Every finding on record at Vero Beach Care Center

Based on interview and record review, the facility failed to obtain a completed informed consent (with date) for residents prescribed psychotropic medications for 1 of 5 sampled residents reviewed for unnecessary medication review, Resident #9. The findings included:Review of the facility's policy, titled, Medication Utilization and Prescribing - Clinical Protocol, with a revised date of 01/2024, included in part the following: Consent for medications including but not limited to psychotropic medications are included in the consent to treat. Review of the facility's policy, titled, Documentation, with a revised date of 01/2026, included in part the following: Documentation for procedure and treatments will include care-specific details, including the date and time the procedure/treatment was provided. Record review for Resident #9 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Generalized Anxiety Disorder, Cognitive Communication Deficit, Dementia, Unspecified Mood (Affective) Disorder, Bipolar Disorder, and Major Depressive Disorder. Review of the Minimum Data Set assessment dated [DATE] documented in Section C, a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #9 revealed in part the following:An order dated 09/24/25 for Lithium Carbonate Oral Capsule 300 MG Give 300 mg by mouth two times a day related to Bipolar Disorder.An order dated 09/24/25 for Zoloft Oral Tablet 100 MG (Sertraline HCl) Give 100 mg by mouth one time a day related to Major Depressive Disorder. An order dated 09/24/25 for Nuedexta Oral Capsule 20-10 MG (Dextromethorphan HBr-Quinidine Sulfate) Give 1 capsule by mouth one time a day related to Pseudobulbar Affect. Review of the Psychoactive Medication Informed Consent for Resident #9 revealed 5 separate consents for the following: Seroquel XR 150mg, Keppra 1,000mg, Nuedexta 20-10mg, Zoloft 100mg, and Lithium Carbonate 300mg. All consent forms documented a verbal consent from the resident representative, signed by 2 staff members and no date on any part of any of the 5 consents. During an interview conducted on 02/18/26 at 4:30 PM with Director of Nursing (DON), the DON who confirmed there were no dates on any of the informed consents (5) for Resident #9 and that the informed consents should have a date on them.

Based on interviews and record reviews, the facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving psychotropic medications for 1 of 5 sampled residents reviewed for unnecessary medications, Residents #9. The finding included:Review of the facility's policy titled, Medication Utilization and Prescribing - Clinical Protocol, with a revised date of 01/2024, included in part the following: The physician and staff will identify situations in which a resident is taking medications associated with potentially significant medication-related problems such as allergies, drug-drug interactions, drug-food interactions and adverse drug reactions. The physician and IDT (Interdisciplinary Team) will identify significant factors that may affect medication effectiveness and medication related problems. Risks and benefits of utilization of psychotropic mediations will be reviewed with resident and/or responsible party prior to initiation or increased dose as indicated. Record review for Resident #9 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Generalized Anxiety Disordr, Cognitive Communication Deficit, Dementia, Unspecified Mood (Affective) Disorder, Bipolar Disorder, and Major Depressive Disorder. The Minimum Data Set, dated [DATE] documented in Section C, a Brief Interview of Mental Status score of 10 indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #9 revealed in part the following:An order dated 09/24/25 for Lithium Carbonate oral capsule 300mg give 300 mg by mouth two times a day related to Bipolar Disorder.An order dated 09/24/25 for Zoloft oral tablet 100mg (Sertraline HCl) give 100mg by mouth one time a day related to Major Depressive Disorder. An order dated 09/24/25 for Nuedexta oral capsule 20-10mg (Dextromethorphan HBr-Quinidine Sulfate) give 1 capsule by mouth one time a day related to Pseudobulbar Affect.An order dated 09/24/25 for Behavior: Enter # in Supplementary Documentation: 0 No behaviors; 1 Aggressiveness 2 Wandering; 3 Agitated; 4 Angry Comments; 5 Anxiety; 6 Avoidance/Resisting Care; 7 Compulsive Actions; 8 Crying; 9 Delusion/Paranoia; 10 Depressed/Withdrawn; 11 Fear/Panic; 12 Hallucinations; 13 Insomnia; 14 Jittery/Nervous; 15 Mood Changes; 16 Noisy/Yelling; 17 Pacing; 18 Pulling Tube (NG, Cath, IV); 19 Other enter note every shift for Use of Psychoactive Medication Non-Pharm Intervention: 0 Not applicable; 1 1:1; 2 Activity; 3 Back-rub/Touch; 4 Change Position; 5 Change Environment 6 Give Fluids; 7 Food; 8 Redirect; 9 Toilet; 10 Other - enter nurses note. Effectiveness I Improved, NC No Change, W WorseAn order dated 09/24/25 for Side Effects of psychotropic Medications - Including: Sedation, Insomnia, increased agitation, dry mouth, increased thirst every shift for Medication Side Effects Observations Select 'Y' if monitored and none of observed Select N' if monitored and side effect WERE observed. Select chart code Medication Side Effects Observation' and document behaviors in progress note. Review of the Medication Administration Record for Resident #9 for month of February 2026 documented in part the following:On 02/06/26, day shift, behaviors of 1, 3, and 7 indicating aggression agitated and compulsive action with an intervention as 19 indicating other see notes.On 02/08/26, night shift, 1 and 6 indicating agitated and avoidance/resisting with the intervention as N/A (not applicable).On 02/01/26, day and evening shift, on 02/06/26 day shift, on 02/09/26 day, evening and night shift, and on 02/10/26 day shift, all documented an N indicating side effects observed. Review of Progress Nots for Resident #9 from 02/01/26 to 02/10/26 revealed no documentation of notes related to behaviors or side effects. During an interview conducted on 02/18/26 at 4:30 PM with the Director of Nursing (DON), the DON confirmed the documentation for behaviors and side effects for Resident #9 were incomplete.

Based on record review and interview, the facility failed to ensure residents who were trauma survivors had triggers identified and implemented in the care plan in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 sampled resident review for Post Traumatic Stress Disorder (PTSD), Resident #7. The findings included: Review of Resident #7's records revealed Resident #7 was admitted to the facility on [DATE] and readmitted [DATE] from the hospital, with diagnoses that included PTSD (Post Traumatic Stress Disorder), Major Depressive Disorder, Generalized Anxiety, Insomnia, Type II Diabetes, Coronary Artery Disease, Alcoholic Cardiomyopathy, Migraines, Muscle Weakness and Chronic Obstructive Disease. (COPD). Review of Resident #7 MDS (Minimum Data Set) Medicare 5-day assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognition impairment.Review of the resident's care plan documented the resident has experienced a traumatic event which has impacted the resident's emotional health as evidence by the diagnosis of PTSD. The interventions in place included: Refer to psychiatric/psychological services as needed, Alert MD/designee of any significant changes in behavior, Encourage and assist resident with activities of choice, Encourage and assist the resident to have contact with family/friends as able, Encourage expression of feelings/concerns/thoughts, Provide a quiet, non-threatening environment as indicated, and Respect resident's space and privacy. The care plan did not mention anything about his triggers.Review of a Psychiatric note dated 02/12/26 documented a history of PTSD and the history suggests that this resident had suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the past, with the symptoms having caused significant distress and functional impairment to the resident, having lasted for more than one month and have occurred without any substance use or organic brain pathology. Care Plan for PTSD diagnosis: Trauma: [Name] war, Triggers: Loud noises - stranger. Care Plan: Medications management refer to psychology for psychotherapy. Review of the resident's admission dated 12/24/25 did not document the resident has PTSD. Review of the Social Service assessment dated [DATE] documented under the Trauma screen 'no PTSD' and 'no military experience', as the baseline; and for 12/25/26 it did not document any PTSD. When he was readmitted from the hospital on [DATE], there was documentation of PTSD.During an interview with the resident on 02/16/26 at 1:30 PM, he was asked about PTSD and asked about his triggers. He was unable to verbalize what his triggers were but did say that he was in the military.During an interview on 02/17/26 at 2:26 PM with Staff I, LPN (Licensed Practical Nurse), she was asked about Resident #7 having PTSD. She stated she knew he had PTSD but when asked what his triggers were, she stated she did not know what they were. She then stated he had a change in condition (had a stroke).During an interview on 02/18/26 at 11:20 AM with Staff M, LPN, she was asked about Resident #7's PTSD, and stated she knows he has it. When asked what his triggers were, she stated she didn't know.During an interview on 02/18/26 at 11:24 AM with Staff E, LPN MDS Coordinator, she was asked about the resident and his PTSD. The surveyor asked if they were supposed to document his triggers in the care plan, and she stated they should, but it is Social Services person that does the assessments and the care plan for PTSD. She stated that 'right now we don't have a Social Service Director'. She acknowledged that she did not see any care plans that document his triggers though he does have a PTSD care plan.

Based on policy review, record review and interview, the facility failed to ensure pain management for 1 of 4 sampled residents, as evidenced by the failure to provide pain medication as per physician's orders for Resident #66.The findings included:Review of the policy, titled, Medication Administration, issued on 10/2020 and revised on 01/2024, documented in part, 22. Medications, including narcotics, will be reordered as needed with practitioner approval unless otherwise indicated (auto-refill from pharmacy, emergency medication supply use).Review of the record revealed Resident #66 was admitted to the facility on [DATE] with a diagnosis that included Alcohol Dependence, Chronic Obstructive Pulmonary Disease (COPD), Opioid Dependence, Chronic Pain Syndrome, Pain in Right and Left Knees, and Other Low Back Pain. Review of the most current Minimum Data Set (MDS) assessment documented that Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of physician order, dated 12/02/25, documented, in part, Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 4 hours for break through pain. Review of the Medication Administration Record (MAR) for 02/16/26 and 02/17/26 revealed missing doses with code 12, Medication on order from pharmacy. Further review of the MAR revealed that Resident #66 had a pain level of 5/10 on the night shift of 02/16/26 after the 3rd dose of 5 MG Oxycodone was not given. Resident #66's pain level had been at zero when the medication was given as prescribed.An initial interview was conducted on 02/16/26 at 12:50 PM with Resident #66 who stated that the facility ran out of his pain medication today. I have three vertebrae that are destroyed.An interview was conducted on 02/18/26 at 9:20 AM with Resident #66 who stated he had only received one dose of the pain medication when they ran out of it on Monday night and Tuesday morning, I felt pain, and was sleepy, and cold.An interview was conducted on 02/19/26 at 12:57 PM with Staff D, Licensed Practical Nurse (LPN), Manager for Unit 1, who stated that she was not working on 02/16/26 but was advised of the issue with Resident #66's medication and that the Manager for Unit 2 ended her employment with the facility on Friday 02/13/26, and there was a nurse who typically was assigned to Resident #66 who also ended her employment on 02/13/26 and nobody had contacted the pain management doctor to renew the medication order until Staff D was advised. Staff D was asked if the medication could have been given to the resident from the Medbank machine and Staff D stated that if the prescription is not current, the Medbank machine does not provide the code needed to get the narcotic medication. Staff D confirmed that the facility should have contacted the physician prior running out of the pain medication.

Based on observation, record review, and interview, the facility failed to ensure care and services for oxygen equipment for 1 of 2 sampled residents as evidenced by the failure to clean the oxygen filter for Resident #77.The findings included:Review of the record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses to include COPD (chronic obstructive pulmonary disease, a progressive lung disease making it difficult to breathe) and shortness of breath. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident was on oxygen therapy.Physician orders documented as of 01/30/26, Resident #77 was receiving oxygen continuously at 2 liters per minute for shortness of breath. The current orders documented instructions for staff to change the oxygen tubing weekly, but lacked any orders related to cleaning of the oxygen canister filter.A current care plan that was initiated on 04/15/25 documented that the resident was at risk for altered respiratory status and difficulty breathing related to episodes of shortness of breath and pneumonia.During an observation and interview on 02/16/26 at 11:21 AM, Resident #77 was lying in bed with oxygen running at 2 liters per minute. The resident stated the oxygen tubing had been changed that day. The filter on the back of the concentrator (the machine that delivered the oxygen to the resident) was dust ladened and appeared gray instead of black.During a second observation on 02/17/26 at 10:32 AM, the oxygen filter remained in the same dirty condition. When asked if he knew if anyone cleaned or changed the oxygen filter, the resident stated he was unsure.Photographic Evidence Obtained.During an interview and observation on 02/19/26 at 1:30 PM, when asked who was responsible for cleaning the oxygen filters, the Assistant Director of Nursing (ADON) stated she thought it was the Central Supply staff. When asked if she was responsible for the cleaning of the oxygen filters, the Central Supply staff person stated she was. When asked about the process, the Central Supply staff person stated she just knew who had oxygen. She further explained she washes the filters weekly but often gets asked to do something else or find something else from multiple staff and gets distracted. When asked about the filter for Resident #77, she agreed it had been missed, was dirty, and was unsure exactly what happened. Photographic Evidence Obtained.

Based on observations interviews and record review, the facility failed to ensure residents with indwelling urinary catheters have care provided for indwelling urinary catheter for 1 of 4 sampled residents reviewed for urinary catheter or UTI (Urinary Tract Infection), Resident #14; failed to ensure indwelling urinary catheters were maintained in a manner to prevent infection for 1 of 4 sampled residents reviewed for urinary catheter or UTI, Resident #68; and failed to ensure proper peri care for 1 of 4 sampled resident reviewed for Urinary catheter/UTI, Resident #41. The findings included: Review of the facility's policy, titled, Catheter Care -Quality of Care, with a revised date of 01/2024, included in part the following: Routine hygiene and care of the peri area is appropriate when providing incontinence care and bathing. Ensure the drainage spigot is not touching the floor. 1. Record review for Resident #68 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, and acute Cystitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented in Section C, a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. Review of the Physician's Orders for Resident #68 revealed in part the following: An order dated 01/28/26 for Suprapubic Urinary Catheter: Monitor every shift. Notify the physician of changes in urinary appearance (color, consistency, odor, etc.) and/or no urinary output. An order dated 01/28/26 for Suprapubic Urinary Catheter: Size 22fr 30ml for Diagnosis of: Obstructive and Reflux Uropathy. During an interview conducted on 02/16/26 at 10:30 AM with Resident #68 who was asked about urinary tract infections (UTI), she said she has urinary tract infections quite frequently. On 02/16/26 at 10:30 AM, an observation was made of Resident #68 sitting up in bed with indwelling urinary catheter drainage bag suspended from the bed frame with the drain out of the drain holder and it was touching the floor. On 02/16/26 at 12:00 PM, a second observation was made of Resident #68 lying in bed with indwelling urinary catheter drainage bag suspended from the bed frame with the drain out of the drain holder and was touching the floor. On 02/18/26 at 8:00 AM a side-by-side observation was made with Staff A, Registered Nurse (RN), who acknowledged Resident #68 had an unsecured indwelling urinary drainage tube and the drain for the urinary drainage bag was out of the drain holder. During an interview conducted on 02/18/26 at 9:15 AM with Staff B, Certified Nursing Assistant (CNA), and Staff C, CNA, when asked about the catheter drainage bag and if the drainage tube needs to be secured, they both said yes. When asked if the drain needs to be in the drain holder, they both said yes. Staff B stated you never to leave the drain out. Staff C stated if you leave the drain out it can catch bacteria. 2. Record review for Resident #14 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Fracture of Unspecified Part of Neck of Right Femur, Unspecified Fall, Anxiety Disorder, and Dementia. The MDS assessment dated [DATE] documented in Section C, a BIMS score of 2 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #14 revealed in part the following: An order dated 02/12/26 to insert Foley every night shift for urinary retention for 1 Day There was no active order for indwelling urinary catheter care. Review of the Medication Administration Record, Treatment Administration Record and progress notes for Resident #14 for the month of February 2026 revealed no documentation of catheter care being performed On 02/16/26 at 11:00 AM, an observation was made of Resident #14 sleeping in bed with indwelling urinary catheter drainage bag suspended from bed frame, with privacy cover in place. On 02/16/26 at 1:14 PM, a second observation was made of Resident #14 sleeping in bed with indwelling urinary catheter drainage bag suspended from bed frame, with privacy cover in place. An interview was conducted on 02/17/26 at 7:45 AM with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who was asked about catheter care. She stated each resident should have an order for the catheter care and the nurse would document the care performed on the Treatment Administration Record. When asked specifically about Resident #14, she acknowledged the resident had an indwelling urinary catheter since 02/12/26 with no catheter care documented from 02/12/26 to 02/17/26. 3. Review of the Incontinence/Perineal (area between the anus and the external genitalia) Care for a Female Competency checklist documented, 12. Washing the genital area, turn the resident to their side, wash the rectal area moving from the front to the back using a clean area of the washcloth each time. Review of the record revealed Resident #41 was admitted to the facility on [DATE] with an admitting diagnosis of ESBL (Extended-Spectrum Beta-Lactamase, an enzyme produced by bacteria that is resistant to many antibiotics) of the urine, indicating a severe urinary tract infection (UTI). Review of the admission MDS assessment dated [DATE] documented the resident had a BIMS score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident was always incontinent of urine with a UTI in the past 30 days. During an interview on 02/16/26 at 11:34 AM, Resident #41 stated she has a UTI and it hurt when she urinated. The record documented Resident #41 was currently on an antibiotic for a UTI. The record lacked any documented excoriation to the perineal area. During an observation on 02/18/26 at 12:06 PM, Staff G, Certified Nursing Assistant (CNA), provided personal care to Resident #41. The resident's groin and buttock were notably red and excoriated overall. During the care Resident #41 stated it was hurting but told the CNA to continue. After cleaning the front of the resident, the CNA cleaned the buttock and anal area of the resident by wiping each time from the back to the front, toward the urethra (area where urine exits the body), and opposite the checklist directions. During an interview on 02/18/26 at 12:40 PM, when asked in what direction she should clean the resident's perineal area, Staff G stated from front to back, and then confirmed she cleaned back to front. When asked about the redness, the CNA stated the resident had been on a zinc ointment treatment for some time.

Based on policy review, record review, and interview, the facility failed to ensure appropriate care and services for 6 of 44 sampled residents as evidenced by the failure to ensure hospice nursing services for Resident #29; failure to ensure timely medication administration for Residents #110, #155, and #169; and failure to follow physician ordered blood pressure parameters for Residents #1 and #41. Findings include:Review of the Hospice Agreement dated January 5, 2024, between the hospice agency and the facility indicated: Hospice agrees to provide services to eligible residents according to a hospice plan. Regulations require that each hospice patient has a hospice plan, and that all services provided be consistent with such plan. Hospice shall provide the appropriate scope and frequency of services individualized to patient needs. Home shall prepare and maintain medical records for each hospice patient receiving services pursuant to the agreement. Medical records shall consist of progress notes describing all services and events. Hospice, in conjunction with the patient, family, and facility, schedules visits as indicated in the hospice plan. This includes visits from all team members. The scope and frequency of services will reflect the needs of the patient. 1. Clinical record review revealed Resident #29 was admitted to the facility on [DATE] and 10/12/22. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 00, indicating significant cognitive impairment. Review of the physician order dated 08/19/25 indicated admission to hospice services related to Cerebral Atherosclerosis. Review of the care plan revised 01/20/26 documented the resident was receiving Palliative and/or Hospice Services. Review revealed the Hospice Recertification Period was from 11/17/25 through 02/14/26. Review of the Orders indicated Skilled Nursing: 1 visit per week for 13 weeks (effective 11/17/25); Home Health Aide (HHA): 1 visit per week for 1 week (effective 12/28/25); and then 2 visits per week for 6 weeks. Review of the documentation lacked evidence of required HHA visits for multiple weeks, as follows: 01/11/26–01/17/26: Only 1 documented visit (01/12/26); no evidence of second required visit. 01/18/26–01/24/26: Only 1 documented visit (01/22/26); second required visit not evidenced. 01/25/26–01/31/26: No documented HHA visits. 02/08/26–02/14/26: No documented HHA visits. Due to lack of documentation, there was no evidence ordered services were provided. Review of the documentation lacked evidence of weekly skilled nurse visits for the following weeks: 11/23/25–11/29/25 12/07/25–12/13/25 12/14/25–12/20/25 12/21/25–12/27/25 01/11/26–01/17/26 01/25/26–01/31/26 02/01/26–02/07/26 02/08/26–02/14/26 There was no documented evidence to support that ordered skilled nursing visits were completed. On 02/19/26 at 9:32 AM, an interview and side-by-side record review was conducted with the Director of Nursing (DON). When asked to provide documentation of the hospice nurse and HHA visits in accordance with the recertification period (11/17/25–02/14/26), the DON acknowledged a lack of documented visits in the facility record. When asked how often the hospice nurse and aides were scheduled to visit Resident #29, the DON did not provide a response. When asked how hospice visits were tracked, the DON stated that hospice typically emails visit notes to the facility. The DON contacted the hospice agency and requested documentation for the specified certification period. Documentation was not provided to account for the required visits. On 02/19/26 at 12:01 PM, the hospice nurse was interviewed and was informed of the lack of documented skilled nurse and HHA visits based on the ordered frequency. The hospice nurse stated she would search for the documentation. The requested documents were not provided. 2. Review of the policy for Medication Administration issued 10/20 and revised 01/24 documents that medication are ordered and administered safely and as prescribed; 6. documents under procedures that medications are administered within one hour before or after their prescribed time unless otherwise specified. 2a. Review of Resident #110 medical records revealed Resident #110 was admitted to the facility on [DATE] with diagnoses to include Nondisplaced Bimalleolar Fracture of Right Lower Leg, Chronic Obstructive Pulmonary Disease (COPD), Type II Diabetes, and Migraines. Review of Resident #110 MAR (Medication Administration Record) for February 2026 revealed the following medications on the dates and times below were administered past the 1-hour requirement: On 02/10/26, the 3:00 PM medication Metoprolol Tartrate Oral Tab 50 MG Give 1 tablet by mouth every day and evening for Hypertension, was not given until 9:07 PM. On 02/11/26, the 3:00 PM medication Metoprolol Tartrate Oral Tablet 50 MG Give 1 tablet by mouth every day and evening for Hypertension, was not given until 7:52 PM. On 02/11/26, the 5:00 PM medication Fluticasone-Salmeterol 100-50 MCG/ACT Aerosol Powder 1 inhalation orally two times a day for COPD, was not given until 7:45 PM. On 02/12/26, the 3:00 PM medication Metoprolol Tartrate Oral Tablet 50 MG Give 1 tablet by mouth every day and evening for Hypertension, was not given until 9:14 PM. On 02/13/26, the 9:00 AM medications were not given until the following times. *Cyanocobalamin tab 1000mcg Give 1 tablet by mouth one time a day for Anemia, was not given until 11:19 AM. *Fluticasone-Salmeterol 100-50 MCG/ACT Aerosol Powder 1 inhalation orally two times a day for COPD, not given until 11:22 AM. *Aspirin EC tab delayed response 81 mg Give 1 tablet by mouth one time a day for Coronary Artery Disease, was not given until 11:19 AM. *Furosemide Oral Tab 20 MG Give 3 tablets by mouth one time a day for Edema, was not given until 11:19 AM. *Metoprolol Tartrate 50 MG Give 1 tablet by mouth two times a day for Hypertension, was not given until 11:19 AM. *Prednisone Oral tab Give 20 MG by mouth one time a day for swelling for 5 days until finished, was not given until 11:20 AM. *Lactulose Oral Solution 20 GM/30ML. Give by mouth one time a day for constipation, was given until 11:22 AM. On 02/17/26, the 9:00 PM medications were given at 10:53 PM for the following medications: Topiramate Oral Tablet 100 MG Give 1 tablet by mouth at bedtime for seizure activity/mood disorder. Rosuvastatin Calcium Tablet 10 MG 1 tablet by mouth at bedtime for hyperlipidemia Gabapentin Oral Tablet 600 MG Give 1 tablet by mouth every morning and at bedtime for neuropathy. Amitriptyline HCL Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for depression Metformin HCL oral tablet 500 MG Give 500 mg by mouth every 12 hours for DM2. During an interview on 02/16/26 at 2:36 PM with Resident #110, she stated her medications are always late. 2b. Review of Resident #155 medical records revealed Resident #155 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Atrial Fibrillation, Hyperlipidemia, Depression and Heart Failure. Review of the MDS assessment dated [DATE] documented a BIMS (Brief Interview Mental Status) score of 14, indicating intact cognition. Review of Resident #155's MAR for February 2026 revealed that the following medications on the dates and times below were administered past the 1-hour requirement: On 02/03/26, the 9:15 PM medication Trazadone HCL Tablet 50 MG 1 tablet by mouth three times a day for MDD (Major Mood Disorder) was not given until 11:04 PM. On 02/06/26, the following medications that were scheduled for 5:00 PM, and were not given until 9:02 PM: Fluticasone-Salmeterol 50-50 MCG/ACT Aerosol Powder 1 inhalation inhale orally two times a day for short of breath was not given until 9:02 PM Amiodarone HCL oral tablet 200 MG Give 1 tablet by mouth two times a day for arrythmia. Tizanidine HCL oral tablet 4 MG Give 1 tablet by mouth three times a day for muscle spasm. Eliquis oral tablet 5 mg Give 1 tablet by mouth two times a day for Atrial-Fib. Rosuvastatin Calcium Oral Tab 5 MG Give 1 tab by mouth at bedtime for Hyperlipidemia. Buspirone HCL Oral tab 5 MG Give 1 tablet by mouth two times a day for Anxiety. On 02/07/26, the following medications scheduled for 9:00 AM, were given at the following times: Desvenlafaxine ER oral tab extended release 24-hour 50 MG 1 tab by mouth (PO) one time a day for MDD, not given until 11:06 AM. Centrum Women oral tab Multi vitamins with minerals. Give 1 tab PO one time a day for supplement, not given until 11:02 AM. Culturelle oral capsule Give 1 tab by mouth one time a day for probiotic, not given until 11:01 AM. GlocoLax Powder Give 17 gram by mouth one time a day for constipation mix with 8 oz of liquids, not given until 11:06 AM. Eliquis oral tablet 5 mg Give 1 tablet by mouth two times a day for Atrial Fibrillation, not given until 11:07 AM. Furosemide Tab 20 MG Give 1 tab by mouth one time a day for Edema, not given until 11:06 AM. Cholecalciferol tablet 1000 unit Give 2 tablets by mouth one time a day supplement, not given until 11:01 AM. Biotin Oral tab 2.5 MG Give 1 tab by mouth one time a day supplement, not given until 11:01 AM. Metformin HCL Oral tab 500 MG Give 1 tablet by mouth one time a day for Diabetes Mellitus, not given until 11:06 AM. Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder 1 inhalation inhale orally two times a day for short of breath, not given until 10:57 AM. Guaifenesin ER tab extended release 12-hour 600 MG Give 1 tab by mouth every 12 hours for cough, not given until 11:06 AM. Pepcid oral tablet 20 MG Give 1 tab by mouth one time a day for heartburn, not given until 11:09 AM. Pantoprazole 30 MG caps delayed release Give 1 capsule by mouth every shift for GERD, not given until 11:09 AM. Tizanidine HCL oral tablet 4 MG Give 1 tablet by mouth three times a day for muscle spasm, not given until 11:09 AM Roflumilast Oral tablet 500 MCG Give 1 tablet by mouth 1 time a day for COPD, not given until 11:09 AM Metoprolol Succinate ER oral tablet extended release 24 hours 25 MG. Give 1 tablet by mouth one time a day for Hypertension, not given until 11:16 AM. Amiodarone HCL oral tablet 200 MG Give 1 tablet by mouth two times a day for arrythmia, not given until 11:00 AM. Morphine Sulfate ER 60 MG Give 1 tablet by mouth every 12 hours for pain, not given until 11:00 AM. On 02/08/26, the following medications scheduled for 5:00 PM, were given at the following times: Amiodarone HCL oral tablet 200 MG Give 1 tablet by mouth two times a day for arrythmia, not given until 7:29 PM. Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder 1 inhalation inhale orally two times a day for short of breath, not given until 7:25 PM. Tizanidine HCL oral tablet 4 MG Give 1 tablet by mouth three times a day for muscle spasm, not given until 7:25 PM. Eliquis oral tablet 5 mg Give 1 tablet by mouth two times a day for Atrial Fibrillation, not given until 7:25 PM. Buspirone HCL Oral tab 5 MG Give 1 tablet by mouth two times a day for Anxiety, not given until 7:25 PM. On 02/13/26, the following medications scheduled for 9:00 AM, were given at the following times: Centrum Women oral tab Multi vitamins with minerals. Give 1 tab PO one time a day for supplement, not given until 12:28 PM. Morphine Sulfate ER 60 MG Give 1 tablet by mouth every 12 hours for pain, not given until 12:33 PM. Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder 1 inhalation inhale orally two times a day for short of breath, not given until 12:33 PM. Tizanidine HCL oral tablet 4 MG Give 1 tablet by mouth three times a day for muscle spasm, not given until 12:35 PM. Metoprolol Succinate ER oral tablet extended release 24 hours 25 MG. Give 1 tablet by mouth one time a day for Hypertension, not given until 12:37 PM. Trazadone HCL Tab 50 MG 1 tab by mouth three times a day for MDD, not given until 12:35 PM, not given until 12:35 PM. On 02/15/26, the following medications scheduled for 9:00 AM, were given at the following times: Trazadone HCL Tab 50 MG 1 tab by mouth three times a day for MDD (Major Depressive Disorder), not given until 10:33 AM. Morphine Sulfate ER 60 MG Give 1 tablet by mouth every 12 hours for pain, not given until 10:32 AM Metformin HCL Oral tab 500 MG Give 1 tablet by mouth one time a day for Diabetes Mellitus, not given until 10:32 AM Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder 1 inhalation inhale orally two times a day for short of breath, not given until 10:33 AM Metoprolol Succinate ER oral tablet extended release 24 hours 25 MG. Give 1 tablet by mouth one time a day for Hypertension, not given until 10:41 AM. On 02/17/26, the following medications scheduled for 5:00 PM, were given at the following times: Trazadone HCL Tab 50 MG 1 tab by mouth three times a day for MDD, not given until 7:08 PM. Amiodarone HCL oral tablet 200 MG Give 1 tablet by mouth two times a day for arrythmia, not given until 7:12 PM. Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder 1 inhalation inhale orally two times a day for short of breath, not given until 7:12 PM. Tizanidine HCL oral tablet 4 MG Give 1 tablet by mouth three times a day for muscle spasm, not given until 7:08 PM. Eliquis oral tablet 5 mg Give 1 tablet by mouth two times a day for Atrial Fibrillation, not given until 7:12 PM. During an interview on 02/16/26 at 1:06 PM with Resident #155, the resident stated she has been getting her meds late, she is supposed to be getting her 8:00 AM medication that includes Blood Pressure (B/P) medication and doesn't receive it until 11:45 AM; and when the nurse comes in to check her blood pressure (BP), it was high. She stated to the nurse that's because I haven't received my BP medication yet. 2c. Review of Resident #169 medical records revealed Resident #169 was admitted to the facility on [DATE] with diagnoses to include Displaced Posterior Arch Fracture of First Cervical Vertebra, Displaced Intertrochanteric Fracture oof Left Femur, Major Depressive Disorder, Hypothyroidism, Chronic Obstructive Pulmonary Disease (COPD), Muscle Weakness, and Lack of Coordination. Review of the February 2026 MAR documented, that on 02/13/26, her 9:00 AM medications were not given until the following times: Flomax Capsule 0.4MG Give 1 capsule by mouth one time a day for urinary retention for 14 days, was not given until 11:15 AM. Trazadone HCL Oral Tablet 150 MG Give 150 MG by mouth three times a day for Depression, was not given until 11:15 AM. Midodrine HCL Tablet 5 MG Give 1 tablet by mouth three times a day for hypotension for 10 days, was not given until 11:15 AM. Enoxaparin Sodium Solution 30 MG/0.3ML Inject 30 MG Subcutaneously two times a day, was not given until 11:31 AM. On 02/15/26, the resident's midnight medication Methocarbamol Oral Tablet 500 MG Give 1 tab by mouth every 6 hours for spasms for 10 days, was not given until 2:08 AM; and Tylenol Oral Tablet 325 MG Give 2 tablets by mouth every 6 hours for pain for 10 days, was not given until 2:08 AM. On 02/17/26, her 9:00 PM Medications were not given until 11:01 PM. Trazadone HCL oral Tab 150 MG Give 1 tab three times a day for Depression Midodrine HCL Tab 5 MG Give 1 tab by mouth three times a day for Hypotension. Holed for SBP [systolic BP] greater than 130. During an interview on 02/16/26 at 10:00 AM with Resident #169, she stated her nighttime meds were not brought to her until 2:00 AM and were supposed to be at 10:00 PM. On 02/16/26 at 1:30 PM, the resident was asked if she refused her meds last night, as that was documented in the progress notes, and the resident stated no. During an interview on 02/18/26 at 10:00 AM with Staff I, Licensed Practical Nurse (LPN), she was asked what the parameters are for giving medications. She stated it is 1 hour before and 1 hour after the med is supposed to be given. She acknowledged that she was late on several occasions. During an interview on 02/18/26 at 10:25 AM with Staff H, LPN / Wound Care Nurse, she stated she can give the meds 1 hour before and 1 hour after when they are due. 3. Review of the record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis to include hypotension (low blood pressure). Review of the current physician orders documented as of 12/22/25, the resident was to receive midodrine (a medication to increase blood pressure) 10 mg (milligrams) three times daily for hypotension at 9:00 AM, 1:00 PM, and 5:00 PM. This order further directed the nursing staff to hold the medication if the resident's systolic blood pressure (the upper number) was greater than 120. There was an additional order for nursing staff to obtain the resident's vital signs every six hours - at midnight, 6:00 AM, 12:00 PM, and 6:00 PM. These blood pressures were documented on the Medication Administration Record (MAR). The electronic record also contained sporadic additional blood pressure readings in the vital sign section of the record. Review of the current February 2026 MAR revealed the following: a) On 02/11/26 at 6:00 AM, the resident's blood pressure was 126/76 as per the MAR. The record lacked any documented blood pressure reading at 9:00 AM, which was the scheduled time of administration for the midodrine. The medication was administered with a systolic blood pressure greater than 120 and no other reading at 9:00 AM. b) On 02/14/26 at 12:00 PM, the resident's blood pressure reading was 123/67 and the medication was administered. c) On 02/17/26 at 6:00 AM, the record lacked a blood pressure reading on the MAR. The vital sign report also lacked a blood pressure reading for the 9:00 AM medication dose. The medication was administered without any documented blood pressure reading. Review of the January 2026 MAR revealed the following: d) On 01/09/26 at 12:00 PM, the record lacked a blood pressure reading on the MAR. The 1:00 PM scheduled dose of midodrine was administered. A blood pressure reading at 2:13 PM was documented in the vital sign section of the record as 121/72, after the scheduled dose of medication. e) On 01/09/26 at 6:00 PM, the resident's blood pressure was documented as 124/74 on the MAR. The medication was administered outside of physician ordered parameters. 4. Review of the record revealed Resident #41 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] revealed the resident had a BIMS score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the record revealed the physician order dated 12/03/25 for metoprolol 25 mg was to be given twice daily for hypertension. This order further instructed nursing staff to hold the medication for a systolic blood pressure less than 120. During an interview on 02/16/26 at 11:34 AM, Resident #41 stated her blood pressure had been high that morning. The resident further stated at other times it is very low. The resident stated she could take her blood pressure pill when her reading was over 120, and the resident stated the nursing staff do not always follow the instructions. Review of the current February 2026 MAR for Resident #41 revealed the following: a) On 02/08/26 at 9:00 AM, the resident's blood pressure was 114/76 and the metoprolol was given. b) On 02/10/26 at 5:00 PM, the resident's blood pressure was 118/64 and the medication was given. c) On 02/14/26 at 9:00 AM, the resident's blood pressure was 118/74 and the medication was given. d) On 02/14/26 at 5:00 PM, the resident's blood pressure was 112/62 and the medication was given. e) On 02/15/26 at 9:00 AM, the resident's blood pressure was 109/76 and the medication was given. f) On 02/17/26 at 5:00 PM, the resident's blood pressure was 118/76 and the medication was given. Review of the January 2026 MAR for Resident #41 revealed the following: g) On 01/05/26 at 5:00 PM, the resident's blood pressure was 104/61 and the metoprolol was given. h) On 01/27/26 at 5:00 PM, there was no documented blood pressure reading in the record and the medication was given. During an interview on 02/19/26 at 3:52 PM, the Director of Nursing (DON) agreed with the findings for both Resident #1 and Resident #41.

Based on interview and record review, the facility failed to accurately code antipsychotic medication use for 1 of 5 sampled residents reviewed for unnecessary medications, Resident #82; failed to accurately code mobility status for 1 of 4 sampled residents reviewed for Activities of Daily Living, Resident #42; and failed to code the presence of a colostomy for 1 of 3 sampled residents reviewed, Resident #153. The findings Included:1. Clinical record review revealed Resident #82 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Depression. Review of the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/04/25 revealed the following: Under Section N (Medications), item N0410A (Antipsychotic Medications), the resident was coded as No. Review of the December 2025 Medication Administration Record (MAR) indicated the resident received Seroquel (quetiapine) 25 mg by mouth twice daily for brief psychosis/mood stabilization from 12/01/25 through 12/05/25. Section N0410A should have been coded as Yes. On 02/19/26 at 9:20 AM, a side-by-side review and interview was conducted with Staff E, the MDS Coordinator. Staff E confirmed the medication was administered during the look-back period and agreed the assessment was coded inaccurately. 2. Review of the medical record documented Resident #42 was admitted to the facility on [DATE] with medical diagnoses that included Mild Left-Hand Contracture (left hand curling inwards) and Ataxia (lack of muscle control or coordination). Review of the current MDS assessment, dated 02/04/26, documented Resident #42 had no impairment to the upper extremities and a diagnosis of Left-Hand Contracture. Review of the Physician's order dated 01/12/26, instructed that Resident #42 wear a left-hand Blue Carrot orthosis (carrot shaped hand splint) in the mornings and after activities of daily living as the resident tolerated. During a side-by-side record review and interview on 02/19/26 at 10:00 AM, Staff E, MDS Coordinator, was asked about the documentation of the resident's range of motion. Staff E confirmed that the MDS assessment documented no impairment to the resident's upper extremity and the resident's left hand is contracted. 3. Review of the record revealed Resident #153 was admitted to the facility on [DATE]. Further review of the record revealed the resident had a colostomy (a surgical procedure that creates an opening in the abdominal wall to divert waste into a replaceable bag) as of 10/30/24. During an observation on 02/17/26 at 3:08 PM, when asked if he had a colostomy, Resident #153 stated he did and showed it to the surveyor. Review of the Quarterly MDS assessment dated [DATE] documented the resident did not have a colostomy. During an interview on 02/19/26 at 2:33 PM, when asked if she knew Resident #153 had a colostomy, Staff E, MDS Coordinator, stated she did. When asked about the MDS coding of no colostomy, Staff E stated, I know he has a colostomy, and agreed with the findings.

Based on policy review, record review and interview, the facility failed to ensure that when residents are admitted to the facility that there are physician orders for the residents' immediate care for 1 of 1 sampled resident reviewed for dialysis, Resident #171. The findings included:Review of the facility Policy and Procedure for New Admissions issued 01/19 and revised 02/24 documents, in part, the following: the primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The objectives of our admission policies are to admit residents who can be adequately cared for by the facility, reduce the fears and anxieties of the resident and family during the admission process, and assure the appropriate medical and financial records are provided to the facility prior to or upon the resident's admission. Review of Resident #171 medical records revealed the resident was admitted on [DATE] with a diagnosis to include Acute Kidney Failure, Alcoholic Cirrhosis of the Liver with Ascites, End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Muscle Weakness, Muscle Wasting and Atrophy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Lack of Coordination. The resident's Brief Interview for Mental Status (BIMS) was not conducted due to the resident being a new admission, although the discharge document (Form 3308) documented he was alert, oriented and could follow directions.Review of the 3008-transfer form from the hospital did not have a discharge date but documented the last vital signs were taken at 3:30 PM for Resident #171 and included in part the following: Dialysis M_W_F [Monday, Wednesday, and Friday] chair time 5:15 AM.Review of the Physician's Orders for Resident #171 included in part the following:-Hemodialysis (HD) Res [resident] receives HD every Monday, Wednesday, Friday at [dialysis facility name and address]. Chair time is 555am [5:55 AM] transported by [Transport Name and phone number] via (W/C [wheelchair], stretcher, geri-chair, etc.) with P/U [pick-up] time of 5am [5:00 AM]. Start date: 02/18/26.-HD Right Subclavian extremity precautions - no lab draws, no B/P [blood pressure], etc. every shift for hemodialysis. Start date 02/16/26 3:00 PM.-Hemodialysis - Offer Res a packaged meal and/or snack on Monday, Wednesday, Friday before HD appointment. Start date 02/18/26.-HD Right Subclavian dialysis access port/line: Do not access this line - for Hemodialysis use only. every shift for hemodialysis Start date 02/16/26 3:00 PM.-Hemodialysis - Right Subclavian PORT, dialysis access port/line: HD center [Name of renal faciliy] to complete routine dressing changes. May reinforce the dressing if dislodged. May replace the dressing if unable to reinforce using sterile technique.-Hemodialysis - Right Subclavian Port dialysis access port/line. Monitor site for s/s of infection, pain, drainage, increased temp, edema, bleeding, etc. Notify physician of abnormal findings.-Hemodialysis - Right Subclavian chest port: [NAME], [NAME], Permcath dialysis access port/line. Monitor site for s/s of infection, pain, drainage, increased temp, edema, bleeding, etc. Notify physician of abnormal findings. every shift for ESRD.-Observe for signs and symptoms of excessive bruising, hematuria, hemoptysis, or bleeding. Report abnormalities to the physician.-Renal diet, Regular texture, thin consistency. Start date 02/15/16.In summary, there were no orders for dialysis until 02/16/26, (admitted [DATE]), and the resident missed the treatment of dialysis on 02/16/26 (Monday).During an interview conducted on 02/16/26 at 9:00 AM with Resident #171 when asked if he had any concerns, he stated he was upset about dialysis not being done today, and he was supposed to go today at 5:00 AM. He also added he is a new dialysis patient and just started when he was in the hospital and was told he was to continue the dialysis, but he is unsure of the process since this is all new to him. It was observed that the resident was concerned about missing his dialysis treatment.During an interview on 02/18/26 at 3:34 PM with the DON (Director of Nursing) who was asked about Resident #171 and his dialysis treatment, she stated that on 02/18/26 she was reviewing Resident #171's orders since he was a new admission to the facility on [DATE]. She stated she did not see any orders for dialysis including the dialysis center, days or chair time. She called Registered Nurse (RN) Unit Manager and instructed her to ask the resident where he normally goes to dialysis and what days. The RN Unit Manager informed the DON the resident could only tell them he is new to dialysis and not sure where he was supposed to go but believed it was supposed to be in the [city] area. The DON contacted a dialysis center in [city] and the person who answered confirmed the resident was supposed to start dialysis at their center Monday, Wednesday, and Fridays with a chair time of 5:45 AM once he was discharged from the hospital, but they were never notified of the resident being discharged from the hospital.During an interview on 02/18/26 at 3:50 PM with Staff R, Admissions/ Marketing Director, who was asked about Resident #171, stated the hospital contacted her on 02/13/26 regarding the admission to see if we would accept him. Staff R stated she read the clinicals and then got authorization from his insurance. The hospital did not inform me that he was currently receiving dialysis and would need to continue dialysis treatments. When asked if she had inquired about any special circumstances or treatment(s) the resident would need, she said she did not ask. When asked what if she had any clinical knowledge, and she said she had been a Certified Nursing Assistant. She added the Form 3008, transfer document, was given to them upon admission and would come with the resident. She was asked what she looked at to determine if he was the right fit for this facility. Staff R stated that I look at history and physical, the physical therapy and occupational therapy notes and the medication list'. She further stated if we knew he was on dialysis then I would have scheduled him for transport but didn't know.During a telephone interview on 02/19/26 at 10:36 AM with Staff Q, LPN (Licensed Practical Nurse), he was asked what the admission process. He stated we go over the hospital notes/orders and review the notes that were sent with him. He was asked when a resident comes in with a dialysis port, do they obtain physician orders, and Staff Q stated, he does a brief interview with the resident and then he does a head-to-toe assessment. When asked about Resident #171, the LPN stated he had an issue with his documents, he could not find paperwork or orders about dialysis. The LPN stated he reached out to his unit manager via text message, and the Unit Manager responded the next day that she would be in the next day and would take care of getting the dialysis order and setting up transportation to the dialysis center for the resident. When asked if he documented this interaction with the Unit Manager, he said I don't remember if I made a note. When asked if he contacted the admitting physician, he said he did not reach out to the physician.During an interview conducted on 02/19/26 at 12:15 PM with Staff K, RN Unit Manager (RNUM), she was asked about Resident #171, and responded she received a text message from Staff Q on Friday night (02/13/26) but she did not see the text message until the next day (02/14/26) regarding Resident #171 who was supposed to receive dialysis but he had no orders for dialysis. She texted the nurse back once she saw the message saying she would follow up and called Admissions (Staff R) to set up the dialysis, he had dialysis chair time but no orders. Staff R stated she would be in on Sunday and would set it up. Staff K, RN/UM, came in on Sunday to work but did not see Staff R following up with her to make sure the dialysis was set up. She said she spoke to the DON (Director of Nursing) on Sunday to inform her of the situation. Monday, she notified Staff R again; on Tuesday the orders were in, and the dialysis was set up. When asked if she had made the physician aware of the situation, she said no. When asked if a resident is supposed to receive dialysis, and it is not set up or they have no orders would they notify the physician, she said they would notify the physician. When asked if she did this, she said she thinks the Nurse Practitioner was aware.During an interview conducted on 02/19/26 at 1:50 PM with the Medical Director (Attending Physician / Medical Director), he was asked about Resident #171 and the dialysis. He stated he has no credentials to give dialysis orders, that would be up to the nephrologist. He said his ARNP (Advanced Registered Nurse Practitioner) saw the resident on Monday 02/16/26. He was unaware if the resident needed dialysis or if it had been just short term while the resident was in the hospital.During a telephone interview conducted on 02/19/26 at 2:10 PM with Medical Assistant (MA) for the Hospital Nephrologist whose care Resident #171 was under while in the hospital, she confirmed the resident was to have dialysis Monday, Wednesday, and Fridays at dialysis center in [city] in the early morning.During a telephone interview conducted on 02/19/26 at 2:20 PM with the Registered Nurse (RN) with dialysis center, she verified the Resident #171 had a chair time of 5:55 AM on Mondays, Wednesdays and Fridays. She stated he did not have any orders for dialysis to start on Monday (02/16/26) because they were not notified of Resident #171 being discharged from the hospital on [DATE]. The dialysis facility was not notified by the nursing home until 02/16/26 after the resident's chair time had passed, the resident had been discharged from the hospital, and at that time they set up the dialysis for Wednesday, his next scheduled day.

Based on observations, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in 5 of 14 resident rooms in the [NAME] Unit affecting residents in rooms 107, 112, 115, 116, and 117. The findings included:Review of the facility's policy titled, Homelike Environment, with a revised date of 01/2025, included in part the following: Staff shall provide person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The facility staff and management shall provide to the extent possible: a clean, safe, comfortable homelike environment catered to the resents personal preferences as able. 1. On 02/16/26 at 11:30 AM, an observation was made in the bathroom of room [ROOM NUMBER] of the emergency pull cord in the bathroom wrapped around the grab bar. Both residents in the room utilize the toilet. On 02/17/26 at 8:35 AM, an observation was made in the bathroom of room [ROOM NUMBER] of the emergency pull cord in the bathroom continued to be wrapped around the grab bar.On 02/17/26 at 10:0 AM, an observation was made in the bathroom of room [ROOM NUMBER] of the emergency pull cord in the bathroom continued to be wrapped around the grab bar. 2 On 02/16/26 at 10:32 AM, an observation was made in room [ROOM NUMBER] of the bathroom with no paper towels. The light above the head of the bed for Resident #68 did not work unless the light switch located at the room door was activated. The pull cord from the light (located behind the resident) was only about 8 inches long and the resident was unable to reach it.On 02/17/26 at 11:45 AM, a second observation was made in room [ROOM NUMBER] of the bathroom with no paper towels. 3 On 02/16/26 at 10:10 AM, an observation was made in the bathroom of room [ROOM NUMBER] of the emergency pull cord wrapped around the grab bar and no paper towels. On 02/16/26 at 3:30 PM, a second observation was made in the bathroom of room [ROOM NUMBER] of the emergency pull cord wrapped around the grab bar and no paper towels. On 02/17/26 10:39 AM, a third observation was made in the bathroom of room [ROOM NUMBER] of the emergency pull cord wrapped around the grab bar and still no paper towels. 4 On 02/16/26 at 10:20 AM, in room [ROOM NUMBER], an observation was made of the bathroom with one light bulb not working. 5 On 02/16/26 at 10:15 AM, in room [ROOM NUMBER], an observation was made of no paper towels in the bathroom.On 02/16/26 at 10:27 AM, an observation was made in room [ROOM NUMBER] of light above bed not working unless the light switch on the wall next to the door is activated. The emergency cord in the bathroom was wrapped around the grab bar. During an interview conducted on 02/16/26 at 10:32 AM with Resident #68 who was asked about the light behind her bed, she said she cannot put it on, it has to be turned on from the switch on the wall next to the door to her room. When asked if she gets up to turn on the light switch to put the light on, she said she cannot, she cannot get out of bed without assistance. When asked if she would like to turn on the light by herself, she said sometimes it would be nice to do it herself. When asked if she uses the bathroom, she said yes but she needs assistance, she cannot do it by herself. On 02/18/26 at 9:15 AM, a tour of the facility and laundry area was conducted with the Administrator, Director of Maintenance, Director of Housekeeping and Regional Plant Operations as well as interviews while doing the tour. They acknowledged one of the light switches in the rooms next to the door controls the lights on the wall behind the head of the bed(s) in the rooms and if it is in the off position, the pull cord from the light on the wall behind the bed would not work. They also acknowledged some of the pull cords from the lights on the wall behind the beds were too short and residents were unable to reach the cord. They acknowledged some of the rooms did not have any paper towels in the bathroom. They also acknowledged some of the emergency pull cords in the bathrooms were wrapped around the grab bars and they should be hanging freely.

Based on policy review, observation, interview, and record review, the facility failed to ensure the accommodation of needs for 1 of 1 sampled resident as evidenced by the lack of bedside rails for Resident #42 as per the facility's assessment and the resident's request. The findings included:Review of the facility's policy titled, Proper Use of Side Rails, dated September 2022, documented in part, 1. Side rails are only permissible if used to treat a resident's medical symptoms or assist with mobility and transfer of residents, or at the request of the resident or resident's representative. 2. A side rail evaluation will be completed to determine the resident's need for using side rails. Review of the record for Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses that included mild Left-Hand Contracture (left hand curling inwards) and Ataxia (lack of muscle control or coordination). Review of the current Minimum Data Set (MDS) assessment, dated 02/04/26, documented a Brief Interview for Mental Status (BIMS) score of 15, on a 0-15 scale indicating the resident was cognitively intact. Review of the Physician's Orders indicated Resident #42 had an order dated 01/07/26 for Side rail to bilateral bed as an enabler for bed mobility. Review of the current Side Rail Evaluation, dated 01/30/26, documented the resident would benefit from the use of both side rails to promote independence for transferring and movement in bed. This evaluation also documented that Resident #42 understood the risks and benefits of the side rail and consented to its use. Review of the Side Rail Consent form dated 06/11/25 had no signature. During an observation on 02/17/26 at 9:33 AM, Resident #42 was observed in bed with no side rails in place. On 02/18/26 at 9:10 AM, the resident was again observed in bed with no side rails. During an interview on 02/19/26 at 9:45 AM, the Director of Nursing (DON) was asked to explain the facility's Side Rail policy. She stated that Physical / Occupational Therapy would screen the resident for the appropriateness, the resident would provide consent if he or she is deemed appropriate, and an order would be placed. The DON confirmed that there was an order for side rails for the resident since 01/07/26, and Resident #42 was deemed as appropriate. She further stated that not only did the resident's son provide consent in the admission records on 11/24/25, but also, Resident #42 requested to have them during a facility-wide side rail audit in January but did not get them.

Based on observation, record review and interview, the facility failed to ensure a resident was treated in a dignified manner for 1 of 1 sampled resident reviewed for dignity, Resident #171. The findings included:Review of the policy for Resident Rights dated 09/21 and revised 01/24 documents: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Employees shall treat all residents with kindness, respect and dignity. These rights include the resident's right to: a. dignified existence; b. be treated with respect, kindness and dignity.Record review documents Resident #171 was admitted to the facility on [DATE] with diagnoses to include: Acute Kidney Failure, Alcoholic Cirrhosis of the Liver with Ascites, End Stage Renal Disease, Dependence on Renal Dialysis, Muscle Weakness, Muscle Wasting and Atrophy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Lack of Coordination.During an interview with Resident #171 on 02/16/26 at 11:00 AM, the resident stated that he had asked to be changed after he soiled his brief and every day the CNA's (Certified Nursing Assistants) tell him that they cannot change him during breakfast, so he sits in his dirty brief until they can. On 02/17/26 at 9:00 AM while talking to Resident #171, Staff J, CNA, walked into the resident's room, and he asked to be changed. She stated to the resident in front of the surveyor that she could not change him during mealtime until after all the trays are picked up. He stated to the surveyor that he pressed his call light around 2:00 AM and a CNA came in and said what do you want now he told her that he spilled his urinal that had urine in it, on the bed and himself and needed to be changed. He could not remember the CNA's name but found out later that it was Staff P, CNA. He said she gave him a nasty attitude. He stated she changed everything except his gown, which he had rolled up because it was wet. When he pressed the call light again, he could hear her stomping down the hall, she came in and he mentioned aren't you going to change my gown, I am freezing and wet. He stated again she had an attitude.During an interview on 02/17/26 at 9:05 AM with Staff J, CNA, the surveyor asked why she would not change him. She stated that they are not allowed to change residents during mealtimes because that is an infection control issue.During an interview on 02/18/26 at 10:15 AM with Staff K, Register Nurse (RN) / Supervisor / Unit Manager, she was asked about staff changing the residents' during mealtimes. She stated that the CNA's are not allowed to go into the rooms to change residents until the meals are delivered. She also stated that she wrote a grievance on what Resident #171 had told her which was slightly different than what he had told the surveyor.During an interview on 02/18/26 at 10:43 AM with Staff L, CNA, when asked if a resident requested to be changed during mealtime, what would she do and responded, 'we were trained not to do care during meals. We have to wait until the food is delivered and taken up. I will try to do my care before the trays come out. If there is an emergency, then I might do it.' The surveyor asked what is considered an emergency, and she did not answer. The surveyor asked her if a resident has a bowel movement once the meals are delivered and were eating, could she change the resident. She responded she didn't know and said there is a policy saying we can't.Review of the grievance dated 02/18/26 documented that Resident #171 told Staff K: the CNA had answered the call light on the overnight shift; the CNA asked the resident why my light was on, then turned it off and said she would be right back; when she came back, she stated 'she had to start rounds over again', she hit my light off again after the resident spilled urine accidentally from my urinal, and she asked, 'Why did I keep calling?'

Based on interview, clinical and administrative record review, the facility failed to honor the resident's bath preference and ensure the resident consistently received his bath preference for 1 of 8 sampled resident, Resident #4. The findings included: During the observational tour of the facility on 05/19/25 at 11:30 AM, the surveyor approached Resident #4, who was sitting in his wheelchair in front of his room. The resident voiced his dissatisfaction that they forget about us in room [room number]. The housekeeping aide was observed in the room at this time mopping the floor. The resident stated, I haven't got my medications yet and has gone about 3 weeks without a shower. They don't ever change my linen. I told them my toilet is leaking, and they don't do anything about it. The resident stated that they will wash him in his private area, but he wants a shower. He stated also that he has said he prefers to wear the pull up type of incontinent briefs but some of the aides keep putting the ones with the tabs on. An interview was conducted on 05/19/25 at approximately 11:40 AM with Staff E, the assigned Certified Nursing Assistant (CNA), for Resident #4. The surveyor inquired about the care needs for Resident #4. She stated the resident requires assistance with his activities for daily living (ADLs). She confirmed she hadn't gotten to the resident yet nor had she changed his linen because they were waiting on linen. She stated she has only been on the job two weeks and this was her first day on this hallway. The surveyor inquired about the resident's shower. Staff D, another CNA, joined the interview and stated the resident gets a shower on Tuesday. Another interview was conducted with Resident #4 on 05/19/25 at approximately 1:00 PM, who remained repeated they will bathe his bottom but he had asked for a shower. He acknowledged that he is a big guy and needs help, and confirmed he had been approached today by staff regarding his showers and medications, but he didn't want to get anyone in trouble so he just accepted it. Review of the Minimum Data Set (MDS) asssessment dated 02/23/25 revealed the resident's Brief Interview for Mental Status (BIMS) score was 15 on a scale of 0-15, meaning the resident is cognitively intact. Review of the facility's Resident Council minutes and Grievance log for January 2025 to present, revealed in the March 2025 Resident Council meeting, Resident #4 expressed he would like to have a shower 2-3 times a week. The Activity Director reported it for grievance. The Director of Nursing (DON) noted the shower schedule was updated to Monday, Wednesday and Friday 7AM-3PM shift. The grievance was noted as resolved on 03/26/25. Review of Resident # 4's Kardex documented the resident requirements for bathing, as: The resident needs assist of 1-2 based on fatigue, weight-bearing, weakness. Shower / Bathing Schedule Monday, Wednesday, Friday 7-3. Reivew of Resident #4's plan of care identified a concern initiated 04/11/24 that the resident needs assist with ADL care related to multiple factors including weakness / decreased mobility s/p (status post) recent hospitalization /illness. Both resident and staff believe resident is capable of increased independence in at least one ADL prior to returning to the community. ADL needs and participation vary. Interventions identified: ADL Care: the resident may need assistance of 1 -2 for ADL care. This may fluctuate with weakness, fatigue, and weight bearing status. BATHING: The resident needs assist of 1-2 based on fatigue, weight bearing, weakness. BED MOBILITY: the resident needs extensive help to move and reposition the bed. Will need one- or two-person assistance to change position or scoot up in the bed. This may involve some lifting of the legs or boosts. TOILETING: the resident can transfer on and off of the toilet bedpan without physical help, but will need limited with wiping, clothing, and washing up. TRANSFER: the resident is limited to extensive and may need assistance x 1 or x 2 for transfers in and out of chair or bed. This may fluctuate with weakness, fatigue, and weight bearing status. Review of the task (Documentation Survey Report of the resident's ADL implementation) for May 2025 revealed the following for the resident regarding bathing 7-3 shift: 1st - NA (not applicable) 2nd (Friday) - NA 3rd - nothing documented 4th - NA 5th (Monday) - sb (sponge bath), physical help 6th - fb (full bath) physical help 7th (Wednesday) - NA 8th - sb 9th (Friday) NA 10th - NA 11th - NA 12th (Monday) NA 13th NA 14th (Wednesday) fb (total dependence) 15th - fb physical help 16th (Friday) NA 17th nothing documented 18th - sb 19th - nothing documented. Further review of the task sheet documentation for April 2025 for 7 - 3 shift revealed the resident received one shower on April 26th on the 7-3 shift. During this month, the resident was provided 9 sponge baths or full baths on the 3rd, 4th, 8th, 11th, 13th, 18th 20th, 21st and the 27th. The remainder of the month the staff documentation for 7-3, revealed NA or the date was left blank. Review of the facility's recorded individual sheets for showers revealed the staff are to document when the resident receives a bath or shower: All residents must be offered and provided a shower unless they request a bed bath. Wash hair, clean under fingernails, shave. [NAME] any abnormal skin conditions. The form provides for the staff to select one: whether the resident was provided a: Shower, Device used (circle one): standard shower chair, reclining shower chair, shower bed, other: Bed bath Resident refused ** Nurse must verify refusal, notify responsible party and document in PCC [Point Care Click system]. Review of the PCC documentation (Progress Notes) for Resident #4 did not provide documentation confirming the resident's refusal of showers during April and May 2025. The documentation revealed 2 completed shower sheets for April and May which were dated 04/01/25 and 05/02/25. Review of the facility's policy regarding ADL care and services, revised 01/2024 documented, The resident has the right to refuse any and all ADL care. The refusal of care will be documented in the resident's medical record with appropriate notification including physician and resident representative.

Based on observation, clinical and administrative record review and interview, the facility failed to ensure the residents received the necessary care and services for skin assessments and timely medication administration, as evidenced by the facility's consistent failure to respond in a timely manner fo residents who developed new skin issues and failed to ensure that residents received their prescribed medications in a timely manner, for 3 of 8 sampled residents, Residents # 1, # 4 and # 6. The findings included: 1. Record review revealed Resident #1 was readmitted to the facility on [DATE] with pertinent diagnosis which includes, Diabetes Mellitus, Cerebrovascular disease, Chronic Kidney disease, Stage 3, Essential Hypertension, and Blind Left eye. Review of the resident's plan of care identified a concern initiated on 02/24/25, The resident has a Skin Impairment: eczema. Interventions included: Encourage and assist resident to Off Load Heels as ordered Monitor the Resident's changes in skin condition, and pain levels. Report changes to the physician (MD) Monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated. Skin checks weekly and as indicated. Report any s/s (signs and symptoms) of skin breakdown to MD/wound team as indicated. Treatments as ordered/indicated. An observation and interview was conducted on 05/19/25 at approximately 2:50 PM with Resident #1. Interview with Resident #1 revealed the resident asked the surveyor to look at her thighs because she had some spots on her thighs that itch and hurt. The resident confirmed she couldn't see what it was, but stated it felt like she was allergic to something because it feels like a rash but it hurts. Upon closer assessment, the surveyor observed the resident had dark colored rash like areas on her right and left thighs which are slightly raised and had pimples like bumps on the area, of approximately 2-3 inches in diameter. The resident stated there was an another area under her left arm near her elbow that itched and hurt. Upon observations, the area was dark colored and of about 1 inch in diameter. The resident then lifted her duster dress and pointed to an area on her stomach that was itchy The surveyor asked Staff B, Licensed Practical Nurse/LPN, to assess the resident to address the resident's concern. After assessing the resident, Staff B stated she would get a dermatology consult. Review of the clinical record on 05/20/25 at 11:15 AM did not provide evidence that Staff B had documented the new identified skin issues; and there was no evidence that the nurse contacted the physician or that new orders to treat the resident's new symptoms or skin issues were ordered. An interview was conducted on 05/20/25 at approximately 11:25 AM with the Director of Nursing (DON). The surveyor explained to the DON that the review of the electronic record for Resident #1 did not document identification of the skin issues identified yesterday, 05/19/25. An interview was conducted on 05/20/25 at 11:45 AM with the DON and Unit Manager, who reported the resident's skin issues are similar areas which reoccur periodically and they previously had an order to treat this reoccurrence but the order must have fallen off. She stated she has just contacted the physican and obtained an order for cortisone. She confirmed when new skin issues arise, the area(s) are to be documented in the clinical record. 2. During the observational tour of the facility on 05/19/25 at 11:30 AM, the surveyor observed Resident #4, who was sitting in his wheelchair in front of his room. The resident was voicing his dissatisfaction that they forget about us in this room. The resident stated, I haven't got my medications yet, and have gone about 3 weeks without a shower. They [staff] don't ever change my linen. I told them my toilet is leaking and they don't do anything about it. The resident stated they will wash him in his private area, but he wants a shower. He stated he has told them he 'prefers to wear the pull up type of incontinent briefs but some of the aides keep putting the ones with the tabs on'. The surveyor asked the Director of Nursing at approximately 12:00 PM to check to see if Resident #4 had received his medications because the resident has stated he had not received his medications. She reviewed the electronic record and the medications were signed off as given. She stated she would follow-up with the nurse, who had gone to lunch and was off the unit. The DON later reported to the surveyor that she spoke with the nurse and the nurse had given the resident his medications. At approximately 12:35 PM, the surveyor observed Staff B down the hall giving medications. The surveyor inquired and noted the nurse was preparing to give medications to Resident #4. The surveyor then conducted a medication administration observation with Staff B for Resident #4. The nurse prepared the following medications: 1. FeSo4 325 mg one tablet 2. ASA 81 mg one tablet 3. Sodium Bicarbonate 650 mg one tablet 4. Drizaline Cap 20 mg DR one cap Twice daily for depression 5. Furosemide tablet 40 mg one tablet every day Shortness of breath 6. Metroprolol suc tab 50 mg one tablet Hypertension 7. Potassium Chloride 10 meq one tablet every day All 7 pills were verified. An interview was conducted at 12:43 AM with Staff B. The surveyor inquired because of what was previously told to her regarding the nurse having already administered the medication and the medication was already signed off as administered. The nurse stated she had poured the resident's medications previously and she clicked on the meds. Then the resident stated he wanted to eat his popcorn first. So she went to lunch. The surveyor asked about her previously poured medications because she prepared them again. Staff B responses they aren't allowed to pre-pour meds. The surveyor asked about the medications being signed as administered, when she had not administered the medications, and Staff BB stated she clicked on them and was going to go back to click them green once she had administered the medication but they were already showing as administered. Staff B stated she went to lunch and told the resident she was going to lunch and would finish after lunch. The morning medication time is 9:00 AM. Another observation was conducted on the next day on 05/20/25 at 11:28 AM with Staff B. The nurse was again observed with her medication cart in the hallway administering medications. The surveyor inquired what medication pass was she completing and Staff B confirmed she was still completing her morning medication administration. Staff B stated, This is a heavy hall with 32 residents. I don't finish medication pass until 11 AM-12 PM, and I have 6 more residents still to give medications to. 3. An interview was conducted on 05/20/25 at 11:50 AM with Resident #6, who stated that he resigned today from being the Resident Council President as it's useless. He stated he has been in this position for one year and expressed his dissatisfaction with getting things resolved. He stated that 'we continue to have the same ongoing issues, meds late, showers, food cold and late and food quantity.' He stated he had an issue with his medications on Mother's Day, as the usual nurse was off and he normally would receive his meds by 9:30 AM but on this day at around 11:00 AM he had told the nurse but he still didn't get his morning medications until after 12:30 PM. He stated the nurse did his blood sugar as well. He stated he went to the DON about this because he could speak up for himself, but his concern was about the residents who couldn't. He said he also got his afternoon meds on the evening that day and the evening nurse told him, she was giving him his medications that he didn't get earlier. Observation on 05/20/25 at 12:35 PM revealed the Registered Nurse, Staff C, came into the room and gave Resident #6 his medications. The surveyor asked what medications were being administered and Staff C stated some morning and some afternoon medications were being given. An interview was conducted at 12:45 AM with Staff C who stated that the hall has 29 residents and he typically finishes between 11:00 AM - 12:00 PM. An interview was conducted on 05/20/25 at approximately 1:00 PM with the DON. The DON confirmed the resident had come to her about his medication being late on Mother's Day, and that he was concerned about other residents. It should be noted that there was no grievance initiated for this resident's concern and the facility had not addressed the persistent late medication administration concerns. Review of the facility's policy and procedure regarding Medication Administration, revised 2024, documented, Medication are administered in accordance with prescriber orders, including any required time limit. Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before or after meal orders, at bedtime).

Based on observation and interview, the facility failed to ensure all medications and/or supplements were not stored at the residents' bedside but were safely secured in locked compartments for 1 of 8 sampled residents, Resident #5. The findings included: An interview was conducted on 05/19/25 at 10:50 AM with Resident #5. Upon speaking with the resident, the surveyor observed there were approximately 10 bottles of pills and liquid supplements neatly stored unsecured on top of the resident's bedside night stand. Photographic Evidence Obtained. The following supplemental pills were stored on the night stand and clearly visible upon entering the resident's side of the room: 1. Two (2) bottles of 32 ounces of MCT oil weight management 2. Two (2) bottles of Nugenix Thermo X - 60 capsules bottles 3. One (1) bottle of weight loss probiotics 4. One (1) bottle of Veggies capsule 5. One (1) bottle of Testerone Booster 6. One (1) bottle of Fruit Dietary Supplement 7. One (1) bottle of Nugenix Ultimate Testerone Booster. An interview was conducted with the resident at this time revealed the resident has been taking these supplements daily and he has the medication stored on top of his night stand. An interview was conducted on 05/19/25 at 11:50 AM with the Director of Nursing, who confirmed that the resident had not been assessed for self administration of medication and was aware that the resident was not to have medication stored at his bedside.

Based on observation, interview and clinical and administrative record review, the facility failed to ensure 1 of 8 sampled residents, Resident #5, was assessed by the interdisciplinary team and established a plan of care for self-administration of medication before the resident participated in the practice. The findings included: An observation was conducted on 05/19/25 at 10:50 AM with Resident #5. Upon speaking with the resident, the surveyor noticed that there were approximately 10 bottles of pills and liquid supplements neatly stored on the resident's night stand. The bottles were noted to be open. Photographic Evidence Obtained. The following supplements were stored on the night stand: 1. Two (2) bottles of 32 ounces of MCT oil weight management 2. Two (2) bottles of Nugenix Thermo X 3. One (1) bottle of weight loss probiotics 4. One (1) bottle of Veggies capsule 5. One (1) bottle of Testerone Booster 6. One (1) bottle of Fruit Dietary Supplement 7. One (1) bottle of Nugenix Ultimate Testerone Booster An interview with the resident at this time revealed the resident has been taking these supplements daily because he says the facility doesn't serve him the right food and he is trying to lose weight. The Licensed Practical Nurse (LPN) came into the room at 11:00 AM and administered the resident his medication. The resident then proceeded to tell the nurse what the surveyor said about his supplements. An interview was conducted on 05/19/25 at 11:50 AM with the Director of Nursing, who confirmed that the resident had not been assessed for self-administration of medication and was aware that the resident was not to have medications stored at his bedside. Review of the clinical record for Resident #5 revealed the resident was originally admitted to the facility on [DATE]. The clinical record did not provide evidence of an assessment by the interdisciplinary team nor was there a plan of care developed for the resident to self-administer medications. Review of the facility's policy, titled, Medication Administration, revised 01/2024, documented, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on observation, record review and interview, the facility failed to provide necessary care and services to prevent and promote healing of pressure ulcers, for 2 of 2 sampled residents reviewed for pressure wounds, Resident #3 and Resident #1. The findings included: Review of the policy, titled, Wound Care and Treatment, revised 01/2024, documented, in part: Standard: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Guideline: Only staff trained to complete physician orders will complete wound care and treatments as prescribed. Procedure: Preparation 1. Verify that there is a physician's order for this procedure . 4. Assess residents pain level as needed. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure . 12. Assess residents tolerance of wound care throughout the procedure. 16. Reposition the bed covers. Make the resident comfortable. Use supportive devices as instructed. Documentation: The following information should be recorded in the resident's medical record: I. The type of wound care given . 4. Any change in the resident's condition. 5. Any problems or complaints made by the resident related to the procedure. Reporting: 2. Report other information in accordance with facility policy and professional standards practice. 1. Observation of wound care conducted on 02/12/25 at 10:20 AM revealed the Wound Care Nurse (WCN) prepared supplies for Resident #3 and explained the floor nurse had previously medicated the resident for pain. The WCN prepared Dakins solution, Gentamycin ointment, Calcium Alginate dressing, skin prep pad and border gauze, the unit manager was present during the observation. Resident #3 was severely contracted. It was noted the resident had a pillow between the contracted legs and a green offloading boot was in place to the left leg. The wound nurse performed hand hygiene, opened all the supplies, forcefully removed the pillow from between the resident's legs. The resident yelled and the WCN explained he had to remove it to do his dressing. The WCN then removed the green offloading boot by lifting the resident's contracted leg and the resident yelled again. The WCN proceeded to remove the dirty dressing, cleansed the area with the Dakins solution, and again the resident yelled when the solution was applied. The WCN continued by applying skin prep around the wound, applied the Gentamycin ointment, Alginate and dry border gauze and reapplied the offloading boot. Interview with the WCN conducted upon completion of the wound care observation, confirmed the staff failed to perform hand hygiene after removing the dirty dressing and prior to cleansing the wound and applying the treatment. The WCN reiterated the resident was medicated for pain prior to the treatment. The WCN did not acknowledge the resident's tolerance to the treatment. Clinical record review conducted on 02/11/25 revealed Resident #3 has diagnoses that included Cerebral Palsy, Malnutrition and Contractures. Review of the Minimum Data Set (MDS), quarterly assessment with reference date of 12/21/24, documented the resident was assessed as severely impaired for skills of daily decision making, and has a pressure ulcer stage IV present on reentry. Review of the care plans, titled The resident is at risk for skin impairment related to incontinence, weakness and decreased mobility, initiated on 03/01/23 and revised on 10/23/24 revealed the plan documented interventions including patient to have contracture cushion/leg positioning device(black) on to be removed for when in wheelchair, for skin check, hygiene, shower and tolerance. To be on in AM/Off in PM. Can be removed for skin check, range of motion and hygiene as ordered and skin checks weekly and as indicated. Report any signs of skin breakdown to physician and wound team as indicated. Review of the Physician's order dated 01/31/25 documented wound care left lateral metatarsal head fifth: Cleanse wound with Dakins 1/4 cleanser - pat dry, apply skin prep to peri wound, apply Gentamycin ointment 0.1%, calcium alginate, cover with border gauze, every Tuesday, Thursday and Saturday. PLACE GREEN OFFLOADING BOOT. The observation determined the WCN failed to follow policies and procedures during the treatment administration to promote wound healing and minimize risk of infection. 2. Clinical record review conducted on 02/11/25 revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation after a cervical fracture. Review of the Initial skin assessment documented the skin was intact, and no evidence of pressure wounds. Review of the MDS, admission assessment with reference date 11/22/24, documented the resident was assessed as moderately impaired for skills of daily decision making, was at risk for developing pressure wounds and had no pressure wounds on admission. Review of the plan of care dated 11/18/24 documented, The resident is at risk for skin impairment related to weakness/decreased mobility. The interventions included: Encourage and assist resident to minimize pressure to bony prominences as tolerated; Preventative skin treatments as ordered/indicated, as tolerated by resident; Skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to physician and wound team as indicated. The record documented Resident #1 developed a pressure wound to the right heel on 12/04/24. There was no stage of the wound documented. On 12/24/24 the nurse documented the resident now has bilateral pressure wounds to right and left heel. Review of the Treatment Administration Records (TARs) dated 11/2024 and 12/2024, the nurses' progress notes and the weekly skin checks failed to provide evidence of preventative measures to minimize pressure wound to the resident's heels. There was no documentation the resident refused offloading of his heels. The record indicated Resident #1 was transferred to the hospital on 12/30/24. Review of the Hospital records, reviewed on 02/12/25, revealed Resident #1 was admitted to the acute care facility on 12/30/24 with bilateral Stage II pressure wounds to the right and left heels. Interview with the WCN conducted on 02/12/25 at 12:09 PM revealed that after reviewing his notes, Resident #1 was admitted to the nursing home with no pressure wounds, he had a cervical collar and did not like to turn on his side. On 12/04/24, a wound to the right heel was identified. There were no measurements or stage documented on that date. On 12/24/24, the right heel was assessed as a deep tissue injury and the left heel had developed a stage II pressure wound. The WCN explained the wounds were unavoidable due to the resident's preference to stay on his back. The WCN was asked what the facility practices to minimize pressure to the residents' heels were. He responded they have offloading boots, or they use skin prep as another measure if the residents refuse the offloading devices. The WCN confirmed Resident #1 did not have offloading boots or use of skin prep prior to the development of the pressure wounds and he did not recall if the wounds to the heels resolved prior to hospitalization . The investigation determined that the facility failed to implement preventative measures to minimize the development of pressure wounds for Resident #1. The staff were aware the resident preferred to stay on his back due to the cervical collar in use, there is no documentation of the resident refusal to offload his heels, and the treatment to mitigate pressure ulcers, with skin prep, was initiated after the first wound developed on 12/04/24.

Based on observation, record review and interview, the facility failed to provide necessary care and services to prevent, identify and properly assess wounds, for 1 of 2 sampled residents reviewed for wounds (Resident #3), as evidenced by the facility failed to identify the blister or subsequent open wound to the resident's right foot, prior to surveyor intervention; the wound care nurse failed to properly assess the wound, documenting erroneous measurements and staff nurses failed to capture the wound during skin check assessment completed on 02/11/25, the day prior to the surveyor's observation. The findings included: Observation of wound care conducted on 02/12/25 at 10:20 AM revealed the Wound Care Nurse (WCN) performed wound care for Resident #3's left foot. At the end of the treatment, the surveyor asked the reason why the offloading boot was only applied to the left leg, as the resident was severely contracted on both legs. The WCN responded that the resident prefers to lay on the left side and that is where the wound is located, so an offloading boot is not necessary to the right leg. The WCN was asked if the resident had any wounds to the right leg or foot and replied 'no'. At this time, the resident spoke up and said, yes he had pain to the right foot. The WCN then proceeded to inspect the right foot. An open wound was noted to the right foot below the big toe, that looked like a blister that had opened up, with visible depth and yellow slough, about the size of a dime. The WCN stated he was going to contact the physician for treatment orders and that the wound provider would evaluate the resident tomorrow (Thursday). Interview with the WCN, conducted upon completion of the wound care observation, on 02/12/25 at approximately 10:30 AM, revealed the nurse had no knowledge of a previous blister or wound to the right foot and stated that he has provided the wound care to the left foot but has not inspected the right foot. He stated the wound care provider rounds weekly and inspects the resident's skin, so the blister was not present last Thursday. An interview was conducted with Staff A, Certified Nursing Assistant (CNA), assigned to care for Resident #3, on 02/12/25 at 10:37 AM. Staff A stated she has not seen the resident as of yet today, she has a heavy assignment, was attending to other residents, and did not have the resident the day before. Staff A denied knowledge of any blisters or wounds to the right foot. An interview with Staff B, Registered Nurse (RN), conducted on 02/12/25 at approximately 10:46 AM, revealed this is her regular hallway assignment, and she is not aware of a blister or wound to the resident's right foot. Clinical record review conducted on 02/11/25 revealed Resident #3 has diagnoses that included Cerebral Palsy, Malnutrition and Contractures. Review of the Minimum Data Set (MDS), quarterly assessment with reference date of 12/21/24, documented the resident was assessed as severely impaired for skills of daily decision making, and has a pressure ulcer stage IV present on reentry. Review of the care plan, titled, The resident is at risk for skin impairment related to incontinence, weakness/decreased mobility, contractures multiple sites (left & right knees), sacral, left foot, right dorsal foot and right heel, was initiated on 03/01/23 and revised on 10/23/24. The plan documented interventions including patient to have contracture cushion/leg positioning device (black) on to be removed when in wheelchair, for skin check, hygiene, shower and tolerance. To be on in AM/Off in PM. Can be removed for skin check, range of motion and hygiene as ordered and skin checks weekly and as indicated, report any signs of skin breakdown to physician and wound team as indicated. Review of the weekly skin assessments, the progress notes and the wound care notes failed to document the presence of a wound to the right foot. Review of the Progress notes dated 02/12/24 documented the WCN measured the right foot wound noting 1.5 centimeter (cm) in length, 2.0 cm in width, 0 cm in depth. The surveyor's observation validates the newly identified wound had depth, it was not a superficial wound, and the noted assessment was not accurate. An interview with the Director of Nursing (DON) conducted on 02/12/25 at approximately 12:20 PM, revealed that last night, she had the staff conduct facility wide skin sweeps and one hundred percent of the skin audits were completed. Staff B had performed the skin check for Resident #3 and did not identify the right foot wound. The DON further stated the nurse feels bad that she missed the identification of wound and the DON was made aware the surveyor had previously interviewed the nurse and that she confirmed no knowledge of a blister or wound to the resident's right foot. The facility nurse failed to properly assess Resident #3's foot to identify the existing wound. Review of the Wound Care Provider documentation dated 02/13/25 documented the following: Right Metatarsal head first, Trauma Wound, measures 1.6 cm in length, 2 cm in width and 0.2 cm in depth, wound base 20% slough, Required surgical debridement Treatment Dakins, betadine, gentamycin and calcium alginate and offload. Post debridement assessment documented no changes from the initial measurements. Interview with the Wound Care Provider conducted on 02/14/25 at 2:10 PM revealed the wound was assessed as a trauma wound, because of the coloration, it looks like a bruise at the base. After questioning the nature of the trauma, the provider explained it was a self-inflicting wound, meaning that the resident most likely moved his foot and hit the area. The provider was made aware the resident is severely contracted and has very limited mobility. The provider stated it is possible he moved his contracted legs a unit, the wound could be caused by friction, trauma and understands the possibility the wound could have been inflicted by pressure. The investigation determined the facility failed to identify the blister or subsequent open wound to the resident's right foot, prior to surveyor intervention; the wound nurse failed to properly assess the wound, documenting erroneous measurements and the staff nurse failed to capture the wound during skin check assessment completed on 02/11/25, the day prior to the surveyor's observation.

Based on observation, interview, and record review, the facility failed to ensure sufficient staffing as evidence by falls and a consistent stale urine odor on 1 of 5 units ([NAME]); lack of ADL care for 1 of 5 sampled residents (Resident #44); lack of Hospice coordination for 2 of 2 sampled residents (Resident #25 and #87); and voiced complaints by residents, families, staff, and resident council. The findings included: 1) Resident #128, who was admitted to the facility on [DATE], sustained eleven falls while residing on the [NAME] unit. Review of these falls lacked evidence the facility followed their fall prevention policy. (Refer to F689 for details). Review of the fall log from 07/01/24 through the survey date of 09/13/24 revealed the facility had 38 falls, 10 of which were on the [NAME] unit. Upon entering the [NAME] unit on all five days of the survey (09/09/24 - 09/13/24) a constant urine odor was noted throughout. Although a specific resident was not identified during the survey, the odors remained. 2) Observation and interview revealed staff failed to provide personal care on two occasions during the survey, when requested by Resident #44. Staff also failed to assist the resident out of bed upon her request. (Refer to F677 for details). 3) Residents #25 and #87 were both on Hospice services, and the facility failed to coordinate care, ensure orders, and ensure hospice documentation was available. (Refer to F684 for details). 4) The following voiced complaints were voiced by residents and family members during the survey process: a) During an interview on 09/09/24 at 11:02 AM, Resident #90 who had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating she was cognitively intact, stated it took the night shift two hours the previous evening to answer her call bell. The resident stated she was feeling short of breath, and when staff finally came in, they did assist her with repositioning/raising the head of the bed, and completed a set of vital signs. During this interview, her roommate, who also had a BIMS of 14, agreed with her roommate's concerns. b) During an interview on 09/09/24 at 11:27 AM, Resident #143, who had a BIMS of 15 indicating she was cognitively intact, stated the facility needs more aides as she has had to wait an hour for help. c) During an interview on 09/10/24 at 7:59 AM, Resident #95, who had a BIMS of 13 indicating she was cognitively intact, stated the staff on the 11 PM to 7 AM shift is not answering the call lights timely. The resident also stated the staff are double diapering for their convenience, and when she complained that she didn't like that, staff told her it doesn't matter because no one will come check at night. d) During an interview on 09/10/24 at 11:14 AM, Resident #60, who had a BIMS of 13 indicating she was cognitively intact, stated the facility did not have enough staff as they are always complaining they are too busy. The resident stated that wasn't her problem and if they are too busy, they shouldn't accept any more residents or they should hire more people. e) During an interview on 09/10/24 at 11:46 AM, Resident #147, who had a BIMS of 6, indicating moderate cognitive impairment, stated that they did not have enough staff and that he has to wait an hour for staff to answer his call light. During this interview, his roommate Resident #145, who had a BIMS of 15, confirmed Resident #147 put on his call light and it goes unnoticed for two hours. f) During an interview on 09/09/24 at 10:06 AM, Resident #104, who had a BIMS of 15, stated when he calls to get assistance with personal care during the night shift, he often waits an hour to an hour and a half to get cleaned up, especially if he'd had a bowel movement. Resident #104 stated staff are often heard fighting about their job duties with respect to getting a resident up for therapy. The resident complained that often the CNAs (Certified Nursing Assistants) won't get him up in the morning, so his therapist has to take 15 minutes out of their time to do the CNA's work. g) During an interview on 09/09/24 at 11:34 AM, Resident #150, who had a BIMS of 14, stated the facility is understaffed as it takes 45 minutes to an hour for her call light to be answered, the resident stated at night it is worse and she has to ask staff a couple of times to get anything done. h) During an interview on 09/10/24 at 9:25 AM, Resident #27, who had a BIMS of 13, stated she waits a minimum of one hour for assistance. During this interview, her roommate stated, I was here all night one night with crap in my pants. i) During an interview on 09/10/24 at 11:53 AM, Resident #145, who had a BIMS of 15, stated the facility is understaffed, especially at night. The resident stated he can't get any water during the night shift, has waited over an hour for staff to answer the call light, and the CNAs get overwhelmed. j) During a phone interview on 09/09/24 at 2:36 PM, the daughter of Resident #128 voiced her concern with a lack of staff, as her mother had had seven falls since April 2024. k) During an interview on 09/09/24, Resident #132, who had a BIMS of 15, stated he relies on staff for personal care, and he had missed physician appointments because staff won't attend to him in a timely manner. 5) During an interview on 09/11/24 at 2:45 PM, Staff K, Licensed Practical Nurse (LPN) stated the current staffing for the [NAME] unit was not enough, considering the cognitive impairment and needs for safety in the memory care unit. (Refer to F689 for details). When asked about leaving Resident #112 alone during a nebulizer treatment on 09/11/24 at 12:25 PM, Staff K explained that she had to leave Resident #112 alone because she saw another resident who should not have been walking independently, doing so, and she had to go attend to her. During an observation on 09/11/24 at 2:45 PM, Resident #112 was alone, with the nebulizer running, and the nebulizer mask had been pulled down to his chin, instead of over his nose. 6) Review of Resident Council minutes revealed concerns with delayed response to call lights in June 2024, August 2024. During the Resident Council meeting held on 09/11/24 at 9:59 AM, Resident #85, who had a BIMS of 15, stated one night when he was sick and ended up in the hospital, it took 52 minutes for staff to answer his call light. This resident stated he has seen and taken photos of staff sleeping.

Based on observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services to maintain a clean, comfortable and homelike environment on 4 of 5 units and in common areas. The findings included: During an environmental tour of the facility on 09/12/24 at 4:25 PM with the Maintenance Director, the following was observed: a. In room [ROOM NUMBER], there were two picture hanging hooks protruding from the wall with sharp points on them by the head of the bed. b. In room [ROOM NUMBER], there was an accumulation of residue on the exterior of the wall mounted air conditioning unit and an accumulation of debris inside of the vents of the unit. c. In room [ROOM NUMBER], there were multiple holes in the wall from where the chair rail once was. d. In room [ROOM NUMBER], the wall by the wall mounted air conditioning unit was in disrepair. e. In room [ROOM NUMBER], the bed frame was in disrepair and showed signs of wear. f. In room [ROOM NUMBER], there was residue and debris on the fall mat to the left of the B-bed closest to the air conditioning unit, there was water underneath the fall mat, the baseboard and the wall at the head of the bed, and at the wall mounted air conditioning unit was in disrepair. g. In room [ROOM NUMBER], there was an accumulation of debris under the A bed (door-bed). h. In room [ROOM NUMBER], there was an accumulation of debris in the air conditioning vent of the wall mounted unit and an accumulation of dust on the air conditioning vent over the commode in the restroom. i. In room [ROOM NUMBER], there was an accumulation of debris in the corner of the room by the bathroom, there was an accumulation of debris inside of the vent of the wall mounted air conditioning unit and on the floor throughout the room. j. In room [ROOM NUMBER], there were several towels underneath the wall mounted air conditioning unit, the wall by the unit was damaged, there was an accumulation of residue on the wall between the dressers, the top of the dresser used by the resident in the A-bed (door-bed) was not secured to the dresser and came off with minimal effort and the surfaces of the dressers showed signs of wear, and there was an accumulation of dust on the air conditioning vent over the commode in the restroom. k. In room [ROOM NUMBER], the door of the closet used by the resident in the A bed was missing, the baseboard at the entrance to the restroom was not secured to the wall, there was an outlet that was not secured in the opening in the wall, and the surface of the overbed table for the resident in the B-bed was damaged to a point that the particle board underneath was exposed. l. In room [ROOM NUMBER], the privacy curtain between the beds was stained, the floor was stained and dirty, there was an accumulation of debris in the vents of the wall mounted air conditioning unit, and the bed linens on the B-bed were stained with what appeared to be bodily fluid. m. In room [ROOM NUMBER], the back of the room entry door is in need of painting and the wall behind the A bed is damaged. n. In room [ROOM NUMBER], there was an accumulation of debris under the A bed. o. In room [ROOM NUMBER], the over-bed table used by the resident in the A-bed had multiple areas of scotch tape. p. In room [ROOM NUMBER], there was an accumulation of debris in the vent of the wall mounted air conditioning unit, the blinds were damaged, there was an accumulation of debris in the blinds and the baseboard was not secured to the wall. q. In room [ROOM NUMBER], there was an accumulation of debris in the wall mounted air conditioning unit, the floor around the B-bed was dirty and the commode was dirty in the bathroom. r. In room [ROOM NUMBER], there was an accumulation of a mold-like substance on the caulk at the bottom of the commode. s. The wall over the handrail between Rooms #232 and #233 was damaged. t. In room [ROOM NUMBER], there was an accumulation of debris on the fall mat to the resident's right side of the A-bed, there was an accumulation of debris in the vent of the wall mounted air conditioning unit, and the bowl of the commode in the restroom was dirty. During the environmental tour of the facility, on 09/12/24 at 4:25 PM with the Maintenance Director, the Maintenance Director acknowledged understanding of the concerns.

Based on observations, interviews and record reviews, the facility failed to provide ADL (Activities of Daily Living) care related to incontinence care, oral and personal hygiene, and personal grooming for 5 of 9 sampled residents, Residents #228, #6, #106, #16, #111. This failure in ADL assistance resulted in psychosocial harm for Resident #228. The findings included: 1. Review of clinical record revealed Resident #228 had been a previous resident who had been discharged home on 06/12/23 but had been readmitted to the facility on [DATE] due to the inability to care for himself at home. Resident #228 had diagnoses that included: Idiopathic Peripheral Autonomic Neuropathy, Gastroesophageal Reflux Disease (GERD), Hypertensive Heart Disease without Heart Failure, Peripheral Vascular Disease, Hyperlipidemia, Type-2 Diabetes with Circulatory Complications, Absence of Right Leg above the Knee, Osteomyelitis, Muscle Weakness, and Dysphasia. The Discharge Minimum Data Set (MDS) assessment completed on 06/12/23 documented Resident #228 was assessed as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of 15. The Admission / Readmission Nursing Evaluation Form completed on 07/08/23 documented the following: 'Functional status was unknown; uses wheelchair. Resident is alert and easily arousable, oriented to person, place, time and situation. Resident is able to communicate. Resident is to have upper and lower dentures, but they are missing (not provided by daughter) Resident is continent of bowel and bladder. Resident's safety awareness/cognition intact; Resident is impulsive, anxious/restless, and agitated. Resident needs assistance with toileting Urinal within reach Documented the resident is 'completely immobile: does not make even slight changes in body or extremity position without assistance.' - Note: Resident observed independently sitting up on side of bed on 07/10/23 and 07/11/23. Also, independently self-propelling in wheelchair on 07/12/23 and 07/13/23 (see observations below). No Mental Health Concerns or Psychosocial Concerns noted. No Depression Screening Summary completed. Resident does not smoke. - Note: It was determined through the smoking evaluation review and resident interview, the resident is a smoker. Resident does have frequent pain. ADLs (Activities of Daily Living) require assistance, including toileting. Eating is documented as being dependent (total assistance) -Note: Based on observation and Nutritional Assessment effective 07/12/23, Resident is able to eat independently.' During initial observations on 07/10/23 at 9:26 AM, Resident #228 was sitting up on the side of his bed, dressed in a hospital gown. The resident was missing his right leg. His hair appeared a bit oily and unwashed. As soon as I introduced myself, Resident #228 stated, Please help me. Please! I have been treated terrible. I hate it here. It is a horrible place. They do nothing for me. They close the door at night and ignore me. They let me lay here in my pee and poop. I have no clothes. It makes me feel like I just want to kill myself. Can you just please give me my wheelchair, I can get myself out of bed if you will just move it over here close to my bed. Please, just give me my wheelchair so I can get up. Resident #228's wheelchair was located in the corner of the room, out of reach of the resident. When I told him I would notify the CNA that he wanted to get up, he stated, Please just get me my wheelchair. They won't do it. They don't do anything for me. I push my call light, but they don't come. I just want to die. An odor of feces was detected near the resident. It was noted that according to readmission assessment, Resident #228 was continent of bowel and bladder and should have a urinal within reach. The resident was to have assistance for toileting, not be placed in adult briefs and encouraged to go to the bathroom in these briefs / diapers. There was no urinal observed at bedside at this time. On 07/10/23 at approximately 9:35 AM, the Unit Manager, Staff R, was notified that the resident was requesting assistance with transfers and incontinence care. The Certified Nursing Assistant (CNA) stated she would assist the resident when she was finished with her current resident. On 07/10/23 at approximately 9:45 AM, the Unit Manger was observed entering Resident #228's room. On 07/10/23 at 1:00 PM, Resident #228 was observed in bed, dressed in hospital gown. His wheelchair was parked in the resident's bathroom. Once again, the resident stated that he gets no assistance from staff, and he just wanted to die because no human being should have to live like this. On 07/10/23 at 4:30 PM, the Director of Nursing (DON) was made aware of the resident's observations and the DON admitted to his state of depression and hopelessness, and that the resident stated he felt like killing himself. She stated she was going to set up a tele-consult with a psychiatrist for the resident that evening. On 07/11/23 at 10:05 AM, Resident #228 was sitting on edge of his bed in his hospital gown. An odor of feces was again noted when approaching the resident. Resident #228 stated he needed help and wanted to get out of bed. He begged the surveyor to bring him his wheelchair. He stated, I can get out of bed myself, if I just had my wheelchair, please bring it to me. I told him I would check with the nurse to make sure he could transfer independently, and he responded, Please, please help me. They won't come. I have to sit here in my pee and poop because no one comes. I just want to die. They treat me like an animal, and I am not an animal. No one should have to live like this. On 07/11/23 at 10:10 AM, the Registered Nurse, Staff E, was asked if Resident #228 could transfer independently. She said she didn't think so but would check with the Unit Manager. She returned and stated that the Unit Manager said the resident needed assistance X 1 person for transfers. On 07/12/23 at 9:50 AM, Resident #228 was in his wheelchair coming out of the bathroom. The CNA was in his room changing the resident's bed. Resident #228 was dressed in a navy-blue sweatshirt and pull-on pants. He stated, The sores on my arm hurt. I don't know what they are from. I am not getting anything for it. They treat me like an animal here. No one cares. No one helps me. I just want to die. This isn't living. I just wish I knew how to end it. I haven't had a shower since I have been here. My hair is so dirty. The resident's hair appeared oily, as if it hasn't been washed recently. On 07/12/23 at 1:34 PM, Resident #228 was seen outside of his room. He again confirmed that he had not had a shower and would like one. he stated, My hair needs washed; there is dirt on my head. I just feel dirty. Why can't I just let me die. There is no reason to live anymore. No one needs me and no one cares about me. On 07/12/23 01:40 PM, the Unit Manager, Staff C, was informed that Resident #228 was requesting a shower for today. On 07/13/23 at 9:28 AM, Resident #228 was observed sitting in his wheelchair wearing the same clothes that he was wearing the previous day. He stated that he had received a shower, and he only had this one outfit. His daughter had not brought him any clothing or cigarettes. He stated again, My life is not worth living. My daughter just dumped me here and the staff don't care about me. I really don't want to be alive anymore. The Social Services Director walked by during this time and stopped and told the resident that she was going to try to contact his daughter again. Interview with CNA, Staff L on 07/13/23 at 2:09 PM confirmed that Staff L frequently finds residents soiled at the beginning of her shift. On 07/11/23 at 4:19 PM, Staff F, Licensed Practical Nurse (LPN) who was interviewed by another surveyor on the survey team, confirmed that she had heard from other nurses and CNAs that there have been times when only one CNA was on the unit, and she had followed when there has been just 1 CNA on the night shift. Staff F stated, The residents just get changed once overnight. The day CNAs are then 'pissed' because they [the residents] are soaking wet and they have to change the whole bed . Some of the CNAs are saying they are too old, so I'm chasing them around making sure stuff gets done. Review of the Progress Notes and documentation showed the following: 07/10/23 at 4:54 PM -Narrator informed by AHCA representative the resident expressed feelings of hopelessness - resident states r/t [related to] placement in a nursing home. Telemedicine done with the resident who verbalizes he has no plan but does not want to be isolated r/t not leaving the room (awaiting personal clothing from daughter who was contacted for his clothing). He is not at risk of harming himself after being interviewed by psych services. He has no plan. Clothing provided to the resident. Psych to follow up with the daughter. Emotional support provided. Primary nurse notified to provide additional support as needed r/t adjustment. Social services to reach out to the daughter. Review of the 07/10/23 at 5:02 PM Note documented: The ARNP [Advanced Registered Nurse Practitioner] was updated on the resident along with psych follow up and that the resident has no plan. 25404 2. Review of the record revealed Resident #6 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident needed limiting assistance for personal hygiene and extensive assistance for incontinence care. This MDS lacked any documented behaviors. During an interview on 07/11/23 at 9:53 AM, while speaking, observation revealed food was noted in the teeth and gum line of Resident #6. When asked if she was able to brush her teeth, Resident #6 stated she could not as her left hand shakes when she tries to brush her teeth, and she is left-handed. When asked if staff help her with oral care, Resident #6 stated, No, they just put the stuff in front of me and leave, so it just sits there. When asked how her teeth feel, Resident #6 said, Nasty. Long facial hair was also noted on the chin of Resident #6. When asked if it bothers her to have facial hair, she did not directly answer but stated, It was really long and sticking to my blanket before. During an interview on 07/13/23 at 1:41 PM, Staff I, Licensed Practical Nurse (LPN), for Resident #6, stated she was dependent upon staff for her grooming as she had tremors. On 07/13/23 at 2:31 PM, when asked if her teeth had been brushed today, Resident #6 opened her mouth and food particles were again observed. Resident #6 stated, They haven't brushed my teeth because they haven't been in here today. When asked if she had been changed or washed up today, the resident again confirmed she had not. Resident #6 put on her call light. The restorative aide answered the call light, Resident #6 requested that her adult brief be changed, and the aide went to get supplies. An observation of the assignment board at the nurses' station revealed Staff J, CNA, was assigned to care for Resident #6. During an interview on 07/13/23 at 2:35 PM, Staff J was asked what she had done for Resident #6 that day. Staff J stated, she's not on my assignment. Staff J explained she had the middle part of the hall, and that they (the CNAs) had divided the hall so that she had the middle 10 residents, ending on the room just before Resident #6. Staff J was told the assignment board had her name as CNA for Resident #6, and she again explained how they had divided up the hall that morning, and that Staff K, CNA, had Resident #6. During an interview on 07/13/23 at approximately 2:40 PM, Staff K, CNA for the back part of the hall, was asked what care she had provided to Resident #6 that day. Staff K stated, I didn't have Resident #6 today. Look at the assignment board. On 07/13/23 at 2:55 PM, Staff I, LPN, and the DON explained the night shift does the assignments and puts them up on the white board. When asked what happened this morning, Staff I, LPN, stated when she came in that morning the CNAs told her they had their assignments, front, middle, and back, and the LPN thought everything was fine. Staff I, LPN, stated she did not have any complaints from Resident #6 today when she passed medications, so she was unaware of any problems. On 07/13/23 at approximately 3:15 PM, Resident #6 was provided incontinence care by two CNAs. Resident #6 was wet and had had an incontinent bowel movement, but was not saturated as she does not void much, as she was receiving dialysis services. The buttock of Resident #6 was pink, but no open areas were noted. 3. Review of the record revealed Resident #16 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a 0 to 15 score, indicating the resident was alert and oriented. This MDS also documented the resident needed the extensive assistance of one person for incontinence care. Review of the current care plans completed on 06/22/23 documented Resident #16 was at risk for complications related to bowel and/or bladder incontinence. Interventions included to offer and assist with toileting tasks as needed, and to provide incontinence care with each incontinence episode, as tolerated. A second care plan documented Resident #16 had moisture associated skin damage (MASD) to the right and left buttocks. Interventions included to provide incontinence care promptly should any episodes of incontinence occur. Review of the weekly skin assessments documented the MASD was noted on 06/24/23. During an interview on 07/11/23 at 12:30 PM, Resident #16 stated, My bottom is really raw; I am not being changed or cleaned as much I should be. They are not putting any cream on me either. During a subsequent interview on 07/13/23 at 1:29 PM, when asked why her bottom hurts, Resident #16 stated, Because I'm laying in peepee. When asked if she could tell when she is wet, the resident confirmed she could. When asked if she uses the call light to ask to be changed when she is wet, Resident #16 confirmed she did, but further stated it can take from 2 to 4 hours to get changed. During an observation on 07/13/23 at 2:09 PM, the buttock of Resident #16 was noted with a large area of excoriation from moisture on both buttock. When asked how long she had the excoriation, Staff L, CNA who usually cared for Resident #16 on the 7 AM to 3 PM shift, stated, basically for a long time. When asked if the resident was dry when she arrived at 7 AM, the CNA stated, No! and further added, Or she will have on a dry brief, but the entire bed will be wet! What good is that. 4. Review of the record revealed Resident #106 was admitted to the facility on [DATE]. The current MDS dated [DATE] documented the resident had a BIMS score of 6, on a 0 to 15 scale, indicating the resident had some cognitive impairment, and needed the extensive assistance of one staff for personal hygiene. A progress note written by the Director of Rehab indicated she provided nail care while working with the resident's right-hand splint on 03/30/23. Review of the current care plan initiated on 11/02/22, and revised on 03/16/23 documented Resident #106 had an ADL self-care deficit and staff were to encourage and assist with all ADL tasks, including personal hygiene. During an observation on 07/10/23 at 10:40 AM, the fingernails to both hands of Resident #106 were noted to be long with a black substance under the nails. The left thumb nail was broken with a jagged corner. On 07/11/23 at 9:25 AM, the fingernails of Resident #106 remained long and dirty. On 07/13/23 at 3:03 PM, the Assistant Director of Nursing (ADON) was asked if the CNAs were allowed to clean and trim fingernail, and she confirmed that was part of their personal hygiene tasks. The ADON observed the resident's fingernails and agreed they needed to be cleaned and trimmed. The ADON was informed the resident's fingernails had been observed long and dirty since 07/10/23. 5. Review of the record revealed Resident #111 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented Resident #111 had a BIMS score of 3, on a 0 to 15 scale, indicating she was cognitively impaired. This MDS lacked any documented rejection of care, and revealed the resident needed the extensive assist of one person for personal hygiene. Review of the current care plan initiated on 11/02/22, and revised on 03/17/23 documented Resident #106 had an ADL self-care deficit and staff were to encourage and assist with all ADL tasks, including personal hygiene. An observation on 07/10/23 at 10:57 AM revealed the fingernails of Resident #111 were excessively long with a black substance under the nails. On 07/11/23 at 9:44 AM, the resident's fingernails remained long and dirty. On 07/13/23 at 3:02 PM, Resident #111 was sitting in the common area. The ADON was asked to look at the resident's nails and was asked if they could be cleaned and trimmed, and she stated of course. Resident #111 stated she would let the staff clean and trim her nails and further stated, Oh yes, they need it.

Based on observation, interview, and record review, the facility failed to ensure sufficient staffing to ensure care and services to meet the needs of bathing and showering for 2 of 5 sampled residents (Resident #22 and #100); to provide incontinence care, oral and personal hygiene, and grooming for 5 of 32 sampled residents (Residents #6, #16, #106, #111, and #228); and to follow dietary recommendations and orders for obtaining weights for 3 of 5 sampled residents (Residents #111, #120, and #123). Interviews from random residents, families, and staff revealed voiced concerns of a lack of staff. Review of current residents with skin impairments revealed 7 of 9 current pressure injuries were facility acquired (Residents #33, #72, #51, #20, #64, #10, and #76). The facility utilized managers to supplement Certified Nursing Assistant (CNA) assignments on 2 of 13 days reviewed. The findings included: 1. Residents #22 and #100 voiced concerns with a lack of staff and indicated they were not being provided baths and showers as per facility scheduling or per their request. Refer to F561 for details. 2. Resident #228 was admitted to the facility on [DATE], complained of a lack of assistance to include a lack of incontinence care, and was not assisted out of bed until 07/12/23. The resident voiced concerns of distraught and wanting to kill himself. Resident #16 developed Moisture Associated Skin Damage (MASD) to both sides of her buttock due to a lack of timely and consistent incontinence care. Staff failed to assist Resident #6 with oral care and incontinence care as needed. Staff failed to keep the fingernails of Residents #106 and #111 clean and trimmed. Refer to F677 for details. 3. Residents #111 and #123 both had significant weight losses, and staff failed to obtain weekly weights as per Registered Dietician recommendation. Staff failed to obtain weekly weights for newly admitted Resident #120. Refer to F692 for details. 4. The following residents, families, and staff interviews were obtained by the survey team, that included voiced concerns of a lack of sufficient staff: During an interview on 07/10/23 at 9:19 AM, Resident #46 stated there was not enough staff to help with needs. When asked what makes her think that, the resident explained she has a problem eating her food because she can't see, and when she asked the staff for help they don't help. During an interview on 07/10/23 at 10:23 AM, Resident #70 stated there were very few people on the night shift, and she had to wait two hours one night for staff to answer her call light. During an interview on 07/10/23 at 10:36 AM, Resident #35 stated, You'll press the button, nobody comes. Sometimes I waited 2 hours. I press the call light for my roommate, because he couldn't reach his, and they didn't come. There's not enough staff. You don't get them when you want them. During an interview on 07/10/23 at 10:39 AM, Resident #51 stated, They take a long time to get here. I've waited 20 minutes for staff to answer call lights. During an interview on 07/10/23 at 11:03 AM, Resident #54 stated, It takes a long time when you push the bell. There's not enough of people here. I guess people just quit or get fired. I've had to wait half an hour or more for staff to answer call light. During an interview on 07/10/23 at 11:04 AM, Resident #21 stated it can take up to 45 minutes to get help around here. Stated she only calls when she needs to be changed. The resident stated sometimes the light will be on for that long; other times they come in and turn the light off and say they will get help, and never come back, so she has to put it back on again. During an interview on 07/10/23 at 11:26 AM, Resident #41 stated, They won't take me to the bathroom because it takes too long. They ignore me when I ask to go to the bathroom. They come back with a diaper, so I know I'm being diapered. They don't have the help. Sometimes it's just one aide and one nurse for our unit. I've been waiting all morning to have my sheet fixed. I've asked three different staff and they just walk on. An observation at that time revealed the fitted sheet was halfway down the top half of her bed. During a phone interview on 07/10/23 at 11:49 AM, the spouse of Resident #33 stated, They don't have enough staff during the weekends. The spouse stated she was always helping feed residents who reside on the [NAME] unit at lunch time as they never have enough help. The spouse stated they allow her to feed other residents. On 07/11/23 at 12:00 PM, the spouse of Resident #33 came into the conference room to introduce herself, and confirmed she was always assisting other residents on the [NAME] unit at mealtime. During an observation on 07/11/23 at 12:06 PM, the spouse of Resident #33 assisted two residents by pushing their wheelchairs up to the table in the dining room. The spouse stated, Today they have enough help, so everyone is being fed that I usually help feed. Later the spouse of Resident #33 peeked her head into the conference room and stated, You all need to be here every day so they would have enough help. During an interview on 07/10/23 at 1:53 PM, Resident #100 stated, It takes two or three hours to get changed when I have a BM [bowel movement]. They don't have enough staff. They always blame me for everything. The private companion stated, They work these girls to death, but there are not enough staff to keep them [residents] clean and dry timely. If there is a call out, they will have just one CNA for the entire hall. During an interview on 07/11/23 at 9:02 AM, Resident #87 stated the facility does not have enough staff. When asked what makes her think that, the resident explained when she needs to urinate, she will put the call light on and it can take up to a half hour for staff to answer the light. Resident #87 stated she has had accidents because of the lack of response and added, I am concern about that because I feel helpless, real helpless. During an interview on 07/11/23 at 9:20 AM, Resident #232 stated she was admitted on [DATE]. The resident explained the other night she had her call light on for over two hours waiting for her medication and to get help to the bathroom. The resident stated she ended up urinating in her brief. During an interview on 07/11/23 at 9:29 AM, Resident #230 stated, There just isn't enough staffing. I know everywhere is experiencing the same issue. The ones that are here are great and do the best they can, but it results in long wait times when you need assistance. The daughter of Resident #39 voiced to two different surveyors during the survey, that when there was a call-out, they only have one CNA on the hall. The daughter stated her mother had a facility acquired pressure ulcer, that had since healed. The daughter stated she hired a private aide, and between the two of them they ensure her mother was taken care of. The daughter stated they don't have enough staff and have to pull from other halls for a few hours to help cover shifts. During an interview on 07/11/23 at 3:10 PM, Staff S, CNA, stated she usually works the [NAME] Unit, that has the capacity of 28 residents. The CNA stated there are usually just two CNAs working on that unit, but there has been just one on the weekends sometimes. The CNA stated when she is by herself or with just one other CNA, not everyone gets their scheduled shower. During an interview on 07/11/23 at 3:37 PM, Staff M, CNA stated he usually works the 11 PM to 7 AM shift on the [NAME] Unit. When asked if he had ever worked the unit as the only CNA, Staff M stated he had, with just one nurse, who may or may not help. The CNA stated it happened more often, before they were in their survey window. When asked what happens when he is the only CNA, Staff M stated he just has to speed through everything. When asked what he can't get done when there is only one aide on the unit, the CNA stated the residents who are supposed to get up before he leaves at 7 AM, he can usually get them cleaned up and dressed, but can't get them up out of bed, especially if they are a Hoyer lift, which needs two persons. At the time of the survey, one of five residents on the 11 PM - 7 AM Get Up list was a two person assist, Resident #74. During an interview on 07/11/23 at 4:19 PM, Staff F, Licensed Practical Nurse (LPN), stated she is part time, floats throughout the building and usually works the 7 AM to 3 PM shift. When asked if she had ever worked a unit with just one CNA, the LPN stated she had not, but had heard other nurses had. The LPN stated she has followed a shift when there was just one CNA on the unit during the previous shift. The LPN stated when that happens, my CNAs are pissed because the residents are soaking wet and then her CNAs have to change the whole bed. The LPN also stated the residents who are to be up early are not. The LPN stated it had not happened in a few weeks for her, but it has happened more than just once in a while. On 07/12/23 at 1:36 PM an interview was held with Staff O, CNA, who had been working at the facility for [AGE] years. The CNA complained of insufficient staffing, and stated, There's not enough staff and that affect the residents care really bad. When asked her to explain how the lack of staffing affects resident's care, Staff O stated, Because if I am feeding one resident, and two or three other residents are yelling and need help, I can't get to all of them. Staff O added she had worked the [NAME] Unit by herself, mostly on Sundays. During a supplemental interview on 07/12/23 at 2:59 PM, Staff O, CNA, stated this past Sunday (07/09/23) she was on the [NAME] unit as the only CNA. Staff O stated her coworker who was a CNA assigned to the [NAME] Unit came over to help her turn and clean the residents. When shown the Daily Staffing Assignment for 07/09/23, when asked whose name was listed with her name for the [NAME] Unit, Staff O stated, I might get fired for saying this, but I believe she is the weekend supervisor. When asked if the weekend supervisor worked the front half of the hall as assigned, Staff O stated, No, ma'am, I had the whole hall and a CNA, who had her own assignment on the [NAME] Unit, came and helped me when I needed a second person. 3. On 07/12/23, the facility was asked to provide a list of all current residents with skin impairments. On 07/13/23 at approximately 3:30 PM, upon review of the provided list, the Wound Care Nurse confirmed there were currently seven residents with facility-acquired pressure injuries, including sampled Residents #10 and #33, along with additional Residents #72, #51, #20, #64, and #76. Upon further review of the provided list, the Wound Care Nurse stated Resident #229 had a facility acquired pressure injury that had healed during the survey week. The Wound Care Nurse also confirmed that Resident #39, who currently was listed on the list as having a blister to the top of her foot, had a facility acquired pressure injury to her buttock recently, that has since healed. 4. Review of the staffing assignments from 06/28/23 through 07/10/23, revealed management had CNA assignments on 2 of the 13 days reviewed. On 07/09/23, the Weekend Supervisor was listed as a CNA for the [NAME] Unit on the 7 AM to 3 PM shift. On 07/10/23, Staff R, Unit Manager, was listed as a CNA for the [NAME] Unit on the 7 AM to 3 PM shift.

Based on record review, interview, and policy review, the facility failed to ensure timely weights to assess for weight loss for 2 of 7 sampled residents reviewed for nutritional concerns, resulting in a significant weight loss (Resident #75 and #41). The findings included: 1) Review of the record revealed Resident #75 was admitted to the facility on [DATE], was briefly hosptalized on [DATE] and returned to the facility on [DATE]. Review of the transfer form dated 11/30/20 documented the resident's weight at 133 pounds. Review of the orders revealed on both 11/30/20 and upon re-admission on 02/05/21, orders were written to obtain weekly weights for four weeks, then monthly unless otherwise indicated. Review of the weight history documented the following: On 11/30/20 Resident #75 weighed 145 pounds. On 02/22/21 Resident #75 weighed 103 pounds. On 02/25/21 Resident #75 weighed 102.9 pounds. On 03/01/21 Resident #75 weighed 102.4 pounds. During an interview on 03/03/21 at 9:47 AM, the Assistant Director of Nursing (ADON) stated that all weights should be in their electronic record. When asked what would be done if a resident refused a weight or if they were unable to get a weight for some reason, the ADON stated there should be a note regarding the issue, a care plan for refusals, and they would let the Registered Dietician know. When asked specifically about Resident #75, the ADON stated they had a restorative person doing weights for awhile but now they all do the weights. The ADON further stated they also had an issue with the scales and had to have them calibrated. The record lacked any additional weights and failed to follow their protocol and orders of weekly weights after both admissions. These weights revealed a 29.03% weight loss in three months from 11/30/20 to 02/25/21. The current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of two on a zero to 15 scale. This MDS documented the resident as independent for eating with a current weight of 145 pounds. (As noted above, that weight was from his admission on 11/30/20. An Initial Nutritional Evaluation dated 12/04/20 and completed by the Registered Dietician documented the resident's weight as acceptable at 145 pounds, at risk for an altered nutritional status. This assessment lacked any nutritional interventions as the resident was at an acceptable weight, except to follow weight trends. The next Nutritional Evaluation dated 02/11/21 was completed by the Registered Dietician, and was completed because of the re-admission of 02/04/21. This evaluation documented the estimated daily needs for Resident #75 was based on an actual weight, yet there was no new weight obtained. The only intervention was again to obtain weights as ordered. A progress note dated 02/24/21 at 10:52 AM by the Registered Dietician documented a weight warning. This note documented the current weight for Resident #75 as 103 pounds, revealing a weight loss of 42 pounds or 29% in about 90 days. This note documented the lack of weights in December 2020 and January 2021. Interventions were then put into place to include continuing with weekly weights and the addition of extra calories and protein. During an interview on 03/03/21 at 10:20 AM, the Registered Dietetic Tech (DTR) explained that she is at the facility twice weekly and the Registered Dietician is at the facility once weekly. The DTR confirmed weights should be obtained upon admission weekly for four weeks, and then if stable they should be monthly. If fluctuating, the weights would continue weekly. The DTR stated weights are currently being obtained from nursing and entered into the electronic medical record. The DTR runs a weekly report to identify weight loss concerns. When asked about the lack of weights, the DTR stated she brought it to the attention of management back in November or December 2020 via morning meetings and emails, with no changes being done until the new DON was hired in February 2021. When asked specifically about Resident #75, the DTR agreed with the lack of weights and the weight loss. Review of the policy Weighing the Resident revised 09/05/17 documented, Policy: Residents of the facility shall be weighed upon admission and monthly and as needed unless ordered otherwise by the physician. 2). Resident # 41 was admitted to the facility on [DATE], was briefly hosptalized on [DATE] and returned to the facility on [DATE]. According to the resident's most recent assessment, A Significant Change MDS, dated [DATE], Resident #41 had a BIMS score of 03, indicating that the resident had 'severe impairment'. The assessent documented that the resident was dependent upon staff for ADLs. Resident #41's [DIAGNOSES REDACTED]. Resident #41's care plan for nutrition documented, The resident has nutritional problem related to (r/t) recent need of altered diet consistency. History (hx) of [MEDICAL CONDITION], progressive [MEDICAL CONDITIONS] disorder, orofacial [DIAGNOSES REDACTED], mild intellectual disabilities, HTN, poor skin integrity r/t wounds, noted [MEDICAL CONDITION]. 02/18/21 sig weight loss r/t overall decline in overall health status, fluid changes. Potential for unavoidable weight loss r/t hx. Difficulty swallowing. Date initiated: 09/30/19. Revision on 03/01/21. The goal of the care plan was documented as, Minimize complications r/t clinical [DIAGNOSES REDACTED]. Revision on 02/24/21. Interventions to the care plan were documented as: GI consult for PEG tube. Date initiated: 02/19/21. * Monitor/document/report PRN any signs/symptoms of dysphagia: Pocketing, Choking, coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date initiated: 09/30/19. * Monitor/record/report to MD PRN signs/symptoms of malnutrition: emaciation (Cachexia), muscle wasting, significant weight loss: >5% in 1 month, >7.5 % in 3 months, > 10% in 6 months. Date initiated: 09/30/19. Revision on: 06/24/20. * Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicate. Date initiated 09/30/19. * OT to screen and provide adaptive equipment for feeding as needed. Date initiated: 09/30/19. * Provide and served diet as ordered. Date initiated 09/30/19. * Provide and serve supplements as ordered. Date initiated: 02/24/21. * RD to evaluate and make diet change recommendations PRN. Date initiated: 09/30/19. * ST Evaluation and Treatment. Date initiated 03/19/21. * Weight as per physicians orders. Notify physician of weight loss. Date initiated 02/18/21. Revision on: 03/01/21. * Weekly weights every shift every Monday. Resident #41's diet orders included: * Regular diet, Dysphagia Puree texture, Regular/Thin Liquids consistency 02/24/21. * MedPass put Amt ordered PO in add direc - two times a day for nutrition 02/25/21. * Magic Cup Amt ordered PO in add direc - two times a day Dietary will provide w/ lunch and dinner tray 02/25/21. On 09/01/2020, the resident weighed 202.0 lbs. On 03/01/2021, the resident weighed 163.0 pounds which is a 19.31 % Loss in 6 months. On 03/05/21 at 12:11 PM, the resident was observed outside of his room in his wheelchair. During an interview with Staff A, RN, when asked why the resident had not been served lunch, Staff A replied, he doesn't get his meal until after the food is delivered to the rooms because he is assisted. During an interview, on 03/05/21 at 12:56 PM, with the Scheduling Coordinator, when asked about the resident's dning habits, she replied, I have taken care of him for a while and he has always been the same (requiring assistance). During an interview, on 03/05/21 at 1:01 PM, with the Dietitian and the Registered Dietetic Technician, when asked about Resident #41's weight loss, the Dietitian replied, the CNAs do the weights. On 02/05/21, I was given a weight of 171. And requested a re-weight and proceded to write a note. He recently had COVID (DX date of 01/05/21) and a downgraded diet. He started on regular and went to dysphagia mech soft 02/19/21. Then he was being followed by speech and was upgraded to dysphagia advanced (one step up from mech soft). Went back to puree 02/24/21 and that is what he is on now. 204 was a normal weight trend for him that I had. That is the reason for the re-weigh when I got weight of 178. I asked for a re-weigh on 02/05/21 and in between the next weight on 02/24, he went to the hospital for a week. The Dietitan further stated that the resident was not re-weighed per her request. When asked about protocols for maintaining a resident's weight, she replied, Weights upon admission/readmission weekly x 4 if weight is stable and then monthly. We got a weight of 183.6 on 12/23/20 that was struck out and asked for a reweigh on 12/24/20 and did not receive another until 01/27/21. Review of the resident's electronic health record and paper record revealed that there were no additional weights documented for the month of December, 2020 During an interview, on 03/05/21 at 1:21 PM, with Staff E, LPN/Unit Manager, when asked about the process for resident's weights being attained, she replied, we will ask floor staff to obtain the weight. We had been doing weights on the weekends and leave a list for the weekend staff to do the weights on the weekends. Since that was the issue, we are now doing weights on Mondays and there is only one CNA designated to obtain the weights.

Based on interview, policy review, and record review the facility neglected to ensure the Advanced Directives were followed as per the resident's wishes, potentially causing physical harm, pain and mental anguish due to resuscitation efforts. The resident was transferred to the hospital intubated (breathing tube placed) and was receiving further medical interventions. The facility neglected to ensure the medical record was readily available for staff to verify code status, for 1 of 16 residents reviewed (Resident #1). There were 144 residents in the facility all of which could be affected by this deficient practice. On [DATE], it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the resident residing in the facility. The facility's Executive Director was informed of the immediate jeopardy on [DATE] at 5:30 PM. The immediate jeopardy was identified on [DATE], as beginning on [DATE] and removed on [DATE]. The scope and severity were decreased to a D, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The scope and severity were lowered as a result of the facility's corrective actions implemented as of [DATE]. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of corrective actions. Cross reference F578 The finding included: Review of the facility policy titled, Abuse, Neglect, Exploitation, & Misappropriation, dated [DATE] revealed: Neglect is the failure of the center, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the policy titled, Clinical/Medical Records, dated [DATE] revealed the Resident's clinical record is readily accessible and systematically organized to facilitate retrieving and compiling information. Required clinical information pertaining to the residents stay is centralized in the medical record. A record review conducted for Resident #1 revealed the resident had Advanced Directives. The record revealed a yellow Florida Do Not Resuscitate (DNR) Order, which was in the front of the medical record. This order was signed by a durable power of attorney, the resident's daughter, on [DATE] and signed and dated by a physician on the same date. The resident's [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) Quarterly assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 03 indicating severe cognitive impairment. A review of the resident's care plans revealed a care plan initiated on [DATE] for Advanced Directives. This care plan stated the resident had a living will and a DNR order. The goal of the care plan was the resident will have Advanced Directives followed and the interventions included a physician order for [REDACTED]. Further record review of Resident #1's chart revealed on [DATE] (time not documented) the resident was found by an x-ray technician in her room, unresponsive to verbal stimuli. The x-ray Tech called for the resident's nurse, Staff C, a Licensed Practical Nurse (LPN). Staff C responded to the resident's room to do an assessment and found the resident had no pulse or respirations. The nurse asked the x-ray Tech to call for help while the nurse stayed with the resident. Staff C documented that no one came, and she yelled down the hallway. Staff D, an LPN arrived and verified her findings. The X-Ray Tech was attempting to get an abdominal x-ray that had been ordered by the resident's physician for diarrhea. In an interview with the Executive Director (ED) and the Risk Manager (RM) on [DATE] at approximately 1:00 PM, they stated their investigation revealed that Resident #1 was found unresponsive shortly after 7:00 PM on [DATE]. The resident had a DNR order in her record but facility staff and Emergency Medical Services (EMS) performed Cardiopulmonary Resuscitation (CPR) on the resident. After Staff C located the resident's record at the nurse's station, Staff C notified the emergency room (ER) where the resident was taken. The resident's death was pronounced at 8:13 PM in the ER. The facility's immediate response was: ED notified and responded on site. A full investigation initiated. Suspend all nursing staff involved. Re-educate all licensed staff regarding CPR, Advanced Directives, Resident Rights, and following the care plan. A facility-wide review of the medical records was initiated reviewing the code status which included the physician orders and DNR forms. Mock code blue drills were initiated facility wide. An immediate report was submitted to the State Agency on [DATE] at 7:04 PM. An interview on [DATE] at 2:57 PM with Staff B, a certified nursing assistant (CNA) revealed that Staff B was Resident #1's CNA for this shift. Staff B had put the resident to bed at 7:00 PM and stated she was doing okay at that time. They had a conversation about adjusting her head, she completed her care and left the room. Staff B was in the shower room with another resident when she heard the code blue called. She thinks it was about 7:30 PM but was in the shower room and not sure. After she finished with the resident in the shower Staff B went to Resident #1's room. CPR was in progress and the room was full of staff from all over the building. Staff B did not assist. Staff B stated she has received education since this event regarding CPR and DNR's. Random interviews were conducted with nursing staff on [DATE] starting at 10:05 AM asking what they would do if they came across an unresponsive resident with no pulse and no respirations. Staff F, an LPN, stated that she would call for help and to look for code status she would look in the record for a yellow DNR form. If not there she would check the physician orders and that will state whether a resident is a DNR or full code. Staff G, an RN, stated this was her first day working in this facility. She stated she has been trained to look for a yellow DNR form in the front of the record. Staff F further stated she would get help and check code status. Staff H, a RN, stated she would call for help and look for the yellow form in the resident's chart. If not there she would check physician orders. In a phone interview conducted with Staff C, a LPN, on [DATE] at 10:55 AM it was revealed that Staff C was Residents #1's nurse for the evening. The resident was in the Essex Unit, which is a locked memory care unit. Staff C stated that an x-ray tech called her to the room saying the resident was not arousable. Staff C stated the resident had just ate and was put to bed. Staff C assessed the resident and noticed she had vomited, had no pulse and was not breathing. Staff C stated she turned her on her side and told the x-ray tech to get help. When no one came to help, Staff C yelled down the hallway and stayed with the resident. Staff D arrived along with other nurses. Staff C stated someone yelled the resident was a full code from the hallway but does not know who it was. Staff C initiated CPR. Staff C stated Resident #1 had been having diarrhea and was not feeling well. An abdominal x-ray was ordered for the persistent diarrhea. Staff C stated the resident was sleeping more than normal and seemed a bit weak. Staff C stated she does not know who called 911 or who checked the chart for the code status. She found the chart sitting by the phone after the EMS left with the resident and noticed the yellow DNR form in the front of the record. Staff C stated she had taken care of this resident many times and knew this resident well. Staff C stated she has not been back to the facility since this event occurred. A phone interview conducted with Staff D, a LPN, on [DATE] at 11:15 AM revealed staff D was working on the [NAME] unit when she heard a code blue called over head to Essex. Staff D stated it was a man's voice and very jumbled, so she went over to see what was going on. Staff D stated the unit was very chaotic. Staff D arrived at the resident's doorway and asked Staff C if the resident was a full code. Staff C responded yes, so Staff D took over compressions. Staff D stated the resident had food in her mouth and there was a lot of fluid in her throat. Staff D asked for someone to get the chart but was informed that the chart could not be found, so they continued CPR until EMS arrived and took over. Staff D stated that Staff S (LPN) called 911 but could not locate the chart. Staff D stated the chart is supposed to be brought in to the room when there is a code blue. Staff D stated that they used to have more mock code blue drills but lately have not been having them, possibly because they have had more code blues. Staff D felt more drills needed to be conducted. In interview with Staff E, a Registered Nurse (RN), on [DATE] at 11:05 AM revealed she was working on the Friar unit when she heard the code blue called to Essex. Staff [NAME] stated she responded to the room with the crash cart and was hooking up the suction when EMS arrived. Staff [NAME] is not sure who contacted 911. Staff [NAME] stated she asked the primary nurse (Staff C) if the patient was a full code because the chart could not be located. Staff C stated yes, the resident is a full code. Staff [NAME] stated mock code blues are done but the last one was ,[DATE] months ago. Staff [NAME] is certified in CPR and current. Staff [NAME] stated to check for code status she would look in the record to see if there was a yellow DNR form and check the physician orders. A follow up interview with the ED and RM on [DATE] at 2:55 PM revealed the ED was notified about 8:30 PM on [DATE] that there was an error made on reading the DNR for a resident. The ED called and spoke to Staff C and asked her how it occurred and who was with her. The ED arrived at the facility at 10:45 PM. On [DATE] at 5:37 PM an interview was conducted with the Medical Director (MD) via telephone. The MD stated that it is expected if staff find a resident who is down, they should initiate CPR until you can get help. They cannot wait until someone locates a chart and let that person wait. The MD further stated The nurse taking care of residents should know the code status of everyone they are taking care of. There is no excuse to not know the code status on a patient you are taking care of. The MD stated, this is what needs to be addressed, knowing every resident they are taking care of. In this case the facility neglected to ensure the advanced directive was followed as per the resident's/resident representatives wishes potentially causing physical harm, pain and mental anguish due to resuscitation efforts. The resident was transferred to the hospital intubated (breathing tube placed) and was receiving further interventions. The facility neglected to ensure the medical record was readily available for staff to verify code status. The facility's Immediate Jeopardy removal plan dated [DATE] included the following: Corrective Action for resident affected -Resident #1 was sent to the emergency roiagnom on [DATE]. Identification of other residents to be affected by deficient practice -All other residents have the potential to be affected. Systemic Corrective Actions: 1. On [DATE] during the ,[DATE] shift, the facility administrator reported to the center and initiated an investigation. Staff education began with the ,[DATE] shift regarding CPR/DNR policy and Abuse/neglect. A code drill was completed on [DATE] with the ,[DATE] and ,[DATE] staff on shift. Thirty-five (35) staff members participated in this code drill. Nurse C who was assigned to the resident and initiated CPR was suspended pending investigation on the evening of [DATE]. The immediate report to the State agency was completed at 7:00 PM on [DATE], the abuse registry was notified at approximately 6:30 PM on [DATE] and the police department was notified at approximately 6:25 PM on [DATE]. The other three nurses (Nurse D, Nurse E, and Nurse S) involved with the mock code drill were suspended on [DATE] and did not work after their ,[DATE] shift was completed on [DATE]. Mock code drills with re-education were initiated on [DATE] and are ongoing. Licensed nursing staff received education beginning on [DATE] to [DATE] to include following Advanced Directives, resident rights, abuse and neglect, and mock code drills. On [DATE], 110 out of 117 nursing staff members received education either in person or telephonically. For those they were unable to reach telephonically, staff were sent a certified letter as of [DATE] indicating they may not return to work until the education is received. Seven letters were mailed. On [DATE], education was initiated with licensed nurses regarding safeguarding medical records with an emphasis on storage and placement of the medical record at the nurse's station. This education is ongoing and will continue until all nurses are educated. The education will be received prior to working assigned shift. Newly hired staff will receive education in orientation. All active charts were audited on [DATE] by licensed nurses to ensure that residents' code status orders matched the Advanced Directive documents present in the chart. An Ad-hoc Quality Improvement Performance Committee meeting was held on [DATE] to review the plan. The following team members were in attendance: Executive Director, Director of Clinical Services, Medical Director via telephone, Assistant Administrator, Regional Director of Clinical Services, and Risk Manager. The Ad-hoc QAPI Committee approved the recommendations and the plan is set forth to continue. Mock code drills will continue weekly, minimally one per shift for the next 6 weeks and monthly thereafter to ensure staff are responding appropriately to CPR events and understand their responsibility during the event. Results of these drills will be submitted to QAPI for further recommendations. On [DATE] the information in the facility's removal plan was verified. Ten additional staff members were interviewed to confirm the implementation of the facility's removal plan including five nurses, one CNA, one housekeeper, one dietary staff, and two rehab staff members. Multiple resident records were randomly chosen to ensure they were easily accessible and code status was verified in all records. The facility's immediate jeopardy was removed on [DATE] at 2:00 PM.

Based on interview and record review, the facility failed to ensure Advanced Directives (Do Not Resuscitate orders) were followed as per the resident's wishes for one of sixteen residents reviewed for Advanced Directives (Resident #1). There were 144 residents in the facility, 58 residents had Do Not Resuscitate (DNR) orders and could be affected by this deficient practice. On [DATE], it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the resident residing in the facility. The facility's Executive Director was informed of the immediate jeopardy on [DATE] at 5:30 PM. The immediate jeopardy was identified on [DATE], as beginning on [DATE] and removed on [DATE]. The scope and severity were decreased to a D, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The scope and severity were lowered as a result of the facility's corrective actions implemented as of [DATE]. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of corrective actions. Cross reference F600 The finding included: Review of the facility policy titled, Florida Do Not Resuscitate (DNR), dated [DATE], included: The properly executed DNRO (Do Not Resuscitate Order) will be placed in the resident's medical record. Review of the policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE] revealed: 1. In the event of [MEDICAL CONDITION], immediately call for assistance. 2. Two licensed nurses are to verify: - Resident Identity -Current physician order for [REDACTED].>3. Use the paging system and call Code Blue to room number _, three times (or location of event). 4. In the absence of a physician's order for the DNR the facility will immediately begin CPR. 5. Center staff will continue performing CPR until Emergency medical Technicians assume responsibility for CPZR, or it may be discontinued if the resident responds. 6. Notify the physician and resident representative/legal representative. 7. Document in the medical record. A record review conducted for Resident #1 revealed the resident had Advanced Directives. The record revealed a yellow Florida Do Not Resuscitate (DNR) Order, which was in the front of the medical record. This order was signed by a durable power of attorney, the resident's daughter, on [DATE] and signed and dated by a physician on the same date. The resident's [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) Quarterly assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 03 indicating severe cognitive impairment. A review of the resident's care plans revealed a care plan initiated on [DATE] for Advanced Directives. This care plan stated the resident had a living will and a DNR order. The goal of the care plan was the resident will have Advanced Directives followed and the interventions included a physician order for [REDACTED]. Further record review of Resident #1's chart revealed on [DATE] (time not documented) the resident was found by an x-ray technician in her room, unresponsive to verbal stimuli. The x-ray Tech called for the resident's nurse, Staff C, a Licensed Practical Nurse (LPN). Staff C responded to the resident's room to do an assessment and found the resident had no pulse or respirations. The nurse asked the x-ray Tech to call for help while the nurse stayed with the resident. Staff C documented that no one came, and she yelled down the hallway. Staff D, an LPN arrived and verified her findings. The X-Ray Tech was attempting to get an abdominal x-ray that had been ordered by the resident's physician for diarrhea. In an interview with the Executive Director (ED) and the Risk Manager (RM) on [DATE] at approximately 1:00 PM, they stated their investigation revealed that Resident #1 was found unresponsive shortly after 7:00 PM on [DATE]. The resident had a DNR order in her record but facility staff and Emergency Medical Services (EMS) performed Cardiopulmonary Resuscitation (CPR) on the resident. After Staff C located the resident's record at the nurse's station, Staff C notified the emergency room (ER) where the resident was taken. The resident's death was pronounced at 8:13 PM in the ER. The facility's immediate response was: ED notified and responded on site. A full investigation initiated. Suspend all nursing staff involved. Re-educate all licensed staff regarding CPR, Advanced Directives, Resident Rights, and following the care plan. A facility-wide review of the medical records was initiated reviewing the code status which included the physician orders and DNR forms. Mock code blue drills were initiated facility wide. An immediate report was submitted to the State Agency on [DATE] at 7:04 PM. An interview on [DATE] at 2:57 PM with Staff B, a certified nursing assistant (CNA) revealed that Staff B was Resident #1's CNA for this shift. Staff B had put the resident to bed at 7:00 PM and stated she was doing okay at that time. They had a conversation about adjusting her head, she completed her care and left the room. Staff B was in the shower room with another resident when she heard the code blue called. She thinks it was about 7:30 PM but was in the shower room and not sure. After she finished with the resident in the shower Staff B went to Resident #1's room. CPR was in progress and the room was full of staff from all over the building. Staff B did not assist. Staff B stated she has received education since this event regarding CPR and DNR's. Random interviews were conducted with nursing staff on [DATE] starting at 10:05 AM asking what they would do if they came across an unresponsive resident with no pulse and no respirations. Staff F, an LPN, stated that she would call for help and to look for code status she would look in the record for a yellow DNR form. If not there she would check the physician orders and that will state whether a resident is a DNR or full code. If the resident had a DNR order she would not start CPR. Staff F stated she has had training in CPR (certified), Advanced Directives, and code blue. Staff G, an RN, stated this was her first day working in this facility. She stated she has been trained to look for a yellow DNR form in the front of the record. Staff F further stated she would get help and check code status. If resident was a DNR then she would contact physician and family. If resident is a full code, she would initiate CPR. Staff H, a RN, stated she would call for help and look for the yellow form in the resident's chart. If not there she would check physician orders. Staff H further stated all staff had Advanced Directive/DNR training this morning before starting their shift. In a phone interview conducted with Staff C, LPN, on [DATE] at 10:55 AM it was revealed that Staff C was Residents #1's nurse for the evening of [DATE]. The resident was in the Essex Unit, which is a locked memory care unit. Staff C stated that an x-ray tech called her to the room saying the resident was not arousable. Staff C stated the resident had just ate and was put to bed. Staff C assessed the resident and noticed she had vomited, had no pulse and was not breathing. Staff C stated she turned her on her side and told the x-ray tech to get help. When no one came to help, Staff C yelled down the hallway and stayed with the resident. Staff D arrived along with other nurses. Staff C stated someone yelled the resident was a full code from the hallway but does not know who it was. Staff C initiated CPR. Staff C stated Resident #1 had been having diarrhea and was not feeling well. An abdominal x-ray was ordered for the persistent diarrhea. Staff C stated the resident was sleeping more than normal and seemed a bit weak. Staff C stated she does not know who called 911 or who checked the chart for the code status. She found the chart sitting by the phone after the EMS left with the resident and noticed the yellow DNR form in the front of the record. Staff C stated she had taken care of this resident many times and knew this resident well. Staff C stated she has not been back to the facility since this event occurred. A phone interview conducted with Staff D, LPN, on [DATE] at 11:15 AM revealed staff D was working on the [NAME] unit when she heard a code blue called over head to Essex. Staff D stated it was a man's voice and very jumbled, so she went over to see what was going on. Staff D stated the unit was very chaotic. Staff D arrived at the resident's doorway and asked Staff C if the resident was a full code. Staff C responded yes, so Staff D took over compressions. Staff D stated the resident had food in her mouth and there was a lot of fluid in her throat. Staff D asked for someone to get the chart but was informed that the chart could not be found, so they continued CPR until EMS arrived and took over. Staff D stated that Staff S (LPN) called 911 but could not locate the chart. Staff D stated the chart is supposed to be brought in to the room when there is a code blue. Staff D stated that they used to have more mock code blue drills but lately have not been having them, possibly because they have had more code blues. Staff D felt more drills needed to be conducted. In interview with Staff E, a Registered Nurse (RN), on [DATE] at 11:05 AM revealed she was working on the Friar unit when she heard the code blue called to Essex. Staff [NAME] stated she responded to the room with the crash cart and was hooking up the suction when EMS arrived. Staff [NAME] is not sure who contacted 911. Staff [NAME] stated she asked the primary nurse (Staff C) if the patient was a full code because the chart could not be located. Staff C stated yes, the resident is a full code. Staff [NAME] stated mock code blues are done but the last one was ,[DATE] months ago. Staff [NAME] is certified in CPR and current. Staff [NAME] stated to check for code status she would look in the record to see if there was a yellow DNR form and check the physician orders. On [DATE] at 1:50 PM an interview with the ED revealed the nurse managers do the mock code drills with the staff. The ED provided sign in sheets for the mock code blue drills done over the past year. Two of the four nurses involved in the event on [DATE] were noted on the code blue drill forms. A follow up interview with the ED and RM on [DATE] at 2:55 PM revealed the following: The ED was notified about 8:30 PM on [DATE] that there was an error made on reading the DNR for a resident. The ED called and spoke to Staff C and asked her how it occurred and who was with her. The Regional Nurse and Corporate Risk Manager for the facility was notified. Staff C was notified that she had to be sent home immediately and was suspended pending investigation. Spoke with Staff D who responded to overhead page. Staff D informed ED that Staff C had initiated compression and had already confirmed code status. ED arrived at facility at 10:45 PM. ED further stated that Staff C saw the DNR order immediately after EMS left with the resident. The resident arrived at the emergency room (ER) at 7:37 PM and had been intubated. The facility called the ER at 7:51 PM and notified them of the DNR status and faxed them the form. The resident was extubated, and death pronounced at 8:13 PM. ED stated the other three nurses involved in the event were suspended pending investigation prior to leaving their shift. The on-coming shift of 11PM to 7 AM were educated on the CPR policy prior to starting their shift. The 7 AM to 3 PM shift the following day were educated prior to the start of their shift. An immediate report was submitted on [DATE] at 7:00PM. The education is still ongoing and code drills are being done on every shift. The ED stated the crash carts and documentation were looked over to see what staff had available to them. All nursing staff were re-educated on the code blue documentation sheet. Audits were completed for DNR forms and physician orders. These audits were previously being done weekly by Social Service Personnel. The ED stated that This was a nurse not following the protocols the facility has in place. On [DATE] at 5:37 PM an interview was conducted with the Medical Director (MD) via telephone. The MD stated that it is expected if staff find a resident who is down, they should initiate CPR until you can get help. They cannot wait until someone locates a chart and let that person wait. The MD further stated The nurse taking care of residents should know the code status of everyone they are taking care of. There is no excuse to not know the code status on a patient you are taking care of. The MD stated, this is what needs to be addressed, knowing every resident they are taking care of. The facility's Immediate Jeopardy removal plan dated [DATE] included the following: Corrective Action for resident affected -Resident #1 was sent to the emergency roiagnom on [DATE]. Identification of other residents to be affected by deficient practice -All other residents have the potential to be affected. Systemic Corrective Actions: 1. On [DATE] during the ,[DATE] shift, the facility administrator reported to the center and initiated an investigation. Staff education began with the ,[DATE] shift regarding CPR/DNR policy and Abuse/neglect. A code drill was completed on [DATE] with the ,[DATE] and ,[DATE] staff on shift. Thirty-five (35) staff members participated in this code drill. Nurse C who was assigned to the resident and initiated CPR was suspended pending investigation on the evening of [DATE]. The immediate report to the State agency was completed at 7:00 PM on [DATE], the abuse registry was notified at approximately 6:30 PM on [DATE] and the police department was notified at approximately 6:25 PM on [DATE]. The other three nurses (Nurse D, Nurse E, and Nurse S) involved with the mock code drill were suspended on [DATE] and did not work after their ,[DATE] shift was completed on [DATE]. Mock code drills with re-education were initiated on [DATE] and are ongoing. Licensed nursing staff received education beginning on [DATE] to [DATE] to include following Advanced Directives, resident rights, abuse and neglect, and mock code drills. On [DATE], 110 out of 117 nursing staff members received education either in person or telephonically. For those they were unable to reach telephonically, staff were sent a certified letter as of [DATE] indicating they may not return to work until the education is received. Seven letters were mailed. On [DATE], education was initiated with licensed nurses regarding safeguarding medical records with an emphasis on storage and placement of the medical record at the nurse's station. This education is ongoing and will continue until all nurses are educated. The education will be received prior to working assigned shift. Newly hired staff will receive education in orientation. All active charts were audited on [DATE] by licensed nurses to ensure that residents' code status orders matched the Advanced Directive documents present in the chart. An Ad-hoc Quality Improvement Performance Committee meeting was held on [DATE] to review the plan. The following team members were in attendance: Executive Director, Director of Clinical Services, Medical Director via telephone, Assistant Administrator, Regional Director of Clinical Services, and Risk Manager. The Ad-hoc QAPI Committee approved the recommendations and the plan is set forth to continue. Mock code drills will continue weekly, minimally one per shift for the next 6 weeks and monthly thereafter to ensure staff are responding appropriately to CPR events and understand their responsibility during the event. Results of these drills will be submitted to QAPI for further recommendations. On [DATE] the information in the facility's removal plan was verified. Ten additional staff members were interviewed to confirm the implementation of the facility's removal plan including five nurses, one CNA, one housekeeper, one dietary staff, and two rehab staff members. The facility's immediate jeopardy was removed on [DATE] at 2:00 PM.