. Intent: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Resident # 2 On 06/24/2026 at 5:35 AM, Resident #2 was observed in a wheelchair in the hallway, having consumed 75% of breakfast. The resident had no pain complaints and appeared well-groomed. Levothyroxine was administered before the meal, as noted on the dialysis communication form. Follow up observations on 06/24/2026 at 12:39 PM, 06/25/2026 at 7:55 AM, and 06/25/2026 at 11:37 AM revealed Resident# 2 was served a meal, and no medications were administered prior to the meal.Record review of Resident # 2's clinical record revealed the resident was readmitted on [DATE] with diagnosis that included End Stage Renal Disease. Record review of Resident #2's physician order sheet revealed an order dated 04/28/2026 for Levothyroxine Sodium Oral Tablet 25 micrograms (mcg): Give 1 tablet by mouth one time a day for thyroid; Order dated 06/09/2026 for Sevelamer Carbonate Tablet 800 Milligrams (mg): Give 1 tablet by mouth before meals every Tuesday, Thursday, Saturday and Sunday for Hemodialysis (HD) Supplement and give 1 tablet by mouth two times a day every Monday, Wednesday, Friday for HD Supplement.Record review of Resident # 2's admission Minimum Data Set (MDS) reference dated 05/01/2026 revealed the resident had no cognitive impairment, received dialysis, required supervision or touching assistance for eating. Record review of the clinical record revealed a Nutrition Note dated 6/22/2026 indicated call placed to Dialysis Unit, Dietitian, not available. Spoke with Nurse. Monthly labs. received. Phos. (Phosphorous) 5.2 slightly above normal Resident aware. Sevelamer in place for phosphorous management. Phos. and K rich foods restricted in diet. Record review revealed Resident # 2 had a care plan for the potential for complications related to hemodialysis with interventions that included: Administer/monitor effectiveness of medications as ordered. Further Record review of the clinical record revealed no nutritional care plan was in place for Resident# 2. Record review of Resident # 2's Dialysis communication sheets dated: 06/24/2026, 06/04/2026, 6/08/2026, 6/10/2026, 6/10/2026, 6/12/2026, 6/13/2026, 6/15/2026, 6/17/2026, 6/22/2026, and 6/23/2026, revealed medications given prior to dialysis were Levothyroxine sodium 25 mcg. Record review of Resident # 2's Medication Administration Records for Sevelamer for 06/11/2026 to 06/25/2026 revealed Sevelamer was not given prior to meals on the prescribed days. Record review of Resident # 2's Labs dated 06/04/2026 revealed a Phosphorus level result was 5.2 compared to the normal range of 2.0- 5.0 indicating result was higher than the normal.During an interview on 06/22/2026 at 12:21 PM, Resident # 2 stated, The staff is not giving me the medications to lower my phosphorous levels on time. On 06/24/2026 at 5:58 AM, Staff H, Registered Nurse (RN) stated, Before [Resident # 2] goes to dialysis I complete vital signs, check the port, check the blood sugar, complete the paperwork for the dialysis center and make sure she had breakfast and snack. I administered Levothyroxine Sodium Oral Tablet 25 Micrograms. On 06/25/2026 at 10:55 AM, Staff B, Registered Nurse stated, I administered the Sevelamer tablet to [Resident # 2] after breakfast. It is ordered before breakfast for her kidneys. During a telephone interview on 06/25/2026 at 12:17 PM, Staff I, RN stated: The Sevelamer Carbonate Tablet 800 mg should be taken before or during meals to help decrease the resident's Phosphorus levels. If it is taken after meals, it won't decrease the levels, and the levels can be high. On 06/25/26 at 11:07 AM, during an interview, the Director of Nursing (DON) was apprised of the identified concerns. The DON stated that medications should be administered in strict accordance with physicians' orders. Resident # 54 On June 22, 2026, at 8:33 AM, Resident #54 stated that her nephrostomy tube had been removed and that staff had not been changing the dressing. An observation on 06/24/2026 at 9:52 AM revealed an undated bandage on Resident # 54's back. A follow up observation on 06/25/2026 at 1:34 PM revealed an undated bandage on Resident # 54's back.Record review of Resident #54's clinical records revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Hydronephrosis with renal and ureteral calculous obstruction, decreased white blood cell count and sepsis. Record review of a care plan initiated: 05/30/2025 revealed Resident # 54 was at risk for further skin breakdown due to Diagnosis: Impaired mobility, Incontinence) with interventions that included: Treatment as ordered. Record review of Resident #54's physician's order sheets revealed orders dated 06/19/2026 to change former left nephrostomy tube dressing daily. Cover with gauze and secure with Medi pore tape one time a day. Record review of the June 2026 treatment record revealed signatures daily for change former left nephrostomy tube dressing daily. Last signature was on 06/25/2026 at 9:00 AM. On 06/25/2026 at 10: 50 AM, Staff B, RN stated: I have not done any skin treatments today yet because I didn't have time. I signed the treatment record ahead of time because I didn't want the screen to show late. It is very hard to complete everything on time. On 06/25/2026 at 11:07 AM, the DON stated: Staff are required to follow physician orders or let the supervisor or myself know if they cannot complete a treatment. Whenever staff do a dressing, it should be dated.

Based on observations, record reviews, and interviews, it was determined that the facility did not consistently develop or implement comprehensive care plans for two out of four residents sampled. 1) The facility failed to establish a side rail care plan for Resident # 26, who utilized side rails daily; at the time of the survey, thirty-six residents were using side rails. 2) The facility did not create a nutritional care plan for Resident #2, the only resident in the facility undergoing hemodialysis and did not administer medications according to Resident #2's dialysis care plan. At the time of the survey there were forty-five residents residing in the facility. The findings included:Record review of the facility's policy and procedure titled, Care plans revised 01/02/2026 revealed INTENT: It is the policy of the facility to create Care Plans in accordance with State and Federal regulations.PROCEDURE:Each resident admitted to the nursing home facility shall have a plan of care.The plan of care must consist of:Physician's orders, diagnosis, medical history, physical exam, and rehabilitative or restorative potential.4.A complete, comprehensive, accurate, and reproducible assessment of each resident's functional capacity which is standardized in the facility and is completed within 14 days of the resident's admission to the facility, and every twelve months, thereafter.c. Revised as appropriate to assure the continued accuracy of the assessment.6.The facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.7.The care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being.Record review of the facility's policy and procedure titled, Bed Rails revised 01/02/2026 revealed POLICY: The facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.PROCEDURE:The facility will attempt to use appropriate alternatives prior to installing a side or bed rail.If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.Assess the resident for risk of entrapment from bed rails prior to installation.Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.Ensure that the bed's dimensions are appropriate for the resident's size and weight.Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.The admitting nurse will evaluate the resident for the use of bed/side rails.When bed/side rails are requested by the resident/resident representative, the admitting nurse will complete the Side Rail Evaluation.When bed/side rails are deemed to be appropriate for the resident, upon completion of the Side Rail Evaluation, the admitting nurse will review risks and benefits, obtain informed consent and obtain an order to monitor the resident while in bed with side rails are in use. Resident # 26 On 06/22/2026, at 7:43 AM, Resident #26 was observed in bed with eyes closed and both half-length side rails raised. On 06/22/2026 at 12:47 PM, Resident #26 was observed eating lunch in bed with both side rails up. His left arm appeared contracted, and he stated he could not move the side rails. Observations on 06/23/2026 at 8:48 AM, 06/24/2026 at 8:02 AM, and 06/25/2026 at 8:03 AM, revealed Resident #26 in bed with both half side rails up.Record review of Resident # 26's clinical record revealed the resident was admitted on [DATE] with diagnosis that included: Hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side and Generalized muscle weakness. Record review of Resident# 26's admission Minimum Data Set (MDS) reference dated 05/25/2026 revealed a Brief Interview of Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive impairment; the resident required partial/moderate assistance for eating, substantial/ maximal assistance for roll left and right/ sit to lying/ toileting hygiene/ shower/bathe self, and was dependent for chair/bed-to-chair transfer and always incontinent of bowel and bladder, and no restraints used. Review of Resident # 26's clinical record revealed no documented physician orders or a care plan regarding the use of side rails. During an interview on 06/252026 at 8:04 AM, Staff E, Certified Nursing Assistant (CNA) was asked how Resident # 26 used side rails. Staff E, CNA stated: I have [Resident #26] regularly and this resident uses the side rails to reposition himself in the bed. Surveyor asked Staff E, CNA to be shown the resident using the side rails.On 06/252026 at 8:07 AM, Surveyor and Staff E, CNA entered the room and Resident# 26 grabbed the side rails and repositioned himself. On 06/25/2026 at 8:29 AM, the Director of Rehabilitation stated: We recommend side rails when it is beneficial for the resident for log rolling which is moving from side to side by grabbing onto the side rails. [Resident #26] is receiving Physical, Occupational, and Speech therapy. The Doctor of physical therapy has not recommended side rails after two evaluations. During an interview on 06/25/2026 the Director of Nursing (DON) stated: The protocol for implementing side rails for a resident is to complete a side rail assessment, receive a physician's order and complete a care plan. We didn't complete a side rail assessment upon readmission, nor obtain a physician order or a care plan prior to today for [Resident # 26] side rails usage. We did not obtain a side rail consent. On 06/25/26 at 11:31 AM, the MDS Coordinator Registered Nurse stated: I complete care plans according to the physician order. A care plan was not completed for [Resident # 26] for the side rails prior to today because there was no physician's order. On 06/25/2026 at 1:54 PM Resident# 26's assigned nurse, Staff F, Registered Nurse stated, [Resident# 26] uses the side rails for repositioning due to left side muscle weakness. Resident # 2 On 06/24/2026 at 5:35 AM, Resident #2 was observed seated in a wheelchair in the hallway. The resident consumed approximately 75% of the breakfast, reported no pain, and appeared well groomed. Review of the dialysis communication form, Levothyroxine was administered prior to the meal. Follow up observations on 06/24/2026 at 12:39 PM, 06/25/2026 at 11:37 AM, and 06/25/2026 7:55 am revealed Resident# 2 was served a meal, and no medications were administered prior to the meal. Record review of Resident # 2's clinical record revealed the resident was readmitted on [DATE] with diagnosis that included End Stage Renal Disease. Review of the admission MDS reference dated 05/01/2026 indicated Resident #2 had no cognitive impairment, received dialysis and required supervision or touching assistance for eating. Review of Resident #2's physician order revealed Resident #2 had an order dated 04/28/2026 for Levothyroxine Sodium Oral Tablet 25 micrograms (mcg) Give 1 tablet by mouth one time a day for thyroid and order dated 06/09/2026 for Sevelamer Carbonate Tablet 800 milligrams (mg). Give 1 tablet by mouth before meals every Tuesday, Thursday, Saturday, Sunday for Hemodialysis (HD) Supplement and give 1 tablet by mouth two times a day every Monday, Wednesday, Friday for HD Supplement.Record review of a Nutrition Note dated 6/22/2026 revealed call place to Dialysis Unit; Dietitian not available. Spoke with nurse. Monthly labs received Phosphorous 5.2 slightly above normal. Resident aware. Sevelamer in place for Phosphorous management. Phosphorous and K rich foods restricted in diet. Review of the clinical documentation indicated that Resident #2 did not have a Nutritional Care Plan in place. Review of Resident # 2 Care Plans revealed the resident had a care plan for the potential for complications related to hemodialysis with interventions that included: Administer/monitor effectiveness of medications as ordered. Record review of Resident # 2's Dialysis communication sheets dated: 06/24/2026, 06/04/2026, 6/08/2026, 6/10/2026, 6/12/2026, 6/13/2026, 6/15/2026, 6/17/2026, 6/22/2026, and 6/23/2026, revealed meds given prior to dialysis were Levothyroxine sodium 25 mcg Resident #2's Sevelamer administration record from 06/11/2026 to 06/25/2026 shows the medication was not given before meals as prescribed. A review of Resident #2's laboratory results dated [DATE] indicated a phosphorus level of 5.2, which exceeded the normal reference range of 2.0-5.0. On 06/22/2026 at 12:21 PM, Resident # 2 stated: The staff is not giving me the medications to lower my phosphorous levels on time. On 06/24/2026 at 5:58 AM, Staff H, Registered Nurse (RN) stated, Before [Resident# 2] goes to dialysis I complete vital signs, check the port, check the blood sugar, complete the paperwork for the dialysis center and make sure she had breakfast and snack. I administered Levothyroxine Sodium Oral Tablet 25 Micrograms. During an interview on 06/24/2026 at 3:51 PM, the Registered Dietitian stated, I completed nutritional assessments for [Resident #2] upon admission. I tried to reach the dialysis Dietitian, but she was unavailable, so I spoke with the dialysis nurse to help in formulating the assessment and reviewed the labs for any recommendations. I did not complete a nutritional care plan for [Resident #2] I usually only do an assessment for dialysis residents. On 06/25/2026 at 10:55 AM, Staff B, Registered Nurse stated: I administered the Sevelamer tablet to [Resident # 2] after breakfast. It is ordered before breakfast for her kidneys.During a telephone interview conducted on 06/25/2026 at 12:17 PM, Staff I, a Registered Nurse, explained that Sevelamer Carbonate Tablet 800 MG should be administered before or during meals to effectively reduce the resident's phosphorus levels. Administration after meals may result in insufficient reduction of phosphorus levels.

Based on observations, record reviews, and interviews, the facility did not ensure privacy during blood glucose checks and medication administration for three of four residents sampled (Resident #52, Resident #35, and Resident #37), as well as on one computer screen. Staff were observed measuring Resident #52's blood glucose level with the door open and the curtain not drawn, and administering medications in the hallway to Resident #52, Resident #35, and Resident #37. At the time of the survey, there were 45 residents residing in the facility.The findings included: On 06/22/2026 medication administration observations revealed:At 7:59 AM, Staff J, Licensed Practical Nurse (LPN), was observed checking Resident # 52's blood glucose level with the door open and the curtain not drawn (photo evidence).At 8:16 AM, Staff J (LPN) administered medication to Resident #52 in the hallway.At 8:29 AM, Staff J, LPN was observed administering medications to Resident #35 while the resident was standing in the hallway.At 9:05 AM, Staff F, a Registered Nurse, gave medications to Resident #37 in the doorway, where the resident was clearly visible (photo evidence).On June 24, 2026, at 11:13 AM, an open and unattended computer screen displaying resident information was observed upon exiting the therapy office. (photo evidence). Record review of the facility's undated policy and procedure titled, Resident Rights - Personal Privacy/Confidentiality of Records revealed: It is the policy of the facility to provide the resident and or legal representative personal privacy and confidentiality of records in such a manner to acknowledge and respect resident rights.PROCEDURE: The resident has a right to personal privacy and confidentiality of his or her personal and medical records.Personal privacy includes accommodation, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident, Record review of the facility's undated policy and procedure titled, Medication Administration indicated: DIGNITY:Use privacy curtains and close doors to protect the privacy of each ResidentDo not pass meds in the dining room or hallwayRecord review of a demographic sheet revealed Resident # 52 was admitted on [DATE] with diagnosis that included: Acidosis and had a Brief interview of mental status (BIMS) score of 13, indicating no cognitive impairment. Record review of a demographic sheet revealed Resident # 35 was admitted on [DATE] with diagnosis that included: Human Immunodeficiency virus and had a BIMS score of 13, indicating no cognitive impairment.Record review of a demographic sheet revealed Resident # 37 was admitted on [DATE] with diagnosis that included: Acute Respiratory Failure with Hypoxia and had a BIMS score of 15, indicating no cognitive impairment.On 06/22/2026 at 2:34 PM Staff F, Registered Nurse stated: I provide privacy by pulling the curtain or close the door for all treatments including Accu-Chek. I realize I didn't do that for [Resident # 37]. On 06/22/2026 at 2:41 PM, Staff J, Licensed Practical Nurse stated: After pouring the medication, I provide privacy by speaking in a low tone, pulling the curtain and or closing the door. I realize I didn't provide privacy for [Resident # 52] during medication administration and checking glucose level. I also realize I administered medications in the hallway to [Resident # 35] because I was administered the medications in the hallway and did not redirect the resident to the room. On 06/25/2026 at 11:07 AM, the Director of Nursing (DON) was made aware of the identified concerns. The DON stated: The Inservice from the pharmacy instructed staff to provide privacy for residents when giving medications. All invasive procedures require privacy. On 06/24/2026 at 11:13 AM, the Administrator was notified about the unattended open computer screen and stated: The computer screen should not be left open due to resident information.

Based on observations, record reviews and interviews, the facility failed to maintain an accurate medical record for two (Resident #54 and Resident #11) out of three sampled residents as evidenced by: 1) Facility staff signed a treatment record for Resident # 54 despite not having done the treatment. 2) Facility staff signed the electronic medication administration record before administering the medications to Resident #11. The findings included:Record review of the facility's policy and procedure titled Medication Administration undated revealed Preparation: No medications are pre-poured or pre-charted.Review of the facility's policy and procedure titled, Documentation of medication Administration Date: February 1, 2024, Revision date: January 2, 2026, indicated: Policy:A medication administration record is used to document all medications administered. Policy Interpretation and Implementation:A nurse documents all medications administered to each resident on the resident's medication administration record (MAR).Administration of medication is documented immediately after it is given. Resident # 54On 06/22/2026 at 8:33 AM, Resident # 54 revealed she had a nephrostomy tube that was removed and staff haven't been changing the dressing.An observation on 06/24/2026 at 9:52 AM, revealed an undated bandage on Resident # 54's back. A follow up observation on 06/25/2026 at 1:34 PM revealed an undated bandage on Resident # 54's back.Record review of Resident # 54's clinical records revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Hydronephrosis with renal and ureteral calculous obstruction, decreased white blood cell count and sepsis.Record review of a care plan initiated 05/30/2025 revealed Resident # 54 was at risk for further skin breakdown due to Diagnosis: Impaired mobility and incontinence with interventions that included: Treatment as ordered. Record review of a physician's order sheet revealed Resident #54 had orders dated 06/19/2026 to change former left nephrostomy tube dressing daily. Cover with gauze and secure with Medi pore tape one time a day.Review the June 2026 treatment record, showed daily signatures that the former left nephrostomy tube dressing had been changed each day. The last recorded entry was signed by Staff B, Registered Nurse (RN) on 06/25/2026 at 9:00 AM.On 06/25/2026 at 10:50 AM, Staff B, RN stated: I have not done any skin treatments today yet because I didn't have time. I signed the treatment record ahead of time because I didn't want the screen to show late. It is very hard to complete everything on time.On 06/25/2026 at 11:07 AM, the Director of Nursing stated: Staff are required to follow physician orders or let the supervisor or myself know if they cannot complete a treatment. Whenever staff do a dressing, it should be dated. Resident #11On June 23, 2026, at 9:03 AM, during a medication administration observation, Staff K, LPN (Licensed Practical Nurse) prepared medications for Resident #11. At 9:40 AM, Staff K, LPN proceeded to administer these medications to Resident #11. Upon returning to the medication cart, the Electronic Medication Administration Record (EMAR) showed a green indicator meaning the medications had been administered. It was noted, however, that the EMAR recorded the medication administration time as 9:33 AM, whereas the actual observed administration occurred at 9:40 AM. Record review of the clinical record revealed Resident # 11 was admitted to the facility on [DATE] with diagnosis that included: Systemic Lupus Erythematosus and had no cognitive impairment. During an interview on 06/23/2026 at 3:00 PM, with Staff K, Licensed Practical Nurse stated: I am supposed to sign after administering medications. I signed before administering medications to [Resident #11] because I was waiting so long for the resident to get ready. During an interview on 6/25/26 at 11:07 AM, the Director of Nursing revealed staff are expected to sign after administering medications.

Based on observations record review and interview, the facility failed to safeguard and ensure privacy of residents' confidential Electronic Health Records (EHR); as evidenced by one out of two of the facility's medication carts' computer screen was left unlocked and unattended and a physical note posted on two of two medication carts revealing residents' information. There were 44 residents residing in the facility at the time of the survey. The findings include: On 04/27/25 at 08:51 AM during an observational of the facility, a note pertaining to Resident #23's allowed visitors and what steps to follow (Photo evidence) was observed posted on Medication Cart A and Medication Cart B computer screens. On 04/27/25 at 09:15 AM during medication administration observation the Electronic Medication Administration Records (EMAR) screen on the computer on Medication Cart A was left unlocked and unattended with a resident's EMAR information visible (Photo evidence). Interview on 04/27/25 at 09:45 AM Registered Nurse (Staff B) stated: Yes I forgot to lock the computer before going to administer medications to the resident, it was a mistake, I know I am supposed to lock the computer screen when I am not with the medication cart. Interview on 04/29/25 at 07:54 AM Director of nursing (DON) revealed the signs were posted on the computers regarding Resident #23 to make sure all staff, including the as needed (PRN) nursing staff were aware of visitor restrictions for Resident # 23. The signs were supposed to be flipped backwards to the empty side and not displaying residents' information. The brother's behavior is an issue, every time he visits, he refuses to leave the facility. The police had been called several times about the brother, when he takes his brother out on pass, he never brings him back to the facility on time and is very combative and unruly to staff. Review of the undated facility policy and procedure titled Resident Rights - Personal Privacy/Confidentiality of Record indicate: It the policy of the facility to provide the resident and or legal representative personal privacy and confidentiality of records in such a manner to acknowledge and respect resident rights.

Based on record review and interview, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR)for individuals with a serious mental illness (SMI), or intellectual disability or related conditions (ID)was completed accurately prior to admission and failed to revise the screenings following admission for three (Resident #13, Resident #8 and Resident#12) out of 20 sampled residents. There were 44 residents residing in the facility at the time of the survey. The findings Included: Resident #13 During observations on 04/27/25 at 08:36 AM, Resident #13 is awake in bed. On 04/28/25 at 07:39 AM Resident #13 was observed in room walking around and stated she is ok, just getting around for the day. Observation on 04/29/25 at 10:23 A; Resident #13 was her room sitting on the side of the bed, conversing with roommate and stated, today is a good day. Review of the medical records for Resident #13 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, Major Depressive Disorder recurrent unspecified. Unspecified Psychosis is not due to a substance or known physiological condition. Review of the Physician's Orders Sheet for April 2025 revealed, Resident #13 had orders that included but not limited to: Quetiapine Fumarate Oral Tablet 25 Milligram (MG) -Give one (1) tablet by mouth one time a day for Unspecified Psychosis. Escitalopram Oxalate Oral Tablet 5 MG -Give 1 tablet by mouth one time a day for Depression. Quetiapine Fumarate oral tablet 50 MG -give 1 tablet by mouth at bedtime for unspecified psychosis. Mirtazapine Oral Tablet 7.5 MG -Give 1 tablet by mouth at bedtime for Depression. Record Review of Resident #13's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASARR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check all that apply) - No diagnoses checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked - no. Does individuals have validating documentation to support dementia or related Neurocognitive disorder - no. Section III Not a provisional admission. Section IV. No diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. PASRR Level I completed by a Social Worker at the hospital on 12/11/2024. Record review of Resident # 13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is currently considered by the state level II PASRR process to have a SMI or ID or a related condition-Not available. Section C for Cognitive Patterns documented Brief interview for mental status score (BIMS) of 11 on a 0-15 scale indicating the resident is cognitively moderately impaired. Section I for Active diagnosis documented Anxiety disorder, Psychosis and Depression Disorder. Section N indicated that the resident's medications include antidepressants, antipsychotics and anticonvulsant. Record review of Resident #13 's Care Plans Reference Date 03/02/2025 revealed: Resident #13 is on Psychotropic drugs related to Diagnosis of Depression, psychosis, anxiety and is at risk for drug-related adverse effects from medicine. Date Initiated: 12/13/2024 .will benefit from the therapeutic effects of medication and be monitored adverse effects daily through the next review date . Psychological consultation and follow-up as needed. Record Review of Resident #13's Psychological Consultation dated 04/21/25 documented: medications were reviewed and reconciled, the patient was alert and oriented to person and place (x 2). She denied any new or worsening psychiatric or medical symptoms, including changes in mood, emergence of psychotic features, or further cognitive decline . appeared calm and showed no signs of distress . denied suicidal ideation, homicidal ideation, or self-injurious behavior. Patient affect was appropriate to the situation, and her behavior was cooperative and pleasant throughout the session. There were no hallucinations or delusions reported. Ongoing monitoring is in place. 51065 Resident # 8 Record Review of Resident # 8's admission records revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE]. Medical Diagnosis revealed Resident #8's diagnoses included, but not limited to, anxiety disorder and Unspecified Psychosis. Review of Resident #8's Physician Order Sheet dated 02/21/2025 revealed Resident #8 is currently receiving Olanzapine Oral Tablet 5 mg (milligrams). Directions: Give 1 tablet by mouth at bedtime related to Unspecified Psychosis. Review of Resident # 8's PASRR Level I dated 09/05/023 revealed no diagnoses checked or identified under 1A. Section 1B for Serious Mental Illness (SMI), Section 2,3 (A/B) and 4 (A/B) were checked. Section II Part A & B were checked. Section IV was completed. Record Review of a Quarterly Admission Minimum Data Set (MDS) Section A (identification) dated 12/12/2024 revealed Resident #8 was not considered by the level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I revealed Resident #8 had Anxiety and Psychotic disorder . Record Review of Care Plan dated 03/12/2025 revealed Resident # 8 is at risk for possible adverse side effects of psychotropic medications. Goals: Will benefit from the therapeutic effects of medication and be monitored adverse effects daily through next review date. Interventions: Monitor for mood/behavior and record on behavior sheet. Monitor for drug-related side effects .Work with MD/Psychiatrist for possible drug reduction. 42532 Resident # 12 Observations on 04/27/2025 at 8:45 AM, Resident #12 was seated on his bed finishing his breakfast. Observation on 04/28/2025 at 10:30 AM Resident # 12 was watching television and did not answer questions asked. Record review of Resident # 12's clinical records revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include Mood Disturbance, Anxiety; Unspecified Psychosis not Due to a Substance or Known Physiological Condition and Generalized Anxiety disorder. Review of the Admissions MDS (Minimum Data Set) Section A Identification Information dated 03/16/2023 revealed the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition documented- NO Record review of PASRR Level I dated 03/14/2023 revealed identification of a Serious Mental Illness under Section 1A and Section 1B was not checked for Serious Mental Illness (SMI). Section 2, Other Indications for PASRR Screen Decision-Making, no questions were answered no indicating the resident had no behaviors. Section 4 PASRR Screen Completion revealed the resident had Serious Mental Illness and the Level II PASRR is required. Review of Physician Orders and the Medication Administration Records for April 2025 revealed Resident # 12 is receiving Quetiapine Fumarate Tablet 25 milligrams. 1 tablet by mouth at bedtime for psychosis; and monitored for Antipsychotics, Antianxiety, Sedative, Other psychoactive. Record review of Annual Minimum Data Set (MDS) Section C Cognitive Patterns dated 03/12/2025 revealed the Brief Interview for Mental Status (BIMS) summary score was 99 meaning the resident was unable to complete the interview. Review of the Annual MDS Section I Active Diagnosis dated 03/12/2025 include Anxiety Disorder, Psychotic Disorder (other than schizophrenia). Review of the Annual MDS Section N Medications dated 03/12/2025 revealed the resident was taking antipsychotic medication. The Care Plan initiated on 3/15/2023 and the next review date 6/12/2025 documented the resident is on psychotropic drugs and was at risk for drug-related adverse effects from medicine .Psych consult and follow-up as needed. Work with physician/psychiatrist for possible drug reduction. Review of Psychiatrist consultation dated 04/14/2025 revealed the resident with a history of psychosis, major depressive disorder (MDD), and generalized anxiety disorder (GAD) . receive treatment for his psychiatric conditions. Assessment: 1. Unspecified psychosis not due to a substance or known physiological condition: Quetiapine Fumarate Oral Tablet 25 mg. 2. Major depressive disorder, recurrent 3. Generalized anxiety disorder. Interview on 04/30/2025 at 1:45 PM, the Director of Nursing revealed the Social Services Director (SSD) is responsible for completing the Level I PASRR assessments; and if the SSD does not complete the assessments, then she (DON) is responsible to complete the Level I PASRR. Interview on 04/30/2025 at 1:30 PM; the Social Services Director revealed she does not have the required license to complete the PASRR assessments. Record review of the Policies and Procedures Subject PASRR Pre-Admission /Screening and Resident Review, Effective date: 01/2025 I- Purpose: Pre-Admission Screening and Resident Review (PASSR) is a federal requirement mandated by the Social Security Act. It is intended to ensure that Medicaid-certified nursing facility applicants and residents with a diagnosis of or suspicion of serious mental illness or intellectual disabilities, or related conditions are identified and admitted or allowed to remain in the nursing facility only if there is a verified need for such services. IV-Policy: The facility ensures that all residents admitted to the facility have PASRR Level I done prior to admission to facility or Level II PASRR as indicated by resident's condition and behavior. The facility ensures that PASRR Level I must reflect current condition and diagnosis or resident. Facility will follow from mandated by AHCA at any given time.

Based on observation, record review and interview, the facility failed to implement infection control procedures for two Residents (Resident 23 and Resident #34), out of 20 sampled residents. As evidenced by staff failed to dispose used Blood Glucose Monitoring supplies in the sharps container, failed to clean the insulin vial before extracting medications via needle syringe and failed to wear Personal protective equipment (PPE) during catheter care for one ( Resident # 34)out of one resident reviewed indwelling urinary catheter. There were 44 residents residing in the facility at the time of the survey. The findings Included: During a Blood Glucose Monitoring observation on 04/27/25 at 11:08 AM for Resident #34 with Staff A, Licensed Practical Nurse. Staff A prepared the supplies, entered the resident's room, identified the resident, explained treatment, washed hands, donned gloves, cleaned the residents right index finger with an alcohol pad, checked the Blood Glucose (BG), the results was 326. Staff A, cleaned the resident's right index finger again with an alcohol pad, discarded lancet, blood glucose test strips and used alcohol pads in the garbage can in the resident's room. Staff A exited room, cleaned blood glucose machine with micro kill-wipes, let dry, returned the unused supplies to the medication cart, checked resident's sliding scale orders-Eight (8) units of insulin required. Staff A extracted eight (8) units of insulin from the insulin vial using a needle syringe, Staff A did not clean the top of insulin vial with an alcohol pad before inserting the needle syringe into the vial. Interview on 04/27/25 at 11:32 AM, Staff A revealed she forgot to wipe the top of insulin vial with an alcohol pad before inserting the syringe needle into the insulin vial to withdraw the 8 units of insulin needed for administration to Resident #34 and was not sure if she was allowed to put any unused supplies taken into a resident's room back in the cart and she placed all the used supplies into her gloves and disposed it in the garbage can in the resident's room; and thought that was ok because the used supplies were wrapped in the gloves. Interview on 04/30/25 at 08:36 AM, the Director of Nursing (DON) was informed of the concerns mentioned above related to infection control procedures and care for the residents. Review of the facility policy and procedure titled Infection Control revision date 10/2019 states: The facility will develop and maintain an effective infection control program that protects residents, families, visitors and staff by preventing and controlling infections and communicable diseases as an integral part of the quality assessment performance improvement program. The infection control program will be in accordance with States and Federal Regulations. and national guidelines. The Infection Preventionist will ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection. 51065 On 04/30/2025 at 10:24 AM during Resident #23's indwelling urinary catheter care observation being performed by Licensed Practical Nurse (Staff C) The nurse performed hygiene care gathered catheter supplies and entered Resident #23's room identified the resident explained procedure and provided privacy. Staff C did not put on a gown, Staff C performed hand hygiene, perineal care and catheter care, discarded used supplies in a biohazard bag washed hands exited the resident's room and placed the bag in the biohazard bin (located outside). Review of medical records for Resident #23 revealed, the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include Paraplegia and Neurogenic Dysfunction of Bladder. Review of the Physician Orders Sheet for October 2024 revealed, Resident #23 had orders that included but were not limited to: [] indwelling catheter Care every shift. For April 2025, revealed, Resident #23 had orders that included but were not limited to: Enhanced Barrier Precautions (EBP) for risk of infection related to indwelling medical device every shift. Review of Resident #23's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Resident # 23 is cognitively intact; needs substantial or maximal assistance for toileting hygiene and care and has an indwelling catheter. Record Review of Resident #23's Care Plan reference date 04/11/2025 revealed: Resident #23 is at risk for urinary tract infections due to indwelling catheter use. Interventions included but not limited to: Change catheter, tubing, and drainage bag as ordered, catheter care daily and as needed, and monitor amount, character, color, odor of urine output, note for recurring urinary tract infections. Interview on 04/30/2025 at 11:08 AM, Staff C revealed, Resident #23's catheter care is done daily and as needed, and handwashing is the number one priority. Infection control practices we implement for a patient with a [indwelling catheter] is always following Enhanced Barrier Precautions (EBP) by using Personal Protective Equipment (PPE) and handwashing. PPE includes using gloves, gown, mask, and eye protection (if needed). PPE helps prevent infection. During an interview on 04/20/2025 at 11:30 AM Staff D, Registered Nurse Supervisor revealed: when a patient is on EBP, there would be PPE inside the patient's room and the nurse should always wear PPE when taking care of patients on EBP. Nurses will know if a patient is on EBP when they receive report at the beginning of shift and the nursing supervisor always tries to reinforce it.

Based on observations, interview and record review, the facility's Quality Assessment and Assurance (QAA)/QAPI) committee demonstrate effective plan of action were implemented to correct identified quality deficiency in problem areas related to repeated deficient practice for F880-Infection Prevention & Control. As evidenced by: F880 was cited during a Recertification survey ending 12/07/23 when the facility failed to implement infection control procedures. This repeated deficient practice has the potential to affect any of the 44 residents residing in the facility at the time of the survey. The findings included Record review of the facility's survey history revealed, during a recertification conducted on December 04, 2023, through December 07, 2023, F880- Infection Prevention & Control was cited due to the facility's failure to implement infection control procedures related to staff's not changing gloves during tracheostomy care and staff failure to adhere to proper sharps disposal related to used Blood Glucose Monitoring supplies. Review of the facility's policy and procedure titled Quality Assurance and Performance Improvement revision dated/02/25 states: These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. The facility will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 02/27/2025, 03/27/2025, and 04/24/25 documented the facility had a QAA Committee had meetings monthly. Interview on 04/30/2025 at 3:00 PM Administrator (NHA) stated the QAA Committee meets every month, the last meeting was held on 04/24/2025. The committee consists of the Medical Director, Administrator, Director of Nursing (DON), Infection Preventionist and all interdisciplinary team members. The purpose of QAPI is to meet with the IDT ( interdisciplinary team) staff to make improvements for the residents, measure results, determine what issues to be worked on and need to be corrected. Make improvements and have interventions in place to have better patient/resident outcomes.

Based on observation, interview, and record review, the facility failed to ensure the garbage disposal was clean and discarded materials were properly disposed and contained on the facility grounds. The findings included: Observation on 12/04/23 at around 09:36 AM showed the outside dumpster area was noted with a large dumpster for trash and a medium dumpster for card board. The dumpster for the cardboard was observed to be overflowing, and the lid was unable to closed. On 12/07/23 at 01:46 PM, during an interview with the Administrator, he stated that he did not see or notice the dumpster on Monday. He stated, he looked at the dumpster earlier today and saw it was not full at all. He then stated that he thinks they picked up the trash this morning. On 12/07/23 at 02:35 PM, the Administrator brought the policy and procedure document and stated, You remember I told you about the dumpster. it's pretty much empty now. You can go and verify. Review of the facility's undated policy and procedures relating to Recycling/waste disposal revealed: Intent: It is the policy of the facility to maintain a safe and sanitary environment. Procedure: 1. It is the facility policy to discard any disposable material in the proper environment. 2. Staff will attend to proper disposal of items dependent on material requirement. 4. Staff will notify proper responsible party if extra pick up is necessary. 5. If additional pick-up is necessary, the administration or designee will contact contracted company to schedule service be performed.

Based on record review and interview, the facility failed to ensure nine out of ten sampled nursing staff (Staff 1, 2, 3, 4, 5, 6, 8, 9, and 10) received the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility had no documentation that the staff received the orientation in-service training including Alzheimer's and Dementia, Abuse, Neglect, and Exploitation. The findings included: Review of the facility's staff records revealed, Staff 1 was hired on 08/14/2023; Staff 2 was hired on 10/02/2023; Staff 3 was hired on 10/23/2023; Staff 4 was hired on 08/15/2023; Staff 5 was hired on 05/14/2023; Staff 6 was hired on 05/23/2023; Staff 8 was hired on 07/14/2023; Staff was 9 hired on 06/26/2023; Staff 10 was hired on 08/15/2023. Further review of the facility's staffing records relating to new hire orientation revealed, Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, Staff 6, Staff 8, Staff 9, and Staff 10 did not receive their in-service new hire orientation. Interview on 12/06/2023 at 01:05 PM with the Director of Human Resources (HR) revealed, the staff received a verbal orientation. She stated, that the facility doesn't have a list of in-service training needed for the staff to do. The Director of HR also stated that she was new to the job and that she did not know if they needed to document the trainings the staff received during orientation. On 12/07/2023 at 2:30PM, during an interview with the Director of Nursing (DON), she stated, During orientation, they are reminded about abuse and dementia training. We verbally went over all the in-service training, but I didn't have the list for them to sign. They were made aware. I just don't have the paper to prove it. Review of the undated policy and procedures regarding staffing in-service orientation labeled, Staff Education Plan: Intent: It is the policy of the facility to provide a Staff Education Plan in accordance to State, Federal and OSHA [Occupational Safety and Health Act, regulations that is consistent with resident needs based on Comprehensive Assessments and Care Plans, as well as the Facility Assessment. Procedure: 1. This staff education plan will be reviewed at least annually by the quality assurance committee and revised as needed. 2. The facility will ensure this staff education plan includes both pre-service and annual requirements. 9. The facility will ensure that all employees who are expected to, or whose responsibilities require them to, have direct contact with residents with Alzheimer's disease or a related disorder must, in addition to being provided the information required, also have an initial training of at least 1 hour completed in the first 3 months after beginning employment. This training will include, but it is not limited to, an overview of dementia and must provide basic skills in communicating with persons with dementia. An individual who provides direct care will be considered a direct caregiver and must complete the required initial training and an additional 3 hours of training within 9 months after beginning employment. This training will include, but it is not limited to, managing problem behaviors, promoting the resident's independence in activities of daily living, and skills in working with families and caregivers. 10. The facility will ensure that Risk Management training be a part of the facilities new hire orientation.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 47) out of 23 sampled residents. Resident # 47's MDS was coded wrong for a discharge to the hospital, but the resident was discharged home. This deficiency has the potential to affect 45 residents residing in the facility at the time of survey. The findings included: Record review of the clinical records for Resident # 47 revealed the resident was admitted on [DATE], and discharge on 10/27/2023. Clinical diagnoses include, but were not limited to, Bipolar Disorder, Psychotic disorder (other than schizophrenia), Schizophrenia, Rhabdomyolysis, Muscle Weakness (Generalized), Other Abnormalities of Gait and Mobility, Weakness, Drug induced Acute Dystonia, Gastro-Esophageal Reflux Disease without Esophagitis. Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section A, Discharge status - short term, - General Hospital, Section C, Cognitive Status revealed, the resident's Brief Interview for Mental Status (BIMS) summary score was 15 out of 15 indicating the resident did not have cognitive impairment. Record review of the progress note dated 10/26/2023 revealed, the resident will be discharged home, tomorrow as per Medical Physician orders and resident's request. He has good family support. Resident appears alert and oriented to place, person and time currently. He is able to communicate coherently verbally at this time. Resident has a BIMS score of 15 at this time. Resident receives prescriptions for medications. Resident is able to walk without any assistive device at this time. Facility will provide transportation for the discharge date . Family will provide food, shelter and clothing for discharge. Social Worker called resident's wife to inform regarding the discharge. Record review of the discharge Care Plan initiated on 10/31/2023 revealed, Focus: Resident is a new admit to facility. Resident is here for short-term Rehab Therapy. Resident plans to discharge home when able with Home Health services. Goal: Resident will attend Therapy as scheduled and participate in treatment program to enable discharge home through Next Review Date (NRD). Approach: Coordinate transportation home. Encourage resident to attend therapy to regain strength. Meet with resident and family at an appropriate time to discuss discharge plans and possible need for home Health agency services. Meet with resident and family at an appropriate time to discuss discharge plans and possible need for home Health agency services. Speak to the family about equipment that may be needed in order for resident to return home safely. Interview over the phone with MDS coordinator on 12/07/23 at 01:44 PM revealed, that she has been working in the facility for a few months only. When asked what happened with the coding on Section A of the MDS she stated, I have to make a correction, I cannot explain. Review of undated Policies and Procedures for Comprehensive Assessments revealed, The Resident Assessment Instrument (RAI) consists of three basic components: The Minimum Date Set (MDS) Version 3.0, the Care area assessment (CAA) process and the resident care plan. The Utilization of the three components of the RAI yield information about a resident's functional status, strength, weakness, and preferences, offers guidance on further assessment once problems have been identified, as well as guides resident care. I. The RAI manual will be the source for instructions on how to complete each section on the MDS, CAA, and resident Care plan. II. The MDS coordinator will check the CMS web site periodically for any changes to the RAI manual. III. Social Services will complete section A, D, and Q. Section Q will only be completed by the social services department when discharge planning is involved. In all other cases, section Q will be completed by the MDS Coordinator. Submission of the MDS is the responsibility of the MDS coordinator.

Based on observation and interview, the facility failed to implement pharmacy procedures for recording daily refrigerator temperatures for the refrigerator in the Medication Storage room. There were 45 residents residing in the facility at the time of the survey. The findings included: During the Medication Storage Room observation on 12/07/23 at 7:40 AM with Licensed Practical Nurse (Staff A) the temperature log for the medication refrigerator in the medication storage room was observed to be last filled out on 12/5/23 with a recorded temperature of 37 degrees Fahrenheit (F). Interview on 12/07/23 at 07:53 AM with the Director of Nursing (DON) it was reported, the 11-7pm nurses are responsible for filling out the refrigerator temperature logs. The DON was shown the temperature log posted on the refrigerator in the medication room, the DON acknowledged the refrigerator Temperature log was not filled out since 12/5/23. The DON had Staff A to check the temperature of the refrigerator and update the log for today,12/7/23. The temperature was recorded as 38 F. Review of the undated facility's policy titled, Medication Administration states, It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with State and Federal Regulations and National guidelines when administering medications. Procedures Step 11 and 12-Refrigerators used to store medications do not include any items other than medications and temperature is monitored daily and documented.

Based on observation, record review and interview, the facility failed to follow physician's order for oxygen therapy for one (Resident #36) out of 9 residents receiving respiratory services and to obtain a physician order for oxygen therapy for one (Resident #12) out of 9 residents receiving respiratory services. The findings included: 1. Observation on 12/04/23 at 09:56 AM, Resident #36 was in bed asleep, and the resident was receiving Oxygen (02) at 4 liters per minute (lpm) via trach collar. On 12/05/23 at 09:36 AM, Resident #36 was observed in bed asleep, and the resident was receiving 02 at 4lpm via trach collar. During a Tracheostomy care observation on 12/06/23 at 07:51 AM, Licensed Practical Nurse (Staff C) gathered tracheostomy care supplies, entered Resident #26's room. The resident was in bed asleep, the head of bed was elevated, Staff C checked the resident's oxygen (02). Staff C reported, the resident's 02 was infusing at 5 liters per minute (lpm). Review of the medical records for Resident #36 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Acute Respiratory Failure and Anoxic Brain Damage. Review of the Physician's Orders Sheet for December 2023 revealed, Resident #36 had orders that included but not limited to: Oxygen at 5 Liters per minute every shift. Record review of Resident #36 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed, Section C for Cognitive Patterns documented, Brief Interview for Mental Status score was unable to be determined. Section GG for Functional Status documented, the resident is dependent for care. Section J for Health Conditions documented, shortness of breath when lying flat and sitting at rest. Section O for special procedures documented, resident received oxygen therapy, suctioning, and trach care while a resident. Record review of Resident #36 's Care Plans Reference Date 10/26/2023 revealed, Resident has a potential for alteration in respiratory function related to Tracheostomy. Interventions included but were not limited to: Oxygen as ordered, Head of bed elevated as tolerated, and monitor vital signs as needed and notify physician. 2. During observation on 12/04/23 at 09:43 AM, Resident #12 was in bed, the bed was in the lowest position, the resident was receiving oxygen (02) at 3.5 liters per minute via nasal cannula. On 12/05/23 at 09:34 AM, Resident #12 was not in the facility, the bed was observed to be stripped of linen, and facility staff stated the resident went to the hospital. Review of the medical records for Resident #12 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Adult Failure to Thrive, and Pneumonia. Resident #12 was discharged on [DATE]. Review of the Physician's Orders Sheet for December 2023 revealed, Resident #12 had no orders for oxygen therapy. Record review of Resident #12 's Admission Minimum Data Set (MDS) dated [DATE] revealed, Section C for Cognitive patterns documented Brief Interview for Mental Status Score was unable to be determined. Section GG for Functional Status documented resident is Dependent for care, has impairment on both sides of upper and lower extremities. Section K for Nutritional status documented no unknown weight loss/gain. Section O for Special Procedures documented no oxygen therapy or special treatments received while a resident in the last 14 days. Interview on 12/07/23 at 08:50 AM with the Director of Nursing (DON) it was reported, the nurses are supposed to be checking on the resident's oxygen (02) concentrators and making sure the 02 is at the prescribed rate during rounds. The nurses have to check the Electronic Medication Administration Records (EMAR) for the doctors (MD) orders and make sure the 02 is flowing at the correct rate during their rounds. DON checked the EMAR orders for Resident #12 and confirmed the resident did not have any orders for oxygen therapy. Review of the facility's policy titled Oxygen Administration with a revision date of October 2010, states the purpose of this procedure is to provide guidelines for safe oxygen administration. Step1-verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, record review and interview, the facility failed to ensure enteral feeding was administered as prescribed and enteral feeding equipment/supplies were dated, labeled and changed daily for one (Resident #12) out of 13 residents receiving enteral tube feeding. The findings included: During an observation on 12/04/23 at 09:43 AM, Resident #12 was observed in bed, the bed was in the lowest position, and the Enteral feeding (TF) was not infusing. The TF supplement in the residents room was Fiber Source and was dated 12/04/2023, the enteral feeding syringe was dated 11/29/23, and the water for tube feeding flush did not have a label and was not dated. (Photograph obtained). On 12/05/23 at 09:34 AM, the Resident was not in the facility, the residents bed was stripped of linen, and facility staff stated the resident went to the hospital. Review of the medical records for Resident #12 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Dysphagia, Oropharyngeal and Gastrostomy Status. Resident #12 was discharged on [DATE]. Review of the Physician's Orders Sheet for December 2023 revealed, Resident #12 had orders that included but were not limited to: Enteral Feed-every shift related to dysphagia, oropharyngeal phase Fiber Source @ 55ml/hr. x 22 hrs. - total volume infused in 24 hrs. is 1210ml-(off 11am/ on 1pm). Autoflush @ 25ml/hr. x 22 hrs. (off 11am/ on 1pm). Record review of Resident #12 's Admission Minimum Data Set (MDS) dated [DATE] revealed, Section C for Cognitive patterns documented Brief Interview for Mental Status Score was unable to be determined. Section GG for Functional Status documented resident is Dependent for care has impairment on both sides of upper and lower extremities. Section K for Nutritional status documented no unknown weight loss/gain. Section O for Special Procedures documented no special treatments received while a resident in the last 14 days. Review of Resident #12's weight logs revealed on 10/30/2023, the resident weighed 86 pounds; last weight recorded on 12/01/2023 the resident weighed 88 pounds. Record review of resident #12 's care plans with a reference date of 10/30/23 revealed: Feeding tube present. resident is at risk for nutrition/ hydration deficit related to medical diagnosis of: pneumonia; dehydration; Parkinson's; dementia; failure to thrive; malnutrition; underweight; dysphagia, weight: 86# Body mass index: 16.2, planned weight gain initiated. Interventions Include but not limited to: Assess my needs at least quarterly and adjust TF as needed. Assess my weight per facility policy. Check patency of my tube daily. Elevate the head of my bed as per facility policy. Flush my tube with water as ordered. Notify my MD of any significant weight changes. Provide me with nutritional supplements via Tube as ordered. Review of the discharge summary progress note for Resident # 12 dated 12/05/2023 time stamped 08:29 documented: Resident was found lying on bed this morning with respiratory distress evidenced by Respirations-28, Oxygen saturation-88%. Doctor was called and order given to send resident to the hospital by 911. Safety and comfort provided to resident. Head of bed elevated, oxygen in place. Continued monitoring maintained until 911 arrived. 08:35 Resident was transferrd to the hospital by 911 as ordered by the Doctor. Family called and notified. Interview on 12/07/23 at 08:56 AM with the Director of Nursing (DON) revealed, when asked about the tube feeding protocols at the facility she reported, the night shift nurses on the 11-7PM shift are responsible for changing the tube feeding supplies and equipment daily, they are supposed to change and date all supplies, any assigned nurse can change and date supplies if they notice something is incorrect during their rounds. The nurses have to make sure that the resident's tube feeding orders for administration are being followed as prescribed, the tube feeing can be temporarily turned off when the Certified Nursing Assistants are providing care. The DON was shown pictures of the water for tube feeding flush for the resident hanging in a clear bag on the tube feeding pole with no identifying label, date or pertinent information, an enteral syringe hanging from the tube feeding pole dated 11/29/23. The DON was informed about the date and time of the observation. Review of the undated facility's policy titled: Enteral Nutrition Care states: Enteral Nutrition will be available for residents who are unable to meet their metabolic needs via oral administration. Procedure: The nurse will review daily how the formula is being administered, monitor weight, skin condition, labs, physical symptoms, and tolerance to feeding. The nurse will visit the residents to check the pump for flow rate, assess down times, and medicine administration records for amount of feeding administered and refer any problems to the nutrition care professional.

Based on interviews, record review and observation, the facility failed to ensure safety measures were implemented to prevent elopement for one resident (Resident # 1) out of six sampled residents. Resident # 1 eloped from the facility on June 24, 2023. Staff failed to use safety measures to prevent Resident #1's elopement. This unsafe practice has the potential to affect any of the (6) residents residing in the facility that were identifed as an elopement risk. There were 42 residents residing in the facility at the time of the survey. On July 6, 2023, Immediate Jeopardy (IJ) was identified and the Administrator and Director of Nurses were informed of the IJ on 7/6/2023 at 5:05pm. It was determined the IJ had been removed on July 7, 2023 after an acceptable IJ Removal Plan was received and the IJ Removal Plan was verified. The findings included: Record review of the clinical records for Resident #1 revealed, the resident was admitted to the facility on [DATE] and discharged on [DATE] (Elopement). Clinical diagnoses included, but were not limited to, Other Seizures; Todd's Paralysis (Post epileptic); Type 2 Diabetes Mellitus with Hyperglycemia; Anemia, Unspecified; Unspecified Protein-Calorie Malnutrition; Muscle Weakness (Generalized); Other Abnormalities of Gait and Mobility; Alcohol Dependence with Alcohol-Induced Psychotic Disorder; Unspecified Essential (Primary) Hypertension; Cerebral Atherosclerosis; Unspecified Sequelae of Cerebral Infarction; Tachycardia Unspecified; Unspecified Fall, Sequelae. Record review of the Admission Minimum Data Set (MDS) Section C, Cognitive Patterns dated 06/13/2023 revealed, the resident's Brief Interview for Mental Status (BIMS) summary score was 13 out of 15, indicating the resident was cognitively intact; Section E, Behavior revealed, the resident did not exhibit behaviors; Section G, Functional Status revealed the resident needed supervision to walk; Section I, Active Diagnoses revealed, the resident's diagnoses included Anemia, Other Seizures, Type 2 Diabetes Mellitus, Cerebrovascular Accident, Non-Alzheimer's Dementia, and Psychotic Disorder. Review of the Care Plan Initiated on 06/14/2023 revealed the following, Focus: Resident was a newly admitted to the facility. The Resident was here short-term for Rehabilitation Therapy. The Resident plans to be discharged home when able with Home Health Services. Goal: The Resident will attend Therapy as scheduled and participate in the treatment program to enable discharge home through the next review date. Intervention: Coordinate transportation home. Meet with resident and family at appropriate time to discuss discharge plans and possible need for Home Health Agency services. Meet with resident and family at appropriate time to discuss discharge plans and possible need for Home Health Agency services. Review of Resident #1's Progress Notes included, but were not limited to the following: Review of the Progress Notes dated 06/24/2023 at 5:45pm revealed, Resident alert, awake, aware, oriented, but missing on facility at this time, Certified Nursing Assistant (CNA) answer last time she saw resident on the patio but cannot find him now. Physician notified. Review of the Progress Notes dated 06/24/2023 at 6:50pm revealed, Resident search in the facility have been done, resident was missing, physician notified, skilled nurse to place call to 911 police. Review of the Progress Notes dated 06/24/2023 at 7:25pm revealed, Resident awake, alert, aware, oriented, self-responsible missing facility left by self-decision. Police officer presented on facility interview skilled nurse, Certified Nursing Assistant (CNA) and staffing related, request camera access; and releases case report card with number PD230624216928. Review of the Progress Notes dated 06/24/2023 at 9:31pm revealed, Skilled nurse placed phone call to both registered contacts, about resident awake, alert, aware, oriented, self-responsible; resident out of medication pass, resident left facility silent by his own decision, skilled nurse call police, physician notified aware. Contacts did not answer phone call from nurse then a voice message was released. Review of the Progress Notes dated 06/25/2023 at 6:02am revealed, Resident alert oriented self-responsible out of medication pass left facility by his own. Interview with Staff A, a Registered Nurse (RN) on 07/05/2023 at 10:27 AM. from the 3:00 PM to 11:00 PM shift, he reported, when he arrived at 3:00 PM, he did a tour with the previous shift nurse. All residents were in their rooms, including the resident who eloped. He stated, he did a round at approximately 4:00 pm to check on all the residents. Around 5:00 pm the evening CNA, was serving dinner and asked him where the resident was. He stated, the resident was in his room. He reported, staff were looking for the resident in the area near the facility. He reported, he contacted the Director of Nursing to inform her. He stated, he called the emergency contacts listed in resident #1's face sheet and no one answered. He stated, he left messages for the contacts. He reported, the resident was ambulatory, and used to walk slowly. He stated, the resident was a good resident, and he never exhibited aggressiveness or anxiety. He stated, he called the police, and the police completed a case report. Phone Interview with Staff B, a Certified Nurse Assistant (CNA) on 7/7/23 at 2:00 PM, She stated, I work the 3:00 PM-11:00 PM shift, and Saturday I worked a double shift from 7:00 AM-3:00 PM and 3:00 PM-11:00 PM, and on Saturday's I work double all the time. That day at around 2:30 PM, I saw him in the bed with his face covered up with his sheets, and at dinner time when I was going to give him his tray, I went and I noticed he was not there, I check in the bathroom, the patio and told the nurse and we kept searching, we went outside, other rooms, the patio again and he was not there. On my shifts, every thirty minutes I check on the residents. The dinner time is 5:00 o'clock. On that day, I notified the nurse, and the nurse told me to go to the room, check the patio, and all over. I was not the usual CNA on that room, but when I was, usually I said hi and that's it and he is independent, we don't have to ask anything else. He was independent, and I placed his tray, he would open it and said thank you. Yesterday during the 3:00-11:00 PM shift, we did get an in-service, they told us that when a person is missing, the first thing to do is, you have to check to see where the patient is and notify the nurse and tell the code, the purple code. We must contact the Director of Nursing and the Administrator, and anyone above me. For the keypad they are going to install a keypad on the door, and we are going to have the code for opening and closing. Interview with the Director of Nursing on 07/07/2023 at 1:31 PM revealed, on June 24th at approximately 5:00 PM while serving dinner the Certified Nursing Assistant (CNA) identified that they could not locate the [resident # 1]. The last known location staff witnessed was the residents assigned room and the facility patio area. Staff searched for the individual throughout the facility and surrounding area. She stated, staff notified her and she notified the Administrator. She stated, all individuals (emergency contacts) on the resident #1's face sheet were called to determine if they had any information, none was found. She stated, local hospitals were called, his physician was called and stated that no medications if missed would cause him any acute problems. She stated, the local law enforcement was called; however, they stated that they would not investigate at this time since the Resident was alert and oriented to person, place, time, and situation and they gave a police case number. The nurse of the floor called emergency services and completed a report. She stated the Administrator contacted the Department of Children and Families (DCF) hotline on 06/24/2023 approximately 7:30 PM and the case was not accepted by DCF. The Agency for Healthcare Administration (AHCA) Immediate report was filed. The facility administration completed an immediate in-service education to all staff, education topics were on elopement, residents' rights, abuse/neglect, free of accidents hazards, elopement code policy, communication, and timely notification on late arrivals, call out notification immediately, and staff advocacy for residents' safety and welfare. Review of the residents medications revealed physician orders for Aspirin oral capsule 81mg (milligrams), Give 1 capsule by mouth one time a day for Moderate pain; Amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day to Treat high blood pressure; Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 1 tablet by mouth at bedtime to Treat depression, Rosuvastatin Calcium Oral Tablet 20 MG (Rosuvastatin Calcium) Give 1 tablet by mouth at bedtime to Treat high cholesterol; Metformin HCl (Hydrocholride) Oral Tablet 850 MG Give 1 tablet by mouth one time a day to Treat Type 2 diabetes; Aspirin EC (enteric coated) Tablet Delayed Release 81 mg (Aspirin) Give 1 tablet by mouth one time a day for Blood clots prevention. Multivitamin-Minerals Oral Tablet Give 1 tablet by mouth one time a day related to Anemia. Review of the Physical Therapy (PT) notes revealed, Resident #1 was receiving Physical Therapy 5 times a week for 8 weeks, starting on 6/14/2023 due to muscle weakness. The focus for the physical therapy was for therapuetic exercise, neuromuscular re-education, gait training, manual therapy, group therapy, physical therapy evaluation and therapuetic activities. The last physical therapy was on 6/23/2023. The physical therapy progress and discharge summary dated 6/24/23 documents the resident had not met his goals and the resident had received 8 visits prior to discharge. Review of the Occupational Therapy (OT) notes revealed, Resident #1 was receiving Occupational Therapy starting 6/14/2023 due to muscle weakness 5 times a week for 8 weeks. The resident was receiving therapuetic exercises, neuromuscular re-education, therapuetic activities and community/work reintegration. The occupational therapy progress and discharge summary dated 6/24/23 documents the resident had not met his goals and the resident had received 8 visits prior to discharge. Record Review of the facility's Policy and Procedures for Free of Accidents Hazards/Supervision/Devices dated 09/13/2022 revealed, Intent: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Supervision/Adequate Supervision referred to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff and the frequency of supervision needed. This determination is based on the individual residents assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. The facility's Immediate Jeopardy Removal Plan was received on July 7, 2023 and was verified as completed through interview, observation and record review. It was determined the IJ had been removed on July 7, 2023. The following information was reviewed and verified as completed: 1) All staff will be re-educated on the elopement process and residents who wander or are exit-seeking, on an ongoing basis beginning on 7/6/2023. This includes initiating the missing person policy immediately upon identifying a resident is missing, as well as initiating the elopement policy once it is confirmed that a resident is missing. Upon identifying that a resident is missing, a Code Purple will be announced immediately which will prompt the staff to take action. No one will be allowed to begin working their shift until they have received the education. The first education sessions took place on the night of July 6-7 for the 3-11pm and 11-7am shifts. Record review of in-services education: Topic: Elopement Process and Importance of rounding every 2 hours. Dated 07/06/2023 time 11:05 PM Staff from 3:00 PM to 11:00 PM-11:00 PM to 7:00 AM Record review of in-services education: Topic Elopement Policies and Importance of rounding every 2 hours. Dated 07/07/2023 Time 7:05 AM Staff from 7:00 AM to 3:00 PM shift. 2) Licensed nursing staff will be re-educated on the Elopement Risk Evaluation Form used to identify residents at risk for elopement, on an ongoing basis, beginning on 7/6/23. For those residents identified as being at risk for elopement, proper interventions will be put in place, such as a wander alert bracelet. Record review of In-services education: Topic: Elopement Risk Evaluation Assessment: Will be completed on admission, and if there is a change in elopement status. Elopement binders will be updated with photo and demographics of all residents. Wander alert bracelet will be placed immediately on all elopement residents' records and all departments will be made aware. Date: 07/07/2023 Time 8:00 AM. Review of sign-in sheet completed. 3) Elopement drills will be conducted on each shift for seven days, 7/6/23-7/12/23. The first drill was conducted at 11:05 pm on July 6th for the 3-11pm and 11-7am shifts. Date: 7-7-23 and signed by all nurses.The facility's assessment document the facility has 23 nurses to include RN's and LPN's. The documentation was reviewed as completed. 4) Current residents have been re-evaluated for being at risk for elopement, as well as care plans and the need for wander alert bracelets. Dated 7/6/2023, 3PM-11 PM Shift and 11PM-7AM shift, Employee Sign In, Time: 11:05 PM. Signed by all the staff. The documentation was reviewed as completed. 5) Elopement Risk Binders will be created and reviewed for accuracy and posted at every department and at the exit. The binders were observed as completed. 6) Ad Hoc QAPI meetings were held on 6/25/23 and 7/6/23 to discuss missing residents and the elopement process. Sign-in Sheet with date: 6/25/23 @ 12:00 noon. Discussed Missing Resident and Next Step to Take Nursing Home Administrator participated via Telephone. Sign-in Sheet with date: 7/6/23 @ 7:15 PM. Discussed IJ Citation for Elopement/Failure to Supervise/Door and measures taken to remove the IJ. Nursing Home Administrator/Risk Manager Director of Nursing Owner, participated via telephone. 7) A repair company is scheduled to install a keypad security system on the front door on 7/7/23. Work should be completed by the end of the day. Until that time, a staff member has been always posted at the front door to ensure no resident exits without authorization. Staff members assigned to guard the front door have received education on not leaving their post unless they are relieved by another employee. Staff member observed at exit door on 7/7/23. General Contractor Invoice dated 7/6/2023, Estimate #3084 Description: 4 EXTERIOR [NAME] DOORS PARTS: MAGNET DYNA- LOCK DELAY EGRESS 3101C KEYPAD 212 INTERIOR KEYPAD 212 EXTERIOR POWER SUPPLY 12VDC-5AMP Heavy Duty Door Closer Commercial MATERIALS Labor: - Install 8 new magnets lock - Install 4 new keypad - Install 4 new power supplies - Config operation Customer signature on 7/6/23 8) Facility doors will be checked daily by Maintenance staff/ Designee to ensure proper functioning. The checks were reviewed and verified as started. 9) Clinical staff (nurses and CNAs) will be re-educated on the importance of rounding at least every 2 hours. First education session took place at 11:05 pm on July 6 for the 3-11pm and 11-7am shift. Employee sign in sheet 7/6/23 of in-service titled elopement process and importance of rounding every 2 hours. 14 signatures 7/7/23 Elopement Policies and rounding every 2 hours. 25 signatures. The documentation was reviewed as completed. 10) The facility's Missing Person and Elopement Policies have been updated as of 7/6/2023 to reflect the current federal guidelines. The policy and procedure was reviewed and updated on 7/6/2023. Based on the facility's assessment date 1/18/2023, the facility has 76 staff members working at the facility. Twenty-six facility staff members were interviewed to confirm the completion of the IJ Removal Plan. This included staff from the nursing department to include, RN's, LPN's and CNA's; the therapy department OT and PT, Social Services and Maintenance staff. Staff were interviewed from the 7AM-3PM, 3PM-11PM and the 11PM-7AM shifts. Staff were interviewed about the dates they received inservice training, the information they were taught during the training, whether they participated in an elopement drill and what they were trained to do if an elopement occurs at the facility.

Based on observation, record review and interview the facility failed to implement the facility's policy to ensure adequate supervision is provided to ensure the safety of a vulnerable resident (Resident #1) out of 3 residents reviewed. As evidenced by the Nursing Home Administrator transported Resident #1 in his personal vehicle to an Assisted Living Facility (ALF). When the ALF did not accept the resident, the Administrator took the resident to a local hospital emergency department in another county approximately 16 miles from the nursing home and left the resident without discharge papers, medication, personal belonging and failed to provide the hospital with the resident's current medical status and did not provide contact information for the resident's representative Resident #1 who is wheelchair bound due to above knee amputation, suffers from anxiety, depression and is an insulin dependent diabetic was left unattended. Resident #1, after not being admitted to the hospital was on the street and called a friend who picked her up and took her back to the nursing home. This practice has the potential to negatively affect the safety and well-being of the resident. The findings included: During observation on 8/16/2022 at 7:45 AM Resident # 1 was observed during medication administration sitting in a wheelchair in her room. The resident had an above knee amputation (AKA) of left leg and was wearing right heel protector. Registered Nurse, Staff A conducted a blood glucose level check on Resident # 1, administered ordered [MEDICATION(S)] (insulin) to Resident #1' upper arm and administered [MEDICATION(S)] 5/325 milligram (mg), one tablet by mouth for pain. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Pressure Ulcer of Right Heel, Stage 4, Cutaneous Abscess of the Groin, Type 2 Diabetes Mellitus with [CONDITION(S)] and Depression. Resident #1 was discharged on [DATE] and final discharge was on 08/16/2022. Review of the Physician's Orders Sheet for August 2022 revealed Resident #1 had orders that included but not limited to: Cleanse left groin wound with normal saline. Apply collagen and bordered dressing daily. Cleanse right heel wound with normal saline, pack with normal saline moistened gauze and dry dressing daily. Medications included: [MEDICATION(S)] 2 mg (milligrams) tab (tablet) 2 mg PO (by mouth) one time a day for [CONDITION(S)], [MEDICATION(S)] 10 mg tab 10 mg PO one time a day for anti-anxiety, [MEDICATION(S)] Solution 100 unit/ml inj. (inject) 26-unit subq. (subcutaneous) one time a day for diabetes mellitus, [MEDICATION(S)] 20 mg tab 1 tab PO one time a day for [CONDITION(S)]/[CONDITION(S)], [MEDICATION(S)] HCL 50mg tab 1 tab PO every 6 hours PRN (as needed) for pain and [MEDICATION(S)] 50mg tab 1 tab PO every 24 hours PRN for [CONDITION(S)]. Review of Resident # 1's 5 Day Minimum Data Set (MDS) dated [DATE] revealed in Section C-for Cognitive Patterns, Brief Interview for Mental Status (BIMS) Score -15, indicating the resident is cognitively intact. Section G- for Functional Status for eating indicated the resident need supervision and for toileting and transfer the resident required extensive assistance. Section H for Bowel and Bladder documented that the resident is always incontinent of bowel and bladder. Section J- for Health Conditions documented no scheduled pain medication regimen received in the last 5 days and no falls. Section K- for Nutritional status documented no unknown weight loss. Section M- for Skin Conditions documented that the resident has 1 stage 4 pressure ulcer present on admission. On 8/16/22 at 7:55 AM Resident #1 reported she was leaving today to go to an ALF at 10:30 AM, and transportation is coming for her. Resident # 1 reported she was told last night, and she has all her stuff packed and ready to go. Resident #1 stated that she is not very happy with something that happened a week ago. Resident #1 stated: A week ago I was told I had a place to go at an ALF, I was transported to the ALF by the Administrator in his car, when we got to the ALF, they said they could not take me because of the wound on my foot. This came up enroute to the ALF, the Administrator was on the phone with the ALF talking with them, about taking me in there and they said no. After they refused me at the ALF, the Administrator drove me to the hospital close by the ALF [hospital name] and dropped me off at the emergency room and left me there, he still had all my belongings in his car. The emergency department said nothing was wrong with me and did not admit me, I did not have a number for the Administrator, I called my friend and told her what was going on, she called the facility and spoke with the Administrator and told him that she will be bringing me back to the facility. She brought me back and I was accepted in the facility in the same room in my same bed which I am in now. On 8/16/2022 review of the Social Worker's progress notes for Resident #1 dated 8/09/22 timestamp 16:47 documented: Resident was safely discharged today, 8/09/22. Resident was discharged to an ALF. Transportation was set for resident with Administrator. On 8/16/2022 review of the discharge summary progress notes for Resident #1 dated 8/09/22 timestamp 19:47 documented: Resident discharged around 4:30 PM to ALF. Resident took all belongings and medications with her. Interview on 8/16/22 at 1:00 PM, the Administrator stated, I was involved in bringing the resident to the Assisted Living facility (ALF) she was discharged to. While we were arriving, I was informed via telephone by the ALF that they were not accepting her, after further investigation when we got to the ALF, the ALF administrator stated that he was not accepting her, they feel that they could not take care of her wounds. The resident stayed in the car while I was talking with the ALF administrator. The information that we were sending the ALF about the Resident before the transfer they accepted but when we got there, they refused to accept the resident. At that point, it was determined that she had been discharged from our facility and there was no bed for her at the facility, after the Resident left the facility, we were waiting on two admissions that day, one of the admissions was for Resident #1's prior bed. I did not have a bed for her, so I did not bring her back to the facility, where was she going to go? It was around 7:00 PM and there was no way to find placement for her. Eventually one admission was canceled which facilitated the resident being able to come back to the building .They did not admit her they put her back on the street. She called a friend when she was on the street, this woman came and got her and called me. I know her name, in conversation with the resident's friend. I told her if she has the resident, to bring her back to the facility and I would reach them at the facility, I was not at the facility at the time. I had the resident's medication with me for transfer to the ALF, when I left her at the emergency room , I did not give her the medications, her medications included narcotics. At the time I think I put her in the right spot at the right time at that moment. The transportation company bus broke down that day and was unable to transfer [Resident #1] to the ALF that day. I have driven this resident to medical appointments before, she has been in my car before. When it was apparent that I did not have a bed for the resident, the emergency room was the best decision at the time. I asked [Resident #1] what emergency room she wanted to go to, the reason she chose the one we went to is because she stated that she was already in their system, I walked [Resident #1] into the emergency room , made sure she got registered and left. The resident was frustrated about not being accepted to the ALF where she had lived before. While we were in the car waiting at the ALF, the resident was conversing with the other residents at the facility that she knew because she lived there before. Interview on 8/16/22 at 1:31 PM with the Director of Nursing (DON) revealed, Resident #1 was accepted to an ALF. The administrator took her to the ALF, and they could not take Resident #1 because of her wounds. We were expecting admissions that day and we did not have any available beds to take the resident back, I was told by the administrator that he took the resident to the ER (emergency room ). Later I got a call from one of the nurses, an agency nurse, [Staff C]. She stated that the resident's bed was still empty, and the resident called and wanted to come back to the facility. I told [Staff C] to let the resident come back and we will deal with the situation tomorrow. The transportation broke down that was supposed to take the resident to the ALF and the administrator had taken her to appointments before in his personal car. The resident came back to the facility the same day, later that night. Review of the EHR records for Resident #1 on 9/12/22, did not show any documentation to indicate a head-to-toe assessment was completed when the resident returned to the facility on the night of 8/09/22. Review of the resident's clinical records revealed on 08/09/2022, Resident # 1 missed the following medications: [MEDICATION(S)] 2 mg tablets PO one time a day for [CONDITION(S)], [MEDICATION(S)] 10 mg tablet 10 mg PO one time a day for anti-anxiety. During a continuation of the complaint survey investigation conducted on 9/12/2022 to 9/13/2022, record review of progress notes revealed several additional late entry notes that were not in the facility's electronic medical records (EMAR) system on 8/16/2022. The late entries that were created on 09/13/2022 revealed: Discharge Summary for 8/16/2022 timestamp 10:45. There was a late entry created on 8/22/22 at 15:54 by Physician, 6 days later. Review of the Physician's Progress note for 8/9/2022 timestamp 09:30 indicated a late entry created on 9/13/2022 at 12:14 PM by facility staff. Discharge summary for 8/9/2022 timestamp 19:47 late entry created on 9/13/22 at 11:20 AM, approximately 34 days later. Late entry for 6/11/2022 time stamped 09:16 for Skin/Wound late entry created on 9/13/22 at 9:19 AM by staff D, approximately 92 days later. Late entry admission notes for 6/11/2022 time stamped 15:04 was created on 6/23/22 at 16:05 PM by the Physician. Late entry admission summary for 6/10/2022 timestamped 23:09 was also created on 09/13/2022. Review of the undated facility policy and procedures titled Free of Accidents Hazards/Supervision/Devices states: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Review of the facility's assessment on 9/12/22 revealed it did not contain any information pertaining to supervision and admission transfer discharge.

Based on observations, record reviews and interviews the facility's administration failed to implement, provide and ensure an effective and efficient preventative measures were in place to prevent the neglect of one resident (Resident #1) out of three sampled residents during the time of this survey. This deficient practice enabled the Administrator to take Resident #1 to an Assisted Living Facility (ALF) in his personal car and when the ALF refused to admit the resident, the Administrator took the resident to a local hospital's emergency department and left the resident at the hospital's emergency department. There were 41 residents residing in the facility at the time of this survey. Refer to F622, F623, F635 and F689. The findings included: Review of the facility's policy titled, Abuse, Neglect and Exploitation protocol and the revision date was on 11/2019, the policy documented: All residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion by the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. A prompt thorough investigation will be conducted by the facility immediately. The facility's Policies and Procedures did not directly address neglect. Review of the Job Description for the Nursing Home Administrator documented: The Administrator administers, directs and coordinates all functions of the facility in accordance with current Federal, state and local regulations. He/she is also responsible for maintaining a safe living environment for the residents. Review of the Job Description for the Director of Nursing documented: The Director of Nursing is responsible for planning, organizing, developing and directing the day to day functions of the nursing department in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Social Services Director documented: The Social Worker will work with residents in the nursing home by identifying their psychosocial, mental and emotional needs along with providing, developing and/or aiding in the access of services to meet those needs. The nursing home social worker is responsible for fostering a climate, policies and routines that enable residents to maximize their individuality, independence and dignity. He/she is to coordinate the resident discharge planning process and make referrals for appropriate home care services prior to the resident's return to the community. Review of the Job Description for the Admissions Director documented: The Director of Admissions is responsible to oversee and direct the coordination of all referrals and admission into the Facility. The Director of Admissions works with the administrative and admissions staff to oversee the coordination of all inquiries, admissions, correspondence and communication with customers. He/she is responsible to ensure that all admissions are correctly documented and processed including that all face sheet information and demographic information is accurate and to communicate with families to determine discharge goals or plans. Review of the Job Description for the Wound Care Nurse documented: The Wound Care Nurse is responsible and expected to assess new admissions and re-admissions residents with impaired skin-review treatment recommendations and document a comprehensive assessment of site, review or initiate a care plan, review/initiate skin assessment; maintain a comprehensive care plan for skin impairments-updating as needed to include any change in treatment, improvement and decline; weekly wound rounds with wound consultant; weekly wound measurements documented; monitoring vascular/arterial/surgical wounds and documenting appropriately and report to Director of Nursing. On 8/16/22 at 7:45 AM Resident #1 was observed and sitting in a wheelchair receiving medications in her room. The resident's left leg was amputated above the knee and the right leg was in a boot. On 8/16/22 at 7:55 AM Resident #1 was observed in the hallway. Resident #1 reported that she is leaving today to go to an ALF at 10:30 AM, transportation is coming for her. Resident # 1 revealed that she was told last night, and she has all her stuff packed and ready to go. Resident #1 stated she is not very happy with something that happened a week ago. A week ago, I was told I had a place to go at an ALF, I was transported to the ALF by the Administrator in his car, when we got to the ALF, they said they could not take me because of the wound on my foot. This came up enroute to the ALF, the administrator was on the phone with the ALF talking with them, about taking me in there and they said no. After they refused me at the ALF, the administrator drove me to the hospital close by the ALF, dropped me off at the emergency room and left me there. He still had all my belongings in his car. The emergency department said nothing was wrong with me and did not admit me, I did not have a number for the Administrator, I called my friend and told her what was going on, she called the facility and spoke with the Administrator and told him that she will be bringing me back to the facility. She brought me back and I was accepted in the facility in the same room in my same bed which I am in now. Resident #1 also stated that she is currently waiting for her long-term care Medicaid application to be approved and the social worker at the facility is taking care of it. The ALF that she is scheduled to go to cost $3000.00 a month and she cannot afford that because she will be short about 800.00 dollars each month. The nursing home told her that she can stay at the ALF until her long-term care comes through. I told the facility I am not going anywhere because I am going to get kicked out in a month. I guess I am going, I don't feel very popular here. During a follow up observation and interview on 8/16/22 at 8:20 AM, Resident #1 was observed sitting in a wheelchair in her room. The resident had just finished eating breakfast. Resident # 1 stated, On the day the Administrator took me from this nursing home, it was around 4:30 PM and I didn't eat dinner, didn't have my meds. They told me I was accepted in an ALF, and they had a bed ready to be filled. The Administrator put my belongings and me in a car and took me to the ALF. When we got there, I stayed in the car and he came back and told me, the ALF would not accept me because of the wound on my foot. He then took me to the closest hospital ED (emergency department) and left me. He said he couldn't take me back to the nursing home because my bed was now taken. He kept my discharge papers and my medications. When he left me in the crowded ED, I had no way of contacting him, so I called my friend. My friend was finally able to contact the Administrator and told him she was going to call [state agency], if he didn't take me back to the nursing home. He told her he would come back and get me, but she didn't believe or trust him, so she came and got me and brought me back here to the nursing home. I didn't receive my meds till the next morning. I haven't seen the discharge paperwork. I have not received a discharge notice. The owner found me an ALF place. I am being discharged today to the ALF at 10:30 AM. I don't think the DON (Director Of Nursing) was in on it and had anything to do with it, but the Administrator definitely was in on it. I feel like I'm being bullied to leave this place. Review of the demographic face sheet for Resident #1 documented the resident was admitted on [DATE] with clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for Resident #1 documented the resident's Brief Interview for Mental Status (BIMS) Summary Score was 15 out of 15, indicating no cognitive impairment, and the resident is able to make own decisions. The functional section of the MDS indicated the resident required extensive assistance with one person to physically assist for ADLs (Activities of Daily Living) and the resident expected to be discharged to the community and active discharge planning already occurring for the resident to return to the community. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Collagen and Bordered dressing daily, Cleanse right heel wound with normal saline, pack with normal saline moistened gauze and dry dressing daily. Medication included: [MEDICATION(S)] 2 mg (milligrams) tab (tablet) 2 mg PO (by mouth) one time a day for [CONDITION(S)], [MEDICATION(S)] 10mg tab 10 mg PO one time a day for anti-anxiety, [MEDICATION(S)] Solution 100 unit/ml inj (inject) 26 unit subq (subcutaneous) one time a day for diabetes mellitus, [MEDICATION(S)] 20 mg tab 1 tab PO one time a day for [CONDITION(S)]/[CONDITION(S)], [MEDICATION(S)] HCL 50 mg tab 1 tab PO every 6 hours PRN (as needed) for pain and [MEDICATION(S)] 50 mg tab 1 tab PO every 24 hours PRN for [CONDITION(S)]. Review of Resident's #1's care plans revealed no discharge care plan documented. A discharge care plan was later received from the Social Services/Activity Director on 8/16/22 at 2:18 PM. The care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term Rehab Therapy. Resident plans to discharge to a facility when able with home health services (no initiated date was written). Goal-Resident will attend therapy as scheduled and participate in treatment program to enable discharge home through NRD (Next Review Date). Interventions-Coordinate transportation home; Meet with resident and family at appropriate time to discuss discharge plans and possible need for home health agency services; Provide d/c (discharge) instructions. A second discharge care plan was received from the Social Services/Activity Director on 8/16/22 at 4:14 PM. This care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term rehab therapy. Resident plans to discharge to a facility when able with home health services (initiated date 6/30/22). Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #1 documented the resident was given the notice on 7/15/22 with an effective Date of 8/09/22. The location to which the resident is to be transferred or discharged was an ALF. The reason for discharge or transfer: Your health has improved sufficiently so that you no longer need the services provided by this facility. The form was not signed nor dated by the resident and the section for resident or representative name documented: Notified verbally. Review of the social worker's progress note for Resident #1 dated 8/09/22 16:47 documented: Resident was safely discharged today, 8/09/22. Resident was discharged to an ALF. Transportation was set for resident with Administrator. Review of the discharge summary progress note for Resident #1 dated 8/09/22 19:47 documented: Resident discharged around 4:30 PM to ALF. Resident took all belongings and medications with her. Interview with the Social Services/Activity Director on 8/16/22 at 10:08 AM. She stated, My responsibilities include plan with the resident upon admission, discuss with the resident their discharge plan. I complete a discharge care plan upon admission. I give the discharge notice to the resident. I give the discharge notice at least a week before they are going. For the 8/09/22 discharge, we planned everything with the facility, setup transportation. It was her choice to be discharged and she suggested the place. We couldn't find transportation that week which had issues, the Administrator transported her. As they were on the way, they said they wouldn't accept her with the wounds. We sent paperwork to the facility about the wounds, and they said they would accept her, and they knew about the wounds. On the way to the facility, they found out the facility would not accept her. I think he took her to the hospital. I don't know what happened at the hospital, but she came back here the next morning. There was a lot going on and I told her verbally. I didn't have the time to have her sign the form. Interview with the Administrator on 8/16/22 at 1:00 PM. He stated, I was only involved in bringing her to the assisted living facility. While we were arriving, we were informed that they were not accepting her. They called me and did further investigation when I got there. I spoke to the facility Administrator and was told, that they were not accepting her, and they felt they could not take care of her wound. She stayed in the car the whole time. We had been sending them information, they said they would accept her and when we got there, they changed their mind. In consultation with the resident, we determined that we had to bring her to the emergency room , we didn't have a bed here and she can't take care of herself. The facility has 45 beds, and we didn't have any beds left. We were to receive two admissions on that day and one of them would have had her bed. I didn't have a bed that's why, I didn't bring her back and she needed to go into a safe environment. This was approximately about 6:30 PM to 7:00 PM. Eventually, one admission was canceled and did not come to the facility, which facilitated the resident to come back to the facility. The emergency department streeted her, they did not take her, and they put her back in the street. She called a friend while she was on the street, the woman came and got her. Her friend called me, I told her to bring her back to the facility and I would meet her here. That's how she ended up back here. I had the medications with me to transfer to the assisted living facility. I didn't give her the medications when I left her at the emergency room because there was a narcotic involved. I think I put her in the right spot at the right moment. The transportation company van broke down that day and was unable to take her to the assisted living facility, so I took her myself. I walked her in the emergency room , and she got registered and then I left her. She was frustrated because the assisted living didn't admit her. Interview with the Director of Nursing (DON) on 8/16/22 at 1:31 PM. She stated, We all worked on her discharge plan. She accepted she would go to an ALF for discharge. The Administrator took her, and they gave him problems because she had a wound. We were expecting admissions that day. The Administrator told me he took her to the hospital, and he didn't want her roaming the streets and he didn't want her to be unsafe. A nurse that works here at the facility, called me and told me the bed was still empty. I told them to let her come back. The transportation that we have contracted with, her truck broke down, that is why the Administrator took her to the ALF. The Administrator has taken her to appointments before. She came back the same day but later that night. Review of the EHR records for Resident #1, documented no head-to-toe assessment was completed when the resident returned to the facility on the night of the incident on 8/09/22. Review of the admissions, transfer and discharges list dated June 1, 2022, to August 16, 2022, documentation did not have the resident listed as discharged on [DATE] and the resident was not listed as readmitted on [DATE] upon return to the facility. Review of the facility's policy titled Resident Discharge (Revised Date 7/2017) documented: Policy-A resident may be discharged to his/her home or another facility only with permission of the attending physician unless he/she is signing out against medical advice; Procedure-1) An order must be received from the physician to transfer or discharge a resident, 7) If the resident is discharged to another facility, transfer and referral forms are made out by the nurse and sent with the resident. Review of the facility's policy titled Admission Policy (implemented date 10/2016) documented: Policy-Admission to our facility is on a space available basis and may be initiated by inquiries from families or referrals from physicians, hospices, and hospital discharge planners; Procedure-Categories of residents this facility accepts are as followed: Individuals requiring skilled, palliative or extended care. Additional documentation was requested from the Administrator and the DON concerning the census for 8/09/22 and the documentation was not provided. Upon exit from the facility on 8/16/22, the documentation was still not provided. The documentation concerning the census was received on 8/24/22 and the census was 45 on 8/09/22. Review of the mental health services and consultation on 9/12/22 for Resident #1 documentation showed no psychiatric orders, no psychiatric consultations, nor was there a psychiatric evaluation done since the incident on 8/09/22 noted in the Electronic Health Record (EHR). Review of Resident #1's clinical records revealed several additional late entry notes added to the facility's electronic medical records (EMR) system that were not in the records during the initial visit on 8/16/2022. Review of the Daily/Nursing Progress Note on 9/12/22, revealed a late entry for 8/16/22 at 12:15: Patient was transported to a facility, medications and narcotic was sent, via wheelchair, vital signs stable. When initial complaint investigation occurred on 8/16/22, this progress note was not in the resident's recorded documentation. On 9/13/22 at 2:00PM Director of Nursing (DON) was asked about the numerous late entries in Resident # 1's medical records. The DON did not provide an explanation and stated, they are all in her medical records, I can print them for you. Review of the Facility's Assessment on 9/12/22 did not contain any information pertaining to supervision and admission transfer discharge. Throughout the survey on 9/12/2022 to 9/13/2022, several documentation was requested from the Administrator and the DON and the documentation was not provided. The following were requested: Administration Policy & Procedure (P&P) and Resident Assessments P&P. Interview with the DON on 9/13/22 at 2:37 PM. The Resident Assessment P&P was requested again and received the Admissions Order P&P. The DON revealed that she doesn't have a specific policy on Resident Assessment, she refers to the RAI tool.

Based on observation, record review and interviews, the facility failed to provide a safe and appropriate discharge for one (Resident #1) out of three residents reviewed for admission, transfer, and discharge rights. Resident #1 was taken by the Administrator in his personal car to an Assisted Living Facility (ALF), when the ALF refused to admit the resident, the Administrator took the resident to a local hospital's emergency department located approximately 16 miles away from the nursing home and left the resident without any personal belonging, no discharge transfer documents and did not provide the hospital with documentation nor information related to the resident's health status medications and contact information for the resident's representative. This deficient practice placed the resident in a situation that could have caused an adverse effect. Refer to F 623, F 639, F 689 and F 835. The findings included: On 8/16/22 at 7:45 AM Resident #1 was observed sitting in a wheelchair receiving medications in her room. The resident's left leg was amputated above the knee and the right leg was in a pressure reducing boot. On 8/16/22 at 7:55 AM Resident #1 was observed in the hallway. Resident #1 reported that she is leaving today to go to an ALF at 10:30 AM, transportation is coming for her. Resident # 1 revealed that she was told last night, and she has all her stuff packed and ready to go. Resident #1 stated she is not very happy with something that happened a week ago. A week ago, I was told I had a place to go at an ALF, I was transported to the ALF by the Administrator in his car, when we got to the ALF, they said they could not take me because of the wound on my foot. This came up enroute to the ALF, the administrator was on the phone with the ALF talking with them, about taking me in there and they said no. After they refused me at the ALF, the administrator drove me to the hospital close by the ALF, dropped me off at the emergency room and left me there. He still had all my belongings in his car. The emergency department said nothing was wrong with me and did not admit me, I did not have a number for the Administrator, I called my friend and told her what was going on, she called the facility and spoke with the Administrator and told him that she will be bringing me back to the facility. She brought me back and I was accepted in the facility in the same room in my same bed which I am in now. Resident #1 also stated that she is currently waiting for her long-term care Medicaid application to be approved and the social worker at the facility is taking care of it. The ALF that she is scheduled to go to cost $3000.00 a month and she cannot afford that because she will be short about 800.00 dollars each month. The nursing home told her that she can stay at the ALF until her long-term care comes through. I told the facility I am not going anywhere because I am going to get kicked out in a month. I guess I am going, I don't feel very popular here. During a follow up observation and interview on 8/16/22 at 8:20 AM, Resident #1 was observed sitting in a wheelchair in her room. The resident had just finished eating breakfast. Resident # 1 stated, On the day the Administrator took me from this nursing home, it was around 4:30 PM and I didn't eat dinner, didn't have my meds. They told me I was accepted in an ALF, and they had a bed ready to be filled. The Administrator put my belongings and me in a car and took me to the ALF. When we got there, I stayed in the car and he came back and told me, the ALF would not accept me because of the wound on my foot. He then took me to the closest hospital ED (emergency department) and left me. He said he couldn't take me back to the nursing home because my bed was now taken. He kept my discharge papers and my medications. When he left me in the crowded ED, I had no way of contacting him, so I called my friend. My friend was finally able to contact the Administrator and told him she was going to call [state agency], if he didn't take me back to the nursing home. He told her he would come back and get me, but she didn't believe or trust him, so she came and got me and brought me back here to the nursing home. I didn't receive my meds till the next morning. I haven't seen the discharge paperwork. I have not received a discharge notice. The owner found me an ALF place. I am being discharged today to the ALF at 10:30 AM. I don't think the DON (Director Of Nursing) was in on it and had anything to do with it, but the Administrator definitely was in on it. I feel like I'm being bullied to leave this place. Review of the demographic face sheet for Resident #1 documented the resident was admitted on [DATE] with clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for Resident #1 documented the resident's Brief Interview for Mental Status (BIMS) Summary Score was 15 out of 15, indicating no cognitive impairment, and the resident is able to make own decisions. The functional section of the MDS indicated the resident required extensive assistance with one person to physically assist for ADLs (Activities of Daily Living) and the resident expected to be discharged to the community and active discharge planning already occurring for the resident to return to the community. The section for skin conditions indicated that the resident had one stage 4 pressure ulcer present on admission. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Collagen and Bordered dressing daily, Cleanse right heel wound with normal saline, pack with normal saline moistened gauze and dry dressing daily. Medication included: [MEDICATION(S)] 2 mg (milligrams) tab (tablet) 2 mg PO (by mouth) one time a day for [CONDITION(S)], [MEDICATION(S)] 10 mg tab 10 mg PO one time a day for anti-anxiety, [MEDICATION(S)] Solution 100 unit/ml inj (inject) 26 unit subq (subcutaneous) one time a day for diabetes mellitus, [MEDICATION(S)] 20 mg tab 1 tab PO one time a day for [CONDITION(S)]/[CONDITION(S)], [MEDICATION(S)] HCL 50 mg tab 1 tab PO every 6 hours PRN (as needed) for pain and [MEDICATION(S)] 50 mg tab 1 tab PO every 24 hours PRN for [CONDITION(S)]. Review of Resident's #1's care plans revealed no discharge care plan documented. A discharge care plan was later received from the Social Services/Activity Director on 8/16/22 at 2:18 PM. The care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term Rehab Therapy. Resident plans to discharge to a facility when able with home health services (no initiated date was written). Goal-Resident will attend therapy as scheduled and participate in treatment program to enable discharge home through NRD (Next Review Date). Interventions: Coordinate transportation home; Meet with resident and family at appropriate time to discuss discharge plans and possible need for home health agency services; Provide d/c (discharge) instructions. A second discharge care plan was received from the Social Services/Activity Director on 8/16/22 at 4:14 PM. This care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term rehab therapy. Resident plans to discharge to a facility when able with home health services (initiated date 6/30/22). Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #1 documented that the resident was given the notice on 7/15/22 with an effective Date of 8/09/22. The location to which the resident is to be transferred or discharged was an ALF. The reason for discharge or transfer: Your health has improved sufficiently so that you no longer need the services provided by this facility. The form was not signed nor dated by the resident and the section for resident or representative name documented: Notified verbally. Review of the social worker's progress note for Resident #1 dated 8/09/22 16:47 documented: Resident was safely discharged today, 8/09/22. Resident was discharged to an ALF. Transportation was set for resident with Administrator. Review of the discharge summary progress note for Resident #1 dated 8/09/22 19:47 documented: Resident discharged around 4:30 PM to ALF. Resident took all belongings and medications with her. Interview with the Social Services/Activity Director on 8/16/22 at 10:08 AM. She stated, My responsibilities include plan with the resident upon admission, discuss with the resident their discharge plan. I complete a discharge care plan upon admission. I give the discharge notice to the resident. I give the discharge notice at least a week before they are going. For the 8/09/22 discharge, we planned everything with the facility, setup transportation. It was her choice to be discharged and she suggested the place. We couldn't find transportation that week which had issues, the Administrator transported her. As they were on the way, they said they wouldn't accept her with the wounds. We sent paperwork to the facility about the wounds, and they said they would accept her, and they knew about the wounds. On the way to the facility, they found out the facility would not accept her. I think he took her to the hospital. I don't know what happened at the hospital, but she came back here the next morning. There was a lot going on and I told her verbally. I didn't have the time to have her sign the form. Interview with the Administrator on 8/16/22 at 1:00 PM. He stated, I was only involved in bringing her to the assisted living facility. While we were arriving, we were informed that they were not accepting her. They called me and did further investigation when I got there. I spoke to the facility Administrator and was told, that they were not accepting her, and they felt they could not take care of her wound. She stayed in the car the whole time. We had been sending them information, they said they would accept her and when we got there, they changed their mind. In consultation with the resident, we determined that we had to bring her to the emergency room , we didn't have a bed here and she can't take care of herself. The facility has 45 beds, and we didn't have any beds left. We were to receive two admissions on that day and one of them would have had her bed. I didn't have a bed that's why, I didn't bring her back and she needed to go into a safe environment. This was approximately about 6:30 PM to 7:00 PM. Eventually, one admission was canceled and did not come to the facility, which facilitated the resident to come back to the facility. The emergency department streeted her, they did not take her, and they put her back in the street. She called a friend while she was on the street, the woman came and got her. Her friend called me, I told her to bring her back to the facility and I would meet her here. That's how she ended up back here. I had the medications with me to transfer to the assisted living facility. I didn't give her the medications when I left her at the emergency room because there was a narcotic involved. I think I put her in the right spot at the right moment. The transportation company van broke down that day and was unable to take her to the assisted living facility, so I took her myself. I walked her in the emergency room , and she got registered and then I left her. She was frustrated because the assisted living didn't admit her. Interview with the Director of Nursing (DON) on 8/16/22 at 1:31 PM. She stated, We all worked on her discharge plan. She accepted she would go to an ALF for discharge. The Administrator took her, and they gave him problems because she had a wound. We were expecting admissions that day. The Administrator told me he took her to the hospital, and he didn't want her roaming the streets and he didn't want her to be unsafe. A nurse that works here at the facility, called me and told me the bed was still empty. I told them to let her come back. The transportation that we have contracted with, her truck broke down, that is why the Administrator took her to the ALF. The Administrator has taken her to appointments before. She came back the same day but later that night. Review of the admissions, transfer and discharges list dated June 1, 2022, to August 16, 2022, documentation did not have the resident listed as discharged on [DATE] and the resident was not listed as readmitted on [DATE] upon return to the facility. Review of the facility's policy titled Resident Discharge (Revised Date 7/2017) documented: Policy-A resident may be discharged to his/her home or another facility only with permission of the attending physician unless he/she is signing out against medical advice; Procedure-1) An order must be received from the physician to transfer or discharge a resident, 7) If the resident is discharged to another facility, transfer and referral forms are made out by the nurse and sent with the resident. Review of the facility's policy titled Admission Policy (implemented date 10/2016) documented: Policy-Admission to our facility is on a space available basis and may be initiated by inquiries from families or referrals from physicians, hospices, and hospital discharge planners; Procedure-Categories of residents this facility accepts are as followed: Individuals requiring skilled, palliative or extended care. Additional documentation was requested from the Administrator and the DON concerning the census for 8/09/22 and the documentation was not provided. Upon exit from the facility on 8/16/22, the documentation was still not provided. The documentation concerning the census was received on 8/24/22 and the census was 45 on 8/09/22. Review of the mental health services and consultation on 9/12/22 for Resident #1 documented there were no psychiatric orders, no psychiatric consultations, nor was there a psychiatric evaluation done since the incident on 8/09/22 noted in the Electronic Health Record (EHR). Review of the Discharge Summary Progress Note on 9/12/22, revealed a late entry note dated for 8/16/22 at 10:45: Late Entry-Patient was evaluated today at [facility name] for discharge purpose. Patient has gained agility and mobility since admission. Patient evaluated at bedside in no acute distress. Psychiatric: Appropriate mood and affect according to disease process. Plan: Ready to be discharged ALF; Home health evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . I have seen and examined the patient on their discharge day. When initial complaint investigation occurred on 8/16/22, this progress note was not documented. Review of the Daily/Nursing Progress Note on 9/12/22, dated 8/16/22 at 12:15: Patient was transported to a facility, medications and narcotic was sent, via wheelchair, vital signs stable. When the initial complaint investigation occurred on 8/16/22, this progress note was not documented. Review of the EHR records for Resident #1 on 9/12/22, documentation did not show any documentation to indicate a head-to-toe assessment was completed when the resident returned to the facility on the night of the incident on 8/09/22. Review of the local hospital's emergency department medical record for Resident #1 on 8/09/22, documented the resident indicated, she needed to see a doctor. The resident's comment was: I discharge from the nursing home, sent to ALF, they can't help my wound. They dropped me off here, I have a right heel ulcer. Review of the Facility Assessment on 9/12/22 did not contain any information pertaining to supervision and admission transfer discharge. Throughout the survey on 9/12-13/22, several documentation was requested from the Administrator and the DON and the documentation was not provided. The following were requested: Administration Policy & Procedure (P&P) and Resident Assessments P&P. Interview with the DON on 9/13/22 at 2:37 PM. The Resident Assessment Policy and Procedure was requested again and the Admissions Order Policy and Procedure was received. The DON revealed that she does not have a specific policy on Resident Assessments, she refers to the RAI tool.

Based on observation, record review and interviews, the facility failed to provide a discharge notice with the resident's signature for three (Resident #1, Resident #4, and Resident #5) out of three residents reviewed for admission, transfer and discharge rights. This has the potential to affect any of the 41 residents residing in the facility at the time of this survey. Refer to F 622, F 639, F 689 and F 835. The findings included: 1) Observation and interview with Resident #1 on 8/16/22 at 8:20 AM revealed the resident had just finished eating breakfast and was sitting in a wheelchair in her room. The resident's left leg was amputated above the knee and the right leg was in a protective boot. She stated, On the day the Administrator took me from this nursing home, it was around 4:30 PM and I didn't eat dinner, didn't have my meds. They told me I was accepted in an ALF (Assisted Living Facility), and they had a bed ready to be filled. The Administrator put my belongings and me in a car and took me to the ALF. When we got there, I stayed in the car and he came back and told me, the ALF would not accept me because of the wound on my foot. He then took me to the closest hospital ED (Emergency Department) and left me. He said he couldn't take me back to the nursing home because my bed was now taken. He kept my discharge papers and my medications. When he left me in the crowded ED, I had no way of contacting him, so I called my friend. My friend was finally able to contact the Administrator and told him she was going to call [state agency], if he didn't take me back to the nursing home. He told her he would come back and get me, but she didn't believe or trust him, so she came and got me and brought me back here to the nursing home. I didn't receive my meds till the next morning. I haven't seen the discharge paperwork. I have not received a discharge notice. The owner found me an ALF place. I am being discharged today to the ALF at 10:30 AM. I don't think the DON (Director Of Nursing) was in on it and had anything to do with it, but the Administrator definitely was in on it. I feel like I'm being bullied to leave this place. Review of the demographic face sheet for Resident #1 documented the resident was admitted on [DATE] with clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for Resident #1 documented the resident's Brief Interview for Mental Status (BIMS) Summary Score was 15 out of 15, indicating no cognitive impairment, and the resident can make own decisions. The functional section of the MDS indicated the resident required extensive assistance with one person to physically assist for ADLs (Activities of Daily Living), the resident expected to be discharged to the community and active discharge planning already occurring for the resident to return to the community. Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #1 documented the resident was given the notice on 7/15/22 with an effective Date of 8/09/22. The location to which the resident is to be transferred or discharged was an ALF. The reason for discharge or transfer: Your health has improved sufficiently so that you no longer need the services provided by this facility. The form was not signed nor dated by the resident and documented that the resident was notified verbally. Review of Resident #1's care plans did not show a documented discharge care plan noted. A discharge care plan was later received from the Social Services/Activity Director on 8/16/22 at 2:18 PM. The care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term rehab therapy. Resident plans to discharge to a facility when able with home health services (no initiated date was written), Goal-Resident will attend Therapy as scheduled and participate in treatment program to enable discharge home through NRD (Next Review Date), Interventions-Coordinate transportation home; Meet with resident and family at appropriate time to discuss discharge plans and possible need for home health agency services; Provide d/c (discharge) instructions. A second discharge care plan was received from the Social Services/Activity Director on 8/16/22 at 4:14 PM. This care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term rehab therapy. Resident plans to discharge to a facility when able with home health services (initiated date 6/30/22). Interview with the Social Services/Activity Director on 8/16/22 at 10:08 AM. She stated, My responsibilities include plan with the resident upon admission, discuss with the resident their discharge plan. I complete a discharge care plan upon admission. I give the discharge notice to the resident. I give the discharge notice at least a week before they are going. For the 8/09/22 discharge, we planned everything with the facility, setup transportation. It was her choice to be discharged and she suggested the place. We couldn't find transportation that week which had issues, the Administrator transported her. As they were on the way, they said they wouldn't accept her with the wounds. We sent paperwork to the facility about the wounds, and they said they would accept her, and they knew about the wounds. On the way to the facility, they found out the facility would not accept her. I think he took her to the hospital. I don't know what happened at the hospital, but she came back here the next morning. There was a lot going on and I told her verbally. I didn't have the time to have her sign the form. 2) Closed record review of Resident #4's demographic face sheet documented the resident was admitted on [DATE] with clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for Resident #4 documented the resident's Brief Interview for Mental Status (BIMS) Summary Score was 15 out of 15, indicating no cognitive impairment, able to make own decisions. The functional status section of the MDS indicated the resident required extensive assistance with one to person physically assist for ADLs. The resident was uncertain about discharge plans and no active discharge planning was occurring for the resident to return to the community. Review of Resident #4's care plans documentation indicated no noted discharge care plan. A discharge care plan was later received from the Social Services/Activity Director on 8/16/22 at 2:18 PM. The care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term rehab therapy. Resident plans to discharge to a facility when able with home health services (no initiated date was written). Goal-Resident will attend therapy as scheduled and participate in treatment program to enable discharge home through NRD. Interventions-Coordinate transportation home; meet with resident and family at appropriate time to discuss discharge plans and possible need for home health agency services; Provide d/c (discharge) instructions. A second discharge care plan was received from the Social Services/Activity Director on 8/16/22 at 4:14 PM. This care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term rehab therapy. Resident plans to discharge to a facility when able with home health services (initiated date 7/14/22). Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #4 documented the resident was given the notice on 7/29/22 with an effective Date of 8/05/22. The location to which the resident is to be transferred or discharged was an ALF. The reason for discharge or transfer indicated: Your health has improved sufficiently so that you no longer need the services provided by this facility. The form was not signed and dated by the resident and documented that the resident was notified verbally. Interview with the Social Services/Activity Director on 8/16/22 at 12:11 PM. She stated, The resident did not sign the form and was told verbally. The resident was involved in her discharge. 3) Closed record review of the demographic face sheet for Resident #5 documented the resident was admitted on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for Resident #5 documented the resident's Brief Interview for Mental Status (BIMS) Summary Score was 12 out of 15, indicating mild cognitive impairment. The functional section indicated that the resident required extensive assistance with one person physically assist for ADLs. The resident expects to be discharged to the community and active discharge planning already occurring for the resident to return to the community. Review Resident #5's care plans documents revealed there was no discharge care plan noted. A discharge care plan was later received from the Social Services/Activity Director on 8/16/22 at 2:18 PM. The care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term rehab therapy. Resident plans to discharge to a facility when able with home health services (no initiated date was written). Goal-Resident will attend therapy as scheduled and participate in treatment program to enable discharge home through NRD. Interventions-Coordinate transportation home; meet with resident and family at appropriate time to discuss discharge plans and possible need for home health agency services; Provide d/c (discharge) instructions. A second Discharge care plan was received from the Social Services/Activity Director on 8/16/22 at 4:14 PM, this care plan documented the following: Focus-Resident is new admit to facility. Resident is here for short-term rehab therapy. Resident plans to discharge to a facility when able with home health services (initiated date 7/11/22). Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #5 documented the resident was given the notice on 7/05/22 with an effective Date of 7/20/22. The location to which the resident is to be transferred or discharged was an ALF. The reason for discharge or Transfer: Your health has improved sufficiently so that you no longer need the services provided by this facility and the resident's family also wanted the resident to go back to ALF. The form was not signed nor dated by the resident or the resident's representatives and documented that the resident was notified verbally. Interview with the Social Services/Activity Director on 8/16/22 at 12:13 PM. She stated, The resident did not sign the form and was told verbally. The resident's family wanted him discharged to an ALF.

Based on observation, interview, and record review the facility failed to ensure resident care plans, resident assessments and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As evidenced by Resident #1's discharge, wound/skin and admission assessments were noted to be recorded as late entries ranging from 6 to 92 days later respectively. Resident #1's wounds and care plans contained inaccurate classification and description of Resident #1's wounds and the care plans did not reflect the current treatment process in place for the resident's wound care. The facility's failure to ensure residents' records and assessments are accurate, complete and available have potential to cause an adverse effect on residents admitted to the facility at the time of the survey. The findings included: During observation on 8/16/2022 at 7:45 AM Resident # 1 was observed during medication administration sitting in a wheelchair in her room. The resident had an above knee amputation (AKA) of left leg and was wearing right heel protector. Registered Nurse, Staff A conducted a blood glucose level check on Resident # 1, administered ordered [MEDICATION(S)] (insulin) to Resident #1' upper arm and administered [MEDICATION(S)] 5/325 milligram (mg), one tablet by mouth for pain. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/22 at 7:55 AM Resident #1 was observed in the hallway. Resident #1 stated she is not very happy with something that happened a week ago. A week ago, I was told I had a place to go at an ALF, I was transported to the ALF by the Administrator in his car, when we got to the ALF, they said they could not take me because of the wound on my foot. This came up enroute to the ALF, the administrator was on the phone with the ALF talking with them, about taking me in there and they said no. After they refused me at the ALF, the administrator drove me to the hospital close by the ALF, dropped me off at the emergency room and left me there. He still had all my belongings in his car. The emergency department said nothing was wrong with me and did not admit me, I did not have a number for the Administrator, I called my friend and told her what was going on, she called the facility and spoke with the Administrator and told him that she will be bringing me back to the facility. She brought me back and I was accepted in the facility in the same room in my same bed which I am in now. During a follow up observation and interview on 8/16/22 at 8:20 AM, Resident #1 was observed sitting in a wheelchair in her room. The resident had just finished eating breakfast. Resident # 1 stated, On the day the Administrator took me from this nursing home, it was around 4:30 PM and I didn't eat dinner, didn't have my meds. They told me I was accepted in an ALF, and they had a bed ready to be filled. The Administrator put my belongings and me in a car and took me to the ALF. When we got there, I stayed in the car and he came back and told me, the ALF would not accept me because of the wound on my foot. He then took me to the closest hospital ED (emergency department) and left me. He said he couldn't take me back to the nursing home because my bed was now taken. He kept my discharge papers and my medications. When he left me in the crowded ED, I had no way of contacting him, so I called my friend. My friend was finally able to contact the Administrator and told him she was going to call [state agency], if he didn't take me back to the nursing home. He told her he would come back and get me, but she didn't believe or trust him, so she came and got me and brought me back here to the nursing home. I didn't receive my meds till the next morning. I haven't seen the discharge paperwork. I have not received a discharge notice. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Collagen and Bordered dressing daily, Cleanse right heel wound with normal saline, pack with normal saline moistened gauze and dry dressing daily. Medications included: [MEDICATION(S)] 2 mg (milligrams) tab (tablet) 2 mg PO (by mouth) one time a day for [CONDITION(S)], [MEDICATION(S)] 10 mg tab 10 mg PO one time a day for anti-anxiety, [MEDICATION(S)] Solution 100 unit/ml inj. (inject) 26-unit subq. (subcutaneous) one time a day for diabetes mellitus, [MEDICATION(S)] 20 mg tab 1 tab PO one time a day for [CONDITION(S)]/congestive heart failure, [MEDICATION(S)] HCL 50 mg tab 1 tab PO every 6 hours PRN (as needed) for pain and [MEDICATION(S)] 50 mg tab 1 tab PO every 24 hours PRN for [CONDITION(S)]. Review of Resident # 1's 5 Day Minimum Data Set (MDS) dated [DATE] revealed in Section C for Cognitive Patterns, Brief Interview for Mental Status (BIMS) Score of 15 out of 15, indicating the resident is cognitively intact. Section G for Functional Status for eating indicated the resident need supervision and for toileting and transfer the resident required extensive assistance. Section H for Bowel and Bladder documented that the resident is always incontinent of bowel and bladder. Section J for Health Conditions documented no scheduled pain medication regimen received in the last 5 days and no falls. Section K for Nutritional status documented no unknown weight loss. Section M for Skin Conditions documented that the resident has 1 stage 4 pressure ulcer present on admission. Review of Resident's #1 care plans with reference date 6/16/2022 revealed the resident has pressure ulcers, located on the right heel stage 4 related to impaired mobility Goal: Pressure ulcer(s) will exhibit signs of healing evidenced by decrease in size, improved appearance, and be free from signs and symptoms of infection by next review date. Interventions: Avoid Skin to skin contact, complete skin checks as per facility protocol, educate resident/responsible party about pressure ulcer, primary risk factors, treatment, and prevention, minimize pressure over bony prominences, monitor effectiveness of /response to treatments as order, monitor for pain and medicate per physician order, monitor lab/diagnostics as ordered and report results to Medical Doctor (MD), position with pillows to maintain proper body alignment as needed, provide diet as ordered and monitor nutritional status and dietary needs, provide pressure relieving and reduction device-air loss mattress with bilateral side rails, provide supplemental protein, amino acids, vitamins, minerals as ordered by physician to promote wound healing, report changes in skin status to MD, use lifting device, draw sheet to reduce friction, turning and reposition program, wound care as ordered by physician, wound evaluations as per facility protocol, resident has pressure ulcer(s). Review of the weekly wound care progress notes dated 8/11/2022 revealed right heel measurements: 4.8 centimeters (cm)x 4.8 cm x 0.3 cm depth. Measurements for the left groin: 1.5 cm x 1.5 cm x 0.3 cm depth, outcome improved. Documentation for 7/14/22 indicated right heel measurements: 5 cm x 4.6 cm x 0.4 cm depth/improved and left groin measurements: 1.8 cm x 1.8 cm x 0.2 depth improved. Documentation for 6/11/22 indicated measurements for the right heel: 6 cm x 6 cm x 0.1 cm depth. The left groin measurements: 2. 5 cm x 2.5 cm x 0.2 cm Depth-Outcome-Improved. Other weekly wound assessments were documented as completed on 8/4/22, 7/28/22, 7/21/22, 7/7/22, 6/30/22, 6/23/22 and 6/16/22. On 8/16/2022 review of the Social Worker's progress notes for Resident #1 dated 8/09/22 timestamped 16:47 documented: Resident was safely discharged today, 8/09/22. Resident was discharged to an ALF. Transportation was set for resident with Administrator. Review on 8/16/2022 of the discharge summary progress notes for Resident #1 dated 8/09/22 timestamped 19:47 documented: Resident discharged around 4:30 PM to ALF. Resident took all belongings and medications with her. Review of the admissions, transfer, and discharges list dated June 1, 2022, to August 16, 2022, documentation did not have the resident listed as discharged on [DATE] and the resident was not listed as readmitted on [DATE] upon return to the facility. Review of the EHR records for Resident #1 did not show any documentation to indicate a head-to-toe assessment was completed when the resident returned to the facility on the night of 08/09/2022. During a continuation of the complaint investigation conducted on 9/12/2022 to 9/13/2022, record review of Resident #1's progress notes revealed several additional late entry notes added to the facility's electronic medical records (EMAR) system that were not in the records during the initial visit on 8/16/2022. The late entries included discharge summary for 8/16/2022 timestamped 10:45, the documentation was created on 8/22/22 at 15:54 by the Physician (approximately 6 days later). The documentation indicated: Resident is a patient with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] .evaluated today at nursing home for discharge purpose .Chronically ill appearance requires care with Activities of Daily living (ADL), alert x 3(time three). Skin: warm and dry to touch, wound to right groin and right heel. Pressure ulcer . Extremities: pain in right leg, 6/10 of intensity. Assessment Plan: Ready to be discharged Assisted Living Facility (ALF). Home health evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Follow up with Primary Care Physician (PCP) 5-7 days. Resume home diet and medications. Condition at discharge, stable. Patient will benefit of home health services to increase patient quality of life and prevent hospital readmission. I have seen and examined the patient on their discharge day .I have electronically signed this document. Late entry Physician's Progress note for 8/9/2022 timestamped 09:30 indicated the late entry was created on 9/1/2022 at 12:14 PM by facility staff (approximately 22 days later) documented: Resident is a patient with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient was evaluated today . Patient with generalized weakness. Today, the patient stated that she has not felt that this weakness is completely alleviated. Continue with vitamin prescribed. Patient evaluated at bedside. The documentation included review of systems and that 14 points were reviewed. Late entry Discharge Summary documentation for 8/9/2022 timestamped 19:47 revealed the late entry was created on 9/13/22 at 11:20 AM (approximately 34 days later). The document indicated that the resident was discharged around 4:30 PM to an ALF. Resident took all belongings and medications with her. Wound care was provided prior to discharge. Vital signs stable and no complains of pain. Instruction for wound care were provided to Alf. No concerns voiced at this time. Late entry documentation on Resident #1's skin/wound notes revealed a late entry documentation for 6/11/2022 time stamped 09:16. The late entry on the skin/wound note was created on 9/13/22 at 9:19 AM by Staff D, LPN Wound Care Nurse (approximately 92 days later). The documentation indicated: Resident admitted to facility with open wounds to right heel and left groin. Braden scale (tool used for predicting pressure sore risk) of 19 (indicating the resident is not at risk) upon admission. Resident with history of wounds and left above knee amputation. Wounds to right heel and left groin were evaluated and treatment applied as order. Please refer to wound skin assessment for details. Resident will continue under the care of the vascular surgeon. Will continue to evaluate resident on a weekly and as needed basis. Late entry admission notes revealed a late entry documentation for 6/11/2022 time stamped 15:04. The late entry admission note was created on 6/23/22 at 16:05 by the Physician (approximately 12 days later) documented that the resident is a patient with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin: warm and dry to touch, wound to right groin and right heel, pressure ulcer, deformity, decreased range of motion is noted to all joints, muscle strength is 4/5 bilaterally. Plan: History and Physical exam performed today, medications reconciled, social and family history updated, preventive medicine importance counseling provided, nutritionist evaluation, skincare daily and PRN, universal precautions, wound care evaluation . psychological evaluation .etc Code Status: Do Not Resuscitate (DNR). Late entry admission summary for 6/10/2022 timestamped 23:09 also created 09/13/2022 documented: Resident admitted to Nursing Home to room [Room #] from Local ALF accompanied by 2 attendants under the care of physician with Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has a left above the knee amputation. Open area to left groin. Old scar to right knee. Resident has a dressing to right foot. Refused to have right foot assessed despite encouragement. Spinal cord stimulator implant to lower back. Pressure ulcer to heel. Call placed to Medical Director (MD) for medication verification. Return call pending. During an interview on 9/12/22 at 10:15 AM, Licensed Practical Nurse Wound Care (Staff D) stated, I started working at this facility in April 2022, this resident had two wounds on admission, right heel surgical wound graft, and a wound in her left groin from a revascularization procedure she had at the hospital, it was also a surgical wound. This resident came from the hospital to our facility with the two surgical wounds, she may have had a staged wound prior. We were doing the treatment following the recommendations of the vascular surgeon, on the heel a wet to moist dressing and the groin we were treating with collagen, I was treating this resident from the time she was admitted until she left, I remember this resident, because she was alert and oriented and could voice her needs, the treatment process in the right heel never changed in the time the resident was here, the left groin surgical wound order was changed a few times by the vascular surgeon, both of the wounds were improving but it was a slow process because of her circulation issues. The resident was being medicated for pain prior to wound care and I know she received as needed (PRN) pain medications. Any changes in the resident's condition were being reported to the vascular surgeon and the resident's Medical Doctor (MD). I document my wound care notes and do my wound care assessments on my patients once a week or as needed if there was a reason for additional documentation. I was providing treatment to this resident for surgical wounds not pressure ulcers. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This resident was not seen by the facility's wound care Team/MD, her wounds were treated daily, and she was being seen by her vascular surgeon, she went on several appointments to him out of the facility, after her appointments any changes in her treatment orders were communicated to the facility by the resident's vascular surgeon via paperwork that came back with the resident when she returned to the facility from her appointments. Review of Resident #1's vascular surgeon appointments records revealed documentation from 6/30/22 to current patient, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Right calcaneus (bone) graft site appears to continue incorporating appropriately with excellent skin margins around the edges. No surrounding [CONDITION(S)] or further signs of infection. Patient can follow up with vascular surgeon in 2 weeks. Plan: Left Groin: keep area dry, [MEDICATION(S)] twice daily covered with dry gauze. Right Calcaneus daily dressing changes: Saline wet to dry dressing on, secure with [MEDICATION(S)], moderate ace dressing compression, if necessary, be careful not to apply too tightly. The documentation showed that Resident #1 had 2 additional appointments with the vascular surgeon on 7/13/22 and 8/17/22. On 9/13/22 at 9:36 AM Staff D, LPN Wound Care Nurse was asked about the assessment sheets, Staff D reported that there are no daily skin assessment sheets, the Certified Nursing Assistants (CNAs) observe the residents daily during care and report any findings to the nurse who is responsible for documentation of findings and notifications are then made to the appropriate persons. On 9/13/22 at 9:42 AM Director of Nursing (DON) reported, currently the way we do our skin checks/assessments is the CNAs during daily care check the resident's skin, report any findings to the nurse, the nurse assesses the resident and call the resident MD, let them know what the findings are and place a consult for wound care, wound care follows up the same day or next day. On admission or discharge of a resident the nurse assigned to the resident does a complete assessment of the resident. The DON was asked if Resident #1 had a stage 4 pressure ulcer. The wound DON stated, let me check her records. The DON then proceeded to call the wound care nurse on the phone. The DON stated, her information shows she had a stage 4 pressure ulcer to the right heel, the wound care nurse said she had a skin graft to her right heel and a surgical site to left groin that he was treating. This resident was not seen by the facility's wound care Team/MD, her wounds were treated daily, and she was being seen by her vascular surgeon, she went on several appointments to him out of the facility, after her appointments any changes in her treatment orders were communicated to the facility by the resident's vascular surgeon via paperwork that came back with the resident when she returned to the facility from her appointments. The resident was accompanied to her appointments by facility staff. On 9/13/22 at 2:00 PM Director of Nursing (DON) was asked about the numerous late entries in Resident # 1's medical records. The DON did not provide an explanation and stated, they are all in her medical records, I can print them for you. The DON later presented copies of several late entry progress notes for Resident #1's assessments and discharge summary. The DON also reported that social services take care of the facility's admission paperwork, and the facility was currently in transition with a new consultant social worker that started recently. On 9/13/22 2:30 PM the Facility's Administrator reported that Facility's Medical Director first contracted day with the facility was 9/12/2022. The contract for the Medical Director was not provided to the surveyors for review at the time of the survey. On 9/13/22 at 2:37 PM the DON was asked about the facility's policy and procedures for resident assessments. The DON stated, we do not have a specific policy for resident assessments and that she refers to the RAI tool.

Based on interview and record review, the facility failed 1) To follow care plans involving two-person physical assistance with Activities of Daily Living (ADL) care, which resulted in a fall with injury, for one (resident #25) resident sampled for accidents, out of 16 residents whose care plans were reviewed and 2) To provide care in accordance with the resident's written plan of care for alteration in Musculoskeletal status as it relates to right hand contracture for 1 (Resident #14) out of 3 residents reviewed on stage two for Range of Motion out of thirty residents with contractures. This has the potential to affect all 45 residents residing in the facility at the time of the survey. The findings included: 1) Record review of the medical facesheet for resident #25 revealed, the resident was originally admitted on [DATE]; the resident's [DIAGNOSES REDACTED]. Record review of the fall risk assessments dated 01/27/2017, 4/28/17, and 07/28/2017 revealed, resident #25 was assessed for the risk of falls. Based on the assessments the resident's fall risk score ranged from 15 to 17, indicating resident #25 was moderate to high risk for falls. Further review of the assessments revealed, the resident was unable to independently come to a standing position. Record review of the Annual and Significant Change Minimum Data Sets (MDS's) dated 02/08/17 and 05/01/2017 revealed, resident #25 encoded as being totally dependent on staff for assistance with all activities of daily (ADL) care. The resident required two-person physical assistance with bed mobility, involving how the resident moved to and from her lying position, turning from side to side, and positioning while in bed. In addition, the resident required two-person physical assistance with transferring, related to how well the resident moved between surfaces including to or from bed, chair, wheelchair, and standing position. Record review of the Self-Care Deficit care plan for resident #25, Reviewed and revisions made during the years of 2011 to 2017, revealed that the resident was care planned related to her cognitive impairment, and dependence on staff for ADL care as demonstrated by inattention and inability to complete her ADL's. The goals included, but not limited to, receiving comfort care according to the hospice philosophy, and having her needs met in a safe and growth promoting environment through the next review date of 11/07/2017. The interventions included, but not limited to, providing two person assistance with all transfers and that resident #25 was totally dependent on two staff members for repositioning and turning in bed. Record review of the Falls care plan for resident #25, Reviewed and revisions made during the years of 2011 to 2017, revealed that the resident was care planned for the risk of injury characterized by multiple risk factors related to impaired balance, pain, lack of awareness of safety needs, and incontinence. The goal included that the resident would have no injury from falls, receive comfort care according to the hospice philosophy, and have her needs met in a safe and growth promoting environment through next review date 11/07/2017. The interventions included, but not limited to, transfer and change positions slowly. Record review of the daily nursing note dated 08/30/2017 for resident #25 revealed that the resident remained in crisis care with hospice nurse at her bedside. At 7:30 am, the hospice nurse reported to nursing staff that the resident fell out of bed that morning while she was providing morning care. The resident was assessed, and noted to have a large lump on her forehead and a laceration to her upper lip with a small amount of bleeding. First-aid treatment provided and pressure was applied to her upper lip. The resident had facial grimacing, indicating pain, and 650 milligrams (mg) of Tylenol was given. Record review of the health status notes for resident #25 dated 08/30/2017 revealed, hospice staff contacted and made aware of the resident's status; nursing staff were informed that a hospice nurse was coming to evaluate the resident. Post-fall neurological checks were initiated for 72 hours. Further review of the health status notes indicated orders to place ice packs to the resident's forehead every 20 minutes, and off for 20 minutes, for 48 hours as per the facility's protocol. Subsequently, orders were received to transfer the resident to the hospital for evaluation. Record review of the telephone physician's orders [REDACTED].#25 dated 08/30/2017 revealed, orders for application of triple antibiotic ointment (TAO) 1% to the laceration of the resident's upper lip sustained during her fall. Cleansing the laceration with normal saline, patting dry, applying TAO, and leaving open to air daily or as needed until resolved. In addition, post-fall neurological checks for 72 hours were ordered, and lastly the resident was ordered to be transferred to the hospital for evaluation. Interview with the Director of Nursing (DON) on 11/09/2017 at 9:24 am revealed, the fall would have never happened if it was the resident's regular Hospice certified nursing assistant (CNA) and nurse. Resident #25 was on crisis care and hospice sent over someone from their crisis team; she was new to the resident. The Hospice nurse said that she should have asked for help. The DON confirmed, the Hospice nurse should have asked for assistance from other staff. Interview with the licensed practical nurse (Staff A) on 11/09/2017 at 9:58 am revealed, she remembered resident #25, and that she was under her care; the resident had received hospice services. She was very contracted, and totally dependent on staff for transfers and bed mobility. The resident was also heavy, which was also why she required two staff members to assist her when transferring or repositioning in bed. Staff A was present on 08/30/2017 when the resident had her fall. She was on crisis care, which meant that someone had to be with her every 24 hours. The Hospice Nurse that came to assist the resident was not her usual nurse. The Hospice nurse told Staff A she was trying to clean resident #25, she turned her, but did not ask for help and the resident fell out of the bed. Staff A went to assist the resident, and the resident had a bump on her forehead and a laceration to her upper lip. The resident had some facial grimacing, so she was medicated with 650 mg of Tylenol. First-Aid was provided and pressure was applied to her upper lip. The resident's primary care physician was contacted, as well as the hospice physician. Resident #25 was sent to the hospital, and returned back to the facility on [DATE]; the laceration had already healed so treatment did not need to be provided. Nursing staff always communicated with hospice staff about residents' medical conditions, especially when a resident was on crisis care. Staff A said the Hospice nurse knew that she needed two people to assist with the resident, and that if she needed any help she could have asked nursing staff. When she asked the hospice nurse why she did not ask for any help, the hospice nurse said that she did not realize that the resident was so heavy. Interview with the Hospice Nurse (Staff P) on 11/09/2017 at 1:06 PM, via telephone, revealed she worked with resident #25 on 08/30/2017; she was not the resident's usual Hospice nurse, and she stated that she worked with whoever hospice services sent her to. The resident was on a crisis care, and someone had to be with her 24 hours a day. Staff P was performing ADL care on the resident before she was going to leave the facility. She said that before she started to bathe resident #25 she looked for a certified nursing assistant (CNA) to assist her, but she could not find one; she believed that they were all busy with their residents. As she was turning her, Staff P pulled resident #25 close to her to turn her, and then the resident rolled and fell on the floor. The resident was heavy and there was no way for her to lift up the resident. She went to the nurses' station, she got the nurse and then the nurse called for other staff to come and help them. The resident had some swelling on her forehead, and she had a small cut on the top of her lip. Resident #25 was placed in bed, and they put ice on the swelling. The hospice care team was notified, and the nurse came and wrote an incident report. The resident's family and physician were notified. Staff P did not know what happened after that, she finished caring for the resident, made sure that she was stable, and she left the facility. She never worked with the resident again after that. Staff P said that she was not aware that the resident required two staff members for assistance with transferring or repositioning. Whenever working with residents, hospice staff would ask nursing staff for assistance, but if they could not find anyone they would just do it on their own. When she went into the facility, no one informed Staff P that resident #25 required two person physical assistance, and there was no report given to her about the resident's ADL functional status. If she would have known this about the resident, she would have made sure someone was there to help assist her. Interview with the Certified Nursing Assistant (Staff N) on 11/09/2017 at 1:44 PM revealed, she was present on the day that resident #25 had her fall, on 08/30/2017. When Staff N came to work that day, in the morning, she made her rounds as usual. The Hospice nurse sat in the room with the resident because the resident was on crisis care; this was the first time that she had saw the Hospice nurse. From her experience of working with the resident, the resident always required two people assisting her with transfers and repositioning. At no point did the Hospice nurse ask her for assistance with resident #25. 2) Record review of the Restorative Services Policy and Procedure (No written date) revealed: Policy Statement: Specialized rehabilitative service goals and objectives shall be developed for problems identified through resident assessments; Policy Interpretation and Implementation: 1) Rehabilitative goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services; 2) Goals may include, but are not limited to: a) Assisting the resident in adjusting to his/her abilities, b) Assisting the resident in developing and strengthening his/her physiological and psychological resources and c) Encouraging the resident to maintain his/her independence and self-esteem. Observation of Resident #14 on 11/07/17 at 2:33 pm revealed the resident sitting in a wheelchair in the hallway, outside her room. Bilateral upper contractures in arms and no splint devices were noted. Review of the Demographic Face Sheet for Resident #14 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Annual Assessment for Resident #14 dated 9/02/17 revealed the resident was cognitive impaired, required total dependence with one person physical assist for ADLs (Activities of Daily Living) and had functional limitation in range of motion (ROM) for upper extremity with impairment on both sides. Review of the Alteration in Musculoskeletal Status care plan (written 8/30/11; revision 10/10/14) revealed: Focus: Alteration in Musculoskeletal Status related to Right hand contracture; Goal: Will remain free of injuries or complications through next review; Interventions: Right hand roll on at all times and off at bedtime. Interview with Staff A on 11/08/17 at 10:19 am confirmed the resident had bilateral upper contractures. She stated, She had hand rolls when she is out of bed in the morning. I was told she had the hand roll d'cd (discontinued). Interview with Staff B on 11/08/17 at 10:26 am revealed, the following: 1) Resident #14 had bilateral upper contractures; 2) No splints were ordered for Resident #14 at this time and 3) She stated, Once this interview is over, I will go and look for her previous chart for the PT notes. Subsequent interview at 12:17 pm, she stated, The medical record with the resident's previous physical therapy notes could not be found. The order was written in 2011 for the hand roll when the resident was on hospice. I cannot find an order saying the hand roll was d'cd since the resident is no longer on hospice. The nurses have been putting washcloths in between her fingers as a hand roll. We used the washcloths for hand rolls when she was on hospice. We have hand rolls for residents that are not on hospice. Interview with Staff C on 11/08/17 at 10:47 am confirmed Resident #14 had contractures in both hands. She stated, When I finish washing her hands, I put a small towel in her hand. I do not leave it like that. Interview with Staff D on 11/08/17 at 11:07 am confirmed Resident #14 had contractures in both hands. She stated, Always put two wash cloths with her, when I work with her on Wednesdays and Saturdays.

Based on interview and record review, the facility failed to ensure that one (resident #25) resident sampled for accidents was provided with two-person assistance during Activities of Daily Living (ADL) care, which resulted in a fall with injury. This had the potential to affect 21 residents who required one or two staff members for assistance with transfers, out of 45 residents present in the facility. The Findings included: Record review of the facility's policy and procedure titled, Fall Reduction Program, dated 07/25/2003, revealed, In the interest of residents' safety, it is responsibility of all personnel at the (facility name) to participate in the Fall Reduction Program. All falls cannot be prevented, however, reduction can minimize risk of accidents and injury. All employees must report damaged equipment and potentially hazardous situations or environments. All residents admitted will be assessed with [REDACTED]. The Fall Reduction Program will be coordinated/monitored by the Restorative Coordinator Supervisor Identify residents at high risk for falls and take appropriate steps to reduce risk of injury. Record review of the medical facesheet for resident #25 revealed, the resident was originally admitted on [DATE]; the resident's [DIAGNOSES REDACTED]. Record review of the fall risk assessments dated 01/27/2017, 4/28/17, and 07/28/2017 revealed, resident #25 was assessed for the risk of falls. Based on the assessments the resident's fall risk score ranged from 15 to 17, indicating that resident #25 was a moderate to high risk for falls. Further review of the assessments revealed that the resident was unable to independently come to a standing position. Record review of the annual and significant change minimum data sets (MDSs) dated 02/08/17 and 05/01/2017 revealed, resident #25 encoded as being totally dependent on staff for assistance with all activities of daily (ADL) care. The resident required two-person physical assistance with bed mobility, involving how the resident moved to and from her lying position, turning from side to side, and positioning while in bed. In addition, the resident required two-person physical assistance with transferring, related to how well the resident moved between surfaces including to or from bed, chair, wheelchair, and standing position. Record review of the daily nursing note dated 08/30/2017 for resident #25 revealed, the resident remained in crisis care with hospice nurse at her bedside. At 7:30 am, the hospice nurse reported to nursing staff that the resident fell out of bed that morning while she was providing morning care. The resident was assessed, and noted to have a large lump on her forehead and a laceration to her upper lip with a small amount of bleeding. First-aid treatment provided and pressure was applied to her upper lip. The resident had facial grimacing, indicating pain, and 650 milligrams (mg) of Tylenol was given. Record review of the health status notes for resident #25 dated 08/30/2017 revealed, hospice staff contacted and made aware of the resident's status; nursing staff were informed that a hospice nurse was coming to evaluate the resident. Post-fall neurological checks were initiated for 72 hours. Further review of the health status notes indicated orders to place ice packs to the resident's forehead every 20 minutes, and off for 20 minutes, for 48 hours as per the facility's protocol. Subsequently, orders were received to transfer the resident to the hospital for evaluation. Record review of the telephone physician's orders [REDACTED].#25 dated 08/30/2017 revealed, orders for application of triple antibiotic ointment (TAO) 1% to the laceration of the resident's upper lip sustained during her fall. Cleansing the laceration with normal saline, patting dry, applying TAO, and leaving open to air daily or as needed until resolved. In addition, post-fall neurological checks for 72 hours were ordered, and lastly the resident was ordered to be transferred to the hospital for evaluation. Interview with the Director of Nursing (DON) on 11/09/2017 at 9:24 am revealed, the fall would have never happened if it was the resident's regular Hospice certified nursing assistant (CNA) and nurse. Resident #25 was on crisis care and hospice sent over someone from their crisis team; she was new to the resident. The Hospice nurse said that she should have asked for help. The DON confirmed that the Hospice nurse should have asked for assistance from other staff. Interview with the licensed practical nurse (Staff A) on 11/09/2017 at 9:58 am revealed, she remembered resident #25, and that she was under her care; the resident had received hospice services. She was very contracted, and totally dependent on staff for transfers and bed mobility. The resident was also heavy, which was also why she required two staff members to assist her when transferring or repositioning in bed. Staff A was present on 08/30/2017 when the resident had her fall. She was on crisis care, which meant that someone had to be with her every 24 hours. The Hospice Nurse that came to assist the resident was not her usual nurse. The Hospice nurse told Staff A she was trying to clean resident #25, she turned her, but did not ask for help and the resident fell out of the bed. Staff A went to assist the resident, and the resident had a bump on her forehead and a laceration to her upper lip. The resident had some facial grimacing, so she was medicated with 650 mg of Tylenol. First-Aid was provided and pressure was applied to her upper lip. The resident's primary care physician was contacted, as well as the hospice physician. Resident #25 was sent to the hospital, and returned back to the facility on [DATE]; the laceration had already healed so treatment did not need to be provided. Nursing staff always communicated with hospice staff about residents' medical conditions, especially when a resident was on crisis care. Staff A said the Hospice nurse knew that she needed two people to assist with the resident, and that if she needed any help she could have asked nursing staff. When she asked the hospice nurse why she did not ask for any help, the hospice nurse said that she did not realize that the resident was so heavy. Interview with the Hospice Nurse (Staff P) on 11/09/2017 at 1:06 PM, via telephone, revealed she worked with resident #25 on 08/30/2017; she was not the resident's usual Hospice nurse, and she stated that she worked with whoever hospice services sent her to. The resident was on a crisis care, and someone had to be with her 24 hours a day. Staff P was performing ADL care on the resident before she was going to leave the facility. She said that before she started to bathe resident #25 she looked for a certified nursing assistant (CNA) to assist her, but she could not find one; she believed that they were all busy with their residents. As she was turning her, Staff P pulled resident #25 close to her to turn her, and then the resident rolled and fell on the floor. The resident was heavy and there was no way for her to lift up the resident. She went to the nurses' station, she got the nurse and then the nurse called for other staff to come and help them. The resident had some swelling on her forehead, and she had a small cut on the top of her lip. Resident #25 was placed in bed, and they put ice on the swelling. The hospice care team was notified, and the nurse came and wrote an incident report. The resident's family and physician were notified. Staff P did not know what happened after that, she finished caring for the resident, made sure that she was stable, and she left the facility. She never worked with the resident again after that. Staff P said that she was not aware that the resident required two staff members for assistance with transferring or repositioning. Whenever working with residents, hospice staff would ask nursing staff for assistance, but if they could not find anyone they would just do it on their own. When she went into the facility, no one informed Staff P that resident #25 required two person physical assistance, and there was no report given to her about the resident's ADL functional status. If she would have known this about the resident, she would have made sure someone was there to help assist her. Interview with the Certified Nursing Assistant (Staff N) on 11/09/2017 at 1:44 PM revealed, she was present on the day that resident #25 had her fall, 08/30/2017. When Staff N came to work that day, in the morning, she made her rounds as usual. The Hospice nurse sat in the room with the resident because the resident was on crisis care; this was the first time that she had saw the Hospice nurse. From her experience of working with the resident, the resident always required two people assisting her with transfers and repositioning. At no point did the Hospice nurse asked her for assistance with resident #25.