Every finding on record at Terrace Healthcare & Rehabilitation Center

Based on interview and record review, the facility failed to make prompt efforts to resolve grievances and keep residents appropriately apprised of progress toward resolution of grievances for one (Resident #1) of four residents reviewed for grievances.Findings include:Review of the Grievance/Complaint Log from February 2026 through April 2026 documented no grievance by or on behalf of Resident #1.During an interview on 5/04/2026 at 3:55 PM, Resident #1 stated that he had spoken with the Social Services Director about the situation with the heater and his roommate, but he hadn't heard back from her. When he made a complaint he got a lot of lip service but no follow-through. During an interview on 5/05/2026 at approximately 9:00 AM, the DON (Director of Nursing) stated she had received a 6-page grievance for Resident #1 on April 13th [2026]. She confirmed that the grievance had not been documented on the Grievance/Complaint Log. She had not specifically discussed the grievance with Resident #1 or her efforts to address or resolve it.Review of the policy and procedure, titled Grievances, last reviewed on 1/21/2026, read, Policy: It will be the policy of this facility to provide residents, resident representatives, family and visitors with methods of sharing grievances and/ or concerns with the facility. The resident has a right to and the facility will make prompt efforts to resolve grievances. Procedure: 4. The individual filing the grievance has a right to a reasonable expected time frame for completing the review of the grievance, being kept apprised of progress toward a resolution and a right to obtain a written decision regarding his or her grievance.

Based on observation, interview, and record review, the facility failed to ensure care plan was revised for oxygen administration for 2 of 4 residents reviewed for respiratory care (Residents #71 and #116).Findings include:1) Review of Resident #116's physician order dated 2/10/2026 read, Oxygen at 5 liters/minute via nasal cannula with humidification when on concentrator. May be without humidification when on a tank every shift.During an observation on 3/17/2026 at 7:57 AM, Resident #116 was in bed, being administered oxygen at 4 liters per minute via nasal cannula, with an empty humidity bottle.Review of Resident #116's comprehensive care plan showed a focus for a potential for complications of respiratory distress related to chronic obstructive pulmonary disease and pneumonia, with the interventions that included administration of oxygen as ordered. There was no intervention to address adjustment of oxygen by the resident.During an interview on 3/19/2026 at 9:33 AM, Staff E, Licensed Practical Nurse (LPN), stated, He will adjust his oxygen levels as he sees fit. He has been using oxygen for a long time.2) Review of Resident #71's physician order dated 12/10/2025 read, Oxygen at 2 liters/minute via nasal cannula with humidification when on concentrator. May be without humidification when on a tank every shift.During an observation on 3/17/2026 at 8:17 AM, Resident #71 was in bed, with oxygen being administered at 4 liters per minute via a nasal cannula.During an observation on 3/18/2026 at 9:04 AM, Resident #71 was being administered oxygen at 4 liters per minute via nasal cannula. The oxygen concentrator was on the right side of the resident's bed outside of the resident's reach.Review of Resident #71's comprehensive care plan showed a focus for a potential for complications of respiratory distress related to rhinovirus and history of pneumonia, with the interventions that included administration of oxygen as ordered. There was no intervention for adjustment or removal of oxygen by Resident #71's representative.During an interview on 3/19/2026 at 9:33 AM, Staff E, Licensed Practical Nurse (LPN), stated, Her daughter will come in and adjust her oxygen. Sometimes she will actually remove it. We had educated her that this shouldn't happen, but she still does it anyway.Review of the facility policy and procedures titled Respiratory Care with the last approval date of 1/21/2026 read, Policy: It is the policy of this facility to provide respiratory care and safe oxygen administration to meet the needs of the residents. Procedure: 15. The use of oxygen, respiratory conditions/medications or trach [tracheostomy] needs should be reflected in the residents plan of care.

Based on record review and interview, the facility failed to ensure residents on hospice received the care and services ordered by the hospice physician for 1 of 2 residents reviewed for hospice services (Resident #117) and failed to ensure residents received medications via gastrostomy tube consistent with standard of practice for 2 of 3 observations of medication administration via gastrostomy tube (Resident #151). Findings include: 1) Review of Resident #117's physician order dated 12/2/2025 read, [Name of the hospice] Hospice Services – [Name of the hospice] Hospice & Palliative Care. Review of Hospice-Skilled Nursing Facility Agreement between the facility and hospice, with an effective date of 11/6/2025, read Article II. Responsibilities of Hospice. 2.2 Professional Responsibility. Hospice shall be responsible for determining the appropriate course of hospice care, including the determination to change the level of services provided, including making arrangements for any necessary continuous care or hospice-related inpatient care in a participating Medicare/Medicaid facility as provided by 42 C.F.R. [Code of Federal Regulations] 418.108. 2.3 Patient Assessments. 2.5 (a) Coordination of Services. For each Hospice Patient in the Nursing Home, the Hospice Interdisciplinary Group shall (1) maintain responsibility for directing, coordinating, and supervising the Hospice Care and Hospice Services provided under this Agreement, (2) require all care and services provided to Hospice Patients shall be provided in accordance with the Hospice Plan of Care, based on all Hospice assessments of the patient and family needs. (b) Hospice Physician Services. Hospice Medical Director and Hospice Physicians (in conjunction with the Attending Physician) shall be responsible for providing Hospice Patients with medical services for the palliation and management of the terminal illness and conditions related to the terminal illness. Article V. Records. 5.1 Maintenance and Retention of Records. Nursing Home and Hospice shall each prepare and maintain complete and appropriate clinical records concerning each Hospice Patient in Nursing Home in accordance with prudent record keeping procedures, their own policies and procedures, applicable federal and State law and regulations, and applicable Medicare and Medicaid program guidelines. Review of Resident #117's Hospice Physician's Telephone/Verbal Order, signed by the Hospice Physician on 12/8/2025, read, Discontinue: Fleet enema, Citroma solution 1.745 gm [grams]/30 ml [milliliters], Aspirin 81 mg [milligrams], multivitamin, polyethylene glycol powder, Voltaren arthritis pain gel. New: Comfort Kit – Atropine 0.01% ophthalmic drops place 2 drops into mouth every 4 hours as needed for excessive secretions, Haloperidol liquid 2mg/ml give 0.5 ml by mouth every 4 hours as needed for agitation, Lorazepam liquid 2 mg/ml- give 0.25 ml by mouth every 4 hours as needed for anxiety, agitation, restlessness; morphine concentrate 20 mg/ml or 100 mg/sl [sublingual] give 0.2 sl by mouth every 2 hours as needed for non acute pain or dyspnea, ondansetron 4 mg give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. Review of Resident #117's physician orders on 3/18/2026 showed the following orders: Fleet Enama, Insert 1 application rectally as needed for constipation if no results 1 day after suppository. Order Status: Active. Order Date: 10/06/2026; Citroma Solution 1.745 gm/30 ml (Magnesium Citrate), Give 296 ml by mouth as needed for constipation in AM [morning] if no results after enema. If no results within 1 hour of completion of bowel protocol, contact MD immediately for further orders. Order Status: Active. Order Date: 10/06/2024; Aspirin Oral Tablet Chewable 81 mg (Aspirin), Give 1 tablet by mouth one time a day related to unspecified osteoarthritis, unspecified site. Order Status: Active. Order Date: 10/07/2024; Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ [with] minerals), Give 1 tablet by mouth one time a day related to Vitamin Deficiency, unspecified. Order Status: Active. Order Date: 10/07/2024; Polyethylene Glycol Powder (Polyethylene Glycol 1450), Give 17 gram by mouth two times a day for Constipation. Order Status: Active. Order Date: 05/26/2025; Voltaren Arthritis Pain External Gel 1% *Diclofenac Sodium (Topical)), Apply to L [left] knee topically every 6 hours as needed for pain, Apply 4 gram. Order Status: Active. Order Date: 11/05/2025. Review of Resident #117's clinical records revealed a progress note authored by the Facility Physician on 1/5/2026 that showed the Facility Physician had addressed the continuation of the arthritis pain gel but failed to provide justification for continuation of other medications the Hospice Physician had ordered for discontinuation. Review of Resident #117's active physician orders on 3/18/2026 showed no order for the comfort kit medications ordered by the Hospice Physician. Review of Resident #117's physician progress notes showed no justification for not providing Resident #117 with the comfort kit medications ordered by the Hospice Physician. During an interview on 3/18/2026 beginning at 9:45 AM, the Director of Nursing confirmed the Hospice Physician's orders had not been implemented. She confirmed orders discontinued by the Hospice Physician were still in effect, the comfort kit medications ordered by the hospice physician had not been implemented, and Resident #117's Facility Physician had not provided justification in the clinical record for Resident 117's active medication regimen. During an interview on 3/18/2026 at 10:02 AM, the Facility Physician stated, I never saw that document [Hospice Physician's Telephone/Verbal Order]. I probably just wrote continue course. During an interview on 3/18/2026 beginning at 10:14 AM, Staff C, Licensed Practical Nurse/Unit Manager, stated, Honestly, can't say that I recall this [Hospice Physician's Verbal Order], but probably have seen it. I remember reviewing with [Name of the Facility Physician]. I remember this because of Haldol and Lorazepam. He did not want her to be snowed. He is particular about his patients, orders from outside are reviewed with him. I don't believe I did [document the conversation with him]. 2) Review of Resident #151's physician order dated 3/10/2026 read, Check tube residual to verify placement prior to administration of feeding, medication, and prior to flush. If residual is 100 ML [milliliters] or more, hold feeding and notify physician every shift. During an observation of medication administration for Resident #151 on 3/19/2026 at 5:05 AM, Staff C, Licensed Practical Nurse (LPN), assembled all supplies, performed hand hygiene, left the medication cart to get refrigerated medication, returned to the medication cart, performed hand hygiene and donned gown and gloves. Staff C did not attempt to verify gastrostomy tube placement by verifying gastric residual volume. Staff C did not flush the gastrostomy tube with water prior to administering medications. Staff C attached the syringe and provided liquid medications through the gastrostomy tube by pushing them in with the syringe instead of allowing gravity flow of medications. Resident #151 requested pain medication. Staff C removed gown and gloves and performed hand hygiene, and obtained pain medication. Staff C donned a new gown and gloves, and administered the medication without administering a water flush and checking for gastric residual volume. Staff C pushed the medication into the gastrostomy tube without allowing gravity flow of the medication. During an interview on 3/19/2026 at 5:50 AM, Staff C, LPN, stated, I should not have pushed the medication in. I should have let gravity flow it in. I should have checked to see if he had any residual volume before giving the medications. Review of the facility policy and procedure titled Medication Administration via Enteral Feeding Tube with the last review date of 1/21/2026 read, Policy: Medications shall be prepared and administered according to the following established guidelines. Licensed Staff shall not administer a drug that is inadequately dissolved (i.e., particulate matter still evident); that may clog the enteral feeding tube. Tube placement will be verified prior to the administration of a medication. The enteral tube will usually be flushed with 30-50 ml of water before and after medication administration and 5-10 ml water between medications administered, unless otherwise ordered by a physician. Procedure: 5. Verify feeding tube placement. 6. Flush feeding tube with a least 30-50 ml of warm water, or per physician orders to clear it of formula. Precautions: 2. Do Not administer drugs without flushing the tube before and after delivery.

Based on record review and interview, the facility failed to ensure acceptable parameters of nutritional status, specifically residents' body weight, were maintained for 1 of 7 residents reviewed for nutrition (Resident #68).Findings include:Review of Resident #68's Weights and Vitals Summary revealed the resident weighed 124.2 pounds on 10/16/2025 and 118.6 pounds on 11/6/2025, which shows a 4.51% weight loss. The resident weighed 109 pounds on 12/8/2025, which shows 8.09% weight loss from 11/6/2025. The resident weighed 111 pounds on 1/7/2026, 107 pounds on 2/5/2026, and 108.1 pounds on 3/16/2026. The resident had a 12.96% weight loss between 10/16/2025 and 3/16/2026.Review of Resident #68's SBAR (Situation, Background, Assessment, Recommendation) read, Situation. The change in condition, symptoms, or signs observed and evaluated is/are: Weight loss. This started on 01/06/2026. There was no documentation of notification of the Registered Dietitian.Review of Resident #68's dietary narrative note dated 1/16/2026 read, 88 y/o [year old] F [female] evaluated for a change in condition d/t [due to] weight loss . Resident is not currently receiving oral nutritional supplements. Weight hx [history] is admission wt [weight] of 124.2# [pounds] on 10/16/25, 11/6/25, 118.6# (-5.6%), 12/8/25 109# (-12.2), 1/7/26 111# (10.6%); percent weight loss compared to admission weight. No new labs currently available. Resident weight trend shows weight loss during the first 2 months in the facility . Continue to monitor and follow prn [as needed].Review of Resident #68's Nutritional Progress Note dated 2/16/2026 read, Resident is triggering for significant weight loss in 3 months of 9.8%/ 11.6# . Weight hx is admission wt of 124.2# on 10/16/25, 11/6/25 118.6# (-5.6%), 12/8/25 109# (-12.2), 1/7/26 111# (10.6%), 2/5/25 107#. Resident has gained 2# in January of 2026 compared to December 2025 and has now lost 4# compared to Jan '26 [January 2026] weight. Resident has referral (2/3/26) to gynecology d/t lump in lt (left) breast. Recommend house nutritional supplement BID [Twice a day]. Continue to monitor and follow prn.Review of Resident #68's Nutritional Progress Note dated 3/16/2026 read, Resident is triggering for weight loss trend. Resident is not currently receiving oral nutritional supplements. Recommend house nutritional supplement BID. Continue to monitor and follow prn.Review of Resident #68's physician orders from 10/15/2025 through 3/16/2026 revealed an order dated 3/16/2026 that read, House Nutritional Supplement two times a day for risk of malnutrition, Offer 120 ml [milliliter] BID. Document amount consumed. Further review showed no orders prior to 3/16/2026 for nutritional supplements or appetite stimulant medications.During an interview on 3/18/2026 at 12:10 PM Staff B, Licensed Practical Nurse (LPN), stated that if a resident had a significant weight loss, the expectation was to complete a Change in Condition form and notify the MD (medical doctor), the family, and the RD (Registered Dietitian). During an interview on 3/18/2026 at 12:53 PM, the RD stated, Staff routinely notify me for nutritional concerns with the residents, including weight loss. My process is to dig in the first working day after the 15th regarding resident weights and nutritional concerns, unless I am notified specifically about an issue. I entered supplements last month [for Resident #68]. I don't know where the disconnect was. Obviously with her downtrend, she needed to be on supplements. I evaluated her and ordered supplements in February and noticed on Monday [3/16/2026] that it didn't get started.During an interview on 3/18/2026 at 1:30 PM, Staff A, LPN, stated she called the RD on 1/6/2026 when she completed the change of condition form for Resident #68's weight loss, because she always called him. She thought she remembered Resident #68 being on a nutritional supplement, but she was not able to find that one had been ordered or given prior to 3/16/2026.During an interview on 3/18/2026 at 2:36 PM, the Director of Nursing (DON) stated, We enter weights monthly. We don't determine if weight loss is significant. We enter the weights and [name of the RD] lets us know if the weight loss is significant. The weights are done by restorative between the first and the seventh [of each month] and I enter the weights [in the medical record]. The unit manager spoke with the restorative CNA [Certified Nursing Assistant] who took [Resident #68's name] weight and knew she had lost weight. That's when she put in the change in the condition. We never put his [the RD's] orders in; we review the orders he puts in.During an interview on 3/18/2026 at 2:55 PM, Physician #1 stated he was sure he had talked to the nutritionist about a supplement [for Resident #68]. Maybe he could start her on [appetite] stimulants. He could have done something sooner about starting her on nutritional supplements or an appetite stimulant. Review of the facility policy and procedures titled Weights and Weight Loss with the last review date of 1/21/2026 read, Policy: It will be the practice of this facility to implement the following systems regarding weight documentation. Procedure: 5. Significant weight loss shall be addressed by the physician and/or RD through discussion with the resident and/or resident representative for known preferences and desires and development and implementation of interventions to attempt to address the weight loss.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a safe and secure manner.Findings include:During an observation on 3/16/2026 at 9:45 AM, there were three pills and two tablets on cup of medications on top of the medication cart. There was no staff present at the medication cart. Residents were going by the medication cart and staff members were at the desk. Staff D, Licensed Practical Nurse (LPN), returned to the medication cart at 9:52 AM.During an interview on 3/16/2026 at 9:53 AM, Staff D, LPN, stated, I should not have left those on the medication cart. I went to answer the telephone. I should have brought them with me.During an observation on 3/19/2026 at 5:10 AM, Staff C, LPN, went to the medication room, poured a refrigerated liquid medication, Gabapentin 22.5 milliliters, returned to the medication cart, and verified the order for the resident. Staff C removed 2.5 milliliters of the medication from the medication cup and left the remaining medication on the medication cart while Staff C administered gastrostomy tube medications. Staff C returned to the medication cart to prepare additional medications and placed the liquid Gabapentin into the top drawer of the medication cart. Staff C then went on to administer medications to three residents with the liquid medication left in the top drawer of the medication cart.During an interview on 3/19/2026 at 5:55 AM, Staff C, LPN, stated, I should have taken the Gabapentin back to the refrigerator when I realized that I had poured too much. I should not have left it on top of the medication cart or in the drawer. I should have brought it back.During an interview on 3/19/2026 at 8:30 AM, the Director of Nursing (DON) stated, Medications should not be left on the medication carts.Review of the facility policy and procedures titled Medication/Biological Storage with the last approval date of 1/21/2026 read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure: 1. Medications, drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received, unless otherwise necessary.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 of 4 residents reviewed for skin conditions, Resident #3. Findings include: During an observation on 10/1/2024 at 9:09 AM, Resident #3 was lying in bed. Resident #3's left arm had bruising and scabbed skin tears. During an interview on 10/1/2024 at 1:20 PM, Staff B, Wound Care Licensed Practical Nurse (LPN), stated, [Resident #3's name] will get skin tears once a week. If she bumps against something her skin will open up and she will have a skin tear. Review of Resident #3's Weekly Skin Check/Nurse dated 9/2/2024 read, Description: Wound to left upper arm. Wound to left knee. Bruising to BUE [Bilateral Upper Extremities] and to BLE [Bilateral Lower Extremities]. Dry scabs to left hand and to bilateral feet/toes. Review of Resident #3's Wound Evaluation dated 9/17/2024 read, Site: Lt [Left] forearm. Type: Skin Tear . Describe Percentage of tissue type present in each wound: epithelial, granulation, slough, eschar. 3a. Wound #1: Epithelialized and resolved. Review of Resident #3's Wound Evaluation dated 9/23/2024 read, Site: Rt [Right] lateral knee. Type: Skin Tear . Describe Percentage of tissue type present in each wound: epithelial, granulation, slough, eschar. 3a. Wound #1: 15% granulation, 85% intact normal skin. Review of Resident #3's care plan did not document a focus for skin integrity. During an interview on 10/2/2024 at 1:50 PM, Staff C, MDS and Care Plan Coordinator, stated, [Resident #3's name] is not care planned for skin integrity and she needs it for potential skin integrity. Review of the facility policy and procedure titled Comprehensive Assessment and Care Plans with the last review date of 8/7/2024 read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS [Centers for Medicare and Medicaid Services] . Guidelines . 8. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c) (2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care according to standard of practice for 1 of 4 residents reviewed for skin condition, Resident #374, and for 1 of 3 residents reviewed for pain management, Resident #116. Findings include: 1) During an observation on 10/1/2024 at 9:46 AM, Resident #374 was sitting at the edge of his bed. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/1/2024 at 9:46 AM, Resident #374 stated, I do not know what happened to my leg. It probably happened while I was sleeping. During an observation on 10/2/2024 at 8:12 AM, Resident #374 was sitting at the edge of his bed with breakfast tray in front of him. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/2/2024 at 8:12 AM, Resident #374 stated, No one has come to change my bandage. During an observation on 10/2/2024 at 1:30 PM with the Director of Nursing (DON), Resident #374 was sitting in his wheelchair in his room. There was a bandage dated 9/27 on his left shin. The DON removed the bandage and observed a small open area on the resident's left shin. Review of Resident #374's physician order dated 9/27/2024 read, Clean area, apply Xeroform and Zinc to skin tear on left shin one time a day for skin tear. During an interview on 10/2/2024 at 1:31 PM, the DON stated, I expect nursing staff to follow the physician orders and do wound care according to those orders. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Procedure . 6. Wound care procedures and treatment should be performed according to physician orders. 2) Review of Resident #116's physician order dated 9/19/2024 read, Oxycodone HCl oral tablet 5 mg [milligram] (oxycodone HCl), Give 2 tablets by mouth every 4 hours as needed for severe 7-10/10) pain, non acute. Review of Resident #116's Medication Administration Record (MAR) for September 2024 for Oxycodone 5 mg showed the resident received the medication on 9/23/2024 at 6:57 AM for pain level of 5, on 9/24/2024 at 2:32 AM and at 6:38 AM for pain level of 5, and on 9/25/2024 at 9:26 AM for pain level of 6. During an interview on 10/2/2024 at 1:33 PM, the DON stated, It was a new nurse, and she was not following physician orders. The medication was given out of parameters. I expect nurses to look at the orders and follow them. Review of the facility policy and procedure titled Medication Administration with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medications by the resident. Review of the facility policy and procedure titled Pain Screening and Management with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to screen residents and attempt to provide effective pain and comfort management. Procedure . 4. Administer pain medications according to physician's orders and resident request for PRN [as needed] medications.

Based on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 1 of 4 residents reviewed for skin conditions, Resident #374. Findings include: During an observation on 10/1/2024 at 9:46 AM, Resident #374 was sitting at the edge of his bed. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an observation on 10/2/2024 at 8:12 AM, Resident #374 was sitting at the edge of his bed with breakfast tray in front of him. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/2/2024 at 8:12 AM, Resident #374 stated, No one has come to change my bandage. During an observation on 10/2/2024 at 1:30 PM with the Director of Nursing (DON), Resident #374 was sitting in his wheelchair in his room. There was a bandage dated 9/27 on his left shin. The DON removed the bandage and observed a small open area on the resident's left shin. Review of Resident #374's physician order dated 9/27/2024 read, Clean area, apply Xeroform and Zinc to skin tear on left shin one time a day for skin tear. Review of Resident #374's Treatment Administration Record (TAR) for September 2024 showed the resident received wound care on his left shin on 9/28/2024, 9/29/2024, and 9/30/2024 at 6:00 PM. Review of Resident #374's TAR for October 2024 showed the resident received wound care on his left shin on 10/1/2024 at 6:00 PM. During an interview on 10/2/2024 at 1:31 PM, the Director of Nursing stated, Nursing were documenting as performing wound care when they had not done the wound care. The documentation was not accurate. Nurses are expected to only sign off on orders when they have done the wound care. I expect nurses to have accurate documentation. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Procedure . 6. Wound care procedures and treatment should be performed according to physician orders . 10. Document in the clinical record when treatments are performed.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing wound care according to the practice standard for 1 of 4 residents reviewed for skin conditions, Resident #76, and failed to ensure staff used appropriate personal protective equipment (PPE) while providing high-contact care for 1 of 6 residents reviewed, Resident #274, to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 10/2/2024 at 1:20 PM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, was inside Resident #274's room adjusting the IV (intravenous) tubing and turning the IV pump off. Staff A did not have gloves or gown on. There was a signage on the resident's room that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. Review of Resident #274's physician order dated 10/2/2024 read, Enhanced barrier precautions related to L [left] arm picc [Peripherally Inserted Central Catheter]. During an interview on 10/3/2024 at 1:02 PM, the Infection Preventionist sated, Staff should have donned a gown when going into the resident room if she was going to be handling the IV tubing. Enhance barrier is a constant battle, we keep educating. During an interview on 10/3/2024 at 1:25 PM, Staff A, LPN, Unit Manager, stated, I should have donned a gown before entering [Resident #274' name] room but the IV pump had been beeping for some time and I went in quickly. 2) During an observation on 10/3/2024 at 11:30 AM, Staff B, Wound Care Licensed Practical Nurse (LPN), performed hand hygiene before entering Resident #76's room. Staff B donned a pair of gloves and removed dressing from Resident #76's buttock area. Without changing her gloves or performing hand hygiene, Staff B cleaned Resident #76's wound. Staff B removed her gloves and donned a glove on her right hand without performing hand hygiene. A therapy staff member knocked and stated she needed to take Resident #76's roommate to therapy and Staff B, with her left hand which did not have a glove, pulled Resident #76's curtain to provide privacy while the therapy staff member removed the roommate from the room. Staff B proceeded to apply hand sanitizer to her left hand and donned the other glove she was holding with her right hand. Staff B applied the treatment and applied the new wound care dressing. Staff B removed her gown and gloves and washed her hands. During an interview on 10/3/2024 at 11:40 AM, Staff B, Wound Care LPN, stated, I did hand hygiene outside by the cart when we were first coming in. I do not like using the hand sanitizer in the room. I like using my own. If I removed my gloves making sure not to touch anything and keep sterility, then I can don a new pair of gloves and do not need to hand sanitize. During an interview on 10/3/2024 at 1:20 PM, the Infection Preventionist sated, Staff should have performed hand hygiene after removing the old dressing and before cleaning the wound. After removing a pair of gloves, staff should preform hand hygiene before donning a new pair of gloves. During an interview on 10/4/2024 at 8:12 AM, the Director of Nursing (DON) stated, While the nurse is dirty, she does not have to remove her gloves. While she is dirty, she is dirty, and while she is clean, she is clean. The staff did not need to change her gloves after removing the old dressing before cleaning the wound because she is in her dirty filed. The staff should sanitize her hands after removing gloves and before donning new pair of gloves. The staff should don gloves and a gown if she will be in contact with the IV tubing of a resident. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 8/7/2024 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 5. Use an alcohol-based hand rub containing 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . g. Before handling clean or soiled dressings, gauze pads, etc. k. After handling used dressing, contaminated equipment, etc. m. After removing gloves. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure . 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact care activities that have been found to increase risk for transmission of multidrug-resident organism. Procedure . 4. For residents for whom EBP are indicated, EBP is employed when performing the following High-contact resident care activities . g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

Based on interview and record review, the facility failed to ensure residents received copies of their medical records in a timely manner for 1 of 3 residents reviewed, Resident #1. Findings include: During an interview on 4/26/2024 at 11:26 AM, Resident #1's Daughter stated, I still have not received the medical records. I requested them in January 2024 and still get excuses. Review of the Durable Power of Attorney signed by Resident #1 on 7/28/2004 showed the resident appointed Resident #1's Daughter as the attorney-in-fact to manage all her affairs. Review of the email communication between Resident #1's Daughter and the Admissions Assistant dated 3/4/2024 read, I am touching base back with you since I had the meeting with the care plan staff on [DATE]. I discussed a few things and asked some questions that I have not gotten a response to yet . 2. Where are the copies of my dad's medical records that I have already requested to you since there has not been a medical records staff person yet? Review of email communication between Resident #1's Daughter and the Director of Nursing dated 3/19/2024 read, I am just checking to find out what is happening with getting the copies of my dad's records to me . I still do not know who is responsible for medical records since I first requested them back in January. Can you get all that together for me soon? During an interview on 4/26/2024 at 10:52 AM, the Administrator stated, I accept responsibility. There was a delay in providing medical record. Once the request is made, we should provide the medical records within 48 hours. When a record is requested, we have to send the request to corporate, and the legal team will review, and we provide the records. During an interview on 4/26/2024 at 11:18 AM, the Admission Assistant stated, [Resident #1's name] daughter did request medical records. The request was made probably at the beginning of this year. She requested the record from me personally and I send the request to medical record and forwarded the email to the department she really needed to talk. She asked again about the medical records. I then told her to go to the receptionist desk and get a paper and do a medical records request. I left a note with reception, and she did pick up the medical record request form. I assume she did because she sent an email weeks later wanting an update. I have not heard from her this month. Maybe a couple of months ago that she sent them. Review of the facility policy and procedure titled Resident Identifiable Information/Medical Records issued on 4/1/2022 read, Policy: It is the policy of this facility to maintain a medical record for each resident in accordance with applicable federal and state guidelines. Procedure . 3. Medical Records on each resident will be accurately documented; readily accessible; and systematically organized.

Based on record review, observation, and interview the facility failed to ensure residents were provided treatments, wound care, and services in accordance with professional standards of practice and physician orders for 4 of 8 residents, Residents #18, #274, #80, and #113. Findings include: 1) Review of Resident #18's medical record documented the resident was admitted on [DATE] with medical diagnosis to include lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), congestive heart failure (heart does not pump well), respiratory failure (difficult to breath), diabetes mellitus, chronic kidney disease, abnormalities of gait and mobility, and atrial fibrillation (irregular heartbeat). Review of the physician order dated 4/13/2023 for Resident #18's documented, Apply ace wrap to bilateral lower extremity every day shift for chronic edema. Review of Resident #18's care plan dated 3/30/2023 read, Focus: Potential for complications r/t [related to] an alteration in cardiac function. Interventions: Apply ace wraps to bilateral lower ext [extremities] in am [morning] and remove at bedtime. Review of Resident #18's Treatment Administration Record (TAR) for June 2 and 5 did not document wound care was provided. During an observation on 6/4/2023 at 11:19 Resident #18 was resting in bed, there were no ace wraps noted on the lower legs. During an interview conducted on 6/4/2023 at 11:19 AM, Resident #18 stated she never receives ace wraps on her legs. During an observation on 6/5/2023 at 9:54 AM Resident #18 was sitting in a wheelchair in the common living area. No ace wraps were noted on her lower legs. During an observation on 6/5/2023 at 12:01 PM Resident #18 was sitting in a wheelchair beside her bed. There were no ace wraps noted on her lower legs. During an interview conducted on 6/5/2023 at 1:58 PM Staff A, Registered Nurse (RN) verified Resident #18's order for ace wraps to the bilateral lower legs. Staff A, RN stated, I do not remember her ever having ace wraps on her legs, but I will check. During an interview conducted on 6/5/2023 at 2:30 PM the Director of Nursing (DON), stated, The Resident [Resident #18] needs the ace wraps on and the orders need to be followed. 2) Review Resident #274's medical record documented the resident was admitted on [DATE] with medical diagnosis to include nontraumatic ischemic infraction of muscle of the left lower leg, methicillin staph aureus infection, local infection of the skin inside the Canadian tissue (a study first in Canada to characterize the incidence of skin and soft tissue infections), unspecified open wound of the left lower leg, peripheral vascular disease, and type 2 diabetes. Review of the physician order dated 6/1/2023 for Resident #274 documented, Cleanse left Achilles with ns [normal saline] apply sorbact gauze and cover with bordered drsg [dressing] Tuesdays and Fridays and prn [as needed] for Sx [signs and symptoms] wound. Cleanse left and right shin with ns [normal saline] apply Medi honey cover with bordered drsg [dressing] daily and prn [as needed] every day shift for Trauma. During an observation on 6/4/2023 at 10:10 AM Resident #274's left and right legs were wrapped in gauze and dated 5/31/2023, a Wednesday. (Photographic evidence obtained) During an interview on 6/4/2023 at 10:10 AM Resident #274 stated, They have not changed my dressing. During an observation on 6/5/2023 at 1:25 PM Resident #274's left, and right legs were wrapped in gauze dressings dated 5/31/2023. During an interview conducted on 6/5/2023 at 1:25 PM Resident #274 stated, The dressing changes have not been done. During an interview on 6/5/2023 at 1:45 PM Staff C, LPN (Licensed Practical Nurse) stated, The dressing has not been changed since 5/31/2023. During an interview on 6/5/2023 at 2:31 PM the DON stated, The dressing changes for [Resident #274's name] were not done and should not have been charted that they had been completed. 3) Review of Resident #80's medical record documented the resident was admitted [DATE] with medical diagnosis to include hemiplegia and hemiparesis (paralysis) left non dominant side, dysphasia (difficulty swallowing), chronic obstructive pulmonary disease (difficulty breathing), respiratory failure , acute congestive heart failure, cognitive social or emotional deficiency following cerebral infraction, muscle weakness, weakness, unspecified protein calorie malnutrition, major depressive disorder, hypothyroidism, gastric esophageal reflux disease. Review of the physician order dated 8/9/2022 for Resident #80 documented Multi podus boots while in bed every shift. Review of TAR for Resident #80 did not document the multi podus boots while in bed every shift was conducted on June 5, 2023. During an observation on 6/4/2023 at 9:48 AM Resident #80 was lying in bed and podus boots were not on the resident's feet. During an interview on 6/4/2023 at 9:48 AM Resident #80 stated, I don't have boots on my feet. During an observation on 6/5/2023 at 8:37 AM Resident #80 was lying in bed and podus boots were not on the resident's feet. During an observation on 6/5/2023 at 1:44 PM Resident #80 was lying in bed and podus boots were not on the resident's feet. During an interview on 6/5/2023 at 1:46 PM Staff S, RN stated, I don't remember [Resident #80's name] ever having boots on. They could be in laundry services. During an interview on 6/5/2023 at 2:31 PM the DON stated, The multi podus boots should be on resident when she is in the bed. Even if they were sent to the laundry they come back by the next day. 4) Review of Resident #113's medical record documented the resident was admitted [DATE] with medical diagnosis to include pain syndrome, COPD (chronic obstructive pulmonary disease), heart failure, hyperlipidemia, sleep apnea, morbid obesity, muscle weakness, unspecified abnormalities of gait and mobility, and hypertension. Review of the physician order dated 5/9/2023 for Resident #113 documented, Compression stockings in the morning on during the day off at night. During an observation on 6/4/2023 at 10:40 AM Resident #113 was sitting in a recliner with her legs prompted up; there were no compression stockings on her legs. During an observation on 6/5/2023 at 12:22 AM Resident #113 was sitting in a recliner at bed side with her feet prompted up. Compression stockings were not on the resident's legs. During an interview on 6/5/2023 at 12:22 AM Resident stated I never wear the compression socks they are in the cabinet, but no one assists me to put them on. I can't reach down there and do it myself. I've not had my compression stockings on. During an interview conducted on 6/5/2023 at 1:15 PM Staff C, LPN, confirmed Resident #113 was not wearing compression stockings and should be. During an interview on 6/5/2023 at 2:30 PM the DON stated, The resident needs her compression stocking on. Review of the policy and procedure titled, Wound Care issued 4/1/2022 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. 6.Wound care procedures and treatments should be performed according to physician orders. 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. 8. Preventative measures such as barrier creams, can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots and use of positioning devices.

Based on observations, interviews, and policy review, the facility failed to ensure stored food is labeled and dated, thawed according to professional standards, and that food is distributed in a safe manner. Findings Include: During a walk-through tour of the kitchen on 6/04/23 at 09:16 AM with the morning cook, an observation was made in the walk-in cooler in the kitchen of a large pan of what appeared to be diced chicken; the food item was not labeled identifying the content or dated and a quart size container with what appeared to be gravy or sauce that was not labeled identifying the contents or dated. An interview was conducted with the morning cook on 6/04/2023 at 9:20 AM. The cook stated, That is a large pan of chicken, and the quart container was breakfast gravy, and both items should have had a label and date. An observation was made on 6/04/23 at 9:25 AM of four 5# (pound) rolls of raw ground beef being thawed in a prep sink of 12 of standing water. An interview was conducted with the Dietary Manager (DM) on 06/04/2023 at 10:00 AM regarding thawing of frozen foods. The DM stated, Foods should always be thawed under running water. Review of a document provided, with no date, titled Food Preparation read, 5. The Dining Services Director/Cook(s) is responsible to ensure that proper practice is utilized in thawing frozen foods. Completely submerged under cold water that is running fast enough to agitate and float off loose ice particles. An observation of the food carts being transported to seven various hallways for delivery was conducted on 6/04/23 at 12:30 PM. Observations of the tray delivery showed food trays included pork loin, seasoned potatoes, buttered zucchini, roll, and a dessert of a piece of chocolate cream pie. An observation was made of the food trays being removed from the food cart located at one end of each hallway, drinks being added from a drink cart and then being transported by a staff member down the hall and delivered to the resident rooms. An observation was made of the trays without any covering or lid on the dessert on all the room trays that were being delivered throughout the entire length of each hallway. An interview was conducted with the DM on 06/04/2023 regarding covering food items during transport. The DM confirmed all drinks and food should be covered during transporting to the residents' rooms and not be delivered uncovered in the hallways. Review of a document provided, dated October 2019, and titled Meal Distribution read, 3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered.

Based on record review and interview, the facility failed to ensure residents' medical records were complete and accurately documented for 7 of 12 residents, Residents #44, #54, #18, #274, #80, #85, and #113. Findings Include: 1) Review of the Health Status Note dated 5/16/23 at 11:09 PM [eINTERACT form] for Resident #54 read, At approximately 2200 [10:00 PM] this writer was notified by the CNA [Certified Nursing Assistant] that resident was not responding. On arrival to the residents room resident was noted laying on the bed with eyes closed and mouth breathing. Resident was not wearing her O2 [oxygen] as ordered. Pulse ox noted to be 76. B/P [blood pressure] noted to be 179/78 with HR [heart rate] at 104. Or [sic] at 5L [liters] via non-rebreather mask was applied O2 noted to increase to 91%. Resident remained unresponsive. Accu check was performed and noted to be 25. Glucagon injection administered and 911 called. Resident transported to [Hospital's name] for further eval. Review of Resident #54's Nursing Home to Hospital Transfer Form dated 5/16/2023 at 11:17 PM read, Key Clinical Information. Reason(s) for transfer: Other -- planned surgery. During an interview on 6/5/23 at 3:50 p.m., the Director of Nursing (DON) stated, The eINTERACT form was not filled out correctly on the 16th. The form populates information from previous forms, and it looks like that information is from a previous form. This was not a planned hospitalization . I would expect the nurse completing the form, to provide the correct information on the form prior to transfer. 2) Review of the physician's order for Resident #44 dated 5/30/23 read, Anasept Antimicrobial External Gel 0.057%. Apply to buttocks and sacrum topically every day shift for wound. Review of the Treatment Administration Record (TAR) for Resident #44 did not document wound care on 6/3/23 or 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Anasept Antimicrobial External Gel 0.057%. Apply to coccyx R & L [right and left] buttocks topically every day shift for wound. Review of TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/22/23, 5/24/23, 5/26/23, and 5/29/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse coccyx wound with ns [normal saline], skin prep periwound, apply moistened gauze with Anasept gel cover with bordered drsg [dressing] daily and prn [as needed] every day for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse left buttock wound with ns, skin prep periwound, apply moistened gauze with Anasept gel cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse left lat [lateral] foot wound with ns, skin prep periwound apply medihoney on ca [calcium] alaginate, cover with bordered drsg daily, and prn every day for wound. Review of the TAR Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right buttock wound with ns skin prep periwound, apply moistened gauze with Anasept gel cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right heel wound with ns, skin prep periwound, apply medihoney on ca alginate cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right inner thigh wound with ns, skin prep periwound, apply medihoney on ca alginate cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right lat calf wound with ns, skin prep periwound apply medihoney on ca alginate cover with bordered drsg daily and prn every day for wound care. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. Review of the physician's order for Resident #44 dated 5/2/23 read, Cleanse right lat foot wound with ns, skin prep periwound apply medihoney on ca alginate cover with bordered drsg daily and prn every day shift for wound. Review of the TAR for Resident #44 did not document wound care on 5/6/23, 5/13/23, 5/14/23, 5/17/23, 5/18/23, 5/19/23, 5/20/23, 5/22/23, 5/24/23, 5/26/23, 5/29/23, 6/3/23, and 6/4/23. 3) Review of the physician's order for Resident #18 dated 4/13/2023 documented, Apply ace wrap to bilateral lower extremity every day shift for chronic edema. Dated 4/13/2023, Cleanse wound with wound cleanser, pat dry, apply calcium alginate, and cover with dry dressing every day shift. Review of Resident #18's TAR did not document wound care on 4/7/23, 4/9/23, 4/13/23, 4/14/23, 4/16/23, 5/3/23, 5/10/23, 5/17/23, 5/19/23, 5/23/23, 5/27/23, 6/2/23 and 6/5/23. 4) Review of the physician's order dated 6/1/2023 for Resident #274 documented, Cleanse left Achilles with ns, apply sorbact gauze and cover with bordered drsg Tuesdays and Fridays and prn as needed for Sx [signs and symptoms] wound. Cleanse left and right shin with ns apply Medi honey cover with bordered drsg daily and prn every day shift for trauma. Cleanse left heel wound with ns, apply medi honey on calcium alginate cover with bordered drsg daily and prn as needed for wound. Review of Resident #274's TAR did not document wound care for the left Achilles on 5/19/23, 5/23/23, and 5/27/2023 and did not document wound care to the left heel and left shin wounds on 5/18/23, 5/19/23, 5/20/23, 5/21/23, 5/22/23, 5/23/23, 5/24/23, 5/25/23, 5/26/23, and 6/2/23. 5) Review of the physician's order dated 4/21/2023 for Resident #85 documented, Nystatin triamcinolone cream 100000-0.1 unit gram %, apply to left palm topically two times a day for dermatitis for 14 days start. Dated 5/24/2023 Eucerin Eczema Relief External Cream 2% colloidal oatmeal, apply to left palm topically three times a day for eczema for 30 days. Review of the TAR for Resident #85 did not document wound care of the Nystatin triamcinolone cream on 4/24/23, 4/25/23, 4/28/23, 4/29/23, 4/30/23, 5/1/23 and 5/2/23 at 5:00 PM, and on 4/29/23 at 9:00 AM. Review of the TAR did not document wound care of Eucerin Eczema Relief External Cream 2% colloidal oatmeal on 5/27/23 at 9:00 AM, 1:00 PM, and 9:00 PM, and on 6/2/23 at 9:00 PM. 6) Review of the physician's order for Resident #80 dated 8/9/2022 read, Multi podus boots while in bed every shift. Review of the TAR for Resident #80 did not document care and treatment for the multi use podus boots on 4/2/23, 4/8/23, 4/14/23, 4/28/23 night shift, 4/8/23, 4/15/23, 4/27/23 day shift, 4/23/23 evening shift, 5/3/23, 5/11/23, 5/16/23, 5/27/23, 5/31/23, 6/2/23, 6/5/23, 6/6/23 day shift, 6/5/23, and 6/6/23 evening shift. 7) Review of the physician's order for Resident #113 dated 5/9/2023 read, Compression stockings in the morning on during the day off at night. Review of the TAR for Resident #113 did not document care and treatment for compression stockings on 5/20/23, 5/25/23, 5/27/23 and 6/1/23. During an interview on 6/6/23 at 9:45 a. m. Staff J, LPN Wound Care Nurse stated, If it was a weekend or holiday, I may not have been here to do it. We know if it wasn't documented, it isn't done. But, when I come back on Mondays or after being gone, the dressings have been changed. The dressings were always labeled and I'm sure they were done because I check the date on the actual dressing. It is a documentation problem. The care was given. There is a way for them to chart it even if it is done later. But they didn't do that. Maybe they got busy, but it wasn't charted. Review of policy and procedure titled, P & P Charting and Documentation dated 4/1/22 read, Policy: It is the policy of this facility that services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as needed. Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records.

Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 3 of 7 residents, Residents #12, #80, and #113, reviewed for respiratory services Findings include: 1) Review of Resident #12 medical record documented the resident was readmitted into the facility on [DATE] with diagnosis to include pneumonia, emphysema, chronic obstructive pulmonary disease, respiratory failure, diabetes, abnormal finding of lung field, hypertension, anemia. During an observation on 6/4/2023 at 11:33 AM Resident #12 was being administered oxygen via nasal cannula at 2 liters per minute. During an interview on 6/4/2023 at 11:33 AM Resident #12 stated, My oxygen is set at 3. During an observation on 6/5/23 at 11:59 AM Resident #12 was sitting in a wheelchair. Oxygen was being administered at 3 liters per minute via nasal cannula. Review of Resident #12's physician's orders did not document an order for oxygen. During an interview on 6/5/2023 at 1:48 PM Staff A, RN (Registered Nurse) stated, There are no oxygen orders for the resident [Resident #12] the oxygen order was discontinued on 5/11/2023. 2) Review of Resident #80's medical record documented the resident was admitted into the facility on [DATE] with diagnosis to include hemiplegia and hemiparesis (paralysis) left non dominant side, dysphasia (difficulty swallowing), chronic obstructive pulmonary disease (difficulty breathing), respiratory failure, and acute congestive heart failure. Review of the physician order dated 10/18/2022 for Resident #80 read, Change oxygen tubing weekly and PRN [as needed] ensure to label date and time. During an observation on 6/4/2023 at 9:48 AM Resident #80 was lying in bed. Oxygen was being administered at 2 liters per minute via nasal cannula, the tubing was not labeled with the date and time. During an observation on 6/5/2023 at 8:37 AM Resident #80 was being administered oxygen at 2 liters per minute via nasal cannula. The oxygen tubing was not labeled with the date and time. 3) Review of Resident #113's medical record documented the resident was admitted on [DATE] with diagnosis to include pain syndrome, chronic obstructive pulmonary disease, heart failure, sleep apnea, morbid obesity, muscle weakness, and hypertension. Review of the physician's order dated 3/16/2024 for Resident #113 read, Change oxygen tubing weekly and PRN every night shift every Thursday. During an observation on 6/4/2023 at 10:40 AM of Resident #113 the oxygen concentrator at the bedside was administering oxygen at 2 liters per minute and was being humidified with water to Resident #113 via nasal cannula. The nasal cannula tubing and the water utilized for humidification was not labeled or dated of when the tubing was changed. During an observation on 6/5/2023 at 12:22 PM Resident #113's oxygen tubing and water utilized for humidification was not labeled or dated. During an interview on 6/5/2023 at 1:15 PM Staff C, Licensed Practical Nurse stated, [Resident #113's name] oxygen tubing is not dated. During an interview on 6/5/2023 at 1:22 PM Staff D, Medical Record stated, They are supposed to be changed [oxygen tubing] and dated on night shift. During an interview on 6/5/2023 at 02:30 PM the Director of Nursing stated, It is my expectation that physician orders are followed, oxygen tubing is changed out on Thursday nights or as needed and is dated. During an interview on 6/6/2023 at 10:22 AM the Assistant Director of Nursing/Infection Preventionist stated, It is my expectation that oxygen tubing is changed out on Thursday nights and are dated at that time. Review of the policy and procedure titled, Oxygen Administration issued 4/1/2022 read, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff but is only required to have tubing dated appropriately demonstrating that the tubing was changed.

Based on observation and interview, the facility failed to store medications under proper temperature for 1 of 4 medication carts. Findings include: During an observation on 6/6/23 at 3:15 p.m. of the medication cart for the 300 Hall, a bag of intravenous bag of Vancomycin 1.75 GM/500 ML D5W [1.75 grams/500 milliliters dextrose 5% water] dated 6/4/23. a use by date of 6/13/23, labeled for Resident #44 was located in the bottom drawer of the medication cart. The solution was at room temperature. There was no condensation on the bag. There was no indication the bag had been refrigerated. There was no date or time on the bag indicating when the bag was removed from the refrigerator. During an interview on 6/6/23 at 3:15 p.m. Staff F stated, I gave the 8:00 a.m. dose of Vancomycin. I don't know where this bag came from. I had not noticed it in the cart until just now. Vancomycin must be refrigerated. I did not take that bag out. I don't know how long it has been in the cart. During an interview on 6/7/23 at 8:17 a.m. the Consultant Pharmacist stated, Vancomycin is always refrigerated.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection for 1 of 3 residents reviewed, Resident #1. Findings include: During an observation conducted on 06/04/23 at 11:10 AM, Resident #1's catheter bag was lying on the floor next to the bed without a protective barrier between it and the floor. Review of Resident #1's clinical record documented Resident #1 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis of vertebra, sacral and sacrococcygeal, sepsis, pulmonary embolism, type II diabetes mellitus, protein calorie malnutrition, and neuromuscular dysfunction of bladder. Review of Resident #1's physician orders dated 6/5/23 read, insert/maintain indwelling catheter (14 French), change indwelling catheter for leakage or blockage as needed, catheter care every shift and as needed for soiling or leakage. Review of Resident #1's care plan dated 4/24/23 read, Focus: Resident has a urinary catheter with interventions including resident has a urinary catheter in place and needs the following care: keep the drainage bag below bladder level, cover the bag for dignity, give catheter care as ordered . During an interview conducted on 06/04/23 at 11:13 AM Staff N, Licensed Practical Nurse, confirmed Resident #1's catheter bag was on the floor with no barrier between it and the floor and stated, that should not be on the floor. Review of the policy and procedure (P & P) titled, P & P Indwelling Catheters, dated 4/1/22 read, Policy: It will be the policy of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's [sic] that have the indication for use beyond 14 days. Procedure: 8. Staff will provide daily catheter care or as ordered by the physician and or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site.

Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation on 3/6/2023 at 8:35 AM, upon entrance to the facility, the nurse staffing information was displayed on the Receptionist's desk in the front lobby, which was dated Friday March 3, 2023 (Photographic evidence obtained). During an interview on 3/6/2023 at 8:52 AM, the Director of Nursing Stated, Staffing is supposed to be posted daily even on the weekends. During an interview on 3/6/2023 at 10:45 AM, the Staffing Coordinator Stated, Staffing is to be posted the night before. I did not post it over the weekend. Review of the facility policy and procedure titled Staff Postings issued on 4/1/2022 reads, Policy: It will be the policy of this facility to display staff posting information for visitors, families, residents and staff to be able to see. Procedure . 2. Posting requirements. (i) The facility will post the nurse staffing data specified daily at the beginning of each shift.

Based on interview and record review the facility failed to notify a residents representative of alleged abuse for 1 (Resident #1) of 2 residents reviewed for allegations of abuse. Findings include: During an interview on 7/14/22 at 1:30 PM the Director of Nursing stated that Resident #1's representative was not notified of the allegation or the investigation of abuse. She stated, It was late on a Saturday, I did not notify. During an interview conducted on 7/14/22 at 1:35 PM the Social Service Director stated that she usually follows up with any abuse investigation. She confirmed Resident #1's representative was not notified of the allegation of abuse. Review of alleged abuse investigative report did not document notification of Resident #1 representative. Review of Resident #1's electronic chart from the date of the alleged abuse on 6/25/22 to 7/14/22 did not contain any documentation in the progress notes, assessment notes or any other document reflecting the notification to Resident #1's representative was made. Review of the facility policy titled Abuse Protection and Response Policy revised date of 3/3/22 reads on page 7 Procedure: A thorough investigation will be conducted following the reporting of any allegation or suspicion including, but not limited to, staff, resident, and family/resident exam, clinical record, time frame of incident and witness statements, ect. The resident representative and physician should be notified that there is an ongoing investigation regarding the alleged event.

Based on interviews, document review, and review of facility policy, the facility failed to meet the requirement for 100% compliance that all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose COVID-19 vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the Centers for Disease Control Prevention (CDC). One hundred twelve out of 156 current staff were either fully vaccinated against COVID-19 or had been granted an exemption or delay in accordance with CDC guidelines, for a compliance rate of 98.1%. Three staff members, two Licensed Practical Nurses (LPNs) and one Patient Care Assistant (PCA), were not fully vaccinated, had not been granted a qualifying exemption or identified as having a temporary delay as recommended by the CDC. In addition, the facility policy failed to address staff receiving, at a minimum, a single dose of COVID-19 vaccination, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine, prior to providing any care, treatment, or other services for the facility and/or residents. Also, the facility failed to follow their policy regarding their contingency plan for staff that were not fully vaccinated. Findings include: Review of the facility policy titled, P&P COVID-19 Vaccination and Mandate revised 04/06/22, revealed, Employees who fail to comply with this policy by the effective date listed above will have their employment terminated. Further review of the policy revealed the policy failed to address procedures for staff receiving, at a minimum, a single dose of COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine, prior to providing any care, treatment, or other services for the facility and/or residents. Review of LPN1's Florida Shot Record provided by the facility revealed that she received the first dose of COVID-19 on 01/18/22. However, there was no evidence further doses were received. LPN1's hire date for the facility was 04/14/22. Review of LPN1's Timesheets provided by the facility revealed that she worked the following dates: 05/26/22, 05/24/22, 05/23/22, 05/15/22, 05/14/22, 05/08/22, 05/07/22, 04/30/22. Review of LPN2's COVID-19 Vaccination Record Card provided by the facility revealed that her first COVID-19 vaccine was on 01/24/22. Her date of hire to the facility was 09/02/20. Review of LPN2's Timesheets provided by the facility revealed that she worked the following dates: 05/26/22, 05/25/22, 05/19/22, 05/18/22, 05/11/22, 05/05/22, 05/04/22, 04/28/22, 04/27/22, 04/21/22, 04/20/22, 04/14/22, 04/13/22, 04/07/22, 04/06/22, 03/31/22, and 03/30/22. Review of PCA Florida Shot Record provided by the facility revealed that she received her first dose of COVID-19 on 04/12/22. There was no evidence of further doses received. The PCA was hired by the facility on 02/13/22. Review of her 'Timesheets provided by the facility revealed that she worked the following dates: 05/06/22, 05/05/22, 05/02/22, 05/01/22, 04/30/22, 04/26/22, 04/22/22, 04/21/22, 04/17/22, 04/16/22, 04/14/22, 04/13/22, 04/12/22, 04/11/22, 04/08/22, 04/07/22, 04/06/22, 04/04/22, 04/03/22, 04/02/22, 03/31/22, 03/30/22, 03/29/22, and 3/28/22. Interview with the Infection Preventionist (IP) on 05/27/22 at 11:15 AM, she indicated that there was to be a COVID-19 clinic held on 05/26/22; however, the vaccines did not come to the facility and that the clinic was going to be held today. She confirmed that the two LPNs and one PCA had been reminded several times about getting their second vaccine but confirmed that they did not receive the second vaccine. She indicated that the last COVID-19 vaccine clinic was last week, and the one prior to that was held in February 2022. Interview with the Director of Nursing (DON), during interview with the IP, on 05/27/22 at 11:15 AM, she confirmed that these three staff, who were not fully vaccinated, nor had been granted an exemption or met the temporary delay per CDC guidelines, had not been suspended and/or terminated, per facility policy. She indicated that if the facility suspended staff that did not have their second vaccine, then they would not have staff to care for the residents. She verbalized that the facility was not in 100% compliance with their COVID-19 vaccines. Review of the PharmScript Portal provided by the facility for the COVID-19 clinic roster dated 05/19/22 and 02/16/22 revealed that neither of the two LPNs nor the one PCA were scheduled to receive the COVID-19 vaccine during either one of these clinics. Interview with the Administrator on 05/27/22 at 2:30 PM, he confirmed that there was a contingency plan in the facility policy; however, that the contingency plan had not been followed. During interview, he confirmed no evidence in the policy regarding staff receiving vaccine prior to providing services to the facility and/or residents.

Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Resident #1's hospital history and physical dated 1/5/2022 revealed the resident had been transferred from the facility due to abdominal pain and constipation and diagnosed with fecal impaction and possible early inflammation of the colon wall. Review of Resident #1's medication administration records for the period from 2/1/2022 through 2/28/2022 and from 3/1/2022 through 3/31/2022 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication administration records did not contain any documentation of administrating [MEDICATION(S)] 400 MG/5 ML as ordered by the physician. Review of Resident #1's Documentation Survey Report dated February 2022 and March 2022 revealed the resident did not have a bowel movement for 3 days two times during February 2022 and two times during March 2022. Review of Resident #2's medication administration records for the period from 3/1/2022 through 3/31/2022 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication administration records did not contain any documentation of administrating [MEDICATION(S)] 400 MG/5 ML as ordered by the physician. Review of Resident #2's Documentation Survey Report dated March 2022 revealed the resident did not have a bowel movement for 3 days three times during March 2022. Review of Resident #3's medication administration records for the period from 3/1/2022 through 3/31/2022 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication administration records did not contain any documentation of administrating [MEDICATION(S)] 400 MG/5 ML as ordered by the physician. Review of Resident #3's Documentation Survey Report dated March 2022 revealed the resident did not have a bowel movement for 3 days two times during March 2022. During an interview on 4/1/2022 beginning at 7:52 AM, the Director of Nursing confirmed there was no documentation on Resident #1's, Resident #2's and Resident #3's medication administration records that the facility bowel protocol had been followed by administering milk of magnesium after three days of no bowel movement. During an interview on 4/1/2022 at 10:50 AM, the Director of Nursing stated the facility previously did not have a bowel management protocol. She stated that there was no documentation available in any other form or location that the facility had ensured Resident #1, Resident #2 and Resident #3 had been administered [MEDICATION(S)] 400 milligrams/5 milliliters as ordered by the physician.

Based on interview and record review, the facility failed to ensure residents were free from abuse and neglect when the facility accepted an individual from a nurse staffing agency without verifying the identity, licensure, and level II background screening, who was found not to be the person they presented to be, was not licensed as a practical nurse, and did not have a level II background screening, which resulted in a substantiated allegation of physical abuse due to the unlicensed person presenting as a practical nurse, when attempting to administer oral and intravenous (IV) medications, caused facial bruising and arm skin tear for 1 of 3 residents, Resident #2, and allowing an unlicensed person to provide nursing care and services over 33 shifts for 212 residents using a sample of 3 of 3 residents of the total 212 residents, Residents #2, #5, and #6. This facility failure resulted in Immediate Jeopardy. Findings include: Cross Reference to F607 and F835 Review of Staff D's Timesheet Hours Details report from the staffing agency for the period of 12/31/21 - 02/16/22, documented Staff D worked in the facility 33 shifts for a total of 365.64 hours. Review of the job description titled Licensed Practical Nurse/Registered Nurse with a revision date of 1/1/2015 reads, Education: Must possess, at a minimum, a Nursing Degree from an accredited college or university, or graduate from an approved LPN/LVN/RN [Licensed Practical Nurse/Licensed Vocational Nurse or Registered Nurse] program. Review of the incident investigation report dated 2/16/2022 revealed the facility received a report from Staff H, Certified Nursing Assistant (CNA), that 4 days earlier on 2/12/2022, Staff D had handled Resident #2 roughly when attempting to administer medication to the resident. Staff H reported that on 2/12/22, Resident #2 was agitated. Staff D wanted Resident #2 to take [MEDICATION(S)] but the resident spit out the medication and refused to take it. Staff D stepped behind Resident #2, grabbed her chin, pulled her head back and forced the resident to take the medication. Resident #2 had blood all on her arms and a skin tear. Resident #2 was talked to poorly and nasty. The conclusion of the investigation documented that the allegation of physical abuse was substantiated against Staff D for physical abuse of Resident #2. Review of the written statement completed by Staff I, CNA, on 2/22/2022 reads, On 2/12/22, [Staff D's name] called for her help and when I entered [Resident #2's name] room, the patient was up walking around with no gown on. The nurse and I tried to help and the nurse sat her on the bed and tried to get her dressed. The nurse wheeled the patient out to the nurse station with no gown on. No matter how many times they tried to put the gown on, she still took it off. The nurse called the patient's doctor to see if we could give something to her. The nurse tried many times to give the patient her med. The patient spit it out on the nurse and I. The nurse took the pill and put it in her mouth and held her jaw and mouth shut. Then brought her in a hallway and gave her an [MEDICATION(S)] shot after many tries for a pill. The nurse also told me that the patient had been acting like this before for many nights. Review of the written statement completed by Staff H, CNA, on 2/16/2022 reads, I, [Staff H's name] worked 3-11 pm shift. After shift change at 7 PM, the 500 hall was having problems with [Resident #2's name] being combative. The CNA on 500 brought her out to the nurse. The nurse wanted her to take [MEDICATION(S)] and [Resident #2's name] spit it out and refused. After a moment, the nurse went to [Resident's #2's name] by the nurse station and stepped behind her and grabbed her by the chin hard and pulled her head back and forced her to take the meds. Also, at that point [Resident #2's name] had blood all on her arms and skin tear. I'm not sure where came from but fresh. [Resident #2's name] also had pulled her clothes off and was placed in front of the TV covered with blood on arms and naked. She was talked to poorly and nasty. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #2 sustained a skin tear to her left and right forearms, as well as bruising to her chin and lower face. During an interview on 2/28/2022 at 2:03 PM, the Director of Nursing (DON) stated, [Staff D's name] presented herself to the nurse staffing agency and the facility as a male transitioning to a female. [Staff D's name] presented herself as [Staff E's name] and was given access in the facility under the name of [Staff E's name] who she claimed to be her true identity. During an interview on 3/1/2022 at 8:35 AM, Staff F, Registered Nurse (RN), who is an agency nurse, stated, [Staff G's name, who is also an agency Licensed Practical Nurse] had approached her and told her [Staff E's name] was not the person she presented herself to be. [Staff G's name] reported that [Staff E's name] was a person named [Staff D's name] a female and not a transitioning male. I am an agency nurse and only knew [Staff E's name] as [Staff E's name] and she thought [Staff E's name] was a male having the qualities of a female. [Staff G's name] recognized [Staff D's name] and came to her with the accusation. [Staff G's name] and me reported this suspicion to the Director of Nursing. During an interview on 3/1/2022 at 9:23 AM, the Director of Nursing stated, The facility did not initially have a copy of [Staff D's name] license. I had requested the license after receiving information from [Staff F's name and Staff G's name] that [Staff D's name] was not the person, she presented herself to be [Staff E's name]. I had not initially asked for identity or credential verification related to [Staff D's name]. The facility did not ask for her license, background screening or picture identification when [Staff D's name] reported to the facility. The facility did not request a copy of [Staff D's name] license until the incident with [Resident #2's name] on 2/16/2022. Once I received the documentation with the picture identification from the nursing agency, I saw that [Staff D's name] was not the person she had portrayed herself to be. During an interview on 3/3/2022 at 8:28 AM, the Chief Nursing Officer stated, [Staff D's name] signed all clinical documents, the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [Staff D's name] signed her time sheets under the name known to the nurse staffing agency as [Staff E's name]. The facility gave [Staff D's name] initial access to Point Click Care as [Staff E's name]. No manager admitted to registering [Staff D's name] as [Staff X's name] in the computerized resident records system. [Staff D's name] charted as [Staff X's name] the entire time she worked in the facility. None of the managers remembered giving [Staff D's name] access to the facility computerized resident records system as [Staff X's name]. I did not know how she was able to access the system as [Staff X's name]. During an interview on 3/3/2022 at 8:42 AM, the Director of Nursing stated, I was notified by one of the agency nurses that [Staff D's name] was not [Staff E's name] that [Staff E's name] was [Staff D's name]. I called the agency and asked the agency to send me anything they had on [Staff E's name]. We took [Staff E's name] off the schedule until we could figure it out. When the nurse staffing agency sent over the picture of [Staff E's name], I said this is not who is coming to our building. I tried to confront [Staff D's name] with this information, but she would not return telephone calls or come to the building. When I looked into it, I saw Staff D was charting as [Staff E's name] and [Staff X's name]. She stated she asked [Staff D's name] why she charted as [Staff E's name] if that wasn't her name. [Staff D's name] said she also used the name [Staff X's name]. During an interview on 3/3/2022 at 1:22 PM with the Regional Nurse Consultant, when asked if she felt that the facility should have done more to screen staff that was coming in from agency, she stated, We validate the contract is completed with the agency that in the agency contract reads that the agency is responsible for the verification of identification, education, and background screening. The agency staff comes to the right building, at the right time with their name tag from the staffing agency. We consider this their form of identification and validation of competency. I feel that we could not have done anything differently. During an interview on 3/3/2022 at 1:24 PM with the Director of Nursing, when asked the due diligence the facility could do to verify the agency staffing, she stated, We expect the agency to verify all agency staff prior to sending staff to our facility. This is part of the contract that we have with them. Review of the Florida Department of Health (DOH) license verification on 3/2/2022 revealed Staff D did not have a current license for a Licensed Practical Nurse (LPN), Registered Nurse (RN) or certification for a Certified Nurse Assistant (CNA). Staff D impersonated Staff E and Staff X when completing nursing duties and documentation at the facility from 12/31/2021 to 2/16/2022. Review of the facility medical record for Resident #2 documented the resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] vomiting, repeated falls, contact with and exposure to other [CONDITION(S)] communicable diseases, mood disorder due to known physiological condition with depressive features (prominent and persistent period of depressed mood or markedly diminished interest/pleasure). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility medical record for Resident #5 documented the resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #5 revealed Staff D administered insulin on 2/3/2022, 2/4/2022, and 2/5/2022, tested the resident for COVID-19 on 2/4/2022, and completed pain and behavioral assessments on 2/2/2022 and 2/4/2022. Review of the facility medical record for Resident #6 documented the resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #6 revealed Staff D tested the resident for COVID-19 on 2/8/2022, completed a pain and urine assessment and applied bilateral compression hose on 2/8/2022. Review of the facility policy and procedure titled, Abuse Protection and Response Policy, reads, Policy: Abuse, as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardians, friends or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Definitions: Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the resident. Physical Abuse: includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to develop and implement policies and procedures to verify the identification, licensure, and background screenings for all agency nursing staff and to ensure the documentation of the agency staff were verified and maintained prior to having access to the residents and providing nursing care and services to 212 residents throughout their assignment at the facility. This facility failure resulted in Immediate Jeopardy. Findings include: Cross Reference to F600 and F835 Review of the Florida Department of Health (DOH) license verification on 3/2/2022 revealed Staff D did not have a current license for a Licensed Practical Nurse (LPN), Registered Nurse (RN) or certification for a Certified Nurse Assistant (CNA). Staff D impersonated Staff E and Staff X when completing nursing duties and documentation at the facility. Review of Staff D's Timesheet Hours Details report from the staffing agency for the period of 12/31/21 - 02/16/22, documented Staff D worked in the facility 33 shifts for a total of 365.64 hours. Review of the job description titled Licensed Practical Nurse/Registered Nurse with a revision date of 1/1/2015 reads, Education: Must possess, at a minimum, a Nursing Degree from an accredited college or university, or graduate from an approved LPN/LVN/RN [Licensed Practical Nurse/Licensed Vocational Nurse or Registered Nurse] program. Review of the incident investigation report dated 2/16/2022 revealed the facility received a report from Staff H, Certified Nursing Assistant (CNA), that 4 days earlier on 2/12/2022, Staff D had handled Resident #2 roughly when attempting to administer medication to the resident. Staff H reported that on 2/12/22, Resident #2 was agitated. Staff D wanted Resident #2 to take [MEDICATION(S)] but the resident spit out the medication and refused to take it. Staff D stepped behind Resident #2, grabbed her chin, pulled her head back and forced the resident to take the medication. Resident #2 had blood all on her arms and a skin tear. Resident #2 was talked to poorly and nasty. The conclusion of the investigation documented that the allegation of physical abuse was substantiated against Staff D for physical abuse of Resident #2. Review of the written statement completed by Staff I, CNA, on 2/22/2022 reads, On 2/12/22, [Staff D's name] called for her help and when I entered [Resident #2's name] room, the patient was up walking around with no gown on. The nurse and I tried to help and the nurse sat her on the bed and tried to get her dressed. The nurse wheeled the patient out to the nurse station with no gown on. No matter how many times they tried to put the gown on, she still took it off. The nurse called the patient's doctor to see if we could give something to her. The nurse tried many times to give the patient her med. The patient spit it out on the nurse and I. The nurse took the pill and put it in her mouth and held her jaw and mouth shut. Then brought her in a hallway and gave her an [MEDICATION(S)] shot after many tries for a pill. The nurse also told me that the patient had been acting like this before for many nights. Review of the written statement completed by Staff H, CNA, on 2/16/2022 reads, I, [Staff H's name] worked 3-11 pm shift. After shift change at 7 PM, the 500 hall was having problems with [Resident #2's name] being combative. The CNA on 500 brought her out to the nurse. The nurse wanted her to take [MEDICATION(S)] and [Resident #2's name] spit it out and refused. After a moment, the nurse went to [Resident's #2's name] by the nurse station and stepped behind her and grabbed her by the chin hard and pulled her head back and forced her to take the meds. Also, at that point [Resident #2's name] had blood all on her arms and skin tear. I'm not sure where came from but fresh. [Resident #2's name] also had pulled her clothes off and was placed in front of the TV covered with blood on arms and naked. She was talked to poorly and nasty. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #2 sustained a skin tear to her left and right forearms, as well as bruising to her chin and lower face. During an interview on 2/28/2022 at 2:03 PM, the Director of Nursing (DON) stated, [Staff D's name] presented herself to the nurse staffing agency and the facility as a male transitioning to a female. [Staff D's name] presented herself as [Staff E's name] and was given access in the facility under the name of [Staff E's name] who she claimed to be her true identity. During an interview on 3/1/2022 at 8:35 AM, Staff F, Registered Nurse (RN), who is an agency nurse, stated, [Staff G's name, who is also an agency Licensed Practical Nurse] had approached her and told her [Staff E's name] was not the person she presented herself to be. [Staff G's name] reported that [Staff E's name] was a person named [Staff D's name] a female and not a transitioning male. I am an agency nurse and only knew [Staff E's name] as [Staff E's name] and she thought [Staff E's name] was a male having the qualities of a female. [Staff G's name] recognized [Staff D's name] and came to her with the accusation. [Staff G's name] and me reported this suspicion to the Director of Nursing. During an interview on 3/1/2022 at 9:23 AM, the Director of Nursing stated, The facility did not initially have a copy of [Staff D's name] license. I had requested the license after receiving information from [Staff F's name and Staff G's name] that [Staff D's name] was not the person, she presented herself to be [Staff E's name]. I had not initially asked for identity or credential verification related to [Staff D's name]. The facility did not ask for her license, background screening or picture identification when [Staff D's name] reported to the facility. The facility did not request a copy of [Staff D's name] license until the incident with [Resident #2's name] on 2/16/2022. Once I received the documentation with the picture identification from the nursing agency, I saw that [Staff D's name] was not the person she had portrayed herself to be. During an interview on 3/1/2022 at 1:25 PM, the Director of Nursing stated that agency staff identification, licensure, and background screenings documents were not maintained at the facility. During an interview on 3/1/2022 at 2:15 PM, the Director of Nursing stated, Usually the staffing agency takes the responsibility to complete the background, check the identification, and license through our contract agreement. We check the name tags when the agency staff reports for work. In the past, it was not our practice to verify agency staff identity. During an interview on 3/3/2022 at 8:42 AM, the Director of Nursing stated, I was notified by one of the agency nurses that [Staff D's name] was not [Staff E's name] that [Staff E's name] was [Staff D's name]. I called the agency and asked the agency to send me anything they had on [Staff E's name]. We took [Staff E's name] off the schedule until we could figure it out. When the nurse staffing agency sent over the picture of [Staff E's name], I said this is not who is coming to our building. I tried to confront [Staff D's name] with this information, but she would not return telephone calls or come to the building. When I looked into it, I saw Staff D was charting as [Staff E's name] and [Staff X's name]. She stated she asked [Staff D's name] why she charted as [Staff E's name] if that wasn't her name. [Staff D's name] said she also used the name [Staff X's name]. During an interview on 3/3/2022 at 1:22 PM with the Regional Nurse Consultant, when asked if she felt that the facility should have done more to screen staff that was coming in from agency, she stated, We validate the contract is completed with the agency that in the agency contract reads that the agency is responsible for the verification of identification, education, and background screening. The agency staff comes to the right building, at the right time with their name tag from the staffing agency. We consider this their form of identification and validation of competency. I feel that we could not have done anything differently. During an interview on 3/3/2022 at 1:24 PM with the Director of Nursing, when asked the due diligence the facility could do to verify the agency staffing, she stated, We expect the agency to verify all agency staff prior to sending staff to our facility. This is part of the contract that we have with them. Review of the verification records for agency staff maintained by the facility showed the facility had not verified the licenses, identification, and/or background screenings for 21 of 40 agency nursing staff. Review of the facility policy titled, Abuse Protection and Response Policy reads, I. Screening. Policy: The center will screen potential employees for a history of abuse, neglect, or mistreating residents as defined by the applicable requirements 483.12 (c)(1)(ii)(a) and (b). This includes attempting to obtain information from previous employers and/or current employers. Procedure: Check references for all applicants to obtain information from previous employers and current employers (with applicant permission). Check the appropriate licensing board or registry prior to hire. Criminal background checks will be performed as required by law through AHCA [Agency for Healthcare Administration] Clearinghouse. The policy does not include screening for contracted/agency employees.

Based on interview and record review, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility ensuring the safety for 128 residents by not verifying identification, licensure and level II background screenings for agency nursing staff, which resulted in a substantiated allegation of physical abuse for 1 of 3 residents, Resident #2, and allowing an unlicensed person to provide nursing care and services over 33 shifts for 212 residents using a sample of 3 of 3 residents of the total 212 residents, Residents #2, #5, and #6. This facility failure resulted in Immediate Jeopardy. Findings include: Cross Reference to F600 and F607 Review of the job description titled Administrator with a revision date of 1/1/2015 reads, Purpose of Your Job Position. The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality care can be provided to our residents at all times. Duties and Responsibilities. Administrative Functions. Ensure that appropriate Facility policies and procedures are followed when conducting background checks and when providing information to the Nurse Aide Registry. Assist in the development and implementation of policies and procedures governing the management and control of protected health information (e.g. assignment and use of passwords, unauthorized use and release of protected health information, etc.). Personnel Functions. Ensure that appropriate employment identification and work documents are present prior to the employment of personnel and that appropriate documentation is filed in the employee's personnel record in accordance with current regulations mandating such documentation. The job description was signed by the Administrator on 12/6/2021. Review of the job description titled Director of Nursing Services with a revision date of 1/1/2015 reads, Purpose of Your Job Position. The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities. Administrative Functions. Ensure background checks on nursing service personnel in accordance with established procedures. Nursing Care Functions. Ensure that direct nursing care be provided by LPNs [Licensed Practical Nurses], CNAs [Certified Nursing Assistant], and /or a nurse aide trainee qualified to perform the procedure. The job description was signed by the Director of Nursing on 11/12/2021. Review of the job description titled Licensed Practical Nurse/Registered Nurse with a revision date of 1/1/2015 reads, Education: Must possess, at a minimum, a Nursing Degree from an accredited college or university, or graduate from an approved LPN/LVN/RN [Licensed Practical Nurse/Licensed Vocational Nurse or Registered Nurse] program. Review of the Florida Department of Health (DOH) license verification on 3/2/2022 revealed Staff D did not have a current license for a Licensed Practical Nurse (LPN), Registered Nurse (RN) or certification for a Certified Nurse Assistant (CNA). Staff D impersonated Staff E and Staff X when completing nursing duties and documentation at the facility. Review of Staff D's Timesheet Hours Details report from the staffing agency for the period of 12/31/21 - 02/16/22, documented Staff D worked in the facility 33 shifts for a total of 365.64 hours. Review of the incident investigation report dated 2/16/2022 revealed the facility received a report from Staff H, Certified Nursing Assistant (CNA), that 4 days earlier on 2/12/2022, Staff D had handled Resident #2 roughly when attempting to administer medication to the resident. Staff D stepped behind Resident #2, grabbed her chin, pulled her head back and forced the resident to take the medication. Resident #2 had blood all on her arms and a skin tear. Resident #2 was talked to poorly and nasty. The conclusion of the investigation documented that the allegation of physical abuse was substantiated against Staff D for physical abuse of Resident #2. Review of the written statement completed by Staff I, CNA, on 2/22/2022 reads, On 2/12/22, [Staff D's name] called for her help and when I entered [Resident #2's name] room, the patient was up walking around with no gown on. The nurse tried many times to give the patient her med. The patient spit it out on the nurse and I. The nurse took the pill and put it in her mouth and held her jaw and mouth shut. Then brought her in a hallway and gave her an [MEDICATION(S)] shot after many tries for a pill. The nurse also told me that the patient had been acting like this before for many nights. Review of the written statement completed by Staff H, CNA, on 2/16/2022 reads, I, [Staff H's name] worked 3-11 pm shift. After shift change at 7 PM, the 500 hall was having problems with [Resident #2's name] being combative. The CNA on 500 brought her out to the nurse. The nurse wanted her to take [MEDICATION(S)] and [Resident #2's name] spit it out and refused. After a moment, the nurse went to [Resident's #2's name] by the nurse station and stepped behind her and grabbed her by the chin hard and pulled her head back and forced her to take the meds. Also, at that point [Resident #2's name] had blood all on her arms and skin tear. I'm not sure where came from but fresh. [Resident #2's name] also had pulled her clothes off and was placed in front of the TV covered with blood on arms and naked. She was talked to poorly and nasty. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #2 sustained a skin tear to her left and right forearms, as well as bruising to her chin and lower face. During an interview on 2/28/2022 at 2:03 PM, the Director of Nursing (DON) stated, [Staff D's name] presented herself to the nurse staffing agency and the facility as a male transitioning to a female. [Staff D's name] presented herself as [Staff E's name] and was given access in the facility under the name of [Staff E's name] who she claimed to be her true identity. During an interview on 3/1/2022 at 8:35 AM, Staff F, Registered Nurse (RN), who is an agency nurse, stated, [Staff G's name, who is also an agency Licensed Practical Nurse] had approached her and told her [Staff E's name] was not the person she presented herself to be. [Staff G's name] reported that [Staff E's name] was a person named [Staff D's name] a female and not a transitioning male. I am an agency nurse and only knew [Staff E's name] as [Staff E's name] and she thought [Staff E's name] was a male having the qualities of a female. [Staff G's name] recognized [Staff D's name] and came to her with the accusation. [Staff G's name] and me reported this suspicion to the Director of Nursing. During an interview on 3/1/2022 at 9:23 AM, the Director of Nursing stated, The facility did not initially have a copy of [Staff D's name] license. I had requested the license after receiving information from [Staff F's name and Staff G's name] that [Staff D's name] was not the person, she presented herself to be [Staff E's name]. I had not initially asked for identity or credential verification related to [Staff D's name]. The facility did not ask for her license, background screening or picture identification when [Staff D's name] reported to the facility. The facility did not request a copy of [Staff D's name] license until the incident with [Resident #2's name] on 2/16/2022. Once I received the documentation with the picture identification from the nursing agency, I saw that [Staff D's name] was not the person she had portrayed herself to be. During an interview on 3/1/2022 at 1:25 PM, the Director of Nursing stated that agency staff identification, licensure, and background screenings documents were not maintained at the facility. During an interview on 3/2/2022 at 3:06 PM, the Medical Director stated he was aware of the report that an unlicensed person was working as a nurse in the facility. He stated the facility was scheduled to have a Quality Assurance meeting on 2/24/2022 to address the incident and the outcome of the incident but the meeting was canceled. He stated that there was a lot going on that week. During an interview on 3/3/2022 at 8:28 AM, the Chief Nursing Officer stated, [Staff D's name] signed all clinical documents, the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [Staff D's name] signed her time sheets under the name known to the nurse staffing agency as [Staff E's name]. The facility gave [Staff D's name] initial access to Point Click Care as [Staff E's name]. No manager admitted to registering [Staff D's name] as [Staff X's name] in the computerized resident records system. [Staff D's name] charted as [Staff X's name] the entire time she worked in the facility. None of the managers remembered giving [Staff D's name] access to the facility computerized resident records system as [Staff X's name]. I did not know how she was able to access the system as [Staff X's name]. During an interview on 3/3/2022 at 8:42 AM, the Director of Nursing stated, I was notified by one of the agency nurses that [Staff D's name] was not [Staff E's name] that [Staff E's name] was [Staff D's name]. I called the agency and asked the agency to send me anything they had on [Staff E's name]. We took [Staff E's name] off the schedule until we could figure it out. When the nurse staffing agency sent over the picture of [Staff E's name], I said this is not who is coming to our building. I tried to confront [Staff D's name] with this information, but she would not return telephone calls or come to the building. When I looked into it, I saw Staff D was charting as [Staff E's name] and [Staff X's name]. She stated she asked [Staff D's name] why she charted as [Staff E's name] if that wasn't her name. [Staff D's name] said she also used the name [Staff X's name]. During an interview on 3/3/2022 at 1:22 PM with the Regional Nurse Consultant, when asked if she felt that the facility should have done more to screen staff that was coming in from agency, she stated, We validate the contract is completed with the agency that in the agency contract reads that the agency is responsible for the verification of identification, education, and background screening. The agency staff comes to the right building, at the right time with their name tag from the staffing agency. We consider this their form of identification and validation of competency. I feel that we could not have done anything differently. During an interview on 3/3/2022 at 1:24 PM with the Director of Nursing, when asked the due diligence the facility could do to verify the agency staffing, she stated, We expect the agency to verify all agency staff prior to sending staff to our facility. This is part of the contract that we have with them. Review of the verification records for agency staff maintained by the facility showed the facility had not verified the licenses, identification, and/or background screenings for 21 of 40 agency nursing staff. Review of the facility policy titled, Abuse Protection and Response Policy reads, I. Screening. Policy: The center will screen potential employees for a history of abuse, neglect, or mistreating residents as defined by the applicable requirements 483.12 (c)(1)(ii)(a) and (b). This includes attempting to obtain information from previous employers and/or current employers. Procedure: Check references for all applicants to obtain information from previous employers and current employers (with applicant permission). Check the appropriate licensing board or registry prior to hire. Criminal background checks will be performed as required by law through AHCA [Agency for Healthcare Administration] Clearinghouse. The policy does not include screening for contracted/agency employees.