Every finding on record at Solaris Healthcare Celebration

Based on observation, interview, and record review, the facility failed to ensure the flow rate for Oxygen (O2) therapy was administered as per physician's order for 1 of 2 residents reviewed for O2 therapy, of a total sample of 57 residents, (#88).Findings:Resident #88 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, failure to thrive, anemia, anxiety, depression, and subsequent encounter for palliative care. On 2/02/26 at 11:55 AM, resident #88 was observed in bed, she wore a nasal cannula attached to an oxygen concentrator. The O2 was set at 2.5 liters per minute (LPM), with the concentrator located inside her bathroom. A review of resident #88's medical record revealed O2 was ordered by the physician for 2 LPM by nasal cannula. The Quarterly Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status of 12/15, which indicated the resident's cognition was moderately impaired. The assessment indicated the resident required moderate to maximum assistance for activities of daily living. The next day on 2/03/26 at 9:00 AM, resident #88 was observed with O2 via nasal cannula. The oxygen concentrator was set at 2.5 LPM. On 2/03/26 at 9:25 AM, Licensed Practical Nurse (LPN A) confirmed resident #88's oxygen concentrator was set to 2.5 LPM of oxygen. She verified the physician's order was for 2 LPM. She explained that possible a CNA had bumped it. She confirmed she was supposed to check the oxygen every shift in the morning and said she did it before she got report or counted medications. On 2/04/26 at 3:52 PM, the Director of Nursing (DON) commented no staff were supposed to change the flow rate of oxygen without a physician's order, and they should check the flow rate every shift to ensure accuracy. A review of the Oxygen Administration policy, revised 12/08/25, recommended to review the physician's orders and administer the proper flow of O2 at the rate it was ordered.

Based on observation, interview, and record review, the facility failed to implement physician orders for pain management accurately and timely; and failed to effectively manage pain in accordance with the resident's care plan and goals, for 1 of 2 residents reviewed for pain, of a total sample of 57 residents, (#189). Findings: Cross Reference F656 Review of resident #189's medical record revealed she was admitted to the facility on [DATE] with diagnoses including fracture of the neck of the left femur, fracture of the lower end of the left radius, and history of falling. Review of resident #189's Brief Interview for Mental Status assessment dated [DATE] revealed a score of 15 out of 15 indicating intact cognition. Review of the comprehensive care plan, initiated on 1/30/26, revealed resident #189 had pain and discomfort related to fractures of the left femur and left radius. The goal was for pain to be at or below the resident's stated acceptable level. Interventions included administering pain medication per physician orders; encouraging the resident to verbalize pain; evaluating pain levels; observing for nonverbal signs and symptoms of pain; reporting to the charge nurse; and providing comfort measures per resident preference. Review of physician orders initiated on 1/29/26 included:*Non-weight bearing (NWB) to he left upper (LUE) and left lower extremities (LLE)*Methocarbamol (muscle relaxer) 500 milligram (mg) with meals for muscle spasm for seven days *Ibuprofen 600 mg with meals for pain for seven days *Acetaminophen 325 mg, two tablets, four times a day for pain for seven days *Lidocaine 4% topical patch applied to lower back daily for pain*Pain Management Log every shift and as needed (PRN) On 2/02/26 at 12:39 PM, resident #189 stated she asked for pain medication prior to therapy but did not receive it. She explained was unable to work with therapy due to her pain. On 2/03/26 at 9:24 AM, resident #189 stated she experienced significant pain during the previous therapy session and was uncertain if she could participate again. She reported pain at 8 out of 10, with episodes of 10 out of 10 pain when positioned poorly. She stated she had not previously required pain medication but now needed it and believed pain medication prior to therapy would allow participation. On 2/03/26 at 5:24 PM, Certified Nursing Assistant (CNA) G stated resident #189 had complained of back pain previously, but not that day. CNA G indicated she did not recall seeing a Lidocaine patch on the resident's back. On 2/04/26 at 11:06 AM, CNA F stated resident #189 often complained of back pain and required assistance with repositioning. CNA F indicated she worked with resident #189 on 2/03/26 and 2/04/26 and did not observe a Lidocaine patch in place. On 2/04/26 at 11:52 AM, resident #189 stated she did not have a Lidocaine patch applied and had not received one previously. On 2/04/26 at 12:02 PM, Registered Nurse (RN) E stated resident #189's care primarily focused on pain management and reported her pain ranged from 2 to 4, stating pain management was effective. RN E acknowledged the resident was ordered a Lidocaine patch but stated he had not yet applied it. When asked why the Medication Administration Record (MAR) reflected administration of the patch, RN E stated it was his fault for documenting administration when it had not occurred. RN E stated he believed the patch may have fallen off previously and acknowledged he did not follow the physician's order. Review of the Medication Admin Audit Report revealed RN E documented on 2/04/26 at 10:37 AM, that the Lidocaine Patch was administered at 9:36 AM. On 2/04/26 at 12:49 PM, the first floor Unit Manager (UM) stated medications and treatments were to be documented after administration, not before. On 2/04/26 at 3:53 PM, the Director of Nursing (DON) confirmed documentation of medication administration prior to actual administration constituted inaccurate medical record and a failure to follow physician orders. On 2/05/26 at 10:20 AM, resident #189 expressed continued concerns regarding pain during therapy. At approximately 10:30 AM, a therapist and Licensed Practical Nurse (LPN) H entered the room. The therapist asked whether pain medication had been given. LPN H stated the resident had been medicated and left the room. The resident stated she needed additional pain relief. The therapist indicated he would contact nursing. On 2/05/26 at 10:36 AM, resident #189's physician informed the resident of her current pain regimen. The resident requested additional pain control prior to therapy. At 10:45 AM, the physician stated he believed Tramadol had been administered prior to therapy the previous day. He later stated pain medication should be administered as prescribed, and nursing should report ineffective pain management. On 2/05/26 at 10:51 AM, LPN H showed the Tramadol tablets in the medication cart for resident #189 and stated none had been administered. He stated the medication was scheduled for 1:00 PM. Review of physician progress notes dated 2/04/26 and 2/05/26 revealed Tramadol was ordered due to ongoing pain limiting participation in therapy and later increased in frequency due to inadequate pain control. On 2/05/26 at 11:10 AM, the Director of Rehabilitation (DOR) stated pain had limited the resident's participation in therapy and confirmed therapy communicated pain concerns to nursing. Review of a Physical Therapy (PT) and Occupational Therapy (OT) evaluations and treatment notes from 1/29/26 through 2/04/26 consistently documented pain as a barrier to therapy, with nursing notified, and noted the resident was unable to tolerate treatment due to pain. Review of physician orders revealed Tramadol was ordered on 2/04/26, discontinued, re-entered, and scheduled for 2/05/26 at 1:00 PM. Review of the MAR confirmed Tramadol was not administered on 2/04/26. Review of controlled substance records revealed no Tramadol was removed from the automated medication dispenser on 2/04/26 - 2/05/26. On 02/05/26 at 11:37 AM, the DON stated resident #189 did not arrive from the hospital with an opioid prescription to treat pain. She further stated that if therapy did not communicate pain with nursing, we cannot read minds. The DON acknowledged fractures were painful and stated effective pain management was important. She further stated she was not a physician and could not prescribe medications. Later at 1:18 PM, the DON stated Tramadol was available in the automated medication dispenser machine and the nurse could have obtained it. She stated she was unaware of unrelieved pain for resident #189's or that therapy had informed nursing of ongoing pain concerns. On 2/05/26 at 1:39 PM, the first floor Unit Manager confirmed therapy informed her of resident #189's pain and that she was aware of the Tramadol order. She acknowledged she did not follow up to reassess the resident's pain level or response after therapy reported pain. Review of the facility policies titled Pain Assessment and Management and Administration Procedures for All Medications, dated 12/08/25, revealed expectations for timely pain management, reporting ineffective treatment, and accurate documentation following medication administration.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan to address a hearing impairment, including interventions to promote the resident's highest practicable well-being for 1 of 1 residents reviewed for communication/sensory needs, of a total sample of 57 residents, (#189). Findings: Cross Reference F697 Review of resident #189's medical record revealed she was admitted to the facility on [DATE] with diagnoses including fracture of the neck of the left femur, fracture of the lower end of the left radius, and history of falling. Review of the original State Agency 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 1/28/26, revealed resident #189 was non-ambulatory, alert, oriented, and able to follow instructions. The form indicated the resident had impaired hearing and used a left hearing aid. Review of the hospital History and Physical form, dated 1/09/26, revealed a medical history of hearing loss, and on physical examination, the resident was documented as hard of hearing. Review of resident #189's Baseline Care Plan, dated 1/28/26, revealed hearing adequate was checked, while hearing impaired and appliance used were not checked. Review of the Activity Comprehensive Evaluation, dated 1/30/26, indicated activities should be modified to accommodate the resident's hearing deficit. On 2/02/26 at 12:39 PM, during an interview attempt, resident #189 was observed to be very hard of hearing. Friends visiting the resident stated she used a left hearing aid, which had broken the previous week. Resident #189 requested the surveyor write questions in a notebook so she could understand. The resident reported the hearing aid battery was replaced but the device was still not functioning. Her friends stated that when the hearing aid worked, communication was effective, but without it communication was very difficult. Observation noted the words hearing aids written on a whiteboard in the resident's room. One hearing aid was observed on top of some tissues on the bedside table; the friend placed it in the resident's left ear and instructed her to keep it in place to prevent loss. Review of a Social Service progress note, dated 2/03/26, revealed resident #189 was alert and oriented to self, time, and place, and was documented as very hard of hearing. The note revealed the resident was short-term and social services would assist with discharge planning and social services needs as required. On 2/03/26 at 9:30 AM, resident #189 stated she frequently asked staff to write what information on a notepad because she could not hear. She explained her left hearing aid was not working, and friends were attempting to obtain a replacement. On 2/03/26 at 5:24 PM, Certified Nursing Assistant (CNA) G stated resident #189 could hear her and she was unaware whether the resident used hearing aids. On 2/03/26 at 6:10 PM, Registered Nurse (RN) I stated she spoke louder when communicating with resident #189 due to hearing difficulty. She stated she did not use a notebook to communicate and reported the resident used a hearing aid. On 2/04/26 at 11:06 AM, CNA F stated she was unaware whether resident #189 used a hearing aid and had not seen one in the room. She indicated when unsure of resident needs, she referred to the resident's care plan. Upon review of the care plan with the surveyor, CNA F validated no information regarding hearing impairment or hearing aid use was present. On 2/04/26 at 12:02 PM, RN E stated resident #189 had a left hearing aid that was not functioning well, and a family member was expected to bring a special battery. RN E stated the resident could hear when spoken to loudly and at close range. Review of the comprehensive care plan for resident #189 revealed no interventions addressing hearing impairment or communication needs. On 2/04/26 at 12:49 PM, the first floor Unit Manager stated she was unaware of hearing aids or communication issues for resident #189. She indicated the Minimum Data Set (MDS) staff created and updated the care plan based on hospital documentation. On 2/04/26 at 1:30 PM, the MDS Lead stated she was responsible for developing care plans, including identifying individualized areas of concern and interventions for residents. She stated care plans were created after admission and updated at least quarterly, and all staff used the care plans. Upon review of resident #189's care plan, she validated there was no communication focus addressing the resident's hearing impairment. She stated it was important for staff to be aware of such needs. She indicated she did not have an explanation for why this information was not included. On 2/04/26 at 3:53 PM, the Director of Nursing stated use of hearing aid should be included in the care plan and staff relied on it for pertinent resident information. Review of the facility's policy titled Care Planning - Interdisiplinary Team (IDT) dated 12/08/25 revealed the IDT was responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, interview, and record review, the facility failed to obtain wound care orders and document wound care treatment per the resident's comprehensive, person-centered care plan, (#188); and failed to implement physician orders for treatment of psoriasis consistent with professional standards of practice, (#33), for 2 of 2 residents reviewed for non-pressure skin conditions, of a total sample of 57 residents.Findings: 1.Review of resident #188's medical record revealed he was admitted to the facility on [DATE] with diagnoses including syncope and collapse, thrombocytopenia, anemia, and atrial fibrillation. Thrombocytopenia refers to a low platelet count, which increases the risk of bleeding due to impaired clot formation, (retrieved from www.mayoclinic.org on 2/07/26). Review of resident #188's physician orders revealed the following wound care orders initiated on 2/02/26: *Skin tear to left inner forearm: cleanse with normal saline, apply skin prep to periwound, apply Xeroform, cover with rolled gauze and tape every evening shift on Monday, Wednesday, and Friday (M-W-F). *Skin tear to right shin: same treatment and schedule. *Skin tear to right lower arm: same treatment and schedule. * Monitor every shift for signs of abnormal bleeding including black tarry stools, hematuria, bruising, nose bleeds, bleeding gums, sudden severe headache, coffee ground emesis, muscle joint pain, changes in mental status or vital signs and lethargy. Document N if none of the above are noted; if Y, document in a progress note and notify the physician. * Clopidogrel 75 milligrams (mg) daily, initiated 1/31/26, for clot prevention. Review of resident #188's comprehensive care plan, revised on 2/02/26, identified actual and potential impairment to skin integrity related to fragile skin, dryness of extremities, and incontinence. The care plan identified skin tears to the right shin, left inner forearm, and right lower arm, and instructed nurses to perform wound care as ordered. An addition focus area identified the resident was receiving anticoagulant and platelet aggregation inhibitor therapy, placing him at increased risk for bleeding, bruising, and hemorrhage. On 2/03/26 at 9:13 AM, resident #188 was observed in bed eating breakfast with a rolled gauze dressing dated 2/02/26, shift 3-11, on his right arm that was saturated with blood. Blood smears were observed on the right bed enabler rail. The resident stated he was on blood thinners and bled a lot. On 2/03/26 at 5:11 PM, Certified Nursing Assistant (CNA) G stated she reported blood on resident #188's wound dressing to the assigned nurse the previous day. She indicated the dressing was clean when she began her shift at 3:00 PM. On 2/04/26 at 10:48 AM, CNA F stated resident #188's wound dressing had required two dressing changes the previous day due to bleeding. She shared blood was visible again that morning and she notified the nurse. On 2/04/26 at 11:54 AM, Registered Nurse (RN) E stated he previously served as the Wound Care Nurse (WCN) for one year before returning to floor nursing. He shared he changed resident #188's wound the dressing twice the previous day and the resident was scheduled to be seen by the wound care physician the following day. RN E stated the previous day he first applied calcium alginate, and an abdominal pad, secured with rolled gauze, but the second time he changed the wound dressing he applied Xeroform as ordered. He indicated he did not obtain a physician order for the calcium alginate and abdominal pad because he wanted to see if it worked first. He acknowledged the treatment did not work initially. He stated he later applied Xeroform, which controlled the bleeding for the remainder of the shift. Review of resident #188's progress notes and physician orders from 2/03/26 through 2/04/26 revealed documentation by RN E regarding wound care provided to a to the left inner forearm. On 2/04/26 at 3:05 PM, RN E stated there was no bleeding noted for resident #188 on Monday. He indicated the dressing was changed twice on 2/03/26 and he reported this to the WCN that day. He acknowledged he was expected to document the dressing changes in a progress note or the Treatment Administration Record (TAR) but stated he forgot. He explained there was no option to document the dressing change in the TAR because the order was not written as PRN (as needed). He stated he was unsure whether he could request a PRN order. He validated he did not notify the physician or the WCN at the time of increased bleeding and changed the dressing twice without obtaining an order. On 2/04/26 at 12:49 PM, the first floor Unit Manager (UM) confirmed there was no progress note and no physician order addressing the wound care provided on 2/03/26. She acknowledged the wound care orders did not include PRN dressing changes and stated nurses were expected to notify the WCN so she could evaluate the resident and obtain additional orders if needed. On 2/04/26 at 3:17 PM, during an interview with the WCN and the Director of Nursing (DON), the WCN stated she was responsible for performing a second head-to-to-toe skin assessment on newly admitted residents. She indicated if she identified skin impairments requiring treatment, she contacted the wound care physician to obtain orders. She explained she entered the physician's wound care orders into the system and the assigned nurse carried out the treatment. The WCN stated she assessed resident #188 on 2/02/26 and identified three skin tears, a deep issue injury to the sacrum, and discoloration to the left knee. She stated she entered the wound care orders as given by the physician and the orders did not include PRN dressing changes. The WCN mentioned RN E informed her on 2/04/26 that resident #189's dressing had been a little bit dirty the previous day. The WCN said RN E did not inform her the dressing was saturated with blood or that it had been changed twice due to bleeding. She stated if she had informed of increased bleeding, she would have assessed the resident and contacted the physician as indicated. The DON stated the assigned nurse would be expected to obtain a one-time PRN order if a dressing needed to be changed outside of the schedule order. The DON confirmed there was no progress note documenting increased bleeding, no documentation of two dressing changes on 2/03/26, and no physician order obtained for a change in treatment. On 2/05/26 at 9:17 AM, the Medical Director stated if there was a significant change in a wound, including increased bleeding, it should be communicated to the physician. He indicated nurses could contact his group or the on-call physician to obtain additional orders. Review of the facility's policy titled Skin and Wound Management, dated 12/08/25, revealed nursing staff were to assess, describe, document and report wound conditions, and the physician would authorize appropriate wound treatment orders. The policy indicated treatments were to be implemented in accordance with physician authorization and documented accordingly. 2. Resident # 33 was admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation/osteomyelitis, type 2 diabetes mellitus and morbid obesity. A review of the medical record revealed physician orders for resident #33 to receive Triamcinolone Acetonide External Cream 0.5% with directions for nurses to apply topically to rash on extremities and abdomen twice a day for psoriasis. On 2/02/26 at 12:02 PM, resident #33 appeared was sitting up in his wheelchair. He had dry, reddened areas on his arms and legs. Resident #33 said he had psoriasis but was not getting the cream ordered by the physician as prescribed. He explained that staff always told him they were out or they were waiting on pharmacy for the cream. He continued to explain that he could not understand how administration of the medication could be so inconsistent, or why the pharmacy could not send a larger amount, so it did not run out so quickly. On 2/04/26 at 2:30 PM, the TAR revealed resident #33 did not receive the 9:00 AM treatment on 2/02/26, nor on 2/03/26; and the entry was left blank on 2/04/26 by RN B. The TAR revealed resident #33 had documentation to indicate he received the 5:00 PM treatment the same day on 2/02/26 by RN D and on 2/03/26 by RN C. On 2/04/26 at 2:52 PM, the assigned RN B explained he did not apply the cream for the last three days because the cream was not here. RN B explained that on 2/02/26 he might have heard during shift report that the cream was on its way from the pharmacy but said he did not write awaiting pharmacy in his progress note because he was unsure. He continued that on 2/03/26 he had forgotten to call the pharmacy nor to write a progress note about what happened. RN B said he did not sign the TAR today because he was waiting to see if the medication came in on the 2:00 PM pharmacy delivery, and since it was almost the end of his shift, he would call the pharmacy to find out if when it would arrive. On 2/04/26 at 3:10 PM, RN C explained that on 2/03/26 at 5:00 PM, the cream was applied as ordered because it was in the treatment cart. On 2/04/26 at 3:20 PM, RN D said that on 2/02/26, the cream was applied because it was in the treatment cart. Together with the Assistant Director of Nursing (ADON), RN C proceeded to open the locked treatment cart to reveal two tubes of the prescribed cream for resident #33. The almost empty tube had a received date of 1/28/26 and the other almost full tube had a received date of 2/01/26. On 2/05/26 at 10:45 AM, the DON acknowledged that all assigned nurses except RN B had provided the treatment and said her expectation was that if the medication was not there or not given, nurses were supposed to call the pharmacy, call the doctor, notify the family and also document in the medical record. The DON acknowledged RN B did not do that. The undated facility policy on specific medication administration procedures, addressed the notification of the physician for persistent refusals, held medications and suspected adverse drug reactions.

Based on observations, staff interview, cleaning schedule, and policy and procedure review, the facility failed to maintain food safety standards, such as ensuring food employees used beverage containers that prevented contamination from hands; resident Time/Temperature Control for Safety (TCS) food was not stored too long under refrigeration; ensure that food and non-food contact surfaces were clean to sight and touch; bathrooms used by food employees were equipped with handwashing signage; ensure that exposed food, clean equipment and clean utensils were protected from contamination from non-Food and Nutrition Services staff unrestrained hair; and clean equipment and utensils were stored in a clean and dry location and protected from splash. These findings have the potential to cause foodborne illness for 101 out of 109 residents who consumed the facility's food. The findings included: During the Initial Brief Tour of the Kitchen with the Director of Food and Nutrition Services on 5/20/24 at 10:24 AM, there was an employee's bottled water container with a twist off lid and a blue colored insulated beverage container with a twist off lid, stored under the preparation table. Although these beverage containers were closed with tight fitting lids, they were not designed to prevent the contamination of employee hands from saliva. Photographic evidence obtained. During a follow up visit to the kitchen on 5/21/24 at 8:04 AM with the Director of Food and Nutrition Services, there were three bottled water containers that belonged to staff placed on a cart near an exit to the kitchen. The top of the cart was covered with a sheet of parchment paper that had a written statement Staff beverages only. The three water bottle containers had twist off lids and were not designed to prevent employee's hands from being contaminated by saliva. Photographic evidence obtained. On 5/22/24 at 8:57 AM, the resident Maytag refrigerator in the Egret 1 nourishment area had an opened can of whipped cream dated with a hand written date of 4/08/24, The whipped cream was a Time/Temperature Control for Safety (TCS) food (a category of perishable food that requires time and temperature controls to limit the growth of illness causing bacteria) and must not be stored longer than 7 days in refrigeration at 41 degrees Fahrenheit. Additionally, there was an ice wrap stored in the freezer compartment of the Maytag refrigerator. During a follow up visit to the kitchen on 5/22/24 at 4:28 PM there was an accumulation of brown food spatter and rust underneath the shelf installed over the steam table. Photographic evidence obtained. At 4:35 PM, the surface of the grill had rust and a coating of old grease and the front exterior had old, dried food spills (the grill located next to the fryer). The Director stated the grill was not functional, and they've tried to clean it and the rust won't come off. He said that the grill was being used to store pans of food on top of the grill. Additionally, at 4:40 PM, there were no signs to notify food employees to wash their hands in the men and women's bathroom. There was a sign in the men's bathroom, but the sign documented, Remember to hand wash the FROG way! (Friction Rubs Out Germs), which was about procedures on how to wash hands for infection control. During a follow up visit to the kitchen on 5/23/24 at 10:00 AM, a nursing staff person was observed walking around the front entry of the kitchen near tray carts. This staff person did not wear a hair restraint to protect exposed food, clean equipment, clean utensils, etc., from contamination. At 10:11 AM, dishwashing was occurring. The employee who was on the clean side of the dish machine was placing sanitized bowls on a tray to dry. This tray was on the drain board of the dirty side of the three compartment sink (the dish machine was across from the three compartment sink. Although the three compartment sink was not in use at the time, there were soiled pans stacked in the wash sink compartment on the dirty side of the three compartment sink. Additionally, there were multiple clean pots and utensils hung above the three compartment sink, except over the wash compartment of the sink. These clean pots and utensils were not stored in a clean, dry location, where they were not exposed to splash. Photographic evidence obtained. On 5/23/24 at 4:02 PM, an interview with the Director of Food and Nutrition Services about the kitchen cleaning schedule revealed that the Director assigned his employees to the cleaning of various equipment and areas. He said some things were done daily and weekly and provided a copy of the cleaning schedule. Review of the cleaning schedule also known as the AM and PM Duty Roster that the Director of Food and Nutrition Services provided, which had a Wednesday date of 11/30 indicated that assignments for the cleaning of the flattop grill was N/A (Not Applicable) for both the morning and afternoon duty roster. Additionally, the steam table was to be cleaned by the afternoon shift cook. The Director of Food and Nutrition Services was informed about the food safety concerns identified in the kitchen. He said at that time that the ice wrap should not be stored in the residents' nourishment refrigerator. The Director was asked if he conducted sanitation audits. He stated that they had a contracted service that conducted kitchen sanitation audits every two to three months. The last audit was done 1/04/24 and they scored 93%. The contract service used a formal auditing tool to perform these audits. Additionally, the corporate Registered Dietitian performed a sanitation audit once a month. The facility policy and procedure, titled Cleaning and Sanitizing Procedures, dated 1/30/24, included the following Policy Statement: Cleaning and sanitizing procedures are posted in the kitchen area. Policy Interpretation and Implementation: . Cleaning duties are individually assigned based on job description, on a daily, weekly, or monthly basis, and are posted in the kitchen area. Food service personnel sign when the task is completed. 3. Procedures for cleaning all equipment and work areas are established and posted. 5. Equipment and chemicals are available for proper cleaning and sanitizing of dishes, utensils, pots and pans. 8. It is the responsibility of the Food Service Director to: - Review cleaning schedules and to spot check upon completion of cleaning task. The facility policy and procedure, titled, Storage of Foods Brought to Residents by Family/Visitors, dated 2/9/23, included the following: .7. The nursing staff is responsible for discarding perishable foods within 3 days or before the use by/expiration date, whichever comes first. The facility policy and procedure, titled, Food Handling, dated 1/30/24, did not include any information about food employees' beverage containers.

Based on observation, interview, and record review, the facility failed to honor resident's rights to choose their bathing preference for 1 of 3 residents reviewed for choices, of a total sample of 47 residents, (#17). Findings: Review of the medical record revealed resident #17 was admitted to the facility on [DATE] from a skilled nursing facility. His diagnosis included cervical disc disorder, syncope and collapse, difficulty in walking, ataxic gait, major depressive disorder, muscle weakness, and need for assistance with personal care. Resident #17's Annual Minimum Data Set (MDS) with an assessment reference date of 4/08/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status which indicated he did not have any cognitive impairment. The MDS assessment also indicated it was very important to the resident to choose his bathing preferences. The MDS assessment showed the resident required substantial/maximal assistance for bathing and noted the resident did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Review of resident #17's medical record revealed a care plan was initiated on 4/04/23 and revised on 4/10/24 which indicated the resident had an activities of daily living (ADL) self-care performance deficit related to need for assistance with personal care. Interventions included 2-person assistance with mechanical lift for transfers and 1 person assistance with showering. The bathing task report for resident #17 noted he was scheduled to receive showers/bathe self on Wednesdays and Sundays on the 7:00 AM-3:00 PM shift. The task report revealed the resident had a bed/towel bath on 4/24/24, 4/28/24, 5/01/24, 5/05/24, 5/08/24, 5/12/24, 5/15/24, 5/19/24. There was no documentation to show the resident received a shower during the 4 weeks between 4/24/24 and 5/22/24. On 05/20/24 at 1:21 PM, resident #17 stated the nursing aides were consistently giving him bed baths but he preferred showers. He conveyed he had made his preference for showers known to the nurses, aides, and doctor however his preferences were not accommodated by staff. He stated Certified Nursing Assistants (CNAs) told him about a month ago they could not find the shower chair, so he had to have bed baths. He reiterated he had not had a shower in a month. On 5/22/24 at 10:26 AM, CNA D stated she had worked at the facility for one year on the 7:00 AM-3:00 PM shift. She stated shower chairs were used for residents who could not stand during bathing. CNA D stated there was only one shower chair for the whole building. She conveyed she could not give residents a shower if they could not stand because shower chairs were not easily available. She confirmed resident #330 was given bed baths on Wednesdays and Sundays even though he had asked for showers. She acknowledged the resident mentioned to her he would prefer showers, but she told him she was unable to accommodate his preference because a shower chair was not available. She did acknowledge the residents had the right to choose if they wanted a shower or a bath. On 5/22/24 at 12:17 PM, Licensed Practical Nurse (LPN) E stated residents who could not ambulate were provided a shower chair so they could receive showers. If residents wanted a shower and did not have their own shower chair, the CNA would get one for them from the first floor. On 5/22/24 at 12:34 PM, the Central Supply Manager stated the facility had 1 bariatric shower chair stored on the 200 unit and 2 regular shower chairs stored on the 100 and 400 units for those residents that did not have their own personal shower chair in their bathroom. He stated he had not been advised the facility did not have enough shower chairs to accommodate the residents' needs and was not told to order any additional shower chairs. On 5/22/24 at 2:50 PM, the Director of Nursing (DON) stated it was extremely important for residents to have the option to choose between a bath or a shower. It was their right. The DON acknowledged resident #17 was alert and oriented and able to make his preferences known. She confirmed the resident's preference was to have showers on Wednesdays and Sundays on the 7:00 AM-3:00 PM shift. She conveyed the expectation was the resident would receive showers twice a week unless he chose otherwise. She accessed the resident's task report and confirmed the documentation revealed the resident had a bed/towel bath for the past 30 days with no documentation of shower refusal. The DON acknowledged the resident's bathing preferences should have been honored and he should have had showers instead of the bed/towel baths. The facility's Resident Right's policy read, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .participate in decisions and care planning .residents are entitled to exercise their rights and privileges to the fullest extent possible.

Based on interview and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 3 of 3 residents reviewed for hospitalization , of a total sample of 47 residents, (#51, #64 and #117). Findings: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, gastrointestinal hemorrhage, chronic respiratory failure, type 2 diabetes, chronic obstructive pulmonary disease, Alzheimer's Disease, and cerebrovascular disease. Review of resident #51's medical record revealed she was transferred to the hospital on 3/17/24 due to hypokalemia and on 4/03/24 due to gastrointestinal bleeding. Resident #51 returned to the facility following each hospital transfer. The medical record contained a Notification of Transfer or Discharge form for each hospital transfer. The form dated 3/17/24 indicated resident #51's daughter was notified of the transfer by phone and the form dated 4/03/24 indicated resident #51's husband was notified verbally of the hospital transfer. The medical record did not contain any documentation to indicate the resident or resident's representative had been provided a written notice of the transfer. 2. Resident #64 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, hemiplegia, adult failure to thrive and unspecified dementia. Review of resident #64's medical record revealed she was transferred to the hospital on 1/12/24 due to a wound infection and returned to the facility on [DATE]. The medical record contained a Notification of Transfer or Discharge form dated 1/12/24 which indicated resident #64's son was notified by phone of the hospital transfer. The medical record did not contain any documentation to indicate the resident or resident's representative had been provided a written notice of the transfer. On 5/22/24 at 1:14 PM, the Social Services Director (SSD) stated nurses started the Notification of Transfer or Discharge form. She explained she reviewed the form the next day and made sure the resident representative was notified. The SSD reviewed the medical record and the Notification of Transfer or Discharge for residents #51 and #64. She verified the resident representatives were notified verbally. The SSD acknowledged she had not provided written notification to the resident representatives since they were notified verbally. She stated she would sometimes give a copy to the resident representative if she saw them but was unable to provide proof. On 5/23/24 at 2:01 PM, the Administrator verified the SSD was responsible for completing the Notification of Transfer or Discharge forms and providing to resident or resident representative. She stated the expectation was that the forms would be provided in written format to the resident or resident representative. 46665 3. Review of the medical record revealed resident #117, a [AGE] year old female was admitted on [DATE] and readmitted to the facility from an acute care hospital on 3/26/24. The resident was discharged from the facility to the hospital on 3/15/24 and 4/11/24. The State Agency (SA) AHCA (Agency for Healthcare Administration) 3120-0002, April 2014 Nursing Home Transfer and Discharge Notice forms dated 3/15/24 and 4/11/24 noted resident #117's family representative was provided the notices in handwritten documentation as, verbal. In an interview with the Social Services Director on 5/23/24 at 1:16 PM, she said she had not mailed resident #117's written notices and stated, I didn't know it had to be in writing. Review of the facility's standards and guidelines titled Chapter 1 Admission, Transfers, Discharges and dated January 30, 2024, read, . The resident and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. The name, address, and telephone number of the state long-term care ombudsman; e. The name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmentally disabled individuals (as applies), and f. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices.

Based on interview and record review, the facility failed to employ a qualified professional to serve as the Activity Director. Findings: On 5/23/24 at 3:37 PM, during a Background Screening review with the Human Resources (HR) Director, the HR Director reported the Activity Director was hired on 1/23/24. A review of the Activity Director's Background Screening revealed she had worked for an Assisted Living Facility (ALF) for 1 year and 8 months prior to her employment date. The HR Director reviewed the Activity Director's personnel file and stated she was unable to locate certification for the Activity Director. Verbal information was provided the Activity Director was enrolled in the course to become certified but was not currently certified. On 5/23/24 at 3:54 PM, the Activity Director verified she was hired 1/23/24. She explained prior to this position she worked as an Activity Assistant at an ALF. The Activity Director stated she enrolled in an online national activity training course in March 2024. She acknowledged she had not completed the course as of 5/23/24. The Activity Director was provided with the requirements for a qualified professional. She reviewed the requirements and acknowledged she did not meet any of the requirements in order to serve as a qualified Activity Director. On 5/23/24 at 4:04 PM, the Administrator stated the Activity Director had two years of experience prior to coming to the facility and was enrolled in an activity professionals training course. The Administrator was informed of the conversation with the Activity Director and shown the requirements for a qualified professional to serve as Activity Director. She reviewed the qualifications and acknowledged the Activity Director did not meet those qualifications when she was hired.

Based on meal observation, resident and staff interviews, menu review, and medical record review, the facility failed to provide three residents (#43, #106, and #419) their prescribed sodium-restricted diets out of three residents reviewed for food quality and a randomly observed resident during the Dining Observation Task. This occurred at three meals during the four day survey. The findings included: During the Dining Observation task on 5/20/24 at 12:57 PM, Resident #419 was eating lunch in her room. She had her lunch tray and the tray ticket documented NAS [No Added Salt] Regular. There was a salt packet on her tray and saltine crackers. Photographic evidence taken. On 5/22/24 at 9:20 AM. Resident #106 was in bed awake. His wife was setting up his meal tray. He had scrambled eggs, French toast, cranberry juice; milk, oatmeal. The tray ticket documented Liberalized Renal diet. There were two salt packets on his tray. Photographic evidence obtained. On 5/22/24 at 9:33 AM, Resident #419 was in bed and she finished her breakfast and her tray was set aside. She ate her oatmeal and some of the French toast. Her tray ticket documented No Added Salt and there were two salt packets on her tray, although she did not use them. Photographic evidence obtained. On 5/22/24 at 9:39 AM, Resident #43 was out of the room, and her breakfast tray was on the bedside table. The tray ticket documented NAS Regular diet. There were three salt packets on the tray. Photographic evidence taken. Resident #43 was prescribed a NAS diet, regular texture, thin consistency liquids on 5/10/24. The resident had essential high blood pressure. The resident's comprehensive care plan included that the resident was at nutritional/hydration risk (initiated 4/17/24). The care plan approaches included, Provide, serve diet as ordered. Monitor intake. Resident #106 was prescribed a liberalized renal diet, regular texture, thin consistency liquids on 4/17/24. The resident had end stage kidney disease and was receiving hemodialysis. The resident's comprehensive care plan included that the resident was at nutritional/hydration risk (initiated 4/17/24). The care plan approaches included, Provide, serve diet as ordered. Monitor intake and record each meal. Resident #419 was prescribed a NAS diet, regular texture, thin consistency liquids on 5/9/24. The resident had essential high blood pressure. The resident's comprehensive care plan included that the resident was at nutritional/hydration risk (initiated 4/17/24). The care plan approaches included, Provide, serve diet as ordered. Monitor intake and record each meal. On 5/22/24 at 12:41 PM, while observing in the kitchen, there were multiple meal trays - 11 trays on an open cart and approximately 56 trays stacked on a cook's counter, which were already set up with a placemat, tray ticket, salt and pepper packets. Photographic evidence obtained. Review of the facility's Week 4 of the 4 week cycle menu for the days of the survey indicated that the condiments for the NAS diet and the liberalized renal diets do not include salt. During an Interview with the Director of Food and Nutrition Services on 5/22/24 at 4:47 PM, he was asked if a liberalized renal diet include salt on the tray. He replied that they go by the diet and nutritional manual and also it depends on the stage of chronic kidney disease. He printed the menu extension for a liberalized renal diet and it documented that for the condiments that were to be served included sugar and pepper. The Director of Food and Nutrition Services was asked if this means on the menu, that the liberalized renal diet would not get salt as a condiment. He responded, that's a safe assumption. At 4:59 PM, the Director was informed that salt packets were observed on no added salt diet trays. He said staff were trained on tray set up 4/11/24. During a follow up interview with the Director of Food and Nutrition Services, on 5/23/24 at 4:26 PM, the Director was informed about the residents who received salt packets on their trays for NAS diets and the liberalized renal diets. He stated he provided training to staff about these diets. He stated that he does tray audits including diet accuracy and resident satisfaction surveys once a month and they do a shorter version once a week. The facility policy and procedure titled, Tray Identification included the following information: . Policy Interpretation and Implementation: . 2. The Food Services Manager or designee will check trays for correct diets before the food carts or meal trays are delivered to their designated areas. . 3. Nursing staff shall check each food tray for the correct diet before serving the residents. . 4. If there is an error, Nursing will notify the Dietary Department immediately so that the appropriate food tray can be served.

Based on interview and record review, the facility failed to indicate the duration of an as needed (PRN) anti-anxiety/anxiolytic medication for 1 of 1 residents reviewed for psychotropic medications, of a total sample of 47 residents, (#56). Findings: Review of the medical record revealed resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Her diagnosis included major depressive disorder, generalized anxiety disorder, Alzheimer's disease, encounter for palliative care, and adult failure to thrive. Resident #56's Annual Minimum Data Set (MDS) with an assessment reference date of 4/30/24 revealed the resident had moderately impaired cognitive skills for daily decision making. The Annual MDS noted that the resident received antianxiety medications. The MDS also noted the resident did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Review of resident #56's medical record revealed a care plan initiated on 8/03/21 and revised on 4/11/24 indicated the resident was taking antianxiety and antidepressant medications for anxiety and depression and had the potential for adverse effects associated with medications. Resident #56's Order Summary Report and the Medication Administration Record (MAR) showed the resident had an active order dated 4/02/24 for Alprazolam 0.25 milligram (mg) by mouth every 8 hours PRN for anxiety with no stop date and Alprazolam 0.25 mg by mouth every 12 hours for anxiety disorder. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include but are not limited to anti-anxiety medication. Based on a comprehensive assessment of the resident, the facility must ensure that PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. (Retrieved on 5/24/24 from www.ecfr.gov.). Review of the MAR revealed the resident received 14 doses of Alprazolam PRN between 4/02/24 and 5/18/24. The 14-day duration for the PRN medication should have been 4/02/24 to 4/16/24. The resident received 8 doses of Alprazolam after the 14-day duration. Further review of the medical record revealed the physician did not provide a rationale for the extended time-period for PRN Alprazolam use and did not indicate a specific duration for the anti-anxiety PRN order. On 5/21/24 at 12:42 PM, the Assistant Director of Nursing (ADON) stated when an antianxiety medication was prescribed PRN it should have a stop date of 14 days. She conveyed if the psychotropic medication was to be continued, the provider would write a new order with a limited duration of 14 days. She acknowledged a psychotropic medication PRN prescribed to a hospice resident would also be given a 14 day stop date. The ADON confirmed resident #56 had an active order for Alprazolam PRN for anxiety since 4/02/24 with no stop date but the PRN order should have been limited to a 14-day duration. She also confirmed there was not a provider rationale documented for continuing the medication past the 14 days. On 5/21/24 at 12:51 PM, the Director of Nursing (DON) stated the expectation was every resident prescribed a psychotropic medication PRN should have a 14 day stop date. She acknowledged resident #56 had an active routine and PRN order for Alprazolam and the PRN Alprazolam order should have had a 14-day stop date. The DON also acknowledged there was not a rationale documented in the medical record for the PRN Alprazolam to be extended past the 14 days. She stated it got missed and did not know how they missed it. The facility's Medication Order Policy read, New medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication .The following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given .PRN psychotropic medication orders 14 days.

Based on observation, interview, and policy and procedure review, the facility failed to ensure that a garbage receptacle in the kitchen food preparation area was covered during non peak food production time. This was observed on one out of 4 Kitchen Observation Task visits. The findings included: On 5/22/24 at 4:25 PM, during a follow up kitchen visit to the kitchen, the garbage can in the food preparation area near food preparation sink had no lid. The garbage can was almost full of garbage. Photographic evidence obtained. The Director of Food and Nutrition Services was present at that time and stated that a new lid was on order.

Based on observation, interview, and record review, the facility failed to ensure resident received appropriate health care services to minimize further decrease in range of motion by not applying a palm grip cushion, or carrot for contracted left hand for 1 of 3 residents reviewed for limited range of motion, of a total sample of 47 residents, (#42). Findings: Review of the medical record revealed resident #42 was admitted to the facility on [DATE] with previous admission on 9/05/23, with diagnoses of functional quadriplegia, multiple sclerosis, need for assistance with personal care, and other abnormalities of gait and mobility. Review of the Clinical Nursing Admission assessment dated [DATE] at 9:15 PM, under the function sub section for occupational therapy (OT), revealed resident #42 was able to move all extremities, and had no contractures. Review of the Care Plan initiated on 3/15/24 revealed no focus for contracture, splint, or limited range of motion positioning for the left hand. Review of the Care Plan initiated on 3/15/24 revealed no focus for contracture, splint, restorative or limited positioning for the left hand. A focus for activities of daily living (ADL's) self-care performance deficit showed an intervention for OT evaluation and treatment as ordered by the physician. Review of the Occupational Evaluation and Plan of Treatment dated 3/17/24 at 2:13 PM, revealed, Functional Limitations Present due to Contracture, grasping with the left hand, and OT to treat to address contracture impairment. Further review of resident #42 electronic medical record revealed no physician orders regarding left hand contracture or splint. A review of the Admission Minimum Data Set (MDS) with assessment reference date 3/17/2024 and signed by the MDS Coordinator on 3/22/24 disclosed no identified impairments of the upper extremities. During an interview with resident #42 on 5/20/24 at 10:53 AM, he was observed to be alert, lying in bed, with his left hand closed in a fist. He had no carrot, washcloth or palm guard present in that hand. Resident #42 stated he use to wear a splint every day, and noted there was nothing in his hand when he didn't have the splint on. On 5/20/24 at 12:18 PM, observation of resident #42 lying in bed revealed no carrot, wash cloth or splint present in his left contracted hand. On 5/21/24 at 10:21 AM, resident #42 was again observed lying in bed with his left hand in a tightly closed grasp with no palm guard or splint present. On 5/22/24 at 11:06 AM, observation revealed resident #42 in bed with his left hand closed. He remained unable to open the left hand, or move his fingers, and no wash cloth, palm guard or splint was applied to the left hand for the third day in a row. On 5/22/24 at 11:45 AM, Certified Nursing Assistant (CNA) U in the presence of the Director of Nursing (DON) verbalized resident #42 should have something in his contracted left hand. Review of CNA Kardex with CNA U revealed no documentation regarding left hand contracture positioning, interventions for splint, hand cushion, or carrot. She stated ADL care included cleaning the resident carefully, she could put a wash cloth in his hand to keep it a little open, but he did not have a splint or cushion for the left hand. On 5/22/24 at 11:47 AM, the DON stated recommendations for residents with contractures came from therapy. Nursing received the recommendation, MDS updated the CNA Kardex and the residents care plans. This surveyor explained neither the CNA Kardex nor resident #42 care plan revealed a focused problem for limited range of motion, interventions for left hand contracture or a splint. DON reported that resident #42 did not have a physician order for his left-hand contracture. On 5/22/24 at 1:11 PM, OT C explained he worked with resident #42 on mobilization and extension for the digits of his chronic left-hand contracture. He recalled he opened resident #42 left hand to wash it out, cleaned it, but he did not get up to splinting. He stated if he was stretching him out he was going to clean the hand. He acknowledged he did not follow up with a splint for the left-hand contracture because he did not have the opportunity to follow up with resident #42 every day. He stated the resident had these contractures for years. He stated a splint was not appropriate for resident #42 as he had the chronic left-hand contracture for years. He then validated therapy oversaw the treatment plan for limited mobility and contractures. Further review of resident #42's medical record showed an Occupational Evaluation and Plan of Treatment which revealed a section for assessment summary reason for therapy . Due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient was at risk for decreased ability to return to prior level of assistance . and the orthotic recommendation was for a resting hand splint which was dated and signed by OT C on 3/17/24 at 2:13 PM. The facility did not ensure resident #42 received appropriate treatment, services or healthcare for increase in or the prevention of further decrease with limited range of motion of his left hand. Nursing fundamentals for mobility revealed limb positioning with assistive devices could be used to prevent and minimize flexion of contracture formation by placing the limb in an arresting position using positioning aids which include handrolls and/or hand wrist splints (2021). (Retrieved on 6/06/2024 from www.ncbi.nlm.nih.gov/books/NBK591828/) Review of the facility policy Rehabilitation and Restorative Care with a revision date of 1/25/23 showed under functional impairments assessment and recognition upon admission to the facility, at a significant change and any time during the resident's stay the physician and staff would assess the resident's physical condition and functional status. The physician and staff would help to identify residents who had recent history of functional decline, who were at risk for additional functional decline, review results, implications of evaluations and use them to guide subsequent care planning. In conjunction with the physician and staff, therapists would propose a rehabilitation or restorative care plan that provided an appropriate intensity, frequency, and duration of interventions to help achieve anticipated goals and expected outcomes efficiently using available resources.

Based on observation, interviews, and record review, the facility failed to assure safe and accurate medication administration for 1 of 6 residents reviewed for Medication Administration, of a total sample of 47 residents, (#270). Finding: Review of the medical record revealed resident #270, a [AGE] year old male, was admitted to the facility on [DATE] from an acute care hospital with diagnoses of severe chronic kidney disease, nonrheumatic aortic (valve) stenosis, heart failure, cerebral infarction (stroke), hypo-osmolarity and hyponatremia (electrolyte imbalance), gout, hypotension, hypertension, and ataxia (impaired coordination). The Minimum Data Set Admission assessment with assessment reference date 5/16/24 was incomplete and noted as in progress. The Brief Interview for Mental Status 3.0 assessment noted the resident scored 15 out of 15 that indicated he was cognitively intact. The Section GG Documentation evaluation noted the resident required moderate staff assistance to complete his Activities of Daily Living. Resident #270's active physician's medication orders included, aspirin 81 milligrams (MG) once daily for coronary artery disease, Metoprolol Succinate extended release 25 MG once daily for hypertension, Clopidogrel Bisulfate 75 MG once daily for blood clot prevention, Cyanocobalamin (Vitamin B-12) 1000 Micrograms (MCG) once daily for supplementation, Torsemide 100 MG once daily for edema (fluid retention), Omeprazole 40 MG every morning for acid reflux, Renal-Vite 0.8 MG once daily for kidney disease, and Sevelamer HCI 1600 MG three times daily for hypocalcemia (low blood calcium). On 5/21/24 at 8:47 AM, a medication cup that contained 8 pills was observed on resident #270's over bed table. The resident was sitting in bed and stated, I didn't want to take them until I ate something. On 5/21/24 at 8:55 AM, Registered Nurse (RN) B entered the resident's room with a breakfast tray and placed it on the overbed table. The RN acknowledged the cup of pills was left on the table and stated, It's my fault. The RN then left the resident's room without removing the cup containing the medications. In a joint observation on 5/21/24 at 8:58 AM, the Flamingo Unit Manager acknowledged there was a cup that contained pills on resident #270's overbed table. She stated, The nurses are not supposed to leave them there. Review of the Comprehensive Care Plan did not include self-administration of medications. Review of the medical record revealed there were no evaluations for self-administration of medications. In an interview with the Director of Nursing (DON) on 5/21/24 at 11:39 AM, the DON explained nurses were expected to witness residents' medication administration unless they had been evaluated through the facility's process for safe self-administration which included locked storage. She said nurses were not supposed to leave medications at the bedside during administration. The DON stated, If they leave them at the bedside somebody can go and take it. Review of the facility's standards and guidelines titled Preparation and General Guidelines IIA2: Medication Administration-General Guidelines dated January 2018 read, . 14) Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications . 18) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate.

Based on meal observation, resident and staff interviews, menu review, and medical record review, the facility failed to provide food that accommodated preferences for one (#106) of three residents reviewed for food quality for two meals out of two meals observed. The findings included: On 5/22/24 at 9:20 AM, Resident #106 was in bed and his wife was setting up his meal tray. He had scrambled eggs, French toast, cranberry juice; milk, oatmeal served for breakfast. The tray ticket documented liberalized renal (kidney) diet, and included his food dislikes including cranberry juice. Resident #106 said he told Food and Nutrition Services that he doesn't like cranberry juice. He said he liked mashed potatoes and wanted them once a day. During the lunch meal observation on 5/23/24 at 1:33 PM, resident #106 had his lunch meal on his bedside table. He was waiting for his wife to come to the facility to heat it up for him. He had pork, white rice, and corn. There was cranberry juice on the tray, even though his tray ticket indicated no cranberry. During an interview with the Director of Food and Nutrition Services on 5/22/24 at 4:58 PM, he was informed about Resident #106 receiving cranberry juice on his tray when cranberry was indicated as a dislike on the tray ticket. The Director of Food and Nutrition Services confirmed that cranberry was a food dislike for Resident #106 and provided a copy of the resident's tray ticket for 5/22/23. On 5/23/24 at 4:36 PM, the Director of Food and Nutrition Services was informed that Resident #106 was served cranberry juice on his lunch tray on 5/23/24. The Director said he had talked to his employees yesterday about this concern. The facility policy and procedure titled, Tray Identification included the following information: . Policy Interpretation and Implementation: . 2. The Food Services Manager or designee will check trays for correct diets before the food carts or meal trays are delivered to their designated areas. . 3. Nursing staff shall check each food tray for the correct diet before serving the residents. . 4. If there is an error, Nursing will notify the Dietary Department immediately so that the appropriate food tray can be served.

Based on observation, interview, and record review, the facility failed to complete an accurate admission assessment coding of the Minimum Data Set (MDS) under Functional Abilities and Goals for 1 of 1 resident reviewed for limited range of motion, of a total sample of 47 resident, (#42). Findings: During an interview with resident #42 on 5/20/24 at 10:53 AM, it was noted he had a left-hand contracture with no carrot, washcloth or palm guard present in the hand. He stated he used to have a splint on every day, but there was nothing in his hand when he didn't have the splint. Review of the Clinical Nursing Admission assessment dated [DATE] at 9:15 PM, showed under the function section a sub-section for occupational therapy (OT), which revealed he was able to move all extremities, and had no contractures. Review of the Care Plan initiated on 3/15/24 revealed no focus for contractures, splints, or positioning for the left hand. Review of the Occupational Evaluation and Plan of Treatment dated 3/17/24 revealed, Functional Limitations Present due to Contracture, grasping with the left hand, and included OT to treat to address contracture impairment. A review of the admission MDS assessment with reference date 3/17/2024 and signed by the MDS Coordinator on 3/22/24 revealed no identified impairments of the upper extremities indicated on the assessment. On 5/22/24 at 4:45 PM, the MDS Coordinator stated normally we do put something in the care plan for resident with contractures, unless we missed it. She confirmed the OT evaluation showed a contracture of the left hand, and she said, We must have missed it. In an interview on 5/23/24 at 9:50 AM, the MDS Coordinator stated to ensure accuracy of assessments, information was captured by reading resident's medical record notes, communicating with the entire interdisciplinary team, and review of therapy recommendations. She stated she was responsible for the MDS accuracy. Centers for Medicare & Medicaid Services Long-Term Care Facility RAI (Resident Assessment Instrument) User's Manual 3.0, v.1.18.11 (October 2023) revealed the definition for functional limitations as a loss of range of motion which included contractures, muscle weakness, fatigue, decreased ability to perform Activities of Daily Living, paresis, or paralysis. Review of the facility nursing policy and procedure with a review date of 1/30/24 revealed a resident's ability to perform activities of daily living will be measured by clinical tools and the MDS. Functional decline or improvement is to be evaluated in reference to the Assessment Reference Date.

Based on observation, and interview, the facility failed to ensure staff donned appropriate Personal Protective Equipment (PPE) before or upon entry into the environment of a resident on transmission-based precautions (e.g., contact precautions) for Clostridioides difficile (a germ that causes diarrhea and inflammation of the colon and can be life-threatening) and perform soap and water handwashing before exiting; and failed to ensure nursing staff followed appropriate hand hygiene practice during medication administration for 4 of 8 residents reviewed for medication administration, of a total sample of 47 residents, (#25, #98, #42 and #32) . The findings included: 1. On 5/22/24 at 1:18 PM, the Restorative Certified Nursing Assistant, Staff G entered Resident #37's room to deliver a lunch tray and did not don a gown and gloves before entering the room. Staff G went in and out of the room within a minute, which was not time enough to wash her hands with soap and water before exiting the room. Resident #37 had a diagnosis of recurrent Clostridioides difficile infection and was on transmission-based precautions (TBP) (isolation) to prevent the spread of the infection. The TBP signage on the door to the resident's room documented that staff must don a gown and gloves before entering the room and wash hand with soap and water before exiting. The facility policy and procedure, titled, Transmission-Based Precautions, reviewed 1/30/24, included the following information: . f. Types of Transmission-Based Precautions: i. Contact Precautions: a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. a. Examples of infections requiring Contact Precautions include, but are not limited to: . ii. Diarrhea associated with Clostridium [currently known as Clostridioides] difficile. . d. Certain disease precautions require enhancements to contact precautions that include special enteric precautions that require use of soap and water for hand hygiene before and after entering the room. PPE utilized include gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment. 35339 2. During a medication administration observation on 5/20/24 at 12:10 PM, Registered Nurse (RN) A prepared medication to administer to resident #25. She did not wash or sanitize her hands before preparing the medication. She knocked on resident #25 door, introductions were made, she explained she was going to administer seizure medication. She donned gloves, administered the medication Carbamazepine 200 milligrams (mg) 1 tablet by mouth; she gathered the medication cup, doffed her gloves, placed the supplies into the wastebasket, and then exited the room. She did not wash or sanitize her hands after administering the medication, removing her gloves, or before exiting the residents room. 3. On 5/20/24 at 12:16 PM, RN (A) prepared medication to give to resident #98. RN A knocked, entered the room, and explained to resident #98 that she had his pain medication. She then inquired regarding his pain level. RN A exited the room, then proceeded to prepare Naproxen 220 mg 1 tablet by mouth for administration. Observation revealed RN A did not use the hand sanitizer on top of medication cart to sanitize her hands before preparing the medication for administration. Further observation showed RN A donned gloves, entered resident #98 room, administered the medication, doffed the gloves and threw the medication cup into the trash can next to the exit door then exited resident #98's room. She did not sanitize, or wash her hands after administering the medication. 4. On 5/20/24 at 12:18 PM, RN A was observed preparing Baclofen 20 mg 1 tablet by mouth for resident #42. She prepared the medication, knocked, entered the room and put on her gloves, then explained to the resident she had his Baclofen medication. She administered the medication and assisted resident #42 in drinking clear fluid to swallow the medication. RN A then proceeded to the trash can with the medicine cup, doffed her gloves, and exited the room. She did not wash or sanitize her hands before preparing, after entering or exiting resident #42's room. 5. On 5/20/24 at 12:26 PM, RN A was observed walking from her nursing cart in the hallway outside of resident #42's room to speak to a man dressed in black nursing scrubs. RN A and the man had a conversation in Spanish then RN A hugged the man in black nursing scrubs then returned to her medication cart, pushed the cart around the corner to the right, and prepared medication for administration to resident #32. Observation revealed she did not use the hand sanitizer on top of her medication cart, nor wash her hands after hugging the man in black scrubs before she prepared the medication for resident #32. On 5/20/24 at 12:30 PM, further observation revealed RN A knock on resident #32's door, introduce herself, then explain she was going to administer Diltiazem 90 mg 1 tab by mouth. She donned gloves, administered the medication to resident #32, offered fluids to the resident, doffed the gloves, placed the medication cup and used gloves into the trash can near the doorway and exited resident #32's room again without handwashing or sanitizing her hands. Observations during medication administration pass for 4 of 4 residents revealed RN (A) did not follow good nursing principles and practices by not using hand sanitizer, or washing her hands in between preparing, administering, or exiting residents rooms. On 5/20/24 at 12:38 PM, RN A stated she was aware she should sanitize or wash her hands between residents when doing medication administration pass. She said, I used the hand sanitizer. RN A was reminded she was observed to not sanitize or wash her hands during the medication pass with residents #25, #98, #42, and #32 and was asked when did she wash or sanitize her hands? She paused and acknowledged she did not clean her hands until after after taking resident #32 a beverage with ice. On 5/20/24 at 1:23 PM, the Director of Nursing (DON) stated the facility practice was nurses should knock on the door, ask the resident's name, their date of birth, explain the medications, and wash their hands or use hand sanitizer during medication administration pass and between each resident. A review of the policy, Medication Administration- General Guidelines with a revision date January 2018 revealed medications were administered in accordance with good nursing principles and practices. The procedures section indicated for handwashing, and hand sanitization the person administering medications should adhere to good hand hygiene which included washing hands thoroughly before beginning a medication pass. Prior to handling any medications, hand sanitizer can be used between hand washings when returning to the medication cart or preparation area assuming hands have not touched a resident, contaminated surface, and at regular intervals during the medication pass such as after each room.

Based on interview and record review, the facility failed to ensure the baseline care plan summaries were reviewed with the resident or resident representative for 4 of 4 new admission residents out of a total sample of 42 residents (#15, #88, #273 & #274). Findings: 1. Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with previous admissions on 12/01/22, 11/15/22, and 5/24/21 with diagnoses of acute kidney failure, pain, urinary tract infection, hypertension, history of traumatic brain injury. The Minimum Data Set (MDS) entry assessment had an assessment reference date (ARD) of 1/24/23. Nurses' notes from 1/24/23 at 10:00 PM through 2/16/23 at 2:29 PM did not contain any documentation of the resident's refusal to sign a baseline care plan summary. The medical record did not contain a copy of a baseline care plan summary provided to resident #15 or the resident's representative. On 2/13/23 at 9:37 AM, resident #15 stated she did not have any concerns with care plans and could not remember receiving a baseline care plan summary form. 2. Resident #88's medical record revealed the resident was readmitted to the facility on [DATE], and originally admitted on [DATE] with diagnoses of diabetes, post-acute respiratory failure with hypoxia, malignant neoplasm of brain, and abdominal aneurysm. The MDS Medicare 5-day had an ARD of 1/25/23. Nurses' notes from 1/06/23 at 3:03 PM through 2/16/23 at 2:23 PM did not contain documentation of the resident's refusal to sign a baseline care plan summary within 48 hours of admission, and there was no copy of a baseline care plan summary signed by resident #88 or a family representative in the medical record. On 2/13/23 at 10:45 AM, the resident stated he did not have any concerns with care plans and was not sure if he received a copy the baseline care plan. 3. Resident #273's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including previous spine fracture T7, T8, thoracic vertebra routine healing, chronic systolic heart failure, and epilepsy. The MDS entry assessment had an ARD of 2/08/23. The medical record did not contain any documentation from 2/08/23 at 8:27 PM through 2/15/23 at 6:51 PM for the resident's refusal to sign a baseline care plan, and there was no documentation that a copy of the baseline care plan summary was provided to resident #273 or the resident's representative. On 2/13/23 at 10:37 AM, the resident did not voice any concerns regarding care plans and did not know if he received a copy of the care plan of if he had signed a care plan. 4. Resident #274's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, heart failure, and pneumonia. The MDS entry assessment had an ARD of 2/09/23. Nurses' notes from 2/09/23 at 10:23 PM to 2/16/23 at 2:19 PM did not contain documentation of the resident's refusal to sign the baseline care plan summary. The medical record did not contain a copy of a baseline care plan summary provided to resident #274 or the resident's representative. On 2/13/23 at 10:43 AM, resident #274 stated she did not have any concerns with care plans and could not remember receiving a baseline care plan summary form. On 2/16/23 at 1:30 PM, a copy of the baseline care plan summary information provided to resident and/or family representative for residents #15, #88, #273, and #274 was requested from Director of Nursing (DON). The DON revealed that they discuss this with the resident and/or representative in their care plan meeting. On 2/16/23 at 1:59 PM, the MDS Director stated she handles all the care plans, and the nurses do the baseline care plans. She stated she is not aware that the resident or the resident's representative should have a copy of baseline care plan summary and said there was no MDS documentation. On 2/16/23 at 2:15 PM, the DON stated she is aware of residents receiving a baseline care plan summary. It is done by nursing and the residents are given a copy. She stated sometimes the baseline care plan is signed and sometimes it is not. She stated nursing is responsible for the baseline care plans. She stated if there is a refusal to sign a baseline care plan, nursing should make a note in the progress notes. She stated if the baseline care plan is signed, a copy is given to MDS staff, then MDS staff speaks to the resident, and MDS staff will write a progress note. The DON stated she is responsible for following up with nursing and she confirmed there were no baseline care plans for resident #15, #88, #273, or #274. She validated there was no documentation of baseline care plan summaries provided, or refusal to sign for residents #15, #88, #273, #274 or their family representatives. On 2/16/23 at 2:20 PM, the Social Services Director confirmed she does have any involvement with residents' baseline care plans. A review of the policy Care Plan, with a review date of 10/24/22, read in part, PROCEDURES . 2. An Interim Baseline Care Plan shall be initiated and implemented within 48 hours of admission that includes interventions to provide person-centered, culturally competent and trauma informed resident care as indicated. This interim care plan shall include but is not limited to: physician's orders, dietary orders, therapy services, social services and PASRR recommendations when applicable.

Based on observation, record review and interview, the kitchen staff failed to follow hygienic practices, during food distribution, to prevent the cross contamination of food, utensils, and clean equipment. Finding: Review of the facility menu for 2/13/21 revealed the residents would be served Cinnamon Oatmeal, Cheese Omelet, Hashbrown Patty, and Raisin Toast for breakfast. Review of the facility's mealtimes noted that breakfast would start at approximately 7:30 AM. On 2/13/23 at approximately 8:09 AM, the cook and a dietary aide had already started the breakfast tray line. The cook wore gloves and was the actual staff person plating the food. Approximately 2-3 minutes later, the cook, who was still wearing the same gloves, lowered his surgical mask below his nose and mouth, and drank from a Styrofoam cup that did not have a lid. The cook could not explain why he was drinking during the tray line service but indicated he should not have done so. He indicated he was aware that eating and drinking was prohibited during tray line. Approximately 1-2 minutes later, the Certified Dietary Manager (CDM) said that the kitchen staff had been educated about not eating or drinking during the tray line service. The cook returned to the tray line, but he did not sanitize his hands and don new gloves. The cook used his gloved hand to plate a cheese omelet and a hashbrown patty. Chapter 2 of the 2022 Food and Drug Administration (FDA) Food code, delineates hygienic practices for foodservice employees. Eating and drinking is allowed only in designated areas where contamination/cross contamination to food, utensils and clean equipment can occur. Chapter 2 also notes that food service employees shall clean/wash their hands after eating or drinking.

Based on observation, interview and record review, the facility failed to follow physician ordered liters of oxygen administration for 1 of 1 resident reviewed for oxygen therapy out of a total sample of 42 residents (#274). Findings: Resident #274's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of anemia, chronic kidney disease, heart failure, COVID-19 and pneumonia. The Minimum Data Set (MDS) entry assessment with assessment reference date (ARD) of 2/09/23 did not show an oxygen order. Review of the care plan initiated and revised on 2/10/23 showed a problem of respiratory distress with a goal and an intervention to administer oxygen as ordered. On 2/13/23 at 10:43 AM, observation of resident #274 revealed oxygen via nasal cannula running at 3 liters per minute. The medical record revealed a physician's order dated 2/10/23 for oxygen at 2 liters per minute via nasal cannula every shift. On 2/13/23 at 3:16 PM, observation of resident #274 with Registered Nurse (RN) A revealed that oxygen was set at 3 liters per minute. Review of the physician's order with RN A revealed oxygen was ordered at 2 liters per minute. Upon observation of resident #274's oxygen rate with RN A, he confirmed oxygen was running at 3 liters per minute. He stated he last checked resident #274's oxygen dosage on 2/12/23. He stated oxygen rate for residents should be checked every shift and it is his fault that the oxygen was running at the wrong rate for resident #274. Physician's order for oxygen was not followed and resident #274 did not receive care and services appropriate with the plan of care. On 2/13/23 at 4:04 PM, the Director of Nursing (DON) stated the nurse is responsible to check the resident's ordered oxygen rate. On 2/15/23 at 11:03 AM, the DON stated, I am ultimately responsible, and the expectation is nursing will follow the physician orders. The facility's policy Physician Orders, reviewed 1/19/2018 read, PROCEDURES . 3. Physician orders will be transcribed, noted, implemented, and followed in a timely manner . The facility's policy Care Plan, reviewed 10/24/2022, read, PROCEDURES . 5. Person-centered and culturally competent care plan approaches shall be communicated to staff for use in providing care .

Based on interview, and record review, the facility failed to report an alleged violation of neglect as required by regulatory guidelines for 1 of 3 residents reviewed for quality of care of a total sample of 10 residents, (#7). Findings: Resident #7 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medicare 5-day Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/07/22 revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15/15. Resident #7 required extensive assistance of one person for bed mobility, dressing, toilet use, and personal hygiene. The assessment revealed the resident had unsteady balance, and was only able to stabilize with staff assistance, and had functional limitation in range of motion to one side of her lower extremity. The assessment indicated the resident was frequently incontinent of bladder and bowel. On 4/11/22 at 2:09 PM, resident #7 explained she was bedridden for the past two months from a crushed femur. She recalled on 3/24/22, she sat in urine and waited two hours to receive incontinence care. She said she told Registered Nurse (RN) A, who gave her the call light, left her, and never came back. The resident stated she called her son and daughter in law by telephone and asked them to call the facility and send someone to assist her. Resident #7 explained when Certified Nursing Assistant (CNA) B came to her room, she reported RN A did not tell her the resident needed help. Resident #7 said she spoke with the Administrator about the incident, and the Administrator asked her if she would consider the incident abuse or neglect. The resident said she asked, why and the Administrator said she would have to file a complaint. Resident #7 noted she told the Administrator it was not for me to say if it was abuse or neglect, I gave you the facts for you to make the decision. Resident #7 stated she felt it was neglect. Review of the grievance log for the period 1/01/22 to 04/12/22 revealed an entry on 3/25/22 for resident #7 regarding care. Review of the Alleged Abuse/Potential Neglect/Exploitation Log for the same period, showed no entry regarding resident #7. On 4/11/22 at 5:40 PM, resident #7's grievance was discussed with the Administrator/Risk Manager and the Director of Nursing (DON). They reported on 3/25/22, resident #7 complained she was not assisted with toileting care on 3/24/22. They said she had told RN A of needing care and nothing was done. The Administrator stated an investigation revealed the resident was assisted with toileting before dinner and was then assisted to bed. After 8 PM, the resident asked RN A to send CNA B in to provide incontinence care, but RN A forgot to send the CNA to assist the resident. When CNA B returned to the unit after her break, RN A sent her to the resident's room at approximately 9:30 PM. The RN's statement indicated that between 8-8:30 PM, resident #7 told her she wanted to go to the bathroom, she was busy and forgot to tell the other CNA who was on the unit. The DON stated they spoke with resident #7, and her daughter in law, and they were asked if they felt that the incident met the level of neglect and both said no, so the facility filed a grievance. They reported the incident was not entered on the Alleged Abuse/Potential Neglect/Exploitation Log, and a report to the regulatory and investigative agencies was not initiated. On 4/11/25 at 5:55 PM, the Assistant Administrator stated when the incident was discussed, the resident seemed upset with the nurse, RN A. She acknowledged it was not the resident's responsibility to decide if the incident rose to the level of neglect. The Administrator, Assistant Administrator, and DON verbalized the resident's need was not acted upon in a timely manner but they did not enter the incident on the facility's Alleged Abuse/Potential Neglect/Exploitation Log, and did not initiate a regulatory agency report. The Administrator verbalized the resident showed some emotional distress on 4/11/22 when they discussed the past incident with her. The facility's policy Alleged Abuse/Potential Neglect/Exploitation/Investigation with effective date of 8/26/2008 and review date of 8/22/2017 read, The investigation should commence as soon as possible following receipt of any allegation of abuse or potential neglect .Allegations of abuse, neglect .will be reported to the appropriate regulatory and investigative agencies, by the Administrator or the person designated to act on behalf of the administrator, in accordance to state requirements.

Based on observation, interview and record review, the facility failed to conduct accurate elopement risk evaluations to identify and implement appropriate interventions for elopement risk to prevent a physically and cognitively impaired resident from exiting the facility; and failed to respond to an exit door alarm in a timely manner and conduct a thorough search for a missing resident, for 1 of 5 residents reviewed for elopement, of a total sample of 8 residents, (#3). These failures contributed to the elopement of resident #3 and placed her at risk for serious injury/impairment/death. While resident #3 was out of the facility unsupervised, there was a likelihood she could have fallen, become lost or been hit by a car. On 9/18/21 at approximately 4:00 PM, the facility failed to prevent resident #3 from exiting the facility unsupervised through the Flamingo B Hall exit door. Resident #3 walked along the entire length of the hallway unnoticed by staff, pressed on the exit door's panic bar to release the lock and activated the door alarm as she left the building. She crossed an uneven, grassy area then wandered back and forth through the facility's back parking lot and walked up an embankment and entered the adjacent property. Resident #3 crossed a driveway in front of a departing car and when the driver stopped the car she opened the passenger side door and got in without invitation. The facility was unaware of resident #3's whereabouts until a Good Samaritan called the facility to ask if they were missing a resident. The facility's failure to provide adequate supervision and ensure an appropriate response to an exterior exit door alarm placed all residents who wandered at risk. This failure resulted in Immediate Jeopardy starting on 9/18/21. The Immediate Jeopardy was removed on 9/23/21. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F609 and F641. Resident #3, an [AGE] year-old female, was admitted to the facility from an acute care hospital on 9/05/21. She was hospitalized for a possible [CONDITION(S)] with temporary loss of consciousness and required rehabilitation before returning home. Resident #3's primary admitting diagnosis was [CONDITION(S)], .a term used to describe brain disease or brain damage. These changes in the brain can cause altered mental status, confusion, and behavior changes (retrieved on 10/27/21 from www.webmd.com). Resident #3 had additional diagnoses including chronic dementia, a recent fall that resulted in a left arm fracture, generalized muscle weakness, and stroke. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 9/05/21 revealed resident #3 was alert, disoriented, but could follow simple instructions. The transfer form indicated she used an assistive device for ambulation and required assistance from 1 person for transfers. Resident #3 had risk alerts for falls and seizures. Review of the Clinical Admission Evaluation dated 9/05/21 revealed resident #3 was alert with forgetfulness. The admission evaluation was incomplete as there were no responses to questions regarding mood and behaviors such as wandering, and no documentation to show evaluation of her safety needs, functional status, or necessary assistive devices was conducted. A State of Florida Determination of Inability to Make Healthcare Decisions form dated 9/05/21 indicated a physician evaluated resident #3 and determined she lacked the physical or mental capacity to communicate decisions regarding her health care needs. Review of resident #3's medical record revealed an admission Elopement Evaluation dated 9/05/21 which scored the resident as 0 and not at risk for elopement. The document was completed by Registered Nurse (RN) G, the weekend nursing supervisor, and it showed resident #3 did not have a history of attempted or actual elopements while at home, nor any type of wandering behaviors. The Minimum Data Set (MDS) Admission assessment with assessment reference date of 9/11/21 revealed resident #3 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated she had no wandering behavior, required supervision for walking in her room and walked independently in the corridor. Resident #3 had unsteady balance but was able to stabilize herself without staff assistance. The MDS assessment indicated the resident had an impairment of one arm, previously used a walker for ambulation, but currently did not have a mobility device. The document showed resident #3 fell during the month prior to admission and suffered a fall-related fracture within the six months prior to admission. The MDS assessment Section V Care Area Assessment (CAA) Summary showed the care area for behaviors including wandering did not trigger, and therefore no care plan was indicated. Resident #3 had a care plan for risk for falls related to gait and balance problems and poor safety awareness that was initiated on 9/06/21. Interventions included anticipate and meet the resident's needs. A care plan for impaired cognition and impaired thought process related to dementia was initiated on 9/06/21. The interventions directed staff to communicate with the family regarding the resident's needs and capabilities and cue, reorient and supervise her as needed. A care plan for behaviors including wandering to other residents' rooms was initiated on 9/13/21. An intervention dated 9/16/21 encouraged pursuit of diversionary activities. The document did not include specific approaches regarding staff supervision or recommendations for the frequency of monitoring necessary to ensure resident #3 was safe during periods of wandering. Review of the Certified Nursing Assistant (CNA) care plan or Kardex revealed no instruction on safety and behavior interventions related to wandering or elopement prior to 9/18/21. Review of resident #3's medical record revealed documentation of wandering behavior, contrary to the MDS Admission assessment finding, during the seven-day lookback period. A nursing progress note dated 9/07/21 at 11:55 PM read, Resident required frequent redirection throughout the shift . continuously required redirection from entering other rooms and requesting to find the door to where she might be able to host a banquet. Nursing progress notes revealed resident #3 continued to exhibit wandering behaviors after the MDS Admission assessment was completed. A note dated 9/12/21 at 1:07 PM indicated she wandered outside her room on two occasions. A note dated 9/13/21 at 4:22 AM, indicated the resident required some redirection during that shift and the previous shift. Another note written later that day on 9/13/21 at 3:57 PM, revealed resident #3 wandered around the unit without assistance and entered other residents' rooms throughout the day. The note indicated multiple attempts at redirection were ineffective and the resident continued the wandering behavior. On 9/14/21 at 1:39 PM, a nursing note revealed the resident continued wandering and required redirection due to her forgetfulness. A nursing note dated 9/14/21 at 4:46 PM, showed the behavior continued. The note read, Resident requires frequent re-direction from wandering. A nursing progress note written by the weekend nursing supervisor, dated 9/18/21 at 4:30 PM, revealed during rounds of the facility at approximately 4:00 PM, she heard an exit door alarm sounding on the Flamingo unit. The note indicated she investigated the source of the alarm, did not see anyone outside, and initiated the facility's protocols for a head count and search for a missing resident. The weekend supervisor noted the facility received a telephone call almost 30 minutes later regarding resident #3 being found on the property next door to the facility. On 10/20/21 at 10:13 AM, the Executive Director of the Assisted Living Facility (ALF) next door to the facility recalled hearing about an elderly person who was found in the ALF parking lot by a member of his staff approximately 2 to 3 weeks before. On 10/20/21 at 10:21 AM, the ALF Life Enrichment Coordinator confirmed she found a confused elderly woman in the side parking lot of the ALF on Saturday 9/18/21 at approximately 4:10 PM. She stated she was driving out of the parking lot and saw the woman standing near the parked cars to her left. She said, I slowed down, stopped, and she crossed right in front of my car. She kept looking at me intently while she walked in front of my car. She finished crossing the parking lot and came to the passenger side of my car. The ALF Life Enrichment Coordinator stated she rolled down the passenger side window and the woman asked, Are you driving towards the front? Can you drop me off at the gate? She stated the elderly woman opened the passenger side door and got into the car without invitation. The ALF Life Enrichment Coordinator stated the woman provided her name and explained she lived a couple blocks away but was not able to provide a local address. She said, It was clear she had some type of dementia. The ALF Life Enrichment Coordinator then drove to the front of the ALF and parked her car under the portico. She left the elderly woman in the car alone while she entered the building to get advice on how to handle the situation. She explained after speaking to the ALF concierge and nurse on call, they decided to contact the police and report the incident. The ALF Enrichment Coordinator stated after speaking to the police, she recalled the elderly woman had mentioned that she broke her arm which made her wonder if this was a resident of the skilled nursing facility next door. She stated when she called the facility to ask if they were missing a resident, they confirmed a resident eloped. She recalled soon after the telephone call, three facility nurses ran into the ALF parking lot. She explained by that time the elderly woman seemed tired, was reclined in the front seat of her car, and had opened the passenger door to let some air inside. The ALF Life Enrichment Coordinator stated one of the three nurses got into the back seat of her car and she drove the nurse and the elderly woman back to the facility. On 10/20/21 at 2:25 PM, Licensed Practical Nurse (LPN) B stated she was assigned to resident #3 during the day shift, before she got out of the facility. She recalled at approximately 3:00 PM during change of shift report, she noted resident #3 was very active, walking in and out of her room. LPN B stated she paused report and directed CNA C to guide the resident to the unit's activity room. LPN B said she finished report and last saw resident #3 between 3:00 PM and 3:30 PM. She explained she clocked out at approximately 4:00 PM and as she walked to the parking lot, the weekend Nursing Supervisor came outside and told her the alarm at the Flamingo B Hall exit door had been activated. LPN B stated she returned to the unit, assisted with the head count of residents, and discovered resident #3 was missing. She stated the facility initiated a search and said, At one point, I got into my car, and I was driving down the street to make sure she wasn't out on the road. LPN B acknowledged staff at the nearby ALF found resident #3 and notified the facility. She said after the resident was returned to the facility, she entered a progress note in the medical record regarding her last interaction with the resident. Review of the medical record revealed there were two progress notes written by LPN B after resident #3 was found and returned to the facility at approximately 4:30 PM. In a late entry note created on 9/18/21 at 5:29 PM, LPN B wrote that she last saw resident #3 at 3:40 PM, not between 3:00 PM and 3:30 PM as she stated when interviewed. The note read, Resident currently standing by nurses station under close supervision. Resident guided by CNA to activity area. LPN B created another late entry note on 9/18/21 at 5:47 PM that was timed for 2:10 PM which indicated resident #3 was seated in a bedside recliner and was noted ambulating around nurses station periodically. Although both notes mentioned close supervision and safety precautions, neither specified the frequency of monitoring, specific safety precautions in place, or how resident #3 managed to leave the unit unnoticed and exit the facility unsupervised. On 10/20/21 at 2:42 PM, RN A recalled when the weekend Nursing Supervisor informed her she was unable to locate one of the residents, she assisted with the exterior search for resident #3, including the construction site to the right of the facility. She stated when the facility was notified of the resident's whereabouts she joined other nurses as they ran to the ALF to retrieve her. RN A stated the resident was seated in a car and verbalized she wanted to go home. RN A stated RN I got into the car and returned to the facility with the driver and resident #3. RN A stated she called the resident's daughter to notify her that her mother got outside of the facility. RN A said, She told me it had happened before, and the family called her Houdini because she had disappeared from home twice before. RN A acknowledged the admission process included an elopement evaluation and it would be appropriate to contact a family member to obtain this type of essential information if a resident was confused or cognitively impaired. On 10/20/21 at 3:09 PM, the elopement incident was discussed with the Administrator and the Director of Nursing (DON). They confirmed resident #3 exited the facility without supervision on 9/18/21 and was retrieved after staff at the ALF next door called to inform them of her location. The DON stated after the incident she reviewed camera footage that showed resident #3 walking in the back parking lot until she disappeared out of camera range. The Administrator explained she no longer had access to this videotape as she did not know how to save it, and the videotape was overwritten. The DON recalled she spoke with resident #3's daughter after the incident and was informed about her mother's history of two successful elopements from home. The DON stated the daughter had not provided that information to the facility on admission. However, the DON could not confirm that nurses attempted to contact resident #3's family to participate in the admission evaluations. The Administrator stated the facility determined the root cause of the incident to be . we did not have the correct information about the resident. Review of the facility's root cause analysis with the Administrator and DON revealed the facility did not identify or describe the reason(s) for the lack of correct information, such as the failure of multiple staff to accurately evaluate and re-evaluate resident #3 by obtaining pertinent input from her family, as possible causative factors for the elopement. On 10/20/21 at 3:43 PM, in a telephone interview, resident #3's daughter verified facility staff notified her that her mother was found outside on 9/18/21. She said, The call took me by surprise. I was a little freaked out at the call, and even worse to find out she was in a stranger's car! Resident #3's daughter recalled on the day she came in to complete and sign admission paperwork she informed front office staff her mother had a history of wandering and escaping. Questions on the facility's admission and elopement evaluations were read to the daughter and she said, Nobody called me when she got there. And nobody asked me those questions. My mother could not answer those questions. Resident #3's daughter recalled her mother wandered into other residents' rooms from the beginning of her stay. She stated a staff member was once very rude when describing her mother as scaring other residents when she entered their rooms. The daughter said, They should have known she would try to get out because they told me she wandered everywhere. The daughter was asked if she informed staff about the extent of her mother's wandering history including the elopements. She said, Of course I did. She did it twice at home and I wouldn't have forgotten to tell anyone that. Resident #3's daughter described her mother as very confused every day. She stated her mother was not oriented to place and still believed she was in New York, not Florida. The daughter stated the incident was very upsetting to her as her mother would not have been safe on her own outside the facility. She explained her mother probably could not have crossed the busy street in front of the facility safely, and said, She absolutely, no way, could not give her address. The daughter explained her mother now lived with her at home and still needed to be watched 24 hours daily. Resident #3's daughter said I sleep with her at night and spend all day making sure she is safe. I was expecting that if she went from the hospital to skilled nursing she would at least stay in the building. It is very scary that they let her get out. On 10/21/21 at 11:15 AM, CNA C recalled she worked from 7:00 AM to 11:00 PM on the day resident #3 got outside the facility. She explained she was not assigned to care for the resident and had never seen her before. CNA C stated a nurse instructed her to take resident #3 to the activity room. She said, [The nurse] did not tell me to stay with her. [The resident] sat down and I left her there and continued to do my work. CNA C stated she was in a room providing care to a resident when someone came to ask if she knew the whereabouts of resident #3. CNA C said, I put her in the TV room between 2:45 PM to 3:00 PM. The last time I saw her could be about 3:30 PM to 4:00 PM. She stated she never heard any alarms that afternoon as she was behind closed doors attending to her assigned residents. On 10/21/21 at 11:36 AM and 11:48 AM, the Admissions and Marketing Director stated she was not made aware of any concerns regarding resident #3 as an elopement risk prior to admission. She was informed the resident's daughter stated she told Admissions Department staff about her mother's wandering and elopements on the day she signed admission paperwork. The Admissions and Marketing Director said, I would have expected my staff to communicate that with nurse leadership. She acknowledged the facility had an electronic wander system and was therefore equipped to handle any residents who wandered towards exit doors by utilizing a personal electronic wander device if indicated. On 10/21/21 at 12:40 PM, the Director of Rehabilitation stated resident #3 was on therapy caseload during her stay in the facility. She recalled the resident had dementia and sometimes experienced difficulty understanding instructions and precautions. The Director of Rehab said, We tried to see her in her more lucid moments. She would sundown towards afternoon, so we tried to see her in the morning. We would not get near as much compliance later in the day. The Director of Rehab explained resident #3 had weakness in her legs and said, She could walk most of the time but sometimes would just lose it. Either her feet would get close together, she would trip herself up or she would not pick her feet up enough to clear the floor. The Director of Rehab stated resident #3 was not safe outside the facility due to her physical and cognitive impairments and would not have been able to cross a street safely. She explained that uneven terrain and sidewalks would be hazardous as the resident was already at risk for falls because she did not pick up her feet. On 10/21/21 at 1:12 PM, the Occupational Therapist (OT) recalled resident #3 was confused and required cuing for safety with ambulation as she had issues with her balance. The OT stated she would not recommend resident #3 walk without supervision. When asked if the resident would be safe outside the facility on her own, the OT said, She absolutely would need supervision. On 10/21/21 at 1:15 PM, the Speech Therapist (ST) reiterated resident #3 was very confused. The ST stated resident #3 had severe short-term memory deficit and would forget strategies taught within 30 seconds to one minute. On 10/21/21 at 1:17 PM, the Physical Therapist (PT) said resident #3 was very forgetful. He stated she required a walker for stability and due to her arm fracture she used a special walker in therapy which had a tray surface to rest her arm. The PT noted, She needed assistance with a gait belt for safety. She was definitely at risk for falls. He explained during a normal therapy session he walked 150 to 200 feet with resident #3, and no further. On 10/21/21 at 3:54 PM, resident #3's elopement route was retraced with the Director of Plant Operations. He stated he watched the video footage about three times and could retrace her path from memory. He recalled how emotional he got while he watched the video of resident #3 wandering alone outside the facility. Resident #3 ambulated approximately 160 feet from the middle of the Flamingo unit, along the hallway and arrived at the B hallway exit door. She released the door lock by pressing on the panic bar, triggered the alarm and continued walking another 130 feet across an uneven, grassy field to the sidewalk that bordered the back parking lot. Resident #3 stepped down off the curb and crossed the parking lot to the opposite sidewalk. She paused for a short time before she continued to walk away from the facility, crossing the parking lot diagonally and continuing towards the far end. Resident #3 backtracked across the middle of parking lot to the point near where she initially crossed and again turned towards the far end of the parking lot. She followed the sidewalk until she faced a thick double row of [NAME] between the facility and the ALF next door. The resident probably stepped off the curb, crossed the driveway and walked between low bushes to arrive on the ALF's property. She crossed another uneven grassy area, walked through a shallow drainage [NAME], and managed to navigate a sloping embankment that was slippery due to layers of pine needles. She walked through the ALFs parking lot until she arrived at the area near the dumpster where she got into the ALF Life Enrichment Coordinator's car. Resident #3 traveled a total distance of over 1400 feet, or more than a quarter of a mile, unsupervised and without an assistive device. Additional environmental hazards included the facility's location on a heavily trafficked road. On the left was the large combined independent and assisted living facility with a busy driveway and parking lot used by staff, residents, and visitors. To the right of the facility there was a construction site. There was a large hospital nearby and emergency vehicles drove past the facility regularly. Review of historical weather data revealed on 9/18/21 at 3:53 PM, it was 87 degrees Fahrenheit (F) with 63% humidity level (retrieved on 10/27/21 from www.timeanddate.com). The heat index or feels like temperature in the shade that day was 94 degrees F. Extreme caution is necessary in these conditions as heat exhaustion is possible with prolonged exposure or physical activity (retrieved on 10/27/21 from www.weather.gov). On 10/21/21 at 4:20 PM, the Director of Plant Operations stated when he watched the facility's video recording, resident #3 seemed steady enough on her feet. He acknowledged she was elderly, and terrain that would be easy for others to navigate could be dangerous for this resident. He was informed resident #3 could have headed towards the front of the facility and reached the busy road. He stated, That street is not safe for me to cross. On 10/22/21 at 3:51 PM, the Director of Plant Operations explained he identified the volume of the exit door alarms as a significant issue related to resident #3's elopement. He stated he discovered staff were not able to hear the alarm if they were inside other rooms or further up the hallway, away from the exit doors. On 10/22/21 at 11:56 AM, CNA J stated resident #3 was confused, wandered, and required redirection. He recalled he was assigned to resident #3 on the afternoon she eloped. He stated she was in her room sometime after 3:00 PM as he did his rounds at the start of the shift, and he did not see her again until after she was returned to the facility. CNA J said, Probably I was in another room when she left the building. I did not hear any alarm. I always close the door for privacy when I'm with residents. On 10/22/21 at 12:10 PM, in a telephone interview the weekend Nursing Supervisor stated while walking towards the Flamingo unit on 9/18/21, she heard a beeping sound. She stated she continued down the B hallway and when she arrived at the exterior exit door she saw that it was closed, and the alarm was sounding. She explained she opened the door and, I propped it open with my foot and I peeked over to look and see if I found somebody. She stated she did not walk outside to thoroughly check the area as the door would have locked behind her. Instead, she turned the alarm off and returned to the Flamingo unit to alert staff to conduct a complete head count. RN G acknowledged she directed staff to search the interior and exterior of the facility but did not notify law enforcement during the 30-minute period resident #3 was missing. She could not explain why she did not see resident #3 who would have been in the open grassy field or wandering through the parking lot which was visible from the exit door. RN G stated to her knowledge, the resident-was never a wanderer, but rather she was at risk for falls. When asked if resident #3 was adequately supervised on the afternoon she eloped, RN G said, I don't have a proper answer regarding supervision because I was not there when she eloped. They could have been busy with change of shift activities. RN G confirmed she completed resident #3's admission elopement evaluation which showed she was not at risk for elopement. RN G acknowledged she did not speak with the resident's family at that time although resident #3 was confused. She said, Normally we wait until we have the full information. We should call the family. On 10/22/21 at 4:53 PM, in a telephone interview, LPN H stated she was resident #3's assigned evening shift nurse at the time she eloped from the facility. She recalled resident #3 walking in the hallway towards the nurses' station during change of shift report. She stated LPN B stopped report and asked a CNA who stood nearby to assist the resident to the activities area. She recalled LPN B mentioned we had to keep an eye on her. LPN H stated she was familiar with resident #3 and described her as pleasantly confused and easily redirected back to her room. She said, I do know that based on reported behaviors that she was exit seeking. She needed close supervision. I can't say what other staff would do, but on my watch I do. LPN H stated she last saw resident #3 between 3:45 PM and 3:55 PM before she entered a resident's room to respond to a call light. She stated she shut the door to provide care and explained it was impossible to hear the door alarm through the closed door. LPN H stated she was not aware resident #3 was missing until the weekend Nursing Supervisor knocked at the door and informed her. Review of the facility's policy and procedure for Missing Resident / Resident Elopement dated 3/21/14 revealed the facility would immediately respond to the report of a missing resident in an organized manner. The document indicated staff would immediately respond to alarms and conduct a comprehensive search outside the exit door where the alarm was activated. The procedures included evaluation by the interdisciplinary team and implementation of a plan of care to address a resident's identified elopement risk. The policy guidelines instructed staff to conduct scheduled elopement risk screenings on admission and one week from admission. The policy read, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. order for discharge or leave of absence) and/or any necessary supervision to do so. On 10/22/21 at 12:53 PM, during an interview with the Administrator, DON, and the Corporate Director of Risk Management they acknowledged prior to resident #3's elopement incident, the facility did not have a process in place to ensure the families of newly admitted residents were contacted to ensure accuracy of elopement evaluations. The DON stated she implemented a new process within the previous 48 hours to ensure nurses contacted family members about wandering and /or elopement history and documented the contact in a progress note. The DON acknowledged the facility's elopement policy and procedure directed nurses to re-evaluate residents' elopement risk seven days after admission. She explained the rationale was that residents' behavioral symptoms that were not identified on the day of admission could become apparent during this period. The DON stated re-evaluation of elopement risk provided an opportunity to validate or revise initial findings. She acknowledged an accurate evaluation was the basis for an appropriate care plan to address the identified level of elopement risk. She confirmed the facility had not conducted the 7-day elopement risk re-evaluation for resident #3 as recommended, and the essential information regarding previous elopements was not obtained. The Corporate Director of Risk Management explained there was a problem with the facility's electronic medical record and the alert for the scheduled 7-day elopement risk re-evaluation was not being triggered in the system. She stated nurses were therefore not aware when the elopement re-evaluations became due. Review of the job description for the Director of Nursing (undated) revealed her principal duties and job responsibilities included ensuring each resident had an individualized plan of care that was reviewed and revised as necessary. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 9/18/21, resident #3 was returned to the facility, assessed, and did not have any injury or distress noted. She was immediately placed on 1:1 supervision, had an electronic wandering device applied and was re-evaluated for elopement risk with appropriate care plan updates completed. *On 9/18/21, the facility conducted an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting which was attended by the Administrator, DON, Medical Director, and 4 additional staff members. A Performance Improvement Plan was developed and approved by the Medical Director. *On 9/18/21, all residents with moderate to severe cognitive impairment as determined by a BIMS score of 12 or less had a new elopement risk evaluation completed. There were no residents newly identified to be at risk for elopement. *On 9/21/21, the resident was discharged to a memory support unit which provided structured support specialized for residents with dementia or cognitive decline. *From 9/18/21 to 9/23/21, 100% of facility and contracted therapy staff were educated on elopement prevention. The topics were the facility's elopement policy, including responding to alarms immediately, area to be searched, area outside of exit alarmed to be searched immediately. Those educated were 152 total facility employees (150 received education. Of two staff out on leave, one remained on leave, and one received education upon return on 09/27/21) and 22 contracted therapy staff. Review of in-service attendance sheets validated elopement education was completed using the facility's elopement policy and procedure, with 100% facility and contracted staff compliance achieved as of 9/23/21. *From 9/18/21 to 9/24/21, nine elopement drills were conducted to include all shifts. 115 staff members participated in the elopement drills. Review of elopement drill sheets and sign-in sheets revealed all scheduled staff participated. Drill report sheets were used to document and analyze staff response. *On 9/21/21, screamer al[TRUNCATED]