Every finding on record at Titusville Rehabilitation & Nursing Center

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was available on 1 of 3 units to meet residents' needs related to the timely administration of scheduled medications, (Unit 2).Findings: Cross Reference F755 1. During a medication pass observation with Licensed Practical Nurse (LPN) A on 6/03/26 at 10:05 AM, eight residents listed on the electronic Medication Administration Record (MAR) appeared in red, indicating their scheduled morning medications had not yet been administered. When asked why the residents' names appeared in red, LPN A stated the morning medications were past due. She explained nurses were expected to administer 9:00 AM medications between 8:00 AM and 10:00 AM. LPN A prepared and administered medications for resident #4 at 10:33 AM. Upon completion of the medication administration at approximately 10:40 AM, LPN A stated medication administration required significant time to complete because residents could not be rushed, often required assistance, asked questions, and often requested additional time during medication pass. Review of the staffing assignment sheet and documentation on Unit 2's assignment board with the assignment dated 6/03/26 revealed a census of 36 residents. The assignment sheet showed two licensed nurses were assigned to the unit. LPN A was assigned rooms 202-236. Review of the resident census list revealed LPN A was responsible for approximately 25 to 26 residents during the morning medication pass. 2. On 6/03/26 at 10:53 AM, resident #3 stated he had been in the facility for approximately seven months. He shared he had his physician change his pain medication from as needed to a scheduled administration time because he needed the medication administered timely; however, the change had not improved the timeliness of administration. He indicated that, as of that time, he had not yet received his morning medications. He mentioned one of the medications he received in the morning was Oxycontin 15 milligrams (mg) for chronic pain related to a spinal cord injury and a wound on his coccyx. He stated his pain level was currently 9 out of 10 and explained after receiving his medication his pain level typically decreased to 7 out of 10. He further stated if received his pain medication as scheduled, his pain would be manageable. Review of the medical record revealed resident #3 was readmitted to the facility on [DATE] with diagnoses including paraplegia, type 2 diabetes, unstageable pressure ulcers on the left and right buttocks, insomnia, and major depressive disorder. Review of resident #3's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/24/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. Review of resident #3's MAR for May and June 2026 revealed the following medications were scheduled for administration:*8:00 AM: Oxycodone 10 mg*9:00 AM: Amlodipine 10 mg, Aspirin 81 mg, Ascorbic acid 500 mg, Furosemide 20 mg, Gabapentin 300 mg, Oxycontin 15 mg, Senna-S 8.6-50 mg, Tizanidine 2 mg, Baclofen 20 mg *12:00 PM: Oxycodone 10 mg*1:00 PM: Baclofen 20 mg Review of the Medication Admin (Administration) Audit Report for resident #3 revealed the 8:00 AM medication was administered at 10:16 AM and 9:00 AM medications were administered between 10:16 AM and 10:17 AM on 5/29/26. The 12:00 PM medication was administered at 2:22 PM on 5/29/26. On 5/30/26, the 8:00 AM medication was administered at 11:59 AM and the 9:00 AM medications were administered between 11:50 AM and 12:23 PM. The 12:00 PM and 1:00 PM medications were administered at 2:32 PM. On 5/31/26, the 8:00 AM medication was administered at 10:59 AM and the 9:00 AM medications were administered between 10:55 AM and 11:01 AM. On 6/02/26, the 8:00 AM Oxycodone was administered at 9:23 AM, and the 12:00 PM and 1:00 PM medications were administered at 2:50 PM. Review of the medical record revealed no documentation that the physician was notified regarding the delayed administration of medications on the dates and times identified above. 3. On 6/03/26 at 11:13 AM, resident #1 stated the nurses did not tell her which medications she received. She indicated the majority of the time her morning medications were administered late. She said, Sometimes there is just one nurse and two Certified Nursing Assistants (CNAs) for the entire unit with almost 40 residents. Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses including multiple sclerosis, obstructive and reflux uropathy (abnormal flow through the urinary system), sepsis, and major depressive disorder. Review of resident #1's quarterly MDS assessment with ARD of 3/25/26 revealed a BIMS score of 15/15, indicating intact cognition. Review of resident #1's MAR for May and June 2026 revealed the following medications were scheduled for administration:*9:00 AM: Oxycontin 20 mg, Atropine eye drops, Acidophilus, Losartan 25 mg*12:00 PM: Ropinirole 2 mg and Oxycodone 15 mg Review of the Medication Admin Audit Report for resident #1 revealed the 9:00 AM medications were administered at 10:14 AM on 5/29/26, at 11:28 AM on 5/30/26 (except Oxycontin which was administered at 10:20 AM), and between 10:35 AM and 10:42 AM on 5/31/26. The 12:00 PM medications were administered at 2:21 PM on 5/29/26 and at 2:48 PM on 6/02/26. Review of the medical record revealed no documentation that the physician was notified regarding the delayed administration of medications on the dates and times identified above. 4. On 6/03/26 at 12:27 PM, resident #5 stated some medications were given always late. She indicated one of her medications was supposed to be administered every six hours, but she received it every eight hours. She stated delays occurred at different times throughout the day. She said the facility keep(s) getting agency nurses, they get behind and it takes them forever. She further stated when she asked some nurses what medications they were administering, she was told, the same thing you received yesterday. Review of the medical record revealed resident #5 was readmitted to the facility on [DATE] with diagnoses including nontraumatic subarachnoid hemorrhage (brain bleed), spinal stenosis (narrow spaces within the spine), type 2 diabetes, and restless legs syndrome. Review of resident #5's quarterly MDS assessment with ARD of 2/22/26 revealed a BIMS score of 15/15, indicating intact cognition. Review of resident #5's MAR for May and June 2026 revealed the following medications were scheduled for administration:*8:00 AM: Lantus SoloStar 10 units*9:00 AM: Lyrica 75 mg, Nifedipine 60 mg, Humalog sliding scale insulin, Brimonidine eye drops, MiraLAX, Cyanocobalamin 500 micrograms (mcg), Aspirin 81 mg, Senokot 8.6-50 mg, Plavix 75 mg, Magnesium Oxide 400 mg, *12:00 PM: Methocarbamol 500 mg and Hydrocodone-Acetaminophen 7.5-325 mg*1:00 PM: Brimonidine eye drops and Humalog sliding scale insulin Review of the Medication Admin Audit Report for resident #5 revealed the 9:00 AM medications were administered at 10:37 AM on 5/29/26. On 5/30/26, the 8:00 AM, 9:00 AM, 12:00 PM and one of the 1:00 PM medications (Brimonidine eye drops) were administered between 2:10 PM and 2:11 PM. On 5/31/26, the 12:00 PM medications were administered between 1:58 and 1:59 PM. On 6/01/26, the 8:00 AM and 9:00 AM medications were administered between 10:04 and 10:10 AM. Review of the medical record revealed no documentation that the physician was notified regarding the delayed administration of medications on the dates and times identified above. On 6/04/26 at approximately 11:55 AM, the Unit Manager (UM) stated she frequently assisted with medication administration and was working on the medication cart that day because a nurse had called out. She indicated the facility did not have a weekend supervisor and often utilized agency nurses. She explained medications were expected to be administered within one hour before or one hour after the scheduled administration time. She stated delayed medication administration could occur when nurses were unfamiliar with the residents, unfamiliar with the facility, or required additional time to review physician orders. The UM further stated timely medication administration was dependent on staffing circumstances and said, On a good day you can pass the medications timely. On 6/04/26 at 4:46 PM, Regional Nurse Consultant (RNC) C reviewed Medication Admin Audit Reports for residents #1, #3, #5, #13, #14, #15, #16, #17, #18, and #19 and confirmed multiple medications had been administered outside the facility's established administration time frame. She stated medications should be administered within one hour before or one hour after the scheduled administration time. RNC C indicated nurses were expected to notify the physician when medications were administered late and document the notification in the medical record. Review of the facility policy titled Staffing, effective August 2024, revealed the Administrator (NHA) and Director of Nursing (DON) were responsible for ensuring sufficient nursing staff was available to provide nursing and related services necessary for the residents to attain or maintain their highest practicable, physical, mental, and psychological well-being, as required by federal regulations. The policy further indicated projected staffing plans were to be reevaluated on an ongoing basis in response to changes in resident census, resident acuity, staffing needs, and other facility circumstances. The policy directed the facility leadership to monitor staffing on an ongoing basis and evaluate staffing daily. The policy also required staffing adjustments throughout the day based on resident census and changes in resident care needs. Review of May and June 2026 Medication Admin Audit Reports for residents #1, #3, #5, #13, #14, #15, #16, #17, #18, and #19 revealed a pattern of delayed medication administration affecting multiple residents on Unit 2 over several consecutive days. The delayed medication administration occurred despite the facility's expectation that medications be administered within one hour before or after the scheduled administration time and despite facility policy requiring ongoing evaluation and adjustment of staffing based on resident needs.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services in accordance with professional standards of practice by: failing to appropriately dispose of medications during medication administration for 1 of 2 residents reviewed during medication pass observations (#4); failing to accurately account for and document controlled substance administration and maintain security of medications for 1 of 4 residents reviewed for narcotic administration, (#11); and failing to administer medications according to physician orders and the facility's established medication administration schedule for 10 residents on 1 of 3 units reviewed, out of 19 sampled residents, (#1, #3, #5, #13, #14, #15, #16, #17, #18, and #19). Findings: Cross Reference F725, F867 1. During a medication pass observation with Licensed Practical Nurse (LPN) A on 6/03/26 at 10:05 AM, she indicated nurses were expected to administer 9:00 AM medications between 8:00 AM and 10:00 AM. While preparing medications for resident #4, a Bisacodyl tablet fell from the medication cup onto the medication cart. LPN A discarded the tablet into a trash receptacle attached to the medication cart and continued preparing medications after performing hand hygiene. LPN A administered the medications to resident #4 at 10:33 AM and informed the resident she had medications to take but did not identify the medications being administered. Following the medication pass, LPN A stated she had completed the controlled substance count with the outgoing nurse at the beginning of the shift and confirmed the count matched the Controlled Drug - Key Exchange Audit form. Observation of the audit form revealed LPN A had not signed the 7:00 AM to 3:00 PM shift verification. LPN A acknowledged she was expected to sign the form after completing the narcotic count and confirming no discrepancies. On 6/03/26 at 4:05 PM, LPN A confirmed she had discarded the Bisacodyl tablet in the trash receptacle attached to the medication cart. She stated this was a mistake and acknowledged medications requiring disposal should be discarded in the designated medication disposal container located within the medication cart. LPN A indicated she had received education regarding medication administration practices, including medication disposal procedures, during orientation approximately one month earlier. 2. On 6/03/26 at 11:52 AM, LPN B stated she completed a controlled substance count with the outgoing nurse at the beginning of her shift and compared the count to the Controlled Drug - Key Exchange Audit form. She explained nurses were expected to verify the count and sign the form when assuming responsibility for the medication cart. LPN B stated she became distracted during shift change and did not sign the form as required. She acknowledged the outgoing nurse had signed in the space designated for her signature and stated she intended to correct the error later. When informed a narcotic inspection would be conducted, LPN B stated she had administered one tablet of Norco (Hydrocodone-Acetaminophen 5-325 milligrams (mg)) to resident #11 at approximately 10:30 AM but had not yet documented the removal or administration on the Controlled Drug Record form. Review of resident #11's Hydrocodone-Acetaminophen blister pack revealed seven tablets remaining. Review of the Controlled Drug Record form reflected a count of eight tablets remaining and contained no documentation of medication administration on 6/03/26 at 10:30 AM. LPN B validated she was expected to document controlled substance removal and administration at the time the medication was administered. During an inspection of medications stored in the medication room refrigerator, LPN B left the medication cart unlocked. Upon returning to the medication cart, LPN B acknowledged the cart had remained unlocked and stated the medication carts were expected to remain locked whenever they were not under direct supervision of the nurse. 3. Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses including multiple sclerosis, obstructive and reflux uropathy (abnormal flow through the urinary system), sepsis, and major depressive disorder. Review of resident #1's MAR for May and June 2026 revealed the following medications were scheduled for administration at 9:00 AM: Oxycontin 20 mg, Atropine eye drops, Acidophilus, and Losartan 25 mg. Ropinirole 2 mg and Oxycodone 15 mg were scheduled for administration at 12:00 PM. Review of resident #1's Medication Admin (Administration) Audit Report revealed the 9:00 AM medications were administered at 10:14 AM on 5/29/26, at 11:28 AM on 5/30/26, except Oxycontin, which was administered at 10:20 AM, and between 10:35 AM and 10:42 AM on 5/31/26. The 12:00 PM medications were administered at 2:21 PM on 5/29/26 and at 2:48 PM on 6/02/26. Review of the medical record revealed no documentation the physician was notified regarding delayed administration of medications on these dates and times. 4. Review of the medical record revealed resident #3 was readmitted to the facility on [DATE] with diagnoses including paraplegia, type 2 diabetes, unstageable pressure ulcers of the bilateral buttocks, insomnia, and major depressive disorder. Review of resident #3's MAR for May and June 2026 revealed the following medications were scheduled for administration at 8:00 AM: Oxycodone 10 mg, at 9:00 AM: Amlodipine 10 mg, Aspirin 81 mg, Ascorbic acid 500 mg, Furosemide 20 mg, Gabapentin 300 mg, Oxycontin 15 mg, Senna-S 8.6-50 mg, Tizanidine 2 mg, Baclofen 20 mg, at 12:00 PM: Oxycodone 10 mg, and at 1:00 PM: Baclofen 20 mg. Review of resident #3's Medication Admin Audit Report revealed the 8:00 AM medication was administered at 10:16 AM and the 9:00 AM medications were administered between 10:16 and 10:17 AM on 5/29/26. The 12:00 PM medication was administered at 2:22 PM. On 5/30/26, the 8:00 AM medication was administered at 11:59 AM, the 9:00 AM medications were administered between 11:50 AM and 12:23 PM, and the 12:00 PM and 1:00 PM medications were administered at 2:32 PM. On 5/31/26, the 8:00 AM medication was administered at 10:59 AM and the 9:00 AM medication between 10:55 AM and 11:01 AM. On 6/02/26, the 8:00 AM medication was administered at 9:23 AM, the 12:00 PM and 1:00 PM medications were administered at 2:50 PM. Review of the medical record revealed no documentation the physician was notified regarding delayed administration of medications on these dates and times. 5. Review of the medical record revealed resident #5 was readmitted to the facility on [DATE] with diagnoses including nontraumatic subarachnoid hemorrhage, spinal stenosis (narrow spaces within the spine), type 2 diabetes, and restless legs syndrome. Review of resident #5's MAR for May and June 2026 revealed the following medications were scheduled for administration at 8:00 AM: Lantus SoloStar 10 unit, at 9:00 AM: Lyrica 75 mg, Nifedipine 60 mg, Humalog sliding scale insulin, Brimonidine eye drops, MiraLax, Cyanocobalamin 500 micrograms (mcg), Aspirin 81 mg, Senokot 8.6-50 mg, Plavix 75 mg, Magnesium Oxide 400 mg, at 12:00 PM: Methocarbamol 500 mg and Hydrocodone-Acetaminophen 7.5-325 mg, and at 1:00 PM: Brimonidine eye drops and Humalog sliding scale insulin. Review of resident #5's Medication Admin Audit Report revealed the 9:00 AM medications were administered at 10:37 AM on 5/29/26. On 5/30/26, the 8:00 AM, 9:00 AM, 12:00 PM and one 1:00 PM medications were administered between 2:10 PM and 2:11 PM. On 5/31/26, 12:00 PM medications were administered between 1:58 - 1:59 PM. On 6/01/26, the 8:00 AM and 9:00 AM medications were administered between 10:04 - 10:10 AM. Review of the medical record revealed no documentation the physician was notified regarding delayed administration of medications on these dates and times. 6. Review of the medical record revealed resident #13 was readmitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, cardiomyopathy (abnormal enlargement of the heart muscle), anxiety disorder, lymphedema (buildup of fluid called lymph in the tissues), and emphysema (respiratory disease). Review of resident #13's MAR for May and June 2026 revealed the following medications were scheduled for administration at 9:00 AM: Ferrous Sulfate 325 mg, Spironolactone 50 mg, Magnesium 400 mg, Protonix 40 mg, Sennosides 8.6 mg, Potassium Chloride 40 milliequivalent (mEq), Dorzolamide eye drops, and Hydralazine 50 mg, and at 10:00 AM: Nifedipine 60 mg. Review of resident #13's Medication Admin Audit Report revealed the 9:00 AM medications were administered at 10:15 AM on 5/29/26. On 5/30/26, the 9:00 AM and 10:00 AM medications were administered between 11:32 and 11:36 AM, and Dorzolamide eye drops were administered at 1:12 PM. On 5/31/26, the 9:00 AM medications were administered between 10:43 and 10:48 AM and the 10:00 AM medication was administered at 11:53 AM. Review of the medical record revealed no documentation the physician was notified regarding delayed administration of medications on these dates and times. 7. Review of the medical record revealed resident #14 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, fluid overload, dysphagia (difficulty swallowing), major depressive disorder, alcoholic cirrhosis of liver, and cognitive communication deficit. Review of resident #14's MAR for May and June 2026 revealed the following medications were scheduled for administration at 9:00 AM: Spironolactone 100 mg, Thiamine 100 mg, Sertraline 50 mg, Furosemide 20 mg, Gabapentin 600 mg, and Folic Acid 1 mg, at 1:00 PM: Gabapentin 600 mg, and at 2:00 PM: Buprenorphine 8 mg. Review of resident #14's Medication Admin Audit Report revealed the 9:00 AM medications were administered at 10:15 AM and the 1:00 PM medication was administered at 2:22 PM on 5/29/26. On 5/30/26, the 9:00 AM medications were administered between 11:37 and 11:41 AM, and the 1:00 PM and 2:00 PM medications were administered at 5:04 PM. On 5/31/26, the 9:00 AM medications were administered between 10:49 and 10:50 AM. On 6/02/26, the 1:00 PM medication was administered at 2:49 PM. Review of the medical record revealed no documentation the physician was notified regarding delay administration of medications on these dates and times. 8. Review of the medical record revealed resident #15 was readmitted to the facility on [DATE] with diagnoses including aphasia (language disorder), chronic obstructive pulmonary disease, type 2 diabetes, stroke, and heart failure. Review of resident #15's MAR for May and June 2026 revealed the following medications were scheduled for administration at 9:00 AM: Spironolactone 25 mg, Empagliflozin 10 mg, Symbicort 160-4.5 mcg/Act inhaler, Apixaban 5 mg, Toprol 12.5 mg, Sertraline 100 mg, Bupropion 150 mg, and Entresto 24-26 mg. Review of resident #15's Medication Admin Audit Report revealed the 9:00 AM medications were administered between 10:17 and 10:18 AM on 5/29/26, between 12:05 PM and 12:08 PM on 5/30/26, between 11:22 AM and 11:28 AM on 5/31/26, and at 10:04 AM on 6/02/26. Review of the medical record revealed no documentation the physician was notified regarding delayed administration of medications on these dates and times. 9. Review of the medical record revealed resident #16 was readmitted to the facility on [DATE] with diagnoses including transient ischemic attack (temporary blockage of blood flow to the brain), chronic obstructive pulmonary disease, dysphagia (trouble swallowing), and cognitive communication deficit. Review of resident #16's MAR for May and June 2026 revealed the following medications were scheduled for administration at 9:00 AM: Tamsulosin 0.4 mg, Furosemide 40 mg, Citalopram 20 mg, Clopidogrel 75 mg, Aspirin 81 mg, Losartan 50 mg, Potassium Chloride 10 mEq, Docusate Sodium 100 mg, Probiotic 250 mg, and Baclofen 10 mg, and at 12:00 PM: Hydrocodone-Acetaminophen 5-300 mg. Review of resident #16's Medication Admin Audit Report revealed the 9:00 AM medications were administered at 10:16 AM on 5/29/26, between 11:42 AM and 11:46 AM on 5/30/26, and between 10:54 and 10:55 AM on 5/31/26. The 12:00 PM medication was administered at 2:22 PM on 5/29/26, at 1:16 PM on 5/30/26, at 1:06 PM on 5/31/26, and at 2:50 PM on 6/02/26. Review of the medical record revealed no documentation the physician was notified regarding delayed administration of medications on these dates and times. 10. Review of the medical record revealed resident #17 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis (rapid breakdown of skeletal muscle), alcohol abuse, metabolic encephalopathy (brain dysfunction), cognitive communication deficit. Review of resident #17's MAR for May and June 2026 revealed the following medications were scheduled for administration at 9:00 AM: Naprosyn 500 mg and Omeprazole 40 mg, at 1:00 PM: Naprosyn 500 mg, and at 2:00 PM: Folic Acid 1 mg. Review of resident #17's Medication Admin Audit Report revealed the 9:00 AM medications were administered at 10:17 AM on 5/29/26, at 12:10 PM on 5/30/26, and at 11:12 AM on 5/31/26. The 1:00 PM medication was administered at 2:23 PM on 5/29/26 and at 2:50 PM on 6/02/26. Further review revealed the Naprosyn scheduled for 1:00 on 5/30/26 was administered concurrently with the 9:00 AM dose at 12:10 PM. Review of the medical record revealed no documentation the physician was notified regarding delay administration of medications on these dates and times. 11. Review of the medical record revealed resident #18 was readmitted to the facility on [DATE] with diagnoses including type 2 diabetes, multiple sclerosis, major depressive disorder, and history of falling. Review of resident #18's MAR for May and June 2026 revealed the following medications were scheduled for administration at 9:00 AM: Dalfampridine 10 mg, Metformin 500 mg, Dimethyl Fumarate 240 mg, Lyrica 75 mg, Jardiance 25 mg, Fluticasone 50 mcg/Act, Benadryl 50 mg, Escitalopram 5 mg, and Neuriva supplement, at 12:00 PM: Oxycodone-Acetaminophen 10-325 mg and Methocarbamol 750 mg, and at 1:00 PM: Benadryl 50 mg. Review of the Medication Admin Audit Report for resident #18 revealed the 9:00 AM medications were administered at 10:18 AM on 5/29/26, Neuriva given at 11:29 AM on 5/30/26, 9:00 AM medications administered between 11:15 and 11:18 AM on 5/31/26, and at 10:25 AM on 6/02/26. The 12:00 and 1:00 PM medications were administered at 2:23 PM on 5/29/26 and at 2:51 PM on 6/02/26. Review of the medical record revealed no documentation the physician was notified regarding delayed administration of medications on these dates and times. 12. Review of the medical record revealed resident #19 was readmitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, chronic obstructive pulmonary disease, dysphagia, heart failure, and malignant neoplasm of main bronchus. Review of resident #19's MAR for May and June 2026 revealed the following medications were scheduled for administration at 9:00 AM: Alogliptin 6.25 mg, Aspirin 81 mg, Furosemide 20 mg, Levetiracetam 1000 mg, and Potassium Chloride 10 mEq. Review of resident #19's Medication Admin Audit Report revealed the 9:00 AM medications were administered at 10:16 AM on 5/29/26, between 12:00 and 12:01 PM on 5/30/26, and at 10:52 AM on 5/31/26. Review of the medical record revealed no documentation the physician was notified regarding delayed administration of medications on these dates and times. On 6/04/26 at 4:46 PM, Regional Nurse Consultant (RNC) C reviewed Medication Admin Audit Reports for residents #1, #3, #5, #13, #14, #15, #16, #17, #18, and #19 and confirmed multiple medications were administered outside the facility's established administration time frame. She stated medications were expected to be administered within one hour before or one hour after the scheduled administration time. RNC C reviewed the medial records and confirmed there was no evidence the physicians had been notified regarding the repeated delayed medication administrations identified above. She stated nurses were expected to communicate with the physician and document notification when medications were administered outside the established administration window. Review of the facility's Medication Administration policy dated January 2026 revealed medications were to be administered as prescribed, in accordance with physician orders, manufacturers' specifications, and accepted nursing standards of practice. The policy further required routine medications to be administered according to the established medication administration schedule and required the individual administering the medication to document administration on the resident's MAR immediately following administration. The policy also required the medication carts to remain closed and locked when not under the direct supervision of the medication nurse. Review of the facility's Medication Administration - Controlled Substances policy dated January 2026 revealed the licensed nurse administering a controlled substance was required to immediately document removal of the medication on the accountability record, administer the medication and document administration on the resident's MAR. The policy further required a physical inventory of controlled substances to be completed and documented at each shift change.

Based on interview, and record review, the facility failed to maintain a complete and accurate medical record for one of one residents sampled for wound treatments, of a total sample of 19 residents, (#3).Findings:Medical record review revealed resident #3 was admitted to the facility on [DATE] with diagnoses that included colostomy, pressure ulcers to his left heel, right and left buttock and left hip.A colostomy is a surgical opening in the abdomen to allow stool to exit the body when it cannot pass through the rectum. It connect the large intestine to the outside of the body and stool is collected in a pouch worn on the outside, (retrieved on 6/17/26 from www.hopkinsmedicine.org).Review of current physician orders revealed resident #3 had physician orders for colostomy care every shift starting 6/18/25; wound care orders every day and night shift for right great thumb on 2/16/26, wound care every night shift for a left plantar callus dated 4/20/26, wound care every night shift for sacrum and right and left buttocks dated 4/30/26, and skin prep application every shift to the bilateral heels dated 4/23/26.Review of the Treatment Administration Record (TAR) for May 2026 revealed missing documentation for the right great thumb on day shift on May 9, May 10, May 14, May 18, and May 24.Review of the TAR for May 2026 revealed missing documentation for the right great thumb for evening shift on May 5, May 7, May 8, May 27, May 28, and May 29.Review of the TAR for May 2026 revealed missing documentation for the left plantar callous, on May 9, May 19, and May 27.Review of the TAR for May 2026 revealed missing documentation for resident #3's sacrum, on May 9, May 19, and May 27.Review of the TAR for May 2026 revealed missing documentation for resident #3's right buttock, on May 9, May 19, and May 27.Review of the TAR for May 2026 revealed missing documentation for resident #3's left buttock, on May 9, May 19, and May 27.Review of the TAR for May 2026 revealed missing documentation for the resident's left and right heel, for day shift on May 1, May 9, May 10, May 18, May and 24.Review of the TAR for May 2026 revealed missing documentation for the left and right heel, for evening/night shift on May 5, May 7, May 8, May 9, May 27, May 28 and May 29.Review of the TAR for May 2026 revealed resident #3's colostomy care was not documented a total of 13 times across all three shifts. Review of the TAR's legend, an entry of the number 2 meant the resident refused and an entry of the number 9 meant other/see nurse's notes. All the TARs' missing entries had no number to explain whether the treatment was completed for resident #3, or why.On 6/04/26 at 3:05 PM, the Regional Nurse Consultant (RNC) acknowledged the holes in resident #3's record after being informed by the survey team. The RNC said if there was a hole in the Medication Administration Record or the TAR, the medication or treatment was not given or not done. She said the expectation was for the nurse to write a progress note about the resident's refusal, what the resident's reason for refusal was, education related to the refusal given to the resident and documentation the physician was informed of the refusal.

Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee implemented, monitored, evaluated, and revised a Performance Improvement Plan (PIP) to address identified concerns related to narcotic accountability and diversion prevention. The facility failed to ensure corrective actions were sustained after identifying repeated narcotic management concerns, resulting in continued deficiencies related to narcotic accountability, documentation, and medication management practices.Findings: Cross Reference F755 Review of a report submitted to the Agency for Health Care Administration (AHCA) on 4/14/26 for alleged misappropriation of property revealed the facility identified 28 missing Oxycodone tablets pertaining to resident #1. Following completion of the investigation, the facility determined there was a discrepancy between the number of narcotic cards received by a nurse and the number documented on the narcotic accountability records, resulting in the potential for a one-card discrepancy. In a joint interview with the Interim Administrator and the Regional Nurse Consultant (RNC) C on 6/04/26 at 2:59 PM, RNC C stated the facility initiated a PIP on 4/16/26 after identifying concerns related to potential narcotic diversion. Review of the PIP titled Narcotic Management and Narcotic Diversion Prevention included education for the Director of Nursing (DON), Unit Managers (UM), and licensed nurses regarding narcotic management and diversion prevention. The PIP also included ongoing education related to key exchange process for licensed nurses. The PIP identified system changes including the implementation of a new narcotic accountability log at the beginning of each month and daily rounds by the DON or designee to verify narcotic control records were completed. The monitoring plan included random audits of narcotic control logs weekly for four weeks followed by monthly audits for three months. Audit results were to be reviewed during monthly QAPI meetings until substantial compliance was achieved. The RNC provided audits tools dated 4/19/26, 4/21/26, 4/23/26, 4/30/26, and 5/04/26. Review of the audit tools revealed seven medication cart observations were conducted throughout the facility; however, the audit forms did not identify the shifts during which the observations occurred. The audits evaluated completion of incoming and outgoing nurses' signatures, narcotics counts, verification of individuals narcotic cards, double locking of narcotics, documentation of narcotic additions and removals, identification of discrepancies, and follow-up by the DON. RNC C stated facility management also reviewed narcotic accountability and maintained management coverage in the facility 24 hours per day for approximately six weeks following the initial incident. Review of a second report submitted to AHCA on 5/11/26 for alleged misappropriation of property on 5/11/26 revealed concerns regarding documentation of a narcotic medication administered to resident #12. The narcotic accountability records documented administration of Dilaudid 4 milligrams at 2:00 AM on 5/11/26; however, the medication administration was not documented on the Medication Administration Record (MAR). Review revealed the medication was ordered for administration at 9:00 AM and 9:00 PM. Documentation reflected the 9:00 PM dose on 5/10/26 had already been administered, making the documented 2:00 AM administration inconsistent with the physician's order. On 6/04/26 at approximately 3:10 PM, RNC C stated the facility investigated the second incident and interviewed additional residents assigned to the nurse involved. She stated no additional concerns were identified during the investigation. RNC C further stated the facility was unable to determine whether the medication had been administered and reported the nurse to the Board of Nursing for concerns related to narcotic documentation practices. RN C stated no additional Ad Hoc QAPI meeting was conducted following the second narcotic-related incident. She explained no revisions to the PIP were made and no additional audits were implemented after the second incident occurred on 5/11/26. She further stated the audits conducted under the PIP occurred during daytime hours between 8:00 AM and 5:00 PM, and not on other timeframes to incorporate the evening or overnight shifts. RNC C further reviewed resident #12's May 2026 MAR and confirmed the 9:00 PM Dilaudid dose scheduled for 5/08/26 lacked documentation of administration. She stated this concern was not identified during the facility's investigation initiated on 5/11/26. Review of the attendance record for the 4/14/26 narcotic diversion prevention PIP revealed the Pharmacy Consultant was not listed as a participant. Review of the PIP documentation revealed no evidence the QAPI committee reviewed, revised, or expanded the PIP after the second reportable narcotic incident was identified on 5/11/26. During the course of the survey, additional concerns related to narcotic accountability and medication management practices were identified: *On 6/03/26, Licensed Practical Nurse (LPN) A failed to sign the Controlled Drug - Key Exchange Audit log after completing the beginning of shift narcotic count with the outgoing nurse. LPN A acknowledged she was required to sign the narcotic log following completion of the count. *On 6/03/26, LPN B failed to sign the Controlled Drug - Key Exchange Audit log after completing the beginning of shift narcotic count with the outgoing nurse. In addition, LPN B administered a narcotic medication to resident #11 at approximately 10:30 AM but had not documented removal of the medication on the Controlled Drug Record as of 11:55 AM. LPN B acknowledged she was required to document narcotic administration at the time the medication was removed and administered. *Review of the Controlled Drug - Key Exchange Audit log for Cart 2-A on Unit 2 revealed the 11:00 PM to 7:00 nurse signature was missing on 6/03/26 under the section Time keys given to oncoming nurse. *Review of the Controlled Drug - Key Exchange Audit log for Cart 2-B on Unit 2 revealed multiple missing signatures including the 11:00 PM to 7:00 AM shift on 6/01/26, the 3:00 to 11:00 PM shift on 6/02/26, and the 7:00 AM to 3:00 PM shift on 6/03/26 under the On-Coming Nurse Signature section. Additional missing signatures and date identified on a 11:00 PM to 7:00 AM shift in June, and the 3:00 to 11:00 PM shift on 6/02/26 in the section documenting transfer to the incoming nurses. *Review of the Controlled Drug - Key Exchange Audit log for Cart 3 on Unit 3 revealed multiple missing signatures. Missing signatures were identified for the 7:00 AM to 3:00 PM shift on 6/03/26 and 5/31/26, the 3:00 to 11:00 PM shift on 5/28/26, and the 11:00 PM to 7:00 AM shift on 5/15/26, 5/04/26 and 5/01/26. Review of the facility's Quality Assurance Performance Improvement (QAPI) Program policy, effective January 2025, revealed the QAPI Program was designed to use data driven indicators focused on resident care outcomes and quality of life. The policy documented the program would: 1) track and measure performance; 2) establish goals and thresholds for performance measurement; 3) identify and prioritize performance concerns and other issues; 4) systematically investigate and analyze underlying causes of systemic problems and adverse events; 5) develop and implement corrective actions and performance improvement activities; and 6) monitor and evaluate the effectiveness of corrective actions and performance improvement activities. The policy further indicated the Quality Assurance, Assessment, and Compliance Committee was responsible for implementing the QAPI Program through individual and committee assignments. The policy identified staffing concerns, including hiring staff, staff turnover, use of agency staff, and overtime, as quality indicators to be tracked and measured. Under the section titled Develop and Implement Corrective Actions, the policy described the Plan-Do-Study-Act process and specified once an issue was identified and prioritized, a specific corrective action plan would be developed, implemented, and monitored to measure its effectiveness. The policy further stated the Process Improvement team would continue an action if effective, modify the action if ineffective, or discontinue the action once the issue was resolved.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the policy and procedure, QAPI Facility Plan dated 10/19/25, revealed the QAPI committee monitored progress to ensure that interventions or actions were implemented and were effective in making and sustaining improvements.The facility had a deficiency cited at F842 for complete and accurate medical records during the previous recertification survey conducted 6/03/24 through 6/07/24. During this survey, the facility was found to again be in noncompliance with F842. As a result of this repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation.On 3/06/26 at 5:10 PM, the Administrator stated the facility had a QAPI committee that met monthly. He explained that the committee reviewed several areas which included information obtained during rounds on the floor, clinical metrics, care issues, grievances and issues raised by residents during concierge' rounds. He stated when an issue was identified, the QAPI committee would create a performance improvement plan to address the concern to bring it back into compliance. Concerns from the current survey were reviewed with the Administrator. He acknowledged the repeat citation from the previous recertification survey. He explained that multiple providers still documented on paper and felt that contributed to medical records not being complete and accurate.

Based on observation, interview, and record review, the facility failed to provide care and services to maintain the highest practicable physical well-being by failing to prevent a facility acquired pressure ulcer, implement revisions to the pressure ulcer care plan after a change in wound status, and failing to implement physician orders for existing pressure ulcers for 2 out of 2 residents reviewed for pressure ulcers, of a total sample of 44, (#7, & #107).Findings: 1.Resident #7 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, peg tube (feeding tube in stomach), type two diabetes, and brain damage from low oxygen. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed resident #7 was severely impaired cognitively, he was dependent for all activities of daily living (ADL) and had no pressure injury. The MDS assessment revealed the resident was dependent on the helper for all functional abilities and the resident did none of the effort to complete. Additionally, the MDS showed that resident #7 was at risk for developing pressure injuries. The assessment indicated treatments to prevent pressure injuries included the use of a pressure reducing device for bed and applications of ointments and medications other than to the feet. A review of resident #7's care plan dated 1/28/26, revealed the resident had an ADL self-care performance deficit and was documented as total dependent upon staff for all ADLs. Additionally, the care plan initiated on 1/28/26 with no revision date, reflected the resident was at risk for developing a wound with interventions for Certified Nursing Assistants (CNA)s to encourage/remind/assist the resident in turning and repositioning as needed or requested, and for staff to float the resident's heels. The review of the Treatment Administration Record (TAR) for resident #7 revealed missing documentation for turning and repositioning and skin observations every shift. The February 2026 TAR revealed turning and repositioning was not documented as performed a majority of nights on the nightshift, for a total of 19 out of 28 shifts for the month. For the evening shift on the February 2026 TAR, 12 out of 28 shifts were not documented as performed, and for the dayshift was 6 out of 28 shifts did not include documentation the task was performed. For the task of skin observation, the February 2026 TAR was missing documentation of performance during nightshift for 18 out of 28 shifts. For the evening shift 12 out of 28 shifts were missing documentation as performed, and for dayshift 6 out of 28 shifts, performance of skin observation was not documented as completed. Review of the weekly skin check for resident #7, Section 2, revealed documentation for 2/23/26 showed No New Areas of Skin Impairment, Care Plan Reviewed and Current, See Skin/Wound Note and section 3 documentation Coccyx. On 3/2/26, section 2 documentation revealed No New Area of Skin Impairment, Care Plan Reviewed and Current, and on section 3, Right Buttock - pressure and Left Buttock – pressure. Review of resident #7's nursing progress notes dated 2/17/26 revealed new skin issues that were acquired in-house. The note indicated skin issues were a stage three pressure ulcer on the left side of buttock, stage three left upper buttock, stage two sacrum, and stage two right side buttock. Stage II pressure ulcers present as a shallow open ulcer with a red-pink wound bed without dead tissue (slough); stage III pressure ulcers are full thickness with possible subcutaneous fat visible, they may have dead tissue, undermining, and tunneling depending on the area of the wound. Stage IV pressure ulcers are full thickness tissue loss with exposed bone, tendon or muscles, and often include undermining and tunneling, (retrieved on 3/19/26 from www.in.gov/health). Physician orders dated 2/24/26 for treatment reflected, Treatment as follows: Sacrum – Cleanse wound with normal saline/wound cleanser, pat dry. Apply calcium alginate to wound bed and cover with dry dressing daily and as needed. Resident #7's TAR for wound care included, Sacrum – Cleanse wound with normal saline/wound cleanser, pat dry. Apply calcium alginate to wound bed and cover with dry dressing daily and as needed. There was no documentation of the treatment having been performed from 2/24/26 through 2/28/26 nor on 3/04/26. On 3/02/26 at 11:05 AM, resident #7 was observed in bed lying flat with the head of bed slightly elevated. His was mouth and lips were dry. The resident was dressed in a hospital gown; skid free socks and his heels were resting on the mattress. On 3/02/26 at 1:25 PM, resident #7 was observed in same position. His mouth and lips remained dry. On 3/03/26 at 9:20 AM, resident #7 was observed in bed lying flat, the head of bed slightly elevated, his eyes were closed. The resident was dressed in a hospital gown; skid free socks and his heels were resting on the mattress. On 3/03/26 at 11:10 AM, resident #7 remained in the same position. The bed sheet had fallen off to the side of the bed exposing the resident wearing only a disposable brief. On 3/03/26 at 11:20 AM, CNA N explained she tried to get residents who needed less assistance with ADLs finished first in the morning. She stated they were short staffed on many days, and it took longer to get care done. She stated she asked the nurse for help, but conveyed they were short staffed as well and often couldn't help. CNA N stated resident #7 needed to be repositioned every two hours but said she had not been in resident #7's room yet. She stated that she looked at the plan of care and documents when she had time and they had gone into the resident's room at shift change. On 3/03/26 at 2:40 PM, Resident #7 was observed in bed lying flat, head of bed slightly elevated, eyes closed. The resident was dressed in a hospital gown, skid free socks and heels resting on mattress. Two pillows on floor next to bed. On 3/04/26 at 9:00 AM, resident #7 was in bed lying flat, with the head of bed slightly elevated, and his eyes open. His wife was at bedside. Resident #7's wife stated she felt her husband did not receive good care and was on a waiting list for another facility. She stated her husband did not have a pressure wound when he came first came here and now, he does. She stated that one day her husband's bedsheets were full of brown stool all the way up to his shoulders and said she knew it had been there for a while because some of it was dried. Resident #7's wife stated she was a CNA for more than 30 years and felt the only care her husband received at the facility was from her. She stated, no one turns him but me and I can't be here all the time. On 3/04/26 at 9:11 AM, the 100 UM stated that resident #7 had stage two and three pressure wounds. She stated she completed wound care, described, staged and documents the wounds. The UM explained she did not receive training at the facility for staging wounds and only had what she learned in nursing school. She stated when she first came to the facility, she was told if it was an existing wound and it opened; it was a stage two or three. The UM expressed skin observations were done each shift and verified resident #7 should be repositioned every two hours. She said it was the CNA's responsibility. On 3/04/26 at 9:20 AM, CNA C stated she assisted the nurses with wound care when they asked. She stated she tried to always check on the residents if they were not mobile. The aide stated she got busy and sometimes can't get in to check on everyone. The CNA said she let the nurses know if she couldn't do it but said they were busy as well. CNA C confirmed it was the CNA's responsibility to reposition residents. On 3/05/26 at 10:20 AM, resident #7 was again lying flat with head of bed slightly elevated. There were pillows on the floor next to his bed. His sheet was off exposing his briefs. The resident was dressed in a hospital gown; skid free socks and his heels were resting on the mattress. On 3/05/26 at 10:25 AM, the 200 UM stated she became aware of resident #7's pressure wound from a CNA. She explained she evaluated and took pictures of the wound. She said she did not have education on wound staging but had known how to do it from experience. The UM expressed, they met daily to discuss wounds, and the Director of Nursing (DON), MDS Coordinator, Social Worker, and UMs met twice a week. She stated that she looked at the care plan, treatment record, and documents in the computer. The 200 UM related she did not know the care plan for resident #7 did not have any revisions after the wound was discovered. She stated that care plan revisions were the MDS coordinators' responsibility. On 3/05/26 at 2:45 PM, resident #7 was in bed on his right side with pillows supporting his back. The head of bed was slightly elevated and his eyes were closed. Resident #7's wound was observed with Registered Nurse (RN) A. The resident's brief was removed by RN A to reveal no dressing was present covering the wound. RN A confirmed a dressing should have been present. RN A stated, the wound was looking much better and that it was a stage two. He stated the resident's pressure wounds should be considered one wound sacral wound. The nurse explained they took pictures of the wounds every Tuesday, but something was wrong with their system, so the pictures were not in there. On 3/05/26 at 3:00 PM, the MDS coordinator confirmed she was responsible for updating care plans including for wounds. She stated nurses could update the plans, but it was ultimately her responsibility. She stated the team met weekly and reviewed residents. She said he was familiar with resident #7 and confirmed his care plan needed to be revised with the most current information. She stated, I don't always have a laptop to update in meetings. 2. Review of resident #107's medical record revealed he was admitted to the facility on [DATE] with diagnoses including sepsis, necrotizing fasciitis, pressure ulcer of right buttocks stage 4, and paraplegia (partial paralysis) and polyneuropathy (nerve pain). Review of hospital paperwork prior to admission to the facility revealed resident #107 was admitted to the hospital with a worsening decubitus ulcer which resulted in sepsis. While at the hospital, the resident had a Computed Tomography (CT) scan that showed a right gluteal wound with fistula (abnormal passage between two parts of the body or organs) track which had a concern for necrotizing fasciitis. According to the Center for Disease Control (CDC), necrotizing fasciitis is a serious bacterial infection which can develop quickly into a life-threatening emergency including sepsis, organ failure, limb loss, or even death. Recent data reveals that even with treatment, up to 1 in 5 people die from this infection (retrieved from www.cdc.gov on 3/06/26). Review of the admission Minimum Data Set assessment with Assessment Reference Date (ARD) of 2/22/26 revealed resident #107 had one Stage 4 pressure ulcer and one unstageable pressure ulcer due to a non-removable dressing or device. Review of hospital discharge paperwork revealed orders for negative pressure wound therapy which indicated the pump settings as 125 millimeters of mercury (mmHg) continuous to the stage 4 pressure ulcer to the right glute. The wound vacuum was to be changed three times weekly and to be monitored for wound healing and infection. Review of resident #107's physician orders revealed a treatment order to change the wound vacuum three times a week on Monday, Wednesdays and Fridays with a start date of 2/21/26. The Treatment Administration Record (TAR) was reviewed for February, and it contained no documentation of the wound vacuum being changed from the date of admission on [DATE] until 9 days later on 2/25/26. Resident #107's admission assessment dated [DATE] revealed under the skin integrity section, scabs to the resident's 2nd, 3rd and 4th toes on bilateral feet, scattered sores to his bilateral lower extremities, a surgical incision to his right buttocks and a pressure ulcer to his sacrum. Review of resident #107's weekly skin checks revealed: - On 2/17/26 at 6:15 AM, documentation of no new areas of skin impairment. In the section underneath titled 'location of new skin impairment,' listed pressure injuries to the left buttocks, coccyx, right and left rear thigh and right front thigh. These location did not have staging or measurements documented. - On 2/18/26 at 6:46 AM, documentation of no new areas of skin impairment. In the section underneath titled 'location of new skin impairment,' indicated pressure injuries to the right and left buttocks, sacrum, and right and left rear thigh. None of the locations had staging or measurements documented. - On 2/18/26 at 6:53 PM, documentation of no new areas of skin impairment. In the section underneath titled 'location of new skin impairment,' listed pressure injury of a stage 3 to left buttocks, stage 4 to coccyx, and stage 3 to right and left rear thigh. The evaluation also listed stage 3 bruising to the right front thigh. None of the locations had measurements documented. - On 2/19/26 at 12:54 AM, documentation of no new areas of skin impairment. In the section underneath titled 'location of new skin impairment,' listed pressure injury of a stage 2 to left buttocks, stage 4 to sacrum, a stage 2 to right rear thigh and stage 2 to right buttocks. None of the locations had measurements documented. - On 2/19/26 at 10:43 PM, documentation of no new areas of skin impairment. In the section underneath titled 'location of new skin impairment,' listed pressure injury of a stage 3 to left buttocks, stage 4 to coccyx, a stage 3 to right rear thigh and a stage 3 to the right buttocks. None of the locations had measurements documented. - On 2/25/26 at 7:08 PM, documentation of no new areas of skin impairment. In the section underneath titled 'location of new skin impairment,' listed right gluteal fold with no documentation of the type of injury due to resident refusal of skin evaluation. On 3/05/26 the Director of Nursing (DON) acknowledged the weekly skin assessments were not consistent with the locations, descriptions and staging of the skin issues for resident #107. Review of the skin issue evaluation dated 2/18/26 revealed a new skin issue of a pressure ulcer/injury to the right gluteal fold which was present on admission. Review of the skin issue evaluation dated 2/25/26 revealed: - An evaluation of right gluteal fold pressure ulcer/injury which was present on admission. This skin issue was documented as receiving negative pressure wound therapy. - A new skin issue of the right lateral thigh abrasion documented as a new wound present on admission. - A new skin issue of the left lateral thigh abrasion documented as a new wound present on admission. - A new skin issue of a pressure ulcer/injury to the sacrum documented as a new wound present on admission. - A new skin issue of a pressure ulcer/ injury to the left heel documented as a new wound present on admission. - Review of the section titled 'current number of unhealed pressure ulcer/injuries at each stage' revealed documentation of 0 for stages 1 to 4 and 0 for number present on admission. Under the section 'does this resident have one or more unhealed pressure ulcers/injuries' the box 'yes' was selected. On 3/05/26 at 2:45 PM, the DON acknowledged there was no documentation of a left heel wound nor left and right lateral abrasions before 2/25/26 even though they were listed in the evaluation as present on admission. She stated her expectation was for a brief documentation of all skin issues to be completed in the admission assessment so all issues could be monitored and treatments ordered as needed. Review of TAR revealed treatment orders with a start date of 2/25/26 for: - A treatment to the left inner thigh which had no documentation as being performed on 2/26/26 - A treatment to the right inner thigh which had no documentation as being performed on 2/26/26 and 2/27/26. - A treatment order to the sacrum which had no documentation as being performed on 2/26/26 and 2/27/26. On 3/05/26 at 2:45 PM, the DON acknowledged the lack of documentation for the treatments having been performed. She stated her expectation was for nurses to follow the physician orders for treatments and to document directly after performing the treatments. She explained if the resident was unavailable or refused, then that should be reflected in the resident's medical record. The DON confirmed there were no treatment orders for the sacrum and the left and right inner thigh before 2/25/26. The DON expressed if the resident was admitted without a treatment order or a new skin issue appeared, the nurse was responsible to notify the physician and receive a treatment order. Review of the facility's policy titled, Physician Orders effective February 2026, revealed at the time of admission, the facility would have physician order for the immediate care of the resident. The facility policy titled, Wound Prevention and Treatment Overview effective October 2021, indicated residents with ulcers would receive continued preventative interventions and necessary treatment and services to promote healing.

Based on observation, interview, and record review, the facility failed to ensure frying pans, refrigerated foods, and spices were stored under clean and sanitary conditions, dry food was stored at the appropriate temperature; prepare, distribute and serve food in a manner to prevent food borne illness, by failing to maintain potentially hazardous pureed and regular foods at the correct hot holding temperature for four residents on a puree diet, and 57 residents on regular house diet, of a total population of 93 residents.Findings:On 3/02/26 at 10:25 AM, the initial kitchen tour was conducted with the Certified Dietary Manager (CDM). In the walk-in refrigerator there was visible food debris and residue along the baseboards and corners. The CDM stated there was a weekly deep clean schedule but could not say when the last time a deep clean was done. In the food preparation area, two spice bins had a visibly sticky residue and debris in the bottom of the container. (photo evidence obtained) The CDM acknowledged the spice bins and stated the containers were expected to be cleaned three days per week. The CDM could not say when was the last time they were cleaned.In the dry storage room, the air conditioning unit had the cover off and the top of the unit had debris and rust visible. The temperature in the room was 76 degrees Fahrenheit (F). (photo evidence obtained) The CDM stated she wasn't sure how long the air conditioning unit had been broken. She stated she notified maintenance but could not recall when and was not able to produce a work order for the repair request. Additionally, there was a bin with granola bars past their expiration date. (photo evidence obtained) In the food preparation area, there was a dietary aide working with a beard covering under their chin, not covering the full beard. The CDM acknowledged the aide's beard needed to be fully covered. On 3/04/26 at 11:35 AM, the facility menu revealed Sloppy [NAME] on a Bun as the lunch main entree on 3/04/26. The lunch tray line was observed. The cook took the hot holding temperatures of the food on the steam table with a digital stem bayonet style instant read thermometer. The cook stated she did not know the hot holding temperature range of potentially hazardous foods but was able to state the hot holding temperature needed to be at least 135 degrees F or greater. During cleaning of the thermometer, the cook dropped a corner of the alcohol wipe into the mashed potatoes. She reached into the mashed potatoes with ungloved fingers to remove the piece of the wipe. The CDM stated gloves were not a requirement for checking temperatures and her hands were not close to the food. The CDM confirmed the cook should have used gloves to remove the corner of the alcohol wipe.Potentially hazardous foods on the steam table were held below the required holding temperature of 135 degrees F or greater. Observed temperatures included: sloppy joe was 120 degrees F, pureed cabbage was 85 degrees F, mashed potatoes were 132 degrees F. Other observations made on 3/02/26 and 3/04/26 included rust on wheels of equipment in the food preparation area, a shelf with three frying pans (one-12 inch, two- 8 inch) lying with handles down had debris and food particles next to the three pans. The Registered Dietitian was in the food prep area with hair net not covering the front of hair, and a male dietary aide was handling plates with food without gloves.

Based on observation, interview, and record review, the facility failed to honor resident rights in regard to self-determination for 1 of 7 residents reviewed for reviewed for choices, of total sample of 44 residents, (#63). Findings: On 3/02/26 at 10:14 AM, resident #63 said she was unhappy at the facility, didn't feel like she belonged, and had requested a transfer. She expressed she preferred to be outside as much as possible, and this facility only allowed residents to exit the building if they smoked. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed resident #63 had a Brief Interview for Mental Status of 13/15, indicating she was mostly cognitively intact, was dependent on staff for all activities of daily living and was unable to move from the waist down. The assessment indicated she had a history of traumatic brain injury, was able to use the internet, hold a conversation, and recall events. Review of resident #63's medical record indicated she sought assistance on 12/05/25 from the Social Services Director, stated a desire to move to a skilled nursing facility in a nearby city, to be closer to family. Resident #63 had a care plan dated 11/19/25 with a goal that the resident wished to adjust to long term care placement. The care plan had an intervention of referral to a local contact agency as needed. On 3/03/26 at 3:42 PM, the Social Services Director (SSD) expressed she sent several referrals for the resident. She stated that resident #63 didn't get accepted to a facility in either of the nearby cities she desired. The SSD said the resident had been to the hospital and wasn't approved to move back to her previous home. On 3/04/26 at 1:38 PM, the Administrator was unable to provide any copies of referrals for resident #63. There were no notes in the resident's medical record that indicated attempts had been made to find alternate placement for resident #63 per her request. On 3/04/26 the Social Services Director (SSD) stated there were no long-term beds available at one facility nearby and had faxed referrals to other facilities nearby. She did not explain why there were no documented referrals for alternative placement for resident #63 until that day. On 3/05/26 at 10:42 AM, in a joint interview with the Director of Nursing (DON) and the Administrator, the DON stated she and the Social Worker were supposed to meet with residents who preferred to move from the facility to assess their needs in a care meeting. The Administrator had no comment. The facility was asked for a policy for helping residents to transfer, but a Discharge Documentation Policy was provided instead.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 out of 2 residents reviewed for care plans, of a total sample of 44 residents, (#99). Findings: Resident #99 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, morbid obesity, and muscle wasting. The hospital transfer form indicated the resident was blind. On 3/02/26 at 1:11 PM, resident #99 remarked she was mostly blind, and needed cataract surgery. She explained the facility had her sign financial paperwork without explaining it to her. The Minimum Data Set (MDS) assessment dated [DATE] revealed resident #99 had severely impaired vision but was cognitively intact and required moderate assistance from staff. Review of resident #99's care plan revealed no interventions related to her blindness or impaired vision. Review of the Electronic Medical Record (EMR) revealed a nurse progress note dated 2/08/26 which indicated resident #99 was legally blind. The medical record revealed several notes from the Social Services Director (SSD) that indicated she was aware resident #99 was unable to see. In a note dated 1/19/26 the SSD documented the resident's cataract surgery needed to be rescheduled. Another SSD note from 2/27/26 documented the resident requested help in getting access to her funds. On 3/03/26 at 3:42 PM, the SSD stated if a resident had trouble seeing, it should be noted in their care plan. She stated the resident should be seen by an eye doctor. The SSD explained if a resident who had vision problems needed to sign paperwork, she would call the family to explain the paperwork. The SSD did not know if or when the cataract appointment had been rescheduled, and with the assistance of the Director of Nursing (DON), they could not find any information on the surgery. On 3/04/26 at 10:05 AM, the Business Office Manager explained they transferred resident #99's money from her previous facility to this one, and she signed her own paperwork. The manager said the SSD obtained her signature; and confirmed they did not call the resident's family to explain the paperwork she was signing. On 3/04/26 at 3:00 PM, the MDS Coordinator explained care plans were the responsibility of the SSD, MDS, and other nursing staff combined. She confirmed resident #99 did not have a care plan for her visual impairment, and said if a resident was blind, it should be in their care plan. On 3/05/26 at 10:42 AM, the DON stated residents who were blind or visually impaired should have that reflected in their care plan. The facility's Care Plan Policy and Procedure - Interdisciplinary Plan of Care from Interim to Meeting dated February 2024 specified, The facility shall assess and address care issues that are relevant to individual residents, to include. monitoring resident condition, and responding with appropriate interventions. The document included care plan development should involve the resident and the resident's representative as appropriate.

Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan to include wound management for 1 of 2 residents reviewed for non-pressure related skin conditions, of a total sample of 44 residents, (#36).Findings:Review of the medical record revealed resident #36, an [AGE] year-old female was admitted to the facility on [DATE] and re-admitted from an acute care hospital on 9/19/25. The resident's diagnoses included type 2 diabetes mellitus, adult failure to thrive, malnutrition, heart disease, muscle wasting and atrophy of multiple sites, and left lateral forehead squamous cell carcinoma (skin cancer).The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date of 12/03/25 noted resident #1 scored 13 out of 15 on the Brief Interview for Mental Status that indicated intact cognition. The skin and wound assessment documented there were no surgical wounds or care during the look-back period.On 3/03/26 at 9:05 AM, resident #36 was observed in her room eating breakfast while lying in bed. There was one small and one large undated bordered adhesive gauze dressing with peeling edges on her forehead and scalp. The resident said she had skin cancer lesions removed at the Dermatologist's office approximately one week earlier where the dressings were applied and facility nurses had not looked at them since then.Review of the active physician's orders and Medication/Treatment Administration Records (MARs/TARs) did not include monitoring of resident #36's head wounds.The Care Plan Report did not include any wound monitoring/care.A nurse progress note dated 2/25/26 documented resident #1 had a head wound dressing after an outpatient medical appointment on 2/24/26.On 3/05/26 at 2:54 PM in an interview with the MDS Coordinator, the nurse explained she was primarily responsible for updating and revising comprehensive care plans. She said the Interdisciplinary Team (IDT) met weekly and the clinical team met every morning to discuss residents' treatment plan revisions where updates were entered. She checked resident #36's medical record and confirmed the care plan was not revised to include the head wounds. The nurse relayed the plan of care should have been updated to include the wound care and monitoring and she didn't see any orders in the record, so she wouldn't have been alerted to update it.On 3/05/26 at 1:46 PM, the Director of Nursing (DON) explained the MDS Coordinator was primarily responsible for updating wound care plans. She said updates were discussed during morning and weekly meetings with the IDT and resident #36's wounds should have been added to the comprehensive care plan after her physician's visit at the next clinical meeting.Review of the facility's standards and guidelines dated February 2024 and titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting outlined that care plans were regularly updated by the IDT which was necessary to plan care and meet the resident's medical and nursing needs.

Based on observation, interview, and record review, the facility failed to provide appropriate care consistent with professional standards of practice, and treatment to promote healing of other skin conditions for 1 of 4 residents reviewed for skin conditions, of a total sample of 44 residents, (#107).Findings:Resident #27 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, flaccid hemiplegia (one-sided paralysis, where muscles are weak), affecting the dominant right side and bladder dysfunction. Review of the Annual Minimum Data Set (MDS) assessment with reference date of 11/22/25 revealed the resident was cognitively intact. The assessment revealed resident #27 was at risk for developing pressure ulcers with treatments that included the application of ointments or medications other than to the feet. Review of physician orders dated 7/30/25 instructed nurses to apply Bacitracin 500 UNIT/GRAM (GM) (Bacitracin (Topical) to buttock excoriation topically every shift for excoriation. The order specified that over the counter medication provided by facility, and instructed pharmacy to not send. A review of resident #27's care plan revealed that the resident had activities of daily living (ADL) self-care performance deficit and required the assistance of one person for bathing. Resident #27 had a care plan for risk for developing wounds related to impaired mobility, bowel and bladder incontinence, fragile skin and right sided hemiplegia. Interventions instructed Certified Nursing Assistants (CNAs) to observe for any new areas of skin breakdown including redness, blisters, discoloration, and report to the nurse. On 3/02/26 at 10:50 AM, resident # 27 stated she believed there was a wound on her right thigh that no one had looked at. She expressed she was afraid the wound might be getting worse. On 3/03/26 and 3/04/26 resident #27 said no nurse had followed up or assessed her skin on the right thigh. She said, not as yet. A review of the weekly skin assessments for February 2026 revealed on 2/06/26 and 2/12/26 for Section 2, No New Skin Impairment was checked. On 2/26/26 there was No New Skin Impairment checked however in section 3, Location of new Skin Impairment, it listed redness to buttock. A review of the Treatment Administration Record (TAR) revealed the Wing 3 Unit Manager (UM) applied the prescribed treatment of Bacitracin ointment on the day and night shift on 3/02/26 and on 3/04/26 on the day shift. The TAR also revealed that Registered Nurse (RN) A applied the prescribed treatment of Bacitracin ointment on the evening shift on 3/02/26 and 3/03/26. The TAR had missing signatures for the day shift application of the prescribed treatment of Bacitracin ointment on 3/01/26 and 3/03/26 and for the evening shift on 3/04/26. On 3/05/25 at 11:07 AM, the assigned CNA E said she often told the nurses of any new skin issue and was aware of the resident # 27's skin breakdown. She could not remember which nurse she informed that resident #27's skin looked worse. With the resident's permission to observe, CNA E propped the resident on her side so her buttocks and upper right thigh could be viewed. The sacral area was covered in a thick pink cream paste, however, the right buttock had bright red drainage, and the right upper thigh had a large, bright, reddened area. CNA E said she often applied the Desitin cream to the buttocks but did not put anything on the right thigh area because it was new and seemed to be getting bigger. Resident #27 said the area was not painful but was very itchy. On 3/05/26 at 11:12 AM, assigned Licensed Practical Nurse (LPN) F explained the treatment orders as she accessed them in the computer. LPN f said it showed an order for Bacitracin to be applied every shift. She explained she had not provided the treatment as yet but said it would be in the treatment cart. Together with the Wing 3 UM, LPN F opened the treatment cart but could not find the Bacitracin she said would be in a tube with the resident's name labelled on it. LPN F went into the stockroom but could not find any Bacitracin. She said she did not know if the medication came from the pharmacy. On 3/05/26 at 11:25 AM, the Wing 3 UM said resident #27 was not on the wound list and did not have any wounds. She explained she did not observe the resident's skin this week on Monday, Tuesday, nor Wednesday because resident #27 had no issues. The UM said she had to check if she signed the TAR in error in regard to her documentation of a treatment applied to resident #27, because the resident did not have skin issues that she was aware of. The Wing 3 UM then excused herself and left. On 3/05/26 at 1:47 PM, the UM explained she had not been paying attention and just signed off the TAR but did not provide any treatment. On 3/05/26 at 1:58 PM, the (DON) acknowledged the skin impairments on resident # 27's sacral area and right thigh after it was brought to her attention. She said that none of the CNAs nor nurses had mentioned any new or worsening areas and she had not been aware previously. She said she could not understand why there was no Bacitracin in the carts nor stock room because they came in small packets. On 3/05/26 at 4:14 PM, RN A said he was not aware of any new or worsening skin issue for resident #27 and he applied Bacitracin to her sacral area but there was not anything on her right thigh. On 3/05/26 at 3:45 PM, the DON said she spoke to the Wing 3 UM and said it was not best practice for the nurse to check off the creams for treatment before completing the task, but she missed the opportunity to address the issue. The DON acknowledged it was not best practice for nurses to sign off something they did not do. The DON said she could not answer why the TAR was left blank with no signature of application of the treatment. The facility's policy on wound prevention and treatment overview effective October 2021, indicated in the facility recognized the most vigilant nursing care may not prevent the development &/or worsening of ulcers in high-risk categories. In those cases, efforts would be directed at managing risk factors and providing therapeutic intervention and providing treatment. In their Procedure section it described the facility reviewed skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition.

Based on observation, interview, and record review, the facility failed to monitor supplemental oxygen therapy for 1 of 2 residents reviewed for respiratory care, of a total sample of 44 residents, (#1).Findings:Review of the medical record revealed resident #1, a [AGE] year-old male was admitted to the facility on [DATE] and re-admitted from an acute care hospital on 1/19/26. The resident's active diagnoses included respiratory failure, pneumonia, Chronic Obstructive Pulmonary Disease (COPD), sepsis, presence of gastrostomy (feeding tube), atrial fibrillation (abnormal heart rhythm), and type 2 diabetes mellitus.The most recent Minimum Data Set Quarterly Assessment with an Assessment Reference Date of 1/26/26 revealed resident #1 scored 10 out of 15 on the Brief Interview for Mental Status that indicated moderate cognitive impairment. Active diagnoses included pneumonia, Multidrug-Resistant Organism (MDRO), dementia, traumatic brain injury, asthma, respiratory failure with hypoxia (tissue oxygen deficiency), and sepsis (major infection causing organ damage). The assessment noted oxygen therapy was administered while a resident during the look-back period.On 3/03/26 at 9:27 AM and 3/03/26 at 3:21 PM, resident #1 was observed lying in bed in his room with a nasal cannula (two-pronged oxygen delivery device) delivering supplemental oxygen at a flow rate of two liters per minute (LPM). On 3/03/26 at 3:33 PM, in a joint observation with Registered Nurse (RN) A, the nurse verified resident #1 was receiving continuous supplemental oxygen at two LPM.Review of the Medication Administration Record's (MARs) active physician's medication nebulization inhalation orders included Aformoterol Tartrate 15 Micrograms (Mcg) twice daily, Budesonide 0.5 Milligrams (MG) twice daily, and Ipratropium-Albuterol 0.5-2.5 MG every four hours as needed for COPD with acute exacerbation. There were no physician's orders for supplemental oxygen, and no directions to monitor the resident's blood oxygen saturations. Review of the Care Plan Report noted a care plan was initiated on 1/28/19 and revised on 12/05/23 for oxygen therapy related to ineffective gas exchange, shortness of breath, and COPD. The interventions included continuous supplemental oxygen at a flow rate of 3 LPM, nurse monitoring/physician reporting of changes in or development of breathing difficulty and respiratory status.On 3/03/26 at 3:33 PM, RN A said nurses were expected to monitor supplemental oxygen per physician's orders which was documented in the MAR. He said he did not recall checking resident #1's oxygen status during that day's 7:00 AM to 3:00 PM shift. The RN explained it was important to monitor and check blood oxygen saturation levels when receiving supplemental oxygen therapy to ensure effective treatment and evaluate whether the physician needed to be notified. The nurse checked the resident's medical record and stated there were no physician's orders for oxygen and without an order, nurses wouldn't accurately know what flow rate of oxygen to administer.Review of the previous 90 days oxygen saturation record noted that resident #1's blood oxygen saturations were not checked by nurses for more than six weeks, with the last recorded measurement on 1/27/26.Oxygen saturation is a key metric in understanding how well oxygen is carried in the blood. Oxygen-saturated hemoglobin (red blood cell protein) is crucial for assessing how well the body is oxygenated, (retrieved from namdrc.org on 3/06/26).On 3/03/26 at 3:40 PM, the Director of Nursing (DON) explained nurses were expected to enter orders upon re-admission and when revised thereafter. She said physician's orders were reviewed every morning and checked for accuracy by the clinical team. She checked resident #1's medical record and was unable to locate supplemental oxygen orders or monitoring. She stated it was very important to have accurate orders and nurse monitoring, otherwise it wasn't known what the resident should be receiving. She conveyed the orders must have been missed on re-admission and stated the resident's oxygen orders were revised several times while in the facility. Review of the facility's standards and guidelines dated August 2025, and titled Oxygen Therapy outlined that oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. The procedures included verification of physician's orders and documentation in the resident's medical record.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 2 residents reviewed for non-pressure related skin conditions, of a total sample of 44 residents, (#36).Findings:Review of the medical record revealed resident #36, an [AGE] year-old female was admitted to the facility on [DATE] and re-admitted from an acute care hospital on 9/19/25. The resident's diagnoses included type 2 diabetes mellitus, adult failure to thrive, malnutrition, heart disease, muscle wasting and atrophy of multiple sites, and left lateral forehead squamous cell carcinoma (skin cancer).The most recent Minimum Data Set Quarterly Assessment with an Assessment Reference Date of 12/03/25 noted resident #1 scored 13 out of 15 on the Brief Interview for Mental Status that indicated intact cognition. The skin and wound assessment documented there were no surgical wounds or care during the look-back period.On 3/03/26 at 9:05 AM, resident #36 was observed in her room eating breakfast while lying in bed. There was one small and one large undated bordered gauze dressing with peeling edges on her forehead and scalp. The resident said she had skin cancer lesions removed at her Dermatologist's office approximately one week earlier where the dressings were applied and facility nurses had not looked at them since then.Review of the active physician's orders and Medication/Treatment Administration Records (MARs/TARs) did not include monitoring of resident #36's head wounds.The Care Plan Report did not include any wound monitoring/care.A nurse progress note dated 2/25/26 documented resident #1 had a head wound dressing after an outpatient medical appointment on 2/24/26.Resident #36's electronic and paper medical records did not include physician's notes or instructions/wound care for an outpatient appointment/surgical procedure done on 1/24/26.On 3/04/26 at 2:20 PM, the Regional Nurse Consultant said she was unable to locate the most recent Dermatology physician's progress notes in resident #36's medical records, so she requested them from the doctor's office.On 3/05/26 at 2:25 PM, Licensed Practical Nurse F said she received information that morning in nurse-nurse report that resident #36 had head wounds and stated the dressings were, to stay put. The nurse explained wound monitoring was documented on the MAR/TAR. She checked the medical record and said there was no directions about the wound and stated, it should be in the MAR to sign off.On 3/05/26/26 at approximately 2:15 PM, resident #36 was observed awake lying in bed in her room. She pointed to her head wounds and said after her Dermatologist appointment the previous week, nurses had changed the smaller dressing the previous day, but not the larger one. There was one small and one large undated bordered gauze dressing with peeling edges on her forehead and scalp.On 3/05/26 at 12:55 PM, the Regional Nurse Consultant explained she was still trying to get resident ##36's recent dermatology appointment records and confirmed the facility should have the post appointment documents in order for a complete medical record. She stated, we should have them.On 3/05/26 at 1:46 PM, the Director of Nursing explained she expected nurses to update orders and all outpatient physician records in the TAR with orders from the primary provider. She said, even if we weren't supposed to touch it, nurses should verify that, note it in the TAR to monitor for signs of complications. She stated outpatient records were expected to be up to date and accessible in electronic and hard charts to ensure up to date access of clinical information. The DON stated, I'm not sure what happened to the records.Review of the facility's standards and guidelines titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting dated February 2024 outlined that resident care records included dated new, revised, or discontinued problems.

Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a homelike environment for residents on 2 of 3 units, (100 unit and 200 unit).Findings: During an initial tour of the facility on 12/29/25 at 9:38 AM, it was observed that the wall paint over the Packaged Terminal Air Conditioner (PTAC) at the entrance to the 100-unit was bubbled and chipped; the sheetrock was broken off and the baseboard was missing on an area of the wall next to the sink in room [ROOM NUMBER]; a hole in the wall outside the door to room [ROOM NUMBER] was covered by the baseboard; the wall was repaired around the PTAC in room [ROOM NUMBER] but was not painted to match the surrounding area; ceramic tile was off the wall behind the toilet and missing from the top of the shower stall in room [ROOM NUMBER]; the paint on the wall next to the window in room [ROOM NUMBER] was bubbled and peeling; the wall area close to the baseboard next to the window in room [ROOM NUMBER] had holes and peeling paint; the baseboard was off the wall and lying on the floor next to the window in room [ROOM NUMBER]; and the sheetrock was broken off and the baseboard was missing on an area of the wall next to the sink in room [ROOM NUMBER] and the surface of the sink base was bubbled. On 12/29/25 at 12:40 PM, the Maintenance Director stated room rounds were conducted daily to identify any maintenance issues. He explained staff were also able to communicate any broken items verbally or could use the electronic reporting system through the computer. The Maintenance Director stated he had some projects scheduled for the next week and would be doing some patch projects. During a tour of the facility with the Administrator and Maintenance Director on 12/29/25 at 12:45 PM, the Maintenance Director and Administrator took note of the identified areas. The Maintenance Director stated some of the identified items were on the project list but could not verify how long they had been on the list waiting to be repaired. The Administrator acknowledged repairs were needed in order to maintain a homelike environment for the residents. The facility's policy and procedure for Maintenance and Repair: To Prevent Spread of Infection effective October 2021 indicated the facility's Maintenance Department would replace or repair damaged structural surfaces (i.e., countertops, sinks, floors, or tiles) as needed.

Based on observation, interview, and record review, the facility failed to ensure the provision of care for blood pressure monitoring for 1 resident, (#2), reviewed for Quality of Care, and failed to ensure staff implemented physician orders to ensure residents received treatment and care in accordance with professional standards of practice, (#5), of a total sample of 7 residents.Findings: 1. Review of the medical record revealed resident #2, an [AGE] year-old male was admitted to the facility from on acute care hospital on 9/16/25 with diagnoses that included Alzheimer's Disease, altered mental status, history of transient ischemic attack (stroke), and essential primary hypertension (high blood pressure). The most recent Comprehensive admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/22/2025 noted resident #2 scored 8/15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. The assessment indicated a diagnosis of hypertension, and that the resident received high-risk anti-platelet (blood clot prevention) medication during the look-back period. The current Care Plan Report revealed there was no Cardiovascular/Hypertension care plan included in the Comprehensive Care Plan, for two months. A Focus titled Cardiovascular related to hypertension and high cholesterol was added on 11/12/25, the same day the survey began. The Order Summary Report showed resident #2's active physician ordered medications included, Metoprolol Tartrate 50 Milligrams (MG) once daily for essential primary hypertension started on 9/17/25, Lisinopril 5 MG every day at bedtime from 9/17/25 to 9/22/25 and increased to 10 Milligrams (MG) on 9/23/25 for essential primary hypertension, and Hydralazine HCI 10 MG every 8 hours as needed with systolic (first/upper number) blood pressure greater than 160 millimeters of mercury (mmHg) for essential primary hypertension. On 11/12/25 at 11:54 AM, Licensed Practical Nurse (LPN) A explained nurses were expected to check and enter blood pressures into the Electronic Health Record (EHR) prior to blood pressure medication administration. The nurse said the typical practice was to obtain a blood pressure during medication pass and stated, it's nursing 101; it doesn't have to be on the Medication Administration Record (MAR), it's proper standard of care; all nurses should know that; if you went to nursing school you know that. On 11/12/25 at 1:35 PM, Registered Nurse (RN) B said all nurses were expected to check blood pressures for all residents who take blood pressure medications prior to their administration. She explained readings were checked and documented in the medical record regardless of any noted parameters. According to the American Heart Association, High blood pressure, also known as hypertension, can lead to serious health problems including heart attack or stroke. Measuring your blood pressure is the only way to know if you have it. Controlling high blood pressure can help prevent major health problems. It measures the pressure your blood is pushing against your artery walls when the heart beats, (retrieved from www.heart.org on 11/14/25). Review of the Weights/Vitals record from 9/16/25 to 11/12/25 revealed nurses failed to check resident #2's blood pressure at least once daily, a total of 25 times over the almost two-month period. The MARs for September, October, and November 2025 showed resident #2's scheduled blood pressure medications were administered every day, and no additional as needed medication was administered. On 11/12/25 at 1:40 PM, the Unit 3 Manager explained she expected all nurses to obtain blood pressures for all residents who received anti-hypertensive medications prior to administration of the medication. She said it was important to make sure the blood pressure was not too low prior to giving those medications because that could be dangerous and if it was too high, additional medication may be needed, or the doctor may need to be notified. The RN said nurses wouldn't know if resident #2 needed additional medication without checking the blood pressure. She said she tried to spot check nurses for accuracy and missing orders however she was unaware resident #2 had missing blood pressure checks. In a telephone interview on 11/13/25 at 11:39 AM, Advanced Practice Registered Nurse (APRN) C said she expected all nurses to check resident's blood pressure prior to administration of all blood pressure medications. She explained it was important to check and make sure the pressure wasn't too low or high before giving that type of medication because it could potentially cause avoidable complications when not monitored. The APRN relayed resident #2 had a history of stroke and unchecked high blood pressure could potentially contribute to stroke and she relied upon nurses to keep the medical record up to date so she could accurately assess if medications were effective or needed to be revised. In an interview on 11/13/25 at 9:09 AM, the Director of Nursing (DON) explained it was her expectation that nurses checked blood pressure prior to any administration of blood pressure medications. She relayed the measurement required an EHR entry where a historical record was maintained and accessed by providers who assessed residents and monitored their medication regimens for effectiveness. The DON checked resident #2's medical record and acknowledged he was prescribed three different blood pressure medications, including one for as needed use for systolic blood pressure readings over 160 mmHg. She checked the MARs from September, October, and November 2025, and acknowledged there were no administrations of the as needed medication. She said nurses had to know the blood pressure reading to determine whether additional medication was needed for a high reading. She checked the Weights/Vitals records and acknowledged resident #2 had multiple missing blood pressure checks since he was admitted to the facility in September 2025, two months prior. She conveyed that if resident #2 required three medications to control his blood pressure that meant it was unstable and required close monitoring to avoid potentially serious complications and/or re-hospitalization. The DON said she was unaware the entries were missing and said it was possible nurses had not entered them into the computer. She checked the Comprehensive Care Plan and said the Cardiovascular/Hypertension care plan should have been added in September 2025 and was not sure why it was delayed and entered the previous day, which was after the survey began. Review of the facility's standards and guidelines dated September 2018, and titled Medication Administration General Guidelines noted that nurses were expected to obtain and record any vital signs necessary prior to administering medications. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy, pneumonia, type two diabetes mellitus, acute kidney failure and adult failure to thrive. Review of the Quarterly MDS assessment dated [DATE] revealed resident #5 was cognitively intact with a BIMS score of 14/15. The assessment detailed the resident was frequently incontinent and required one person for transfers. On 11/12/25 at 11:15 AM, resident #5's son was standing in the hallway and explained he was waiting on the nurse to follow up on the urine collection. He said over the weekend, his mom complained of urinary tract infection (UTI) symptoms and staff were supposed to collect a urine sample for testing. He said he was following up on this because his mom told him they had not yet collected the sample, and now it was Wednesday. On 11/12/25 at 2:17 PM, resident #5 was in bed. She said she did not feel very well and wanted to see the physician. Resident #5 complained of burning pain upon urination for a few days. She explained she had told the nurses previously about the pain and was given Tylenol. Resident #5 continued to explain she was told they would collect a urine sample, but they had not. The resident said her son had to speak with the nurse today to find out what was going on. Review of the medical record revealed no change in condition nor progress notes addressing resident #5's concerns or symptoms over the last week. A physician's order dated 11/12/25 at 1:13 PM, for a Urinalysis (UA) with Culture and Sensitivity (C&S) was noted in the resident's electronic medical record. Urine Re, or urinalysis analyzes a urine sample for its appearance, concentration, and content. Used for detecting a wide range of health issues, including: Urinary tract infections, kidney disease Diabetes. Urine CS, or urine culture sensitivity test identifies the microbes causing urinary infections and to which antibiotic the infectious agent (microbe) is susceptible. A sample of urine is added to a medium that promotes microbial growth (bacterial or fungal growth): Negative culture: No microbial growth Positive culture: Microbial growth, (retrieved on 11/14/25 from www.medicinenet.com). On 11/13/25 at 10:12 AM, the assigned RN B said she became aware yesterday that the resident was complaining of pain on urination but was not aware the resident had complained to other nurses before. RN B said the APRN placed orders for UA C&S. RN B said she did not have a chance to collect the sample yesterday, so she passed it on to the oncoming 3:00 PM to 11:00 PM nurse who said she would collect it sometime today. RN B confirmed that usually they had 48 hours to collect the sample. The Unit 3 Manager (UM) standing nearby was informed by the nurse that resident #5's urine sample had not been collected. The UM said she told the Certified Nursing Assistant (CNA), Whenever resident #5 got up to the bathroom, they needed a urine sample, and explained it would be collected today. On 11/13/25 at 10:23 AM, assigned CNA G, said she had not been informed by the Unit Manager that resident #5 needed a urine sample. She explained the nurses informed them verbally when urine samples were needed because the task did not come up on the electronic tasks. CNA G informed the Unit 3 Manager she had not been aware the resident needed a urine sample, the UM acknowledged she had told a different CNA. On 11/13/25 at 11:14 AM, the DON stated she was not aware of a 48-hour collection policy for urine samples. A few minutes later the DON returned and said, there was no facility policy on specimen collection that nurses had 48 for the collection. She explained it was the standard of practice for nurses to collect urine specimen as soon as possible. The DON acknowledged the order for resident #5's UA C&S placed at 1:13 PM, yesterday was not collected, and that there were not any progress notes as to why the sample had not been collected over three shifts. The DON was unable to answer why the urine sample was not collected by staff and did not know why some staff thought they had 48 hours to collect the urine. On 11/13/24 at 1:01 PM, in a telephone interview RN F acknowledged he knew collection of a urine sample was needed for resident #5 because it came up on his tasks in the electronic medical record. He explained he did not want to wake the resident up in the middle of the night, since she would be able to void in the morning. He said that he passed the message to RN B and the Unit 3 Manager but did not write a progress note about it. On 11/13/25 at 1:42 PM, the DON said nurses should follow the standard of practice to collect urine specimen as soon as possible. The facility did not have a policy that specifically addressed specimen collection for diagnostic testing.

Based on observation, interview, and record review, the facility failed to maintain accurate documentation for medication administration for 1 out of 7 sampled residents, (#7). Findings:Resident #7 was readmitted to the facility on [DATE] with diagnoses which included quadriplegia, neuromuscular dysfunction of the bladder and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE], resident # 7 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. A review of the physician's orders revealed that resident # 7 had orders for Midodrine HCl Oral Tablet 10 milligrams (mg), give one tablet by mouth three times a day for low blood pressure. The order directed nurses to hold the medication if the systolic blood pressure (the first number) was greater than 120. On 11/13/25 at 12:10 PM, the Medication Administration Record (MAR) indicated the assigned nurse Registered Nurse (RN) B, administered Midodrine 10 mg at 9:00 AM. The MAR had a check mark with the nurse's initial's to indicated she had administered the medication. The corresponding blood pressure was 125/70 and per the physician's order, the medication should have been held. Further review of the MAR revealed that for November 2025, resident #7 was administered the Midodrine 10 mg outside the physician's ordered parameters a total of 14 times. 12 out of the 14 times by RN B. The MAR revealed in October 2025, resident # 7 received Midodrine 10 mg a total of 28 times documented by six different nurses. RN B documented the medication as given for a total of 17 out of 28 times. On 11/13/25 at 12:17 PM, the Director of Nursing (DON) acknowledged the documentation on the MAR for October and November of 2025 which indicated nurses administered midodrine without following the physician's ordered parameters. The DON could not give a reason why the order was not followed. On 11/13/25 at 12:33 PM, assigned RN B acknowledged the MAR indicated she administered Midodrine 10 mg. The nurse explained she must have checked it off in error because she did not actually give the medication. RN B said she would hold the medication if the resident's blood pressure was greater than 120 and explained she would never give the medication if the systolic blood pressure was greater than 120. She could not say why she did not mark the medication as not given or held on the MAR as she was familiar with the codes for documenting refusals, held, or not available. RN B again acknowledged the MAR contained documentation that she gave the medication when it should have been held and said she could not prove it was not given. She explained she would change today's documentation of the medication and write a progress note to explain the discrepancy. On 11/13/25 at 1:42 PM, the DON could not explain why the nurses documented Midodrine 10 mg was given to resident # 7 when it should have been held. She explained that RN B was immediately educated and confirmed she was just clicking in error. The DON continued to explain that the expectation was to document accurately in the medical record and if it was in error, the nurse should immediately correct the error and/write a follow up note. The facility's policy on Late entry, Addendum, Corrections and Clarification of the Medical Record effective March 2024 revealed, The facility will utilize the following guidelines when documentation problems or mistakes occur and changes or clarifications are necessary. The procedure for correction in section eight indicated, For electronic record correction, follow the electronic record process to strike out the error. After striking out the documentation, click follow up to enter corrected note.

Based on interview, and record review, the facility failed to follow policy and procedure related to Full Code status leading to a delay in initiating Cardiopulmonary Resuscitation (CPR) for 1 of 5 residents reviewed for Advance Directives of a total sample of 68 residents, (#100). Resident #100 a-[AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included anemia, type II diabetes, occlusion and stenosis of the carotid artery. The resident was admitted to Hospice services on [DATE] with diagnosis of moderate protein-calorie malnutrition. The resident's physician's order dated [DATE] noted full resuscitation. Progress note dated [DATE] at 6:30 AM, documented by Licensed Practical Nurse (LPN) A read, Patient has expired Hospice notified MD (Medical Doctor) notified. Resident #100 died at the hospital on [DATE]. The facility's failure to provide CPR in a timely manner as per resident #100's wishes and physician's order placed all residents in the facility at risk, and could lead to potential injury/impairment or death if code status is not identified and addressed immediately in an emergent situation. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross Reference F609 Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview For Mental Status score of 13 out of 15. The resident's physician's order dated [DATE] noted his code status to be Full Resuscitation. Orders entered by LPN A on [DATE] at 6:29 AM, noted two contradictory orders, one for Full Resuscitation, and another for Do Not Resuscitate (DNR). A progress note dated [DATE] read, Advance care plan meeting held discussed code status wishes. Resident chooses to remain a full code at this time . hospice is caring for resident at this time for palliative comfort care. The Hospice Certification and Plan of Care with certification period [DATE] to [DATE] revealed his hospice diagnosis was moderate protein-calorie Malnutrition. Review of hospice orders for Advance Directive on [DATE] read, Do Not Resuscitate, and a different order dated two days later on [DATE] noted Resuscitate. Review of Hospice Note Reports dated [DATE], and [DATE] revealed the resident's code status was Full code. A progress note documented by LPN A, dated [DATE] at 6:29 AM, read, Patient has expired Hospice notified, MD notified. On [DATE] at 5:25 PM, the 200 Wing Registered Nurse/Unit Manager (RN/UM) stated he recalled resident #100 was on hospice services and had a full code status. He stated he was not at the facility when the resident coded but heard there may have been some confusion by hospice whether the resident was a DNR or full code. The resident's clinical records were reviewed with the RN/UM and he acknowledged the only documentation pertaining to the resident's change in condition was on [DATE] at 6:29 AM, that indicated the resident expired. The RN/UM stated the normal process when a resident passed was for staff to call the Director of Nursing (DON) who would instruct the staff on what to do. He said the facility's protocol for code status was to go by what was in the resident's medical record. On [DATE] at 5:43 PM, an interview was conducted with the DON, and the Regional Consultant Risk Management Specialist. The DON explained the facility's process regarding advance directives. She stated on admission if the resident was alert and oriented, staff would verify the resident's wishes for advanced directives, notify the physician, and place a physician order in the facility's electronic medical record (EMR). If the resident was not alert and oriented, code status would be confirmed with the responsible party. She explained the order for code status would be entered in the EMR, printed and placed at the front of the resident's physical chart. The DON said if a resident was found unresponsive, the nurse should verify the resident's code status in the physical chart, and the physician order in the EMR. She noted the code status orders were usually verified by two nurses. She explained if the resident was without pulse and respiration and was a Full Code, CPR should be initiated immediately. The DON described a code worksheet on the crash cart, that directed staff to record the time the resident was found without unresponsive, the time 911 was called, and who initiated CPR. The code worksheet included staff who assisted in CPR, 911 response time, and the time 911 assumed care of the resident. She said the code worksheet was a tool to guide documentation for the resident's clinical record. The DON and the Regional Consultant Risk Management Specialist reviewed the resident's physician's order, and progress note, and stated documentation on [DATE] at 6:29 AM, indicated the resident expired, and the physician and hospice services were notified. They acknowledged there was no other documentation other than the resident expired and notifications made. The DON stated a DNR order was initiated for the resident on [DATE] at 6:29 AM, discontinued at 8:44 AM, and a Full code order was initiated at 6:45 AM after resident 100 had expired. She said the following day, post code, the Interdisciplinary Team (IDT) usually reviewed code status and identified who initiated CPR. She stated she would have questioned the DNR, and Full Code orders both entered on [DATE]. On [DATE] at 6:13 PM, in a telephone interview, LPN A stated she worked at the facility full-time for six months on the 11 PM to 7 AM shift. She confirmed she was resident #100's primary nurse on [DATE], and noted the resident was very sick. LPN A recalled on [DATE] to [DATE] on the 11 PM to 7 AM shift, she did rounds between 12 AM to 1 AM, and at that time resident #100 was okay. She recalled Certified Nursing Assistant (CNA) B provided hygiene care for the resident, and when CNA B did her last round at about 5:30 AM, the resident was unresponsive. LPN A explained when she went into the resident's room, the resident appeared to have expired, he had no pulse, and was not breathing. The LPN said the resident was a full code, but in the hospice chart he had a DNR order. She recalled she called the hospice service, and was told the resident was a DNR. She remembered the hospice nurse on call was not familiar with the resident, and by the time she called back to say the resident was a full code, she had already verified the resident was a full code. LPN A said she called the physician to verify the resident's code status, reached out to the former DON, and she verified the resident had rescinded his DNR, and was a full code. She said CPR was initiated immediately after the resident's code status was confirmed by the physician. The LPN noted the facility had a CPR log, and information was documented on the log which was given to the former DON. On [DATE] at 6:42 PM, the DON and Administrator stated an investigation was initiated by the former Administrator and DON. They shared the former Administrator put together a file with timeline on the Code Blue, and included statements from LPN A, and CNA C. There were no statements obtained from other nurses on shift, or from CNA B who initially found the resident unresponsive. They shared the Code Blue Worksheet dated [DATE] identified the resident was found unresponsive at 6:15 AM by CNA B. The worksheet timeline indicated the Emergency Code cart arrived at the resident's room at 6:17 AM. LPN A checked the resident's chart for code status at 6:17 AM, initiated CPR and called 911 at 6:17 AM. The Worksheet indicated Emergency Medical Service (EMS) arrived at 6:27 AM. They acknowledged statements were obtained on [DATE] from LPN A, CNA C, and the Director of Rehabilitation, but not from CNA B. Review of the Code Blue Worksheet revealed staff involved in the code were LPN A, CNA B, and CNA C. On [DATE] at 11:28 AM, an interview was conducted with the Regional Nurse Consultant, DON, Regional Risk Management Specialist, Regional [NAME] President (VP) of Operations, and Administrator. The DON stated the facility called all parties involved in the code, and staff present at the time of the incident. The Administrator stated LPN A had called 911 from her personal phone and completed a post event report. The Administrator said LPN A identified resident #100 was found unresponsive on [DATE] at 6:15 AM. The resident's chart and crash cart were bought to the resident's room at 6:17 AM. The Administrator said a statement was obtained from CNA B the resident's assigned CNA on [DATE] during the survey. She verbalized that during the interview with CNA B, the CNA voiced that she spoke with the DON after the event but was not asked to write a statement. On [DATE] at 11:28 AM, the conflicting information from interviews and the Code Blue Worksheet timeline as to when the resident was found unresponsive was discussed with the Administrator and DON. They did not have a response, and stated the facility's Corporate staff reviewed the previous Administrator and DON's investigation after the event. The Administrator provided documentation of the interview conducted with CNA B on [DATE] that revealed the CNA found resident #100 unresponsive at approximately 2:30 AM to 3 AM which contradicted previous interviews with Administration and the Code Blue Worksheets which noted the resident was found unresponsive at 6:15 AM. The Administrator stated the facility had statements to refute the CNA's statement. The Administrator stated LPN F worked on the 300 Wing on [DATE], and in her statement obtained yesterday on [DATE], LPN F stated that on [DATE], the ambulance left the facility at approximately 6:30 AM to 7:00 AM. The Administrator said at the time resident #100 was found unresponsive, his code status in the facility's EMR was Full Code, and she was not aware of any DNR order in the hospice binder for the resident. She stated the facility follows the orders in the EMR. The Regional Nurse Consultant stated that based on the resident's physician's order, the resident was a full code from [DATE] and had never had a DNR order in place. She verbalized that based on new statement given today by LPN A, the LPN had looked in the resident's hospice binder that morning and the resident was a DNR. However, the facility could not identify any DNR order in the closed clinical records for resident #100. Review of statements obtained by the current Administrator between [DATE], and [DATE], revealed LPN A reported she was made aware resident #100 was unresponsive around 5 AM to 6 AM. She checked the electronic record for the resident's code status, called a code and started CPR by herself for approximately ten minutes. CNA B's statement indicated the resident was found unresponsive by the CNA between 2:30 AM and 3 AM. The typed statement read, Told (LPN A's name) he wasn't breathing. She checked the computer and she said he was a DNR. She called the hospice and they confirmed he was a DNR. Then about an hour later hospice called back and said he was a full code, so she went back to the room and started doing CPR. Review of the transcript of the call from the facility to hospice on [DATE] revealed the following: 6:09 AM call comes into triage with report patient expired at 6: 00 AM. LPN A We went into patients' room; he is not breathing. We are starting CPR and sending him out. He is still a full code. Triage RN: He is still a full code? LPN A I believe he is a full code unless you have something different 6:15 AM Triage RN returns to state will need to get access to the chart will follow up with a call and will be making a visit with appropriate paperwork if it is there. LPN A Well I do not have an actual DNR, but I am looking at his hospice book you guys give and under the Medicare thing (the election of benefit) it says, 'I request no cardiopulmonary resuscitative measures at the time of my death'. I mean he is gone at this point so there is nothing I can do anyway. I just need to know whether he is a full DNR or not. 6:23 AM hospice nurse calls LPN A stating she sees a DNR, but LPN A says, our records state full code. The hospice nurse let her know she was on the way to the facility to make a visit and told LPN A if you know if your records show full code, then continue to do CPR and call 911. 6:34 AM hospice nurse called LPN A back to confirm patient was in fact a full code which confirms what LPN A stated at 6:09 AM Review of the report from Emergency Medical Services (EMS) provided by the Administrator revealed EMS arrived at the hospital from the facility on [DATE] at 7:09 AM. On [DATE] at 1:47 PM, the Corporate Director of Risk Management (RM) stated she was made aware by the facility there was a code blue on [DATE]. She said CPR was performed after the code status was identified, and in the middle of the code when hospice was made aware, hospice reported they had record of the resident being a DNR but instructed the nurse to follow physician orders on file. The nurse, LPN A, called the DON during the code, and the DON reassured her that once CPR was started, CPR could not be stopped. Later hospice called back and verbalized they made a mistake, and the resident's code status was not DNR, he was a full code. EMS arrived and assumed care for the resident, he was transferred to the hospital, and passed away. The RM said she provided guidance to facility leadership to investigate the event, interview all staff present, and validate there was no pause in CPR. She recalled she reviewed some statements, and there were no concerns, CPR continued until EMS arrived. The RM said the facility was concerned hospice had an incorrect order for the resident's code status that could have resulted in a potential negative effect. She recalled she had a follow-up phone call within the week of the event with the Administrator, and there were no additional concerns. She stated it was her understanding the facility did a thorough investigation. The RM said the statement obtained from CNA B on [DATE] had errors in the timeline, as evidenced by the resident's clinical condition when he arrived to the emergency room (ER). She said the statement from the assigned LPN A indicated she was made aware of the resident's condition at 6:15 AM. The RM explained the statements, code blue timeline, and verbal interviews were used to determine the timeline of the event was correct. She acknowledged there were conflicts between the statements obtained, interviews, and the timeline on the Code Blue Worksheet. She stated review of the progress note documented on [DATE] at 6:29 AM, indicated the resident expired, but the resident expired in the hospital. The RM said the hospital had documentation that conflicted with the facility's documentation, and the review left her with questions. On [DATE] at 3:41 PM, the RM provided the Fire Rescue Patient Care Record dated [DATE]. Documentation on the EMS Patient Care Record-Admin/Hospital form indicated the initial call from the facility was received by EMS on [DATE] at 7:35 AM. The report revealed EMS arrived to the facility a few minutes later at 6:41 AM and arrived to the resident at 6:48 AM. The report read, Rehab staff relates pt (patient) was last seen normal @-1:00 AM during medication administration with no issue noted at that time. Staff relates coming in @-6:30 AM to find pt unresponsive, pulseless, apneic. Staff relates delay in initiating CPR over confusion involving pt's DNR- staff initially believed DNR was current, however realized shortly after that DNR was rescinded by pt. Staff relates CPR was initiated ~ ,d+[DATE] mins PTA [Prior to arrival] of EMS. The emergency room Record dated [DATE] revealed, Patient was found last seen around 2 AM found unresponsive and asystole [heart not beating] no bystander CPR. Documentation indicated the time of death was 7:13 AM. Information from EMS, and the ER conflicted with the statements obtained from LPN A, CNA B, the Code Blue Worksheet timeline, and the Triage call to the hospice. The EMS record indicated CPR was provided by facility staff approximately 5 to 10 minutes prior to their arrival on scene at 6:48 AM. This would indicate CPR was initiated by facility staff at approximately 6:30 to 6:35 AM and not at 6:17 AM, as documented on the Code Blue worksheet. This was acknowledged by the RM. On [DATE] at 4:40 PM, CNA B stated she had worked at the facility for four years, on the 3 PM to 11 PM shifts, and on the 11 PM to 7 AM shifts, twice weekly. She confirmed she worked on the 11 PM to 7 AM shift on [DATE] through [DATE], and resident #100 was in her assignment. CNA B recalled she checked on the resident between 2:30 AM to 3 AM, found him unresponsive, and immediately alerted LPN A. She recalled LPN A went to the computer to check the resident's code status, and said the resident was DNR. The LPN checked the book, CNA B said she was not sure of which book, and LPN A said it showed DNR. CNA B related CPR was not initiated at that time. CNA B said LPN A instead called hospice, and was told resident #100 was a DNR. She related hospice called back about one hour later and said the resident was a full code, so LPN A then went into the room and started CPR. CNA B stated LPN A performed compressions until EMS arrived and took over. The CNA stated LPN A called 911 before she initiated CPR, and thought CPR was started somewhere between 3:30 AM to 4 AM. She said she would not forget this event, because it was her first death. CNA B stated the Code Blue Worksheet timeline was inaccurate, and the resident was not found unresponsive at 6:15 AM, as documented. She stated her statement was obtained yesterday on [DATE] when the Administrator called her. On [DATE] at 11:44 AM, another interview was conducted with the Regional Nurse Consultant, DON, Regional Risk Management Specialist, Regional VP of Operations, Corporate Director of RM, and the Administrator. The RM stated the facility identified the need for additional investigation, because of the discrepancies identified on the Code Blue worksheet, the documentation in the resident's EMR, the hospital records, and the EMS run report. When asked if CPR was provided timely, or delayed, the RM stated documentation from the hospice triage call indicated LPN A called at 6:09 AM to notify the resident expired at 6:00 AM. She said in the event report 6:00 AM was when the resident expired as per documentation and if 6:09 AM was when CPR was started, it would indicate a nine-minute delay. The RM stated staff were taught to follow physician orders in the EMR regarding code status, not to look at the hospice book. She stated after they received the EMS report, it confirmed the Code Blue Worksheet was not accurate. The RM said the EMS run report showed they arrived at the facility on [DATE] at 6:35 AM, and it appears there may have been a delay in providing CPR based on the EMS run report. (This statement of the EMS arrival time was found to be inaccurate per the EMS record, which indicated 911 call to EMS was at 6:35, with actual arrival time on scene at 6:41 AM.) On [DATE] at 3:12 PM, the Medical Director stated he was not aware of the concern with the discrepancy in code status for resident #100 until today ([DATE]). He stated proper documentation of code status should be in the resident's chart, and if there was no documentation, the resident remained as a full code. He stated the education to the nurse was lacking, and the facility needed to review and put some education in place. The Medical Director said some of the new nurses believed if a resident received hospice services, then the resident would be DNR, which was not always the case. He stated he was not the physician LPN A was reported to have called. He explained it would take the nurse approximately 15 minutes to complete a call to the physician in his opinion. The potential delay in providing CPR to resident #100 was discussed with the Medical Director. He said the facility did not have an AD Hoc Quality Assurance Performance Improvement meeting for this incident. Essential duties and responsibilities listed on the Job description for Licensed Practical Nurse with date of [DATE] included, Handles emergency situations in a prompt, precise, and professional manner. Perform CPR as required .Maintains accurate, detailed reports and records. The policy CPR Code Status Orders & Response updated February 2023, revealed the procedure for initiating CPR directed that Code Status and resident will be verified by 2 identifiers .with another nursing care center personnel, if resident is a full code CPR will be initiated. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: *[DATE] CPR was initiated for resident #100 and resident was transferred from the facility with a rhythm via EMS and passed away at the hospital. *[DATE] Assistant DON initiated staff education on Code Status Orders and Response Policy and Procedure to include procedure for initiating CPR and documentation of the event. 31 out of 31 licensed nurses were educated as of [DATE]. Re-education was initiated for licensed nursing clinical staff to be completed [DATE]. *[DATE] Facility audit of 100 out of 100 residents advance directives was completed, to confirm accuracy of code status present in the front of the medical records and that it matched the physician's orders in the EMR. *[DATE] additional audit of 21 out of 21 residents receiving hospice services conducted to confirm code status of record with hospice matches the facility's record. The hospice chart stored at the facility was combined with the facility's hard chart, removing individual hospice binders. *[DATE] the Regional [NAME] President provided education to the Administrator and Interim DON on their essential core functions and the code of conduct. *[DATE] the Risk Management Consultant provided education to the Administrator and DON on the Abuse Prevention Program and conducting through investigations. *A total of 9 Code Blue Drills has been completed since [DATE] covering all shifts in order to ensure staff are knowledgeable and prepared to accurately verify resident code status in an emergency and ensure staff provide CPR in a timely manner. *[DATE] Ad Hoc Quality Assurance and Compliance committee reviewed removal plan. Review of the in-service attendance sheets revealed evidence to reflect staff participation in education on CPR & Advance Directives. Between [DATE] and [DATE], interviews were conducted with 4 RNs, 4 LPNs, and 3 CNAs. They all verbalized understanding of the education provided. Interviews, and record reviews revealed no concerns for residents #1, #11, #25 and #87 related to Advance Directives and code status.

Based on interviews from the Resident Group Meeting and record reviews, the facility did not promote an environment for residents to voice grievances about care and treatment without fear of discrimination, and/or reprisal. Findings include: During an interview with the Resident Council President on 06/05/24 at 11:15 AM, they said usually 5-6 people attended the Resident Council meetings. They suggested Thursday, 6/06/24 at 9:30 am would be a good time to meet with the residents. The Resident Council President said there was no place to meet privately with a group of residents except in his room. The regular meetings were held in the atrium on the back of the 200 hall closest to his room, but he explained it wasn't private, with staff standing around listening to what was said. During an interview with the Activity Director on 6/05/24 at 11:35 AM, he stated, There is no private area for the Resident Group meeting to be held, so we will hold it at the back of the 200-hall atrium as that is the only place available. The Resident Council Group Meeting was held on the 200-hall atrium, on 06/06/24 at 9:30 AM, in an open area 15 feet away from the nurse's station. At the time of the meeting, there were 5 staff members located around the nurse's station. This large open common area was centrally located in the middle of the atrium. On 06/06/24 at 9:51 AM, residents attending the meeting were asked if they felt like they could not complain about care or treatment. By a show of hands 20 residents indicated they feared retaliation if they brought up a complaint or complained about their care. The individuals did not wish to be identified for fear of retaliation from the facility staff. Record review of Resident Council minutes provided from March 2024 to June 2024 revealed few voiced concerns.

Based on Resident Group interview, and record review, the facility failed to properly and promptly respond to Resident Council concerns and grievances. Findings: During a record review of the June 2023 to June 2024 Resident Council minutes provided by the Activity Director revealed documentation the Council did not believe their previously initiated concerns/grievances were addressed or resolved for the following dates: June 2023, August 2023, December 2023, April 2024, May 2024 and June 2024. The minutes indicated a new Administrator was introduced on 4/16/24 and told the Council that all concerns were being taken care of and the facility was working on them, but the minutes for May and June 2024 indicated the Council continued to feel their concerns were not addressed by the facility. On 6/05/24 at 11:35 AM, the Activity Director stated they worked alone in the Activity Department from Monday through Friday. The Activity Director explained the Activity Department had no volunteers so when they had been out sick in the hospital for a week, there were no activities in the facility during that time. The Activity Director confirmed the concerns from the Resident Council Meeting on 4/08/24 were not addressed or resolved. During the Resident Group Meeting held on 06/06/24 at 9:41 AM, 11 resident responded there was no facility follow up to the Resident Council Group Concerns. During an interview with the Activity Director on 06/06/24 at 1:15 PM, the Activity Director explained the Resident Council concerns were given to the department involved/concerned, with a two week follow up by the Activity Director who received the resolutions verbally. The Activity Director would notify the Resident Council at the next meeting. The Activity Director was not aware there were any issues the Resident Council felt had not been resolved.

Based on Resident Group meeting, review of Resident Council Minutes, and interview, the facility staff failed to review and inform residents of their rights in the facility. Findings include: The Resident Group meeting was held on the 200-hall atrium, on 06/06/24 beginning at 9:30 AM, in an open area that was 15 feet away from the nurse's station. At the time of the meeting, there were 5 staff members sitting and standing around the nurse's station that was centrally located in the middle of the atrium. The meeting was held in this large open common area. During the Resident Group meeting, held on 06/06/24 beginning at 9:30 AM, seven residents and family representatives responded they did not know what their resident rights were, were not provided a copy of their rights either at admission or during their stay, and that resident rights were not reviewed during the Resident Council meeting. Even the Resident Council President said resident rights had not been reviewed in the Resident Council meetings. In review of the Resident Council minutes for a year from June 2023 to June 2024, the agenda indicated that resident rights reviewed (choose 1-2 monthly) and was expanded upon as answer of yes, but never identified what rights were reviewed. In the last year of Resident Council minutes, there was not an attachment or pamphlet of the [NAME] of Rights handed out or reviewed. Interview with the Activity Director on 06/06/24 at 1:15 PM, the Activity Director confirmed he was responsible to be the liaison and helped to facilitate the Resident Council meetings since he started February 27, 2024. He was unable to say whether resident rights had been reviewed during those Resident Council meetings, nor could he provide documentation that resident rights information had been provided at those meetings.

Based on record review and interview, the facility failed to obtain physician orders [REDACTED].#1) reviewed for gastrostomy tube care and feeding. The resident remained in the facility with no orders for feedings or water for 5 ½ days until he required emergency transport to the hospital for treatment for [REDACTED]. This situation compromised resident #1's ability to maintain his highest practicable physical, mental, and psychosocial well-being. Findings: Resident #1 was admitted to the facility from hospital on [DATE] with a history of [MEDICAL CONDITION], airway obstruction with tracheotomy and acute [MEDICAL CONDITION]. The resident was nonverbal and totally dependent for all activities of daily living. He was unable to consume any nourishment orally and had a gastrostomy tube ([DEVICE]) for enteral feedings and water. A gastrostomy tube is a feeding tube put directly into the stomach through the abdominal skin. The tube allows feeding directly into the gastrointestinal tract to occur by bypassing the mouth and esophagus. (www.webmd.com) A review of the physician orders [REDACTED]. Review of the discharge orders from the hospital indicated the resident was to receive [MEDICATION NAME] 1.5 continuous feeding via the gastrostomy tube ([DEVICE]) at 70 milliliters (ml) per hour and he was to receive 250 ml of water via the [DEVICE] twice a day to start on 3/04/15. [MEDICATION NAME] 1.5 is a nutritionally complete, calorically dense, fiber containing formula. An interview was conducted with the director of nursing and the administrator at 2:00 PM on 3/25/2015. They confirmed that the resident did not have physician orders [REDACTED]. She said the orders were verified with the physician, but the resident was originally admitted to wing 1 and then shortly after was transferred to wing 2. The nurse on wing 1 started to input the physician orders [REDACTED]. The orders for the feeding tube care, type of feeding, amount of feeding, and amount of water were never entered into the computer. The DON said the only way staff could have known the resident was to have a [DEVICE] feeding was from the internal communication form, "Admission alert." The form is used internally to communicate information regarding new admissions including name, room, date of birth, physician, payment, diagnoses, dietary needs, special needs, and other. Review of the " admission alert " form for resident #1 revealed it listed "[MEDICATION NAME] 1.5 continuous at 60 ml/hr." The DON said she did not know why it did not match the information received from the hospital. The DON said the facility had a process in which the orders for all residents admitted to the facility are reviewed the following morning. She said she thought resident #1 was reviewed, but she had no documentation of the review and had no explanation of why the omitted orders for the care of the [DEVICE], including feeding and water, were not discovered. The resident received care from 3 nurses each day for 5 ½ days and none of them made any inquiry regarding lack of physician orders [REDACTED]. The resident was transferred to the hospital on [DATE] due to vomiting and abnormal lab values. He was admitted to the hospital with [REDACTED]. He returned to the facility after receiving intravenous fluids and the dehydration, blood potassium level, and kidney failure resolved.

Based on interview and record review the facility failed to meet professional standards of quality for caring for residents with enteral feedings via gastrostomy tube ([DEVICE]) by failing to obtain physician orders for enteral feeding and water and for initiating a tube feeding without physicians orders and without accurate documentation for 1 of 3 residents sampled for enteral feedings (#1). This inconsistent and/or nonexistent administration of feeding/water and care of the resident with a feeding tube resulted in actual harm in the need for emergency transfer to the hospital for treatment for [REDACTED]. Findings: The Florida Statutes Chapter 464 The Nurse Practice Act. (SS464.001.461.027) defines in 3. (a) " Practice of professional nursing " means the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, inured, or infirm, and the promotion of wellness, maintenance of health and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a dully licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing " means the performance of selected acts, Including the administration of treatments and medications, in the care of the injured or infirm and the promotion of wellness, maintenance of health and promotion of illness of other under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shalt be responsible and accountable for making decisions that are based upon the Individuals education preparation and experience in nursing. American Society for [MEDICATION NAME] and Enteral Nutrition, Journal of [MEDICATION NAME] and Enteral Nutrition Practice Guidelines, Volume 33 Number 2 March/April 2009 122-167. II. Ordering and labeling of Enteral Nutrition, Elements of the Order. Record review revealed resident #1 was admitted to the facility on [DATE] with a history of [MEDICAL CONDITION] with tracheotomy, airway obstruction, and gastrostomy tube. He was nonverbal, totally dependent upon staff to meet needs and unable to consume any nourishment orally. He had a gastrostomy tube for enteral feedings and water. A gastrostomy tube is a feeding tube put directly into the stomach through the abdominal skin. The tube allows feeding directly into the gastrointestinal tract to occur by bypassing the mouth and esophagus (www.web.md.com). A review of the admission physician orders for 3/04/15 showed no orders for enteral feedings or water. An interview conducted with the director of nursing on 3/25/15 at 2:00 p.m. confirmed that there were no orders for the enteral feedings or water. The director of nursing stated that the resident was moved from wing 1 to 2 during the admission process and the nurse who entered his initial orders from the hospital neglected to enter the orders for the enteral feedings and water. She said since the orders for the tube feeding, water, and care of the tube were never entered into the computer, they did not print to the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. It includes a place to document all of the above. When asked for a policy and procedure for care of residents with enteral feedings and [DEVICE]s, she did not produce one. When asked how none of the nurses who were caring for resident #1 did not notice there were no orders for feeding or water, no entries on the MAR, and none of them made an inquiry as to why, she was unable to provide an explanation. Review of the MAR indicated [REDACTED]. The resident received care from 3 nurses each day for 5 ½ days and none of them documented anything regarding care of the [DEVICE] and administration of feeding or water on the MAR. Review of the nurses ' notes indicated sporadic documentation regarding the [DEVICE] as follows: On 3/04/15 at 6:58 p.m. the notes read, " [MEDICATION NAME] at 60 cc (cubic centimeters)/hr (hour) initiated at this time." The record showed the resident had no orders for [MEDICATION NAME] at that time. The next entry on 3/05/15 at 6:58 a.m. read, " TF (tube feeding) as ordered, patent." The resident had no orders for tube feeding at that time. On 3/06/15 at 6:46 p.m. the notes read, " [DEVICE] patent at 60 cc/hr." There were no nurses ' notes on 3/07/15 and 3/08/15. On 3/09/15 at 2:59 p.m., the notes read, " [DEVICE] patent at 60 ml/hr." The resident had no orders for any [DEVICE] feedings at that time. On 3/10/15 at 1:53 a.m., the notes read, " [DEVICE] placement verified and patent. [MEDICATION NAME] running at 60 cc/hr." The resident still had no orders for [DEVICE] feedings at that time. An interview was conducted with registered nurse (RN) A on 3/26/15 at 11:45 a.m. She had cared for the resident on 4 out of 5 days since he was admitted . She stated she thought the resident was receiving enteral feedings for 20 hours per day and was receiving free water when she gave his medications via gastrostomy tube. The facility policy for medication administration for enteral tubes ([DEVICE]s) dated 2007 included, " enteral tubes are flushed before administering medications and after all medications have been administered with at least 15 ml of water. The enteral tubing is flushed with at least 5 ml of water between medications." Review of the MAR indicated [REDACTED]. The water received with medications a total of 6 times in 24 hours would be at least 180 ml. She was asked how she knew how much and what type of feeding formula to give since there were no physician orders. She stated that the information regarding the type of feeding and how much to give was passed on from the previous shift and the amount was already set on the feeding pump. When asked if she checked the MAR, she said she just " followed the verbal shift report." Review of the nurses ' notes indicated a telephone call was placed to the physician on 3/09/15 at 2:50 p.m. to report abnormal lab results from bloodwork done earlier that day, but when the physician did not return the call, no follow up call was placed to report the lab values. The nurses ' notes documented the resident had light brown emesis twice the following morning, 3/10/15 and was sent to the hospital via 911. The lab values that were not reported to the physician on 3/09/15 indicated critical values: blood urea nitrogen (BUN) level of 162 milligrams (mg)/deciliter (dl) (normal 7-25), creatinine 4.99 mg/dl (normal 0.7-1.30), and potassium 6.7 milliequivalents (mEq)/liter (L) (normal value 3.5-5.2). BUN and creatinine are tests that can tell how well kidneys are working and show dehydration. [MEDICAL CONDITION], high potassium, can lead to dangerous, possibly deadly, changes in heart rhythm. (www.webmd.com <http://www.webmd.com>) The resident required treatment with intravenous fluids. He returned to the facility after receiving intravenous fluids and the dehydration, blood potassium levels, and kidney failure resolved.

Based on record review and interview the facility failed to ensure appropriate treatments were provided for 5 ½ days for a resident receiving gastrostomy tube feeding to prevent dehydration and metabolic abnormalities which resulted in hospitalization for 1 of 3 sampled residents (#1). The facility's failure to provide tube feeding and fluids as ordered resulted in actual harm and an emergency transfer to the hospital for treatment for [REDACTED]. Findings: Record review revealed resident #1 was admitted to the facility from hospital on [DATE] with a history of [MEDICAL CONDITIONS], airway obstruction with tracheotomy and acute [MEDICAL CONDITION]. He was nonverbal and unable to consume any nourishment or fluids orally. He received a gastrostomy tube for enteral feedings in February 2015, prior to admission to the facility. A gastrostomy tube is a feeding tube put directly into the stomach through the abdominal skin. The tube allows feeding directly into the gastrointestinal tract to occur by bypassing the mouth and esophagus. (www.web.md.com) A review of the physician orders [REDACTED]. On 3/10/2015 at 7:00 a.m., nurses ' notes indicated the resident had 2 episodes of light brown emesis. The next note read, " resident was sent to hospital via 911 at 8:00 a.m. for abnormal labs." Lab work was completed the previous day on 3/09/15. On 3/09/15 at 2:59 p.m. the nurses ' notes documented abnormal labs and awaiting response from the physician. Review of the lab results from 3/09/15 showed a blood urea nitrogen (BUN) level of 162 milligrams (mg)/deciliter (dl) (normal 7-25), creatinine 4.99 mg/dl (normal 0.7-1.30), and potassium 6.7 milliequivalents (mEq)/liter (L) (normal value 3.5-5.2). In comparison with the lab values from the hospital on [DATE] just prior to admission, the values obtained on 3/09/15 were significantly worse. On 3/04/15 the BUN was 38 mg/dl (normal 6-20), creatinine 0.84 mg/dl within normal range (0.70-1.20), and potassium was normal 4.5 mEq/L(3.5-5.2). The notes did not indicate any follow up call to the physician to report the critical lab values and the resident was sent to the hospital via 911 at 8:00 a.m. on the following day, 3/10/15. The record indicated the resident was admitted to the hospital with [REDACTED]. The resident required treatment with intravenous fluids. He returned to the facility after receiving intravenous fluids and the dehydration, blood potassium levels, and kidney failure resolved. BUN and creatinine are tests that can tell how well kidneys are working and show dehydration. [MEDICAL CONDITION], high blood potassium levels, can lead to dangerous, possibly deadly, changes in heart rhythm. (www.webmd.com <http://www.webmd.com>) An interview was conducted with the director of nursing (DON) and the administrator at 2:00 PM on 3/25/2015. They confirmed that the resident did not have any physician orders [REDACTED].½ days. Further discussion revealed the resident had discharge orders for feeding and fluids from the hospital, but the resident was transferred from wing 1 to wing 2 during the admission process on 3/04/15 and those orders for feeding and fluid were never entered into the computer ordering system. The resident had no other orders for the [DEVICE] regarding any other care and treatment of [REDACTED]. Review of the record revealed no documentation other than sporadic nurses ' notes, as listed below, for any care and treatment for [REDACTED]. Review of the discharge orders from the hospital indicated the resident was to receive [MEDICATION NAME] 1.5 continuous feeding via the gastrostomy tube ([DEVICE]) at 70 milliliters (ml) per hour and he was to receive 250 ml of water via the [DEVICE] twice a day to start on 3/04/15. [MEDICATION NAME] 1.5 is a nutritionally complete, calorically dense, fiber containing formula. An acceptable equivalent is [MEDICATION NAME] 1.5 per Nestle product information. Review of the Medication Administration Record [REDACTED]. Review of the nurses ' notes indicated sporadic documentation regarding the [DEVICE] as follows: On 3/04/15 at 6:58 p.m. the notes read, " [MEDICATION NAME] at 60 cc(cubic centimeters)/hr (hour) initiated at this time." The record showed the resident had no orders for [MEDICATION NAME] at that time. The next entry on 3/05/15 at 6:58 a.m. read, " TF (tube feeding) as ordered, patent." The resident had no orders for tube feeding at that time. On 3/06/15 at 6:46 p.m. the notes read, " [DEVICE] patent at 60 cc/hr." There were no nurses ' notes on 3/07/15 and 3/08/15. On 3/09/15 at 2:59 p.m., the notes read, " [DEVICE] patent at 60 ml/hr." The resident had no orders for any [DEVICE] feedings at that time. On 3/10/15 at 1:53 a.m., the notes read, " [DEVICE] placement verified and patent. [MEDICATION NAME] running at 60 cc/hr." The resident still had no orders for [DEVICE] feedings at that time. Review of the care plan dated 3/05/15 revealed tube feeding for enteral nutrition because of dysphagia due to [MEDICAL CONDITION], requires enteral feeding to be delivered by pump. Goal was that resident will obtain adequate nutrition and hydration and will have no untreated side effects or complications related to enteral nutrition. Interventions included, but were not limited to: administration of enteral nutrition as ordered, refer to physician orders [REDACTED]. In an interview on 3/26/15 at 11:45 a.m. with registered nurse RN-A who cared for resident #1 on 3/05, 3/06, 3/09, and 3/10/15, she said the resident received [MEDICATION NAME] at 60 ml/hr for 20 hours. When asked how she would give this feeding at that rate without any physician orders, she said, " she knew from the previous shift and said the tube feed machine was set at 60 ml/hr so that is what I followed." When asked about water, she said she gave water with his medications per facility policy. She said she usually gave more water, but she was not able to provide evidence of such. The facility policy for medication administration for enteral tubes ([DEVICE]s) dated 2007 included, " enteral tubes are flushed before administering medications and after all medications have been administered with at least 15 ml of water. The enteral tubing is flushed with at least 5 ml of water between medication." Review of the MAR indicated [REDACTED]. The water received with medications a total of 6 times in 24 hours would be at least 180 ml. In an interview with the registered dietitian on 3/25/15 at 2:00 p.m., she said she was not made aware the resident was receiving [DEVICE] feedings. She said she saw him on 3/07/15, but could not complete an assessment because the resident refused to be weighed. She said she made recommendations for tube feeding orders and said she gave it to the nurse. In an interview with the DON, she said she could not verify the nurse received any recommendations from the dietitian until 3/16/15, after the resident was readmitted from the hospital. Review of the comprehensive nutrition assessment completed by the dietitian 5 days after admission on 3/09/15 at 12:50 p.m., indicated the resident needed 1800 calories and 933 ml of free water. The assessment indicated the resident should have 200 ml of water three times a day. It included the resident did not take anything by mouth. The intervention read, " current t/f (tube feeding) requirement based on hospital recommendations." As of 3/09/15, the resident continued to have no current physician orders [REDACTED].½ days until he had to be transferred to the hospital and treated for [REDACTED].

Based on observation, interview and record review, the facility failed to develop a plan of care related to the level of assistance needed with showers. The lack of a comprehensive care plan put the residents at risk for harm, injury or death resulting from accidents while in the shower for 6 of 20 sampled residents (#1, 3, 6, 7, 8 & 9). These practices resulted in the determination of Immediate Jeopardy starting on [DATE] and was determined to be on-going as of the exit on [DATE]. Findings: Cross-Reference to F465 1. Record review on [DATE] at 3:37 p.m. for resident #3 revealed [DIAGNOSES REDACTED]. She was a dependent on all staff for activities of daily living (ADLs). She sustained a laceration to the left side of her face and a subarachnoid hemorrhage on [DATE]. The resident was admitted to the hospital on [DATE], discharged on [DATE] back to the facility, and died on [DATE]. Review of the [DATE] Hospital Discharge Summary noted that the resident was admitted through the emergency room after falling at the nursing home and injuring her head. The resident had a laceration to the left forehead and a CT scan of the brain showed a small subarachnoid hemorrhage. Nurse's note dated [DATE] at 3:07 a.m. indicated the resident was found unresponsive to all stimuli with fixed and dilated pupils, and absence of vital signs. The resident was pronounced expired at that time. In an interview with LPN #1 on [DATE] at 3:51 p.m., he did not know what the care plan stated because he did not read the plan. When asked how he knew how to take care of a resident, he said "that would be up to the CNAs to read a care plan, and you would have to ask administration." Observation of the Unit 2 shower room with licensed practical nurse (LPN) #1 on [DATE] at 4:03 p.m. found a shower chair without a safety bar on the left side of the shower room. The right side of the shower room was cluttered with chairs, dirty linen containers, and a shower bed. In an interview with certified nursing assistant (CNA) #1 on [DATE] at 5:45 p.m., the CNA said resident #3 was in a shower chair without a safety bar and fell face first onto the tile floor on [DATE]. CNA #1 said that the shower chair with the safety bar was on the right side of the "Jack and Jill" shower rooms. The right side of the shower room had clutter, and the shower chair could not be easily retrieved. The CNA stated that resident #3 had started leaning in the shower chair about 2 weeks prior to her incident on [DATE]. He said he usually used a shower chair with a safety bar. However, the chair with the safety bar was on the "Jill" (right) side of the shower room which was cluttered with equipment. The "Jack" (left) side was the side where resident #3 had received a shower and fell . When asked about choosing which shower chair to use, he stated he determined it by the resident. Review on [DATE] of the Interdisciplinary Plan of Care Meeting Summary Tool dated [DATE] read that the resident required extensive assistance with ADLs. The CNA "Activities of Daily Living Flow Sheet" dated ,[DATE] read that the resident required 2 person assistance with toileting and was dependent on staff with ADLs. On [DATE], only 1 CNA assisted with the shower. The [DATE] care plan read she required a lap tray while in a wheel chair. 2. Observation on [DATE] at 1:30 p.m. revealed resident #1 playing bingo in her wheel chair with a Hoyer lift sling in her chair. She was alert and oriented while receiving assistance with bingo. No restraints were used at this time. The resident did use protective gloves for skin tears to the hands. In an interview with CNA #8 on [DATE] at 2:57 p.m., the CNA said resident #1 required a mechanical Hoyer lift with 2 person assistance for transfers. She said 2 people always have to do Hoyer lifts for safety, that it has always been in place, and that was the policy at the facility. Record review on [DATE] at 2:35 p.m. for resident #1 revealed [DIAGNOSES REDACTED]. The care plan/Kardex read that bathing required 1 person to assist with a bed bath, 2 to assist with a shower, and no indication as to whether the resident required a shower chair or shower bed. 3. Observation on [DATE] at 5 p.m. revealed resident #6 up in wheelchair, self-propelling and had a bed alarm in place. The resident was confused and could be combative. In an interview with CNA #10 on [DATE] at 5:10 p.m. for resident #6, she indicated that when resident #6 is given a shower, a shower chair is used. She said that another person also helps transfer the resident. Resident #6's record review on [DATE] at 5:30 p.m. revealed [DIAGNOSES REDACTED]. The care plan/Kardex revealed that the resident was to receive a shower or bed bath but did not list how many were to assist with this. Due to the resident's history with falls, there was a physician's orders [REDACTED]. 4. Observation on [DATE] at 4:45 p.m. found resident #7 in bed and did not exhibit any problems. In an interview on [DATE] at 5 p.m., the CNA #10 stated she did not bathe resident #7 but believes the resident uses a shower chair. She stated that the resident will pivot and assist getting into a wheelchair. Review of resident #7's plan of care on [DATE] at 5:15 p.m. revealed that the resident would receive showers with 1 person assistance. Resident #7's [DIAGNOSES REDACTED]. 5. In an interview with CNA #5 on [DATE] at 5 p.m., she said resident #8 required total care. The resident transferred with 2 person assistance and with a mechanical Sara lift. The resident did not transfer in a shower chair. Only 1 person was needed to shower the resident. Record review on [DATE] at 5:15 p.m. for resident #8 revealed [DIAGNOSES REDACTED]. Review of nurse's note on [DATE] revealed "wheezing, X-ray taken no issues noted." The plan of care revealed that to transfer resident #8 would require 2 person assistance, and for bathing would require 1 person to assist for either bed bath or shower. The falls plan of care was to use a wheel chair, lock brakes, and PT and OT PRN (physical therapy & occupational therapy as needed). 6. During an interview on [DATE] at 4:58 p.m. with the director of nursing, the administrator, risk manager, and CNA #6, resident #9's care plan/Kardex was reviewed. There was an area on the Kardex that stated how to transfer a resident and how many staff were needed to help bathe a resident. There was no documentation on what type of shower chair or shower bed to use for each resident. It was left up to the CNA to determine what to use. The facility stated that the Kardex read how to transport for transfer to the wheelchair and also for showers. It was not clear to the CNA using the Kardex or care plan how to transfer a resident when taking a shower. In an interview on [DATE] at 5 p.m. with CNA #5, she said resident #9 was semi-independent and but forgetful and did not shower this resident. Record review on [DATE] at 5:15 p.m. revealed resident #9's [DIAGNOSES REDACTED]. The Kardex/care plan on [DATE] revealed the resident slipped and fell to the floor while walking from the shower room. The resident was wearing "anti-skid" socks. The floor was dry and the resident complained of wrist pain. The X-ray was negative for a fracture. All that was listed as needed for bathing was set-up and supervision. 7. During an interview with the Minimum Data Set (MDS)/Care Plan Coordinator on [DATE] at 4:26 p.m., she stated that the Kardex/care plan under the heading "bathing activity" would show how to bathe the resident. It would also be on the form "Maintenance ADL & Safety Plan Communication Tool". The MDS coordinator stated that it would be on the Kardex but not on the care plan about which safety chair to use with each resident. During an interview on [DATE] at 4:45 p.m. with a CNA #6, she stated that they highlight the residents to shower for the day on a form at the nurses' station. She explained that she knows which residents need a shower chair and who needs a shower bed because of experience working with the residents. During the review of the plan of care, it was not documented who needed a shower chair and who needed a shower bed. She stated that she had never seen which equipment to use written on the Kardex. When asked how to determine who needed a shower chair and who needed a shower bed, she stated she gets to know the resident and by experience. During a review of the care plan/Kardex on [DATE] 4:40 p.m., the care plans of 9 residents read how to transfer residents with either assistance of 1 or 2 staff but did not list if a shower chair/shower bed was to be used. CNAs #1, #5, #6, #8, and #10 were interviewed and stated that when using a Hoyer lift, a shower bed with 2 to assist must be used, and if the resident could walk or could use a Sara (stand up) lift, they could use a shower chair with 1 assist. The CNAs also stated that they use a shower chair with a safety bar at all times with a resident because of safety. The Kardex read how many staff was needed to transfer the resident.

Based on record review and interview, the facility's licensed staff failed to care plan resident safety during showers and allowed certified nursing assistants (CNAs) to determine the safety needs of residents for 14 of 20 sampled residents (#1, 3, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 & 20). The scope of practice for unlicensed staff does not include assessments for safety needs, decisions regarding level of assistance, and determination of appropriate shower devices. These practices resulted in the determination of Immediate Jeopardy starting on 9/23/11. Immediate Jeopardy was determined to be on-going as of the exit on 11/09/11. Findings: Florida Board of Nursing, Nurse Practice Act, 464.003 (3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and the promotion of wellness, maintenance of health, and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to subscribe such medications and treatments, (3) the supervision and teaching of other personnel in the theory and performance of any of the above acts. 1. Review of nurses' notes indicated that resident #3 fell out of a shower chair on the evening of 9/23/11. The resident fell face first onto the tile and was bleeding. The resident was transported to the hospital. Review of the Hospital Discharge Summary indicated that the resident required sutures for a left [MEDICAL CONDITION] and that a CT scan of the brain showed a small subarachnoid hemorrhage. On 11/07/11 at 3:51 p.m., licensed practical nurse (LPN) #1 was interviewed. She stated that CNA #1 was showering the resident #3 and that the shower chair with the safety bar was not used. When asked about the facility's Policy and Procedures for the use of shower chairs, the LPN stated, "You would have to ask administration about the policy." LPN #1 was asked if resident #3 was care planned for the use of a shower chair. She stated she did not read the care plans and did not have any knowledge of what type of shower chair the resident required for safety. Review of resident #3's Kardex/care plan revealed that shower chairs/shower beds were not care planned. On 11/07/11 at 4:26 p.m., the care plan nurse was interviewed. Further review of the Kardex/Care Plans revealed that residents #1, #3, #12, #14 and #16 were coded for two person assistance for showers. She stated that means the residents need 2 staff for assistance with showers. She stated it could mean that the residents required 2 staff person for transfer in the shower room. When asked how residents were care planned for shower chairs/shower beds, she stated if the interdisciplinary team determined that a resident required a shower chair or shower bed, then the Kardex/Care Plan would be updated. Later that evening at 5:45 p.m., CNA #1 was interviewed via phone. The ADM and RM were in attendance during the interview. CNA #1 stated he had showered resident #3 numerous times in the past. He stated he noticed that the resident would lean forward during the shower, so he started using the shower chair with the safety bar. He stated he usually used that particular shower chair and the resident has not had previous falls in the shower. He stated on the evening of 9/23/11, the shower chair with the safety bar was in the right side shower room behind carts and and other chairs. He attributed the clutter in that room as the reason he was not able to retrieve the shower chair with the safety bar. He stated it would have taken too long to "dig it out". He stated there was a shower chair without the safety bar available and he decided to use that one instead. Also, the CNA did not know how to turn on the lights in left side shower room. 2. On 11/07/11 at 4:53 p.m., CNA #6 was interviewed. She stated that residents who use a a Hoyer lift, should use a shower chair. She added that residents who require a Sara Lift transfer can use a shower chair unless specified on the Kardex/Care Plan. Several minutes later, the administrator (ADM), director of nursing (DON) and risk manager (RM) entered the conference room and CNA #6 was asked to name someone on her assignment who required a shower chair. The CNA stated resident #20 needed a shower chair. The resident's care plan was reviewed with the staff present. There was nothing on the resident's care plan that indicated resident #20 needed shower chair. The CNA was asked how she knew if a resident required a shower chair with a safety bar or a regular shower chair. The CNA stated that after working with the residents, they knew which residents required a shower chair with a safety bar. 3. Interview with CNA #7 on 11/07/11 at 4:30 p.m. revealed that residents #11, #12, #13, #14, #15, #16, #17, #18 and #19 required the use of a shower chair. On 11/08/11 at 2:52 p.m., CNA #2 stated resident #10, #11 and #14 used a shower chair with a safety bar. She also added that resident #12 needed a Hoyer lift to transfer. Care plan review revealed that resident #16 also used a Hoyer lift to transfer. It should be noted that CNA #7 indicated that residents #12 and #16 use a shower chair and not a shower bed. CNA #2 also added that she has used the shower chair to transport residents to the shower room. CNA #6 was interviewed again on 11/08/11. She stated that resident #12 used a shower chair with a safety bar. The CNA added that she has used the shower chair to transport residents to the shower room. Care plan review of residents #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19 revealed that these residents were not care planned for the use of shower chairs or shower beds. 3. Record review and interview with CNA #8 on 11/08/11 at 2:30 p.m. revealed that resident #1 needed a Hoyer lift to transfer. This resident had a fall in December 2010 when she fell out of the Hoyer sling. Resident #1 was not care planned for either a shower chair or a shower bed in the shower room. 4. Resident #8 was a total care resident. During an interview on 11/08/11 at 5 p.m., CNA #5 stated that the resident needed a Sara Lift to transfer. The resident's care plan had no indication that the resident required a Sara Lift for transfer and if the resident needed a shower chair or shower bed in the shower room.

Based on observation, record review and interview, the facility failed to provide care and services to ensure resident safety during bathing/showers. The facility's licensed staff failed to care plan resident safety during showers, allowed certified nursing assistants (CNAs) to determine the safety needs of residents, and failed to monitor the care and services provided by CNAs for 15 of 20 sampled residents (#3, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18 & 19). Failure to provide care and services for safety during bathing/showers put residents at risk for harm, severe injuries and subsequent death. These practices resulted in the determination of Immediate Jeopardy starting on [DATE]. Immediate Jeopardy was determined to be on-going as of the exit on [DATE]. Findings: 1. Based on record review and interview it was determined that on [DATE] at 8:30 p.m. resident #3 fell out of the shower chair and incurred an injury. The resident was being assisted in the shower by CNA #1. Nurse's note dated [DATE] at 8:30 p.m. read, "Resident was seen laying in prone position on shower room floor. This writer was called to the shower room nearest to W2's (Wing 2's) nursing station to assess resident. Res (resident) was laying with left side of her face on the floor with a large pool of blood near her forehead. Res was crying moaning loudly. She did not lose consciousness. The shower room was cleared out in order to assess her. No further injuries were noted. 911 was called to treat, transport to PMC ER (Parrish Medical Center emergency room )." Resident #3 returned to the facility on [DATE] at 5:30 p.m. Review of the [DATE] Hospital Discharge Summary read, "Patient was admitted through the emergency room after falling at Titusville Rehab and Nursing Center and injured her head. She had a laceration sutured in the left forehead. CT scan of brain showed a small subarachnoid hemorrhage." Nurse's note dated [DATE] at 3:07 a.m. indicated the resident was found unresponsive to all stimuli with fixed and dilated pupils, and absence of vital signs. The resident was pronounced expired at that time. On [DATE] at 3:45 p.m., CNA #7 was interviewed. She described resident #3 as being non-combative and did not yell or scream. CNA #7 stated that resident #3 required a Sara Lift (standing lift) transfer. CNA #7 was aware that the resident had fallen in the shower room and that CNA #1 was with the resident at the time of the fall. On [DATE] at 3:51 p.m., license practical nurse (LPN) #1 was interviewed. LPN #1 confirmed resident #3's fall in the shower room on the evening of [DATE]. LPN #1 added that she was the first nurse to respond and that she observed the resident lying face down with her arms stretched out. LPN #1 stated that the resident used a shower chair due to the resident's inability to stand during showers. LPN #1 stated the resident was in a shower chair that did not have a safety bar that secures the resident in the shower chair. When asked about facility's Policies & Procedures (P&Ps) for the use of shower chairs, LPN #1 responded, "You would have to ask the administration about the policy." LPN #1 was asked if resident #3 was care planned for using a shower chair and stated she did not read the care plans and did not know what type of shower chair the resident needed. When asked how the nurses ensured that the CNAs were providing care in accordance with the residents' plan of care, LPN #1 did not reply. Several minutes later, Wing 2's shower room was observed with LPN #1 at 4:03 p.m. Wing 2's shower room can be described as a "Jack & Jill" shower room. It is basically 2 shower rooms with separate entrances from the hallway. The rooms are connected by a pass through toilet room at the opposite side (furthest from the entrance) of both rooms. Each room has 2 shower stalls that are not divided by a wall. Observations of the "Jill" side shower room, the right shower room, revealed that the facility stored several linen carts, shower chairs and a shower bed in this room. The "Jack" shower room, the left shower room, had a shower chair that did not have a safety bar. The "Jill" shower room had two shower chairs with front safety bars. LPN #1 stated that CNA #1 was bathing resident #3 in the "Jack" shower room. CNA #1 slipped and the resident fell face first out of the shower chair, away from the entrance door. She also indicated that the lights to the "Jack" shower room were not on when she arrived to assess the resident. Resident #3's care plan was reviewed. This facility utilizes a Kardex system for care plans. The Kardex instructs staff how to provide care for each resident. The facility's Kardex has two sections: 1) Maintenance ADL (activities of daily living) and Safety Care Plan I Communication Tool, and 2) Individualized care plans. Resident #3 required two person mechanical lift for transfer. The bathing section on the Kardex indicated that the resident was a one person assist with bed baths and two person assist with showers. On [DATE] at 4:26 p.m., the care plan nurse was interviewed. She stated that "2 person assist for bathing" means that the resident requires a two person assist transfer to the shower/shower chair/shower bed. The nurse indicated that if the care plan team determined that a resident needed a shower chair or shower bed to shower, the Kardex would be updated to demonstrate the need for such a device. The nurse stated that bath/shower instructions would be on the Maintenance ADL & Safety Care Plan & Communication Tool. There was nothing to indicate that resident #3 required a shower chair on the Kardex. On [DATE] at 4:53 p.m., CNA #6 was interviewed. She indicated that residents who require a Hoyer lift transfer should use a shower bed. She added that residents who require a Sara Lift transfer can use a shower chair unless specified on the Kardex/Care Plan. On [DATE] at 4:58 p.m., the administrator (ADM), director of nursing (DON) and risk manager (RM) were interviewed. At that time, the facility's investigation was reviewed. The facility investigation revealed that two other nurses and another CNA assisted LPN #1 and CNA #1 when resident #3 fell . Statements were taken from the staff involved. In one of the statements, a staff member indicated that the door to the shower room was left open so that light from the hallway could illuminate the shower room. The administrative team (ADM, DON & RM) was asked if the light was on in the shower room at the time of the fall. The ADM was adamant that the light was on in the shower room. The ADM indicated that through the facility's investigation, it was determined that the facility was not in control of the incident and that resident #3's fall was an accident. On [DATE] at 5:45 p.m., CNA #1 was interviewed via phone and the ADM and RM were present. CNA #1 confirmed that the lights were not on in the left side shower room. He stated he turned on the lights in the right side shower room and the pass through toilet area. He stated he did not know how to turn on the lights in the left side shower room and that the light switch for this room was outside the door in the hallway. He also stated that he did not use the shower chair with the front safety bar for resident #3 on [DATE]. CNA #1 stated that the shower chair with the safety bar was in the right side shower room behind carts, a shower bed, and other devices. He stated it would have taken ten minutes to retrieve the chair, so he decided to use the shower chair without the safety bar. CNA #1 stated he has showered resident #3 many times in the past without incident. He stated that he had noticed that during the showers, resident #3 would lean forward and that is why he usually used the shower chair with the safety bar for the resident. He added that since that incident, he uses the shower chair with the safety bar with all the residents. On [DATE] at 5:55 p.m., the shower room on Wing 2 was observed with the ADM, DON, ADON and RM. The right shower room was filled with clutter as CNA #1 described. The lights were turned on in the right side shower room. The lights were turned off in the left side shower room and the door to the pass through toilet area was open so that light from the right side shower room could leak into the left side shower room. The light in left side shower room was dim and it was hard to see. On [DATE] at 3:49 p.m., CNA #1 was interviewed again in person. He stated he came to the facility to clarify information about resident #3's fall on [DATE]. He confirmed that the lights were not on in the left shower room on Wing 2. He was not aware that the light switch was outside the door in the hallway. He also stated he turned the timer switch lights on located in the the shower room but the lights did not turn on. He stated that he has showered resident #3 many times in the past. CNA #1 stated that he noticed that the resident started to lean forward during showers and that is when he decided to start using the shower chair with the safety bar. He stated he always used that shower chair with the safety bar except on the night of [DATE]. The CNA explained that on [DATE], the shower chair with the safety bar was in the right side shower room. It was behind carts, shower beds, and other items described as clutter. The CNA indicated that it would have taken too long to dig out the shower chair with the bar, so he decided to use the shower chair without the safety bar. The CNA stated that he was washing the resident's back when he, the CNA, slipped and fell . The resident fell out of the shower chair face first. CNA #1 stated there was an in-service about falls/slipping after resident #3's incident. He stated it was strongly recommended that the "over-shoes" should be used. The CNA stated is was not mandatory to use them. He stated that he did not use the "over-shoes" because the facility did not have a pair of "over-shoes" that fit him. He stated he told supervising staff that the "over-shoes" did not fit. Finally, he added that he once used the shower chair to transport a resident to the shower room, then a nurse told him not to transport the resident in that manner. 2. On [DATE] at 4:30 p.m., CNA #7 (3 -11 shift) was interviewed about the residents on her assignment. She was not sure if resident #10 needed a shower chair during bathing. CNA #7 indicated that residents #11, #12, #13, #14, #15, #16, #17, #18 and #19 all needed shower chairs. The care plans were reviewed for these residents. There was no indications on the care plans that these residents required a shower chair, shower chair with a safety bar, or a shower bed to shower. 3. On [DATE] at 2:52 p.m., CNA #2 (,[DATE] shift) was interviewed about the residents on her assignment. She indicated she was assigned to residents #10, #11, #12, #13, #14, #15, and #16. CNA #2 clarified that resident #10 used a shower chair with a safety bar. CNA #2 also used a shower chair with the safety bar for residents #11 and #14. CNA #2 stated that resident #12 was a Hoyer lift transfer but CNA #2 did not shower this resident. Also, CNA #2 stated she has used the shower chair to transport residents to the shower room. Further record review of residents #12 and #16 indicated that these residents are Hoyer lift transfers but CNA #7 stated that they use the shower chairs instead of wheel chairs to transport the residents to the shower room. During an interview on [DATE] at 3:15 p.m., CNA #6 stated that resident #12 uses a shower chair with a safety bar. The CNA explained that she at times she will bring Wing 2 residents to the Wing 3 shower room because is is less cluttered. CNA #6 stated at times she has used the shower chair to transport residents to the shower room. 4. Interview with CNA #8 on [DATE] at 2:39 p.m. revealed that resident #1 was a Hoyer lift transfer. At that time, LPN #2 stated that the resident has not had a fall since [DATE]. At that time, the resident fell out of the sling during a transfer. There was no indication on the resident's care plan that the resident required a shower bed for showering. 5. On [DATE] at 5 p.m., CNA #5 was interviewed. She stated that resident #8 was a total care resident who required transfer with the use of a Sara Lift. The CNA stated she showered the resident in a shower chair with a front safety bar. There was no indication on the resident's care plan to indictae the use of a mechanical lift transfer or shower chair. CNA #5 stated that the use of "over shoes", anti-slip shoe covers, was mandatory. 6. Review of the care plans for residents #5, #6 and #7 revealed that resident #5 received a bed bath. Residents #6 and #7 were care planned for both bed baths and showers but there was no indication that residents #6 & #7 were care planed for shower chairs for their showers. On [DATE] at 5:10 p.m., CNA #10 was interviewed. She stated she showered residents #5 and #6 using a shower chair with the safety bar. She also stated that about 2 weeks ago, the staff was in-serviced about falls/slipping. It was her understanding that the use of the "over-shoes" was mandatory.

Based on observation record review and interview the facility failed to effectively investigate falls/accidents and efficiently use resources to maintain highest practicable measure of safety for 12 of 20 sampled residents (#1, 2, 3, 5, 6, 10, 11, 12, 13, 14, 15 & 16) and staff. The failure to investigate falls/accidents resulted in the failure to identify the inadequate assessment for safety needs, inconsistent and inadequate decisions regarding level of assistance, and unlicensed personnel making the determination for appropriate shower devices. The failure of administration to effectively investigate falls/accidents to provide care and services for safety during bathing/showers put residents at risk for harm, severe injuries and subsequent death. These practices resulted in the determination of Immediate Jeopardy starting on [DATE]. Immediate Jeopardy was determined to be on-going as of the exit on [DATE]. Findings: 1. The facility failed to fully investigate resident #3's fall and determine the staff failures that contributed to the fall. On [DATE] at approximately 8:30 p.m., resident #3 fell in the Wing 2 left side shower room. Review of the medical record and interview with licensed practical nurse (LPN) #1 on [DATE] at 3:51 p.m. revealed that CNA #1 was giving the resident a shower. The resident was in a shower chair that did not have a front safety bar. The CNA was standing behind the resident, washing her back, when he slipped. The resident fell face forward on to the tile. The nurse noted that the resident was lying with the left side of her face on the floor and there was a large pool of blood near his forehead. The staff called 911 and the resident was taken to the emergency room at the hospital. Review of the [DATE] Hospital Discharge Summary noted that the resident was admitted through the emergency room after falling at the nursing home and injuring her head. The resident had a laceration to the left forehead and a CT scan of the brain showed a small subarachnoid hemorrhage. LPN #1 stated she was the first nurse to respond and indicated that that the lights in the left side shower room were not on. Nurse's note dated [DATE] at 3:07 a.m. indicated the resident was found unresponsive to all stimuli with fixed and dilated pupils, and absence of vital signs. The resident was pronounced expired at that time. On [DATE] at 4:58 p.m., the facility's Internal Investigation was reviewed with the administrator (ADM), director of nursing (DON) and risk manager (RM). The ADM stated that through their investigation, it was determined that the fall was not within the facility's control and therefore it was not considered an adverse incident. The investigation revealed that statements were taken from LPN #1 and CNA #1. There were statements from two more nurses and one more CNA. The two nurses and CNA were no longer employed at the facility at the time of the survey. In one of the statements taken from the staff involved, it was noted that the door to the shower room was left open so the light could come into the shower room from the hallway. The administrative staff was asked about this particular statement and a question arose about the possibility of CNA #1 showering the resident in the dark. The ADM was adamant that the lights were on in the shower room but the facility staff failed to further investigate this issue. Later that evening at 5:45 p.m.on [DATE], CNA #1 was interviewed via telephone with the ADM and RM present during the call. CNA #1 confirmed that the lights were not on in left side shower room on Wing 2. He was unaware that the light switch was outside the door in the hallway. The CNA turned on the lights in the right side shower room and opened the door that connected the shower rooms so that light could leak into the left side shower room. Also, the CNA stated that he has showered resident #3 many times without incident. He stated he usually used the shower chair with the front safety bar but did not on the night in question, [DATE]. He stated that the chair with the front safety bar was in the right side shower room behind carts, chairs and other items that was described as clutter. He stated it would have taken too long to "dig the chair out" so that was why he used the shower chair without the bar. He added that in the past he noticed that the resident would lean forward during showers and that is when he decided to start using the shower chair with the safety bar. Review of resident #3' medical record revealed that the resident was not care planned for a shower chair during showers. After the telephone interview with CNA #1, the Wing 2 shower rooms were observed at approximately 5:55 p.m. The ADM, DON and RM were present during this observation. The right side shower room was filled with clutter as described by CNA #1. The lights in the right side shower were turned on and the light in the left side shower room was off. The door for the pass through toilet area was open. The only light source was from the right side shower room and toilet area. The left side shower room was dim and it was hard to see. Review of facility training revealed that on [DATE], facility staff had received an in-service on falls and slipping. Training staff reviewed the use of anti-slip over shoes during resident showers. On [DATE] at 2:52 p.m., CNA #1 was interviewed in person. He confirmed that he did not know how to turn on the lights to the Left shower room. He also recalled receiving an in-service after resident #3 expired. He stated the use of the over shoe was not mandatory but strongly recommended. He also stated he does not use the over shoe because he can't find an over shoe that fits. On [DATE] at 5 p.m., CNA #5 stated that it was mandatory to use the over-shoes. During an interview on [DATE] at 5:10 p.m., CNA #10 indicated she had attended the in-service. She stated the use of the over-shoes was mandatory. The facility did not fully investigate resident #3's fall with injury. They failed to analyze staff statements and further investigate the lighting in the shower room at the time of the fall. They also failed to investigate and determine the appropriate safety device that resident #3 required during showers and why it was not available. The facility did not investigate the use of shower chairs for current residents of the facility, ensuring the appropriate safety device was care planned and implemented by staff. 2. The facility did not ensure that the safety needs of the residents were care planned and that licensed staff were determining the safety equipment for the residents. Resident #3's fall was discussed with LPN #1 on [DATE] at 3:51 PM. LPN #1 was asked about the facility's Policy and Procedures for the use of shower chairs. The nurse replied, "You would have to ask administration about the policy." Also, LPN #1 was asked if resident #3 was care planned for a shower chair during showers. LPN #1 stated she did not read the care plans and did not know what type of safety equipment the resident needed in the shower. On [DATE] at 4:26 p.m., the care plan nurse was interviewed. She was asked how the facility determined if residents needs a shower chair or shower bed for showers. She stated that if the interdisciplinary team determined that a resident needed a shower chair/bed, then the Kardex/care plan would be updated to reflect the appropriate device. During an interview on [DATE] at 4:53 p.m., CNA #6 state that if a resident required a Hoyer lift to transfer the resident, then a shower bed would be used. She stated the residents who require a Sara lift transfer can use a shower chair unless the Kardex/care plan specifies otherwise. Based on the interview, it was determined that the CNAs determined what type of shower bed or shower chair was used to shower the residents. CNA #6 stated you get to know the residents and determine what they need. 3. On [DATE] at 4:30 p.m., CNA #7 stated that residents #11, #13, #14, #15 used a shower chair. She added that residents #12 and #16 also required a shower chair. Further record review and interview with CNA #2 on [DATE] at 2:52 p.m. indicated these residents were Hoyer lift transfers. CNA #2 also stated that residents #10, #11 and 14 needed a shower chair with a safety bar. The care plans for residents #10, #11, #12, #13, #14, #15 and #16 were reviewed. There was no indication on the care plans that these residents needed a shower chair, shower bed or a shower chair with a safety bar for showers. 4. Review of resident #1's medical record indicated the resident needed a Hoyer lift to transfer. This was confirmed by CNA #8 during an interview on [DATE] at 2:39 p.m. At that time, LPN #2 indicated that the last time the resident had a fall was when she fell out of the Hoyer sling in [DATE]. There was no indication on the care plan that the resident used either a shower bed or shower chair. 5. Observations on [DATE] at 2:45 p.m. and record review revealed that resident #2 ambulated with the use of the wheelchair. There was no indication on the care plan that the resident needed a shower chair or shower bed. 6. During an interview on [DATE] at 5:10 p.m., CNA #10 revealed that she used a shower chair for residents #5 and #6. The care plan for resident #5 indicated the resident gets bed baths. There was documentation on the care plan that the resident received a shower in a shower chair. There was no indication on resident #6's care plan that indicated the resident required a shower chair. CNA #10 stated she did not shower resident #6 but believed this resident needed a shower chair.

Based on observations, interviews and record review, the facility failed to control the spread of gastrointestinal (GI) symptoms of nausea, vomiting and diarrhea from [DATE] to the present. The facility failed to monitor resident GI symptoms, resulting in inaccurate collected data to implement an effective comprehensive plan of action to prevent the spread of these GI symptoms. The facility failed to ensure staff was educated promptly to prevent the spread of GI symptoms. The facility failed to notify the local health department when GI symptoms occurred in the facility at the initial start of these symptoms. The facility failed to follow their policy on "Norovirus or Norovirus Like Symptoms - Preventing the Spread." These failures resulted in the spread of GI symptoms to 16 of 28 residents on 3 of 3 units (#2, 4, 5, 6, 7, 8, 9, 10, 11 & 12, 40, 41, 42, 43, 44 & 45) in a facility census of 119, which affected 13.4% of the resident population. This failure also affected 12 facility staff members (#A, B, C, D, E, F, G, H, I, J, K & L), and the potential spread to the community by visitors entering and leaving the facility. The facility failed to follow the "Florida Department of Health Recommendations and Guidelines for the Control of Norovirus outbreaks in Nursing Homes and Health Care Facilities". Residents in long term care facilities are at a higher risk for transmission of GI symptoms and complications. It can be introduced through facility staff and visitors, and once spread, controlling it can be difficult. Immediate Jeopardy was identified [DATE] as starting on [DATE]. The director of nursing was advised on [DATE]. Ongoing Jeopardy was determined at the exit on [DATE]. Findings: 1. During an interview with the Administrator and the Director of Nursing (DON) on [DATE] at 9:15 a.m., the DON stated the facility had an "outbreak of gastrointestinal (GI) symptoms (nausea, vomiting & diarrhea) a couple of weeks ago (dates not specified by DON) but was now resolved." She was told by the weekend supervisor on Saturday, [DATE], that there was an "outbreak" and the supervisor had instituted precautions including "hand washing education, posted signs and kept residents on their units for dining and activities" to prevent the spread of symptoms. The Administrator stated they did not report the event to the health department and the Agency for Health Care Administration (AHCA) on the weekend as required. The DON stated she did not know she could contact the health department on the weekend. The DON stated she did not know which residents were affected on [DATE] but said a preliminary investigation based on the facility Policy and Procedure for "Norovirus or Norovirus like Symptoms - Preventing the Spread" was done. The preliminary investigation included only hand washing education to staff, posting signs and keeping residents on their wings. Review of the facility standard for Noro-virus or Noro-virus like symptoms included "consider Noro-virus intervention . . . . if two or more residents or staff develop nausea, vomiting or diarrhea. Advise families, visitors and residents about the importance of hand hygiene to minimize the spread of fecal contamination." The guidelines included to "notify the local department of health (if applicable), notify the medical director and primary care physicians, initiate a separate . . . . 'Monthly Line Worksheet for Confirmed or Suspected Infections', inservice staff on symptomology, hand washing and contact precautions, assess and monitor symptomatic residents for 72 hours, notify responsible parties, verify dish machine temperatures are within limits and properly recorded, and close common areas." Review of Florida Department of "Health Reportable Diseases/Conditions in Florida Practitioner List", dated [DATE], read that "influenza due to novel or pandemic strains should be suspected immediately and reported immediately." On [DATE] at 9:15 a.m., the DON said the facility initiated an action plan on [DATE] for Nausea, Vomiting, and/or Diarrhea. There were no actions or system changes documented at the time the plan was reviewed on [DATE]. The DON said when she returned to work on Monday, [DATE], she was told "no further incidents of the infections had occurred", she considered it resolved, and as a result she removed the previous instituted precautions initiated to prevent the spread of symptoms. She stated the last reported infection was [DATE]. During an interview with the DON at 11:45 a.m. on [DATE], a request for a completed list of all residents affected by the GI symptoms but the DON could not produce it on [DATE] or upon exit on [DATE]. 2. Observation on [DATE] at 10 a.m. found residents in the unit atrium on the 100 and 200 wings, and in the day room on the 300 wing. Multiple residents were receiving therapy in the gym in the center of the building. Signs to alert visitors, staff and residents of GI symptoms were not posted anywhere in the facility. Residents affected with the GI symptoms did not have caution signs posted on their bedroom door. During an interview with a nurse passing medications on the 100 wing at 10:30 a.m. on [DATE], she stated none of her residents had GI symptoms. She was unaware of the recent GI episodes because she had been on vacation for the past week, and had not been informed when she returned to the facility for her shift today. During an interview with resident #13 on the 100 wing at 10:45 a.m., he stated he was feeling well but did know some residents had been sick on the unit. During an interview at 3:30 p.m. on [DATE] with resident #14 in the main hallway outside the service hallway, he stated he resides on the 100 wing and has been well but he knows residents have been sick on the unit and he wants to stay away from them to stay healthy. During an interview with a nurse passing medications on the 200 wing at 11:50 a.m., she stated resident #5 developed nausea, vomiting and diarrhea on [DATE] but had no knowledge of anyone with symptoms today. In an interview with the other nurse passing medications on the 200 wing at 11:55 a.m., she stated she was told during report that resident #2 had diarrhea last night. During the tour of 300 wing on [DATE] at 11:55 a.m., the door to the wing was closed. In an interview at that time with the 300 wing unit manager (UM), she stated the 300 wing was a rehab unit, so the doors are always kept shut to keep it quiet. In an interview with the DON at 12:55 p.m., she stated the doors to the 300 unit are closed to keep it quiet and to prevent confused residents from wandering into other rooms. Observation of residents at approximately 1 p.m. were in the day room on the 300 wing preparing for lunch and watching TV. Most resident rooms were empty. The UM stated "residents are at rehab." A family member was heard asking the UM if the unit was still quarantined and she told him "no" because there were no more events of symptoms. The UM stated that the weekend of [DATE], residents were kept on the units, but the outbreak let up over the past weekend, [DATE], so the precautions were lifted. She said no symptoms have been observed since Saturday, [DATE]. 3. In an interview with the Administrator and DON at about 11:45 a.m. on [DATE], they stated they had not heard about the recent symptoms reported by residents #2 and #5 on the 200 wing but they would investigate it. Prior to exit on [DATE], the facility had not provided their investigative results. 4. After receiving a call from the Department of Children and Families (DCF) on [DATE] at approximately 10:30 a.m., the Orlando office supervisor contacted the Brevard County health department epidemiologist on [DATE] at 11:15 a.m. The epidemiologist stated the health department did not have any reports about the facility concerning multiple GI symptoms. During a second interview by the Orlando office supervisor on [DATE] at about 9 a.m., the health department epidemiologist stated she had gone to the facility on [DATE], found both several residents and staff had GI symptoms, and gave the facility information on infection control for long term care facilities which listed responsibilities for reporting symptoms. The documents provided to the facility included handouts describing signs and symptoms of Norovirus, associated gastroenteritis, incubation period, transmisssion, detection, and reporting. Also included was management of outbreak for residents/patients, staff, and environmental disinfection. Included in the information given to the facility was a worksheet to be completed by the facilty and sent to the health department. The health department also gave the facility the Center for Disease Control (CDC) Norovirus illness key facts which described the Norovirus. The virus is described as follows: a highly contagious illness caused by infection with a virus called Norovirus; other names include viral gastroenteritis and stomach flu. The illness can be serious and spreads rapidly. Review of the "Florida Department of Health Guidelines for the Control of Norovirus Outbreaks in Nursing Homes and Health Care Facilities" descibed the Norovirus as follows: "A norovirus outbreak should be suspected if vomiting and diarrhea are about equally common symptoms among people with gastroenteritis (staff & residents). Norovirus - assosciated gastroenteritis outbreaks may be detected early by recognizing the typical symptoms of illness, and controlled by taking specific infection control steps to prevent the virus from being transmitted from person to person . . . . Signs and symptoms of Norovirus illness usually include nausea, vomiting, diarrhea and stomach cramping. Sometimes people experience a low-grade fever, chills, headache, muscle aches and a general sense of tiredness. The illness often begins suddenly. In most people the illness is self-limiting with symptoms [MEDICATION NAME] for one or two days. In general, vomiting is more common in children and diarrhea is more common in adults. Dehydration is a potential life-threatening problem that is usually only seen among the very young, the elderly, and people with underlying medical conditions. The incubation period . . .begins between one and two days following exposure . . . . Persons working in nursing homes . . . . should pay special attention to residents who have symptoms suggestive of a Norovirus infection. This virus is very contagious and can spread very rapidly throughout such settings." Reporting includes the following: "If you observe any unusual increase in residents with GI symptoms or any other illness, report it to your local county health department. The county health department may be able to assist in controlling the outbreak and with laboratory diagnosis." ([DATE]) Also included was outbreak management for isolating residents and staff, environmental disinfection and case surveillance/management. During an interview with the DON on [DATE] at about 4 p.m., she stated she had contacted the health department but she did not remember when and had no documentation to show when she called or to whom she spoke. She stated again she felt the issue was resolved on [DATE] as she had not heard of any more reported symptoms. She also stated she had instituted procedures to control the spread of symptoms but had only done it verbally. No written memos were posted to alert staff, residents, or visitors to the possible GI symptoms in the facility. 5. During an interview with the nurse working the 200 wing on [DATE] at 12:40 p.m., she stated she had been called in to work the ,[DATE] shift because scheduled nurse #A had called in sick with nausea, vomiting and diarrhea. This nurse said she usually works the ,[DATE] shift but was working a double shift on [DATE] to replace nurse #A. During an interview with certified nursing assistant (CNA) #B passing trays on the 300 wing at 5 p.m. on [DATE], she stated none of her residents were currently sick but she had been sick last weekend. On [DATE], she said she had to leave work early because of nausea, vomiting and diarrhea. She called in sick on [DATE] and went to her physician who told her she had some sort of virus. She was off on Tuesday and returned to work on [DATE]. During an interview with the housekeeping supervisor #C on [DATE] at 1:30 p.m., he stated he had developed symptoms on [DATE] and had nausea, vomiting and diarrhea. He returned to work on [DATE]. During an interview with the rehabilitation director at 2 p.m. on [DATE], she said speech therapist #D was out sick with the same symptoms on [DATE] and returned to work on [DATE]. Review of the staffing sheets from ,[DATE]-,[DATE] showed several staff members who called in sick. On [DATE], CNAs #B and #E left their assigned shifts early due to feeling sick. On [DATE], two additional staff members, CNA #F and nurse #G called in sick. On [DATE], nurse #H called in sick, two CNAs were sent home (# I & J) due to illness. On [DATE], nurses #K and #L called in sick due to nausea and vomiting and not feeling well. On [DATE], CNA #M called in sick. On [DATE], nurse #A called in sick due to nausea and vomiting. There was a total of 13 different staff members (#A, B, C, D, E, F, G, H, I, J, K, L & M) who were sick with GI symptoms from ,[DATE]-,[DATE], five (5) nurses, six (6) CNAs, one housekeeping supervisor, and 1 speech therapist. Documentation was not provided by the facility to monitor the pattern of GI symptoms of staff members as experienced by the residents during this time frame. During an interview with the staffing coordinator on [DATE] at 4:30 p.m., she stated she usually does not ask a reason for call offs but plans to ask now. During an interview with the DON on [DATE] at 4 p.m., she said she did not realize the number of staff members who had called in sick. She said that so many of them had to work because they did not have any more leave. She indicated her staff was working while ill. In an interview with the Administrator on [DATE] at 9:30 a.m., she said she was unaware the housekeeping supervisor and speech therapist had also been sick. The facility did not track employees' GI symptoms, which would have shown the trend of GI symptoms in the facility. 6. Record review for resident #2 revealed she was readmitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of her medication administration record (MAR) and nurses' notes revealed the resident had an episode of nausea and loose stools on [DATE] at 6:30 p.m. A record of her bowel movements indicated she had two loose stools on [DATE] on the ,[DATE] shift. Nurse's notes on [DATE] at 11:20 a.m. indicated she was found on the floor in the doorway to her room. She told staff she was on her way to the dining room at that time for lunch. She had hit her head and sustained a skin tear on the right elbow. During an interview with resident #2 on [DATE] at around 3 p.m., she stated she was having trouble with her bowels and "all I (she) had to do was stand up and things ran." During an interview with the floor nurse responsible for resident #2's care on the ,[DATE] shift on [DATE] at 3:45 p.m., she stated the resident had episodes of diarrhea, nausea and vomiting but that was several days ago but did not know exactly when this occurred. 7. Record review for resident #4 revealed he was readmitted to the facility on [DATE] after hospitalization on [DATE] for dehydration, urinary tract infection, and elevated temperature. Nurses' notes on [DATE] at 12 a.m. read, he "started vomiting x 4 this shift at 8:45 (p.m.). Gave [MEDICATION NAME] at 9 p.m. per standing order from MD. Loose stools noted x 3 so far. Had temperature of 100.9." Another note on [DATE] at 1 a.m. stated "temperature 101.8 ... vomited x 1 this shift, small amount. And at 4:30 a.m. temperature was 101.6." The resident was transferred to the hospital on [DATE] at 8:59 a.m. per hospital records. The history and physical at the time of hospital admission on [DATE] indicated the resident was admitted to the hospital "with fever and chills and nausea/vomiting for the last 24 hours ... he was brought to the hospital from the nursing home after . . . . not . . . feeling well for the last 2-or 3 days, not being himself and feeling lethargic per family. He had a couple of bouts of vomiting last night and very feverish and chills yesterday. Temperature 99.4." His hospital assessment included "dehydration, most likely secondary to vomiting and fever." The resident was observed lying quietly in his bed with eyes closed on [DATE] at 3:40 p.m. at the long term care facility. The resident was documented as non-verbal. His medical history included status [REDACTED]. The facility did not track this resident's GI symptoms, which would have shown the trend of GI symptoms in the facility. 8. Record review for resident #5 revealed she was admitted to the facility with [DIAGNOSES REDACTED]. Nurses' notes on [DATE] at 7:30 a.m. revealed the resident "vomited x 3 during the shift. [MEDICATION NAME] 25 mg (milligrams) given at 4 a.m. Resident vomited again at 5:15 a.m. and at 6:45 a.m. Vomit was mostly liquid. Faxed to MD. Temperature 100.1." Review of documentation of bowel movements revealed the resident had loose bowel movements on [DATE] on the ,[DATE] shift and the ,[DATE] shift. The facility did not track this resident's GI symptoms, including previous hospital admission for influenza, which would have shown the trend of GI symptoms in the facility. 9. Record review indicated resident #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation on the facility's 24 Hour Report and in the nurses' notes for [DATE] revealed the resident had nausea/vomiting and diarrhea at 9 p.m. The facility did not track this resident's GI symptoms. During an interview with the resident on [DATE] at 2:45 p.m., she stated she "had not felt well earlier but is doing alright now." During an interview with the CNA responsible for her care at 2:45 p.m., she stated she did not remember when the resident was sick. 10. Record review for resident #7 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. emesis mixed with eggs today. The pt. (resident) refused lunch today." The physician was notified on [DATE] and orders were received to treat the nausea/vomiting. On [DATE] at 12 p.m., a physician's orders [REDACTED]." An additional nurse's note on [DATE] at 6:30 p.m. revealed "complaint of nausea with one episode of emesis." The facility did not track this resident's GI symptoms. During an interview with the CNA responsible for the resident's care on [DATE] at 2:45 p.m. she stated the resident had multiple episodes of diarrhea last week. She remembers because she had to change the resident's bed linens 5 times during that shift. The resident was observed sleeping quietly in bed on [DATE] at 2:45 p.m. and not interviewable at that time. 11. Record review for resident #8 revealed the resident was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Nurses' notes revealed the resident had an episode of "nausea and vomiting x 3 on [DATE] at 10:45 p.m. Gave [MEDICATION NAME] per MD order. Low grade temp of 99." Further nurses' notes on [DATE] at 4 p.m. revealed the resident had another incident of "two incontinent episodes of loose stools noted this afternoon, complained of sick feeling medicated with [MEDICATION NAME] ... no vomiting noted." The facility did not track this resident's two episodes of GI symptoms. During an interview with the UM on 200 wing on [DATE] at 3:30 p.m., she stated this resident was the only resident this morning who had emesis. The resident was observed lying in her bed asleep on [DATE] at 3:30 p.m. and not interviewable at that time. 12. Record review for resident #9 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurses' notes on [DATE] revealed the resident "vomited x 1, [MEDICATION NAME] given with positive effect." Further documentation revealed the resident had an episode of diarrhea. During an interview with the resident on [DATE] at 3:45 p.m., she stated she "felt pretty bad last evening but is feeling better today." During an interview on [DATE] at 3:45 p.m. with the resident's husband, he indicated he was aware of the outbreak and felt fortunate he had not come down with something as yet since he was in the building every day. During an interview with the 200 wing UM at 4 p.m., she stated the resident had no further episodes of nausea and vomiting. The facility did not track this resident's GI symptoms. 13. Record review for resident #10 revealed he was admitted to the facility and was on Hospice care. He was not on crisis care and nurses' notes from ,[DATE]-,[DATE] revealed the resident was stable, did not have any complaints of pain or discomfort, and his appetite was good. Nurses' notes on [DATE] at 3:15 a.m. revealed the resident had an "extra, extra large bowel movement" with no vomiting. Nurses' notes at 6:30 a.m. revealed the resident had a small loose bowel movement. Nurses' notes at 9:15 a.m. revealed the resident had died . The facility did not track this resident's GI symptoms. 14. Record review for resident #11 revealed she was admitted to the facility with a [DIAGNOSES REDACTED]. stool this shift, no appetite, meds withheld due to emesis x 1. Vitals taken, resident having congestion and elevated temperature (102). Sent to hospital for evaluation." Hospital records revealed the resident expired at the hospital from respiratory arrest. Interview with the hospital risk manager on [DATE] at approxiamtely 3 p.m. by the office supervisor revealed that a cause of death/death certificate was not available because the resident died in the emergency room . The facility did not track this resident's GI symptoms. 15. Resident #12's Medication Administration Record (MAR) revealed she received two doses of [MEDICATION NAME] at 12 p.m. on [DATE] and at 9:30 a.m. on [DATE] for complaints of nausea. 16. During an interview with the Medical Director on [DATE] at 4 p.m., he stated the facility should have tracked the residents with symptoms in order to identify a trend. He said he was not aware of 16 residents who had GI symptoms throughout the facility and said facility staff did not notify him of the suspected outbreak until [DATE], the day after the survey began. He said he would be in on [DATE], the day after survey exit, to work with the nursing staff, developing a plan to control the outbreak and help institute it in his role as medical director. The medical director needed to implement procedures to track and trend GI symptoms after the initial two residents were identified with GI symptoms on [DATE] (#12) and [DATE] (#7). 17. Review of the infection control log showed the last entry as [DATE] as a urinary tract infection. The log did not show any gastrointestinal (GI) issues. During an interview with the corporate nurse on [DATE] at 4:30 p.m., she stated no issues with infection control have been identified during QA and she agreed the facility should have tracked the episodes of GI symptoms to identify the outbreak and to develop an effective comprehensive plan of action to prevent the spread of the infection. The facility did not track residents' and employees' GI symptoms. The facility policy stated a procedure was to be implemented after two resident were identified with GI symptoms. 18. MARs for all 119 active and two discharged residents were reviewed. Of the 119 active resident MARs, 16 had physician orders [REDACTED]. Twelve (12) residents were given [MEDICATION NAME] between [DATE] and [DATE], #4, #5, #7, #8, #9, #12, #40, #41, #42, #43, #44 and #45. Resident #40 received two doses of [MEDICATION NAME] on [DATE]. Resident #41 received one dose of [MEDICATION NAME] on [DATE]. Resident #42 received one dose of [MEDICATION NAME] on [DATE]. Resident #43 received one dose on [DATE]. Resident #44 received one dose on [DATE]. Resident #45 received two doses of [MEDICATION NAME] on [DATE]. Resident #45 received two doses of [MEDICATION NAME] on [DATE]. 19. During an observation in the 200 wing atrium on [DATE] at 5 p.m., a CNA was observed hugging several residents in succession without washing her hands. Inservices on hand washing had been given to all staff on [DATE], [DATE] and [DATE]. 20. In an interview with the Infection Control Preventionist on [DATE] at 4 p.m., she said she was not aware of the staff sick calls until the surveyor notified her at that time. She also said she only knew of one resident, #2, who had symptoms of nausea, vomiting and diarrhea. Responsibilities of a Infection Control Preventionist include tracking and trending GI symptoms to establish a potential pattern of Norovirus or GI Influenza, and to establish preventative measures to prevent the spread of GI symptoms/Influenza.

Based on observations, interviews and record review, the facility failed to control the spread of gastrointestinal (GI) symptoms of nausea, vomiting and diarrhea from 2/15/11 to the present, failed to monitor resident GI symptoms, resulting in inaccurate collected data to implement an effective comprehensive plan of action to prevent the spread of these GI symptoms, failed to follow their policy on "Norovirus or Norovirus Like Symptoms - Preventing the Spread", failed to follow the Florida Department of Health Recommendations and Guidelines for the Control of Norovirus outbreaks in Nursing Homes and Health Care Facilities, failed to oversee an effective infection prevention and control program from 2/15/11 to present, and failed to notify the medical director of all residents with GI symptoms. This resulted in widespread Immediate Jeopardy for all residents on 3 of 3 wings (100, 200 & 300) and staff. Residents in long term care facilities are at a higher risk for transmission of Norovirus-like/GI symptoms and complications. It can be introduced through facility staff and visitors, and once spread, controlling it can be difficult. Immediate Jeopardy was identified 2/28/11 as starting on 2/15/11. The director of nursing (DON) was advised on 2/28/11. Ongoing Jeopardy was determined at the exit on 3/01/11. The findings are: 1. Cross Refer to F441. During an interview with the administrator and DON on 2/28/11 at 9:15 a.m. and resident observations from 10 a.m. on 2/28/11 until 3/01/11 at 3:30 p.m., the facility administration failed to maintain an infection prevention and control program from 2/15/11 to present that would investigate, control and prevent infections in the facility. When residents began to experience Norovirus-like symptoms on 2/15/11, administration failed to provide proof of the collection of resident infection data for those residents, resulting in the inability to analyze the collected data in order to develop an effective comprehensive plan of action to prevent the spread of the infection. Administration failed to ensure staff was promptly educated in principles of infection control in an effort to prevent the spread of the infection other than review of good handwashing protocols which was conducted on 2/21/11, six days after the initial occurrence of symptoms of nausea, vomiting and diarrhea. The administration failed to notify the local health department promptly [MEDICAL CONDITION] symptoms occurred in the facility. These failures resulted in the spread of the symptoms to residents on 3 of 3 units with the potential for harm at the Immediate Jeopardy level for all residents in the facility. The sampled residents included 16 of 28 residents (#2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 40, 41, 42, 43, 44 & 45) identified with GI symptoms in a facility with a census of 119, which affected 13.4% of the resident population. 2. Cross Refer to F501. Interviews and record reviews revealed administration failed to collaborate with the medical director to coordinate and evaluate the medical care for 10 of 28 residents (#2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 40, 41, 42, 43, 44 & 45) identified with GI symptoms on all 3 wings (100, 200 & 300), which affected 13.4% of the resident population. This resulted in the lack of the development and implementation of prevention and protection measures to decrease the spread of [MEDICAL CONDITION] gastrointestinal symptoms to other residents, staff and visitors.

Based on interview and record review, the facility failed to contact the medical director to coordinate and evaluate the medical care when two residents had gastrointestinal (GI) symptoms including nausea, vomiting and diarrhea. This resulted in the lack of the development and implementation of prevention and protection measures to decrease the spread of GI symptoms to other residents. Failure of the medical director to implement protective measures resulted in 16 of 28 residents (#2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 40, 41, 42, 43, 44 & 45) having GI symptoms on all 3 wings, which affected 13.4% of the resident population. The census was 119 residents at the time of the survey. Residents in long term care facilities are at a higher risk for transmission of GI symptoms and complications. It can be introduced through facility staff and visitors, and once spread, controlling it can be difficult. Widespread Immediate Jeopardy was identified [DATE] as staring on [DATE]. The director of nursing was advised on [DATE]. Ongoing Jeopardy was determined at the exit on [DATE]. The findings are: 1. During an interview with the Administrator and the Director of Nursing (DON) on [DATE] at 9:15 a.m., the DON stated the facility had an outbreak of GI symptoms a couple of weeks ago but was now resolved. She stated the last reported infection was [DATE]. She was told by the weekend supervisor on [DATE] that there was an outbreak and the supervisor had instituted precautions (hand washing education, posted signs and kept residents on their units for dining and activities) to prevent the spread of infection. When the DON returned to work on [DATE], she was told no further incidents of the infections had occurred, she considered it resolved, and as a result she removed the previous instituted precautions to prevent the spread of infection. The Administrator stated they did not report the event to the health department and the Agency for Health Care Administration (AHCA) as required. The DON stated she did not know she could contact the health department on the weekend. The DON stated she did not know which residents were affected on [DATE] but she did start a preliminary investigation based on the facility Policy and Procedure for "Norovirus or Norovirus like Symptoms - Preventing the Spread." The action plan initiated [DATE] showed the issue of Nausea, Vomiting, and/or Diarrhea, the action taken, System Changes were none, and Monitoring -action plan reported through Quality Improvement which was to be presented to the Quality Assurance committee on [DATE]. When asked if the medical director had been notified, she said "No". During an telephone interview with the Medical Director on [DATE] at 4 p.m., he stated the facility should have tracked the residents with GI symptoms in order to identify a trend. He said he was not aware of 16 residents and 12 staff members who had GI symptoms throughout the facility and said facility staff did not notify him of the suspected outbreak until [DATE], the day after the survey began. The medical director said he would be in the facility on [DATE], the day after the exit date of the survey, to work with the nursing staff, developing a plan to control the outbreak and help institute it in his role as medical director. The medical director needed to implement procedures to track and trend GI symptoms after two residents were identified on [DATE] with initial GI symptoms on [DATE] (#12) and [DATE] (#7). Review of the primary care physicians for the sampled residents revealed the medical director was the alternative physician for all 16 sampled residents. 2. Review of resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurses' notes on [DATE] at 11:20 a.m. indicated she was found on the floor in the doorway to her room. She said she was on her way to the dining room at that time for lunch. She had hit her head and sustained a skin tear on the right elbow. During an interview on [DATE] at around 3 p.m., she stated she was having trouble with her bowels and "all I (she) had to do was stand up and things ran." During an interview with the floor nurse responsible for her care on the ,[DATE] shift on [DATE] at 3:45 p.m., she stated the resident had episodes of diarrhea and nausea/vomiting but that was several days ago. 3. Record review for resident #4 revealed he was readmitted to the facility on [DATE] after hospitalization [DATE] for dehydration, urinary tract infection, and elevated temperature. Nurses' notes on [DATE] at 12 a.m. read, he "started vomiting x 4 this shift at 8:45 (p.m.). Gave [MEDICATION NAME] at 9 p.m. per standing order from MD. Loose stools noted x 3 so far. Had temperature of 100.9." Another note on [DATE] at 1 a.m. stated "temperature 101.8 ... vomited x 1 this shift, small amount. And at 4:30 a.m. temperature was 101.6." The resident was transferred to the hospital on [DATE] at 8:59 a.m. per hospital records. The history and physical at the time of hospital admission on [DATE] indicated the resident was admitted to the hospital "with fever and chills and nausea/vomiting for the last 24 hours ... he was brought to the hospital from the nursing home after . . . . not . . . feeling well for the last 2-or 3 days, not being himself and feeling lethargic per family. He had a couple of bouts of vomiting last night and very feverish and chills yesterday. Temperature 99.4." His assessment and plan included "dehydration, most likely secondary to vomiting and fever." 4. Record review for resident #5 revealed she was admitted to the facility with [DIAGNOSES REDACTED]. Nurses' notes on [DATE] at 7:30 a.m. revealed the resident "vomited x 3 during the shift. [MEDICATION NAME] 25 mg (milligrams) given at 4 a.m. Resident vomited again at 5:15 a.m. and at 6:45 a.m. Vomit was mostly liquid. Faxed to MD. Temperature 100.1." Review of documentation of bowel movements revealed the resident had loose bowel movements on [DATE] on the ,[DATE] shift and the ,[DATE] shift. 5. Record review indicated resident #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation on the facility's 24 Hour Report and in the nurses' notes for [DATE] revealed the resident had nausea/vomiting and diarrhea at 9 p.m. 6. Record review for resident #7 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. emesis mixed with eggs today. The pt. (resident) refused lunch today." The physician was notified on [DATE] and orders were received to treat the nausea/vomiting. On [DATE] at 12 p.m., a physician's orders [REDACTED]." An additional nurse's note on [DATE] at 6:30 p.m. revealed "complaint of nausea with one episode of emesis." During an interview with the CNA responsible for the resident's care on [DATE] at 2:45 p.m. she stated the resident had multiple episodes of diarrhea last week. She remembers because she had to change the resident's bed linens 5 times during that shift. The resident was observed sleeping quietly in bed on [DATE] at 2:45 p.m. 7. Record review for resident #8 revealed the resident was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Nurses' notes revealed the resident had an episode of nausea and vomiting x 3 on [DATE] at 10:45 p.m. Gave [MEDICATION NAME] per MD order. Low grade temp of 99." Further nurses' notes on [DATE] at 4 p.m. revealed the resident had two incontinent episodes of loose stools noted this afternoon, complained of sick feeling medicated with [MEDICATION NAME] ... no vomiting noted." During an interview with the UM on 200 wing on [DATE] at 3:30 p.m., she stated this resident was the only resident this morning who had emesis. The resident was observed lying in her bed asleep on [DATE] at 3:30 p.m. and not interviewable at that time. 8. Record review for resident #9 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurses' notes on [DATE] revealed the resident vomited x 1, [MEDICATION NAME] given with positive effect. Further documentation revealed the resident had an episode of diarrhea. During an interview with the resident on [DATE] at 3:45 p.m., she stated she "felt pretty bad last evening but is feeling better today." During an interview on [DATE] at 3:45 p.m. with the resident's husband, he indicated he was aware of the outbreak and felt fortunate he had not come down with something as yet since he is in the building every day. During an interview with the 200 wing UM at 4 p.m., she stated the resident has had no further episodes of nausea and vomiting. 9. Record review for resident #10 revealed he was admitted to the facility and was on Hospice care. He was not on crisis care and nurses' notes from ,[DATE]-,[DATE] revealed the resident was stable and did not have any complaints of pain or discomfort and his appetite was good. Nurses' notes on [DATE] at 3:15 a.m. revealed the resident had an "extra, extra large bowel movement" with no vomiting. Nurses' notes at 6:30 a.m. revealed the resident had a small loose bowel movement. Nurses' notes at 9:15 a.m. revealed the resident had died . 10. Record review for resident #11 revealed she was admitted to the facility with a [DIAGNOSES REDACTED]. stool this shift, no appetite, meds withheld due to emesis x 1. Vitals taken, resident having congestion and elevated temperature (102). Sent to hospital for evaluation." Hospital records revealed the resident expired at the hospital from respiratory arrest. 11. Resident #12's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] doses of [MEDICATION NAME] at 12 p.m. on [DATE] and at 9:30 a.m. on [DATE]. 12. MARs for all 119 active and two discharged residents were reviewed. Of the 119 active resident MARs, 16 had physician orders [REDACTED]. Twelve (12) residents were given [MEDICATION NAME] between [DATE] and [DATE], #4, #5, #7, #8, #9, #12, #40, #41, #42, #43, #44 & #45. Resident #40 received two doses of [MEDICATION NAME] on [DATE]. Resident #41 received one dose of [MEDICATION NAME] on [DATE]. Resident #42 received one dose of [MEDICATION NAME] on [DATE]. Resident #43 received one dose on [DATE]. Resident #44 received one dose on [DATE]. Resident #45 received two doses of [MEDICATION NAME] on [DATE]. Resident #45 received two doses of [MEDICATION NAME] on [DATE]. 13. During an interview with the floor nurse working the 200 wing on [DATE] at 12:40 p.m., she stated she had been called in to work the ,[DATE] shift because scheduled nurse #A had called in sick because of nausea/vomiting and diarrhea. She usually works the ,[DATE] shift but was working a double shift to cover nurse #A. 14. During an interview with a certified nursing assistant (CNA) passing trays on the 300 wing at 5 p.m. on [DATE], she stated none of her residents were currently sick but she had been sick last weekend. On [DATE], she said she had to leave work early because of nausea/vomiting and diarrhea. She called in sick on [DATE] and went to her physician who told her she had some sort of virus. She was off on Tuesday and returned to work on [DATE]. 15. During an interview with the housekeeping supervisor on [DATE] at 1:30 p.m., he stated he had developed symptoms on [DATE] and had nausea/vomiting and diarrhea. He returned to work on [DATE]. 16. During an interview with the Rehabilitation Director at 2 p.m. on [DATE], she stated her speech therapist was out sick with the same symptoms on [DATE] and returned to work on [DATE]. 17. Review of the staffing sheets from ,[DATE]-,[DATE] showed several staff members who called in sick. On [DATE], two CNAs left their assigned shifts early due to feeling sick. On [DATE], two additional staff members called in sick. On [DATE], six staff members called in feeling sick and 2 staff had to leave early due to illness. On [DATE], two staff called in sick due to nausea and vomiting or not feeling well. On [DATE], one staff member called in sick. On [DATE], one nurse called in sick due to nausea and vomiting for a total of 12 different staff. 18. During an interview with the staffing coordinator on [DATE] at 4:30 p.m., she stated she usually does not ask a reason for call offs but plans to ask now. During an interview with the DON on [DATE] at 4 p.m., she said she did not realize that many staff members had called in. She said that so many of them had to work because they did not have any more leave. She indicated her staff was working while ill. In an interview with the Administrator on [DATE] at 9:30 a.m., she said she was unaware the housekeeping supervisor and speech therapist had been sick.