Every finding on record at Victoria Crossing Rehabilitation Center

Based on interviews, observation, and record review, the facility failed to provide Activities of Daily Living (ADLs) related to fingernail trimming for one resident (#135) out of four residents sampled.Findings Included: During an observation and interview on 01/05/2026 at 10:30 a.m., Resident #135 was observed to have long untrimmed nails with black build-up underneath. Resident #135 stated I would like my nails trimmed. I don't like them being this long.During an interview and observation on 01/07/2026 at 9:04 a.m., Resident #135's was observed to have long untrimmed nails with black build up underneath. Resident #135 stated, I have asked them to trim my nails, but they have not done it yet.Review of Resident #135's admission record revealed an admission date of 01/02/2026. Resident #135 was admitted to the facility with diagnosis to include cerebral infarction, cerebral amyloid angiopathy, muscle weakness, unspecified lack of coordination, and need for assistance with personal care.Review of Resident #135's Care Plan dated 01/03/2026 revealed a focus - Resident #135 has an ADL self-care performance deficit related to cerebrovascular (CVA), cerebral amyloid angiopathy, dysarthria, right hemiparesis and dementia. Interventions included - Bathing/showering: check nail length and trim and clean on bath day as necessary. Report any changes to the nurse.During an interview on 01/07/2026,11:32 a.m., Staff Q, Certified Nursing Assistant (CNA) stated, There is no schedule for nails to be trimmed and that it is done when they ask or I see it.During an interview on 01/07/2026, at 11:46 a.m., Staff R, Registered Nurse (RN) stated The CNA will do all the showers and any nail trimmings. Staff R stated they normally document it on the shower sheets, but they don't always get filled out like they should be.During an interview on 01/08/2026, at 12:03 p.m., the Director of Nursing (DON) stated her expectation was for residents' nails to be trimmed with showers or as needed.Review of the facility policy titled clinical activities of daily living (ADL's) all this happened with a revision date of 11/11/2025 revealed a purpose: To ensure residents' needs are met in a manner that promotes their quality of life, resident rights, preferences, and independence.Procedure: 1. The facility shall ensure a resident is given the appropriate treatment and services to maintain or improve his or her own ability to carry out the activities of daily living.2. The facility shall provide care and services for the following activities of daily living as needed based on the individual care plan of each resident: a period hygiene: by not coming to bathing, dressing, grooming, and oral care.

Based on record review and interview, the facility failed to allow the resident to remain in the facility during a pending appeal for one resident (#133) out of four residents reviewed for discharge.Findings Included:Review of Resident #133's admission record revealed an admission date of 10/01/2025 and a discharge date of 11/04/2025. Resident #133 was admitted to the facility with diagnosis to include orthopedic aftercare following surgical amputation, other acute osteomyelitis, left ankle and foot, chronic obstructive pulmonary disease, and muscle weakness.Review of a care plan for Resident #133 initiated on 10/03/2025 revealed a focus; [Resident #133] wishes to return home with her [family member]. The goal showed the resident will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge. Interventions included to encourage resident to discuss feelings and concerns impeding discharge. Establish a pre-discharge plan with the resident/resident representative and evaluate the process. SS (Social Services) will make arrangements with required community resources to support independence post discharge.Review of a Physical Therapy (PT) discharge summary dates 10/2/2025 - 11/3/2025 showed Resident #133's plan was to discharge home. The discharge reason showed - Highest practical level achieved. Discharge recommendations showed Home health services were recommended. The summary did not show if Resident #133's home health services were set up prior to discharge.Review of the State of Florida Department of Children and Families (DCF) appeal hearing form revealed an appeal for discharge for Resident #133 was filed on 11/03/2025. The document revealed this hearing was based on the patient's belief that he/she was being erroneously discharged from the nursing facility.Review of Resident #133's electronic medical record revealed there was no record or notes related to Resident #133 or representative filing an appeal. The review of the entire clinical record did not show why the resident may not have been ready to discharge from the facility. Attempts to reach the resident were unsuccessful. An interview was conducted on 01/08/2026 at 3:56 p.m. with the Social Services Director (SSD). The SSD stated having worked at this facility for only a week. The SSD stated not knowing Resident #133 or anything about an appeal for discharge. The SSD reviewed Resident #133's medical record and confirmed there was no documentation regarding the appeal. The SSD confirmed there was no record of the AHCA (Agency for Health Care Administration) discharge/transfer form. The SSD said, I do not see the AHCA discharge form. The SSD confirmed Resident #133's record did not have a documented discharge summary.During an interview on 01/08/2026 at 4:10 p.m., the Nursing Home Administrator (NHA), stated the social services department is the one who discusses the discharge with the residents. The NHA stated they should do an assessment and add notes to the record related to the discharge. The NHA stated if a resident files an appeal they should not be discharged from the facility until after the appeal decision. She said, I believe you when you tell me there is nothing in the record related to the discharge. We did not have someone in social services and the people who were covering were not doing them correctly.Review of the facility policy titled Discharge Planning, with a revision date of 03/10/2023 revealed a purpose: The facility shall have a discharge planning process that focuses on the residents discharge goals, the resident support system, and the transition timing to ensure a smooth process.

Based on observations, interviews and record review the facility failed to follow physician orders related to medication perimeters and wound care for two residents (#10 and #22) out of two residents sampled.Findings Included: Review of Resident #10's admission record revealed an admission date of 11/18/2025. Resident #10 was admitted to the facility with diagnosis to include hepatic failure, acute embolism and thrombosis of right femoral vein, portal hypertension, hypotension, and idiopathic hypotension, sedative, hypnotic or anxiolytic abuse. Review of Resident #10's physician orders dates active as of 01/08/2026 revealed:Midodrine Give 15 mg by mouth three times a day for Hypotension Hold if Systolic Blood Pressure (SBP) great than 130. Start Date: 12/18/2025 Review of Resident #10's Medication Administration Record (MAR) for November 2025 revealed the medication was given with a SBP greater than 130 on 11/01/2025, 11/24/2025, and 11/26/2025. Review of Resident #10's Medication Administration Record (MAR) for December 2025 revealed the medication was given with a SBP greater than 130 on 12/06/2025, 12/18/2025, and 12/20/2025. During an interview on 01/08/2025 at 3:05 p.m., the Director of Nursing (DON) reviewed Resident #10's MAR for November and December 2025 and stated the Midodrine should have been held if the blood pressure was greater than 130. During an interview on 01/08/2025 at 5:02 p.m., the Physician stated, Sometimes we can override the rules if there are circumstances that call for it. I would assume the nurse spoke with a physician getting the okay to continue to give the medication outside of the order parameters. I personally would have to check with the other providers, but I would expect there to be a nurse's note as well. Review of the facility's policy titled, Physician Orders, revised 11/11/2025 revealed a purpose: Physician/Physician extender's orders are administered upon the clear complete order of an individual lawfully authorized to prescribe. On 1/5/26 at 2:13 p.m., during an observation and interview, Resident #22 stated staff had not been putting cream on her calves like they are supposed to. The resident stated no one had applied the cream in a few days. On 1/5/26 at 2:20 p.m., Staff D, Licensed Practical Nurse (LPN)/Unit Manager (UM) entered Resident #22's room after resident had turned on call light to ask for the prescribed cream to be put on their legs. Staff D, LPN/UM removed Resident #22's socks to reveal the resident having dry, flaky skin, sores and wounds that appeared to have drainage with a strong odor present on her calves. Resident #22 told Staff D, UM no one had put their prescribed cream on their legs in a few days. Staff D stated since Resident #22 was at dialysis during wound rounds for the day of 1/5/26, she would be seen by the wound care nurse on the following day, Tuesday, 1/6/25. A review of Resident #22's admission record revealed an admission date of 8/16/25 with diagnoses to include acute on chronic diastolic (congestive) heart failure, type 2 diabetes, difficulty in walking, and stage 5 chronic kidney disease. A review of Resident #22's Quarterly Minimum Data Set (MDS) assessment, dated 11/25/25, in section C - cognitive patterns revealed a Brief Interview for Mental Status (BIMS) score of 12, meaning the resident was moderately impaired. A review of Resident #22's physician orders revealed the following: Ammonium lactate external lotion 12% (Lactic acid (Ammonium Lactate) to be applied every day and evening shift to bilateral lower legs topically starting on 9/23/25. A review of Resident #22's physician progress notes revealed on 1/8/26, 1/7/26, and 1/6/26 showed, Given clinical signs of wound infection, empirically initiated levofloxacin 250 mg orally once a day for 7 days, with plans to adjust antibiotic therapy based on wound culture and sensitivity results. On 1/7/26 another physician note showed Bilateral lower extremity skin changes noted consisted with PVD (peripheral vascular disease). Record review showed there was no further documentation on the condition of Resident #22's bilateral lower legs A review of Resident #22's care plan dated 11/28/25 revealed a focus- the resident will have intact skin, free of redness, blisters or discoloration. Interventions included to follow facility policies/protocols for the prevention/treatment of skin breakdown. Inform the resident/resident representative of any new area of skin breakdown. Monitor or document/report PRN (as needed) any changes in skin status. A second focus in the same care plan showed [Resident #22] has Diabetes Mellitus. The resident will have no complications related to diabetes. Interventions included to monitor/document/report PRN any s/sx (signs/symptoms) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing. A third focus in the same care plan showed [Resident #22] has peripheral vascular disease r/t (related to) diabetes. The goal showed the resident will be free of s/sx of PVD. Interventions included to keep skin on extremities well hydrated with lotion in order to prevent dry skin and cracking of the skin. Monitor for dry skin and apply lotion as needed. A review of Resident #22's Skin Evaluation tool and wound report dated 1/1/26 and 12/25/25 referenced the resident's heel wounds. The evaluation did not include the observed bilateral lower leg flaky dry skin and the ammonia lactate orders prescribed.On 1/8/26 at 3:02p.m. an interview with Staff D, LPN/UM revealed the wound doctor was not seeing Resident #22 for the wounds on their calves. Staff D, LPN/ UM stated no report had been made to the physician or family representative on the state of Resident #22's bilateral lower legs. Staff D stated a change in condition (CIC) was not documented, but it should have been documented. On 1/8/26 at 4:17p.m., an interview was conducted with the Director of Nursing (DON). The DON revealed to have expected some kind of documentation in regards to Resident #22's bilateral lower leg wounds. The DON stated it is their expectation for the physician to have been notified about the issues, for a CIC to have been made, and a risk assessment to be completed. A review of the facility policy titled, Skin Management, dated 8/21/25, revealed a purpose to provide identification of altered skin integrate risk factors and interventions for specific risk factors. General guidelines: 1. Keep the skin clean and free of exposure to urine and fecal matter. Monitoring – 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. A review of the facility policy titled, Wound Treatment Management, revised 2/21/23, revealed the following general guidelines - To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. 4. Treatment decisions will be based on: a. Etiology of the wound: Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic. Photographic Evidence Obtained.

Based on observation and interview, the facility failed to provide Meal Menus to four (Resident #24, Resident #67, Resident #105 and Resident #110) out of four residents reviewed for choices.Findings Included: During an interview on 01/05/2026 at 9:27 a.m., Resident #24 stated they have not passed out menus in a while, so she has no idea what she is getting to eat until they bring the trays in. An observation of Resident #24's wall and overside table revealed no meal menu. During an interview on 01/05/2025 at 10:02 a.m., Resident #67 stated they don't pass out menus anymore, so I never know what they are bringing me to eat. They will bring my tray, and I can order something else, but I cannot order it ahead of time since I don't know what they are serving. An observation of Resident #67's room revealed no meal menu was posted. During an interview on 01/07/2026 at 10:00 a.m., Resident #110 stated I don't know what the meal will be before I get my meal tray so I can not pre-order an alternative meal. They stopped providing us with menus in our rooms. During an interview on 01/07/2025 at 12:30 p.m., the Dietician and Certified Dietary Manager (CDM) stated we stopped passing out lunch menus because residents were not ordering nutritional meals. We had residents who just wanted to order toast, and this is not a nutritional meal. We have their preferences with their likes and dislikes so we know what we can serve them and they won't receive anything they do not want. They can order from the alternative menu but will have to wait to receive the ordered item because we must finish meal services first. An interview was conducted on 1/8/2026 at 10:45 A.M. with Staff A, Registered Nurse (RN) Unit Manager, stated residents do not receive meal menus anymore and the residents cannot pick what they want. She said, it makes more sense for the residents to have a choice. 2. An interview was conducted with Resident #105 on 1/5/26 at approximately 10:30 a.m. The resident reported not getting the food as requested, had requested a cheeseburger (multiple times) and had only received one in the month of being at the facility. The resident provided a menu ticket showing lunch and dinner items for 1/3 and breakfast on 1/4/26. The resident had requested fresh fruit for each of the meals along with numerous handwritten meal choices. During an interview on 1/5/26 at 4:00 p.m. with Resident #105 and a family member, the resident stated the handwritten choices on the meal tickets were suggestions and had not received a menu for Monday (1/5) or Tuesday (1/6). An interview was conducted on 1/7/26 at 12:08 pm, with the Dietitian and regional Certified Dietary Manager. (CDM). The Dietitian reported speaking with residents after admissions, quarterly and annually. The CDM reported the contracted kitchen vendor had started with the facility on 1/1/26 and had not completed any initial (assessments) and the facility hadn't had a consistent CDM. The Dietitian reported meeting with Resident #105 and the family member a week after admission and a copy of renal education had been provided. The CDM stated the meals were resident preference based and the vendor had stopped passing menus due to resident's ordering just one piece of bread and not ordering a nutritional meal. The CDM stated the system could be very specific with preferences and dislikes, for example could add grilled chicken versus breaded chicken. A review of a facility provided policy revised 12/9/2025, titled, Policy and Procedure: Dietary - Food and Drink revealed the purpose is to ensure facility staff supports the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. The procedure is as follows: The facility will provide to each resident: 4: Food that accommodates resident allergies, intolerances, and preferences. 5: Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice.

Based on observations, record reviews, and interviews the facility failed to provide toileting needs for one (#97) of two residents sampled for bladder and bowel incontinence. Findings included: On 1/6/26 at 9:13 a.m. Resident #97 was observed lying in bed. The resident reported to being wet, had not been changed since 5:00 a.m., and normally does not get changed until staff dress around 11:00 a.m. An interview was conducted with Staff O, Central Supply/Certified Nursing Assistant (CNA) on 1/7/26 at 8:52 a.m. The staff member reported the process in morning was to receive report from 11 p.m.-7a.m. shift, rounds on residents to ensure they are clean, and if wet, changed them at that time. Staff O stated Resident #97 was a heavy wetter, checks residents for incontinence every 2-3 hours, checks heavy wetter's more often. On 1/7/26 at 9:08 a.m. Resident #97 was observed lying in bed eating breakfast. The smell of urine was noticeably in the resident room while conducting an observation of medication administration with the resident's roommate. On 1/7/26 at 11:01 a.m. Resident #97 reported buying a medicated barrier cream for incontinency and the facility does provide another type. The resident reported having open areas in groin area and staff do change Resident #97 multiple times. An observation was conducted with Staff P, Licensed Practical Nurse (LPN) of the groin area of Resident #97. The observation showed the resident's incontinence brief appeared to be dry and the groin area outside of the brief was excoriated. Staff P provided incontinence care for Resident #97. Review of a 14-day lookback for Resident #97s Bladder function Certified Nursing Assistant (CNA) documentation showed the following:12/26/25: documentation of 2 episodes of continent bladder function at 6:17 p.m. with no further documentation during the 3 p.m. - 11 p.m. shift.12/27/25: documentation of 5 episodes of incontinence between 2:02 p.m. and 4:31 p.m. (2 hours 29 minutes) with no further documentation during the 3 p.m. - 11 p.m. shift.12/28/25: documentation of 3 episodes of incontinence at 10:04 p.m.12/29/25: documentation showed the resident had 6 episodes of incontinence between 10:04 p.m. (12/28/25) and 12:11 a.m. on 12/29/25 (2 hours 7 minutes). No other documentation of bladder episodes during the 11 p.m. - 7 a.m. shift.12/30/25: documentation of 2 episodes of incontinence at 5:36 p.m., no further bladder episodes during the 3 p.m. - 11 p.m. shift.12/31/25: documentation of 3 episodes at 2:36 a.m. no further documentation of bladder function on the 11 p.m. - 7 a.m. shift. Staff documented the resident had 8 episodes of incontinence prior to 10:02 a.m. (no further documentation of bladder function during the 7 a.m. - 3 p.m. shift) and no documentation of bladder episodes on the 3 p.m. - 11 p.m. shift.1/1/26: Documentation of 2 episodes of incontinence at 1:11 a.m. (14 hours and 51 minutes after the last documentation of bladder functioning.1/2/26: documentation of 1 episode of during the 11 p.m. - 7 a.m. shift. The last documentation of bladder function showed 1 episode between 2:59 p.m. and 7:55 p.m. No further documentation on 1/2/26.1/3/26: documentation of 2 incontinent episodes at 6:46 a.m. and 2 episodes at 2:35 p.m. No further documentation of bladder function on 1/3/26.1/4/26: documentation of 3 episodes of incontinent bladder function at 2:47 p.m. (24 hours and 12 minutes after last documentation on 1/3/26. 3 episodes were documented at 8:04 p.m.1/5/26: no documentation of voiding from 8:04 p.m. (1/4/26) until 2 episodes on 2:59 p.m. No documentation of voiding on 11 p.m. - 7 a.m. shift. Review of Resident #97s admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to multiple sites (of) other specified arthritis, unspecified chronic obstructive pulmonary disease, and unspecified heart failure. Review of Resident #97s comprehensive Minimum Data Set, dated [DATE] showed the resident scored 12 of 15 on the Brief Interview of Mental Status (BIMS), indicating an intact cognition. The assessment revealed the resident was always incontinent of urine and bowel. Review of Resident #97s care plan revealed the resident was incontinent of bladder related to impaired mobility and instructed staff to check and chance (change) as needed for incontinence. Wash, rinse, and dry perineum. Review of the resident focuses showed the resident was on diuretic therapy related to edema and had an Activity of Daily Living (ADL) self-care performance deficit related to impaired mobility which required assistance of one staff member for turning and repositioning in bed, for personal hygiene and oral care, and for toileting. An interview was conducted with Staff D, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 1/8/26 at 3:51 p.m. The staff member stated CNAs document in the plan of care (POC) and normally document at the time the task is completed, staff are to document after each episode or soon after [incontinence], and if done at end of shift they may forget [what has occurred]. The UM stated CNA's work 8 hour shifts: 7 a.m. - 3 p.m., 3 p.m. - 11 p.m., and 11 p.m. - 7 a.m. and each shift documents in the POC. Staff D stated if a resident voiced a refusal to be changed, staff were to wait a minute and reapproach, second refusal - have someone else go in and ask, the third refusal a nurse goes in with staff to the resident. Staff D stated Resident #97 was able to make needs known. The staff member reviewed the bladder function task for the resident and reported seeing the issue with the CNA documentation [missing shifts].During an interview on 1/8/26 at 6:11 p.m. the Director of Nursing (DON) stated we ask that they do it [document] as it happens, it's hard to keep up if they do care and care then come back to it. The DON stated staff should be rounding every 2 hours on residents and make frequent rounding and per request. The DON stated Resident #97 was able to tell staff when wet or not. Review of the CNA POC task for bladder function was conducted with the DON, who confirmed staff were not documenting toileting episodes and if it was not documented it was not done.

Based on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status for three (#1, #71, and #113) residents of eight residents reviewed for nutrition. Findings include:1.An observation on 1/5/2026 at 11:10 A.M. revealed Resident #1 had a foam water cup on his bedside table dated 1/4/2026.An observation on 1/6/2026 at 9:46 A.M. revealed Resident #1 had a foam water cup on his bedside table dated 1/5/2026.An observation on 1/8/2026 at 10:30 A.M. revealed Resident #1 had a foam water cup on his bedside table dated 1/7/2026.An interview was conducted on 01/06/2026 at 10:20 A.M. with Resident #1. He said his still hungry and asked for another breakfast tray. He had not received an additional tray. He said he does not need assistance eating his meals.A review of Resident #1's admission record revealed the resident was admitted on [DATE] and included diagnoses not limited to Type 2 diabetes mellitus, muscle weakness (generalized), and assistance with personal care.A review of Resident #1's weight summary showed on 10/08/2025 the resident weighed 137.3 pounds via mechanical lift, on 01/03/2026 the resident weighed 121.6 pounds via the bed, a weight loss of 15.7 pounds and total body weight loss of 11.43%.A review of Resident #1's physician order summary revealed the resident was to receive 4 ounces of a health shake.A review of Resident #1's medication administration record revealed the resident was consuming a daily average of 25% of the shake for the month of January 2026.A review of Resident #1's task record revealed the resident was offered fluids and snacks twice (12/29/2025 and 12/31/2025) in the past 30 days.A review of Resident #1's care plan showed the resident had a nutritional problem or potential nutritional problem. The focus was initiated on 10/15/2025 and revised on 11/21/2025. The goal for Resident #1 was the resident will exhibit gradual weight gain toward ideal body weight. The interventions for Resident #1 included monitoring/recording/reporting to medical doctor for signs or symptoms of malnutrition: significant weight loss: >3 [pounds] in one week, >[greater than] 5% in one month, >7.5% in three months, or >10% in six months. Another intervention for Resident #1 was provide and serve supplements as ordered.A review of Resident #1's progress notes revealed no attempted contact was made with the medical doctor or the registered dietitian.An interview was conducted on 1/8/2026 at 10:45 A.M. with Staff A, Unit Manager (UM). Staff A, UM said her expectation was fresh water be given to the residents before breakfast trays were delivered.2.An observation on 1/5/2026 at 11:13 A.M. revealed Resident #71 had a foam water cup on his bedside table dated 1/4/2026.An observation on 1/6/2026 at 9:49 A.M. revealed Resident #71 had a foam water cup on his bedside table dated 1/5/2026.A review of Resident #71's admission record revealed the resident was admitted on [DATE] and included diagnoses not limited to Type 2 diabetes mellitus and dysphagia.A review of Resident #71's weight summary showed on 12/18/2025 the resident weighed 179 pounds via mechanical lift on admission. The record showed one weight documented.A review of Resident #71's physician order summary revealed the resident was to receive eight ounces of [high calorie supplement] one time a day for nutritional support.A review of Resident #71's medication administration record revealed the resident had not consumed the ordered supplement for the month of January 2026.A review of Resident #71's task record revealed the resident was offered fluids and snacks twice (12/29/2025 and 12/31/2025) in the past 30 days.A review of Resident #71's care plan showed the resident is a risk for malnutrition related to the need for therapeutic/mechanically altered diet, impaired mental status, and chronic diseases. The focus was initiated on 12/18/2025 and revised on 12/26/2025. The goal for Resident #71 was the resident will maintain weight as evidenced by no significant weight changes. The interventions for Resident #1 included provide and serve supplements as ordered and weigh per policy.3.An interview was conducted on 01/05/2026 3:40 P.M. with Resident #113. Resident #113 said he does not like food and thinks he has lost weight.A review of Resident #113's admission record revealed the resident was admitted on [DATE] and included diagnoses not limited to muscle weakness (generalized) and oropharyngeal phase dysphagia.A review of Resident #113's weight summary showed on 12/17/2025 the resident weighed 150.8 pounds via mechanical lift, on 01/03/2026 the resident weighed 124.2 pounds via the bed, a weight loss of 26.6 pounds and total body weight loss of 17.64%.A review of Resident #113's task record revealed the resident was offered fluids and snacks once on 12/31/2025 in the past 30 days.A review of Resident #113's care plan showed the resident is at risk for malnutrition related to the need for a mechanically altered diet, underweight status, and chronic diseases. The focus was initiated on 12/17/2025 and revised on 12/24/2025. The goal for Resident #113 was the resident will will maintain right as evidenced by no significant weight changes or have a gradual weight gain toward a healthier body mass index. One intervention for Resident #113 was monitoring/recording/reporting to medical doctor for signs or symptoms of malnutrition: significant weight loss: >3#'s in one week, >5% I one month, >7.5% in three months, or >10% in 6 months. Another intervention for Resident #113 was provide and serve supplements as ordered.A review of Resident #113's progress notes revealed no attempted contact was made with the medical doctor or the registered dietitian.An interview was conducted on 1/8/2026 at 4:00 P.M. with Staff F, Registered Dietitian (RD). Staff F, RD said she meets weekly with the interdisciplinary team to review weekly weights of residents newly admitted to the facility. Staff F, RD said to prevent the residents from losing weight, fluids and snacks are offered three times a day. Staff F, RD said Resident #1 should weigh around 130# pounds. Staff F, RD said she did not know Resident #1 had only consumed a daily average of 25% of his shake supplement and was not being offered fluids or snacks daily. Staff F, RD said resident #71 should have been weighed weekly for monitoring. Staff F, RD said she did not know that Resident #71 was not consuming his dietary supplement and was not being offered fluids or snacks daily. Staff F, RD said Resident #113's weight was documented incorrectly and there is nothing I can do about that. Staff F, RD said she did not know Resident #113 was not being offered fluids or snacks daily.An interview was conducted on 1/8/2026 at 3:20 P.M. with the Director of Nursing (DON). She said she did not know that Resident #1 or #113 had a significant weight loss. The DON said she did not know that Resident #71 was not weighed according to facility policy. The DON said she did not know that Resident #1, #71, or #113 was not being offered fluids or snacks. The DON said the resident's nurses are responsible for providing dietary supplements that are ordered by the RD. A review of a policy revised 12/9/2025, titled, Policy and Procedure: Dietary - Food and Drink revealed the purpose is to ensure facility staff supports the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. The procedure is as follows: The facility will provide to each resident: 4: Food that accommodates resident allergies, intolerances, and preferences. 5: Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. 6: Drinks, including water and other liquids consistent with resident needs, preferences, and sufficient to maintain resident hydration.A review of a facility provided policy revised 10/27/2025, titled, Process: Obtaining Resident Weights revealed the purpose is to obtain accurate and timely resident weights. The general information includes: Newly admitted or re-admitted residents are encouraged to have their weight obtained weekly for approximately four weeks or as the resident tolerates. Nursing supervisor/charge nurse or designee should review weight results for accuracy prior to documentation in the electronic medical record (EMR). Once deemed accurate and/or verified with a re-weight, the nurse will enter the weight results in the EMR. The Registered Dietitian/designee will review weights weekly, monthly, and as needed to provided recommendations for nutritional stabilization per individual resident need. The interdisciplinary team (IDT) will review the residents' weight loss/gain to determine if the weight fluctuations require care plan revisions, physician orders, nursing and/or dietary interventions, and/or meet unavoidable weight loss/gain criteria. The process is as follows: 1: Certified Nursing Assistants should: a: ensure the weight scale is zeroed out and is reading (0) before weighing each resident; d: weigh using the same weight scale as previously utilized, if possible. If unable to use the same scale, not this on the weight record; e: weigh residents in the same wheelchair each time.

Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and three errors were identified for two (#138 and #7) of five residents observed. These errors constituted a 12.00% medication error rate.Findings included: 1.On 1/6/26 at 4:10 p.m., an observation of medication administration with Staff J, Licensed Practical Nurse (LPN), was conducted with Resident #138. The staff member dispensed the following medications:Ipratropium - Albuterol sulfate 0.5 milligram (mg)/3 mg/3 milliliter (mL) vial - prescribed to Resident #137insulin Lispro (Humalog) vial - 6 unitsacetaminophen extra strength 500 mg over-the counter (otc) tablets - 2 tabs ferrous sulfate 325 mg tab oral otcThe observation revealed Staff J removing a vial of Ipratropium - Albuterol from a box labeled for Resident #137. The staff member entered the resident's room with the vial and asked if the resident wanted the nebulizer and obtained a blood sugar of 328. Staff J searched the medication cart for the resident's lispro insulin before finding it in the med room refrigerator. The staff member returned to the med cart with the nebulizer vial and dispensed the oral medication and drew up 6 units of lispro insulin. Returning to the room, the staff member handed the resident the medication cup containing oral medications, cleaned back of right arm with alcohol pad and injected insulin. Staff J picked Ipratropium/Albuterol vial from over bed table, opened up the med cup on nebulizer mask, squirted contents of vial into the cup, stretched the masks elastic band, turned to the resident and stepped toward the resident, lifting the mask with straps above the level of the resident's head. The staff member was asked to stop and to step out of room with this writer. Staff J acknowledged the Ipratropium/Albuterol was not prescribed to Resident #138 and stated she would normally not take from another resident, would check the med room and get from the electronic medication dispenser, but the resident was now not going to get the medication. Staff J returned to the room and informed the resident of him not getting the medication. Review of Resident #138s admission Record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified chronic obstructive pulmonary disease, unspecified heart failure, and other nonspecific abnormal finding of lung field. Review of Resident #138s January Medication Administration Record (MAR) showed the resident was to receive Ipratropium-Albuterol Solution 0.5-2.5 mg/3 mL inhale orally via nebulizer every 4 hours for shortness of breath (SOB)/Wheezing for 3 days, starting 1/6/25 at 12:00 a.m. 2.On 1/6/26 at 4:49 p.m., an observation of medication administration with Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #7. The staff member entered the resident room and was informed by unknown Certified Nursing Assistant (CNA) of the resident's blood pressure being high. The resident was observed lying in bed with microwaveable noodle bowl on the over bed table. The staff member reported having to take blood pressure again (pronoun) self. The staff member obtained the blood pressure and was unable to locate the resident's insulin on the med cart. The staff member located the insulin in the facility's medication refrigerator on the other unit. Staff I returned to the medication cart and found the resident's sevelamer and hydromorphone was not available on the cart, stating sometimes they're in Dialysis. The staff member went to the facility's electronic medication dispenser and found sevelamer was not stocked and the hydromorphone was a stock medication but the dispenser did not have any available. The staff member returned to the cart and dispensed the following medications:ferrous sulfate 325 mg tablet otc metoprolol tartrate 50 mg tablet tizanidine 4 mg tablet Humulin R 100 unit vial - 4 unitsThe staff member confirmed dispensing 3 oral tablets and injected the insulin into the left lower quadrant. Staff I informed the resident of not having hydromorphone and would call the pharmacy. Review of Resident #7s admission Record showed the resident was admitted on [DATE] with diagnoses not limited to end stage renal disease, chronic diastolic (congestive) heart failure, and unspecified uncomplicated cannabis use. Review of Resident #7s January MAR included the following orders:sevelamer Carbonate 800 mg tablet - give 1 tablet by mouth with meals for binder. Dialysis to supply. The medication was scheduled for 8:00 a.m., 12:00 p.m., and 5 p.m. The MAR showed the resident received the 5:00 p.m. dose.hydromorphone oral tablet 4 mg - give 1 tablet by mouth four times a day for nonacute pain. Hold for sedation. The medication was scheduled for 4:00 a.m., 10:00 a.m., 4:00 p.m., and 10: 00 p.m. The MAR showed Staff I had documented 9 (other/see nurse notes) for the 4:00 p.m. and 10:00 p.m. dose. Review of the progress notes showed Medication Administration Notes on 1/6/26 at 9:19 p.m. and 9:21 p.m. Resident #7s hydromorphone was pending delivery from pharmacy. The note did not reveal if the pharmacy or physician was notified of the unavailable medication. Review of Resident #7s Medication Admin Audit Report for the evening shift on 1/6/26 showed Staff I had documented the administration of the 5:00 p.m. dose of sevelamer at 8:56 p.m. and at 9:21 p.m. the 4:00 p.m. dose of hydromorphone was 9 - other/see nurse notes. During an interview on 1/7/26 at 10:00 a.m. the Director of Nursing (DON) acknowledged being aware of Staff J stopped attempt to administer another residents medication to Resident #138. An interview was conducted with the DON on 1/8/26 at 5:52 p.m. The DON stated the medication error related to Resident #138 was against our policy and competency, would be a medication misappropriation. The DON stated the pain doctor is at facility 3 times a week and if staff do not have 7 days of (pain) medication they know to get a script. The observations of medication errors were discussed and the DON stated agreed with the findings and stated she could not argue. Review of the policy - Medication Administration, revised 12/10/25 revealed the purpose was To administer medication as per provider's orders and in accordance with regulatory guidelines and practice standards. The guidelines for Medication Administration included: Observe the Rights of Medication Administration: Right Resident, Right Medicine, Right Time, Right Dose, Right Route, (and) Right Documentation. The policy does not address the procedure for reordering medication to ensure a resident does not miss a dose(s). Review of the policy - Administering Medications, revised 2/21/23 revealed its purpose was To ensure that medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, and current standards of practice. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services. The policy does not address the procedure for reordering medications to ensure a resident does not miss a dose(s).

Based on observations, record review, and interviews, the facility did not follow professional standards for food service safety in the kitchen as evidenced by: a) food stored in the walk-in fridge and freezer were not labeled or stored properly b) garbage in the kitchen prep area was not contained safely or hygienically; c) food stored in the nourishment rooms were not labeled or stored properly; d) hand hygiene was not performed during a change of tasks.Findings Included:On 1/5/26 at at 9:11a.m., an initial tour of the kitchen was conducted with the Dietary Director (DD).On 1/5/26 at 9:20a.m., an observation of the facility's walk-in refrigerator revealed an opened, and unlabeled gallon of milk. The DD confirmed that the milk was not properly labled and stored.On 1/5/26 at 9:22a.m., an observation inside the facility's walk-in refrigerator revealed thawed pork loins located 2-3 inches above the floor of the walk-in on a plastic platform. The pork loin had no open date and no pull date from the freezer. The DD stated that the pork loin was not properly labled and should have had a pull date on it. The DD confirmed that the pork loins were not properly stored being on the plastic platform that was on the ground.On 1/5/26 at 9:25a.m., an observation inside the facility's walk-in freezer revealed an open box of cinnamon rolls, not properly stored or labled. A bag of two chicken patties twist tied with no label found on them was laying on top of an unlabeled closed box of chicken patties. An open-to-air box of chicken nuggets and beef patties, not labeled with an open date was present in the walk-in freezer. A ziplock bag of freezer burned hot dogs were present in the walk-in freezer with no stored or opened date was present on the bag. The DD confirmed that the box of cinnamon rolls, chicken patties, chicken nuggets, beef patties, and hot dogs were not properly store, did not have an open date written on them, and should not have been left open to air.On 1/5/26 at 9:34a.m., an observation in the facility's dry storage revealed a large can of juice opened and rusted, covered with loose plastic wrap had no label of an open date found. The DD stated that this item should have been thrown out and not stored in the manner it was.On 1/5/25 at 9:41a.m., an observation of the garbage can being used in the kitchen prep line almost overflowing with trash, and without a lid containing the trash in the can. The DD stated that the garbage can should have been emptied and be covered tightly with a lid.On 1/5/26 at 9:43a.m., an observation of the kitchen prep line revealed a bag with a few pieces of bread twisted closed, and a Ziplock bag of marshmallows with no open date labled on either item. The DD stated that those two items are not properly labeled or stored.On 1/5/26 at 9:51a.m., an observation of the facility's nourishment room down the 200 hall revealed: an open and unlabled carton of 2% milkAn open, unlabled bottle of waterA box of liquid thickener with a open date of 10/25A box of liquid thickener with an open date of 12/25An opened bottle of goat milk, unlabledA pitcher of juice 1/3 of the way full with no labelA soup bowl from the kitchen with no date of storage or who it belonged toA grocery bag of chili with no label of when it was stored or who it belonged toThe refrigerator appeared to be uncleaned as there were multiple dried spills throughout and in the drawers of the refrigerator. All items, the DD confirmed were not properly stored or labeled.On 1/5/26 at 9:55a.m., an observation of the facility's second nourishment room revealed: An open and unlabeled carton of 2% [NAME] pitcher of juice 1/3 of the way full with no labelA soup bowl from the kitchen with no date of storage or who it belonged toA container of a protein shake with no open date or who it belonged toThe refrigerator appeared to be unclean as there were multiple dried spills throughout and in the drawers of the refrigerator. All items, the DD confirmed, were not properly stored or labeled as items in the nourishment room refrigerators must be labeled with the residents name and the date it was received. The DD stated that all items in the refrigerator must be thrown out three days after the receive date. On 1/6/26 at 11:26a.m., Staff K, [NAME] was observed performing multiple tasks such as prepping food and changing food thermometers in the middle of checking food temperatures without performing hand hygiene when Staff K, [NAME] would return to taking food temperatures.On 1/6/26 at 11:40a.m., during the lunch tray line Staff K, [NAME] was observed not completing proper hand hygiene after changing tasks in between preparing meals for residents. Staff K, [NAME] was observed pureeing bread, not completing hand hygiene, then returning to serve food on the tray lines; making a grilled cheese with no hand hygiene being performed before or after preparation and returning to tray line; going to throw away garbage and returning to the tray line without performing hand hygiene before returning back to the tray line to serve food.On 1/6/26 at 11:53a.m., Staff U, Dietary Aide (DA) was observed at the end of the tray line putting drinks on trays then stacking the trays on food transporters with no gloves. Staff U, DA was observed performing multiple tasks (putting items in dish area, washing dishes for Staff K, [NAME] to use) in between building trays and not completing proper hand hygiene in between task changes or before returning to the tray line.On 1/8/26 at 3:25p.m., an interview was conducted with Staff U, DA. Staff U stated No, she did not perform proper hand hygiene and glove use.On 1/8/26 at 3:36p.m., an interview with the DD was conducted. The DD stated the expectation for proper hand hygiene and glove use is for hands to be washed before and after each glove change, and for gloves to be changed before and after each change of task. The DD also stated that proper storage of items requires them to have a receive date and opened date, as well as being covered and closed to where there are no openings of the food item.A review of the facility's Food Storage for Dry Goods revealed: All dry goods will be appropriately stored in accordance with the FDA Food Code. All items will be stored on shelves at least 6 inches above the floor. All packaged and canned food items will be kept clean, dry, and properly sealed. Storage areas will be neat, arranged for easy identification, and date marked as appropriate.A review of the facility's Food Storage for Cold Foods revealed: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. All food items will be stored 6 inches above the floor and 18 inches below the sprinkler unit. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.A review of the facility's Hand Hygiene policy revealed: All staff should perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hands are to be washed with soap and water when hands are visibly dirty, and after handling contaminated objects.Photographic evidence obtained 1/5/26.

Based on observation, interviews and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR)s for two (#3 and #105) were updated to include current diagnoses and screening questions were answered appropriately of two residents sampled for PASRR.Findings Included: During an interview on 01/05/2025 at 10:46 a.m., Resident #3 stated the people who speak spanish have it out for me. They are talking about me in Spanish. When I first got here, they (spanish speaking people) accused me of molesting my daughter. Resident #3 was not able to identify any certain person and just referred to the spanish speaking people. Review of Resident #3's admission Record showed Resident #3 was admitted to the facility on [DATE] with diagnoses of psychotic disorder with hallucinations due to known physiological condition (12/16/2025), bipolar disorder, current episode depressed, mild (04/17/2025), generalized anxiety disorder (11/05/2025), and unspecified dementia, unspecified severity, with psychotic disturbance, primary insomnia, other frontotemporal neurocognitive disorder (11/05/2025). Review of Resident #3's Care Plan dated 04/17/2025 revealed: Focus: Resident #3 is on antipsychotic therapy related to psychosis. Focus: Resident #3 has visual and auditory hallucinations. Exhibiting unrealistic fears with beliefs that his daughter is attempting to get him arrested. Focus: Resident #3 is on sedative/hypnotic therapy related to Insomnia. Focus: has a mood problem r/t bipolar disorder. Resident expresses some feelings of Depression and is at risk for mood decline. Resident further is exhibiting periods of visual and auditory hallucinations. Exhibiting unrealistic fears with beliefs that his daughter is attempting to get him arrested. Focus: Resident #3 has depression related to bipolar disorder. Focus: Resident #3 Has impaired cognitive function/dementia or impaired thought process related to dementia. Review of the Level I PASRR, dated 12/17/2025, revealed Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional Admission was marked. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. During an interview on 01/08/2025 at 11:15 a.m., Social Services Assistant and Director stated Resident #3 did come to them and about the spanish people talking about him in spanish. They notified the nurse who called psych. Resident #3 is known and care planned for having paranoid thoughts. Psych is currently seeing him and adjusting his medications as needed. During an interview on 01/09/2025 at 3:04 p.m., the Director of Nursing (DON), reviewed Resident #3's PASRR and stated, I would say question two, a. Interpersonal functioning should be marked no because Resident #3 can express his needs and wants. I would not say he has any concerns with interacting with other people. Question seven should be marked yes for the dementia. After reviewing the PASRR I would say he needs to be screened for a Level II PASRR. 2. Review of Resident #105s Preadmission Screening and Resident Review (PASRR) revealed the resident did not have a Mental Illness (MI), suspected MI, Intellectual Disability (ID) or a suspected ID based on documented history. The PASRR was completed at an acute care hospital on [DATE]. Review of Resident #105s admission Record showed the resident was admitted on [DATE] and included a diagnosis not limited to adjustment disorder with depressed mood. An interview was conducted with the Nursing Home Administrator (NHA) on 1/6/26 at 3:14 p.m. The NHA provided Resident #105s PASRR from the acute care facility and stated the facility had just updated the PASRR to include the missing diagnosis (adjustment disorder with depressed mood). Review of the policy – Social Services PASRR, effective 4/1/22, revealed The the survey shall ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID re evaluated and received care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. The facility shall ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs. According to state regulation, nursing facilities and hospitals in Florida are also delegated to complete PASRR Level 1 screenings. If the PASRR Level 1 outcome is positive (indicating a possible serious mental illness, intellectual disability, or a related condition) then a PASRR Level II evaluation and determination must be completed prior to a nursing home admission. The procedure detailed the following: 1. The External Liaison or Internal admission Staff/Designee or will obtain a completed pre-admission screen (PASRR Level 1) on all individuals being admitted to the Skilled Nursing Facility (SNF) prior to admission. 2. Individuals will be accepted for SNF admission if the PASRR (Level 1) does not indicate any serious mental illnesses (SMI) Or intellectual disability (ID) or related condition (negative Level 1 screen) OR they qualify for one of the provisional admissions or hospital discharge exemption. 3. If the result of the PASRR (Level 1) screening indicates that serious mental illness (SMI) and/ or intellectual disability (ID) or related condition appears to exist (positive Level 1 screen) and the individual does not meet a provisional or hospital discharge exemption, the individual will be referred to (screening authority) for a Level II screening prior to the individual being accepted for SNF admission. The Resident Review instructed: 1. The facility social service director/ credentialed user shall complete a referral for Level II resident review evaluation for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experience a significant change.

Based on record review and interview, the facility failed to document the required discharge/transfer notifications and the reason for discharge for one resident (#133) out of four residents reviewed for discharge.Findings Included:Review of Resident #133's admission record revealed an admission date of 10/01/2025 and a discharge date of 11/04/2025. Resident #133 was admitted to the facility with diagnosis to include orthopedic aftercare following surgical amputation, other acute osteomyelitis, left ankle and foot, chronic obstructive pulmonary disease, and muscle weakness. Review of Resident #133's electronic medical record revealed revealed no documentation regarding required elements for discharge per policy.An interview was conducted on 01/08/2026 at 3:56 p.m. with the Social Services Director (SSD). The SSD stated having worked at this facility for only a week. The SSD stated not knowing Resident #133 or anything about an appeal for discharge. The SSD reviewed Resident #133's medical record and confirmed there was no documentation regarding the appeal. The SSD confirmed there was no record of the AHCA (Agency for Health Care Administration) discharge/transfer form. The SSD said, I do not see the AHCA discharge form. The SSD confirmed Resident #133's record did not have a documented discharge summary.During an interview on 01/08/2026 at 4:10 p.m., the Nursing Home Administrator (NHA), stated the social services department is the one who discusses the discharge with the residents. They should do an assessment and add notes to the record related to the discharge. Residents should be notified no less than two days before the discharge. There should be a meeting documented with the resident about their discharge plan. I believe you when you tell me there is nothing in the record related to the discharge. We did not have someone in social services and the people who were covering were not doing them correctly.Review of the facility policy titled Discharge Planning, with a revision date of 03/10/2023 revealed a purpose: The facility shall have a discharge planning process that focuses on the residents discharge goals, the resident support system, and the transition timing to ensure a smooth process.Procedure:1. in development of the discharge plan a resident, the facility shall consider the residents discharge goals, resident support available in a safe discharge environment.a. The interdisciplinary team, the family/resident representative along with the resident should be a part of the process of developing the discharge plan.1. Periodic reevaluation of the plan should be done to address any changes in the plan that may require modification of the plan.5. The facility shall develop a discharge summary that includes the following:a. A post discharge plan of care that has been developed with the resident or residence representative that indicates where resident is intending to reside in any arrangements made post discharge for follow up care and post discharge medical and non-medical services.b. A summary of the residents stay that includes diagnosis, treatment or therapy, and pertinent lab, radiology and consultant results.6. The discharge summary should be available for release to authorized persons or facilities with the consent of the resident or residence representative.

Based on observations, record reviews, and interviews the facility failed to ensure two (#25 and #19) of two residents reviewed for self administration of medications were assessed by the facility and a physician order was obtained to allow for the self-administration of medications related to the administration of oral and nebulized medications.Findings included: On 1/6/26 at 10:08 a.m. Resident #25 was observed lying in bed with an over-bed table within reach of the resident. A medication cup containing 10 oral tablets was sitting in the corner of the table within reach of the resident. The resident reported just getting the medication and would take them. Resident #25 reached over to the table, retrieved the cup, and swallowed all of the tablets at one time. During the observation, no staff member was in the room with the resident.Review of Resident #25s admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to acute and chronic respiratory failure with hypoxia, unspecified eye blindness one eye, uncomplicated alcohol abuse, and uncomplicated cannabis abuse.Review of Resident #25s quarterly Minimum Data Set (MDS), dated [DATE]) revealed a Brief Interview of Mental Status (BIMS) score of 5 of 15, indicating a severe cognition impairment.Review of Resident #25s physician orders did not reveal an order allowing for the self-administration of medications.Review of Resident #25s care plan did not show a focus or intervention allowing the resident to self-administer medications.On 1/8/26 at 12:04 p.m. Resident #19 was observed lying in bed wearing a nebulizer mask and the nebulize machine was sitting within reach of the resident on the over-bed table. The observation showed no staff member was in the room with the resident or in the hallway outside of the room. The resident shut off the machine and reported getting a nebulizer treatment at the time then turned machine back on. During the observation, the medication cart was parked near the nursing station (opposite end of hallway then resident room) and the nurse was not observed in any room on the hallway. Review of Resident #19s admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) exacerbation, and unspecified emphysema.Review of Resident #19s quarterly MDS dated [DATE] revealed a BIMS score of 14 of 15 indicating an intact cognition.Review of Resident #19s physician orders did not reveal an order had been obtained for the self-administration of medications.Review of Resident #19s care plan did not include a focus or intervention related to the resident being assessed for and a physician ordered had been obtained allowing for the self-administration of medications.An interview was conducted with Staff H, Licensed Practical Nurse/Unit Manager (LPN/UM) on 1/8/26 at approximately 12:08 p.m. The staff member was sitting at the nursing station and not within sight of Resident #19s room. Staff H reported Staff N, LPN, (nurse assigned to resident) was on break.Review of the Medication Self-Administration Screen dated 1/7/26 at 2:21 p.m. revealed neither Resident #19 nor Resident #25 was included on the list of two residents with the ability to self-administer medications.An interview was conducted with the Director of Nursing (DON) on 1/7/26 at 2:14 p.m. The DON stated the facility did not have any residents who self-administered medications then reiterated I don't have any. The DON later on 1/7/26 provided a list of two residents assessed to self-administer medications. During an interview on 1/8/26 at 3:37 p.m. Staff H stated nebulizer treatments were considered medications. The staff member reported a resident was able to self-administer medications if they could demonstrate what the medication was, the dosage, and what it (medication) was used for, and staff would have to get an (physician) order for self-administration. The staff member reported one resident on the unit (100/200 halls) was able to self-administer an inhaler, the named resident was neither Resident #19 or Resident #25. Staff H stated staff don't have to stay with the resident during a nebulizer treatment but stay close to the room, normally staff park (medication cart) outside the room to keep eye on resident (during treatment) to ensure the resident doesn't remove mask and to ensure they get their whole treatment. An interview was conducted with the DON on 1/8/26 at 5:59 p.m. The DON stated there should be a (self-administration) assessment in the electronic medical record, residents are given a lock box or use of top dresser drawer (to hold medication), report to nurse when they are finished with the medication so staff can document it. The DON stated nurses should be present during a nebulizer treatment. During the interview the DON stated medications (left) at bedside are against their med administration policy and against the competency. The facility did not provide a self-administration assessment for either Resident #25 or Resident #19.Review of the policy - Medication Administration, revised 12/10/25, revealed the purpose was To administer medications as per provider's orders and in accordance with regulatory guidelines and practice standards. The guidelines showed Medications are administered to residents as prescribed and by a person licensed or qualified to do so unless the resident has been deemed capable of self-administration. Observe the resident taking their medication(s). Avoid leaving medication in the resident's room unless the resident has been deemed capable of self-administer. The review of the policy's Self-Administration included the following:Residents who wish to self-administer medication(s) will have:An evaluation and/or competency completed by a licensed nurse to determine safe administration practice.An order from the provider indicating self-administration of medications is permitted.A care plan outlining the resident's choice to self-administer medications.The resident's room shall periodically be observed by nursing personnel for unconsumed/unused or inappropriately stored medications.Residents deemed appropriate to self-administer will be evaluated by a licensed nurse routinely and as needed for continued appropriateness.

Based on observations, interview, and record review the facility failed to ensure proper infection control practices were in place on one out of four units related to proper personal protective equipment (PPE) use, timeliness of contact precaution orders, and hang hygiene. Findings included: An observation was conducted on 9/5/24 at 9:46 a.m. of Staff E, Registered Nurse (RN) during medication administration. Upon exiting a resident room after administering mediation, Staff E did not perform hand hygiene. The nurse proceeded to the medication cart, touched the computer and other items on the cart. An observation was conducted on 9/5/24 at 10:03 a.m. of a visitor in the room of Resident #11. The room had a Contact Precaution sign on the door and the visitor had on no PPE. An observation was conducted on 9/5/24 at 10:21 a.m. of an unknown staff member in Resident #11's room with no PPE. An interview was conducted on 9/5/24 at 10:23 a.m. with a family member of Resident #11. The family member said the resident is on contact precautions for a urinary tract infection (UTI). The family member said they are at the facility daily and staff do not wear PPE in the room unless they are doing something with the resident's urine. The family member said staff told the family that is the only time they would need to wear it also. Review of Admission Records showed Resident #11 was admitted on [DATE] with diagnoses including urinary tract infection, extended spectrum beta lactamase (ESBL) resistance, and carrier or suspected carrier of methicillin resistant staphylococcus aureus. Review of Resident #11's lab results, dated 8/30/24, showed Escherichia coli and ESBL in the urine. The results were reported to the facility on [DATE] at 11:02 a.m. Review of Resident #11's orders showed an order for Isolation Contact Precautions for UTI ESBL positive entered on 9/3/24 at 3:00 p.m. An interview was conducted on 9/5/24 at 3:25 p.m. with Staff B, Licensed Practical Nurse (LPN) and Staff D, LPN. Staff B was confused about the precautions and proper PPE use for Resident #11 due to the bacteria being in the urine and the resident having a catheter. Staff D said PPE should be worn anytime a person enters the resident's room while she is on contact precautions. An interview was conducted on 9/5/24 at 3:47 p.m. with the Director of Nursing (DON.) She said staff should be performing hand hygiene immediately upon exiting a resident room and nurses should not be touching the medication cart prior to performing hand hygiene. The DON said when a resident is on contact precautions, staff should do what the sign tells them to do. She said for a resident on contact precautions a gown and gloves should be worn anytime someone enters the room. The DON reviewed the lab results and orders for Resident #11. She said she would have expected the order for contact precautions to have been put in place on 9/2/24, the day the lab results were reported to the facility. Review of a facility policy titled Nursing-Infection Control Prevention and Control Program, dated 2/21/23 showed the following: Purpose: The facility shall establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Procedure: 3. Transmission-Based Precautions (Isolation Protocols): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Review of a facility policy titled Isolation-Initiating Transmission Based Precautions, dated 4/1/22, showed the following: Purpose: Transmission-Base Precautions should be initiated when there is a reason to believe that a resident has a communicable infections disease. Transmission-Based Precautions include Contact Precautions, Droplet Precautions, or Airborne Precautions .

Based on interviews and record review, the facility failed to ensure Hemodialysis (HD) care was provided per physician orders for one (#1) of two dialysis residents reviewed. Findings included: Review of the medical record for Resident #1 showed he was admitted to the facility on [DATE] with diagnoses to include dependence on Renal Dialysis. Review of Active Physician orders as of 08/21/24 showed orders to: Assess dialysis site for signs and symptoms of infection every shift. Assess dialysis site and indicate yes/no. If yes, please indicate in progress note. Assess dressing site for bleeding upon return from dialysis and after dressing removal every shift. Call MD (Medical Doctor) if bleeding. Check venous access device every shift for bleeding and infection. If bleeding is noted apply adequate continuous pressure to site x 10 minutes and reassess. Repeat x 1 if necessary. Inform MD as needed. Review of a care plan for Resident #1 showed a focus initiated on 08/19/24 showing Resident #1 needed dialysis related to renal failure. Interventions included check and change dressing daily at access site, right upper chest port. If bleeding is noted . notify MD. Encourage resident to go to the scheduled dialysis appointments. Hemodialysis on Tuesday, Thursday and Saturday. Chair time at 0800. Monitor vital signs. Notify MD of significant abnormalities. Monitor/document/report any signs and symptoms of infection to access site. Work with resident to relieve discomfort for side effects of the disease and treatment. Review of dialysis communication forms for Resident #1 showed: 8/20/24, the form showed errors revealing incomplete pre and post dialysis care. 8/15/24 the form showed missing pre and post dialysis documentation. 8/8/24 the form showed pre and post dialysis care was incomplete. On 09/05/24 at 12:27 p.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN.) She stated for pre-dialysis care, the nurse is supposed to check vitals, separate meds, those that need to be held or administered and document accordingly. She stated the assessment is part of the dialysis form and should be completed at the time of care. She stated the nurse receiving the resident after dialysis should monitor site, obtain vitals and document as ordered. On 09/05/24 at 3:42 p.m., an interview was conducted with the Director of Nursing (DON). She stated pre and post dialysis care should be documented on the dialysis form. She stated the nurse assessing the resident should document. A dialysis policy was requested and not received.

Based on observation, interview, and record review, the facility failed to provide wound assessments and wound care for 1 (Resident #12) of 1 sampled residents for wounds. Findings included: An observation and interview was conducted on 9/5/24 at 4:51 p.m. of Staff A, Registered Nurse (RN)/Unit Manager (UM) going to Resident #12's room and looking at the resident's bilateral lower extremities. The left lower extremity knee had a scab with small spots of blood. The posterior end of the right lower extremity stump was noted to be covered with a large area of necrotic eschar with small open areas of slough. The resident complained of pain, said she, told the nurses she needed wound care, and no one ever came. (Photographic evidence obtained with resident permission.) Following the observation, Staff A, RN/UM reviewed Resident #12's medical record. She confirmed the wound care team was not following the resident and there were no wound care orders in place. She said Resident #12 should be getting looked at and treated for her wounds. An interview was conducted on 9/5/24 at approximately 5:10 p.m. with the Director of Nursing (DON.) She reviewed the photographs of Resident #12's right posterior stump and said the resident should at least have orders for betadine and the wound should be assessed. The DON also stated Resident #12 should have been followed by the wound care providers since there were concerns about the resident's wound. The DON stated skin sweeps were ordered, but she did not see documentation the skin sweeps were done. The DON said Resident #12's family and physician should have been notified, but she does not see any documentation of notification in the medical record. 50732 Review of Resident #12's Admission Record showed the resident was admitted to the facility on [DATE] with admitting diagnoses to include type 2 diabetes mellitus, end stage renal disease, acquired absence of right leg below knee, and acquired absence of left leg below knee. Review of Resident #12's hospital records provided prior to the resident's admission to the facility noted the right leg below knee amputation (BKA) was well healed without wounds. Review of Resident #12's Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. Review of Resident #12's Care Plan initiated on 8/11/2024 initiated on 8/18/2024 revealed: Focus: The resident has actual impairment to skin integrity of the left knee related to infection. Goal: The resident will maintain or develop clean and intact skin by the target date of 11/26/24. Interventions: Follow facility protocols for treatment of injury. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #12's Care Plan initiated and revised on 8/12/24 revealed: Focus: The resident has actual potential potential for pressure injury development related to decreased mobility, incontinence and multiple co-morbidities. Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review with a target date of 11/26/24. Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown. Inform the resident/resident representative of any new area of skin breakdown. Monitor/document/report PRN (as needed) any changes in skin status. Review of Resident #12's Physician Orders showed an order from 08/11/2024 revealed an order for weekly skin sweeps to begin on 08/14/2024 to be done on Wednesday every day shift every Wednesday. Review of Resident #12's Skin Evaluation done on 08/18/2024 revealed right stump dark area with small opening, no drainage noted. Review of Resident #12's Assessments and Progress Notes showed no Situation, Background, Assessment and Recommendation (SBAR) or Change in Condition was completed as a result of the Skin Evaluation completed on 08/18/2024. Review of Resident #12's Assessments and Progress Notes showed no documentation indicating the resident's physician was called regarding the results of the Skin Evaluation completed on 08/18/2024. Review of Resident #12's Assessments and Progress showed no documentation indicating the resident's family/responsible party was notified of the change in condition of the resident regarding the results of the Skin Evaluation completed on 08/18/2024. An interview was conducted with the Nursing Home Administrator (NHA) on 09/05/2024 at 6:25 PM. The NHA stated the facility does not have a Wound Care Policy and a Skin Assessment Policy.

Based on interview and record review, the facility failed to notify the resident's family/responsible party and the resident's physician of a change in condition for two (#1, #12) of 12 sampled residents. Findings included: 1. Review of the Medical Record for Resident #1 showed he was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1's diagnoses included acute respiratory failure, acute pulmonary edema, intestinal pulmonary disease, Chronic Obstructive Pulmonary Disease (COPD), Alzheimer's disease and dependence on renal dialysis. Review of a progress note for Resident #1 signed by Staff C, Registered Nurse (RN) dated [DATE] at 7:41 a.m., showed during morning rounds, the night shift nurse reported the patient spent the night calling family members and asking for help. This nurse went to the patient's room, and he was confused, but stable. Family member called 911, but patient refused to be transferred to the hospital. On [DATE] at 2:01 p.m., an interview was conducted with Resident #1's family member. The family member stated they called and requested the nurse who was working the night shift to send the resident out, but the nurse refused. The family member stated the nurse kept saying Resident #1 was fine and hung up on the family member. The family member reported feeling frustrated and calling 911. She stated when Emergency Medical Technicians (EMTs) arrived to the facility, they did not take the resident to the hospital. The family member said the day nurse called. She did not say anything about the doctor seeing my dad. She kept saying, he [Resident #1] refused to go. The family member stated the resident was sick and confused. We pled with them to send him [Resident #1] out. No one cared. Review of Resident #1's medical record showed there were no notes in the resident's record related to his on-going calls to family members requesting help on [DATE] or prior to the 7:41 a.m. note on [DATE]. There was no documentation of a Change in Condition (CIC), physician notification or interventions to address Resident #1's needs the night of [DATE] or the early morning hours of [DATE]. Review of a progress note for Resident #1 signed by the Assistant Director of Nursing (ADON) dated [DATE] at 4:40 p.m., showed results of a urine culture were received revealing the resident was positive for an UTI (Urinary Tract Infection), and the antibiotic started on [DATE] was appropriate to treat the UTI. Review of a care plan for Resident #1 showed a focus initiated on [DATE], for Urinary Tract Infection. Interventions included to encourage adequate fluids, give antibiotic therapy as ordered. Monitor/document side effects and effectiveness. Monitor vital signs. Notify MD (Medical Doctor) of significant abnormalities. Monitor/document/report to MD PRN (as needed) for signs and symptoms of UTI. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of the medical record showed there was no documentation regarding the resident's care and monitoring prior to a progress note dated [DATE] at 05:52 p.m. which showed patient expired. On [DATE] at 2:31 p.m., an interview was conducted with Staff C, RN. She said, I was working that morning. I remember a family member called between 8 a.m. and 10 a.m., and said she had called 911 because the resident had told her he did not feel good. I asked her why she did not tell me. She said he had reported he was short of breath. I went to him and saw he was a little confused. He could answer to Yes or No questions. I started to prepare to send him out when the EMT came and said he had refused to go. When he said he was okay, and he did not want to go, we left him alone. Staff C stated she had assessed the resident but there was no documentation. Staff C stated she had contacted the Director of Nursing (DON) who said to send the resident out anyway. Staff C said, I spoke to the DON, and I said the family wanted us to send him out. She said to go get the EMTs and tell them to take him if that was what the family wanted. By the time I got to them (EMTs], they were gone. I did not call them back. Staff C stated she thought she had called or texted the physician. Staff C could not show the communication on her phone. Staff C said, I think I called him. I don't know why I don't have that. I don't remember speaking to the doctor. I believe I sent him a message. It was my bad, and I did not document. I don't know what he said. On [DATE] at 3:33 p.m., an interview was conducted with the DON. She stated the nurse had called her on the morning of [DATE] and said EMS (emergency medical services) was at the facility. The nurse reported they went and spoke to the resident, and he refused to go to the hospital. The DON stated neither she nor the Unit Manager had documented their assessments on the resident. She confirmed there was no documentation regarding family notification of the on-going changes the night the resident expired. The DON stated the physician had been notified the resident was not feeling well. She said, He was notified by the nurse. I don't know if the doctor came. It should be documented. I'll ask him for the notes. The DON reviewed the residents medical record and said, I see, it is not documented right now. There is no CIC or any skilled notes. The DON stated they should have documented when the physician was contacted regarding the change and when the nurse spoke with the family. On [DATE] at 12:38 p.m., an interview was conducted with Staff A, RN/UM (Unit Manager). She stated if a resident experienced any change of status, the first thing to do would be assess the resident, notify the physician, and then call the family or responsible party. She stated she would then document the CIC under evaluations and follow up with a skilled note. She stated the nurse should continue to assess the resident if they are not sent out. She stated the skilled notes should show the resident's progress and physician's response. On [DATE] at 12:27 p.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN.) She stated if a resident had a change in status, she documents in the evaluation section. She conducts an assessment and notifies the physician and then family. She stated she follows physician orders, if they want the resident sent out or if medications are ordered or if the nurse should continue monitoring. She stated it should all be documented during the point of care. On [DATE] at 11:30 a.m., an interview was conducted with the Medical Director and his ARNP (Advanced Registered Nurse Practitioner). He said, He refused to go the hospital. We can't force him. The residents have a right to refuse care. I don't remember hearing an ambulance came. No, I did not call his family. Staff called me many times about this man. He was non-complaint. I told him many times, if you continue refusing dialysis, with all the problems you have, it will kill you. The doctor stated he never spoke to this resident's family. He said, I never had any interaction with them. The Nurses relayed their concerns. I was never told they ever asked for me to call them. I said, you could die without further treatment. He stated he did not contact the family to let them know of his concerns related to the non-compliance. He stated he should be notified if a resident was refusing medications and treatment. He stated he had notes documenting this resident's care and his non-compliance. He stated between him and his ARNP, he was seen many times. The ARNP stated she could not recall how often she had seen the resident and was not sure when she last saw him. She stated she would provide her notes. Physician notes during this resident's CIC were requested and not provided. There were no physician notes documenting Resident #1's treatment refusal. Review of a facility policy titled, change in condition, dated [DATE], showed the purpose was to identify and communicate changes in condition to the physician and other employees and possibly prevent hospitalization . Procedure showed all staff are encouraged to promptly report any changes in condition to the charge nurse, supervisor, DNS (Director of Nursing Services)/ADNS (Assistant Director of Nursing Services) or designee immediately. This may include but not limited to a significant change in the resident's physical mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include life threatening conditions or clinical complications. Circumstances that may require a need to alter treatment. This may include new treatment and/discontinuation of current treatment due to adverse consequences, acute condition, or worsening of a chronic condition. A complete assessment may need to be conducted of all systems including but not limited to functional status, respiratory evaluation, cardiovascular evaluation, abdominal pain or GI evaluation, urine evaluation, skin evaluation, pain evaluation and vital signs. The physician/nurse practitioner shall be made aware of the condition change and pertinent assessment findings. The residents shall be monitored until conditions significantly improves. An interdisciplinary team conference may be held if needed to address concerns/changes. A care plan may be initiated and or updated on the reason of the change in condition, goals and interventions. The resident's family/legal representative/healthcare agent should be notified about the change in condition as required. 50732 2. An interview was conducted with the Director of Nursing (DON) on [DATE] at 5:10 pm regarding a change in condition for Resident #12. She said Resident #12's family and physician should have been notified of the resident's leg wound, but she does not see any documentation of notification of either in the medical record. Review of Resident #12's Admission Record shows the resident was admitted to the facility on [DATE] with admitting diagnoses to include type 2 diabetes mellitus, end stage renal disease, acquired absence of right leg below knee, and acquired absence of left leg below knee. Review of Resident #12's Minimum Data Set (MDS) dated [DATE] shows the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. Review of the care plan with an initiation and revision date of [DATE] showed a focus for potential for pressure injury development related to decreased mobility, incontinence and multiple co-morbidities. Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review (target date: [DATE]). Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown. Inform the resident/resident representative of any new area of skin breakdown. Monitor/document/report PRN any changes in skin status. Review of Resident #12's Skin Evaluation done on [DATE] revealed two skin issues were noted: right stump dark area with small opening, no drainage noted. Review of Resident #12's Assessments and Progress Notes showed no Situation, Background, Assessment and Recommendation (SBAR) or Change in Condition was completed as a result of the Skin Evaluation completed on [DATE]. Review of Resident #12's Assessments and Progress Notes showed no documentation indicating the resident's physician was called regarding the results of the Skin Evaluation completed on [DATE]. Review of Resident #12's Assessments and Progress showed no documentation indicating the resident's family/responsible party was notified of the change in condition of the resident regarding the results of the Skin Evaluation completed on [DATE]. 46234 An interview was conducted on [DATE] at 4:51 p.m. of Staff A, RN/UM. She reviewed Resident #12's skin assessment, dated [DATE], noting skin changes on the sacrum and right stump. She said at the time of that assessment, a change in condition should have been completed and the provider notified. Staff A reviewed the resident's medical record and confirmed no change in condition was completed or provider notified. An interview on [DATE] at 5:14 p.m. with the DON revealed with the [DATE] skin assessment changes noted for Resident #12, she would have expected a change in condition to be completed.