Every finding on record at Ruleme Center

Based on record review and interview, the facility failed to ensure residents' treatment choice for 1 of 4 residents reviewed, Resident #28.Findings include:Review of Resident #28's physician order dated 6/18/2024 read, [name of palliative care provider]: Resident/resident representative request no further weights to be obtained.Review of Resident #28's weight records revealed the resident's weights were obtained on 7/2/2024 (141.7 pounds), 8/2/2024 (139.5 pounds), 12/4/2024 (128.0 pounds), 10/2/2025 (132.3 pounds), 11/4/2025 (140.5 pounds), 12/4/2025 (139.4 pounds), and 1/7/2026 (133.2 pounds).During an interview on 1/22/2026 at 8:29 AM, Staff A, Licensed Practical Nurse, confirmed Resident #28's representative had requested no more weight to be obtained. Staff A was uncertain why Resident #28's weights had continued to be obtained after Resident #28's representative's request and a physician order not to obtain the weights.During an interview on 1/22/2026 at 10:02 AM, the Director of Nursing confirmed Resident #28 had a physician order for obtaining no more weight.

Based on observation and interview, the facility failed to provide a clean and homelike environment in 1 of 2 halls, Hallway 200.Findings include:During an observation of Resident #88's room on 1/20/2026 at 10:22 AM, the bathroom had a brown ring around the toilet, and there was a brown discoloring of a tile located in front of the toilet.During an observation of Resident #83's room on 1/20/2026 at 10:41 AM, the baseboards had a brown and black substance located on top of the baseboards around the entire room. There was black substance underneath and on top of the air conditioner. There was a white cloth with brown substance on the cloth with yellow, black and brown substances and peeling paint all around the top of the air conditioner, with dust like material and cobwebs protruding out of the air conditioner vents.During an interview on 1/20/2026 at 10:41 AM, Resident #83 stated, I never see the housekeeping or maintenance department in the room cleaning under, over, or inside the AC [Air Conditioner] and vents. Every time it pours rain outside, this room floods with water coming from the AC and the AC area itself. The facility puts large commercial grade air blowers in my room to dry the water after they are done attempting to clean it up with rags and mops.During an observation of Resident 123's room on 1/20/2026 at 10:44 AM, there were two large brown spotted streaks on the tile floor in front of and between the wheels of the resident's bed. There were brown spots. There were large scuffs and gashes on the wall, with chipping paint.During an interview on 1/20/2026 at 10:44 AM, Resident 123's Representative stated, My mother was admitted on [DATE] to facility and the brown streaks, the scuffs and gashes on the left side of the walls were already there when she was admitted . I do not feel like this is a home like environment.During an observation of Resident #52's room on 1/20/2026 at 10:46 AM, there was a large round brown substance ring around the toilet and scuffs/gashes in the walls of the resident's room.During an interview on 1/20/2026 at 10:46 AM, Resident #52 stated, The toilet has been like that for a long time. I use a wheelchair for mobility and think the wheelchair scrapes the sides of the wall to make gashes since there is not enough space between the wall and the beds.During an observation of Resident #27's room on 1/20/2026 at 11 AM, there was black substance below the air conditioner and dust around the air conditioning vents.During an interview on 1/20/2026 at 11:01 AM, Resident #27 stated, I have never seen housekeeping or maintenance clean the areas in or around his air conditioner since my admission.During an interview on 1/22/2026 at 11:46 AM, the Regional Maintenance Director and the Acting Maintenance Director acknowledged the environmental concerns in the resident rooms.During an interview on 1/22/2026 at 1:32 PM, the Environmental Director stated, The environmental department is responsible for cleaning baseboards, sweeping and mopping floors in resident rooms, cleaning air conditioning vents, and disinfecting all touchpoints, including bed rails, toilets, and bathrooms.During an interview on 1/21/2026 at 1:46 PM, the Administrator stated that his expectations for a clean homelike environment for each of the resident rooms would include clean baseboards, clean AC filters, vents and clean unstained floor tiles and clean and sanitized bathroom.

Based on record review and interview, the facility failed to coordinate assessments for the residents with newly evident or possible serious mental disorder and failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 of 4 residents reviewed for PASRR, Residents #9.Findings include: Review of Resident #9's admission record documented the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included psychophysiologic insomnia (onset date of 10/23/2025), major depressive disorder (onset date of 3/10/2025), post-traumatic stress disorder (PTSD) (onset date of 3/10/2025), nightmare disorder (onset date of 3/10/2025), and generalized anxiety disorder (onset date of 2/15/2025). Review of Resident #9's psychiatry note dated 11/13/2025 read, History of present illness: [Resident #9's name] is a [AGE] year old male with a psychiatric history of insomnia, depression, anxiety, and PTSD. Review of Resident #9's medical records showed a PASRR dated 12/25/2025, which documented no mental illness under Section I: PASRR Screen Decision-Making. During an interview on 1/21/2025 at 4:07 PM, the Director of Nursing stated, The diagnosis of depression, anxiety and PTSD have to be written on the PASRR. There is no policy for PASRRs.

Based on observation, interview, and record review, the facility failed to ensure residents received intravenous (IV) therapy consistent with professional standards of practice for 1 of 5 residents reviewed for medication administration, Resident #39.Findings include:During an observation on 1/21/2026 at 2:15 PM, Resident #39 was lying in bed, dressed in a hospital gown. The resident had a PICC (Peripherally Inserted Central Catheter) line on her right upper arm. The PICC line dressing was dated 1/19/2026 and there was a gauze pad under the dressing.Review of Resident #39's physician order dated 12/14/2025 read, PICC Line Right Arm: Change dressing within 24 hours of admission, insertion, or reinsertion and Q7 (every 7) days and PRN [as needed] thereafter using sterile technique. Measure arm circumference and external length of catheter.During an interview on 1/21/2026 at 4:45 PM, Staff C, Licensed Practical Nurse (LPN) Unit Manager, stated that if she were to do a central line dressing change, she would not use gauze, but gauze pads came in the central line dressing kits, and that was probably why Resident #39 had a gauze pad under her transparent PICC line dressing. During an observation on 1/22/2026 at 8:20 AM, Resident #39 had a PICC line on her right upper arm that was covered with a transparent dressing. A gauze pad was observed under the transparent dressing. The dressing was dated 1/19/2026.During an observation on 1/22/2026 at approximately 8:30 AM, Staff B, LPN, obtained a blood pressure reading by applying an electronic blood pressure cuff on Resident #39's right upper arm, directly over her PICC line.During an interview on 1/22/2026 at 11:00 AM, the Director of Nursing (DON) stated that she believed the standard of care was to change a dressing for a central IV line every 72 hours if there was gauze under the transparent dressing. During an interview on 1/22/2026 at 11:20 AM, the DON stated that the expectation was that staff was not to take blood pressure on the arm with a PICC line.During an interview on 1/22/2026 at approximately 2:00 PM, Staff B, LPN, stated that she was aware that it was not standard of care to take a blood pressure reading over a PICC line. Review of the facility policy and procedures titled Central Lines with the last review date of 1/14/2026 read, Guideline: Maintain central line care that is consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered plan, and the resident's goals and preferences. Procedure: 1. The central line should be monitored for patency and signs and symptoms of infection at least daily or per physician orders. Changes in residents' skin, pain, and/or signs of infection should be reported to the physician as soon as practicable. 2. Ensure infection control standards are maintained during the care of the central line including but not limited to: a. Change dressing routinely and per physician orders.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration and used appropriate personal protective equipment (PPE) while providing high contact care to the residents on enhanced barrier precautions (EBP) for 2 of 6 residents reviewed for medication administration, Residents #39 and #51, and failed to ensure respiratory care equipment were stored in a hygienic manner for 2 of 4 residents reviewed for respiratory services, Residents #73 and #98, to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 1/20/2026 at 10:47 AM, Resident #73's nebulizer mask and tubing was lying on the floor. During an interview on 1/20/2026 at 10:47 AM, Resident #73 stated, I completed the breathing treatment about an hour ago. I take breathing treatments at least 3 times a day. During an observation on 1/20/2026 at 1:57 PM, Resident #73's nebulizer mask and tubing was lying on the floor. Review of Resident #73's physician order dated 4/11/2025 read, Ipratropium-Albuterol Inhalation Solution 0.5–2.5 (3) mg [milligram]/3 ml [milliliter] (Ipratropium-Albuterol), 3 ml inhale orally four times a day for Chronic Obstructive Pulmonary Disease [COPD]. 2) During an observation on 1/20/2026 at 11:30 AM, Resident #98's nebulizer mask was hanging from the nebulizer machine, not covered, with the medication still in the chamber. During an interview on 1/20/2026 at 11:45 AM, Resident #98 stated that she received her breathing treatment early in the day and did not want to take it right then. During an observation on 1/20/2026 at 2:38 PM, Resident #98's nebulizer mask was hanging from the nebulizer machine, not covered. Review of Resident #98's physician order dated 4/18/2024 read, Ipratropium-Albuterol Inhalation Solution 0.5–2.5 (3) mg/3 ml (Ipratropium-Albuterol), 3 ml inhale orally every 6 hours as needed for COPD. During an observation on 1/21/2026 at 9:48 AM, Resident #98's nebulizer mask was hanging from the nebulizer machine, not covered. During an interview on 1/21/2026 at 8:55 AM, Staff B, Licensed Practical Nurse (LPN), stated, If residents refuse to take the nebulizer, then the medication should not be placed in the chamber until the resident is ready. The nebulizer needs to be covered after it has dried for storage. During an interview on 1/21/2026 at 9:08 AM, Staff C, LPN Unit Manager, stated, No medication should be left in the nebulizer chamber and the nebulizer mask needs to be covered for infection prevention. During an interview on 1/21/2026 at 4:55 PM, the Director of Nursing stated, The nurse should take the medication in the room and administer the nebulizer at that time and not leave the medication in the nebulizer chamber. The nebulizer has to be covered when not in use. Review of the facility policy and procedures titled Nebulizer with the last review date of 1/14/2026 read, Standard: The purpose of this procedure is to provide guidelines for nebulizer administration. General Guidelines. 4. Store nebulizer in tubing in a hygienic manner when not in use (i.e. labeling bags with date tubing was changed). 3) During an observation on 1/22/2026 at approximately 8:40 AM, Staff B, LPN, picked up an item off of the floor and disposed of it. Without performing hand hygiene, Staff B, LPN, removed Ferrous Sulfate 325 mg tablet from the medication cart and administered it to Resident #39. 4) During an observation on 1/22/2026 at 10:10 AM, Staff C, LPN, crushed four tablets and diluted them in water and administered them to Resident #51 via G-tube (gastrostomy tube). Staff B did not wear a gown for administration of the medication. During an interview on 1/22/2026 at 10:15 AM, Staff B, LPN, stated, When residents are on EBP, appropriate PPE is to be used for any direct contact. If a resident has a G-tube, a gown should be worn during medication administration, as it was direct contact. Staff B confirmed that she had not performed hand hygiene between picking an item up off of the floor, disposing of it, and administering an oral medication to Resident #39. During an interview on 1/22/2026 at 11:00 AM, the Director of Nursing (DON) stated, A gown is to be worn by a nurse administering medications via G-tube, and hand hygiene is to be performed prior to medication administration. Review of the facility policy and procedures titled Enhanced Barrier Precautions with the last review date of 1/14/2026 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . g. device care or use (central line, urinary catheter, feeding tube. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/14/2026 read, Standard: Medications are ordered and administered safely and as prescribed. Procedure. 19. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on observation, interview, and record review, the facility failed to ensure staff used proper personal protective equipment (PPE) while providing high contact care to the residents on enhanced barrier precautions (EBP).to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 1/30/2025 at 10:00 AM, Staff A, Licensed Practical Nurse (LPN), was administering medications into Resident #4's gastric tube. Staff A had gloves. Staff A did not have a gown. There was an Enhanced Barrier Precautions signage on the door. There were personal protective equipment in the hallway, containing gowns and masks. During an interview on 1/30/2025 at 10:15 AM, Staff A, LPN, stated, I wore gloves. I sometimes wear gowns. During an interview on 1/30/2025 at 2:10 PM, the Assistant Director of Nursing (ADON) stated, They have to have all the PPE, the gloves, the gown, the mask, and any additional items that they might require. Review of the facility policy and procedure titled Standards and Guidelines: Enhanced Barrier Precautions issued in March 2024 showed it read, Definitions: Enhanced Barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organism resistant organisms that employs targeted gown and glove use during high contact resident care activities . Procedure: 1. Enhanced Barrier Precautions (EBP) are used for residents with any of the following . b. Wounds and/or indwelling medical devices, even if the resident is not known to be colonized with MDRO [multidrug-resistant organism] . 6. Indwelling Medical Devices include the following: a. Central lines (excluding dialysis catheters), b. Urinary catheters (excluding condom catheters), c. Feeding Tubes, d. Tracheostomies . 10. Employees should wear appropriate PPE when performing the following duties for residents requiring EBP: a. Dressing, b. Bathing/Showering, C. Transferring, d. Providing hygiene, e. Changing linens, f. Providing pericare such as changing briefs, g. Toileting, h. Device care, i. Wound care.

Based on observation, interview, and record review, the facility staff failed to ensure residents were administered oxygen as per physician order for 1 of 3 residents reviewed for respiratory care (Resident #13). Findings include: Review of Resident #13's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included anemia, unspecified, dysphagia following cerebral infarction (a stroke), aphasia (inability to speak) following cerebral infarction, quadriplegia, unspecified, type 2 diabetes mellitus with other circulatory complications, unspecified protein-calorie malnutrition, status gastrostomy, occlusion and stenosis of right vertebral artery, essential (primary) hypertension, and dependence on supplemental oxygen. Review of Resident #13's physician order dated 5/21/2024 showed it read, Respiratory-Oxygen: NC [nasal cannula]/mask continuous. Encourage and assist resident to us O2 [oxygen] @ [at] 2 LPM [liters per minute] via nasal cannula continuously for every shift for CVA [Cerebral Vascular Accident] related to other sequalae of cerebral infarction. During an observation on 8/19/2024 at 10:44 AM, Resident #13 was resting in bed, was being administered oxygen via nasal cannula. The oxygen concentrator was set at 4 liters per minute. The oxygen concentrator was at the head of the bed on the resident's right side, outside the reach of the resident. During an observation on 8/20/2024 at 2:16 PM, Resident #13 was resting in bed, was being administered oxygen via nasal cannula. The oxygen concentrator was set at 4 liters per minute. The oxygen concentrator was at the head of the bed on the resident's right side, outside the reach of the resident. During an observation on 8/20/2024 at 2:18 PM, Staff A, Registered Nurse (RN), verified Resident #13's oxygen concentrator was running at 4 liters per minute. During an interview on 8/20/2024 at 2:18 PM, Staff A, RN, stated, That is not correct [the oxygen rate]. It should not be on 4 liters it is ordered for 2 liters. I should check it every day when I see a resident if they are on oxygen. Review of Resident #13's progress notes from 8/14/2024 through 8/20/2024 showed no documentation indicating the need to increase oxygen or any change in Resident #13's respiratory status. Review of Resident #13's care plan showed it read, Focus: [Resident #13's name] is at risk for altered respiratory status/difficulty breathing r/t [related to] gastrostomy status, CVA, dysphagia . Interventions . Administer oxygen as ordered . Date Initiated: 05/22/2024. During an interview on 8/22/2024 at 12:19 PM, the Director of Nursing (DON) stated, I expect staff to assess residents on oxygen at a minimum daily and make sure that we are following the orders for correct oxygen administration. Review of the facility policy and procedure titled Oxygen Administration with the last revision date of 12/2023 read, Standard: The purpose of this procedure is to provide guidelines for oxygen administration . General Guidelines: 1. Oxygen therapy is administered by way of oxygen mask, nasal cannula and/or other device per physicians' orders and/or facility protocol.

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 1 of 2 residential halls, Hall 100. Findings include: During an observation on 8/19/2024 at 9:49 AM, Resident #9 was in her room lying in bed. There was a plastic cup lid turned up on the bedside table containing five different pills. On 8/19/2024 at 9:49 AM, an interview was attempted with Resident #9 related to the medications observed on the bedside table. Resident #9 stated, You want them? During an interview on 8/19/2024 at 9:52 AM, Staff A, Registered Nurse (RN) confirmed the medications at bedside and verified the plastic cup lid on the bedside table did contain five pills. During an interview on 8/19/2024 at 9:55 AM, Staff A, RN, stated that she passed the medications to Resident #9 at 9:00 AM, and identified the medications as Resident #9's Trazodone, Iron Pill, Clopidogrel, blood pressure medication, and Isosorbide pill. Staff A stated she did not leave the medications at bedside and pointed out that the medications were moist where evidently [Resident #9's name] had spit the pills back out. Staff A stated, I should have made sure she swallowed her pills, and I didn't do that. Review of Resident #9 medical records showed diagnoses including unspecified sequelae of cerebral infarction, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, generalized muscle weakness, type 2 diabetes mellitus with neuropathy, repeated falls, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #9's Minimum data Set (MDS) showed Brief Interview for Mental Status (BIMS) summary score of 3 [indicating severe cognitive impairment]. Review of Resident #9's physician orders did not provide for a physician order for the resident to self-administer medications. Review Resident #9's MAR (medication administration record) for 8/19/24 read, 9:00AM medications were administered and initialed by Staff A. Review of Resident #9's care plan initiated on 1/4/2023, showed it read, [Resident #9's name] has a communication problem r/t dx [related to diagnosis] of dementia, is at elopement risk/exit seeker related to episode of wandering, cognitive impairment, and impaired safety awareness, has potential for behaviors of: restlessness and getting out of bed without assistance; hitting staff, yelling at staff. She is noted not to remain in her room when on isolation. She has been noted to spit out medications, eat her food and then state another resident ate it and demand more food; knocks/pushes meal trays of other Resident's off dining table and onto floor; throwing wash cloth on face of another resident while they were sleeping, resident is resistive to care/refusing care related to dementia. She will decline administration medications and insulin checks, refusing insulin, refusal of labs, spitting out medications. During an interview on 8/22/2024 at 9:03 AM related to the residents' ability to self-administer their medications, the Director of Nursing (DON) stated that any nurse can complete an assessment for alert and oriented residents that wish to self-administer their own medications. The DON stated that Resident #9 was not able to self-administer her own medications due to her cognitive impairment and inability to do so. During an interview on 8/22/2024 at 11:14 AM, related to her expectations of nurses passing medications, the DON stated it is her expectations that all nurses passing medications apply the five rules that include, right patient or resident, right drug, right dosage, right route, and the right time. The DON stated that nurses are expected to ensure residents take the administered medications and the documentation is completed in the medication administration record (MAR). Review of the policy and procedure titled Self-Administration of Medication, last reviewed 3/11/2024, read, 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician/clinician. 2. Should the resident's attending physician/clinician permit the resident to administer his/her medication(s), the following condition should apply: a. A self-administration of medications evaluation will be completed that indicates that the resident is capable of self-administering drugs. This is to be completed quarterly and as needed with resident cognition or physical ability changes. b. Storage of medications in the resident's room must be such that it will prevent access by other residents, c. Only the medications permitted for self-administration shall be left at the bedside. Review of the policy and procedure titled Standards and Guidelines: Medication Administration, last reviewed 1/2024, read, Medications are ordered and administered safely and as prescribed. Procedure: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 21. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview, and record review, the facility administration failed to assume full responsibility for the day-to-day operations of the facility by allowing unlicensed staff to work outside the accepted professional standards and current federal, state, and local regulations to ensure the highest degree of quality care was maintained. The facility administration failed to verify the licensure status of a nurse prior to employment who was found to not have a valid Florida license as a registered nurse. Findings include: Review of personnel records showed Staff A, Registered Nurse, was hired by the facility as a qualified Registered Nurse on 6/11/2024 and was scheduled to work in the facility as a Registered Nurse. Review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed Staff A, RN, was not licensed as a Registered Nurse in the State of Florida. During an observation on 8/19/2024 at 9:00 AM, Staff A, RN, was working at a medication cart in the facility. Staff A had a name tag denoting a position of Registered Nurse. Review of a document from [name of an out of state university] read, Be it known that [Staff A's name] having given satisfactory evidence of the completion of professional and other requirements prescribed by law is qualified to practice as a Registered Professional Nurse in the [name of the state in which Staff A is qualified to work] in witness whereof the education department grants this license under its seal at [name of the city and state] this [date of issuance]. During an interview on 8/22/2024 at 11:30 AM, the Administrator stated, I was not the administrator at the time [Staff A's name] was hired. It is her expectation that all staff offered employment are fully qualified to perform the duties outlined in their job description. I rely on the human resources department to fully vet prospective employees to ensure that residents receive the care and services they need by a qualified individual and to notify her of any discrepancies found prior to an offer of employment. During an interview on 8/21/2024 related to expectations for nurses, the Director of Nursing (DON) stated that it is her expectation that any staff offered employment, are fully vetted by the Human Resources department before an offer for employment letter is sent out. The DON stated that it was her understanding that Staff A was a Registered Nurse and qualified to work in the facility. During an interview on 8/22/2024 at 12:03 PM, the Human Resources Director stated that she had personally interviewed and accepted the application for Staff A, RN. The Human Resources Director stated she then went to the e-web site to check the [out of state name] license and did not see the box to check for a decision of whether the license was only for the [name of the state it was issued for] or if it was a multi-state license. The Human Resources Director stated Staff A would have had 60 days to get a Florida license and it ended August 10, 2024. The Human Resources Director verified Staff A was working in the facility beyond the expiration date of August 10, 2024. An interview was conducted via telephone on 8/22/2024 at 1:34 PM with Staff A related to her license for the State of Florida. Staff A stated, I was so confused and thought I just had to submit for a license and not have to actually have the license to be able to work [in Florida]. Staff A confirmed that she had been working through her scheduled shift on 8/19/24 in the facility as a Registered Nurse. Review of the job description titled, Administrator read, The Administrator administers, directs, and coordinates all functions of the facility to assure that the highest degree of quality of care is consistently provided to the patients. Responsibilities include, recruits and trains team members to create and maintain a highly functioning team environment and maintains high customer satisfaction. Supervises all departments within the facility. Review of the job description titled, Director of Nursing read, Executes the goals and objectives of the nursing department in regards to patient/resident rights, patient/resident care and reflects the mission statement of the facility. Serves as a role model to nursing staff while facilitating outcomes-based care delivery, cost management, and enhanced customer satisfaction within the context of an interdisciplinary framework. Provides leadership and direction for the nursing staff while being responsible for the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. Responsibilities include, interpret and execute administrative, nursing and resident/patient care policies. Ensure compliance with government and accrediting agency standards and regulations pertaining to Nursing. Ensure that all nursing personnel comply with the written policies and procedures established by the department and the facility. Establish and maintain qualifications and functions for each nursing position. Ensure resident safety in accordance with resident safety programs. Review of the job description titled, Human Resources Manager read, The human resources manager is responsible for performing HR-related duties in the following functional areas: benefits administration, employee relations, training, performance management, onboarding, policy implementation, recruitment/employment, and employment law compliance. Responsibilities include Screens and recruits job applicants to fill professional and technical job openings. Create new hire offer letters. Run exclusions, license checks and criminal background checks, employment verifications, and reference checks. Maintains compliance with federal, state and local employment and benefits laws and regulations. Review of the Florida Department of Health Division of Medical Quality Assurance a form titled Important Updates Regarding Nurse Licensed Outside of Florida dated August 8, 2021 read, Section 464.022(8), Florida Statutes, provides that a nurse who is currently licensed in another state or territory of the United States may perform services in Florida for a period of 60 days after furnishing the employer satisfactory evidence of current licensure in another state or territory and by having submitted proper application and fees to the Florida Board of Nursing for licensure prior to employment.

Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for 1 of 3 residents reviewed for wound care, Resident #13. Findings include: Review of Resident #13's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included necrotizing fasciitis, stage 4 pressure ulcer of sacral region, anemia, dysphagia following cerebral infarction (a stroke), aphasia (inability to speak) following cerebral infarction, quadriplegia, type 2 diabetes mellitus with other circulatory complications, occlusion and stenosis of right vertebral artery, essential (primary) hypertension, and dependence on supplemental oxygen. Review of Resident #13's physician order dated 4/26/2024 read, Cleanse wound to sacrum with normal saline, pat dry, apply calcium alginate to wound bed, cover with silicone border foam every day shift for sacral wound. Review of Resident #13's Medication Administration Record (MAR) for April 2024 showed treatment was not documented as completed on 4/28/2024 and 4/30/2024. Review of Resident 13's physician order dated 5/2/2024 read, Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) Apply to sacrum topically every day shift for sacral wound. Cleanse wound to sacrum with Dakin's, pat dry, apply calcium alginate to wound bed, cover with silicone border foam. Review of Resident #13's MAR for May 2024 showed treatment was not documented as completed on 5/5/2024, 5/10/2024, 5/15/2024 and 5/16/2024. Review of Resident #13's physician order dated 5/23/2024 read, Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) Apply to sacrum topically every day shift for sacral wound. Cleanse wound with Dakin's, pat dry, apply collagen powder to wound bed, pack with Dakin's moist kerlex, cover with silicone border foam. Review of Resident #13's MAR for June 2024 showed treatment was not documented as completed on 6/21/2024. Review of Resident #13's physician order dated 6/24/2024 read, Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) Apply to sacrum topically every day shift for sacral wound Cleanse wound with Dakin's, pat dry, apply collagen powder to wound bed, pack with Dakin's moist kerlex, cover with silicone border foam. Review of Resident #13's MAR for July 2024 showed treatment was not documented as completed on 7/31/2024 and documented as 9 (other see nurses notes). Review of medical records showed no note related to wound care on 7/31/2024. Review of Resident #13's MAR for August 2024 showed treatment was not documented as completed on 8/1/2024, 8/5/2024, 8/6/2024, 8/7/2024, 8/9/2024 and 8/13/2024. During an interview on 8/22/2024 at 9:38 AM, Staff B, Licensed Practical Nurse (LPN), stated, When wound care is done, it should be signed off on the MAR as soon as it is done. We have to document all our treatments. If they refuse, we need to document that too. During an interview on 8/22/2024 at 10:00 AM, Staff C, Registered Nurse (RN), stated, All dressing changes should be documented when they are done. During an interview on 8/22/2204 at 10:15 AM, the Director of Nursing (DON) stated, Every time a dressing is done, it should be documented. Review of the policy and procedure titled, Documentation with the last revision date of 1/2024 read, Guideline: Services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Procedure . 2. The following information is to be documented in the resident medical record . c) Treatments or services performed . 8. Documentation of procedures and treatments will include care specific details, including: a) the date and time the procedure/treatment was provided; b). The name and title of the individual(s) who provided the care.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration for 6 of 9 medication administration observations to prevent the possible spread of infection and communicable disease. Findings include: During an observation on 8/20/2024 at 8:37 AM, Staff A, Registered Nurse (RN), was exiting a resident's room after administering medications to the resident. Staff A did not perform handy hygiene and returned to the medication cart. Staff A prepared Resident #86's medications, reached into her uniform pocket, removed keys and locked the medication cart. Staff A entered Resident #86's room, did not perform hand hygiene, administered the medications, exited the room without performing hand hygiene and returned to the medication cart to prepare another resident's medications. During an observation on 8/20/2024 at 8:44 AM, Staff A, RN, was returning to the medication cart after administering medications to Resident #86. Staff A reached into her pocket, removed the keys and unlocked the medication cart without performing hand hygiene. Staff A prepared Resident #54's medications, entered the resident room, administered the medications and exited the resident's room without performing hand hygiene. Staff A returned to the medication cart and began preparing another resident's medications. During an interview on 8/20/2024 at 9:00 AM, Staff A, RN, stated, I should have used the hand sanitizer when I got meds and after I got meds to the residents. During an observation on 8/21/2024 at 8:39 AM, Staff D, Licensed Practical Nurse (LPN), returned to the medication cart after administering medications to a resident, reached in her pocket, removed the keys, and unlocked the medication cart. Staff D removed a hair tie from her hair, flipped her hair, touching her hair with both hands and prepared medications for Resident #83 without performing hand hygiene. Staff D donned gloves without performing hand hygiene and entered Resident #83's room and administered the medications, doffed gloves and returned to the medication cart without performing hand hygiene. During an interview on 8/21/2024 at 9:00 AM, Staff D, LPN, stated, I should have washed my hands before and after I put on gloves. I didn't realize that I pulled out my hair tie. During an observation on 8/22/2024 at 5:02 AM, Staff E, LPN, moved the medication cart to Resident #105's doorway, reached into her uniform pocket, removed the keys, unlocked the medication cart and typed her password into the computer and began preparing medications for Resident #105 without performing hand hygiene. Staff E entered Resident #105's room without performing hand hygiene, assisted the resident by elevating the head of the bed with the bed control and administered the medications, and exited the room, returning to the medication cart without performing hand hygiene. During an observation on 8/22/2024 at 5:06 AM, Staff E, LPN, returned to the medication cart, reached into her uniform pockets, removed the keys, unlocked the medication cart, touched the computer keyboard and began preparing Resident #17's medications without performing hand hygiene. Staff E locked the medication cart, entered Resident #17's room and administered the medications without performing hand hygiene. Staff E exited the room returning to the medication cart without performing hand hygiene and began preparing another resident's medications. During an observation on 8/22/2024 at 5:11 AM, Staff E, LPN, returned to the medication cart, reached into her uniform pockets, removed the keys, unlocked the medication cart, touched the computer keyboard and began preparing Resident #83's medications without performing hand hygiene. Staff E locked the medication cart, entered Resident #83's room and administered the medications without performing hand hygiene. Staff E exited the room returning to the medication cart without performing hand hygiene and began preparing another resident's medications. During an interview on 8/22/2024 at 5:20 AM, Staff E, LPN, stated, I should have washed my hands. I just got nervous. During an interview on 8/22/2024 at 6:30 AM, the Director of Nursing (DON) stated, I expect that all nurses follow our infection control policy for hand washing. Review of the policy and procedures titled Medication Administration with the last revision date of 1/2024, read, Procedure . 19. Staff follows established infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the policy and procedure titled Hand Hygiene Infection Control with the last approval date of 1/2024 read, Standard: Hand hygiene is the single most important measure for preventing the spread of infection. Guideline: This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated . Procedure: The facility acknowledges the CDC (Centers for Disease Control) guidelines to improve adherence to hand hygiene in health care settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in health care settings to promote resident safety. These guidelines state that hand washing is necessary when healthcare personnel's hands are visibly soiled. When the hands are not visibly soiled, the CDC recommends the use of alcohol-based hand rubs by health care personnel for resident care to address the obstacles that health care professionals face when taking care of residents. Situations that require hand hygiene include, but are not limited to . Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). Review of the policy and procedure titled General Dose Preparation and Medication Administration with the last approval date of 12/29/2023, read, Applicability: The Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to the facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications. Procedure . 2. Prior to preparing or administering medications, authorized and competent facility staff should follow facilities infection control policy (e.g., hand washing).

Based on record review, interview, and policy and procedure review the facility failed to ensure the residents rights were honored by failing to provide an opportunity to formulate advance directives. Resident #1's advance directive for Do Not Resuscitate (DNR) was not honored by the facility when they failed to obtain clarification of code status during the admission process, per facility policy. This failure resulted in the resident experiencing serious psychosocial harm by not honoring the resident's wishes for a natural, dignified death. Successful Cardiopulmonary Resuscitation (CPR) may result in major physical trauma including broken ribs, lung bruising, damage to the airway and internal organs, and internal bleeding. Along with the physical trauma, residents who receive CPR may have to deal with serious long-term consequences like possible brain damage from oxygen deprivation. Findings include: Review of Resident #1's Admission Record documented an admitted [DATE] with the following diagnoses: enterocolitis due to Clostridium difficile, unspecified kidney failure, unspecified urinary retention, unspecified dementia (unspecified severity without behavioral disturbances psychotic disturbance mood disturbance and anxiety), and Alzheimer's disease. Review of the form titled Medical Certification for Medicaid Long Term Care Services and Patient Transfer [Also known as Form 3008] dated [DATE], reads, Section H: Advance Care Planning: Do Not Resuscitate (DNR) was not checked yes or no, left blank. Review of the form titled Admission Readmission Nursing Evaluation dated [DATE], at 18:17 (6:17 PM) authored by Staff A, Licensed Practical Nurse (LPN) reads, Section VIII: Baseline Care plan: Section B. Social Service Advanced Directives. Code Status/Advanced Directives 1. Does the resident have advance directives b. Full Code (wants CPR) was documented. 2. Advanced Directives reviewed with Resident/Representative: a. Yes was documented. Review of the document titled Consent To Treat dated [DATE], no time, reads: Telephone consent per [Resident representative's name] was signed by Staff A, LPN and Staff C, Registered Nurse (RN). Review of the document titled Informed Consent for Pneumococcal Vaccine for Resident #1 dated [DATE], no time documented, reads: Per [Resident representative's name] and was signed by Staff A and Staff C. Review of the document titled Informed Consent for Resident Influenza Immunization for Resident #1 with no date or time reads, Per [Resident representative's name] and was signed by Staff A and Staff C. Review of the document titled COVID-19 [Coronavirus 2019) Vaccination/Booster for Resident #1 dated [DATE] no time reads, Per [Resident representative's name] and was signed by Staff A and Staff C. Review of Resident #1's progress notes documented no social services notes within the medical record. Review of Resident #1's electronic medical record [emr] documented the form titled Internal Medicine progress note dated [DATE], scanned in date [into emr] [DATE], reads, Assessment: septic shock due to urinary tract infection Proteus mirabilis on urine culture, right lower lobe pneumonia, history of hypertension, history of coronary artery disease, history of TIA (Transient Ischemic Attack), acute chronic CKD (kidney disease), acute pulmonary insufficiency, improving, advanced age, dementia. Plan: continue with PO (by mouth) antibiotics as per infectious disease, CM (case management) to coordinate SNF (skilled nursing facility), replace magnesium as per protocol, daily labs, PT (physical therapy)/OT (occupational therapy)/DVT (deep vein thrombosis)/GI (gastrointestinal) prophylaxis as appropriate, home medications as appropriate, further pending patients' clinical course and recommendations by consultant's plan of care discussed with patient family at bedside all questions answered. Code Status documented as DNR. Review of the handwritten document titled Code Blue Response worksheet dated [DATE] at 11:46 AM reads: Resident Name: [Resident #1's name], Date: [DATE], Time 11:46 AM, Location of code: Resident #1's room, Nurse in charge of code: [Staff name], Code status verified by: [Staff Name], EMS (Emergency Medical Services)/911 notified (time): 11:47 AM, EMS arrival time: 11:51 AM. MD (Medical Doctor) or ARNP (Advanced Registered Nurse Practitioner) [sic] present: No, Crash cart present: yes, Pulse present: No, Breathing: No, Chest compressions initiated: yes, Time: 11:47 AM by Whom [Staff Name], Rescue breathing initiated: Yes, Ambu mask: checked Time: 11:47 AM Vital signs, heart rate 0, BP (blood pressure) 0, respiratory rate 0, SPO2 (oxygen saturation) 77%, blood sugar unable to read, Number of CPR cycles completed: 5, Resuscitation terminated at 12:08 PM, paramedics took over at 11:52 AM. Regain pulse: No, Regain breathing: No, Conscious: No, Transferred to: not applicable, will transfer to funeral home once family arrives. Review of the nursing progress note dated [DATE] at 1308 (1:08 PM) authored by Staff D, LPN reads, resident was observed unresponsive, chart was checked confirmed to be FULL CODE. paged code blue and 911 was called CPR was started at 11:47. AED (automatic external defibrillator) was applied. No shock advised. Continued CPR until EMS arrived and took over at 1152. Family was called, paramedics continued CPR until 1208 and he was then pronounced dead. family was still on phone and was updated about passing. MD aware and received order to release body to funeral home, [Funeral Home's Name] was called and arrived to pick up body at 1445 (2:45 PM), family was with patient upon release. During an interview on [DATE] at 9:10 AM the Administrator stated, I am aware of this [incident with Resident #1], we did a report, immediate and 5 day. The information we had to work with was not clear on the 3008. I can't tell you why this occurred. We did complete an RCA (Root Cause Analysis) and PIP (Performance Improvement Plan) to make certain this would not happen again. We have fully implemented this plan. During a telephone interview on [DATE] at 10:00 AM, Resident #1's representative stated, I explained that he was a DNR when they called to let us know he was coding. He was a DNR at the hospital. No one called me or asked me about his code status. They did not call me the day he got there or any other time about whether he was a DNR. We came in to see him and no one asked us. I was very upset that they did this. He did not want CPR done. I don't really understand how this happened. They should have either gotten this from the hospital or asked me. They did not have any discussion about whether he was a DNR. I learned about this when the Director of Nursing called and told me that they were doing CPR, that's when I told them, he was a DNR. It was very distressing. He was a [AGE] year-old man, and they probably did more harm than good when they did that. I was called by the nurse that night he went there and asked for a consent to treat and about immunizations for the flu and pneumonia. So, I really can't understand why they didn't ask about that [advance directives]. During an interview on [DATE] at 10:45 AM, the Director of Nursing (DON) stated, I found out that the resident [Resident #1] had a DNR when I called his [resident representative] when he was coding and that was when she told me that he was a DNR. We did realize that there was a progress note scanned into the system that stated DNR after we began to investigate this. The nurses, I guess, went by the 3008 which checked no advanced directives and DNR was not checked yes or no. I was aware that they documented on the admission that he was a full code and that was discussed with him or his family. No call was made to verify his wishes and he was not able to make that decision. Social services did not call and discuss advance directives with the family, they should have. Our policy is that on admission we obtain advance directives, and we did not do this. I think that the Social Service Director usually does advanced directives with the MDS (Minimum Data Set) [coordinator] on day 5. That is too long to wait for that to be done, it should be done on the day of admission. We should be doing them on admission. I did see the physician progress note that stated he was a DNR that was scanned into the system before he arrived. It was available for anyone to review. The nurses and the Social Services Director do have access to that scanned document. We did a QAPI (Quality Assurance Performance Improvement) on that same day and identified that we had opportunities to have determined what his and his representative's wishes were for advanced directives. The nurse did not call and verify the code status on admission when the 3008 was incorrect. I don't know if the nurse actually got report from the hospital. Our Social Service Director did not see the resident after admission, they did not address advanced directives with his representative. During an interview on [DATE] at 3:30 PM, the Medical Director stated, I was aware that [Resident #1's Name] was coded, and I understand that was not his representative's wishes. I do think that we should have determined his wishes for resuscitation prior to his death and we did identify that the information provided by the hospital was incomplete and we really should have called and verified with his family whether or not he was a full code based on the inaccurate documentation. During an interview on [DATE] at 3:45 PM, Staff A, LPN stated, I did not get report from the hospital on this patient [Resident #1]. I looked at the 3008 and it did not indicate DNR or the code status. The DNR was not filled in at all, so I just looked at [it] as he was a full code. I did not call and ask his representative, his family if he was a DNR or full code. He was confused and not able to tell me, so I should have called them and asked. I just don't have a good enough reason why I didn't. I did get verbal consent to treat, flu, pneumonia, and COVID-19 consents over the telephone from his [representative]. I don't know if it was overly busy that evening. I don't know why I did that. I did document that I called the representative on the admission form, but I did not do that for the advance directives. I should not have documented that. During an interview on [DATE] at 4:10 PM, Staff C, RN stated, I did witness the consents for [Staff A's name] on ,d+[DATE] if I signed them. I do not recall her asking about advanced directives when we did that. I did not complete his admission that evening and did not know whether or not he was a full code. I can't remember what time that call was. During an interview on [DATE] at 3:15 PM Admissions Director stated, I did speak with [Resident #1's representative] and review the admission packet with her. I will usually let the residents or families know about the physician services, payor sources, and any copays. I review if the resident has a POA [Power of Attorney], she indicated that she did, and I requested the paperwork be provided to us. I did review the Advance Directives portion with her. She did tell me that he was a DNR, and I explained that I needed the form, the yellow DNR form and that she needed to provide the Social Services Director and the nurses with this information. I can't recall what date exactly that I spoke to her, but I know that the date she electronically signed it was different then the date I actually spoke to her. She told me that she would get in touch with social services to address the DNR, at least I think she did. I did not reach out to his nurse or to the social service department or Social Service Director. I really should have. I really can't say why I didn't follow up, there really is no excuse for this. I don't generally get advanced directives signed, that is the responsibility of the Social Service Director, but I really should have completed this. I should have followed up with social services after our discussion. It was simply a lack of communication all the way around. During a telephone interview on [DATE] at 5:05 PM Resident #1's representative stated, I did speak with the admissions person about the admission package, that I needed to sign it electronically. They did talk to me about his advanced directives. I did tell them that he was a DNR, and she told me that I needed to bring in the yellow form I had and talk to the nurses and social services about this. That's why I thought they knew he was a DNR. Review of the policy and procedure titled, Advanced Directives Code Status, last revision date of ,d+[DATE] reads, Standard: It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate orders in accordance with State and Federal regulations. Guideline: Admission/Readmission: Code Status verified upon admission with resident/representative by admitting nurse. Nurse reviews code status with the resident/representative and confirms decision with the attending physician (MD). DNR: Admitting nurse must review with resident/representative with a witness present (preferably another nurse or social services). Review of the policy and procedure titled, Admissions Policies, last reviewed [DATE], reads: Policy Interpretation and Implementation. 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. 3. The objectives of our admission policies are to: d. Review with the resident, and/or his/her representative (sponsor), the facility's policies and procedures relating to resident rights, resident care, financial obligations, visiting hours, etc. The Immediate Jeopardy was verified as removed on [DATE] and substantial compliance was confirmed on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of the immediacy to prevent the likelihood of serious psychosocial harm and/or possible serious injury when the facility provided evidence of the actions taken to remove the immediacy to include conducting a root cause analysis, assessment of all current residents for the formulation of advanced directives, training of licensed staff in the admission process for obtaining advanced directives and the advanced directives policy and procedure encompassing aspects such as the Do Not Resuscitate (DNR) process for new admissions, readmissions, cases of existing DNR, changes to DNR status, and revocation of DNR. It also covered the importance of reviewing the admission packet for any advanced directive, the protocol for situations where a resident is unable to make decisions (including contacting the responsible party to confirm code status), and the correct procedure for obtaining a physician's order for advanced directives as evidenced by the following: On [DATE], an Ad Hoc [when necessary or needed] QAPI meeting was held with 15 members present to include the Administrator, DON, Medical Director [via telephone], Infection Control & Prevention Officer, Labor Coordinator, Social Worker, Maintenance, Unit Manager Northbrook, Evening Manager, Unit Manager Southbrook, Social Services Assistant, Activities Assistant, and Certified Dietary Manager to develop a Performance Improvement Plan based on the identified Root Cause Analysis. On [DATE], Staff A, LPN, received 1on 1 education from the Director of Nursing on the policies and procedures related to advanced directives, encompassing aspects such as the Do Not Resuscitate (DNR) process for new admissions, readmissions, cases of existing DNR, changes to DNR status, and revocation of DNR. It also covered the importance of reviewing the admission packet for any advanced directive, the protocol for situations where a resident is unable to make decisions, including contacting the responsible party to confirm code status. On [DATE], the Social Services Director received 1on 1 education from the Director of Nursing on identification advanced directives, including code status upon admission and measures for appropriate follow-up to guarantee the implementation of these directives. On [DATE], the Admissions Director received 1 on 1 education from the Director of Nursing on promptly notifying the nursing staff and/or social services about any advanced directives communicated by patients or their responsible parties, either before or after admission. On [DATE], all current licensed staff, 34 of 34, received education from the Director of Nursing and the Unit Manager on the policies and procedures related to advanced directives, encompassing aspects such as the Do Not Resuscitate (DNR) process for new admissions, readmissions, cases of existing DNR, changes to DNR status, and revocation of DNR. It also covered the importance of reviewing the admission packet for any advanced directive, the protocol for situations where a resident is unable to make decisions (including contacting the responsible party to confirm code status), and the correct procedure for obtaining a physician's order for advanced directives. On [DATE], all additional staff, 91 of 91, received education from the Director of Nursing and the Unit Manager regarding the policy and procedure related to advanced directives. On [DATE], the Assistant Director of Nursing, Northbrook Unit Manager, Southbrook Unit Manager, Weekend Supervisor, Evening Supervisor, LPN MDS Coordinator and RN MDS Assessor received 1on 1 education from the Director of Nursing on the policies and procedures related to advanced directives, encompassing aspects such as the Do Not Resuscitate (DNR) process for new admissions, readmissions, cases of existing DNR, changes to DNR status, and revocation of DNR. It also covered the importance of reviewing the admission packet for any advanced directive, the protocol for situations where a resident is unable to make decisions (including contacting the responsible party to confirm code status), and the correct procedure for obtaining a physician's order for advanced directives. Review of the follow up Ad Hoc QAPI meeting conducted on [DATE], the committee reviewed the audits completed to date with 2 audits completed with no deficient practice identified. The committee reviewed staff training to date. At the time of the meeting, 107 of 125 staff had received education. No newly hired employees were onboarded between [DATE] and [DATE]. The committee discussed agency education to date, noting all 29 agency employees (25 Certified Nursing Assistants and 4 LPNs) received advanced directive education. Based on results of audits and training to date, the committee recommended continued audits of all admissions and readmissions as well as continued education until all staff had completed education. The committee also recommended ongoing new hire and agency education. Review of the follow up Ad Hoc QAPI meeting conducted on [DATE], the committee reviewed audits completed to date with 13 audits completed with no deficient practice identified. At the time of the meeting 125 of 125 staff had received education. Six newly hired employees were onboarded between [DATE] and [DATE], 6 of 6 new hires received advanced directive education. Based on results of audits and training to date, the committee recommended continued audits of all admissions and readmissions as well as continued new hire/agency education. During staff interviews on Interviews were conducted with 11 licensed nurses, 14 Certified Nursing Assistants and 5 additional ancillary staff (Physical Therapy Assistants, Occupational Assistants) the Social Services Director, and Admissions Director for verification of training provided for advanced directives and verified having received education and verbalized understanding of all aspects of the facility policies and procedures related to advanced directives.

Based on interview and record review the facility failed to promptly notify the physician or advanced registered nurse practitioner of critical laboratory results in accordance with professional standards of practice for 1 out of 3 residents reviewed for physician notification of laboratory results. (Resident #1) Findings include: Review of Resident #1's Admission Record documented an admitted [DATE] with the following diagnoses: enterocolitis due to Clostridium difficile, unspecified kidney failure, unspecified urinary retention, unspecified dementia (unspecified severity without behavioral disturbances psychotic disturbance mood disturbance and anxiety), and Alzheimer's disease. Review of the physician order for Resident #1 dated 11/15/2023 read: CBC (complete blood count), CMP (comprehensive metabolic panel) in am. Review of the document titled Lab Results Report for Resident #1 reported date of 11/16/23 at 18:21 (6:21 PM) read: Comprehensive metabolic panel: Serum Glucose < 40 (Critical Low). Review of the electronic medical record documented no physician notification within the record. During an interview on 12/4/2023 at 10:45 AM, the Director of Nursing (DON) stated, I was not really aware that he had a blood glucose of < 40 the day before he coded, I was not aware that the nurses did not call and let the provider know about that. We should have called the doctor or nurse practitioner about that and written a progress note that we called them and what they wanted to do. We do not have a specific policy about calling doctors with labs, this would be considered a standard of practice. All nurses should call with abnormal lab results, and I do expect nurses to call right away with any critical lab results. During a telephone interview on 12/4/2023 at 12:03 PM the Advanced Registered Nurse Practitioner (APRN) stated I did not review his labs (Resident #1), they were not available to me at the time I saw him on the 16th. I was not called or notified of any critical lab results for him (Resident #1). I expect staff to let me know that a blood sugar [level] is critically low. I should be notified when patients have critical labs. During a telephone interview on 12/4/2023 at 3:30 PM the Medical Director stated, I was not aware or notified of low blood sugars on his [Resident #1] morning labs. I do think that staff should call all critical lab results to us. But I should be called with any and all abnormal or critical lab results when they receive them. During an interview on 12/4/2023 at 4:10 PM Staff C, Registered Nurse (RN) stated, I was the nursing supervisor on the evening that his (Resident #1) critical lab was reported. I don't know why it was not called to the doctor. It is my usual practice to call the labs and enter physician order for the labs. I did not document that I spoke to the doctor or nurse practitioner. I don't know if I saw the lab or if I was pulled to work on a cart. I just don't know. The blood sugar of less than 40 should have been called, any critical labs should be called, and we should enter any orders and document that we spoke to the doctor. A policy and procedure for physician notification of lab results was requested. None was provided.

Based on interview and record review the facility failed to maintain accurate and complete medical records for 1 out of 3 residents reviewed for advanced directives. (Resident #1) Findings include: Review of Resident #1's Admission Record documented an admitted [DATE] with the following diagnoses: enterocolitis due to Clostridium difficile, unspecified kidney failure, unspecified urinary retention, unspecified dementia (unspecified severity without behavioral disturbances psychotic disturbance mood disturbance and anxiety), and Alzheimer's disease. Review of the form titled Medical Certification for Medicaid Long Term Care Services and Patient Transfer [Also known as Form 3008] dated [DATE], reads, Section H: Advance Care Planning: Do Not Resuscitate (DNR) was not checked yes or no, left blank. Review of the form titled Admission Readmission Nursing Evaluation dated [DATE], at 18:17 (6:17 PM) authored by Staff A, Licensed Practical Nurse (LPN) reads, Section VIII: Baseline Care plan: Section B. Social Service Advanced Directives. Code Status/Advanced Directives 1. Does the resident have advance directives b. Full Code (wants CPR) was documented. 2. Advanced Directives reviewed with Resident/Representative: a. Yes, was documented. During an interview on [DATE] at 10:45 AM, the Director of Nursing (DON) stated, Our policy is that on admission we obtain advance directives, and we did not do this. The nurse did document that the resident was a full code and that she spoke with the resident/resident representative. This was not correct documentation. I do expect my staff to have thorough and accurate documentation of advanced directives. During an interview on [DATE] at 3:45 PM, Staff A, LPN stated, I did not get report from the hospital on this patient [Resident #1]. I looked at the 3008 and it did not indicate DNR or the code status. The DNR was not filled in at all, so I just looked at [it] as he was a full code. I did not call and ask his representative, his family if he was a DNR or full code. He was confused and not able to tell me, so I should have called them and asked. I just don't have a good enough reason why I didn't. I don't know if it was overly busy that evening. I don't know why I did that. I did document that I called the representative on the admission form, but I did not do that for the advance directives. I should not have documented that.

Based on observation, interview, and policy and procedure review, the facility failed to ensure food is safely stored, covered, labeled, or discarded in the kitchen and 1 of 2 nourishment rooms. Findings include: During an observation of the kitchen conducted on [DATE] at 09:16 AM with the Certified Dietary Manager (CDM) of the walk-in cooler there was what appeared to be bulk ham, pork tenderloin, sliced cheese, and pre-packaged pancakes that were not in their original containers, did not have identifying labels and were not dated. On the counter and rack for clean pots and pans there were dirty cloths and scrub pads. An interview was conducted with the CDM on [DATE] at 9:23 AM. The CDM verified the bulk ham, pork tenderloin, sliced cheese, and pancakes in the walk-in cooler were not in their original packaging and did not have identifying labels or dates. The CDM confirmed that dirty cloths and scrub pads should not be placed on the counters or pot and pan rack. Review of the policy and procedure located in the Dietary Services Manual titled, Food Safety, last reviewed ,d+[DATE], read, Any food that is not in its original packaging must be labeled. Review of the policy and procedure titled, Food Receiving and Storage, last reviewed [DATE] read, 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). An observation was made with the CDM on [DATE] at 11:05 AM of the Northbrook nourishment room. There was one opened container of Jevity 1.5 and one opened container of Glucerna 1.2 that were not labeled or dated. During an interview on [DATE] at 11:18 AM the CDM confirmed there were two open drinks with no date or label. The foods or products in the nourishment rooms should have an open date and a resident's name. Review the policy and procedure titled, Food Receiving & Storage, last reviewed [DATE], read, 14. Food items and snacks kept on the nursing units must be maintained as indicated: d. beverages must be dated when opened and discarded after twenty-four (24) hours. E. other opened containers must be dated and sealed or covered during storage. Review the policy and procedure titled, Refrigerator and Freezers, last reviewed [DATE] read 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates.

Based on record review and interview the facility failed to ensure 1 residents, Resident #68, of 3 residents sampled for advance directives review received information related to the right to formulate an advance directive upon admission. Findings include: Record review of Resident #68's admission record showed Resident #68 was admitted to the facility on [DATE] with diagnoses that included history of sepsis, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified protein-calorie malnutrition, acute respiratory failure with hypoxia, dependence on renal dialysis, and end stage renal disease. Record review of Resident #68's Admission Agreement on 4/18/2023 showed documentation Resident #68 had not been provided information related to the right to formulate an advance directive until 4/18/2023. During an interview on 4/18/2023 at 11:08 AM, the Administrator confirmed Resident #68 had not been provided an admission agreement that included information related to the right to formulate an advance directive until 4/18/2023. Record review of the facility policy titled Advance Directives, last reviewed 12/20/2022, showed the policy read 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on observation, interview and record review the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 2 of 3 residents, Residents #86 and #78. Findings include: 1. During an observation on 4/17/2023 at 10:02 AM, Resident #86 was sitting at the edge of her bed with oxygen being administered at 3 liters per minute via nasal cannula. Review of Resident #86 physician orders, dated 11/18/2022, read O2 @ 2L via NC PRN check O2 q shift [oxygen at 2 liters via nasal cannula as needed check oxygen every shift]. During an observation on 4/18/2023 at 9:05 AM, Resident #86 was lying in bed with oxygen being administered at 3 liters per minute via nasal cannula. During an observation on 4/19/2023 at 7:45 AM Resident #86 was lying in bed with eyes closed, oxygen was being administered at 3 liters per minute via nasal cannula. During an interview on 4/20/2023 at 8:05 AM Staff E, License Practical Nurse (LPN), confirmed Resident #86 was being administered oxygen at 3 liters per minute. Staff E stated, It was above 2 liters (L) per minute at 3 liters, the oxygen needs to be adjusted. During an interview on 4/19/2023 at 8:16 AM, the Director of Nursing stated, I need to check that the patient does not readjust her O2 [oxygen] let me look at [Resident #86's name's] care plan. I checked the orders they are 2 liters of oxygen. The order is prn; I'm not sure if [Resident #86's name] changed the number, if she does, we will definitely increase [Resident #86] oxygen if needed. Nurses should monitor and make sure they are following the orders. During an interview on 4/19/2023 at 10:50 AM Resident #86 stated, I have not adjusted my oxygen level in these past few days. I did adjust it once before back when I had double pneumonia and felt I could not breathe, but that was months ago I have not touched it since then. Review of the policy and procedure titled Oxygen Administration, last review date 2/20/2022, read General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device per physician's orders and/or facility protocol. 47275 2. During an observation on 4/17/23 at 10:10 AM, Resident #78 was lying in bed, nasal cannula was in place, with the oxygen concentrator administering oxygen at 2.5 L/min [liters per minute]. During an observation on 4/18/23 at 12:20 PM, Resident #78 was sitting in her wheelchair, nasal cannula in place, with the oxygen concentrator administering oxygen at 2.5 L/min. During an observation on 4/19/23 at 8:08 AM, Resident #78 was lying in bed, nasal cannula in place, with the oxygen concentrator administering oxygen at 2.5 L/min. Review of the admission documented Resident #78 was admitted to the facility with a diagnosis of, but not limited to: hypertensive heart disease, with heart failure and shortness of breath. Review of the physician's order, dated 10/4/21, read O2 [oxygen] at 2L/min. via nasal cannula for shortness of Breath. During an interview on 4/19/23 at 8:10 AM, Resident #78 stated she did not change the level of her oxygen. During an interview on 4/19/23 at 8:55 AM, Staff A, LPN confirmed Resident #78's oxygen concentrator was administering oxygen at 2.5 L/min [liters per minute].

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 4 medication carts and failed to ensure all medications were stored in locked compartments to permit only authorized personnel to have access for 2 of 4 residents, Residents #13 and #68. Findings include: 1. During an observation of the North [NAME] Hall medication cart #2 conducted on [DATE] at 9:38 AM with Staff F, License Practical Nurse (LPN), there was one open Latanoprost ophthalmic solution with no open or expiration date and one expired bottle of Artificial Tears dated [DATE]. During an interview on [DATE] at 9:42 AM, Staff F, LPN stated, Eye drops should be dated when they are opened and if medication is expired, we should toss it. During an observation of North [NAME] Hall medication cart #1 conducted on [DATE] at 9:46 AM with Staff B, LPN there were three open bottles of Artificial Tears with no open or expiration date, one open Basaglar insulin pen with no open or expiration date and one expired Liraglutide Solution insulin pen dated [DATE]. During an interview on [DATE] at 9:53 AM, Staff B, LPN stated, The artificial eye drops, staff should have dated the eye drops upon opening them. The insulin pens should be labeled with their open and expiration date and if the medication is expired nursing staff should dispose of the medication. During an interview on [DATE] at 8:15 AM, the Director of Nursing stated, Once medication was opened, the date should be added. Any expired medication should be thrown out. Review of the policy and procedure titled, Medication Storage with an approval date of [DATE] read, Policy Interpretation and Implementation: 4. The facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 8. Drugs should be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing system. Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 47275 2. During an observation on [DATE] at 11:23 AM, Resident #13 had medications on the bedside table. Items observed were Peri Guard ointment skin protectant, Vitamin A&D ointment, Skin Repair cream, and DermaKlenz wound cleanser. During an observation on [DATE] at 8:15 AM, Resident #13 had medications on the bedside table. Items observed were Peri Guard ointment skin protectant, Vitamin A&D ointment, Skin Repair cream, and DermaKlenz wound cleanser. During an observation on [DATE] at 8:25 AM, Resident #13 had medications on the bedside table. Items observed were Peri Guard ointment skin protectant, Vitamin A&D ointment, Skin Repair cream, and DermaKlenz wound cleanser. During an interview on [DATE] at 8:30 AM, Staff A, LPN stated, I'm not sure if the resident is allowed to have any of the medications at bed side. 15234 3. On [DATE] at 10:21 AM an observation of Resident #68's room was completed. Resident #68 was not in her room. There was no facility staff in the room. A plastic bag that contained a topical steroid with anti-infective cream was stored in a coffee cup on Resident #68's dresser. There was an unbagged skin protectant moisture barrier cream lying on Resident #68's bedside table that was positioned horizontally across Resident #68's bed. (Photographic evidence obtained)

Based on interview and record review the facility failed to inform residents, their representatives and families by 5 PM, the next calendar day each time a confirmed infection of Covid-19 was identified. Findings: Review of the Facility Covid -19-line listing provided by the facility indicated that three residents were confirmed positive for Covid-19 infection on 2/12/2022. Review of the Cliniconex communication record dated 2/14/2022 at 11:06 AM read: Good morning, all, this message is to inform you that there are three staff members and three residents as of 2/14/2022 who are positive with COVID. Please note that even though the facility is on outbreak, it will not affect visitations. If you would like to visit you loved one, please know you are doing so at your own risk. Please continue to keep our residents safe by handwashing prior to visiting and wearing your face mask at all times when in the facility. Staff members will continue to uphold strict infection control policies and procedures to also keep your loved ones safe. There was no communication related to Covid staus prior to 2/14/2022. During an interview conducted on 3/21/2022 at 2:30 PM the Director of Nursing (DON) stated, None of the residents or resident representatives were notified until 2/14/2022 of the Covid-19 status when the residents and staff tested positive on 2/12/2022 and they should have been notified sooner. We did not follow our policies. During an interview conducted on 3/21/2022 at 3:10 PM the Infection Control Nurse stated, We did notify residents and residents families of our covid status in the facility by 5 PM the next day, we did not notify them until 2/14/2022, there is no indication in the record of any earlier notification. Review of the policy and procedure titled: Covid-19 (health screening, surveillance, restrictions on visitation, PPE's, hand hygiene, resident discharges/admissions, education, administrative & engineering controls effective date 1/1/2020, last revision date 11/2021 read: Policy: It is the policy of the Citadel Care Centers to provide the highest practicable physical, mental, and psychosocial well-being to attain ot maintain optimal functioning. It is to that extent that we will make every effort to minimize exposures to [CONDITION(S)]-CoV-2, the virus that causes COVID-19 and to treat and provide the best quality care for our residents. Communicating with residents and their designated representatives: 1.The facility will notify residents and their designated representatives in accordance with CMS and HIPPA guidance to keep them informed of the COVID-19 conditions inside the facility. As such each facility will: a. Inform residents, their representatives, and families of those residing in the facilities by 5 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other.

Based on interview and record review the facility failed to maintain an effective infection control program to prevent the possible spread of infection by not testing and maintaining isolation for residents under investigation for Covid-19 infection for 1 out of 4 sampled residents for Covid -19 infections. Resident #1. Findings: Resident #2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility line listing report indicated that Resident #2 tested positive for Covid-19 on 2/12/2022. Resident #1 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record revealed Covid -19 testing was completed on 2/9/2022 and was negative. There was no documentation in the medical record that testing for Covid -19 was completed on 2/12/2022, the day Resident #1's roommate tested positive for Covid-19 infection. There was no additional testing completed until 2/23/2022. Review of the physician orders indicate there were no orders for isolation. Review of the medical record indicate there were no vital signs documented. During an interview conducted on 3/21/2022 at 10:50 AM Resident #1 stated, My other roommate tested positive last month for Covid-19 infection. I did stay in the room with her. She passed away a few days later. I was not placed on any type of isolation or quarantine. They did not wear any gowns or anything special when they took care of me. They did not check my blood pressure or oxygen levels. They did offer to move me, but I thought she be moved not me, and I did tell them that. They never did move her. I was very worried about getting Covid. I have breathing problems and use oxygen all the time. I know they shouldn't have done that. My brother wanted me to complain, but I don't like doing that. They treat me very well and I don't want to change that and have them think I'm a complainer. During an interview conducted on 3/21/2022 at 2:30 PM the Director of Nursing (DON) stated, There is no indication in the chart that Resident #1 was placed on isolation or quarantine when her roommate tested positive, and we have no proof that she was tested at all in the chart after her roommate tested positive. She did not have any Covid assessments completed per our protocols. She should have been placed on quarantine; she was cohorted with Resident #2 until the resident passed away on 2/15/2022. We should have moved them; we did have open rooms to move them. Our thinking was that we would not move the positive resident. Every option we gave her [Resident #1], and her brother were refused by them. But we did have the ability to move the Covid positive resident to a different room. We did not follow our policies. We do not have a specific policy for cohorting Covid-19 patients, we follow the CDC recommendations for quarantine of residents who have close contact with someone who has tested positive for Covid-19. During an interview conducted on 3/21/2022 at 3:10 PM the Infection Control Nurse stated, We did not move [Resident #1's name] or [Resident #2's name] when {Resident #2's name] tested positive for Covid. I think we felt that she (Resident #1) had already been exposed so why bother. We should follow the CDC guidelines and not cohort residents that are positive and negative together. [Resident #2's name] did stayed in the room until she passed away. We did offer to move [Resident #1's name], but she did not want to move. We did not consider moving [Resident #2's name] because we would have had to move her to the other side of the building. There is a covid -19 assessment in the computer that must be completed that contains vital signs, there is no documentation that [Resident 31's name] had these screenings and there are no vital signs or oxygen saturations documented. There is no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . We messed up. We do not have any documentation in either record of the Covid -19 testing, but we did provide this information to the Department of Health. During an interview conducted on 3/21/2022 at 3:50 PM Staff A, Licensed Practical Nurse (LPN) stated, I was taking care of [Resident #1's name], she did not have Covid-19, but her roommate did. She was not on isolation, but her roommate was, but she passed away. After her roommate passed away, she was not on quarantine or isolation. She did stay in the room with her roommate who was positive. I don't make the decision to move residents. She did not have orders for isolation or any Covid assessments. She was in close contact with her roommate, they lived in the same room. We should follow the recommendations from the CDC and our policies when a resident tests positive for Covid-19. During an interview conducted on 3/21/2022 at 4:10 PM Staff B, Certified Nursing Assistant (CNA) stated, I do take care of [Resident #1's name], she has not been on any type of isolation at all, she doesn't have Covid. Review of the policy and procedure titled Covid-19(health screening, surveillance, restrictions on visitation, PPE's, hand hygiene, resident discharges/admissions, education, administrative & engineering controls effective date 1/1/2020, last revision date 11/2021 read: Policy: It is the policy of the Citadel Care Centers to provide the highest practicable physical, mental, and psychosocial well-being to attain ot maintain optimal functioning. It is to that extent that we will make every effort to minimize exposures to [CONDITION(S)]-CoV-2, the virus that causes COVID-19 and to treat and provide the best quality care for our residents. Testing of Nursing home staff and residents: 1. Facilities can meet the testing requirements through the use of rapid point of care testing (POC) diagnostic testing devices or through an arrangement with an offsite laboratory. When prioritizing individuals to be tested , facilities should prioritize individuals with signs and symptoms of Covid-19 first, then perform testing triggered by outbreak investigation (as specified below): Table 1: Testing summary: testing trigger: Newly identified Covid-19 positive staff or resident in a facility that can identify close contacts. Residents: Test all residents, vaccinated or unvaccinated, that have close contact with a Covid-19 positive individual. Testing of staff and residents during an outbreak investigation: A new Covid-19 infection in any staff or any nursing home onset Covid -19 infection in a resident trigger an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission Upon identification of a single new case of Covid-19 infection in any staff or residents, testing shall begin immediately. Review of the CDC (Centers for Disease Control) Interim infection prevention and control recommendations for healthcare personnel during the Coronavirus Disease 2019 (Covid-19) pandemic updates as of February 2,2022 read: 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspect or confirmed [CONDITION(S)]-CoV-2(Covid-19) infection. The IPC recommendations described below also apply to patient with symptoms of Covid-19 (even before results of diagnostic testing) and asymptomatic patents who have met the criteria for empiric Transmission-Based precautions (quarantine) based on close contact with someone with SAS-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing. Patients are placed in empiric Transmission based precautions based on close contact with someone with [CONDITION(S)]-CoV-2 infection should be maintained in Transmission based precautions for the following time periods. Patients can be removed form Transmission based precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Patients can be removed from transmission based precautions after day 7 following the exposure day ( day 0) if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. The test should be collected and tested with 48 hours before the time of planned discontinuation of Transmission based precautions.

Based on record review and interview the facility failed to permit 1 of 3 sampled residents, Resident #1, to return to the facility after hospitalization . Findings include: Closed record review for Resident #1 revealed an original admitted into the facility of 05/11/2018 with a current readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes dated 05/08/2020 revealed Resident #1 was transferred to a nearby hospital send to ER, (Physicians' names) cannot direct admit but both feel he needs to go to the ER (emergency room ). Review of the receiving hospital's records dated 05/08/2020 revealed, Podiatry Progress Note. Assessment/Plan: Left foot stump infection, [MEDICAL CONDITION], wound reevaluation with or without suture removal left foot stable necrotic ulcer, S/P (status [REDACTED]. Review of the receiving hospital's progress notes dated 05/14/2020 revealed, Physical Exam: Dry black eschars at the distal medial aspect of the left transmetatarsal amputation. The lesion does not tunnel or undermine. There is no exposed bone. The site produces no active exudate. There is no perilesional [MEDICAL CONDITION], [DIAGNOSES REDACTED], or increase in temperature. There is no fluctuance, crepitus, or bogginess . Impression. Continued close follow-up is recommended . Assessment Plan. All other docs (doctors) will cont (continue) wound care F/U (follow up) in office next week. Review of the receiving hospital's Case Management notes revealed Discharge Planning Follow-Up entered on: 05/14/2020 at 19:17 EDT (7:17 PM Eastern Daylight Time). Narrative Note - Follow Up - CM (Case Manger) Narrative Note: This morning I called Ruleme who told me to call (number documented) and I spoke with (name documented). She said they are definitely taking him back today as he came from there. I explained that I cannot run a COVID test without a certain bed given. She said positively they will take him back. The test was ordered and came back negative. I sent all the clinicals and the negative results. They are still getting authorization. At 7:17 pm no more communication noted. Please follow and get patient out in AM. Dated: 05/15/2020 at 10:04 EDT. Narrative Note - Follow Up - CM Narrative Note: Case manager received call back from (name documented), who states all clinical reviews are completed by their Clinical Risk team and they have declined to take the patient back because 'they cannot meet his needs'. Case manager is now awaiting a call from the director with length of stay, remaining Medicare days, etc. Case manager to follow. Dated: 05/15/2020 at 14:56 EDT (2:56 PM). Narrative Note - Follow Up - CM Narrative Note: Case manager received call from patient's daughter-in-law, (name documented) who states patient has been at Ruleme for the last couple of years. Case manager requested (name documented) to get in touch with patient's son and daughter and to contact Ruleme directly to reach a resolution. Case manager received call from patient's daughter, (name and telephone number documented). (Patient's daughter's name) reports she is fighting with administration there to get them to allow him to return. Case manager informed (Patient's daughter's name) that Social Worker (name) has told (facility employee's name) that the proper way to handle this situation is to allow him to come back as he lives there as long term care, and then issue a 45 day letter notifying the family he needs a new place to go. Per (name documented) (facility employee name) stated it was not her decision, it was out of her hands, and to call the state if (hospital employee name) felt she needed to. SW (name documented) has notified ACHA (sic - Agency for Health Care Administration) via telephone. (Name documented) states she is still awaiting a phone call back from administration at Ruleme and will update case manager accordingly. Case manager to follow. Dated: 05/15/2020 at 16:59 EDT (4:59 PM). Narrative Note - Follow up - CM Narrative Note: Case manager received a call from (name documented) SW (Social Worker) at Ruleme. She is covering for (name documented), who is patient's SW there at Ruleme. She provided (name and telephone number documented) and said they will both do whatever they can to help. Case manager to follow. Review of the Nursing Home Transfer and Discharge Notice dated 05/15/2020 revealed under the section titled Reason for Discharge or Transfer: Your needs cannot be met in this facility. Review of Resident #1's nursing progress notes dated 05/15/2020 revealed, IDT (Interdisciplinary Team) due to careful consideration has made a decision customer will not be able to return to facility due to not being able to meet customers current needs; customer is high risk due to pandemic COVID-19 (Coronavirus Disease 2019) crisis, with anticipated continuous follow-up with podiatrist, vascular surgeon and outside wound care treatment, therefore, a Nursing Home Transfer Discharge Notice has occurred and has been sent to the family certified mail and faxed to Ombudsman on this date. Phone call was placed to daughter to relay current information daughter had some concerns in regard to decisions, and a grievance was placed at that time. IDT did offer to assist daughter in finding alternate placement however daughter chose not to utilize. SS (Social Services) reached out to Case Management at (receiving hospital's name, employee name and employee telephone number) to relay current information. Review of a handwritten Doctor's Progress Note signed by the Advanced Registered Nurse Practitioner, dated 05/15/2020 at 2 pm revealed, Resident is being discharged from facility on this date as the specific customer needs cannot be met at this time. These include anticipated continuous follow-up with podiatrist, vascular and outside wound care leading to possible surgery. (Resident's name) is at high risk due to pandemic of COVID-19 crisis with potential risk to all other current residents at Ruleme Center. Ruleme Center is unable to meet current needs secondary to the imposed restrictions due to COVID-19 pandemic by the governor of Florida. Review of the wound consults revealed since 02/05/2020 for Resident #1 transportation was provided for podiatrist visits on 04/22/2020, 04/15/2020, 04/08/2020, 04/01/2020, 03/18/2020, 03/12/2020, 03/05/2020, 03/02/2020, 02/27/2020, 02/19/2020, 02/17/2020, 02/12/2020, and 02/05/2020. The podiatrist provided a dressing change, debridement as necessary, with recommendations. The recommendations noted to return in one week, offload the left foot, wear surgical shoe, and change the dressing as necessary. He was examined by a vascular physician on 02/17/2020. The report noted the [DIAGNOSES REDACTED]. Imaging recommended CTA (Computed Tomography [MEDICATION NAME]) with runoff, which was conducted on 03/02/2020, with no further documentation or vascular reports provided. Review of Resident #1's care plan revealed a discharge plan dated 05/31/2018 directed long-term care as he was unable to return to the community. The plan was initiated in 05/2018, and updated on 04/08/2020, directed care for his [MEDICAL CONDITION] in the left foot along with wound care. Further review of the record revealed the resident received medications, physician's visits, general assistance of his activities of daily living, room activities and meals along with an opportunity to see his friend. Due to the [MEDICAL CONDITION] and [MEDICAL CONDITION] following a cerebral infarction affecting his right side, he suffered some unsteadiness on his feet, in addition to his limited range of motion. His care plan directed extensive to total staff assistance with self-care tasks and mobility. He received assistance with right arm saddle cushion and arm exercises 15 minutes each day; 5 days per week. He was directed to have monitoring for a tendency to wander, in which he wore an adult monitoring device which sounded during attempts to leave the building. There was no further information provided regarding other care rendered prior to the transfer. Review of Resident #1's Medication Administration Record [REDACTED]. He had orders for [MEDICATION NAME] ointment for L (Left) foot topically every night shift vascular wound cleanse w/NS (with normal saline) apply alginate x 2, 4x4 and Kerlix qd (once a day). Additionally, Mupirocin ointment apply to L foot topically every night shift vascular wound cleanse w/NS mix Santyl and Mupirocin 50-50 apply to wound bed then apply hydrogen blue and Kerlix every day and prn (as needed). During an interview on 06/29/2020 at 11:47 AM, the Administrator stated the Advanced Registered Nurse Practitioner (ARNP) meant in her written statement dated 05/15/2020, the facility could not provide the weekly and multiple weekly visits Resident #1 would be needing for his foot wound. She referred to it as anticipated continuous follow-ups. Following the surgery there would be many anticipated doctors' visits, sometimes multiple times per week. At this time with COVID-19, the facility cannot accommodate the multiple visits per week. A request was made to the Administrator for the documentation of the post hospital discharge needs for Resident #1. No documentation was provided. During an interview on 06/29/2020 at 12:00 PM, the Director of Nursing (DON) stated the foot (stump) wound became gradually worse despite weekly visits to the podiatrist since 02/2020. The facility has provided the transportation at that time for all of his wound care appointments. In addition to the transportation issue the facility corporate offices determined there was not going to be any residents going in and out of the facility. The daughter and the doctor moved forward on the surgery and transferred the resident on 05/08/2020 to the hospital. He stated he had no further information regarding the hospital. The Social Services Director left a message on 05/18/2020 for the Case Manager for the hospital to offer assistance if needed. The DON stated they did not have the staff for additional transportation needs the resident would require. The COVID-19 interventions provided were the use of protective equipment, testing, screening of all staff or medical professionals, no visitors or communal groups, and continuous cleaning. No additional COVID-19 needs were stated as provided prior to the transfer. A request was made to review the post hospital discharge needs for Resident #1. No documentation was provided. During an interview on 06/29/2020 beginning at 10:21 AM, Resident #1's Primary Contact confirmed she was told before the surgery he would not be able to return to the facility because of the after care and outside visits to doctors. She stated the facility warned her they would not accept the resident back to the facility after his surgery. They told her he would need to go into quarantine and would not be returning to the same room. They told her they were not able to attempt to maintain an infection free environment if residents were entering and exiting the facility and would not be able to provide extra transportation to doctor appointments. She was asked if she would provide the transportation and she said she really did not want to do that. She didn't want her father to go to the hospital if he could not return to this facility. She gave approval for the surgery after speaking with siblings. She stated she and the other family members live between minutes and an hour from the facility. The new facility he was transferred to is five minutes from this facility. There is no evidence he is unhappy with his new arrangements. She thinks he might want to see his friend at the first facility. She denied filing any kind of complaint or grievance, the hospital staff assisted with the arrangements to the new facility, and stated she had no negative comments about the facility other than they could not take him back after the surgery. During an interview with the Administrator and the DON on 06/29/2020 approximately at 3:00 PM, they confirmed there was no further information regarding other care rendered prior to the transfer. They confirmed the podiatry and vascular visits occurred weekly and on an as needed basis since 02/2020. The facility provided wound care as needed during the week between podiatry visits. The COVID-19 interventions provided were the use of protective equipment, testing, screening of all staff or medical professionals, no visitors or communal groups, and continuous cleaning. No additional COVID-19 needs were stated as provided prior to the transfer. They stated the facility would need additional aides and nurses for 24/7 care Resident #1 would need while in quarantine. The quarantine would extend continuously as each doctor's office visit continued. The number of hours would increase for housekeeping as the isolation room would need cleaning along with the other three rooms to be vacated surrounding the quarantine room. Clearing those rooms would mean six residents would need to be moved. The contract with the transport company ended when the visits stopped for all the residents. Arrangements for transporting the resident to the doctor's visits would require finding a company to transport him. It was confirmed there was no data about the needed services, how to meet them and the cost. The DON and Administrator confirmed there were no specific detailed additional services needed for the resident after the surgery as the listed services were a continuation of the services that had previously been provided.