Every finding on record at Vivo Healthcare Gandy

Based on observations, interviews, and record review, the facility failed to ensure resident rights were honored, related to advance directives and code status, for one resident (#1) out of three residents sampled.On [DATE], facility staff initiated cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury), on Resident #1 when the resident was found unresponsive for approximately twelve minutes. Failure to honor the resident's wishes for Do Not Resuscitate (DNR) caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to a D after verification of removal of immediacy. Findings included:Review of Resident #1's medical record revealed an admission date of [DATE] with medical diagnoses to include: Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Cardiomyopathy, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Nonrheumatic Mitral Valve Disorder Unspecified, Cognitive Communication Deficit, and Immunodeficiency due to conditions classified elsewhere.Review of Resident #1's order summary revealed:Do Not Resuscitate (DNR), created [DATE], no end date.DNR created, [DATE], no end date.Review of Resident #1's medical record documents revealed a Do Not Resuscitate order, dated [DATE], signed by Resident #1 and Staff G, Nurse Practitioner (NP). Review of a 3008 document, dated [DATE], revealed Resident #1's advance directive as a DNR.Review of Resident #1's Minimum Data Set (MDS), dated [DATE], Section C showed Resident #1 had a Brief Interview Mental Status of 15, which indicated intact cognition. Review of progress notes for Resident #1 revealed:-[DATE] 01:00 encounter The difference between Do Not Attempt Resuscitation (DNR/no CPR) and full code was explained to the patient over 30 minutes. The patient decided on a Do Not Attempt Resuscitation (DNR/no CPR) status. During a medical emergency, the patient does not wish to receive resuscitation efforts. --[DATE] 11:32 Social Service, Resident #1 requested and signed a DNR previously. Resident #1, again stated that she does not want to be resuscitated. Resident #1, informed staff that she wants to be a DNR and clearly stated that she does not want to go through chest compressions, etc.-[DATE], revealed the resident had been seen by a provider and the code status was DNR.Review of Resident #1's care plan revealed a focus area as:Resident #1 request DNR, initiated [DATE].The goal was for Resident #1's wishes to be honored, initiated [DATE].During an interview on [DATE] at 12:28 PM, Staff B, Licensed Practical Nurse (LPN), stated having heard an announcement for a code blue, on [DATE] and she went to Resident #1's room. Staff B stated upon arrival, having seen Resident #1 being transferred to the bed by Staff I, Registered Nurse (RN), and a Certified Nursing Assistant (CNA). Staff B stated Resident #1's eyes were closed and the resident was unresponsive. Staff B stated having asked what Resident #1's code status was and there was no response. Staff B stated having seen Staff I, begin chest compressions on Resident #1. Staff B stated having seen Staff A RN, performing chest compressions on Resident #1. Staff B stated Resident #1 was a DNR.During an interview on [DATE] at 1:07 PM, Staff A RN, stated having heard an announcement for a code blue over the intercom on [DATE]. Staff A stated she went to Resident #1's room with Staff B LPN. Staff A stated upon arrival, having helped Staff I RN, and two CNA's put Resident #1 on a bed. Staff A stated at this point, Staff B asked what the code status was and Staff I did not know the code status. Staff A stated Staff B left the room to verify the code status for Resident #1. Staff A stated Staff I had begun assisting with chest compressions on Resident #1, and Staff A assisted with chest compressions as well. Staff A stated shortly after, Staff B returned to the room and stated Resident #1 was a DNR. Staff A stated having switched out with Staff C and Staff D as well, to provide chest compressions on Resident #1. Staff A stated she did not ask about Resident #1's advance directive.During an interview on [DATE] at 1:24 PM, Staff E CNA, explained having been assigned to Resident #1 on [DATE]. Staff E stated having checked on Resident #1 at 12:15 PM, and noticed the resident was sitting in a wheelchair and was not responding after calling out to the resident multiple times. Staff E stated she left the room and notified Staff I RN, of Resident #1's condition. Staff E stated she assisted Staff I, another nurse, and another CNA, with placing Resident #1 on a bed. During an interview on [DATE] at 1:44 PM, Staff D RN, stated having heard a page, for a code blue over the intercom on [DATE]. Staff D explained going to Resident #1's room and saw staff performing CPR on the resident. Staff D stated Staff A was using the bag valve mask, and Staff C was in the room. Staff D stated he assisted with chest compressions, once one of the other nurses got tired. Staff D stated afterwards, a staff member entered Resident #1's room and stated she's a DNR. Staff D explained not having checked Resident #1's code status prior to assisting with CPR. Staff D stated EMS arrived afterwards and told everyone to stop CPR.During an interview on [DATE] at 02:35 PM, the physician stated the facility called when Resident #1 was already deceased . The physician stated the resident was already in the system as a DNR. The physician explained having expectation of the facility staff to have checked Resident #1's code status, prior to performing CPR.During an interview on [DATE] at 05:12 PM, Staff C LPN stated an announcement was made over the intercom, for a code blue. Staff C explained upon arrival to Resident #1's room Staff I RN, and Staff A RN, had begun performing chest compressions on Resident #1. Staff C stated having placed the bag valve mask on Resident #1 to assist with respirations. Staff C stated he did not know Resident #1's code status. Staff C stated no one knew the code status of Resident #1 at the time of compressions. Staff C stated the code status of Resident #1 was determined afterwards. Staff C stated compressions continued until EMS arrived. Staff C stated once EMS arrived, EMS asked why are you even bothering? Staff C stated EMS told the facility staff to stop and promptly proceeded to walk out.During an interview on [DATE] at 02:39 PM, the Social Services Director (SSD), stated the facility checked resident code statuses upon admission and throughout the stay. The SSD stated Resident #1 requested a DNR so staff would not perform chest compressions, due to possible puncture of chest or ribs. The SSD stated Resident #1 was adamant she did not want to be resuscitated or go through the process. The SSD stated Resident #1 just wanted to go to sleep and did not want all the heroics and wanted a natural death. The SSD stated Resident #1's Brief Interview Mental Status was 15 at the time.During an interview on [DATE] at 11:29 AM, Staff G Nurse Practitioner (NP), explained having spoken to Resident #1 in 2025, related to a DNR. Staff G stated the resident wanted to be a DNR. Staff G stated when responding to a code blue, expectations were for two staff to check the code status of the resident on the computer. Staff G stated staff should have followed the code status for the resident.During an interview on [DATE] at 11:34 AM, Staff G NP, stated consequences of performing CPR on a resident with a DNR could include prolonging the life expectancy of a resident. Staff G stated there was a potential for the resident to become a vegetable. Staff G stated the resident could have had ribs broken or fractured.During an interview on [DATE] at 03:30 PM, The Director of Nursing (DON), and Staff H Regional Nurse Consultant (RNC), stated Staff E found Resident #1 unresponsive at 12:15 PM on [DATE]. They stated Staff E alerted the nurse and a code blue was announced on the intercom three times at 12:17 PM. They stated the Staff I RN, made it to the room by 12:17 PM. They stated Staff B LPN, and Staff A RN, arrived to Resident #1's room shortly after. They stated Staff C LPN, and Staff D RN, arrived soon after. They stated facility staff moved Resident #1 to the bed and Staff B went to check the resident's code status. They stated the unit manager went with Staff B to check Resident #1's code status. They stated Staff B yelled she is a DNR. They stated at this point nurses, Staff C and Staff D, began to assist with CPR. They stated the staff contacted EMS and upon their arrival, provided them with Resident #1's DNR. They stated the resident was pronounced at 12:29 PM. They stated the course of events explained were confirmed through camera review. They stated Staff I and Staff A initiated CPR and Staff C and Staff D assisted with CPR. They stated the staff failed to confirm the resident's code status before initiating CPR. They stated the staff should have checked Resident #1's code status, prior to performing CPR. They stated CPR had been performed on Resident #1, against her wishes. They stated when they interviewed Staff I, she stated blatantly, she should have checked the code status but forgot. They stated Staff I stated having reacted in an emergency situation and made a bad decision.During an interview on [DATE] at 03:30 PM, video footage of facility staff responding to Resident #1's code blue was reviewed with the DON and Staff H RNC. Staff E CNA, was observed walking from a resident's room across the hall into Resident #1's room while holding a clear bag of soiled linen. Staff E called out to Resident #1 a few times. No response was heard from the resident. Staff E was observed leaving the room and notifying Staff I RN. Staff I was observed walking pass Resident #1's room to get a blood pressure machine. Staff I was observed walking into Resident #1's room and immediately ran out and went to the nurse station. Shortly after, a code blue was paged. Staff I went back to the resident's room with a crash cart, followed by Staff B LPN, who left shortly after asking the code status of Resident #1. Numerous staff were observed entering and exiting Resident #1's room, including Staff A RN, Staff C LPN, and Staff D RN. Staff B returned to the resident's room and stated she's a DNR. From the time Staff I entered the room and was stated to have started CPR, until EMS arrived was 12 minutes. EMS was observed arriving on camera and asked, who started CPR? EMS was observed leaving Resident #1's room, without Resident #1. Review of a facility policy titled, Residents' Rights Regarding Treatment and Advance Directives Residents' and dated 01/2026, revealed the following:Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Definitions:Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Policy Explanation and Compliance Guidelines: On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Should the resident refuse treatment of any kind, the facility will document the refusal in the resident's chart The facility will use the process as provided by State law for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes. Review of a facility policy titled Communication of Code Status, and dated 01/2026 revealed the following:Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information.Policy Explanation and Compliance Guidelines: The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive.When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to:Full Code Do Not ResuscitateDo Not Intubate Do not Hospitalize The facilities' immediate actions to remove the Immediate Jeopardy included:On [DATE] Implemented a revised admission/readmission process requiring:Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives with follow-up by Social Services. Advance directive discussion forms are reviewed in the daily clinical meeting with the Interdisciplinary team. Following the clinical meeting the Unit manager/ Weekend supervisor conducts a huddle on their units and discuss any changes.Signage was placed on each crash cart which states Stop check physician order prior to starting Cardiopulmonary Resuscitation.It Takes Two education (To verify code status) by two licensed nurses to determine advance directives prior to the initiation of Cardiopulmonary resuscitationOn [DATE] at 12:35pm an internal investigation was initiated with resident record review, staff interviews, and notification to MD and resident representative.On [DATE] Assigned nurse was suspended and terminated, with report of license to licensing board on [DATE]On [DATE]- An additional nurse that responded to the scene and participated in the initiation of CPR was suspended and terminated with report of license to licensing board on [DATE]On [DATE]- Two additional nurses that responded to the scene were suspended pending the investigation. On [DATE] these nurses returned and received disciplinary discipline. Both nurses were provided with education related to ANE/honoring Advance Directives and participated in a code blue drill.On [DATE] Director of Clinical Services conducted an immediate 100% audit of all current residents' code status and care plan.On [DATE] 100% audit was conducted by the Director of Clinical Services of the four crash carts in the facility to ensure that all required items were present. Signage was placed on each crash cart which states Stop check physician order prior to starting Cardiopulmonary Resuscitation.On [DATE], the identified four nurses' Cardiopulmonary resuscitation cards were reviewed. All four were valid and included in person skills competencies[DATE] Ad Hoc QAPI meeting held with Administrator, DON, medical director, and at least three other department heads.On [DATE] an audit was completed of residents who discharged , transferred to the hospital or expired in the last 90 days to verify advance directives were honored[DATE] Ad Hoc QAPI meeting held with Administrator, DON, medical director, and at least three other department headsXXX[DATE] Ad Hoc QAPI meeting held with Administrator, DON, medical director via phone, and at least three other department heads.Staff EducationOn [DATE] Director of Clinical Services and/or designee educated licensed/certified staff on the following:Medical Emergency response/Communication of advance directives code statusFollowing physician's orders related to Advance directiveIt Takes Two education (To verify code status/ Advance Directives)C.N.A roles during code blueOn [DATE] Director of Clinical Services and/or designee educated all staff on the following:Abuse, Neglect and Exploitation Resident Rights with focus on honoring Advance DirectivesOn [DATE] Director of Clinical Services and/or designee educated licensed/certified staff on the following:Medical Emergency response/Communication of advance directives code statusFollowing physician's orders related to Advance directiveIt Takes Two education (To verify code status/ Advance Directives)C.N.A roles during code blueOn [DATE] Director of Clinical Services and/or designee educated all staff on the following:Abuse, Neglect and ExploitationResident Rights with focus on honoring Advance DirectivesOn [DATE] Director of Clinical Services and/or designee educated licensed/certified staff on the following:Medical Emergency response/Communication of advance directives code statusFollowing physician's orders related to Advance directiveIt Takes Two education (To verify code status/ Advance Directives)On [DATE] Director of Clinical Services and/or designee educated all staff on the following:Abuse, Neglect, and ExploitationResident Rights with focus on honoring Advance DirectivesOn [DATE]- 100% Honoring Advance Directives attestation was completed with facility licensed nursing staffOn [DATE]- Licensed nursing staff- Physicians Orders Education 100 percentOn [DATE] Licensed nurse staff -Medical Emergency response/Communication of advance directives code status Education- 100 percentOn [DATE] ANE/Resident Rights Education was completed with all staff-100 percentOn [DATE]-Advance directives posttest was completed with licensed staff -100 percentOn [DATE] ANE/Resident Rights posttest was completed with all staff-100 percentOn [DATE]- Licensed nursing staff- Code blue process/ It takes Two Education- 100 percentOn [DATE] the facility began code blue drills every shift and 97.1% completed of licensed staff with one remaining nurse who has not worked and will not work until she attends a blue drill. 100% completed of C.N.A roles in a code blue.Licensed Nurse will not work prior to attending a mock code blue quality assurance drill.-26 quality reviews were completed with 146 facility staff members validating competencies of education completed.-11 quality reviews were completed of 25 residents newly admitted to the facility to verify completion of advance directive discussion form-Director of Clinical services completes a chart review of residents who expire at the facility or residents who are transferred to the hospital after a cardiac event to verify advance directives were followed.Verification of the facility's removal plan was conducted by the survey team on [DATE] and included the following: Interviews were conducted with 48 staff, 11 licensed nurses, 24 CNAs and 14 ancillary staff. All staff members were able to state that they had been trained and were knowledgeable about the new policies. Record review of education provided by the facility revealed the following:On [DATE] code status orders and care plan review was completed for all residents. This was verified.On [DATE] transfers and death review, to verify advanced directives were honored, was Verified.Reviewed facility audit for [DATE], which showed CPR cards were reviewed for all nurses. This was verified.Between [DATE] and [DATE] education for abuse, neglect, and exploitation was completed. 232 signatures were verified.Reviewed resident rights and advanced directives education sign in sheets were completed for [DATE] through [DATE]. 182 signatures were verified.Reviewed it takes 2, sign in sheets were completed for [DATE] through [DATE], (includes verifying code status). 164 signatures were verified.Reviewed education and competency for CPR, dated [DATE] to [DATE]. 68 signatures were verified.Reviewed education and competency for Medical Emergency Response/Communication of Code Status, dated [DATE] to [DATE]. 69 signatures were verified.Reviewed education and competency for Physician Orders, dated [DATE] to [DATE]. 54 signatures were verified.Reviewed education and competency for Honoring Advanced Directives Attestation, dated [DATE] to [DATE]. 43 signatures were verified.Licensed Nurse Post test - 38 signatures were verified.Code blue drills: - 15 between [DATE] and [DATE], different shifts, were verified.On [DATE] at 10:25 AM, the facility conducted a code blue drill. Staff arrived promptly, with laptops, and a crash cart. A sign on the crash cart showed stop, check physician order prior to starting CPR. Staff confirmed the resident's code status as a full code. The staff started CPR and a staff member documented a timeline. Multiple staff members confirmed if EMS had been contacted. Staff continued CPR, until EMS arrived and took over. Multiple staff members were observed performing CPR and checking the resident's code status.Based on verification of the facility's Immediate Jeopardy removal plan the Immediate Jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on interviews with the facility's nursing and administrative staff, record review and review of the facility policies, the facility administration failed to utilize their resources effectively to ensure allegations of abuse and neglect were thoroughly investigated and reported in a timely manner for five residents (#3, #4, #5, #6 and #8) out of five residents sampled for abuse and neglect, putting all the residents of the facility at risk for ongoing abuse and neglect. [Cross reference F609 and F610].Findings included: Review of a job description signed by the Nursing Home Administrator on [DATE] revealed - the primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times.Duties and responsibilities included:Resident Rights: Ensure that the resident's rights to fair and equitable treatment, self-determination, individuality, privacy. property and civil rights. including the right to wage complaints. are well established and maintained at all times. Review resident complaints and grievances and make written reports of action taken. Discuss such actions with resident and family as appropriate. Assist in establishing and implementing a Resident/Group Council. Ensure that policies governing the timely notice for resident discharges and/or room or roommate changes are strictly followed by all personnel. Ensure that resident funds maintained by the Facility are managed in accordance with current federal and state regulations and that appropriate accounting records are maintained. Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information. Review complaints and grievances made by the resident and make a written or oral report to the Nurse Supervisor, LPN, or RN. Follow Facility's established procedures. Maintain a written record of the resident's complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint. Report all allegations of resident abuse and/or misappropriation of resident property. Must adhere to all HIPAA requirements.Review of a job description signed by the Director of Nursing (DON) on [DATE] revealed - Registered Nurses at [Name of Facility] provide direct bedside care and act as patient advocate and educator. The RN will educate the patient and family members what to expect when dealing with the challenges of aging or specific conditions the patient may have and help them understand what contributions to recovery and long-term wellness they can make. The RN will also inform family members of any changes in the patient's condition and discuss with them any alterations to the patient's medication or other treatments. Collaborating with the facility physician to help create and implement patient care plans and notifying the physician if there is a change in the patient's condition.Essential functions revealed the following: Promote the mission, vision, and values of the organization Provide basic nursing care to patients within [Name of facility] center's scope of practice that includes actions that meet psychosocial needs and physical needs. Provides direct and individualized nursing care to assigned patients based on nursing standards and under the supervision of the Director of Nursing. Ensures quality and safe delivery of nursing services to patients/clients and families/caregivers. Implements plan of care formulated by physicians. Provides accurate and timely documentation consistent with plan of care. Assesses and provides patient/client education and information pertinent to diagnosis and plan of care. Maintains safe and healthy working environment and uses safe work methods and procedures in accordance with company clinical standards. Assists patient in learning appropriate self-care activities. Uses equipment and supplies effectively and efficiently. Ensuring all work areas and residents' rooms are maintained in accordance with safety and sanitation standards. Ordering medications, equipment and supplies as prescribed. Preparing and administering medications ordered by the physician in accordance with policies and procedures. ' Attending rounds with physicians, nurse practitioners and physician's assistants. Assisting with the orientation of new staff to the unit. Collaborating with the resident's physician to provide the care, services, treatments, and rehabilitation ordered. Communication with the resident's physician and/or family members when there is a change in resident's condition or if any incident occurs involving patient. Administering professional nursing practice services such as: tube feedings, suction, catheterization, changing of dressings, packs, and irrigations, as necessary. Gathering samples of sputum, urine and other specimens for lab tests as ordered. Continuous observation and monitoring of seriously ill residents. Being the patient advocate and ensuring that other health care team members are providing care according to the resident's care plan and personal wishes. Receiving, transcribing, and implementing physician's orders according to facility procedures. Accurately completing necessary charting as required and in a timely manner following established charting policies and procedures.Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses to include metabolic encephalopathy, major depressive disorder, antineoplastic chemotherapy, secondary malignant neoplasm of unspecified lung, Malignant neoplasm of the brain, severe calorie malnutrition, Cachexia, COPD, personal history of pneumonia, Acute history respiratory failure with hypoxia.Review of a witness statement dated [DATE] revealed, Security camera footage of the smoking patio from [DATE], shows a resident [Resident #3] assigned to (Staff B, Certified Nursing Assistant- CNA) for care entering the smoking patio in the afternoon. He is seen on the video footage remaining on the smoking patio in the afternoon. He is seen on the video footage remaining on the smoking patio without receiving any visits or care from his assigned CNA. At 5 p.m. the resident was found by other staff to be unresponsive. He was assisted indoors and subsequently a code blue was called. Video shows that the resident received no care of kind from [Staff B, CNA] for over 4.5 hours. The statement was signed by Staff A, Licensed Practical Nurse (LPN), and dated [DATE]).Review of the facility's abuse log dated [DATE] through [DATE] showed the incident above was not listed.During a complaint survey conducted on [DATE] - [DATE] interviews with key personnel revealed the facility staff were not willing/able to participate in the survey process regarding the investigation of abuse and neglect. The key personnel who were employees of this facility during the period of the investigation included; Staff E, RN Unit Manager, Director of Rehabilitation (DOR), Housekeeping Manager, Assistant Director of Nursing, Social Services Directors 1 and 2, and Therapy Staff F and G. They denied knowing anything about Resident #3 having been left unattended for an alleged 4.5 hours, or that he coded and required CPR which lasted more than 10 minutes, from which the resident expired. Their answers included, I do not remember anything about that incident, The administration did not tell us anything, I do not know, I do not feel comfortable answering, I do not have specifics. At the time of the investigation, it was unclear if the key staff had not participated in the investigation of a traumatic event, or if they were not forthcoming, impacting the survey process. On [DATE] at 9:15 a.m. an interview with the RDCS and the facility's Chief Nursing Officer (CNO) revealed, We became aware last night of the witness statement of the resident left outside for 4.5 hours and have now reported neglected. We suspended the DON, unit manager and the NHA, pending investigation. The CNO said they interviewed [Staff A,LPN] and asked why the statement did not go anywhere. The CNO said, She was essentially focusing on the caregiver not the resident. We know the way it looks, it is not good, she said the CNA was not good, so she wanted to school the CNA and get back at him. The RDCS stated Staff A, LPN did not review the video for four and half hours of video. She stated the administration was not forthcoming at all. She stated they had an unsupervised smoking patio which they corrected in [DATE]. The RDCS said, I wanted to be transparent. I have integrity. I did not know about the 4.5 hours. I would have investigated it further. The RDCS stated they took immediate action last night and have several staff members who will not be returning. The RDCS said, We have now reported the neglect allegation. The CNO stated they became aware the NHA had a culture of hiding everything. She said, She is not returning. She hid stuff from us. The CNO stated they could not have an unethical culture.Review of a facility policy titled, Compliance and Ethics Reporting, revised 01/2026 revealed the facility implements and publicizes a reporting system that allows anyone to report compliance violations anonymously without fear of retribution and that ensures the integrity of the reports.Policy explanation and compliance guidelines:1. This facility supports an open door policy in which anyone may discuss concerns or report compliance violations to any supervisor, manager, HR representative, or compliance professional at any time.2. The facility has a designated contact person to which anyone may report suspected violations. This person is (insert job title) and may be reached at (insert contact information, or location of contact information).3. This facility has a (hotline number, intranet application, drop box, etc.) for reporting suspected violations anonymously, without fear of retribution.4. Information related to reporting compliance violations is posted (insert locations). Training shall be provided on a regular basis, not less than upon orientation and annually, to remind individuals of the reporting system, what to report, timeframes for reporting, and how to report.5. All information pertaining to a report will be kept confidential within the law. Anyone who reports a violation or suspected violation in good faith shall not be harassed, reprimanded, or discriminated against in any way.6. Employees with knowledge of a violation or suspected violation of the compliance program's standards, policies, and procedures are required to report it immediately. Staff who knowingly fail to report a violation shall be subject to disciplinary action, up to and including termination.7. Should any person have questions regarding compliance with state or federal laws, they should immediately seek clarification from the compliance officer, a supervisor, or through the facility hotline and/or web reporting.8. Once a report is received, an investigation will be conducted to determine whether a substantial violation or opportunity for improvement exists. Corrective actions will be implemented as necessary.9. The compliance and ethics program contact person shall follow up with those individuals making a report, except in those instances where the report was made anonymously.10. All reports will be tracked for purposes of QAPI and evaluating the effectiveness of the compliance and ethics program. Documentation shall be maintained for a minimum of three years by (insert job title).

Based on observations, interviews, and record review, the facility failed to ensure infection control practices were consistently followed to notify visitors of an influenza outbreak and/or offer personal protective equipment (PPE) such as masks prior to entering the resident care area and in nebulizer masks were not stored in a manner to prevent infection in two of four units (100 and 300).Findings Include: On 1/28/26 at 9:10 a.m. during the initial tour of the facility, all staff members observed in the resident care area were wearing masks. When asked, staff stated that mask use was required due to an influenza (flu) outbreak. Upon further review of the lobby area, no signage was posted to notify visitors of the outbreak or to recommend appropriate personal protective equipment (PPE) and the receptionist did provide information or instructions about the influenza outbreak. On 1/28 /26 at 10:25 a.m. an interview was conducted with Family Member #1 visiting room [ROOM NUMBER]. The visitor stated he had been at the facility this week and last week. He stated he was not notified there was a flu outbreak and he had not been offered a mask. The family member stated not knowing if his family member or his roommate had the flu. On 1/28/26 at 10:27 a.m. an interview was conducted with Family Member #2 visiting rooms [ROOM NUMBERS]. The family member stated she did not receive any notification regarding the flu outbreak. She stated there was no notification posted anywhere. She stated she was not offered a mask upon entering the facility. The family member stated she visited the facility daily. The family member stated the receptionist did not mention it. She said she became aware of the outbreak from being at the facility and seeing staff wearing masks. During an interview and record review on 1/28/26 at 10:30 a.m. with the Infection Preventionist (IP) nurse and the Regional Director of Clinical Services (RDCS), the IP nurse stated that the influenza outbreak began on 1/23/26, at which time 21 residents tested positive for the influenza virus. The IP nurse stated only reporting the newly identified positive residents on 1/26/26. Notification was completed to Resident Representatives (RR) of the flu outbreak by telephone, at this time. During a follow-up interview on 1/29/26 at 9:37 a.m. the IP nurse stated when the RRs were notified of the outbreak the facility did not encourage the use of masks as a precaution when visiting. She stated signage was not posted to notify visitors of the outbreak or to recommend/encourage the use of masks. On 1/28/26 at 10:10 a.m. while touring the facility on the 300 unit an uncovered nebulizer mask on the resident's dresser in front of the television was observed. On 1/28/26 at 10:40 a.m. while touring the facility on the 100 unit an uncovered nebulizer mask on a circular table in the resident's room was observed. (Photographic Evidence Obtained). During a follow-up interview and record review on 1/29/26 at 9:37 a.m. the IP nurse viewed the pictures of the uncovered nebulizer masks. The IP nurse stated the items should be stored in a bag, and all staff members have received instructions every nurse knows. Review of the facility's policy titled, Infection Prevention and Control Program, revised 1/2026 revealed the following: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1) The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2) All staff are responsible for following all policies and procedures related to the program .5g) Visitors coming to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the and precautions necessary when visiting the resident . 13) Resident/Family/Visitor Education and Screening: a) Residents, family members, and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions, and conditions for which to notify the nursing staff. Isolation signs are used to alert staff, family members, and visitors of transmission-based precautions . 13) Resident/ Family/Visitor Education and Screening: a)Residents, family members, and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions, and conditions for which to notify the nursing staff. D) Passive screening, such as signs, are posted in the facility to alert family members use. Review of the facility's policy titled, Oxygen Administration, revised 1/2026 revealed the following: . 5 e) Keep delivery devices covered when not in use.

Based on observations, interviews, and record reviews, the facility failed to provide staff with adequate training on issues regarding language barriers reported through grievances via the resident council and residents in seven of seven grievances sampled for review.Findings include: On 1/28/26 at 2:20 pm, an interview with Resident #7 revealed language is still a big barrier at the facility. Resident #7 stated Resident Council has been discussing this issue for months, and no resolution has been made. Resident #7 stated staff will just shove their phone in the resident's faces and try to make them use a translator application. Resident #7 refuses to use the translator for communication. Resident #7 believes they should be able to communicate with staff without having to use a translator. Resident #7 said they hear staff speak Spanish while caring for other residents who are also only English speaking. A review of Resident #7's admission record revealed an original admission date of 11/28/22, with a readmission date of 1/14/25, with diagnoses to includer respiratory failure, seizures, and difficulty walking. A review of Resident #7's Quarterly Minimum Data Set (MDS) assessment, dated 12/3/25, revealed a Brief Interview Mental Score (BIMS) of 15, meaning resident is cognitively intact. A review of the facility's grievances revealed the following: 5/13/25 a grievance from a resident residing on Unit Three at the facility CNA providing care could not answer a question for [resident's name] because she could not speak English. She did not understand what [resident's name] was asking herResolution: Blank 5/23/25 a grievance from a resident residing on Unit Two at the facility Resident and [family member] complained to social worker that resident has difficult time communicating with [Care Staff Member], language barrier, and has poor response timeResolution: Employee was counseledNo follow up documented 6/2/25 a grievance from the Resident Council meeting Residents state the staff speak Spanish to each other during mealtimes in the dining room in front of non-Spanish speaking residents.Resolution: Staff inserviced 6/6/25In-service on 6/6/25-English (Primary Language in Facility): English is the primary language to be spoken in the facility unless you are speaking with a resident in their primary language. All employees must speak English at all times in the facility. 6/2/25 a grievance from the Resident Council meeting Residents state the CNAs on station three do not speak/know very little EnglishResolution: Staff inservice 6/6/25In-service on 6/6/25-English (Primary Language in Facility): English is the primary language to be spoken in the facility unless you are speaking with a resident in their primary language. All employees must speak English at all times in the facility. 7/1/25 a grievance from the Resident Council meeting Residents state the staff speak Spanish to each other during mealtimes in the dining room in front of non-Spanish speaking residents.Resolution: Already educating on this areaIn-service on 6/30/25-Primary Language in Facility: English is the primary language to be spoken in the facility unless you are speaking with a resident in their primary language. All employees must speak English at all times in the facility. 7/1/25 a grievance from the Resident Council meeting Residents state the CNAs on station three do not speak/know very little EnglishResolution: Already education in this area 7/4/25In-service on 6/30/25-Primary Language in Facility: English is the primary language to be spoken in the facility unless you are speaking with a resident in their primary language. All employees must speak English at all times in the facility. 7/21/25 a grievance from a resident residing on Unit Three at the facility States that aide today didn't understand him.Resolution: Aide moved off assignment. 7/23/25No follow up documented. A review of the facility's resident council minutes revealed the following: On 6/2/25 Residents state the CNAs on station three do not speak English/know very little English.Not Resolved-Action Needed Residents state the staff speak Spanish to each other during mealtimes in the dining room in front on non-Spanish speaking residentsNot Resolved-Action Needed On 7/1/25 Residents state the CNAs on station three do not speak English/know very little English. Residents feel uncomfortable with staff using phone to translateNot Resolved-Action Needed Residents state the staff speak a language other than English to each other during mealtimes in the dining room in front of English-speaking residents.Not Resolved-Action NeededCompliments/Notes of Appreciation: Residents stated last month grievances regarding nursing have not been resolved and would like action taken. On 9/1/25 Residents state the CNAs on station three do not speak English/know very little English. Residents feel uncomfortable with staff using phone to translate from Spanish to EnglishNot Resolved-Action Needed On 1/28/26 at 9:46 am, an interview with Staff H, Certified Nursing Assistant (CNA), was attempted. The interview did not occur due to a language barrier of Staff H, CNA not being able to understand the questions being asked in English. On 1/30/26 at 10:14 am, an interview with Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM), said communicating with staff on Unit 3 is easier for her due to being able to communicate in Spanglish. Staff A, LPN/UM stated it is hard for the CNAs on the unit to understand clinical questions if you don't speak slowly and clearly. Staff A, LPN/UM said resident council brings up hearing staff speaking Spanish in the hallways every month. Staff A, LPN/UM said she tries to encourage staff to speak English as much as possible. Staff A, LPN/UM stated staff will use a translator application on their phones to communicate between residents and English-speaking staff members. On 1/30/26 at 11:43 am, an interview with the Social Services Director (SSD) said there are grievances related to language barriers regarding residents and the care staff. The SSD stated in-services have occurred with staff reminding them not to speak other languages while caring for residents. The SSD said giving a verbal reminder is not being effective in correcting the issue and the care staff knows better. The SSD said grievances related to language barriers were handled by the Director of Nursing (DON). The SSD said the grievance should be completed to include the resolution. On 1/20/26 at 12:11 pm, an interview with the Social Worker (SW), said there is a potential issue with Spanish speaking staff and residents. The SW stated care staff is not allowed to use translators to communicate with the residents. The SW said being able to communicate and read English is a requirement for staff. The SW said they do not specifically document resolutions to grievances presented to them. On 1/30/26 at 12:52 pm, an interview with the Regional Director of Operations (RDO) said the facility must go beyond verbal communication to resolve a repeating issue. The RDO stated something more should have been done by the facility to provide the staff with resources, and residents with resolution to their grievances, and communication in a language they understand. The RDO said the expectation for staff is to speak the primary language of the residents, which is primarily English.A review of the facility's Culturally Competent Care policy revealed the following: It is the policy of this facility to provide culturally competent care in accordance with professional standards of practice. The facility has established a culture that treats each resident with respect and dignity as an individual, as well as address, supports and/or enhances his/her feelings of self-worth including personal control over choices and cultural preference. 'Culture' is the conceptual system that structures the way that people view the world-it is the particular set of beliefs, norms, and values that influence ideas about the nature of relationships, the way people live their lives, and the way people organize the world. 'Cultural Competency' is defined as a developmental process in which individuals or institutions achieve increasing levels of awareness, knowledge, and skills along a cultural competence continuum. Cultural competence involves valuing diversity, conducting self-assessments, avoiding stereotypes, managing the dynamics of difference, and acquiring and institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in communication. 'Effective communication' describes a process of dialogue between individuals. The skills include speaking to others in a way they can understand and active listening and observation of verbal and non-verbal cues. Understanding what the resident is trying to communicate is essential to giving a response. Additionally, effective communication ensures that information provided to the resident is provided in a form and manner that the resident can access and understand, including a language that the resident can understand. The facility will provide sufficient guidance for staff, including temporary staff, on how to communicate and deliver care for the resident. Direct care staff will be trained on effective communication that reflects the needs of the resident population and needs of the staff and will correspond with the Facility Assessment. A review of the facility's Resident and Family grievances policy dated revised 01/2026, revealed: . 'Prompt efforts to resolve' include the facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. The facility Social Services Director has been designated as the Grievance Official and can be reached at [SSD Contact Number]. The facility will make prompt efforts to resolve grievances.

Based on record review, interviews and review of the facility policy, the facility failed to ensure allegations of abuse and neglect were reported in a timely manner for four (#3, #4, #5 and #6) of five residents reviewed.Findings include: Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 1/2026, showed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: . Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.2. Assuring that reporters are free from retaliation or reprisal;3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint.4. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service;5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following:a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences;b. Defining how care provision will be changed and/or improved to protect residents receiving services;c. Training of staff on changes made and demonstration of staff competency after training is implemented;d. Identification of staff responsible for implementation of corrective actions;e. The expected date for implementation; andf. Identification of staff responsible for monitoring the implementation of the plan.B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1.Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses to include metabolic encephalopathy, major depressive disorder, antineoplastic chemotherapy, secondary malignant neoplasm of unspecified lung, Malignant neoplasm of the brain, severe calorie malnutrition, Cachexia, COPD, personal history of pneumonia, Acute history respiratory failure with hypoxia. Review of a witness statement dated [DATE] revealed, Security camera footage of the smoking patio from [DATE], shows a resident [Resident #3] assigned to (Staff B, Certified Nursing Assistant- (CNA)) for care entering the smoking patio in the afternoon, where he remained for the duration of the afternoon. Resident #3 is seen on the video footage remaining on the smoking patio without receiving any visits or care from staff nor assigned CNA. At 5 p.m., Resident #3 was found unresponsive by another staff member (not identified). Resident #3 was assisted indoors, and a code blue was called. Video shows that Resident #3 did not receive care from [Staff B, CNA] for over 4.5 hours. The statement was signed by Staff A, Licensed Practical Nurse (LPN), and dated [DATE]. Review of the facility's abuse logs dated [DATE] through [DATE] did not reveal the incident with Resident #3. On [DATE] at 11:32 a.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Regional Director of Clinical Services (RDCS). The NHA stated there was no allegation of neglect and there would not have been a reason to report/investigate. She stated at the time the patio was not supervised but staff in the dining room had clear view of the patio. During an interview on [DATE] at 6:16 p.m. with the RDCS and the NHA they stated they did not investigate/report Resident #3's sudden death at the patio despite the allegation of the resident being unattended for 4.5 hours. The NHA stated they did not see it as needed to be investigated or reported. On [DATE] at 1:13 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the incident was, just a regular code, we did not investigate or report. The DON stated at the time there was no hydration cart and there was no supervision of the patio. The DON stated this was not a reportable event. It was not an abuse or neglect issue. She said, We would report a death that would be questionable in the facility. If they were not expected to die. The DON stated Resident #3 had a lot of terminal diagnoses, and the prognosis was not good. She stated she was surprised he died that day. The DON said regarding the sudden death, It did not raise an alarm for me. On [DATE] at 4:55 p.m. an interview was conducted with Staff C, Licensed Practical Nurse (LPN) and evening supervisor. Staff C stated there was no sign the resident was going to die. She stated the resident had an appointment the day before and there was, nothing obviously concerning. Staff C said she did not think to investigate/report as Resident #3 was alert and pushed himself out to the patio. Staff C said, I was not supervising him. There was no clear view of him while out there. The incident was not witnessed by staff. We don't know what happened. Staff C stated the resident was suddenly found unresponsive. On [DATE] at 5:11 p.m., a telephone interview was conducted with Staff B, CNA. Staff B, CNA said not remembering Resident #3, nor an incident occurring on [DATE]. Staff B, CNA said, No, I don't have the memory of an elephant. When asked if he recalled the resident sitting outside for four or more hours, he said he did not leave a resident outside for four hours, but also said he did not remember the resident. On [DATE] at 9:15 a.m. an interview with the RDCS and the facility's Chief Nursing Officer (CNO) revealed, We became aware last night of the witness statement of the resident left outside for 4.5 hours and have now reported neglected. We suspended the DON, unit manager and the NHA, pending investigation. The CNO said they interviewed [Staff A, LPN] and asked why the statement did not go anywhere. The CNO said, She was essentially focusing on the caregiver not the resident. We know the way it looks; it is not good, she said the CNA was not good, so she wanted to school the CNA and get back at him. The RDCS stated Staff A, LPN did not review the video for four and half hours of video. She stated the administration was not forthcoming at all. She stated they had an unsupervised smoking patio which they corrected in [DATE]. The RDCS said, I wanted to be transparent. I have integrity. I did not know about the 4.5 hours. I would have investigated it further. The RDCS stated they took immediate action last night and have several staff members who will not be returning. The RDCS said, We have now reported the neglect allegation. The CNO stated they became aware the NHA had a culture of hiding everything. She said, She is not returning. She hid stuff from us. The CNO stated they would not have an unethical culture. On [DATE] at 9:54 a.m. a follow-up interview was conducted with Staff A, LPN. Staff A, LPN stated the statement previously written regarding [Resident #3] remained on the patio for 4.5 hours unattended was false. Staff A said, I do not believe he was toileted, but other staff cared for him. When Resident #3 coded I did not see he was soiled. I do not think he [Staff B, CNA] changed him. Staff A said, The administration was aware of the statement. They did not report it. They could have investigated and reported it if they wanted to. Staff A stated the statement was written about the staff's performance. She stated she did not think about the resident at the time. Staff A stated to her knowledge, Resident #3 was not toileted during the 4.5 hours. 2.Resident #4 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis. A review of the facility's abuse log revealed an abuse allegation was filed for Resident #4 dated [DATE]. Review of a psychology progress note treatment plan dated [DATE] revealed, [Resident #4] is seen today at the request of the facility relative to his allegation of harm at the hands of a professional. [Resident #4] is alert and oriented. He is easily engaged and provides information relative to his allegation of the assault. He maintains eye contact and is attentive. He is not animated, his affect is flat. He repeats words to seemingly emphasize their relevance to him. [Resident #4] reports that a person by the name of [Staff D, title unknown) comes to his room and violates his space by patting him on the head and pinching his cheek asking, how is my guy today. He comes to his room at dusk. [Resident #4] feels demeaned by the interaction. He emphasizes the word violates several times in his conversation. [Resident #4] is not sure of [Staff D's] role. He does not want [Staff D] returning to his room. This happened in the last several days prior to the session. During an interview conducted with the NHA on [DATE] at 5:54 p.m., the NHA stated Resident #4 alleged a short haired man, slapped him and he reported it to the nurse, two days prior. The NHA stated Resident #4 was assessed and there were no injuries. The NHA said, He could not give a name, contrary to the note above. The NHA stated the resident had a similar incident occur in [DATE], at which he alleged a violation that occurred in his room. The NHA stated the incidents were not substantiated. She stated she did not have a name to go by. The NHA did not identify who [Staff D] was and did not reveal the person was part of the investigation. The NHA stated she reported the incident which occurred on [DATE] at 4:29 p.m. She stated she reported the abuse the next day, notified DCF (Department of Children and Families) on [DATE] at 10:08 a.m. and AHCA (Agency for Health Care Administration) on [DATE] at 10:05 a.m. The NHA acknowledged the reporting did not meet their policy standards. She stated, I was educated on the reporting requirements. It should have been within two hours. She confirmed she could have investigated further to confirm who Staff D was. 3.Resident #5 was admitted to the facility on [DATE] with a primary diagnosis of Hemiplegia and Hemiparesis. Review of the facility's abuse log revealed the resident had an incident on [DATE]. During an interview conducted with the NHA on [DATE] at 5:54 p.m., the NHA stated on [DATE] at 2:00 p.m. Resident #5 reported an incident which occurred the night before on 11 p.m. - 7 a.m. shift. The NHA stated the resident reported a female came into her room and refused to give her the call light which was not within reach. The resident reported the staff member said she was not her assigned CNA and that she did not have a CNA and left. The resident stated she needed to be changed, and this CNA did not change her. The NHA stated she reviewed Resident #5's chart and did not see any documentation of the resident being changed, but once at 8:17 p.m. She stated she interviewed the CNA who was assigned and they said they were attending to another resident but eventually came back to Resident #5. The NHA stated they did not have an exact time when this occurred. She stated they could not get to the bottom of it because, the resident has glaucoma, she could not see clearly to tell us who it was. The NHA stated the resident was seen by psych and denied being abused. The NHA said the resident said, it was probably a misunderstanding. She stated having witness statements that were not reviewed during this investigation process. The NHA stated she treated this as a neglect incident and did not see it as abuse. She said it was not abuse because there was no physical injury. The NHA said she was notified on [DATE] at 2:30 p.m. and reported to AHCA on [DATE] at 7:48 p.m. The NHA said, To my knowledge we have 24 hours if there is no injury. The NHA confirmed abuse allegations should be reported within 2 hours. She stated they reviewed the abuse policy. Reviewed policy showed abuse also includes the deprivation by an individual, including a caretaker of goods or services. 4.Review of the admission record for Resident #6 revealed an admission date of [DATE] with diagnoses to include muscle wasting and atrophy, cognitive communication deficit disorder, and unspecified dementia. Review of the facility's abuse log revealed an allegation of abuse was filed on [DATE]. Review of a psychology progress note dated [DATE] revealed, client reported that three people (1 male and 2 females) were in her room. The male was asleep with her in her bed when one of the females began hitting her. She stated the female began to feed others in the room before they all left. During an interview conducted with the NHA on [DATE] at 5:54 p.m., the NHA stated a family member alleged on [DATE] at 1:05 p.m. the resident was beat up by staff. The NHA stated she was notified of the incident when it happened. She stated she notified DCF on [DATE] at 2:50 p.m. She stated she notified AHCA on [DATE] at 3:59 p.m. The NHA stated, I know it was not within the two hours. I was with the police. I was not able to do it. The NHA stated reporting of abuse incidents should be within two hours. She stated their investigation was on-going. On [DATE] at 11:30 a.m. an interview was conducted with the RDCS. She confirmed there were no reports filed or investigated for Resident #3. The RDCS stated they were reviewing their reportable events. She stated the NHA should have filed reports in the required timeframes. She stated if the NHA could not do it for one reason or another, another staff member could submit the report.

Based on record review, interviews and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse and neglect in a timely manner for four residents (#3, #4, #5 and #8) of five residents reviewed.Findings include: Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 1/2026, showed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: . Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation. 1.Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses to include metabolic encephalopathy, major depressive disorder, antineoplastic chemotherapy, secondary malignant neoplasm of unspecified lung, malignant neoplasm of the brain, severe calorie malnutrition, Cachexia, COPD, personal history of pneumonia, Acute history respiratory failure with hypoxia. Review of a witness statement dated [DATE] revealed, Security camera footage of the smoking patio from [DATE], shows a resident [Resident #3] assigned to (Staff B, Certified Nursing Assistant- (CNA)) for care entering the smoking patio in the afternoon. He [Resident #3] is seen on the video footage remaining on the smoking patio in the afternoon. He is seen on the video footage remaining on the smoking patio without receiving any visits or care from his assigned CNA. At 5 p.m. the resident was found by other staff to be unresponsive. He was assisted indoors and subsequently a code blue was called. Video shows that the resident received no care of kind from [Staff B, CNA] for over 4.5 hours. The statement was signed by Staff A, Licensed Practical Nurse (LPN), and dated [DATE]. Review of the facility's abuse logs dated [DATE] through [DATE] showed the incident above was not listed. On [DATE] at 11:32 a.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Regional Director of Clinical Services (RDCS). The NHA stated there was no allegation of neglect and there would not have been a reason to report/investigate. She stated at the time the patio was not supervised but staff in the dining room had clear view of the patio. During an interview on [DATE] at 6:16 p.m. with the RDCS and the NHA stated they did not investigate/report Resident #3's sudden death near the patio despite the allegation of the resident being unattended for 4.5 hours. The NHA stated they did not see it as needed to be investigated or reported. On [DATE] at 1:13 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the incident was, just a regular code, we did not investigate or report. The DON stated at the time there was no hydration cart and there was no supervision of the patio. The DON stated this was not a reportable event. It was not an abuse or neglect issue. She said, We would report a death that would be questionable in the facility. If they were not expected to die. The DON stated Resident #3 had a lot of terminal diagnoses, and the prognosis was not good. She stated she was surprised he died that day. The DON said regarding the sudden death, It did not raise an alarm for me. On [DATE] at 4:55 p.m. an interview was conducted with Staff C, Licensed Practical Nurse (LPN) and evening supervisor. Staff C stated there was no sign the resident was going to die. She stated the resident had an appointment the day before and there was, nothing obviously concerning. Staff C said she did not think to investigate/report as Resident #3 was alert and pushed himself out to the patio. Staff C said, I was not supervising him. There was no clear view of him while out there [on the patio]. The incident was not witnessed by staff. We don't know what happened. Staff C stated the resident was suddenly found unresponsive. On [DATE] at 5:11 p.m., a telephone interview was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B, CNA said he did not remember Resident #3. He said he did not remember an incident that occurred on [DATE]. Staff B, CNA said, No, I don't have the memory of an elephant. When asked if he recalled the resident sitting outside for four or more hours, he said he did not leave a resident outside for four hours. On [DATE] at 9:15 a.m. an interview with the RDCS and the facility's Chief Nursing Officer (CNO) revealed, We became aware last night of the witness statement of the resident left outside for 4.5 hours and have now reported neglected. We suspended the DON, unit manager and the NHA, pending investigation. The CNO said they interviewed [Staff A,LPN] and asked why the statement did not go anywhere. The CNO said, She was essentially focusing on the caregiver not the resident. We know the way it looks; it is not good, she said the CNA was not good, so she wanted to school the CNA and get back at him. The RDCS stated Staff A, LPN did not review the video for four and half hours of video. She stated the administration was not forthcoming at all. She stated they had an unsupervised smoking patio which they corrected in [DATE]. The RDCS said, I wanted to be transparent. I have integrity. I did not know about the 4.5 hours. I would have investigated it further. The RDCS stated they took immediate action last night and have several staff members who will not be returning. The RDCS said, We have now reported the neglect allegation. The CNO stated they became aware the NHA had a culture of hiding everything. She said, She is not returning. She hid stuff from us. The CNO stated they could not have an unethical culture. On [DATE] at 9:54 a.m. a follow-up interview was conducted with Staff A, LPN. She stated the statement she wrote that [Resident #3] remained on the patio for 4.5 hours unattended was false. Staff A said, I do not believe he was toileted, but other staff cared for him. When he coded, I did not see that he was soiled. I do not think he [Staff B, CNA] changed him. Staff A said, The administration was aware of the statement. They did not report it. They could have investigated and reported it if they wanted to. Staff A stated the statement was written about the staff's performance. She stated she did not think about the resident at the time. Staff A stated to her knowledge, Resident #3 was not toileted during the 4.5 hours. 2.Resident #4 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis. A review of the facility's abuse log dates [DATE] -[DATE] revealed an abuse allegation was filed for Resident #4 dated [DATE]. Review of a psychology progress note treatment plan dated [DATE] revealed, [Resident #4] is seen today at the request of the facility relative to his allegation of harm at the hands of a professional. [Resident #4] is alert and oriented. He is easily engaged and provides information relative to his allegation of the assault. He maintains eye contact and is attentive. He is not animated, his affect is flat. He repeats words to seemingly emphasize their relevance to him. [Resident #4] reports that a person by the name of [Staff D, title unknown) comes to his room and violates his space by patting him on the head and pinching his cheek asking, how is my guy today. He comes to his room at dusk. [Resident #4] feels demeaned by the interaction. He emphasizes the word violates several times in his conversation. [Resident #4] is not sure of [Staff D's] role. He does not want [Staff D] returning to his room. This happened in the last several days prior to the session. During an interview conducted with the NHA on [DATE] at 5:54 p.m., the NHA stated Resident #4 alleged a short haired man, slapped him and he reported it to the nurse, two days prior. The NHA stated Resident #4 was assessed and there were no injuries. The NHA said, He could not give a name, contrary to the note above. The NHA stated the resident had a similar incident occur in [DATE], at which he alleged a violation that occurred in his room. The NHA stated the incidents were not substantiated. She stated she did not have a name to go by. The NHA did not identify who [Staff D] was and did not reveal the person was part of her investigation. The NHA stated she reported the incident which occurred on [DATE] at 4:29 p.m. She stated she reported the abuse the next day, notified DCF (Department of Children and Families) on [DATE] at 10:08 a.m. and AHCA (Agency for Health Care Administration) on [DATE] at 10:05 a.m. The NHA acknowledged the reporting did not meet their policy standards. She stated, I was educated on the reporting requirements. It should have been within two hours. 3.Resident #5 was admitted to the facility on [DATE] with a primary diagnosis of Hemiplegia and Hemiparesis. Review of the facility's abuse log dates [DATE] -[DATE] revealed the resident had an incident on [DATE]. During an interview conducted with the NHA on [DATE] at 5:54 p.m., the NHA stated on [DATE] at 2 p.m. Resident #5 reported an incident which occurred the night before on 11 p.m. - 7 a.m. shift. The NHA stated the resident reported a female came into her room and refused to give her the call light which was not within reach. The resident reported that the staff member said she was not assigned CNA and that she did not have a CNA and left. The resident stated she needed to be changed, and this CNA did not change her. The NHA stated she reviewed Resident #5's chart and did not see any documentation of the resident being changed, but once at 8:17 p.m. She stated she interviewed the CNA who was assigned and they said they were attending to another resident but eventually came back to Resident #5. The NHA stated they did not have an exact time when this occurred. She stated they could not get to the bottom of it because, the resident has glaucoma, she could not see clearly to tell us who it was. The NHA stated the resident was seen by psych and denied being abused. The NHA said the resident said, it was probably a misunderstanding. She stated having witness statements that were not reviewed during this investigation process. The NHA stated she treated this as a neglect incident and did not see it as abuse. She said it was not abuse because there was no physical injury. The NHA said she was notified on [DATE] at 2:30 p.m. and reported to AHCA on [DATE] at 7:48 p.m. The NHA said, To my knowledge we have 24 hours if there is no injury. The NHA confirmed abuse allegations should be reported within 2 hours. She stated they reviewed the abuse policy. Reviewed policy showed abuse also includes the deprivation by an individual, including a caretaker of goods or services. 4.Resident #8 was admitted to the facility on [DATE] with diagnosis to include Diabetes Mellitus. Review of the facility's abuse log dated [DATE] through [DATE] showed an allegation of abuse was documented for Resident #8 on [DATE]. An interview was conducted with the NHA on [DATE] at 5:54 p.m. regarding the incident. The NHA stated Resident #8 reported on [DATE] at 3:20 a.m. she was abused by staff. The NHA stated the resident thought it was abuse because the nurse would not leave her medications at bedside. The NHA stated even though the resident alleged abuse, she did not take it as abuse. She stated that night the resident refused care from her aide. She said the CNA had taken care of her before and she could not think of why she would refuse care from her. The NHA said she interviewed the CNA who said nothing happened on her shift. The NHA said, I thought it was odd, but I did not question her further. The NHA said the resident accepted care and medication from another nurse. The NHA stated being notified at 3:45 a.m. She stated she submitted an online neglect report to DCF at 4:52 p.m., police department at 4:05 p.m. and to AHCA on [DATE] at 5:31 p.m. The NHA said, She was saying she was abused, but I did not think it was abuse. She stated her findings were that it was neglect because the medications were provided. The NHA stated the resident refused to be interviewed by herself on [DATE] and [DATE]. She stated she believed the DON may have tried but it was not documented. The NHA said, I don't know why she refused that I interview her. I don't know what she meant by being abused. I never found out. The NHA stated she could have investigated why the resident alleged abuse and why she refused care from her CNA. On [DATE] at 11:30 a.m. an interview was conducted with the RDCS. The RDCS confirmed there were no reports filed or investigated for Resident #3. The RDCS stated they were reviewing their reportable events. She stated the NHA should have filed reports in the required timeframes. She stated if the NHA could not do it for one reason or another, another staff member could submit the report. Review of a job description signed by the Nursing Home Administrator on [DATE] revealed - the primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times.Duties and responsibilities included:-Review resident complaints and grievances and make written reports of action taken. Discuss such actions with resident and family as appropriate.

Based on observations, record review, and interviews, the facility did not ensure one of two community shower rooms were maintained in a clean and sanitary condition. Findings included: On 01/14/2025 at 9:15 AM the following observations were made of the community shower room located on Unit 4: - Shower curtains on the two showers in the room had a black substance on the lower part of both the out-facing and in-facing portions of the curtain. - A caked black substance was observed on the tile floor behind the toilet and the floor in front of and around the toilet was also caked with black substance. - The rim under the toilet seat had a yellow liquid substance on it. The inside of the toilet bowl had a rust-colored stain in the portion where the water drains when flushed. - There were two shower stalls in the room. In the second shower stall closest to the far wall, the floor of the shower, the drain, and the shower head all had a yellow substance on them. There were areas of cement-like porous, uncleanable spots where the tiles were missing on the floor. - The wall vent fan for the room had a thick layer of dust on the fan blades. - Across from the showers there was a large area of cement-like, porous, uncleanable material on the floor along with missing tiles. This area also had a rust-colored stain on one side and parts of the cement-like material were crumbling. - The sink had rust-coloring around the drain and thin rust-colored streaking in the bowl of the sink. - There was one shower bed in the room. On top of the shower bed cushion, near the head portion, there was a comb and a pillow. Brownish-black spots were observed on the top of the shower bed cushion toward the foot end of the cushion. On the under-side of the cushion of the shower bed there were black, brown, and yellow dried substances. - On the top of the shower bed mesh covering there were dried yellow, brown, and black flaky substances. - There was one bedside commode next to the shower bed which had a dried brown substance on the lid. An interview was conducted with the Housekeeping Director on 01/16/2025 at 12:44 PM and she stated her expectation was for the housekeeper assigned to the shower room to spray and clean the walls, sink, toilet, mirror, and mop the floors. She said the shower curtains are cleaned every three weeks and wiped down daily. The Housekeeping Director said there is one housekeeper on each unit, and the shower rooms should be cleaned once per day and more often if needed. She said the Certified Nursing Assistants (CNA) are responsible for cleaning any shower equipment they use. Upon review of the pictures of the shower room on Unit 4, she agreed the shower room did not look appealing. An interview was conducted with Staff G, Registered Nurse/Unit Manager (RN/UM) on 01/16/2025 at 4:00 PM and he said the CNA's are responsible for and should be cleaning all of the equipment they use when giving residents showers. He said he has not been routinely looking at the shower room equipment to ensure the CNA's are cleaning them. An interview was conducted with the Maintenance Director on 01/16/2025 at 4:22 PM. The interview was conducted while viewing the pictures taken of the shower room on Unit 4. The Maintenance Director said the facility is in the process of renovating the facility, specifically Unit 3 and Unit 4, which will include the shower rooms. He said the units are being painted and new flooring will be installed. He agreed the floor of the shower room on Unit 4 is in poor condition and he said it will be a top priority in the renovation project. He said the time frame for completing the renovation of the shower room is projected to be at the end of February. He said he did not realize the shower room on Unit 4 was in such bad condition and he should check it more often. He said the Maintenance Department has three employees, two who work first shift and one on the second shift. The Maintenance Director said he has schedules of monthly and bi-monthly projects throughout the facility. Bi-monthly his staff will look at room conditions and right now the priority is batteries in the hand soap dispensers, clocks, and toilets. A review of the facility's Safe and Homelike Environment policy, undated, showed: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Under the Definitions portion of the Safe and Homelike Environment policy, Sanitary is defined as includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. The policy also revealed under Policy Explanation and Compliance Guidelines, Section 1 number 3: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Photographic Evidence Obtained

Based on observations, record review, and interviews, the facility failed to ensure resident's with diagnosed mental illness or suspected mental illness were referred to the State's Mental Health authority for a Level II Preadmission Screening and Resident Review (PASRR) screenings for four residents (#47, #79, #19, and #73) out of 29 residents sampled. Findings included: 1. Review of Resident #47's Admission Record revealed an admitted [DATE] and an initial admitted [DATE]. Resident #47 was admitted to the facility with diagnoses of paranoid schizophrenia, schizoaffective disorder, depressive type, major depressive disorder, recurrent, and anxiety disorder Review of the Level I PASRR screen dated 07/01/24 showed the following: Section I, Part A - MI (Mental Illness) or suspected MI: Anxiety Disorder, Depressive Disorder, Schizoaffective Disorder, and Schizophrenia were checked. Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption Not a Provisional Admission was marked no. 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. 39866 2. Review of Resident #79's Admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of undifferentiated schizophrenia, bipolar disorder, and major depressive disorder. Review of Resident #79's Level I PASRR screen dated 5/31/24 revealed qualifying mental health diagnoses of bipolar disorder, depressive disorder, and schizophrenia with no recommendation for a Level II PASRR. An interview was conducted on 01/13/25 at 10:23 a.m. with Resident #79. She said, the people throw dirt and water on me. The resident was observed wiping her sheet as she was interviewed and was observed clean without dirt or water on her or her sheets. Resident #79's roommate walked next to the resident's bedside and said, [Resident #79] thinks people put dirt and water on her, but they are people that aren't real. I have to threaten calling 911 on the imaginary people throwing dirt and water on her or I have to scare them. Resident #79 continued to repeat, they put dirt and water on me. Resident #79 was observed crying as she was repeating, they put dirt on me. She then looked at the television, stopped crying, and watched television. A follow up interview was conducted on 01/14/25 at 1:33 p.m. with Resident #79. Upon entering the resident's room, a physical therapist exited the room. The resident was observed in bed, clean, and without odors. She said she just got done exercising her legs, lunch was good and she was going to relax now after her exercising. Review of Resident #79's Psychiatry Subsequent Note dated 11/18/24 revealed: History of Present Illness: This is a [AGE] years old patient with a past psychiatric history of depression, bipolar disorder and schizophrenia. Prior to last visit, patient was screaming in hallways. Patient had mood swings. During last visit, patient was doing well. Patient was sleeping and eating well. No anxiety related symptoms noted. No medication changes were done. Today, I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment. As per collected information, resident continues yelling randomly and talking to herself. Patient denies sleep and appetite related problems. No other psychiatric symptoms are observed. No side effects to current psych meds were reported . Abnormal thought processes: Has hallucinations .Assessments and Plan: [patient] is unstable but requires no med changes: As per collected information and interview, it appears that the patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying mood disorder. However, the symptoms are not causing significant distress to require psychiatric medication changes. Ongoing medical stabilization, emotional support, and closer monitoring from our side would be good enough. We will do follow-up appointments as needed Rational behind diagnoses: Bipolar disorder: The patient's history suggests that the patient has chronic episodes of depression and manic-like symptoms. These symptoms cause significant distress and functional impairment to the patient Schizophrenia (Confirmed [diagnosis]): The history of this patient shows that the patient has chronic and consistent psychosis. These symptoms cause significant distress and functional impairment to the patient . Review of Resident #79's care plan with an initiation date and a revision date of 1/3/22 revealed a Focus, [Resident #79] is here for Long Term placement d/t [due to] need for 24 hour supervision/care r/t [related to] type 2 dm [diabetes mellitus], bipolar, depression, morbid obesity, inability to care for self at former ALF [assisted living facility]. the Goal revealed, Resident's psychosocial needs will be met daily with assist from staff thru the next review date. The Interventions included, Encourage family and friends to visit or call as often as they can-as resident allows. Encourage socialization with peers in the facility. Invite and escort to activities of preference. Involve resident, family, or friends (as allowed) to participate with care as applicable. Praise the efforts of the resident participation in cares. Review of Resident #79's Behavior Care Plan with a revision date of 11/30/23 revealed, Potential for impaired or inappropriate behaviors related to diagnosis of Bipolar and Schizophrenia. [Resident #79] talks out loud during the night. The Goal revealed, Resident will have a decrease in negative behaviors thru next review. The Interventions revealed, Administer medications as ordered. Observe/document for side effects and effectiveness. Anticipate and meet the resident's needs. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Praise any indication of the resident's progress/improvement in behavior. An interview was conducted with the Assistant Director of Nursing (ADON) and Staff K, Social Services Director (SSD) on 1/16/25 at 10:28AM. The ADON said when she did the PASRR assessment for Resident #79 she completed the questions for that specific time. Staff K, SSD and the ADON confirmed Resident #79 does have behaviors of talking to herself at night and yelling out. They confirmed she had mental illnesses of depressive disorder, bipolar disorder, and schizophrenia and came to the facility from a mental disorder assisted living facility. They reviewed Resident #79's PASRR and Staff K, SSD said they can have a Level II PASRR assessment done for Resident #79. Staff K, SSD said the reason for the Level II assessment is to identify a resident with a mental illness, determine correct placement, and determine the resident is receiving the appropriate services for their mental illness. 37999 3. Review of Resident #19's Admission Record showed an admitted [DATE]. The record included diagnoses with onset dates including but not limited to cognitive communication deficit (CCD), onset date 12/5/24, unspecified bipolar disorder, onset date 12/4/24, unspecified recurrent major depressive disorder, onset 12/4/24, and generalized anxiety disorder, onset date 12/4/24. Review of Resident #19's Psychiatry Evaluation Note dated 12/30/24 showed the provider signed the document on 1/4/25. The evaluation revealed the resident's chief complaint as depression, anxiety, and bipolar disorder. The Assessments and Plan revealed, The patient's history suggests that the patient has chronic episodes of depression and manic-like symptoms. These symptoms cause significant distress and functional impairment to the patient. As bipolar disorder is a lifelong disorder, mood stabilizer medicine needs to be continued on a long-term basis. The patient is on psych meds because non-pharmacological interventions are not sufficient to manage the symptoms of the patient. The evaluation showed the provider recommended the resident to continue Bupropion and Sertraline to tackle depression and Alprazolam for anxiety. Review of Resident #19's Level I PASRR dated 1/13/25, completed by the facility's ADON, included mental illness diagnoses of anxiety disorder, bipolar disorder, depressive disorder, and schizophrenia. The screening did not include any intellectual disorders and showed the resident was receiving services for mental illness based on documented history and medications. The decision-making evaluation revealed the resident did not have any indication of having a disorder resulting in functional limitations of major life activities, no interpersonal functioning difficulties, no concentration, persistence, and pace difficulties, no adaptation to change difficulties, any recent outpatient/inpatient treatments, or have experienced an episode of significant disruptions. The screening completion showed the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated and a Level II PASRR evaluation was not required. 4. Review of Resident #73's Admission Record showed the resident was admitted on [DATE]. The Admission Record included secondary diagnoses and onset dates including but not limited to cognitive communication deficit, onset 1/1/25, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, onset 12/10/24, and brief psychotic disorder, onset 12/10/24. Review of Resident #73's acute care documentation revealed a consultation note from a physician dated 12/7/24, [Resident #73] has dementia and worsening memory loss. The note showed the resident was Positive for dementia and recent fall. An acute care facility physician note dated 12/9/24 revealed the resident presented to the emergency room (ER) from an assisted living facility with a past medical history including diagnoses of dementia and depression. The acute care facility's therapy note, dated 12/7/24, revealed the resident had a cognitive deficit and had previously resided on a memory care unit at an assisted living facility and normally utilized a rolling walker (RW) with supervision to ambulate. The therapy assessment, dated 12/7/24 revealed the resident's barrier to learning was cognitive deficit, [and] difficulty concentrating. Review of Resident #73's Level I PASRR screen dated 12/10/24 and completed at an acute care facility, revealed the resident did not have any mental illness, suspected mental illness, intellectual disability and/or suspected intellectual disability based on documented history. The decision-making screening showed the resident did not have any indication of having a disorder resulting in functional limitations of major life activities, no interpersonal functioning difficulties, no concentration, persistence, and pace difficulties, no adaptation to change difficulties, any recent outpatient/inpatient treatments, or had experienced an episode of significant disruptions. The screening revealed the resident had not exhibited actions or behaviors that may make them a danger to themselves or others or validating documentation to support the dementia diagnosis, and the admission was not provisional. The screening revealed the resident could be admitted to a Nursing facility as there was no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated and a Level II PASRR evaluation was not required. Review of Resident #73's Psychiatry Evaluation Note dated 12/23/24 showed the provider was consulted for psychiatric evaluation and treatment of depressed mood, disorganized, and confused thinking. The note revealed the resident had a past psychiatric history of depression, anxiety, dementia, and brief psychotic disorder. The provider noted, As per collected information, resident has been anxious and confused. [Resident #73] is difficult to redirect due to increased confusion. The patient limitations were described as Being in the facility, Away from home. The assessment revealed, As per collected information and interview, it appears that the patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying anxiety disorder. The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient. The rationale behind the dementia without behavioral disturbance diagnosis showed the resident had a gradual decline in memory, executive function, language, concentration, and fund of knowledge. These symptoms have caused distress and have affected the quality of life and activities of daily living. The resident's depression assessment revealed moderate depression, has situational exacerbation of depression due to health and situation of being in a facility and a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of Resident #73's comprehensive assessment dated [DATE] showed a BIMS score of 13 out of 15, indicating an intact cognition. The assessment also revealed the resident had disorganized thinking that was continuously present and does not fluctuate. Review of Resident #73's Level I PASSR completed by the facility's ADON on 1/13/25 showed the diagnoses of anxiety, depressive disorder, and brief psychotic disorders had been added as MI or suspected MI. The decision-making continued to indicate the resident had no disorder resulting in functional limitations in major life activities that would otherwise by age appropriate, did not have any continuing or intermittent issues with interpersonal functioning, concentration, persistence, and pace, or an issue with adapting to change. The revised Level I PASRR did not show the resident had any validating documentation to support the dementia diagnosis and the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASRR evaluation was not required. An interview was conducted on 1/16/25 at 10:16 a.m. with the ADON and SSD. The ADON reported reviewing psych notes whenever she gets them, the admission department reviews the hospital records to see if residents have a psych diagnosis, and the uploaded PASRR. She stated she looks at psych notes for diagnoses to ensure the PASRR's have the same diagnoses. The staff members revealed the resident's history is reviewed to see if they have been involuntarily hospitalized and see if they have anything that effects daily interactions, behaviors, and if a psych diagnosis placed them in the hospital. The SSD reported the facility has meetings daily and behaviors are discussed. The ADON reported validating dementia was any documentation the resident has and the hospital History & Physical (H&P) with documentation of a dementia diagnosis would be considered validating documentation. The ADON reported looking at psych notes and stated just because Resident #19 had bipolar and schizophrenia doesn't mean they need a Level II. She also stated a Level II was to identify anyone with a mental illness or behaviors and to see if they need to receive services or if they need extra ones. Review of the policy - Resident Assessment - Coordination with PASARR Program, implemented 9/7/22 showed the following: This facility coordinates assessments with the pre admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The compliance guidelines revealed the following: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the States Medicaid rules for screening. a. PASARR Level I - an initial prescreening that is completed prior to admission. i. Negative Level I screen - permit submission to proceed and ends the PASARR process unless if possible, serious mental disorder or intellectual disability arises later. ii. Positive Level I screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or in the lateral disability authority has determined as appropriate for admission. 4. Exceptions to the pre admission screening program include those individuals who: a. Are readmitted directly from a hospital. b. Or admitted directly from any hospital requires nursing facility services for the condition of which the individual received here in the hospital and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 5. If a resident who has not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facilities must screen the individual using the states Level I screening process and refer any resident who has or may have MD, ID or a related condition to the state designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 6. The social service director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition would be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. Any resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric state or equally intensive treatment.

Based on observations, record review, and interviews, the facility failed to develop and implement care plan interventions for four residents (#19, #24, #32, and #133) of thirty-nine sampled residents, related to; 1. Fluid restrictions, 2. Self-administration of oxygen, 3. Discharge planning, and 4. Fall interventions. Findings included: 1. On 1/14/25 at 3:40 p.m., Resident #19 was observed lying in bed. A 16 ounce (oz) foam cup and a wine-colored coffee cup was observed on the over-bed table. The resident picked the foam cup up and reported there was a little bit of fluid in it. On 1/15/25 at 1:31 p.m., Resident #19 was observed lying in bed, wearing street clothes and shoes with her eyes closed. A 16-oz foam cup was observed sitting on the resident's over-bed table next to the bed. Review of Resident #19's Admission Record revealed the resident was admitted on [DATE] with diagnoses including but not limited to hypo-osmolality and hyponatremia and essential (primary) hypertension. Review of Resident #19's care plan revealed Special Instructions: Fluid Restriction: 1500 milliliter (ML) every (q) 24 hours (24H). Dietary to provide a total of 840 ML/24H, Nursing to provide a total of 660 ML 24H: 7a-7p shift: 420 ML/24, 7p-7a shift: 240 ML/24H. The care plan showed the resident was at risk for impaired nutrition related to (r/t) diagnosis (dx) of hypertension (HTN), sprain lateral collateral ligament left knee, bipolar, depression, anxiety, HTN, hyperlipidemia (HLD), history (hx) hyponatremia, and weight changes and was on a fluid restriction. This Focus was initiated on 12/6/24 and revised on 1/10/25. The interventions informed Certified Nursing Assistants and Dietary staff of Fluid Restriction per physician orders. No bedside water cup. Nursing providing & Dietary as ordered per MD. Review of Resident #19's January 2025 physician orders revealed an order dated 12/5/24, Fluid Restriction: 1500 milliliter (ML) every (q) 24 hours (24H). Dietary to provide a total of 840 ML/24H, Nursing to provide a total of 660 ML 24H: 7a-7p shift: 420 ML/24, 7p-7a shift: 240 ML/24H. The dietary order showed the resident was on regular texture, thin liquids consistency, and *1500 mL Fluid Restriction. Review of Resident #19's Kardex included the following: - Activities: Additional Fluids. - Eating/Nutrition: Fluid Restriction per physician orders. No bedside water cup. Nursing providing & Dietary as ordered per MD. - Eating/Nutrition: Fluids offered every shift. - Eating/Nutrition: Resident on 1500 mL fluid restriction daily, no bedside fluids. An interview was conducted with Staff Q, Certified Nursing Assistant (CNA) on 1/15/25 at 2:02 p.m. The staff member reported staff can check the resident's Kardex for everything and the resident's care plans are in the computer. Staff Q, CNA explained the Kardex will let you know how to take care of the residents and will indicated if a resident is on a fluid restriction. An interview was conducted with Staff R, Registered Nurse (RN) on 1/15/25 at 2:08 p.m. The staff member confirmed being the nurse for the back portion of the hall, including Resident #19's room. The staff member stated a male resident (not Resident #19) was on fluid restrictions and no one else was on fluid restrictions. An interview and observation was conducted with Staff Q, CNA on 1/15/25 at 2:20 p.m. The staff member confirmed Resident #19 had a foam cup on the over bed table. Staff Q, CNA picked up the cup and said it was empty, removing the lid and straw, then confirmed the cup was empty with a few drops of clear liquid, stating it was empty now. An interview was conducted with the Director of Nursing (DON) on 1/16/25 at 8:43 a.m. The DON stated staff should be aware of a resident being on a fluid restriction, it should be in the Kardex for the aides and in the computer for nurses. The DON stated she was aware of Resident #19 having a cup at bedside and there should not be a cup left at the bedside. The DON provided on 1/16/25 at 9:31 a.m. a list of four residents in the facility on a fluid restriction. The list included Resident #19. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 1/16/25 at 9:10 a.m. The coordinator stated of course staff should follow the Kardex and nurses should know the care plan. The MDS Coordinator confirmed Resident #19 was on a fluid restriction and had been on one since admission. The staff member acknowledged staff should follow the care plan. 50732 2. On 1/13/25 at 9:53 a.m., Resident #24 was observed in his room. An oxygen concentrator and oxygen tubing in a bag was observed sitting against a wall near the resident's bed . At the time of the observation the resident was not using oxygen and the oxygen concentrator was turned off. The resident stated he uses oxygen when he needs it and he puts on, takes off the nasal canula, and turns the oxygen concentrator on himself. On 1/16/25 at 12:13 p.m. Resident #24 was observed sitting in his motorized wheelchair in his room wearing his oxygen. He said he came to his room to relax for a little while before lunch was delivered. He said he turned on the concentrator himself and put the nasal canula in his nostrils without assistance. The resident said he wasn't short of breath or having any difficulty breathing, he just wanted to put the oxygen on. He said he will take the oxygen off when he feels better. Review of the Admission Record showed Resident #24's initial admitted to the facility was 1/17/23 with an additional admitted [DATE]. The admitting diagnoses included but not limited to chronic obstructive pulmonary disease (COPD) with acute exacerbation and chronic respiratory failure with hypoxia. Review of the MDS Quarterly assessment dated [DATE] for Resident #24 showed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, showing the resident's cognition was intact. Review of Resident #24's Care Plan dated 1/18/23 showed: Focus: The resident has oxygen therapy related to COPD. Goal: The resident will have no signs or symptoms of poor oxygen absorption through the review date. Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for signs and symptoms of respiratory distress and report to Medical Doctor (MD) as needed: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color. OXYGEN SETTINGS: Oxygen via nasal canula as ordered. Review of Resident #24's Care Plan did not show an entry for self-administration of oxygen by the resident. Review of Resident #24's Evaluations did not show an evaluation for self-administration of medication or oxygen. Review of the January 2025 physician orders for Resident #24 showed: Oxygen 2 Liters via nasal canula as needed (PRN) related to COPD. Review of the physician orders for Resident #24 did not reveal a physician order to self-administer oxygen. An interview was conducted with Staff J, RN, on 1/15/25 at 11:13 a.m. Staff J, RN stated she regularly has Resident #24 on her assignment and is very familiar with him. She said the resident has an order for oxygen at two liters per minute (LPM) PRN. She said the resident does not ask to have the oxygen put on, he just takes it off and on himself. She said she was not sure if he had an order for self-administration. An interview was conducted with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM) on 1/16/25 at 12:05 p.m. Staff L, LPN/UM said residents cannot self-administer medications unless they have a self-administration assessment to make sure the resident knows about the medication and how to administer it. She said sometimes they will find residents who are on oxygen will take their oxygen on and off without the order or assessment. When the staff discovers this is happening, it is corrected immediately. The doctor is called and if they write an order for self-administration, an assessment is done and the resident's care plan is updated. Staff L, LPN/UM said if the resident shows the capacity and understanding to do it, they can operate the concentrator and put on their oxygen themselves. She said if a staff member sees the resident taking on and off their oxygen they should document the observation and notify the doctor. She stated the facility would then go through the proper steps in order for the resident to be able to self-administer their oxygen. An interview was conducted with the DON on 1/16/25 at 1:15 p.m., who said residents are allowed to self-administer medication after they pass an assessment for self-administration and the physician must approve the self-administration, and if applicable, the medication will be put in a lockbox at the resident's bedside. She said the resident has to sign out the medication before taking it and the nurse would notify the resident when it was time to administer the medication. She said oxygen is a medication and it would be the same process as the self-administered medication, but it would not include a lockbox. The DON said she was alerted to the fact Resident #24 was self-administering his oxygen shortly before the interview began. 3. On 1/14/25 at 9:20 a.m., Resident #32 was observed in his room. The resident was dressed, groomed and independently walking around the room. The resident was alert, oriented, and pleasant. Resident #32 had a tracheostomy (trach) with a collar. An interview was conducted with Resident #32 during the observation. Resident #32 stated he can take care of the trach himself, and it was observed the trach and trach site was clean. He said he is getting physical therapy four times per week and because of the physical therapy he can walk longer distances with a walker. He said the facility is okay, but he is ready to go home. He feels he is able to take care of himself now and is mostly independent. Resident #32 stated he spoke to the Social Worker several times about finding an Assisted Living Facility (ALF) for him to transfer to, but nothing has happened yet. Review of the Admission Record showed Resident #32 was admitted to the facility on [DATE] with diagnoses including encounter for attention to tracheostomy, COPD, malignant neoplasm head/face/neck, dysphagia oral phase, acquired absence of larynx, muscle weakness, unsteadiness on feet, and dyspnea. Review of the MDS Quarterly assessment dated [DATE] for Resident #32, Section C - Cognitive Patterns showed the resident had a BIMS score of 14, showing the resident's cognition was intact. Review of Resident #32's care plan dated 5/7/24 did not show a Discharge Plan for the resident. Review of Resident #32's Social Service Progress Notes dated 6/10/24 revealed the Social Services Director (SSD) received a call from a representative from Elder Affairs informing her Resident #32 voiced interest in applying for Medicaid with the intent to transition to the community. The Social Service Progress Notes dated 7/9/24 revealed Resident #32 voiced interest in ALF placement. The SSD wrote she contacted a local ALF and the representative at that ALF said she would go to the facility that day to assess Resident #32 for possible placement. During an interview on 1/16/25 at 9:19 a.m., Staff E, LPN said she regularly takes care of Resident #32 and has taken care of him since he was admitted to the facility. She said the resident has been educated on his care and he is able to independently take care of his tracheostomy. She said the plan for Resident #32 is to have the trach removed, which will happen within the next several weeks. Staff E, LPN said the resident is independent and she knows he is ready to either go home or to an ALF as soon as possible. She said he has good family support and will do well in the community. An interview was conducted with the SSD on 1/16/25 at 9:44 a.m. The SSD said she had several conversations with Resident #32 regarding his discharge plan. She said the resident wants to discharge to an ALF. The SSD said she knows the resident is interested in discharging to a local ALF and the representative of the ALF has visited the resident several times in the facility. She said she doesn't remember the exact dates the ALF representative visited the resident, but she knows the representative has been in the facility several times. She said the representative from the ALF said the ALF can't take the resident because he still has the trach and once the trach is removed the ALF should be able to take him. The SSD said Resident #32 is aware of the decision of the ALF, but she will go back and speak to him again to make sure he would still like to discharge to the ALF. She said she did not remember if she put the discharge plan on Resident #32's care plan. During an interview on 1/16/25 at 1:10 p.m. with Staff C, Lead MDS Coordinator, she stated it is the responsibility of the SSD to enter a discharge plan onto the resident's care plan. 4. On 1/14/25 at 3:10 p.m. Resident #133 was observed sleeping in bed. The resident's enabler bars/side rails were in the down position and the resident's call light was on the floor under his wheelchair. A review of the Admission Record showed Resident #133 was admitted to the facility on [DATE] with diagnoses including pain in the left knee, muscle weakness, other reduced mobility, unspecified lack of coordination, cognitive communication deficit, repeated falls, and history of falling. A review of Resident #133's Baseline Care Plan dated 11/3/24 showed: Potential Concerns: Resident is at risk for falls box is checked and the related to section is filled in with hx of (history of). Goal: Risk factors will be decreased for fall related injury over next 30 days box is checked. Approach: no boxes are checked in this section which included: place call bell within easy reach, cue for safety awareness, assist for toileting/transfers PRN, bed in low position, safety devices and other. A review of Resident #133's History and Physical completed in the hospital prior to admission to the facility revealed the resident was admitted to the hospital on 10/31/24 presenting to the Emergency Department with complaints of worsening positional lightheadedness over past many months. The resident was seen in the hospital in September 2024 or October 2024 for positional lightheadedness. Since he was discharged , he reported slowly progressive positional lightheadedness which is worse in the morning when he wakes up from bed. He fell from bed two days prior to this hospitalization after a fall where he injured his left upper extremity. Review of a Narrative Nurses note for Resident #133 dated 11/10/24 at 4:30 a.m. revealed Resident #133 was observed sitting on floor between the dresser and air conditioning unit with his back towards the wall. The resident stated he was trying to use the urinal while standing at bedside holding onto the bedside table when the table rolled away causing him to fall forward. The resident was noted with a laceration to the bridge of his nose with a moderate amount of bleeding. Pressure was applied and the bleeding was easily controlled. The resident was also noted with a small abrasion to the left inner elbow with scant bleeding. Review of Post Fall Review dated 11/10/24 at 11:38 a.m. for Resident #133 showed the resident's injuries were fracture to nose, skin tear to left antecubital, and bruising left eye. The interventions listed included bed in low position, call light within reach, and patient teaching to ask for assistance with Activities of Daily Living (ADL). An interview was conducted on 1/14/25 at 3:42 p.m. with Staff H, LPN. Staff H, LPN said he takes care of Resident #133 regularly and knows him well. He said he didn't know if Resident #133 was a fall risk, but after looking at the resident's record in the electronic medical record (EMR), Staff H, LPN said the resident was a fall risk. Staff H, LPN went to the resident's room and observed the resident sleeping and the call light on the floor under the resident's wheelchair. He also observed the resident's enabler bars/side rails in the down position. Staff H, LPN put the call light on the bed within the resident's reach and put the enabler bars/side rails in the up position. He agreed the call light should always be within reach of any resident and enabler bars/side rails should be in the correct position as ordered by the physician. During an interview with Staff E, LPN on 1/16/25 at 9:19 a.m., Staff E, LPN said she knows Resident #133 well and regularly takes care of him. She said he is a fall risk because of his decision making and safety is an issue. She said the resident needs reminding not go get up and walk without assistance. She said she uses the resident's Care Plan for the interventions, and she monitors him closely to see if anything changes with his mobility. An interview was conducted on 1/16/25 at 1:15 p.m. with the DON. She stated the nurse who admitted Resident #133 to the facility should have completed the Baseline Care Plan. She said the Baseline Care Plan was not completed correctly as the approach was not filled out. The DON said she was on call when Resident #133 fell and received a call informing her the resident had fallen. She said she was told the resident stood up to use the urinal, leaned over the bedside table, which is on wheels, and the bedside table rolled away from him. She said the maintenance person who was on call went to the facility immediately to install enabler bars/side rails to the resident's bed. She said the expectation for the admitting nurse is to completely fill out the Baseline Care Plan or get help if they need to. She said all RN's in the facility have been trained to complete the Baseline Care Plans. Review of the policy titled Baseline Care Plan dated 8/25/22 and revised on 3/27/24 showed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The policy also revealed the following Policy Explanation and Compliance Guidelines: 1. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including but not limited to: therapy services. 2. The admitting nurse or supervising nurse on duty shall gather information from the admission physical assessment, hospital transfer information, physician orders and discussion with the resident. Interventions shall be initiated that address the resident's current needs including: any health and safety concerns to prevent decline or injury such as fall.

Based on observations, record review, and interviews, the facility failed to ensure one resident (#118) of two residents sampled for non-pressure related skin conditions received wound care as prescribed by the physician. Findings included: On 1/13/25 at 9:06 a.m., Resident #118 was observed lying in bed. The left lower extremity of the resident had been amputated below the knee and four to five steri-strips were covering the surgical incision. A brown/tan color elastic bandage was observed sitting on the resident's dresser wrapped up and not within reach of the resident. The right ankle was wrapped with white rolled gauze from the toes to above the ankle and secured with paper tape. The right ankle gauze was not dated as to when the dressing had been applied. Resident #118 stated staff changed it every couple of days. On 1/13/25 at 9:21 a.m., Resident #118's dressings were observed with Staff T, Registered Nurse/Unit Manager (RN/UM). The staff member lifted the resident's right ankle and confirmed the dressing was not dated and absolutely should be dated. Staff T, RN stated he would check when it was last done and believed the dressing was to be changed three times a week. On 1/13/25 at 9:26 a.m. Staff T stated the dressing change was documented on Saturday as being completed. Review of Resident #118's Admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to encounter for orthopedic aftercare following surgical amputation, other acute osteomyelitis (of) left ankle and foot, unspecified local infection of the skin and subcutaneous tissue, and acquired absence of left leg below knee. Review of Resident #118's January 2025 Treatment Administration Record (TAR) revealed Staff S, RN documented the right medial ankle treatment of skin prep and cover of rolled gauze was completed on Saturday 1/11/25. The dressing did not reveal the completed treatment date. Review of Resident #118's January TAR revealed an order for staff to cleanse surgical site with wound cleanser of choice, apply betadine paint, cover with 4x4 gauze, wrap with rolled gauze, and light (elastic) wrap every day shift for wound care. The documentation showed the dressing was completed daily. During an interview on 1/16/25 at 8:30 a.m. the Director of Nursing (DON) stated dressings should be dated when changed.

Based on observations, record review, and interviews, the facility failed to ensure the intravenous (IV) access of one resident (#5) of three residents with IV access was maintained in accordance with professional standards. Findings included: On 1/13/25 at 10:35 a.m., Resident #5 was observed with a single lumen peripherally inserted central catheter (PICC) inserted into the right upper arm. The dressing was dated 1/9/(25) and not fully attached to the skin of the resident. Resident #5 reported having an infection in the spinal cord. Review of Resident #5's Admission Record showed the resident was admitted on [DATE] and diagnoses included but was not limited to pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of disease classified elsewhere and unspecified gram-negative sepsis. Review of Resident #5's Admission/Readmission Nursing Evaluation, effective 12/27/24, revealed the admitting diagnosis was bacteremia and had a right upper extremity (RUE) midline. The evaluation did not include a measurement of the RUE midline external catheter or arm circumference. Review of Resident #5s January 2025 Medication Administration Record (MAR) included the following orders: - Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 gram (GM) - Use 3.375 gram intravenously every 6 hours for bacteremia until 2/7/25, started on 12/30/24 and discontinued on 1/5/25. - Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 GM - Use 3.375 gram intravenously every 6 hours for Bacteremia/Osteomyelitis of the spine until 2/7/25, started on 1/6/25. - Measure arm circumference 2 inches above insertion site with each dressing change, RUE every night shift every Thu[rsday] for Bacteremia. The order started on 1/2/25. The documentation showed staff were to use the measurement of centimeters (cm) for the resident's RUE circumference. Review of Resident #5's January 2025 MAR showed on 1/2/25 staff documented 30 and on 1/9/25 staff documented NA, which according to the chart codes meant medication not available, for the circumference of the resident's RUE circumference with no numerical measurement. Review of Resident #5s January Treatment Administration Record (TAR) included the following orders with documentation: - IV PICC change primary intermittent tubing every 24 hours every night shift for Bacteremia, started on 12/30/24. The documentation showed staff had completed every night shift. - IV PICC RUE change transparent dressing on admission, then weekly and as needed (prn) thereafter every night shift every Thu(rsday) for Bacteremia, started on 1/2/25 and discontinued on 1/9/25. - IV PICC RUE change transparent dressing on admission, then weekly and as needed (prn) thereafter every night shift every Thu(rsday) for Bacteremia, started on 1/9/25. - IV PICC RUE Measure catheter length on admission and with each dressing change thereafter every night shift every Thu for Bacteremia, stated on 1/2/25. The documentation revealed the completion of task on 1/2/25 and 1/9/25, however, did not include measurement of the external catheter. - IV PICC RUE change transparent dressing on admission, then weekly and as needed (prn) thereafter every 24 hours as needed for when soiled or missing dressing, started on 1/9/25. The documentation showed the as needed dressing change was completed on 1/13/25 at 1:44 p.m. The order did not include an area to document the length of the external catheter. Review of Resident #5's December 2024 MAR did not include an order for dressing the RUE PICC on admission or to measure the external catheter length on admission. Review of Resident #5's December 2024 TAR included the following orders with corresponding documentation if applicable: - IV PICC - change primary intermittent tubing every 24 hours every night shift for Bacteremia, started on 12/30/24. The order was scheduled for night shift. The documentation had X throughout, without documentation of staff administering the order. - IV PICC RUE monitor site every (q) shift for signs/symptoms of infection and/or infiltration every shift for Bacteremia, started on 12/30/24. The documentation had X throughout, without documentation of staff administering the order. The documentation of the resident's scheduled treatments did not show the resident received any scheduled treatments after readmitting on 12/27/24. The as needed orders on the December 2024 TAR showed they did not start until 1/9/25 and 1/15/25. The TAR did not include orders to change the RUE PICC line dressing at the time of admission or to measure the external catheter. Review of Resident #5's progress notes revealed the following: - A late entry Skilled note 12/28/24 at 1:01 p.m. did not reveal documentation of the resident's PICC line. - A late entry Skin Observation progress note, effective 12/28/24 at 3:50 p.m. showed the resident did have existing pressure injuries but did not include documentation of the resident's IV external catheter or arm circumference. - A Skilled progress note, effective 12/29/24 at 11:31 p.m. revealed the resident's skin was not intact. The note did not mention the condition of the resident's PICC catheter. - A Skin Observation progress note effective 12/30/24 at 9:11 p.m. showed the resident had existing pressure injuries and a right ankle vascular wound. The staff member did not mention the resident had an IV site. - A Skilled progress note effective 12/30/24 at 9:18 p.m. revealed the resident had a PICC line, was receiving IV antibiotics, and the site was clean dry and intact. The note did not have a measurement of the PICC line external catheter or arm circumference. - An Antibiotic Time out note effective 12/30/24 at 9:30 p.m. revealed the resident was receiving an IV antibiotic. The resident had positive blood cultures on 12/21/24, was sent to hospital, then readmitted on [DATE]. The note did not include information regarding the condition of the IV site. - An Advanced Registered Nurse Practitioner (ARNP) note effective 12/31/24 at 11:00 a.m. revealed the resident was sent to the hospital on 12/21/24, returning to the facility on [DATE]. The note showed a PICC line was placed and the resident was started on IV antibiotics while at the hospital. - A Skilled progress note effective 1/2/25 at 12:29 a.m. revealed the resident was receiving IV antibiotics, but did not include a measurement of the external length of the resident's PICC, despite documentation (TAR) revealing the PICC dressing was changed and the catheter length was measured. - A Skilled Progress note effective 1/4/25 at 2:54 a.m. revealed the resident was receiving IV antibiotics via a PICC line, and the site was clean, dry, and intact. The note did not reveal the length of the external catheter. -A Skilled Progress note effective 1/5/25 at 2:21 p.m. showed the resident was receiving IV antibiotics, had a PICC line, and the site was clean, dry, and intact . The note did not include a measurement of the external catheter. -A Skin observation note effective 1/6/25 at 3:11 p.m. showed the resident had an existing skin impairment and a PICC line to the RUA. The note did not include a measurement of the length of the external IV catheter. - A general note dated 1/6/25 at 6:27 p.m. revealed the resident was on IV antibiotics and had a PICC line with no abnormal signs or symptoms displayed. The note did not include a measurement for the length of the external IV catheter. - A Skilled progress note effective 1/7/25 at 2:54 a.m. revealed the resident had a PICC line and was receiving IV antibiotics. The note did not include a measurement of the length of the external IV catheter. - A Skilled progress note dated 1/9/25 at 1:42 a.m. did not show the resident had an IV site. - A Skilled progress note effective 1/10/25 at 2:41 a.m. showed the resident had a PICC line and was receiving IV antibiotics. The note did not include a measurement of the length of the external IV catheter. - A Skilled progress note effective 1/11/25 at 2:18 a.m. did not reveal the resident had any skin impairments, any IV site, or was receiving an antibiotic. The note did not include a measurement of the external length of the IV catheter. - A Skilled progress note effective 1/12/25 at 2:08 a.m. revealed the resident was not receiving medications or antibiotics. - A Skilled progress note effective 1/13/25 at 2:41 a.m. showed the resident had no medications, antibiotics, or adverse med side effects. The note did not reveal the resident had a PICC line or was receiving IV antibiotics. - A Skilled progress note effective 1/14/25 at 2:14 a.m. revealed the resident had no current skilled nursing/rehab status including medications, antibiotics, and/or adverse med side effects. - A Skilled progress note effective 1/15/25 at 1:11 a.m. revealed the resident had a PICC line and was receiving IV antibiotics. The note did not include a measurement of the external IV catheter. - A Skilled progress note effective 1/16/25 at 1:41 a.m. revealed the resident had a PICC line and was receiving IV antibiotics. The note did not include a measurement of the external IV catheter. An interview was conducted with Staff S, Registered Nurse (RN) on 1/16/25 at 1:37 p.m. The staff member stated Resident #5's PICC dressing was becoming dislodged on 1/13/25. Staff S, RN reported measuring the external catheter, but did not document the numbers because she didn't think about it. The staff member stated the measurements were usually documented in the dressing change note. Staff S, RN stated the length of the catheter should be documented, but she would have to check the specific policy. An interview was conducted with Staff T, Unit Manager (UM) on 1/16/25 at 1:42 p.m. The staff member stated the documentation of the PICC line length would be in the hospital records and confirmed staff were documenting the length with the dressing change and as needed. Staff T, UM also stated staff should be documenting the length with the dressing changes. The staff member stated the order was not put in correctly and should have added ancillary information allowing for the documentation of the measurement. An interview was conducted with the Director of Nursing (DON) on 1/16/25 at 2:37 p.m. The DON state staff should be measuring PICC catheters and the stock orders do not ask for length. Review of the policy titled PICC/Midline/Central Venous Access Device (CVAD), copyrighted 2024, revealed, It is the policy of this facility to change peripheral inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify type of dressing and frequency of changes. The Compliance Guidelines included: 6. Inspect the catheter skin junction in surrounding area, palpating through the intact dressing for redness, tenderness, swelling, and drainage. Be attentive to any reports of pain, paresthesia, numbness, or tingling. 13. Use sterile measuring tape to measure external length of the catheter from hub to skin entry to ensure that it has not migrated. 24. Document the procedure.

Based on observations, interviews, and record review, the facility failed to ensure effective communication with the Dialysis center that provides treatment services for one resident (#119) of three sampled residents. It was determined review of fourteen Dialysis service visits, the Dialysis nursing staff failed to collaborate with the nursing facility by not providing and documenting post weights, vital signs, Dialysis vascular access site status, and what Dialysis treatment was provided. Findings included: On 1/13/2025 at 8:50 a.m., Resident #119 was observed seated on the side of his bed in his room. The resident was alert and able to speak about his medical care and daily decision making. Resident #119 confirmed he goes to an End Stage Renal Disease (ESRD) Dialysis center three times a week for Dialysis treatment and he was getting ready to go to his chair treatment appointment today, which was at 12:00 p.m. Resident #119 confirmed he goes to the Dialysis center on Mondays, Wednesdays, and Fridays. Resident #119 revealed the nurse will give him a yellow book to have the Dialysis center document his care, upon his leaving the Nursing facility. He confirmed staff at the Dialysis center are supposed to fill out medical information in this book, but he does not remember the last time the Dialysis staff did that. Resident #119 revealed he just gets the yellow book back and takes it back to the Nursing center. On 1/14/2025 review of Resident #119's medical record revealed he was admitted to the facility on [DATE] and readmitted from the hospital on 3/13/2024. Review of the advance directives revealed Resident #119 was his own responsible party and able to make his own medical decisions. Review of the diagnosis sheet revealed diagnoses to include but no limited to end stage renal disease, anemia, and cognitive communication deficit. Review of Resident #119's current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; Cognition: Brief Interview Mental Status or BIMS score 10 of 15, which indicated Resident #119 had mild cognitive impairment. Active Diagnoses: Renal Insufficiency, Obstructive Uropathy Special treatment: Checked yes for Dialysis services. Review of Resident #119's progress notes dated from 11/1/2024 - 1/15/2025 did not indicate any documented concerns regarding Dialysis or Dialysis services. There was also no indication of refusals or missed Dialysis service days. Review of Resident #119's Physician's Order Sheet dated for January 2025 revealed orders to include but not limited to: 1. Complete Dialysis communication forms and send with resident to dialysis center, order date 1/15/2024. 2. Location Dialysis access site. 3. If declines Dialysis refuses dialysis notify attending MD and nephrologist. 4. If Dialysis site bleeding, apply direct pressure to sit to help control bleeding and notify physician. 5. Monitor Dialysis catheter site to right chest for bleeding and monitor dressing is intact. 6. Check access site for signs and symptoms of infection when performing routine care. 7. Check access site post Dialysis. 8. May hold meds when resident is Leave Of Absences (LOA) to dialysis. 9. diagnosed for Dialysis: ESRD. 10. Send snack with resident on dialysis days. 11. Dialysis days are Mondays-Wednesdays-Fridays, medication times and schedule may be revised with Dialysis days. 12. Complete post communication dialysis form on return Mondays-Wednesdays-Fridays. 13. Liberal Renal diet, Regular textured, thin liquid diet. Review of Resident #119's SUN Dialysis Communication Book revealed: Please record post weight on worksheet everyday. The book contained only one Pre/Post Dialysis Evaluation dated 1/13/2025. The form was blank in section B. Dialysis Nursing Information. The book also contained informational sheets that read, 1. Please fill out Dialysis weight worksheet every dialysis day, 2. Dialysis book *Face sheet, *Most recent labs, *Dialysis information, *Pre and Post dialysis evaluations, *Medication list, * Weight sheet (pre and post). The last sheet in the book revealed a Dialysis weight worksheet for the month of 1/2025. Review of the book did not reveal any past SUN Pre/Post Dialysis Evaluations other than the last visit on 1/13/2025. This was verified by Staff B, Licensed Practical Nurse (LPN) on 1/14/2025. She revealed once the communication sheets are reviewed they are charted in the Electronic Medical Record and scanned into the Electronic Medical Record. Staff B, LPN also confirmed section B of the SUN Pre/Post Dialysis Evaluation, which was the section for the Dialysis center staff to fill in, was blank. She revealed often times they receive this section blank, and the Dialysis center will not fill this section in. She confirmed she and other Nursing facility nurses would not know what Resident #119's medical and vitals status would be while at the Dialysis center. On 1/15/2025 Resident #119's electronic medical record (EMR), to include the Evaluations tab, revealed all the past Dialysis visits SUN Pre/Post Dialysis Evaluations. The past fourteen visits reviewed and all SUN Pre/Post Dialysis forms dated 1/13/25, 1/10/25, 1/8/25, 1/6/25, 1/3/25, 1/1/25, 12/30/24, 12/27/24, 12/25/24, 12/23/24, 12/20/24, 12/18/24, 12/16/24, 12/13/24 revealed only completed information from the Nursing facility, including pre and post weight, vitals, and notes. Section B did not reveal any information, nor any signature from Dialysis staff, to include assessment of weight, vital signs, or notes. Review of Resident #119's current care plans with a next review date 3/8/2025 revealed the following problems areas. Dialysis care plan: Dialysis 3 x week M-W-F (Monday-Wednesday-Friday) chair time 12 noon, with interventions in place to include: 1. Administer meds as ordered; 2. Complete Dialysis communication form and send with resident to dialysis center; 3. Complete post communication dialysis corm upon return, one time a day x Mon-Wed-Fri (Monday-Wednesday-Friday) complete [electronic health record brand] post Dialysis communication form if available; 4. Fill in complete dialysis portion based on return form save and lock; 5. Dialysis days M-W-F med times and schedule may be revised with Dialysis days; 6. Meds not to be given on Dialysis days M-W-F, prior to Dialysis; 7. Monitor dialysis catheter site for bleeding or signs of infection; 8. Notify MD (Medical Doctor) of signs and symptoms; 9. Observe dialysis site for infection, bleeding, edema; and 10. Observe labs as ordered. On 1/15/2025 at 9:40 a.m., an interview with the 200 Unit Manager Staff A, RN revealed for each resident who utilizes Dialysis services, there is a communication form sent with the resident from the facility to the Dialysis center and then brought back when the resident returns from Dialysis treatment. She revealed there is a section of the communication form the facility is responsible for and includes pre-weights, vital signs, medication notes, and other notes. She also revealed there is a second section of the form to be filled out by the Dialysis center staff to include weights, vital signs, medication notes, and other notes prior the resident leaving the center. Staff A, RN also revealed the form had a third section the facility staff must fill out to include post weights, vitals, medication notes, and other notes. Staff A, RN confirmed Resident #119's communication sheets dated from 12/12/2024 through to 1/13/2025 were not filled out by the Dialysis center staff. She revealed they have not been getting the Dialysis center information for Resident #119. Staff A, RN said she along with other nursing facility management have called the Dialysis center staff and they had told them they do not provide and send out information to include post weights, vitals, notes, access site evaluation, and signature of staff who cared for the resident. Staff A, RN revealed they are explained that the Dialysis center would not fill out the sheets and send them along in the communication book. On 1/16/2025 at 8:45 a.m. another interview with Staff A, RN revealed the expectation for receiving Dialysis information. While the resident is at the Dialysis center, the following happens: 1. A Dialysis communication book with a form to include nursing home evaluation expectations pre Dialysis center visit, Dialysis center evaluation expectations while at the Dialysis center, and post evaluation expectations when the resident returns to the facility from the Dialysis center; and Weight and vitals logs. Staff A, RN revealed the book with the evaluation page is carried to the facility by the resident. 2. Once the resident is at the Dialysis center, the Dialysis nursing staff are to take and record post-weights, vital stats, and any information related to the Dialysis access site. 3. Once the resident returns to the facility from the Dialysis center, the nursing staff are to fill out post-weights, vitals, and assess the Dialysis access site. Staff A, RN revealed the facility nursing staff are to evaluate the information from the Dialysis center in order to know how the resident was while at the Dialysis center. 4. After the communication form is completed by both the facility and Dialysis center, the form is uploaded into the Electronic Medical Record. On 1/15/2025 at 1:00 p.m., during an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), both confirmed they have been having problems with the Dialysis center staff filling out their portion of the communication form and have been told they will not document medical information on that form. The DON and NHA also confirmed after they have communicated with the Dialysis Administrator on 1/15/2025, and was told State was in the nursing home facility, the Dialysis staff immediately faxed all the required communication information for review and sent that information to the facility. The DON confirmed they did not have any of this information prior to 1/15/2025. On 1/16/2025 at 9:45 a.m., the Director of Nursing provided the Hemodialysis policy and procedure with a last review date of 8/25/2022 for review. The Policy revealed; The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The Purpose section of the policy revealed; The facility will assure that each resident receives care and services for the provision of Hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: - The ongoing evaluation of the resident's condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility. - Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The Compliance Guidelines section of the policy revealed; 1.) The facility will inform each resident before or at the time of admission of dialysis services available. 2.) The facility will coordinate and collaborate with the dialysis facility to assure that: a.) The resident's needs related to dialysis treatment are met; b.) There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. 4.) The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a.) Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; b.) Physician/treatment orders, laboratory values, and vital signs; c.) Nutritional/fluid management including documentation of weights; d.) Dialysis treatment provided and resident's response; e.) Dialysis vascular access site status; f.) Changes and/or declines in condition related to dialysis; g.) The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility. On 1/16/2025 at 9:45 a.m., the Nursing Home Administrator provided the Long Term Care Facility Outpatient Dialysis Services Coordination Agreement, which was signed by both the Nursing Home Administrator and the Dialysis center Regional Operations Director on 2/15/2021. Section (E) Mutual Obligations of the agreement revealed; 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long Term Care Facility and ESRD Dialysis Unit. Documentation shall include, but not limited to, participation, as members of interdisciplinary team, in care conferences, continual quality improvements program, annual review of infection control of policies and procedures, and the signatures of team members from both parties on a Short Term Care Plan (STCP) and Long Term Care Plan (LTCP). Team members shall include the physician, nurse, social worker and dietitian from the ESRD Dialysis Unit and representative from the Long Term Care Facility. The ESRD Dialysis Unit shall keep the original STCP and LTCP in the medical record of the ESRD Resident and the Long Term Care Facility shall maintain a copy.

Based on observations, record review, and interviews, the facility failed to follow Enhanced Barrier Precautions and don Personal Protective Equipment in accordance with facility policy for one resident (#118) of thirty-nine sampled residents. Findings included: On 1/13/25 at 9:06 a.m., Resident #118 was observed lying in bed. The observation revealed a surgical incision with four to five steri-strips to a left below knee amputation and rolled gauze covering the right ankle from toes to above the ankle. The resident was wearing a nasal cannula delivering three liters per minute (lpm) of oxygen. The observation also revealed the room was not posted for Enhanced Barrier Precautions. On 1/13/25 at 12:28 p.m., Staff U, Certified Nursing Assistant (CNA) asked Staff V, CNA to assist in repositioning Resident #118 in bed for the noon meal. The observation showed the staff members repositioned the resident while wearing gloves, but neither staff member was observed donning a protective gown prior to lifting the resident. Staff U, CNA was observed adjusting the resident's blankets. Review of Resident #118's Admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to encounter for orthopedic aftercare following surgical amputation, sepsis due to methicillin susceptible staphylococcus aureus (MRSA), Methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, unspecified local infection of the skin and subcutaneous, and sepsis due to other specified staphylococcus. Review of Resident #118's Admission/Readmission Nursing Evaluation dated 12/3/24 revealed the admitting diagnosis was sepsis left lower extremity (LLE) cellulitis with the special needs of intravenous (IV) therapy and wound care. Review of Resident #118s December 2024 Treatment Administration Record (TAR) revealed the following: - IV peripherally inserted central catheter (PICC) (all types) - change primary intermittent tubing every 24 hours every night shift. The treatment was discontinued on 12/10/24. - Apply skin prep to right medical ankle and wrap with (rolled gauze) 3 times weekly and as needed (prn), every day shift every Tuesday, Thursday, and Saturday for wound care. The order was started on 12/19/24 and discontinued on 1/13/25. - Cleanse surgical incision to left lower extremity with betadine, cover with abdominal (abd) pad, wrap with rolled gauze then wrap with elastic bandage daily and prn, every day shift for post-surgical care. The order started on 12/5/24 and continued to 1/3/25. Review of Resident #118s January 2025 TAR revealed the following: - LLE Below knee amputation (BKA): Cleanse surgical site with wound cleanser of choice. Apply Betadine paint, cover with 4x4 gauze, wrap with rolled gauze and light elastic wrap every day shift wound care. The order was started on 1/4/25 and discontinued on 1/15/25. - Apply skin prep to right medial ankle, wrap with rolled gauze three times weekly and prn, every day shift every Tuesday, Thursday, and Saturday for wound care. This order started on 12/19/24 and discontinued on 1/13/25 at 9:25 a.m. - Apply skin prep to right medial ankle and wrap with rolled gauze three times weekly and prn every day shift every Tuesday, Thursday, (and) Saturday for wound care. The order started on 1/14/25 and was discontinued on 1/15/25 at 7:29 a.m. The documentation showed the treatment was not completed on 1/14/25 due to the resident being hospitalized . Review of Resident #118's care plan revealed the following Focus areas: - Potential for alteration in comfort related to recent amputation/arthritis. - Altered skin integrity: non pressure location: right ankle, created on 1/5/25. - A focus created on 1/13/25 showed the resident required EBP (Enhanced Barrier Precautions): Risk for impaired psychosocial status and other complications. Enhanced Barrier Precautions per CDC (Centers for Disease Control and Prevention) guidelines due to : Colonized Multi-Drug Resistant Organism (MDRO)(MRSA). The interventions showed Persons caring for the resident and providing high contact resident care activities will require personal protective equipment (PPE), the use of gowns and gloves. The intervention was created by the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on 1/13/25. On 1/13/25 at 3:13 p.m., Staff U, CNA stated during an interview regarding EBP, if working with residents or repositioning residents on EBP, staff needed to wear a gown and gloves. Staff U, CNA reported EBP were for residents with wounds, infections, and catheters. The staff member stated staff should have used PPE when repositioning Resident #118 at lunch and the understanding was the resident did not have wounds, so would not need to be on EBP. On 1/13/25 at 3:17 p.m., Staff S, Registered Nurse (RN) was observed standing at Resident #118's bedside with a pulse oximeter on the finger of the resident. The staff member stated residents require enhanced precautions for any sort of opening in the skin or have an increased potential for infection. Staff S, RN reported the resident had a closed surgical incision. A further review of Resident #118's clinical record showed an order for Enhanced Barrier Precautions was initiated on 1/13/25 at 4:29 p.m., Enhanced Barrier Precautions related to (r/t) MDRO (MRSA) every shift. During an interview on 1/16/25 at 8:30 a.m., the Director of Nursing (DON) stated residents were put on EBP for open wounds, gastrostomy tubes (g-tube), peripherally inserted central catheter (PICC) lines, suprapubic catheters, and did not know about indwelling catheters. The DON stated organisms had to have a way to get in and staff should be aware of EBP. The DON reported Resident #118 should have been on EBP. An interview was conducted on 1/16/25 at 3:10 p.m. with the Assistant Director of Nursing/Infection Preventionist (ADON/IP). The IP reported EBP was for residents who may have a wound with heavy drainage, IV's, indwelling catheters, G-tubes, Dialysis catheters, or any type of invasive equipment or opening. The IP revised their statement, saying a wound doesn't necessarily needs heavy drainage or anything that has an opening in the skin. The staff member reported Resident #118 was originally on EBP due to being on IV therapy then it was discontinued. Treatment was only for skin prep due to no opening and the surgical incision was also healed and the dressing was for preventative measures. The ADON reported they did not have a chance to review diagnoses at time of the observation and staff members should have been wearing PPE when assisting Resident #118 due to the MDRO diagnosis. Review of the policy titled Enhanced Barrier Precautions, revised 9/1/22, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy defines Enhanced Barrier Precautions as the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The Compliance Guidelines included: 1. Prompt recognition of need: c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gowns and gloves. 2. Initiation of Enhanced Barrier Precautions a. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/ or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. ii. Infection or colonization of any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions do not apply. 3. Implementation of enhanced barrier precautions a. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. b. Ensure access to alcohol based hand rub in every resident room (ideally both inside and outside of the room). c. Position a trash can inside the resident room in near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. d. The infection preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. e. Provide education to residents and visitors. f. Do not restrict room placement or out of room activities due to enhanced barrier precautions. 4. High-Contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. h. Wound care: any skin opening requiring a dressing. 6. Examples of targeted an epidemiologically important MDRO's include but are not limited to: f. Methicillin-resistant Staphylococcus aureus (MRSA). 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed for the high risk residents. Review of the CDC guidelines titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated July 12. 2022 (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html) revealed the following key points: 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: o Wounds or indwelling medical devices, regardless of MDRO colonization status o Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 5. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. The guidance's background described Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who, by definition, have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g., months) [10] which contributes to the silent spread of MDROs. The CDC guideline revealed examples of high-contact resident care activities requiring the use of gowns and gloves for EBP included: o Dressing. o Bathing/showering. o Transferring. o Providing hygiene. o Changing linens. o Changing briefs or assisting with toileting. o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. o Wound care: any skin opening requiring a dressing. The implementation instructed providers When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: o Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). o For Enhanced Barrier Precautions, signage should also clearly indicate the high contact resident care activities that require the use of gown and gloves. o Make PPE, including gowns and gloves, available immediately outside of the resident room. o Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). o Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. o Incorporate periodic monitoring and assessment of adherence to recommended infection prevention practices, such as hand hygiene and PPE use, to determine the need for additional training and education. o Provide education to residents and visitors. Photographic Evidence was Obtained

Based on observation, record review, and interview, the facility failed to honor resident rights for four (Residents #55, #80, #124, #11) of 51 residents sampled for dignity related to residents wearing wristbands to identify various health needs/status; Residents provided care in view of the public; and random observations of staff referring to residents as feeders. Findings included: 1. A review of Resident #55's record revealed he was readmitted to the facility on [DATE], with diagnoses which included Idiopathic Peripheral Autonomic Neuropathy, Hemiplegia and Hemiparesis following Cerebral Infraction affecting right dominant side, and arterial fibrillation. An observation of Resident #55 on 11/01/22 at 11:42 a.m., revealed him lying in his bed with a faded pink wrist band on his left wrist. Closer observation of the the wrist band revealed information about the resident's prescribed diet order An observation of Resident #55 on 11/02/22 at 7:36 a.m., revealed the resident lying in his bed. The resident was still noted to be wearing a faded pink wrist band on his left wrist which revealed the residents prescribed diet order. 2. Review of Resident #80's record revealed he was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease, Spinal Stenosis, Spondylosis, and Neurocognitive Disorder with Lewy Bodies. An observations of Resident #80 on 10/31/22 at 10:52 a.m., revealed him lying in bed. He was noted with a yellow wrist band on his right wrist which revealed information that he was a fall risk. An interview with the resident at this time revealed he was not sure why he had the wrist band on. An observation of Resident #80 on 11/02/22 at 7:36 a.m., revealed the resident lying in bed. He was observed to still be wearing the wrist band on his right wrist. In an interview with the resident at this time he reported he still was not sure why he had a wrist band on. 3. Review of Resident #124's record revealed she was admitted to the facility on [DATE] and had diagnoses that included Cerebral Infraction, and Schizoaffective Disorder, Bipolar Type. An observation of Resident #124 on 10/31/22 at 10:44 a.m., revealed she was wearing four wrist bands. One name band on her right wrist, one name band on her left wrist, one yellow wristband indicating Fall Risk, and one pink wristband with no writing on it. At this time, the resident said These are my tags. The resident reported she was unaware as to why she had them on. Observation of Resident #124 on 11/02/22 at 7:35 a.m. revealed the resident lying in bed. The resident was noted to still be wearing her wristbands. At this time, she reported no one had taken her tags off. 4. An interview on 11/02/22 at 7:38 a.m., with Staff A Registered Nurse (RN) and Staff D, Licensed Practical Nurse (LPN), revealed they were unsure of the nature of the wristband. They reported the wristbands might be used as name tags, identification of code status, or were on the resident when they were admitted to the facility. An interview on 11/02/22 at 10:23 a.m., with the Director of Nursing (DON), revealed if residents had on wristbands those were from the hurricane because the entire facility had to evacuate to their sister facility and the wristbands were in place to help identify all residents during the transitions during the evacuation. She reported the residents had been back in the facility for about 2-3 weeks as they were evacuated for 3 days. 5. Dining observations on 11/02/22 at 8:50 a.m., during the passing of meal trays on the 300 hall, revealed staff I, Certified Nurses Assistant (CNA) and Staff J, CNA passing trays. The two staff members questioned a tray on the cart and both indicated the tray was to stay on the cart as it was for a Feeder In an interview on 11/02/22 at 8:51 a.m., Staff J revealed the word Feeder meant someone that had to be fed. In an interview on 11/02/22 at 8:52 a.m., Staff I revealed a Feeder was a person who needed to be fed by staff. On 11/02/22 at 8:55 a.m., the Certified Dietary Manager (CDM) who was present in the 300 hallway said, I will check to see if she is a feeder, he left and went to the nurse and returned to the cart and said Yes she is a feeder. In an interview with the CDM at this time, the CDM said the nurse has to check for feeders. The CDM revealed that when he referred to feeder he meant someone who needed to be fed by staff. 6. During an observation on 11/3/22 at 7:30 a.m., a female staff member assisting a male resident, who was dressed only in an incontinent brief, was seen through a window of the facility from the parking lot that faced a nearby apartment building. The staff member was dressed in green scrubs. The privacy curtain was pulled between the beds in the room and the head of bed was against the wall closest to the facility entrance. The resident had his arms above his head. The Social Worker (SW) was at the entrance of the building and was asked to confirm the observation. The SW confirmed the observation, let this writer into the facility, and stated she was going back to the window. On 11/3/22 at 7:33 a.m., an observation revealed that Resident #11's door was closed. On 11/3/22 at 7:40 a.m., Staff G, Certified Nursing Assistant (CNA), was observed wearing green scrubs in Resident #11's room, Staff G left the room and took a bag toward the soiled utility room. The Staff G stated, at 7:43 a.m. on 11/3/22, normally she did close the blinds (in resident rooms). The SW stated, at 7:44 a.m. on 11/3/22, the Director of Nursing had been notified and the CNA informed the SW the resident did not want the blinds closed. The SW stated she had informed the Staff G the blinds to the room had to be closed during personal care. The Quarterly Minimum Data Set, dated dated [DATE], indicated that Resident #11 required limited assistance from 1-person for dressing and extensive assistance from 1-person for toileting and personal hygiene. The policy - Promoting/Maintaining Resident Dignity, implemented 9/23/22, indicated that It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. The policy identified that All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights and Maintain resident privacy. 37999

Based on observations, record reviews, and interviews, the facility failed to maintain a safe, clean, and sanitary environment on two (300 and 400) of four hallways including repairing a ceiling that had been damaged due to rain for one (Resident #115) of two residents in room [ROOM NUMBER] and ensuring the mattresses fit onto a bed frame for one (Resident #88) of three residents who were identified as needing bolsters. Findings included: 1. On 10/31/22 at 10:25 a.m., an observation was made of room [ROOM NUMBER]. The textured ceiling was peeling off and discolored on the window side of the privacy curtain. A portion of the ceiling sheetrock paper was hanging. Resident #115 stated it (the ceiling) had been like that for awhile and after the last storm the facility had gone up to the roof and fixed the leak. The footboard of the bed near the window had deteriorated to show the particle board underneath the veneer finish. Above the bed, near the door, the ceiling was peeling and discolored. The wall next to the privacy curtain appeared to be melting, the paint was rippled from the top of the wall to the call light box. In the bathroom, which was shared by rooms [ROOM NUMBERS], the tile near the toilet was missing and discolored. Photos were obtained. An observation was conducted on 10/31/22 at 10:38 a.m., of the ceiling in room [ROOM NUMBER]. The textured ceiling was cracked and discolored near the privacy curtain. Photo was obtained. On 10/31/22 at 10:49 a.m., an observation was made of the doorway into room [ROOM NUMBER]. The rubber-like moulding outside of the door frame near the floor was torn and bent away from the wall. Photo obtained. An observation was conducted on 10/31/22 at 11:04 a.m. of room [ROOM NUMBER]. The floor under the resident's bed had a tan-colored substance dried to the floor in a path approximately 8-10 inches. The substance had dried to the floor mat that was lying on the floor beside bed next to the privacy curtain. An outlet across from the second bed in the room was missing a cover and the wall above the packaged terminal air conditioner (PTAC) unit was cracked and bubbled. The box fan, that was directed toward Resident #88, had dust/dirt/lint encrusted in the grate. A gap was observed of greater than 4 inches between the footboard and air mattress of Resident #88. Photos were obtained. On 11/1/22 at 10:05 a.m., an area of tan-colored substance continued to be observed under the bed in room [ROOM NUMBER]. The area along the side of the floor mat had a dried tan-colored substance on it. The nutrition feeding pole next to the bed in room [ROOM NUMBER] had a tan-colored substance dried to it. Photo was obtained. The tan-colored substance was observed on 11/2/22 at 8:23 a.m. under the window bed of room [ROOM NUMBER] and next to the floor mat. An observation was made, at 12:26 p.m. on 10/31/22 of room [ROOM NUMBER]. The veneer of a bedside dresser in the room was chipped revealing the particle board. Further observations of room [ROOM NUMBER] identified two outlet covers were dirty and broke and the rubber-like baseboard was broken, dirty and screwed to the wall. The tile next to the baseboard was discolored and dirty. The wall above the PTAC unit appeared to be water stained. Photos were obtained. On 10/31 at 1:03 p.m., the textured ceiling was cracked and tile was missing next to the doorway in the bathroom. Photos were obtained. An observation was conducted, on 10/31/22 at 12:31 p.m., of room [ROOM NUMBER]. The window frame of room [ROOM NUMBER] was discolored with a tan-colored substance. The sheetrock in the room was cracked and pushed in near the window bed. The rubber-like baseboard was unattached to the wall next to the PTAC unit. A dresser in the room had chipped veneer revealing the uncleanable surface of particle board. In the bathroom of room [ROOM NUMBER] was missing tile and a deteriorated door frame. Photos were obtained. On 10/31/22 at 2:18 p.m., an observation was conducted of room [ROOM NUMBER]. In room [ROOM NUMBER] was a dresser that had the finish bubbled and detached. Another dresser in room [ROOM NUMBER] had the veneer edging missing. Photos were obtained. On 10/31/22 at 2:27 p.m., an observation was made of room [ROOM NUMBER]'s sink vanity located within the room. The areas of the vanity's veneer were missing and the counter was chipped. Photo obtained. On 11/2/22 at 9:52 a.m., Staff H, Housekeeper, stated a machine was needed in room [ROOM NUMBER] to clean up the tan-colored substance. The staff member reported telling everyone of the liquid nutrition on the floor of room [ROOM NUMBER] and a floor technician had to come with a special machine to get it up. Staff H confirmed the box fan sitting on the dresser and blowing towards Resident #88 was dusty. The Director of Housekeeping reported, on 11/2/22 at 9:56 a.m., she was unaware the liquid nutrition had been on the floor of room [ROOM NUMBER] for three days. She stated the liquid nutrition needed to be taken up immediately or it turned into paste and turned rock hard. The Housekeeping Director stated they have worked with nursing to clean up any spilled liquid nutrition immediately. She stated housekeeping did not clean personal fans. A tour and interview was conducted at 4:00 p.m. on 11/2/22, with the Maintenance Director. He reported he started with the facility in June (2022) and two weeks ago the Nursing Home Administrator (NHA) had identified a couple rooms on the 300 hall that needed repairs. The maintenance assistants had been going room to room repairing issues, starting on the 300 hall. The Director indicated the ceiling in room [ROOM NUMBER] looked like it had started to be repaired but was not finished (unpainted) and the rotted window sill should have been brought to his attention. He stated the furniture on the two units were old and he would have to start requisitioning it. An observation was conducted with the Maintenance Director of room [ROOM NUMBER]. He said, I didn't realize it looked like that (ceiling). He reported the facility had a roof leak which had been fixed and the sagging paint on the wall was due to the roof leak. During the observation of room [ROOM NUMBER], he reported it needed a lot of sheetrock work and needed new outlet covers. The director identified Resident #88's mattress was crooked, he straightened the mattress and adjusted the footboard. He stated he did not do bed audits and depended on nursing to ensure that the mattresses fit. The director stated, regarding room [ROOM NUMBER]'s ceiling, the textured ceiling was heavy and it was starting to peel away (cracks in ceiling). He looked at the brown spot on the ceiling and stated it could have come from a previous roof leak. He agreed with the findings of room [ROOM NUMBER] and stated the uncleanable surfaces were not particle board and would not absorb (liquid) like particle board would. He stated each unit had a binder that was checked daily and the items were addressed by the department. He stated they depend on communication from nursing staff to let maintenance know of issues within the building. On 11/2/22 at 4:27 p.m., the director provided audits that maintenance would start to use as they go room to room. A policy - Resident Environmental Quality, implemented 9/23/22, indicated that It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy identified the following: - Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. - Identify areas of possible entrapment by conducting regular inspections on all bed frames, mattresses, and bed rails. These inspections will be apart of the facility's routine maintenance program. - All facility personnel are responsible for reporting broken, defective, or malfunctioning equipment or furnishings immediately upon identification of the issue. 21830 2. An initial room observation was conducted on 10/31/22 at 10:00 a.m. for room [ROOM NUMBER] which revealed the following: (a) Missing plaster board on bedroom wall facing the sink, cove base not adhered to the wall, floors were upswept and dirty with debris on the floor. (b) Closet door not on hinges ripped off from right side of the closet slider, corner of closet door not attached and wide-open gap between wall and closet door. (c) Textured ceiling over the bed in disrepair; photographic evidence obtained. (d) Continuous running water faucet and severe buildup of calcium and iron around base of the faucet. (e) Ceramic tile floor behind toilet cove base was not properly attached to the floor and wall leaving open areas. (f) Damaged drywall holes with missing and loose plaster at entry of the room. 39438 3. On 10/31/22 at 10:20 a.m., a family member of a resident in room [ROOM NUMBER] reported the room was not clean and there was mold in the room. She stated she had reported the concerns to the Assistant Administrator a few days ago and nothing had been done. The following was observed in the rooms: room [ROOM NUMBER]: missing baseboard with black bio growth and deteriorated sheetrock, discolored and heavily stained flooring underneath the sink in the room, discolored grout and tile in the shower, discolored toilet seat, deteriorated door frame, broken sheetrock, discolored and heavily staining flooring in the room and underneath the air conditioner, broken floor tile, and broken dresser. (photographic evidence obtained) room [ROOM NUMBER]: hole in the wall and broken sheetrock with exposed insulation and electrical wiring on the baseboard (photographic evidence obtained) room [ROOM NUMBER]: discolored and heavily stained flooring, unfinished and deteriorated sheetrock on the wall, and missing baseboard (photographic evidence obtained) Rooms 326: deteriorated door frame with cracked and chipped paint (photographic evidence obtained) On 11/03/22 at 9:46 a.m., the Administrator reported they discussed environmental concerns especially on the 300 and 400 units, but they had not formulated a Quality Assurance and Improvement Plan (QAPI). The plan was to do a room sweep and audit everything from beds, walls, curtains, and sinks. They were going to start repairing these items immediately. 20311 4. Observations of room [ROOM NUMBER] on 11/03/22 at 12:08 p.m., revealed there was black bio-growth on the wall below the window and directly above the wall mounted air conditioning unit. Interview with the Director of maintenance at this time revealed he was not aware of the area and was not sure what the black area was.

Based on observation, interview, record review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey, on 11/03/2022 and was cited at F656 and F759. On 12/13/2022 a revisit survey was conducted and the facility was recited at F656 and F759. The facility had developed a Plan of Correction with a completion date 12/03/2022. The facility had not comprehensively implemented the plan of correction for the identified quality deficiencies. Findings included: 1. On 12/13/22 at 11:47 a.m., Resident #1 was observed in bed. The resident answered questions by nodding her head yes or no. She nodded yes she was ok, yes staff were taking good care of her, no she was not in pain, and no she had not had a fall. A review of the [NAME] Abuse Log provided by the facility revealed a neglect incident for Resident #1 dated 11/26/22. The incident occurred in the resident's room, and it was reported per the log. The Incident-by-Incident Type document dated 10/01/22 to 12/13/22 provided by the facility indicated Resident #1 did not have an incident during this time period. A review of the Admission Record for Resident #1 revealed her most recent admitted was 11/30/22. Resident #1's diagnoses included but were not limited to muscle weakness, abnormal posture, anxiety disorder, unspecified dementia, unspecified abnormalities of gait and mobility, major depressive disorder, history of falling, unspecified lack of coordination, and age-related osteoporosis without current pathological fracture. A review of Section C-Cognitive Patterns of the 5 Day Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating severe cognitive impairment. A review of Section G-Functional Status revealed the following: Bed Mobility- Extensive assistance with one-person physical assist Transfer- Total dependence with two plus person physical assist Walk In Room- Activity did not occur Walk in Corridor- Activity did not occur Locomotion On Unit- Total dependence with one-person physical assist Locomotion Off Unit- Total dependence with one-person physical assist Dressing- Extensive assistance with one-person physical assist Eating- Supervision with setup help only Toilet Use- Extensive assistance with one-person physical assist Personal hygiene- Extensive assistance with one-person physical assist A review of the Progress Notes revealed the following: 11/25/22 Nursing Note- Upon removal of resident's socks to get her washed up for the day, the staff Certified Nursing Assistant (CNA) noticed a healing bruised area and localized swelling to the right outer ankle. Nurse was immediately at the bedside to assess. Resident denies pain or discomfort. The area is as described above. There are no open areas or trauma signs and symptoms noted. Vital signs were stable. Elevating this extremity. When asked what happened, resident does not recall. Doctor was notified and new orders were received for x-rays of the foot and ankle to rule out an acute process. There are no further signs and symptoms of acute distress. Pain management in place is effective. Nursing will communicate any results or concerns with doctor for further orders. 11/26/22 Nursing Note- Resident noted to have a bruised area over her left ankle on 11/25. Xray results revealed right ankle fracture involving the lateral malleolus with mild displacement. Physician called and gave an order to send her out to the hospital for evaluation and treatment. 11/27/22 Nursing Note- Resident not complaining of pain on her right ankle during the shift but complaining about pain level 4 on her left knee, knee assessed there is some swelling and warm to touch. Attending physician contacted and new order obtained for left knee x ray, Keflex 500 mg, and Voltaren Gel 1% or lidocaine patch if gel refused. A Change in Condition Evaluation dated 11/27/22 revealed the resident had new or worsening pain. Nursing observations, evaluation, and recommendations indicated to reposition to alleviate pain and medicated with pain cream to knee. X-rays were ordered. 11/30/22 Physician Progress Note- At baseline she is bedbound, minimally interactive only with staff (only expresses her needs) not with any other residents. She needs assist with transfers and position changes, she remains total care except able to feed self. On 11/26, received call from nurse regarding right ankle swelling, redness, and patient in pain with range of motion while CNA was doing their routine care, stat x-ray was ordered. Xray came back with right ankle fracture, patient was transferred to hospital for orthopedic evaluation and further care. There are no reports of fall/injuries from nursing team, patient did not complain of pain in her legs until CNA witness above finding and patient complained of foot pain during care, which prompted to take necessary steps. However, her current x-ray findings and based on her underlying comorbidities this fracture could be likely unavoidable fracture secondary to osteopenia/osteoporosis. Resident went out to the hospital as nursing noted redness and swelling of the left knee with pain with range of motion, x ray of left knee revealed likely fracture. Patient was sent to hospital for further evaluation. Diagnostic test revealed left distal femur fracture. She was seen by orthopedics and had cast placed to LLE. Left distal femur fracture no surgical intervention done. Ortho wanted to go with conservative measures in view of her underlying medical comorbidities and patient being non ambulatory (also her fracture was minimally displaced expecting to heal) will need to follow up with Ortho as outpatient. Patient with left distal femur fracture/right bimalleolar fracture in view of her current clinical status and underlying medical comorbidities and from discussion with patient's nurse no recent injury or fall witnessed by team she also regularly has skin checks which are basically normal so overall picture apparently looks like could be likely fracture secondary to osteoporosis. 12/06/22 (Advanced Registered Nurse Practitioner) ARNP Note- This patient has a palliative diagnosis of dementia. Total dependence with Activities of Daily Living (ADLs), non-ambulatory/wheelchair bound, and incontinent of bowel and bladder. On 11/26/22, this patient presented to a local hospital with complaints of right ankle pain, swelling, and fracture of the lateral malleolus with mild displacement on the outside right ankle. This patient returned to the facility on [DATE] with a boot for her fracture that the hospital staff could not put on due to patient not cooperating with the procedure and yelling out. Nursing home staff was informed that this patient is not a surgical candidate due to comorbidities and nonambulatory status. Fracture to heal on its own. On 11/28/22, presented to a local hospital with acute left leg pain due to left femur fracture. Patient was admitted . Casts were applied to bilateral lower extremities. Patient discharged to nursing home on 11/30/22. The patient's fractures are pathological. This provider spoke with attending physician at length regarding patient's pathological fractures, decline in function, and failure to thrive. A review of the Comprehensive Care Plan related to risk of pain due to osteoporosis and fracture of the right lateral malleolus, right fibula, and distal left femur revealed the following interventions: Administer medications for discomfort as ordered; observe for effectiveness Assess pain level as needed Check circulation, sensation, and movement to bilateral toes Encourage resident to voice discomfort at onset as needed Observe for nonverbal signs and symptoms of discomfort Provide rest periods throughout the day as needed Report changes in comfort level to physician as needed There were no interventions in place related to precautions when providing care to prevent unavoidable fractures. On 12/13/22 at 12:10 p.m. Staff E, CNA, reported she was taking care of the resident on the day of the initial fracture. When she was getting ready to give her a bed bath, she was undressing her, she took her socks off, and saw the swelling on the left foot and it was bruised. No pain noticed. She covered the patient and went to the nurse to let her know what was going on. The doctor went into the room. After that, they finished the bed bath to put clothes on her, put a pillow underneath the leg, and then the nurse came in and said wait to see what the doctor has to say about if the patient is staying or being sent out to the hospital. Staff E, CNA, reported she did not take care of the resident the day prior to the bruising. She stated Resident #1 never mentioned she was in pain but would always say she's tired. Staff E, CNA, reported Resident #1 had not had a fall and she never got her out of bed for anything. A telephone interview on 12/14/22 at 9:32 a.m. with Staff F, Licensed Practical Nurse (LPN), revealed she worked Saturday and got report from the nurse a CNA found a bruise on the resident's ankle and the doctor was called. The lab came in to do x-rays on Thursday and Friday on her shift. The resident returned to the facility the same night she was discharged . Per hospital records, she was not a candidate for surgery, and she was not cooperating with the boot. She reported the resident was always screaming during care and she does not like to be moved around and she always complains of being very tired. The resident just wants to be left alone. She does not like to be moved at all. Staff F, LPN, reported she found the inflammation on the left knee. She received orders for pain and an x-ray. The x-rays were done that night. Monday when she returned to work, she received report the resident had another fracture, and she was discharged to the hospital again. Staff F, LPN, reported before the fractures, she would always scream when you moved her. On 12/13/22 at 12:40 p.m., the Director of Nursing (DON) stated it was reported to her by the nurse the resident had a mild fracture. They called the doctor and did the immediate report. The doctor gave orders to send the resident to the hospital. The DON reported she got statements from staff that worked the day the fractures were found and the day before. Per the statements, there were two CNAs that noticed the swelling and reported to the nurse. Other statements from nurses indicated they did not notice any changes. On 11/25/22, Resident #1 was getting a bed bath when the swelling was noticed. The resident did not leave the bed and they did not notice any skin impairments on 11/24/22. Nothing was noticed the day prior from all staff interviewed and they reported the resident did not fall. After they got findings from the doctor that the resident had the fractures, it was determined it could have happened while they were turning her or changing her. They updated her care plan related to preventative measures as far as checking for circulation and to use a Hoyer Lift. This was implemented due to the fracture. The doctor said the fractures were unavoidable due to osteopenia/osteoporosis and they are most likely pathological fractures secondary to osteopenia/osteoporosis. The DON reported Resident #1 does not get out of the bed much and she needs a Hoyer Lift to get out of the bed. Resident #1 was readmitted with two casts. An ADL assessment was completed related to transferring her. Staff was educated on how to report in the system any findings on a resident. They did not educate staff on how to turn the resident. The education was related to skin impairments because of the bruising and some staff were saying they didn't see the bruising. The DON reported the CNAs are not doing anything differently related to take caring of the resident. 2. An observation was made on 12/13/22 at 1:22 p.m. of Resident #5 sleeping comfortably in bed with bilateral heel protectors on. An interview was conducted on 12/13/22 at 1:28 p.m. with Staff A, Certified Nursing Assistant (CNA). He stated the heel protectors are placed in the orders. Stated it would not be in the care plan. Stated the nurses are the ones who usually put the heel protectors on not the aides. An interview was conducted on 12/13/22 at 1:31 p.m. with Staff B, Licensed Practical Nurse (LPN). She stated Resident #5 is always in bed and rarely gets out of bed and that could be the reason for the heel protectors. She indicated she would have to check the chart to see if there is an order for the heel protectors. Observed Staff B check in Resident #5 chart to indicate if she needs bilateral heel protectors. Staff B stated there is no order for the resident to have heel protectors on. Observed Staff B look in the resident's care plan. She stated the heel protector use was not in the care plan. She stated the morning nurse must have put them on, as they were on the resident when she came in. She confirmed there is supposed to be an order and a care plan area discussing the heel protectors. She noted the resident should not have the heel protectors on. She indicated she would be talking to the unit manager. An observation was made on 12/13/22 at 1:36 p.m. of Staff B approach the Unit Manager about the heel protectors for Resident #5. A review of Resident #5's Admission Record revealed an initial date of 1/15/22 and readmitted [DATE] with diagnoses including dysphagia following cerebral infarction, and chronic obstructive pulmonary disease. A review of Resident #5's orders did not indicate an order relating to the use of heel protectors. A review of Resident #5's care plan did not reveal a focus area or interventions relating to the use of heel protectors. The policy provided by the facility Care Plan Revisions Upon Status Change implemented on 10/23/22 revealed the following: Policy-The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 34768 3. Observation of Staff C, Licensed Practical Nurse (LPN) on 12/14/2022 at 9:24 a.m. entered Resident #6's room with a pink plate with an Accucheck machine, Accucheck strip bottle, lancet, syringe, and alcohol wipe on it. She also had two bottles of insulin which were inside of two medication bottles and a Combivent Aerosol solution box with both the Combivent inhaler and the Flovent HFA inhaler inside. Staff C, LPN sat the insulins and inhaler box on the resident's overbed table. The resident was sitting up in bed. The nurse handed the resident the cup of oral medications. She applied gloves without hand sanitizing and performed the Accucheck by puncturing the right ring finger. The resident's blood sugar was 192. The nurse removed the Glargine insulin bottle from the medication bottle and drew up 25 units and administered into the right thigh. Staff C told the resident to use one of the inhalers, while she stepped out to retrieve another insulin syringe. The nurse removed her gloves but performed no hand sanitizing. The resident inhaled the Combivent inhaler 2 puffs. The nurse returned and told the resident to wait 5 minutes before she used the next inhaler (Flovent). The Resident stated, That was the first time she had heard of waiting 5 minutes between her inhalers. She did not know that. It was new to her. The nurse had the resident rinse her mouth and spit the water out. The nurse told the resident to take one puff of the Flovent and wait a minute for the next puff. In the meantime, she donned gloves, removed the Aspart insulin bottle from a medication bottle and drew up 10 units of insulin. She administered it into the right thigh. The resident stated it had been one minute and puffed the second dose of the Flovent. The resident was given water to rinse her mouth. The resident appeared confused about the minutes in between the puffs and medications. The nurse removed her gloves and did not hand sanitize, again. She exited the room and placed the items she had taken into the room on the top of the medication cart. Before she could replace the medications (insulin) into the cart she was stopped. When asked, she stated the room was dirty so the medication containers would be contaminated and would need to be wiped down. When asked about the inhalers in the same box, she stated the Flovent does not have the resident's demographics to ensure it was the residents. She called over Staff D, LPN, Unit Manager (UM) and she verified Staff C should not have taken the Combivent box nor medicine bottles with the insulin inside into the room. The insulin should be drawn up at the medication cart. Staff D stated they now needed to be cleaned with bleach wipes before replacing them into the medication cart drawer. She also included the Accucheck strip bottle. Staff D stated the Flovent would have to be thrown away and another one ordered for the resident due to lack of demographics showing it was the resident's. Staff D confirmed the nurse should have hand sanitize between glove changes. An interview with the Director of Nursing (DON) on 12/13/2022 at 2:15 p.m. included the medication pass for Resident #6. She agreed the Aspart insulin was given late as a medication error and the Flovent given without identification was also an medication error. Regional Nurse entered the conference room and was informed of the observation of medication pass for Resident #6. The Regional nurse agreed with the findings and stated they needed to do some education with the staff. A review of Resident #6's clinical record revealed she was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to acute and chronic respiratory failure with hypercapnia, COPD (Chronic Obstructive Pulmonary Disease), metabolic encephalopathy, Diabetes, morbid obesity, weakness, asthma, Myocardial Infarction, aortic valve stenosis, cognitive communication deficit, and atrial fibrillation. A review of the physician orders and December Medication Administration Record revealed the following: Aspirin (ASA) 81 mg (milligrams) daily delayed release for CAD (Coronary Artery Disease) Calcium and D3 600 mg / 10 meq (milliequivalents) daily hypokalemia Colace 100 mg daily for constipation Eliquis 5 mg BID (twice a day) for atrial fibrillation Lasix 20 mg BID for HTN (Hypertension) Aspart insulin 10 units with meals for DM at 8 a.m. Glargine insulin 25 units BID for DM at 9 a.m. Combivent Respimat Aerosol solution 20-100 mcg/act 2 puffs inhale orally two times a day for sob (shortness of breath) Flovent HFA aerosol 220 mcg (micrograms)/act 2 puffs inhale orally two times a day for asthma (not labeled, in the Combivent box) A review of the facility's policy, Medication Administration, dated 10/23/22, indicated the following: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 1. Keep medication cart clean, organized, and stocked with adequate supplies. 4. Wash hands prior to administering medication per facility protocol and product. 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. 13. Remove medication from source, taking care not to touch medication with bare hand. 14. Administer medications as ordered in accordance with manufacturer specifications. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Medication requiring a waiting period between inhalations or drops: Metered dose inhalers- follow manufacturer's product information or administration instructions including acceptable wait times between inhalations. A review of the facility's policy, Administering Medications through a Metered Dose Inhaler, dated October 2010, indicated the following: Steps in Procedure: 1. Wash hands. 2. Arrange supplies in the medication room, the medication cart outside the resident's room. 13. Check the label on the inhaler and confirm the medication name, and dose with the MAR. 15. Confirm the identity of the resident. 17. Place inhaler (s) on the bedside table or tray. 21. Administer medication. 22. Repeat inhalation, if ordered. Allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications. 25. Wash hands. An interview was conducted on 12/13/2022 at 1:23 p.m. for Quality Assurance with the Nursing Home Administrator (NHA). The NHA stated the facility completed audits for residents wearing offloading devices and completed education and training with nursing staff related to wearing offloading devices. The NHA stated the faciltiy was performing daily rounds and the unit managers were monitoring any boots that were applied. The NHA stated the faciltiy had looked at the care plans for adaptive devices. The NHA stated the facility had reviewed the orders for medications that can be crushed and they had not had any concerns. The NHA stated education on medication administration with inhalers and wait time in between double dosages had been completed and no concerns had been identified.

Based on observation, interview, record review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey, on 11/03/2022 and was cited at F656 and F759. On 12/13/2022 a revisit survey was conducted and the facility was recited at F656 and F759. The facility had developed a Plan of Correction with a completion date 12/03/2022. The facility had not comprehensively implemented the plan of correction for the identified quality deficiencies. Findings included: 1. On 12/13/22 at 11:47 a.m., Resident #1 was observed in bed. The resident answered questions by nodding her head yes or no. She nodded yes she was ok, yes staff were taking good care of her, no she was not in pain, and no she had not had a fall. A review of the [NAME] Abuse Log provided by the facility revealed a neglect incident for Resident #1 dated 11/26/22. The incident occurred in the resident's room, and it was reported per the log. The Incident-by-Incident Type document dated 10/01/22 to 12/13/22 provided by the facility indicated Resident #1 did not have an incident during this time period. A review of the admission Record for Resident #1 revealed her most recent admission date was 11/30/22. Resident #1's diagnoses included but were not limited to muscle weakness, abnormal posture, anxiety disorder, unspecified dementia, unspecified abnormalities of gait and mobility, major depressive disorder, history of falling, unspecified lack of coordination, and age-related osteoporosis without current pathological fracture. A review of Section C-Cognitive Patterns of the 5 Day Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating severe cognitive impairment. A review of Section G-Functional Status revealed the following: Bed Mobility- Extensive assistance with one-person physical assist Transfer- Total dependence with two plus person physical assist Walk In Room- Activity did not occur Walk in Corridor- Activity did not occur Locomotion On Unit- Total dependence with one-person physical assist Locomotion Off Unit- Total dependence with one-person physical assist Dressing- Extensive assistance with one-person physical assist Eating- Supervision with setup help only Toilet Use- Extensive assistance with one-person physical assist Personal hygiene- Extensive assistance with one-person physical assist A review of the Progress Notes revealed the following: 11/25/22 Nursing Note- Upon removal of resident's socks to get her washed up for the day, the staff Certified Nursing Assistant (CNA) noticed a healing bruised area and localized swelling to the right outer ankle. Nurse was immediately at the bedside to assess. Resident denies pain or discomfort. The area is as described above. There are no open areas or trauma signs and symptoms noted. Vital signs were stable. Elevating this extremity. When asked what happened, resident does not recall. Doctor was notified and new orders were received for x-rays of the foot and ankle to rule out an acute process. There are no further signs and symptoms of acute distress. Pain management in place is effective. Nursing will communicate any results or concerns with doctor for further orders. 11/26/22 Nursing Note- Resident noted to have a bruised area over her left ankle on 11/25. Xray results revealed right ankle fracture involving the lateral malleolus with mild displacement. Physician called and gave an order to send her out to the hospital for evaluation and treatment. 11/27/22 Nursing Note- Resident not complaining of pain on her right ankle during the shift but complaining about pain level 4 on her left knee, knee assessed there is some swelling and warm to touch. Attending physician contacted and new order obtained for left knee x ray, Keflex 500 mg, and Voltaren Gel 1% or lidocaine patch if gel refused. A Change in Condition Evaluation dated 11/27/22 revealed the resident had new or worsening pain. Nursing observations, evaluation, and recommendations indicated to reposition to alleviate pain and medicated with pain cream to knee. X-rays were ordered. 11/30/22 Physician Progress Note- At baseline she is bedbound, minimally interactive only with staff (only expresses her needs) not with any other residents. She needs assist with transfers and position changes, she remains total care except able to feed self. On 11/26, received call from nurse regarding right ankle swelling, redness, and patient in pain with range of motion while CNA was doing their routine care, stat x-ray was ordered. Xray came back with right ankle fracture, patient was transferred to hospital for orthopedic evaluation and further care. There are no reports of fall/injuries from nursing team, patient did not complain of pain in her legs until CNA witness above finding and patient complained of foot pain during care, which prompted to take necessary steps. However, her current x-ray findings and based on her underlying comorbidities this fracture could be likely unavoidable fracture secondary to osteopenia/osteoporosis. Resident went out to the hospital as nursing noted redness and swelling of the left knee with pain with range of motion, x ray of left knee revealed likely fracture. Patient was sent to hospital for further evaluation. Diagnostic test revealed left distal femur fracture. She was seen by orthopedics and had cast placed to LLE. Left distal femur fracture no surgical intervention done. Ortho wanted to go with conservative measures in view of her underlying medical comorbidities and patient being non ambulatory (also her fracture was minimally displaced expecting to heal) will need to follow up with Ortho as outpatient. Patient with left distal femur fracture/right bimalleolar fracture in view of her current clinical status and underlying medical comorbidities and from discussion with patient's nurse no recent injury or fall witnessed by team she also regularly has skin checks which are basically normal so overall picture apparently looks like could be likely fracture secondary to osteoporosis. 12/06/22 (Advanced Registered Nurse Practitioner) ARNP Note- This patient has a palliative diagnosis of dementia. Total dependence with Activities of Daily Living (ADLs), non-ambulatory/wheelchair bound, and incontinent of bowel and bladder. On 11/26/22, this patient presented to a local hospital with complaints of right ankle pain, swelling, and fracture of the lateral malleolus with mild displacement on the outside right ankle. This patient returned to the facility on [DATE] with a boot for her fracture that the hospital staff could not put on due to patient not cooperating with the procedure and yelling out. Nursing home staff was informed that this patient is not a surgical candidate due to comorbidities and nonambulatory status. Fracture to heal on its own. On 11/28/22, presented to a local hospital with acute left leg pain due to left femur fracture. Patient was admitted . Casts were applied to bilateral lower extremities. Patient discharged to nursing home on [DATE]. The patient's fractures are pathological. This provider spoke with attending physician at length regarding patient's pathological fractures, decline in function, and failure to thrive. A review of the Comprehensive Care Plan related to risk of pain due to osteoporosis and fracture of the right lateral malleolus, right fibula, and distal left femur revealed the following interventions: Administer medications for discomfort as ordered; observe for effectiveness Assess pain level as needed Check circulation, sensation, and movement to bilateral toes Encourage resident to voice discomfort at onset as needed Observe for nonverbal signs and symptoms of discomfort Provide rest periods throughout the day as needed Report changes in comfort level to physician as needed There were no interventions in place related to precautions when providing care to prevent unavoidable fractures. On 12/13/22 at 12:10 p.m. Staff E, CNA, reported she was taking care of the resident on the day of the initial fracture. When she was getting ready to give her a bed bath, she was undressing her, she took her socks off, and saw the swelling on the left foot and it was bruised. No pain noticed. She covered the patient and went to the nurse to let her know what was going on. The doctor went into the room. After that, they finished the bed bath to put clothes on her, put a pillow underneath the leg, and then the nurse came in and said wait to see what the doctor has to say about if the patient is staying or being sent out to the hospital. Staff E, CNA, reported she did not take care of the resident the day prior to the bruising. She stated Resident #1 never mentioned she was in pain but would always say she's tired. Staff E, CNA, reported Resident #1 had not had a fall and she never got her out of bed for anything. A telephone interview on 12/14/22 at 9:32 a.m. with Staff F, Licensed Practical Nurse (LPN), revealed she worked Saturday and got report from the nurse a CNA found a bruise on the resident's ankle and the doctor was called. The lab came in to do x-rays on Thursday and Friday on her shift. The resident returned to the facility the same night she was discharged . Per hospital records, she was not a candidate for surgery, and she was not cooperating with the boot. She reported the resident was always screaming during care and she does not like to be moved around and she always complains of being very tired. The resident just wants to be left alone. She does not like to be moved at all. Staff F, LPN, reported she found the inflammation on the left knee. She received orders for pain and an x-ray. The x-rays were done that night. Monday when she returned to work, she received report the resident had another fracture, and she was discharged to the hospital again. Staff F, LPN, reported before the fractures, she would always scream when you moved her. On 12/13/22 at 12:40 p.m., the Director of Nursing (DON) stated it was reported to her by the nurse the resident had a mild fracture. They called the doctor and did the immediate report. The doctor gave orders to send the resident to the hospital. The DON reported she got statements from staff that worked the day the fractures were found and the day before. Per the statements, there were two CNAs that noticed the swelling and reported to the nurse. Other statements from nurses indicated they did not notice any changes. On 11/25/22, Resident #1 was getting a bed bath when the swelling was noticed. The resident did not leave the bed and they did not notice any skin impairments on 11/24/22. Nothing was noticed the day prior from all staff interviewed and they reported the resident did not fall. After they got findings from the doctor that the resident had the fractures, it was determined it could have happened while they were turning her or changing her. They updated her care plan related to preventative measures as far as checking for circulation and to use a Hoyer Lift. This was implemented due to the fracture. The doctor said the fractures were unavoidable due to osteopenia/osteoporosis and they are most likely pathological fractures secondary to osteopenia/osteoporosis. The DON reported Resident #1 does not get out of the bed much and she needs a Hoyer Lift to get out of the bed. Resident #1 was readmitted with two casts. An ADL assessment was completed related to transferring her. Staff was educated on how to report in the system any findings on a resident. They did not educate staff on how to turn the resident. The education was related to skin impairments because of the bruising and some staff were saying they didn't see the bruising. The DON reported the CNAs are not doing anything differently related to take caring of the resident. 2. An observation was made on 12/13/22 at 1:22 p.m. of Resident #5 sleeping comfortably in bed with bilateral heel protectors on. An interview was conducted on 12/13/22 at 1:28 p.m. with Staff A, Certified Nursing Assistant (CNA). He stated the heel protectors are placed in the orders. Stated it would not be in the care plan. Stated the nurses are the ones who usually put the heel protectors on not the aides. An interview was conducted on 12/13/22 at 1:31 p.m. with Staff B, Licensed Practical Nurse (LPN). She stated Resident #5 is always in bed and rarely gets out of bed and that could be the reason for the heel protectors. She indicated she would have to check the chart to see if there is an order for the heel protectors. Observed Staff B check in Resident #5 chart to indicate if she needs bilateral heel protectors. Staff B stated there is no order for the resident to have heel protectors on. Observed Staff B look in the resident's care plan. She stated the heel protector use was not in the care plan. She stated the morning nurse must have put them on, as they were on the resident when she came in. She confirmed there is supposed to be an order and a care plan area discussing the heel protectors. She noted the resident should not have the heel protectors on. She indicated she would be talking to the unit manager. An observation was made on 12/13/22 at 1:36 p.m. of Staff B approach the Unit Manager about the heel protectors for Resident #5. A review of Resident #5's admission Record revealed an initial date of 1/15/22 and readmission date of 08/20/22 with diagnoses including dysphagia following cerebral infarction, and chronic obstructive pulmonary disease. A review of Resident #5's orders did not indicate an order relating to the use of heel protectors. A review of Resident #5's care plan did not reveal a focus area or interventions relating to the use of heel protectors. The policy provided by the facility Care Plan Revisions Upon Status Change implemented on 10/23/22 revealed the following: Policy-The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 3. Observation of Staff C, Licensed Practical Nurse (LPN) on 12/14/2022 at 9:24 a.m. entered Resident #6's room with a pink plate with an Accucheck machine, Accucheck strip bottle, lancet, syringe, and alcohol wipe on it. She also had two bottles of insulin which were inside of two medication bottles and a Combivent Aerosol solution box with both the Combivent inhaler and the Flovent HFA inhaler inside. Staff C, LPN sat the insulins and inhaler box on the resident's overbed table. The resident was sitting up in bed. The nurse handed the resident the cup of oral medications. She applied gloves without hand sanitizing and performed the Accucheck by puncturing the right ring finger. The resident's blood sugar was 192. The nurse removed the Glargine insulin bottle from the medication bottle and drew up 25 units and administered into the right thigh. Staff C told the resident to use one of the inhalers, while she stepped out to retrieve another insulin syringe. The nurse removed her gloves but performed no hand sanitizing. The resident inhaled the Combivent inhaler 2 puffs. The nurse returned and told the resident to wait 5 minutes before she used the next inhaler (Flovent). The Resident stated, That was the first time she had heard of waiting 5 minutes between her inhalers. She did not know that. It was new to her. The nurse had the resident rinse her mouth and spit the water out. The nurse told the resident to take one puff of the Flovent and wait a minute for the next puff. In the meantime, she donned gloves, removed the Aspart insulin bottle from a medication bottle and drew up 10 units of insulin. She administered it into the right thigh. The resident stated it had been one minute and puffed the second dose of the Flovent. The resident was given water to rinse her mouth. The resident appeared confused about the minutes in between the puffs and medications. The nurse removed her gloves and did not hand sanitize, again. She exited the room and placed the items she had taken into the room on the top of the medication cart. Before she could replace the medications (insulin) into the cart she was stopped. When asked, she stated the room was dirty so the medication containers would be contaminated and would need to be wiped down. When asked about the inhalers in the same box, she stated the Flovent does not have the resident's demographics to ensure it was the residents. She called over Staff D, LPN, Unit Manager (UM) and she verified Staff C should not have taken the Combivent box nor medicine bottles with the insulin inside into the room. The insulin should be drawn up at the medication cart. Staff D stated they now needed to be cleaned with bleach wipes before replacing them into the medication cart drawer. She also included the Accucheck strip bottle. Staff D stated the Flovent would have to be thrown away and another one ordered for the resident due to lack of demographics showing it was the resident's. Staff D confirmed the nurse should have hand sanitize between glove changes. An interview with the Director of Nursing (DON) on 12/13/2022 at 2:15 p.m. included the medication pass for Resident #6. She agreed the Aspart insulin was given late as a medication error and the Flovent given without identification was also an medication error. Regional Nurse entered the conference room and was informed of the observation of medication pass for Resident #6. The Regional nurse agreed with the findings and stated they needed to do some education with the staff. A review of Resident #6's clinical record revealed she was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to acute and chronic respiratory failure with hypercapnia, COPD (Chronic Obstructive Pulmonary Disease), metabolic encephalopathy, Diabetes, morbid obesity, weakness, asthma, Myocardial Infarction, aortic valve stenosis, cognitive communication deficit, and atrial fibrillation. A review of the physician orders and December Medication Administration Record revealed the following: Aspirin (ASA) 81 mg (milligrams) daily delayed release for CAD (Coronary Artery Disease) Calcium and D3 600 mg / 10 meq (milliequivalents) daily hypokalemia Colace 100 mg daily for constipation Eliquis 5 mg BID (twice a day) for atrial fibrillation Lasix 20 mg BID for HTN (Hypertension) Aspart insulin 10 units with meals for DM at 8 a.m. Glargine insulin 25 units BID for DM at 9 a.m. Combivent Respimat Aerosol solution 20-100 mcg/act 2 puffs inhale orally two times a day for sob (shortness of breath) Flovent HFA aerosol 220 mcg (micrograms)/act 2 puffs inhale orally two times a day for asthma (not labeled, in the Combivent box) A review of the facility's policy, Medication Administration, dated 10/23/22, indicated the following: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 1. Keep medication cart clean, organized, and stocked with adequate supplies. 4. Wash hands prior to administering medication per facility protocol and product. 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. 13. Remove medication from source, taking care not to touch medication with bare hand. 14. Administer medications as ordered in accordance with manufacturer specifications. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Medication requiring a waiting period between inhalations or drops: Metered dose inhalers- follow manufacturer's product information or administration instructions including acceptable wait times between inhalations. A review of the facility's policy, Administering Medications through a Metered Dose Inhaler, dated October 2010, indicated the following: Steps in Procedure: 1. Wash hands. 2. Arrange supplies in the medication room, the medication cart outside the resident's room. 13. Check the label on the inhaler and confirm the medication name, and dose with the MAR. 15. Confirm the identity of the resident. 17. Place inhaler (s) on the bedside table or tray. 21. Administer medication. 22. Repeat inhalation, if ordered. Allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications. 25. Wash hands. An interview was conducted on 12/13/2022 at 1:23 p.m. for Quality Assurance with the Nursing Home Administrator (NHA). The NHA stated the facility completed audits for residents wearing offloading devices and completed education and training with nursing staff related to wearing offloading devices. The NHA stated the faciltiy was performing daily rounds and the unit managers were monitoring any boots that were applied. The NHA stated the faciltiy had looked at the care plans for adaptive devices. The NHA stated the facility had reviewed the orders for medications that can be crushed and they had not had any concerns. The NHA stated education on medication administration with inhalers and wait time in between double dosages had been completed and no concerns had been identified.

Based on observation, interviews, and record review, and the facility did not respond to grievances in a timely manner for one (Resident #131) of 51 sampled residents. Findings included: Resident #131 was a [AGE] year old female admitted to the facility from an acute care hospital after experiencing a fall at home. She was living independently prior to her fall. The Resident's Brief Interview for Mental Status score was 15 which indicated intact cognition. An interview with Resident #131, on 10/31/2022 at 9:43 a.m., revealed she filed a grievance with the Social Worker on 10/19/2022 and the grievance was taken care of today, 10/31/22. Resident #131 stated the grievance was about the frequency of her dressing changes and she was not receiving some of her psych meds. A follow up interview was conducted on 11/01/22 at 2:53 p.m. and Resident #131 stated, I filed a grievance on the 19th [October 2022] and yesterday when you [surveyor] arrived they came and wanted me to sign saying I agreed with what they wrote. The Social Worker made me feel like I had to sign it so I did. An interview was conducted with the Social Worker on 11/02/22 at 1:48 p.m. She reviewed the October grievance log. The log indicated on 10/19/22 Resident #131 filed a grievance about missing psych and pain medications and on 10/31/22 filed another grievance about not receiving daily dressing changes. The Social Worker stated they had five days to resolve grievances, so this one (10/31/22) was still in process. The Social Worker said the psychiatry Advanced Practice Registered Nurse (APRN) was at the facility yesterday,11/01/2022, and she would make sure to send a note for her to get seen. The Social worker did not give a reason for the delay. Resident #131 was interviewed in her room on 11/02/22 at 2:10 p.m. and stated, Since the grievance on 19th [October 2022], I haven't seen psych. I'm missing two [CONDITION(S)] meds. They were supposed to have psych see me, but I haven't seen them. On 11/03/22 at 10:05 a.m. the APRN was interviewed and stated she was aware of the resident's question to restart meds. The APRN stated the resident was not receiving those meds in the hospital and she gave a verbal order for a psych consult. Resident #131's medical record was reviewed with the APRN for a psych consult order. The APRN confirmed there was no order in the medical record for a consult. The APRN was able to show the Psychiatry APRN had conducted an initial evaluation of Resident #131 on 10/13/22. The Unit Manager was interviewed on 11/03/22 at 11:02 a.m. Unit Manager stated the Psychiatry APRN came twice a week. The Unit manager was unable to locate a more recent psychiatry progress note. A review of the Grievance/Concern Report done on 11/03/22 at 8:33 a.m. confirmed Resident #131 filed a grievance on 10/19/22. The form indicated the resident concern was resolved on 10/26/22 and showed: Spoke with resident advised psych would see with next visit regarding meds. Meds were not on discharge medication list provided to facility. Resident was seen by psychology. On 10/31/22 the document was signed by Resident #131 and Social Worker indicating Resident #131 was satisfied with the resolution.

Based on observations, record reviews, and interviews, the facility failed to implement the care plan related to interventions to manage resident wounds for one (Resident #55) of two residents sampled for wounds. Findings included: Review of Resident #55's record revealed the resident was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 11/03/22 at 8:23 a.m., revealed the resident lying in bed. He was noted to have a left foot wound dressing and no Podus boot. Closer observation of the room revealed the Podus boot was lying in the residents reclining chair by the window. In an interview with the resident at this time, he denied taking the boot off and denied having the boot on during the night. In an interview with Staff B, Certified Nursing Assistant (CNA) who entered the resident room with his meal tray, she reported she was assigned to the resident and did not know why the boot was not on. She reported the night shift might have forgotten to put it on. During an interview on 11/03/22 at 8:24 a.m., Staff D, Licensed Practical Nurse (LPN) revealed the resident should have the boot on while in bed to prevent any additional `skin breakdown. Review of the care plan related to skin impairment dated 8/28/19 revealed an intervention to float heels while in bed as tolerated. Review of the Weekly pressure wound note dated 10/13/22 revealed a Wound Support Intervention that included 3. Offloading boots. Review of the Weekly pressure wound note dated 10/27/22 revealed a Wound Support Intervention that included 3. Offloading boot(s) Request was made for a policy related to implementation of the care plan, but was not provided.

Based on observation, record review, and interviews, the facility failed to ensure the administration of enteral nutrition was completed according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: An observation was conducted on 11/2/22 at 2:04 p.m. with Staff F, Licensed Practical Nurse (LPN) of the administration of liquid nutrition for Resident #88. Staff F removed a 60 cubic centimeter (cc) syringe from the package, picked up the end of the PEG where it lay near the side of the bed, inserted the syringe into the tube, flushed the tube with 30 cc's of water, then inserted the end of nutrition tubing into the PEG, and turned on pump. The pump was programmed to deliver the liquid nutrition at 75 milliliter (mL) per hour and a water flush at 150 mL/hr. Staff F pulled back the residents blanket and observed the PEG's insertion site. The staff member confirmed that checking the nutrition residual had been forgotten, usually checks. Resident #88 was initially admitted on [DATE] and recently on 6/28/22. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Review Report, identified an order dated 6/29/22 that instructed staff to Check residual every shift and record quantity. If more than 100 cc's hold feeding for 1 hour and notify MD, every shift. The report indicated this order had been discontinued. The report also indicated that staff were to Check G-tube placement. Notify MD if dislodged, every shift for Tube management. The October and November Medication Administration Records (MAR) included documentation that the order to check and record the quantity of residual had been completed without the recording the amount of Resident #88's residual. The documentation indicated that the order was written on 6/29/22 and discontinued at 12:03 p.m. on 11/3/22. The Medication Report included two physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Check residual at 2 p.m. prior to administration, one time a day. - Check residual every shift if more that 100 cc's hold feeding for 1 hour and notify MD, every shift. The care plan for Resident #88 identified the resident was at risk for complications associated with enteral feedings due to nothing by mouth (NPO) status and received enteral feeding to meet nutritional and hydration requirements, initiated 8/23/2019. The interventions related to the care plan included: Administer enteral feeding and flushes as orders; observe for tolerance and check enteral feeding residuals as ordered. A review of Resident #88's progress notes dated 10/4 to 11/1/22 did not include any documentation of residual amounts. An interview was conducted on 11/3/22 at 9:22 a.m. with Staff F regarding Resident #88's enteral nutrition. The staff member stated that the electronic record did not include an area to document residual. On 11/3/22 at 11:49 a.m., the Director of Nursing (DON) reviewed Resident #88's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Assistant DON stated the order was from June and the DON replied missed it. The DON stated the expectation was to check for residual prior to medications and starting nutrition and placement should be verified prior to administration. The policy - Care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy included the following explanations and guidelines: - Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. - The resident's plan of care will address the use of feeding tube, including strategies to prevent complications. - In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube); a. Tube placement will be verified before beginning a feeding and before administering medications.

Based on observation, facility staff interviews, medical record review, and policy and procedure review, the facility failed to provide evaluation of risk and supervision for one (Resident #1) of three sampled residents to prevent and identify an unwitnessed exit from the facility. Resident #1 was transferred to the facility from a local hospital where he had a psychiatric assessment that concluded he was not capable of leaving against medical advice and an internal medicine final note of questionable dementia with formal testing needed to make the determination. On admission to the nursing home on 10/8/2021, he was assessed by a nurse and was determined to not be at risk for elopement. He was being treated for pneumonia, was prescribed psychiatric and other prescription medications, and needed oxygen. He began expressing the desire to leave the nursing home, asking staff for the code to the door keypads, spending time near the exit doors and pacing the hallways. On 10/14/2021 staff placed a wander monitoring device on the resident but did not document the reason why the wander monitoring device was placed on the resident, complete a care plan related to wandering or elopement, and/or evaluate his desire to leave the facility or capability for independent discharge to the community. On 10/19/2021 at 2:57 a.m. the resident left the building without staff noticing and without an alarm being triggered by the wander monitoring device. The facility became aware of Resident #1 missing from the facility when the assigned Certified Nursing Assistant (CNA) delivered his breakfast tray at approximately 7:15 a.m., five hours after the resident left the building. His nurse however, documented that he was given a 6:00 a.m. dose of [MEDICATION(S)]-[MEDICATION(S)] Solution inhaler during the time he was not in the building. Resident #1 was located approximately 29 hours later and 17 miles away in adjacent county and across a 2.6 mile bridge that spanned a body of water. He called Emergency Services, said he was suicidal, said he was hallucinating and had fallen off a bench he was sleeping on. He was admitted to the psychiatric unit of the hospital with an assessment that included self-neglect, disordered thinking and lack of decision-making capacity. The facility's failure to document and evaluate the resident's behaviors and implement a plan of care to maintain the resident's safety resulted in the findings of Immediate Jeopardy occurring on 10/08/21 and removed on 11/10/21, with a scope and severity reduced to a D. Findings included: 1. A review of Resident #1's Admission Record revealed an admitted [DATE] from the hospital with a Health Care Proxy (HCP) listed. His medical diagnoses included [CONDITION(S)] ([CONDITION(S)]), hypoxic ischemic [CONDITION(S)] ([CONDITION(S)] caused by oxygen deprivation to the brain or lack of perfusion to the brain), hypoxemia (low blood oxygen), altered mental status, unspecified dementia without behavioral disturbance, unspecified [CONDITION(S)] not due to a substance or know physiological condition, and homelessness. Review of a Psychiatry Consult Progress Note from the transferring hospital dated 10/04/21 signed by a physician revealed that Resident #1's insight and judgement were poor. His level of impairment and interpersonal function was moderate and he required ongoing monitoring and treatment. His ability to carry out a safe, appropriate and reality based discharge plan was impaired. Pertinent psychiatric diagnoses listed were [CONDITION(S)], rule out [CONDITION(S)] secondary to [CONDITION(S)] exacerbation and dementia. The Assessment/Plan revealed, A [AGE] year-old male with history of [CONDITION(S)], noncompliance admitted for [CONDITION(S)] exacerbation and altered mental status after reportedly calling 911 repeatedly and acting strangely . Psychiatry consulted for capacity to leave AMA [Against Medical Advice]. Patient on initial psychiatric exam was found to lack capacity to leave AMA . Has guardianship hearing scheduled for end of this month. Review of the transferring hospital's Internal Medicine progress note dated 10/7/21, titled Final Report revealed an Impression and Plan that included: questionable dementia, needs formal testing and lacks capacity per psychiatry - unable to leave AMA. Review of The Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report dated 10/08/21 from the hospital revealed Resident #1 had a reported medical history of Paranoid [CONDITION(S)], Anxiety, Depression, Suicidal Thoughts, Tobacco Use, [CONDITION(S)], Pneumonia, Acute Respiratory Failure with [CONDITION(S)], Right Lower Lobe Pneumonia, Septic Shock, Leukocytosis (high level of white cells in the blood), Material/Debris in the Esophagus, [CONDITION(S)] (low potassium level in the blood), and [CONDITION(S)] (low magnesium level in the blood). The screening documented that Resident #1 was alert and disoriented but could follow simple instructions. He had a noted long history of leaving placements and noncompliance with medications . He reportedly lacked the capacity to leave AMA. The Level II screening determined that nursing facility placement was appropriate due to the patient's medical needs and the need for medication management. Supportive services cannot be effectively provided in a less restrictive environment at this time and are recommended to continue at the nursing facility. All efforts should be made to transition him to a less restrictive environment, that can meet his mental health needs if agreed upon by the treating physician. The resident met the State of Florida definition for Serious Mental Illness. Review of the Admission Nursing Comprehensive Evaluation dated 10/08/21, signed by Staff D, LPN ( revealed Resident #1 was admitted from the hospital. The resident scored 12 on a Brief Interview for Mental Status (BIMS) signifying moderately impaired cognition. The resident was assessed to be alert and oriented x 3 (to person, place and time) and had an elopement evaluation score of 4 signifying not at risk for elopement, no interventions at this time. The smoking evaluation section showed an answer of No for Does the resident use tobacco/[MEDICATION(S)] products? The Medication section revealed the resident was receiving antibiotics for pneumonia. The AIMS (Abnormal Involuntary Movement Scale)/Mood/Behavior section, revealed the resident was taking antipsychotic medication, had no involuntary movements, was calm, did not feel down, depressed or hopeless, did not feel like he would be better off dead or have thoughts of hurting himself. A review of the 5 Day Admission Minimum Data Set (MDS) with an assessment reference date of 10/12/21 revealed the following: Section C Cognitive Patterns revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 07 out of 15 indicating severe impairment; Section E Behavior indicated that Resident #1 wandered daily, and the wandering placed the resident at significant risk of getting to a potentially dangerous place; Section G Functional Status revealed that the resident needed limited assistance with one-person physical assist with bed mobility and dressing. Resident #1 needed supervision with one-person physical assist for transfer, walk in room, walk in corridor, locomotion on and off the unit, and toilet use. The resident needed supervision with set up help only with eating. For personal hygiene, Resident #1 needed extensive assistance with one-person physical assist; Section H Bladder and Bowel revealed that the resident was occasionally incontinent of urine; Section P indicated that the resident did not have a wander/elopement alarm. Review of Resident #1's care plan revealed a focus area initiated on 10/11/21 Resident has potential for adverse side effects related to the use of [CONDITION(S)] medications for diagnosis of [CONDITION(S)]. Interventions included administer [CONDITION(S)] medication as ordered, observe for effectiveness of [CONDITION(S)] medications, observe for adverse side effects related to [CONDITION(S)] medication use, report to physician if noted, educate resident/family on potential risk/benefits of [CONDITION(S)] medication use, labs as ordered, report findings to physician, Abnormal Involuntary Movement Scale (AIMS) assessment as indicated, [CONDITION(S)] review for dose reduction as able, psychiatry services or psychological services as ordered, observe for changes in mood/behavior, and report to physician if noted. Review of Resident #1's care plan revealed a focus area initiated on 10/08/21 [Resident] has potential for complications related to has active infection as follows: Pneumonia. Goal: will be free on [sic] infection by completion of antibiotic therapy. Interventions included administer antibiotics as ordered, observe for effectiveness, observe for side effects, vital signs as ordered and as needed, encourage resident to get out of bed as able, encourage/remind of handwashing as needed, labs as ordered, report findings to physician, assess lung sounds and respiratory function, report changes to physician as indicated, oxygen saturation as ordered, administer oxygen as ordered, observe for signs and symptoms of reoccurring infection, and notify physician if noted. Review of the resident's medical record showed there was no care plan related to wandering. Review of the Order Summary Report revealed Resident #1's active orders as of 10/19/2021 included: Resident may go leave of absence (LOA) with responsible party (ordered on 10/09/21); May apply O2 (oxygen) at 2 LPM (liters per minute) via nasal cannula as needed for maintaining O2 sats (saturation percentage in the blood) > or = 92% (10/9/21); Wanderguard (wander monitoring device) placed on the right leg. Every shift check for placement and function (10/14/21); Acidophilus Capsule- Give 1 capsule by mouth (po) two times a day for prophylactic for 10 days (10/16/21); [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 MG/3ML 1 vial inhale orally every 8 hours for [CONDITION(S)] (10/09/21); [MEDICATION(S)] Tablet 750 MG- Give 1 tablet po (by mouth) one time a day for pneumonia for five days (10/15/21); [MEDICATION(S)] Tablet 10 MG-Give 1 tablet by mouth one time a day for allergy symptoms (10/15/21); [MEDICATION(S)] Tablet 2 MG- Give 1 tablet by mouth every 12 hours for [CONDITION(S)] (10/09/21); and [MEDICATION(S)] Aerosol Solution 108 2 puff inhale orally every 4 hours as needed for shortness of breath (10/09/21); Upon discussion with the physician, the resident's primary diagnosis is : J44.1 [CONDITION(S)] with exacerbation, P91.60 Hypoxic ischemic [CONDITION(S)] (10/11/21). Review of the Resident #1's Medication Administration Record (MAR) for October 2021 showed documentation of administration of [MEDICATION(S)]-[MEDICATION(S)] Solution to the resident at 6:00 a.m. on 10/19/21. The resident was not in the facility at that time. Review of the Treatment Administration Record (TAR) for October 2021 showed that the function and placement of the wander monitoring device was checked every shift according to orders. Review of the Medication Administration Audit Report for October 2021 revealed the placement for the wander monitoring device was checked regularly according to orders. Prior to the resident leaving the facility, the wander monitoring device was last checked for placement on 10/18/21 at 23:25 (11:25 p.m.). Review of the Certified Nursing Assistants (CNAs) documentation maintained in the facility's electronic record system revealed no behaviors were noted during Resident #1's stay in the facility from 10/08/21 to 10/19/21. The last CNA documentation for behavior was completed on 10/18/21 at 2:09 p.m. and indicated none. Review of Resident #1's progress notes show they included the following: 10/18/21, 2:45 p.m. COVID Monitoring, Resident alert and confused. Unable to concentrate for periods of time. Staff I, LPN 10/18/21, 2:40 p.m. Daily Skilled note, No mood indicators observed. No behaviors observed. Resident alert and confused. Unable to concentrate for periods of time, Staff I, LPN 10/17/2021, 2:40 p.m. Daily Skilled Note, Resident is alert and oriented to person, place and time. No mood indicators. No behaviors observed. Alert and verbally responsive. Staff FF, LPN 10/16/2021, 3:30 p.m. Daily Skilled Note, No mood indicators observed. No behaviors observed. Alert and verbally responsive. Staff FF, LPN 10/15/21, 8:22 p.m. ARNP (Advanced Registered Nurse Practitioner) Progress Note, [AGE] year old male with a history of [CONDITION(S)] and dementia being seen per nursing request for a recent x ray result. On exam he is observed being non compliant with his oxygen, he is not in distress or SOB [shortness of breath] at rest . His pulse ox [oximetry] without oxygen is 77%, with 4 liters he is 92% . he is alert to self, no situation or time, does not answer questions frequently . has been observed ambulating frequently . The Assessment/Plan included Hypoxemia, continue oxygen; Pneumonia, [MEDICATION(S)] 750mg daily for 5 days, [MEDICATION(S)] 10 mg daily written; Non-compliance discussed with patient, he verbalized understanding; [CONDITION(S)] stable, continue [MEDICATION(S)] 2 mg every 12 hours. 10/15/2021, 5:46 p.m. Daily Skilled note, Resident is alert, oriented to person, place and time. No mood indicators. No behaviors observed. Staff D, LPN 10/14/2021, 8:57 p.m. Daily Skilled note, Resident is alert, oriented to person, place and time. No mood indicators. No behaviors observed. Staff D, LPN 10/13/2021, 8:55 p.m. Daily Skilled note, Resident is alert, oriented to person, place and time. No mood indicators. No behaviors observed. Staff D, LPN 10/13/2021, 5:41 p.m. Interdisciplinary Team (IDT) Narrative, Pt [patient] was placed on O2 [oxygen] Resp [respirations] changed. Writer sent to monitor O2 sat [saturation] while ambulating, walking around unit. Writer observe pt O2 sat desatting [decreasing] while walking and ambulating to 80% via room air, writer informed pt to rest before walking again, pt O2 sat increased to 87%, pt then walked to room and placed O2 on via NC [nasal cannula], pt O2 sat increased to 95%. Chest x-ray was order due to [CONDITION(S)] exacerbation. Staff D, LPN. 10/12/2021, 8:53 p.m. Daily Skilled note, Resident is alert, oriented to person, place and time. No mood indicators. No behaviors observed. Staff D, LPN 10/11/2021, 8:34 a.m. Daily Skilled note, Resident is alert, oriented to person, place and time. No mood indicators. No behaviors observed. Staff D, LPN Review of Resident #1's Progress Notes revealed an Incident Note dated 10/19/21 written by the Director of Nursing (DON). The note stated at 7:00 a.m., the resident was unable to be located in room or on the unit. The resident was alert and able to make needs known and follow complex commands, directions, and answer complex questions. Resident #1 was a safe smoker and through staff investigation, he was last seen walking towards the smoking patio. Resident was not at the smoking patio. Resident search of interior immediately begins with all residents accounted for and room checks. Resident location not found. At 7:14 a.m., facility grounds and all other outdoor areas searched. Staff unable to locate. The DON and Administrator were notified. The primary care medical doctor, Medical Director, and resident assigned HCP were notified. Police notification occurred by the DON and Administrator. The search continued to include areas where resident was noted to be previously. Resident previous residency is noted as homeless in St. Petersburg, Florida. The search included the St. Petersburg area. The HCP was notified and stated, It is hard to find him when he does this, he likes to squat in bushes and trees, she also stated that he will probably turn up at the hospital-that's what happened last time. The HCP was asked if she could provide any insight to where he might go-the answer was no. The search continued, police arrived at facility, information on the resident was provided, a picture of resident, and review of medication was provided. Local hospitals were called along with hospitals in the adjoining county. Review of Resident #1's Progress Notes revealed a Narrative Note dated 10/20/21 written by the DON. Facility staff was notified by an officer with the local police department that the resident had been located at a hospital in an adjoining county (Pinellas County). The facility was contacted by law enforcement on 10/20/21 at 7:54 a.m., 29 hours after Resident #1 exited the building. A Google map review revealed the distance from the facility to the location where Resident#1 was found was 17 miles and across a 2.6 mile bridge that spanned a body of water. The weather on 10/19/2021 between 12 midnight and 6:00 am according to the website timeanddate.com indicated the high was 70 degrees Fahrenheit and the low was 66 degrees Fahrenheit, overcast with an east wind at 6.214 miles per hour (mph) in the [NAME] area. Review of the Emergency Department Physician notes from the hospital showed that Resident #1 arrived at a hospital in Pinellas county on 10/19/21 at 15:38 (3:38 p.m.), he presented with altered mental status, and hallucinations. Resident #1 called Emergency EMS (emergency medical services) stating he took a pill and was hallucinating. He stated he took a prescribed medication for sleep and did not know what it was. The record showed He is suicidal and having hallucinations of people trying to shoot him or trying to feed me. The resident stated he fell off a bench he was sleeping on and hit his head. Initially, he stated that he was not short of breath but later reported some shortness of breath and cough. Review of the hospital psychiatric evaluation dated 10/20/21 revealed Resident #1 stated he left the nursing facility because it did not work out and he did not like it there. The Assessment/Plan showed: Patient requires restart of [CONDITION(S)] medications for stabilization. Patient is a potential danger to self-secondary to self-neglect. Patient psychiatric symptoms severe enough to cause a disordered behavior resulting in significant interference with activities of daily living. The resident was admitted for psychiatric care. The patient was found to not have decision-making capacity at this time. A Baker Act [involuntary psychiatric admission]was initiated. The resident remained at the hospital as of 11/15/2021. On 11/10/21 at 3:30 p.m., observation of the street outside of the facility revealed a four-lane road divided by approximately 12-15 ft median. Directly across the four-lane street from the facility, were two large retention ponds. The nearest speed limit posted was 40 mph (miles per hour). (Photographic evidence obtained) On 11/12/21 at 12:56 p.m., Staff F, CNA, reported that she was assigned to Resident #1 the night before he eloped. She reported that her shift ended at 10:45 p.m. on 10/18/21. Staff F, CNA, reported that the resident stated he wanted to leave the night before he eloped because he wanted to get cigarettes. She stated after the resident voiced wanting to leave, she notified the floor nurse, Staff H, Registered Nurse (RN), at about 10:00 p.m. and he notified Staff G, RN Supervisor. Staff F, CNA, reported Staff H, RN, asked the resident if he was okay, gave him a snack, and then returned the resident to his room after she reported the concern to him. A review of CNA documentation revealed Staff F did not document any behaviors for Resident #1. The documentation showed no entries were made by Staff F for Resident #1 despite being assigned to his care on 10/18/21. On 11/09/21 at 3:35 p.m., Staff EE, the assigned CNA to Resident #1 on 10/18/21 and 10/19/21 for the 10:45 p.m. to 7:15 a.m. shift, reported that Resident #1 was in the last room on the 200 unit. She reported that he always went to the smoking patio to smoke. They were always watching him. Staff EE, CNA, reported that he was always angry and asking to be signed out. Resident #1 kept saying he didn't want to be there. He stated he wanted to leave the facility every day. The resident stated every day that he belonged to the street. He had in his mind that he doesn't have money to be there because he was homeless prior to admission. He was very angry and mad that night he eloped that he couldn't go anywhere except to the patio. Staff EE reported that Staff DD, CNA, caught him going in her purse and getting change, but he gave it back. Resident #1 stated he wanted to buy a snack with the change. The resident was sitting next to her and Staff DD for a little while. By 2:30 a.m., she was charting and sent him to his room. There were 2 CNAs on the unit during that shift, her and Staff DD. Staff EE, CNA, reported that the resident put blankets and pillows in the bed to make it look as if he was in the bed. When they went to provide care to other residents, he must've gotten out of the building. She stated they cannot stop him because he was independent, and he smokes. He goes to smoke every 5 or 10 minutes and when he was not smoking, he was sitting next to her. There was a secured designated smoking area for residents to smoke. Resident #1 kept saying he didn't want to be there. She stated she explained that they were treating him but guess in his mind he was already planning to escape. Normally they tried to have him next to them. The unit was far from the smoking patio. One staff member could not calm him down. She guessed in the time that he was supposed to be smoking he escaped. Everyone was aware that he was going to smoke. He walked to the bedroom, and he laid down in the bed. He put the bed in a way that looked like somebody was there. She last worked with him during the night when he eloped on the 10:45 p.m. to 7:15 a.m. shift. A review of CNA documentation revealed Staff EE did not document any behaviors for Resident #1. The documentation showed no entries were made by Staff EE for Resident #1 despite being assigned to his care on the shift where he eloped from the facility. On 11/09/21 at 10:45 a.m., Staff O, the CNA assigned to Resident #1 on 10/19/21 from 6:00 a.m. to 2:45 p.m. was interviewed. She said that she went to do her rounds on 10/19/21 at about 6:45 a.m., and Resident #1 was not in his bed. Staff DD, CNA, reported to her that Resident #1 was in the smoking area which was normal for him. Sometimes he was out at all times of the night to smoke. Between 7:15 a.m. and 7:25 p.m., Staff O, CNA, went to the room to deliver the breakfast tray. She asked Staff R, CNA, to look on the patio for Resident #1 and she reported that he was not on the patio. Staff O, CNA, stated she reported this to the nurse, Staff D, LPN, and proceeded to look in the bathroom and no one could find him. Everyone started to look for him in the building. Resident #1 asked her too many times for the code to the back door prior to leaving the facility. There was an exit door near his room on the 200s unit. She would always tell him that she didn't know about the code. A follow up interview on 11/12/21 at 1:56 p.m., with Staff O, CNA, revealed Resident #1 had asked her for the code to the door, a week before his elopement. She stated she informed the female agency nurse (name unknown) that the resident had asked for the code and saw the nurse talking with the resident. Staff O did not know what the nurse talked to the Resident about or if any additional action was taken. A review of CNA documentation revealed Staff O documented for Resident #1 on 10/11/21, 10/12/21, 10/13/21, 10/14/21 and 10/15/21. All documentation noted that no behavior symptoms were observed. On 11/10/21 at 7:22 a.m., Staff DD, CNA (assigned to the 200 unit during the shift where Resident #1 eloped), stated the resident was walking around all the time. He took money from another CNA, and she caught him. Resident #1 said he wanted to buy cookies. She was doing her charting and he was behind her trying to touch the screen. He was always agitated. She thinks he was studying the building because he was walking all night. When she went to the room, the resident had put a blanket and pillow in the bed to make it look as if he was in bed. A review of CNA documentation revealed Staff DD did not document any behaviors for Resident #1. Although, Staff DD was not the assigned C.N.A. for Resident #1 on the day he eloped, documentation showed that she was the last CNA to document his care. On 10/19/21 between 2:00 a.m. and 2:02 p.m., Staff DD documented that Resident #1: Needed limited assistance/one person physical assistance with bed mobility and dressing. Not applicable for transfers, personal hygiene, toilet use, locomotion off/on unit, and walking in room/in corridor. Resident was continent of urine and had no bowel movement. Resident had no swallowing problems during the shift. On 11/10/21 at 7:17 a.m., Staff H, RN (nurse assigned to the resident on the 7:00 p.m. to 7:00 a.m. shift starting on 10/18/21), reported that the resident did not stay on the unit. He was walking all over the facility going out to smoke. Did not see him smoke, but knew that he was going out to smoke. He asked him for money for medications and food. If you are on the computer, he would come up behind you. Thirty minutes later he was asking for medications then food. Staff H, RN, reported that the last time he saw Resident #1 was at 3:00 a.m. Resident #1 reported to him that he wanted to leave the night before he eloped. Later during the shift, he wrote his name on a sheet of paper and stated he was leaving the facility. Staff H, RN, stated that Resident #1 put something in the bed to make it look as if he was in the bed. Resident #1 went in a staff member's purse and took money. He wanted food for the change that he took from the purse. He tried to take out the garbage to earn money. He was angry but never aggressive. After that, he realized Resident #1 had made a trap in the bed to make it look as if he was actually in the bed. On 11/12/21 at 2:11 p.m., Staff R, CNA, reported being familiar with Resident #1. She reported working on the day shift on 10/19/21 and while passing the breakfast trays, they noticed that Resident #1 was not in his room. Staff O, CNA, asked her to see if he was outside smoking. She stated she went to the smoking patio and observed that the resident was not there, so she notified the nurse and searched the room as the nurse paged the elopement code overhead. On 11/09/21 at 10:19 a.m., Staff D, LPN, stated she was assigned to Resident #1 on the 7:00 a.m. to 7:00 p.m. shift on 10/19/21. When she came in for her shift, she started getting report. Breakfast trays came up between 7:50 a.m. and 8:00 a.m. Staff R, CNA, went outside to get the resident because he was usually on the smoking patio. Staff R, CNA, informed her Resident #1 was not on the smoking patio. Once informed of that, she double checked, searched the floor, called an elopement code, and notified the Director of Nursing (DON) and Administrator. They started searching other units and checking outside of the building. Staff D, LPN, stated she was familiar with Resident #1's behaviors. He was exit seeking days prior to getting out of the building. The wanderguard was the only intervention. He expressed to other employees that he wanted to leave but not directly to her. He had days when you had to cue him. You had to bargain with Resident #1 in order to get care done. She checked the placement and function of the wanderguard daily after it was placed. On 11/12/21 at 12:33 p.m., the Maintenance Director reported that he noticed Resident #1 hanging around the door keypad at the exit door near the receptionist. He stated that he believed he had informed the nurse that the resident was hanging around the keypad but could not recall when or who he may have reported this to. On 11/12/21 at 1:23 p.m., Staff I, LPN, reported she had been assigned to Resident #1 in the past. She stated that the resident was unpredictable and would comment or say things about things that were irrelevant. She said she knew the resident from another facility and that he was really, really, really confused. Staff I, LPN reported having to watch the resident. He was borderline aggressive and could sense having to be careful around the resident as he gave you the sense of aggression. On 11/12/21 at 1:30 p.m., Staff J, Registered Nurse/Unit Manager (RN/UM), stated that when Resident #1 first came to the facility he kept to himself in bed then was transferred to unit two. She reported that the resident was observed standing right by the receptionist window and he did not want to be moved, she had asked an aide to see about getting him to move. On 11/09/21 at 10:30 a.m., the DON (Director of Nursing) reported Resident #1 was interesting. He was disheveled and paced the building a lot. Just back and forth. He got out of the main front door. Maybe he cut the wanderguard off stated the DON. The main front door had an alarm for a resident with a wanderguard. She confirmed there were no progress notes or assessments in the medical record related to him wanting to leave, asking to leave, or related to his risk for elopement. She confirmed that other than the wanderguard order, there were no other interventions put in place. The DON confirmed that no behaviors were reflected in Resident #1's medical record. On 11/09/21 at 11:38 a.m., the surveyor interviewed the DON and the Nursing Home Administrator (NHA) regarding the investigation for Resident #1. They said when the CNA, Staff O, was delivering the breakfast trays, Staff R, CNA, went to the smoking patio to look for the resident. They didn't see him and alerted the nurse. They searched the facility, perimeter, started going out to the community, and called the local hospitals after everyone came back in. They completed an in house check to make sure everyone else was in house. The police were also notified. The DON and the Administrator stated they reviewed the surveillance video, and Resident #1 was observed on unit two behind the nurses' station. He took change from a CNA's purse. The CNA didn't ask Resident #1 any questions after observing him take the money from the purse. He was then observed leaving the unit and going to the smoking patio door, but he did not go out of the door. He then went to the hallway by the bathrooms. At 2:30 a.m., he went through a door into the Admissions Office. The door was usually locked but it was unlocked at that time. He then exited through the main front entrance at 2:57 a.m. The wanderguard system was last checked by Maintenance on 10/18/21. Staff H, RN, was the last person to check the wanderguard. The wanderguard was last checked on 10/19/21 at 11:16 p.m. according to the Medication Administration audit report. Staff made notifications to the doctor, HCP, and the Medical Director. They checked all doors in the building. Anyone at risk for elopement was placed on one to one (staff supervision). Residents that were at risk were transferred to their sister facilities. Resident #1 had a LOA order. He could go out only with a responsible party. They completed an AdHoc meeting, quality assurance (QA) plan, and now have a performance improvement plan (PIP) in place. They put a lock that self-locks on the Admission's office door and they now lock the main front door to the facility at night. You now must have a code to go in and out of the main front door at night. An alarm was added on the Admission's office door. Residents that were at risk for elopement were transferred to secured units at their sister facilities. They are continuously monitoring the main front door and Admission's door. Resident #1 was not at risk for elopement upon admission. The standard for checking on residents was every two hours. Resident #1 had a wanderguard but he must have taken it off because it would have locked down the door and sounded the alarm. The wanderguard alarm on the main front door to enter the facility was working the next morning. The maintenance logs showed no variances that indicated the door wasn't working. The CNAs knew Resident #1 was at risk for elopement because it was on the Kardex. On 11/10/21 at 4:38 p.m., the Administrator reported she went through the trash cans in

Based on observation, record review, and interviews with the administration, nursing, admissions, and transportation staff, the facility failed to provide supervision and accountability for one (Resident #1) out of three residents (Resident #1, Resident #2, Resident #3) transported by facility transportation for re-admission on 11/20/20. This failure resulted in Resident #1 never entering the facility and never being re-admitted on [DATE] as planned. The resident remained unaccounted for four days and four nights until he was found outdoors in a parking lot approximately ¼ mile from the facility and was subsequently readmitted to facility on 11/24/20. The facility neglected to identify that the resident was missing until 11/24/20 which left this cognitively and physically impaired vulnerable resident outdoors in the elements without any personal belongings, including no shoes, food, water, or medication. The facility's lack of protection, supervision, and follow through exposed the resident, who could not protect himself, to the likelihood of injury, assault, dehydration, nutritional insufficiency, and illness due to lack of access to medical and nursing care. This resulted in the findings of Immediate Jeopardy, occurring on 11/20/20 and removed at 7:00 p.m. on 12/4/20 with the scope and severity reduced to a E. Findings included A review of the facility report of all resident admissions received 09/01/20 - 12/03/20 revealed that Resident #2 and Resident #3 were re-admitted to the facility on [DATE], however, Resident #1 was not readmitted to the facility until 11/24/20. During an interview with the facility Nursing Home Administrator (NHA) and Director of Nursing (DON) on 12/03/20 at 1:01 p.m. they identified that three residents: #1, #2, #3 were expected to re-admit to their facility on 11/20/20. Review of the progress notes in the medical record for Resident #1 revealed a nurse's note dated 11/11/20 at 7:04 p.m. which revealed, Resident is . currently isolated in room alone. will be transferred tomorrow per MD (medical doctor) order. The next narrative progress note in the record was an admission note dated 11/24/20 at 8:06 p.m. written by Staff A, Registered Nurse (RN) Supervisor. The note revealed that the resident was a readmission and transported by the facility's transportation van from their sister facility. On 12/02/20 at 1:10 p.m., an IDT (interdisciplinary team) note was entered, written by the DON and revealed, At approximately 4:30P on 11/24/2020 an employee identified a prior resident (Resident #1) sitting in a lawn chair with his feet propped on his walker in the (name of church) parking lot approximately a block from the facility. The employee was expecting the resident to be readmitted to the facility and stopped to ask him if he would like to return to the facility and he was agreeable. The resident was neatly dressed, and shaven with a neat appearance .When resident was asked why he left, resident stated that he didn't know that he had to sign out .Res. educated on signing out process .Resident readmitted to facility. Resident physician was notified. Nursing assessment was completed. Investigation initiated. Further review of the medical record for Resident #1 revealed that he had been initially admitted to the facility on [DATE] from the hospital. On 11/11/20, he was transferred to a sister facility for additional medical services per facility protocol. A review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which meant that the resident had moderate cognitive impairment and revealed that the resident did not display any wandering behavior. The documents titled, Nursing Comprehensive Evaluation dated 10/09/20 and 11/24/20 both revealed that the resident was not considered at risk for elopement. The care plan dated 10/9/20 for Resident #1 revealed the following care needs/problem areas: self-care deficit (initiated 10/9/20); generalized weakness and history of falls (initiated 10/21/20); decreased cognitive skills (initiated 11/25/20); impaired memory (initiated 10/21/20); use of wheelchair as primary mode of locomotion and able to use walker at times (initiated 10/21/20); missing all teeth except for approximately three to bottom (initiated 10/21/20); pain related to venous wound to left calf (initiated 10/21/20); frequently incontinent of bowel and bladder (initiated 10/21/20); at risk for alteration in nutrition and hydration and receiving nutritional supplements (initiated 10/9/20). The resident's primary mode of locomotion was a wheelchair. The resident had very limited ability to walk with a walker yet used a walker to cross a heavy trafficked four lane street without the assistance of a crosswalk or traffic light. On 12/03/20 at 8:15 a.m. observations were made of the outdoor surroundings of the facility and the parking lot where it was reported that Resident #1 was found. From the parking lot of the facility there was a clear view across the four-lane street from where the facility was located to a side street that led to a parking lot next to a shopping center that included a church. Between the shopping center and the main road, were various small tree lined and grass/dirt areas. There were no tables, benches, or chairs observed in or around the entire parking lot area. It was observed that the main road that ran between this large shopping center and the facility had four lanes, two running north and two running south with approximately fifteen feet of median in between. All lanes were observed heavily trafficked with moving vehicles and the speed limit posted as 35 miles per hour. There were no crosswalks or stop lights or stop signs in the immediate area between the facility and the shopping center parking lot. The approximate distance from the front door of the facility and the shopping center parking lot was ¼ mile. Photographic Evidence Obtained. According to http//www.timeanddate.com/weather/usa/tampa, the weather for the days, 11/20-11/24/20, the resident was without shelter ranged from a low of 61 degrees Fahrenheit to a high of 82 degrees Fahrenheit with light rain on 11/21/20. On 12/03/20 at 11:10 a.m., Resident #1 was observed and was agreeable to an interview. The resident was wearing a collared shirt, pajama bottom pants, and non-skid socks. The resident appeared clean, his face was shaven, and there were no visible injuries noted. He was seated on the edge of his bed, which was in the lowest position and surrounded on either side by foam floor mats. There was a metal frame rolling walker positioned near the head of the bed and within his reach. The television was on and the resident was agreeable to reduce the volume for the interview. Regarding the care at the facility, Resident #1 responded that he had no complaints but noted that he was always hungry and said, They really don't feed me here and I am always hungry. He reported that he had been at the facility for a couple weeks and stated he had come to the facility from the hospital. He stated that he had come to the facility to receive rehabilitation services for his legs and knees. He said he was unable to walk long distances on his own and required the use of his rolling walker. He stated that before coming to the facility he had been at various community shelters and that in his past he had served in the military. When asked to recall the details and timeline of his most recent admission to the facility he replied, I was brought here in an ambulance from the hospital from what I remember .they just brought me to my room. When asked if he had ever left the faciity on his own he said, I did .hobbled down the hallway to the front door and just left .nobody was around my room, the hallways, or at the front .I just opened the door and walked out because I was hungry and wanted to go to the store. Resident #1 could not recall the date of this event but reported that the time was around 11:00 a.m. He stated that, if there had been a staff member in the hallway or front lobby, he would have talked to someone. The resident continued his account with very specific details about having $8.00 on his debit card which he used to purchase juice and crackers at a convenience store down the street where he sat on a parking curb to eat. He then returned to the facility where again, he reported there was nobody in the lobby area or hallway and that nobody said anything to him about it. He confirmed that he did not remain out of the facility overnight and said, I was only gone about an hour or an hour and a half. He stated that nobody from the facility found him outside during that event and said, No I didn't see any staff out there at all, and nobody talked to me, I came back to the facility on my own and just walked back to my room with no problems. The resident was again asked if he was sure facility staff did not go out and see him when he was off the property. He then changed his story and stated that a facility employee who he could not remember their name, came up to him while he was in the church parking lot and asked him to come back in. He said he got into a car with them and was taken back to the facility. He could not identify who the facility employee was. Regarding whether he was hurt or had any falls while he was out, he said, I didn't fall and I didn't get hurt while out. Regarding how long he was away from the facility, he continued to maintain the he was only gone about an hour or so and did not stay outside the facility overnight. He denied being outside and away from the facility for several days/nights. On 12/3/2020 at 1:00 p.m., an interview was conducted with Staff B, Social Services Assistant. She confirmed the she was the assigned social worker for the 100 unit of the facility where Resident #1 resided. She revealed that she was familiar with Resident #1 and that he was pleasant, kept to himself in his room, and liked to watch television. She indicated that he was interviewable and would be able to speak about his daily routine. She confirmed that he was his own decision maker and did not have any family contact. She stated that the resident was just readmitted to the facility a few weeks ago from their sister facility. She reported that she had not been involved in his readmission process to the facility and did not see him the first day of his admission. She stated she did not recall Resident #1 ever eloping from the facility and that he was never an elopement risk. She confirmed that she had no knowledge of any incidents of the resident leaving the facility that would match his account of having left to buy crackers and juice and then returning. On 12/03/20 at 11:20 a.m., the facility lobby and entrance were observed. The entrance/exit from the outdoors was an automated sliding glass door that led to a large lobby area furnished with seating for guests between the outside doors and the locked doors that led into the facility. Positioned at the locked doors that led into the facility was a reception desk and on the wall behind the desk was a coded keypad that operated the locked doors. Staff C, Ward Clerk, was present at the reception desk and was interviewed. She confirmed she was the morning clerk and receptionist at the lobby reception desk and that her regular shift was from 6:00 a.m. until 2:00 p.m. She confirmed that only facility staff had access to the code that unlocked the door leading from the lobby into the facility. The facility residents did not go in and out of the facility as they pleased unless they had a scheduled appointment. She stated she had no knowledge of a resident leaving the facility over the last few weeks. She confirmed that she had not seen Resident #1 go in or out of the door during her shifts. She reported that after 7:00 p.m., the evening reception desk shift ended and the sliding glass door to the outdoors was locked. At 1:01 p.m. on 12/03/20, an interview was conducted with the NHA and the DON. They were asked to provide a timeline of events regarding the readmission of Resident #1. They reported that they had viewed the video surveillance footage of the front lobby from 11/20/20 during their investigation which was how they had arrived at some of their timeline details. They recounted that the facility was expecting three residents to readmit from their sister facility on 11/20/20. They stated that the facility's transportation driver went to pick up the residents on 11/20/20 and arrived back to the facility at approximately 12:50 p.m. The video footage revealed that the transportation aide assisted by Staff D, Certified Nursing Assistant (CNA) escorted two wheelchair-bound residents into the facility (Residents #2 & #3). He returned to the van, retrieved bags which he brought inside, and then left the facility around 1:20 p.m. with a resident who was being transported to a doctor's appointment. The NHA said that on 11/20/20, Around 4:30 (p.m.), I was doing my admissions/discharge review and found only two (residents) came and I was expecting three .went to (DON) who called (Staff E, Transportation Aide) who said (Resident #1) went to the hospital. (Staff E) said that he had only picked up two residents from the sister facility. The DON reported that she reached out to Staff F, Admissions Director and asked her to call the sister facility and confirm the whereabouts of Resident #1. The DON stated that Staff F never reported back to her and that because Staff E had reported the resident went to the hospital, she had left it at that. The NHA stated that on 11/24/20, Staff F came to her and told her that she had confirmed with Staff E that he had actually transported three residents to the facility on [DATE] from the sister facility and Staff F said, I think we have a missing resident. The NHA and DON reported that they began a search and reviewed the video camera footage from the lobby from 11/20/20 which did not reveal Resident #1 ever entering the building. They stated that at that time there were only cameras surveilling the lobby and that there was not a camera surveilling the area outside of the entrance. The NHA said, Part of our performance improvement plan (PIP) is to put cameras up outside .they are up now. The NHA and DON stated that by the time they had finished reviewing the video footage Staff F had left for the day but then called and reported that she had identified Resident #1 while driving through a parking lot across the street from the facility. The DON revealed that they discovered during their investigation that Staff F regularly cut through that parking lot on her way to and from the facility. The DON stated that after receiving Staff F's call, she drove in her personal vehicle to the parking lot and discovered Resident #1. She stated that he was found sitting in a lawn chair, was clean-shaven, was eating peanut butter crackers, and wearing clean clothes but no shoes. She stated Resident #1 could not provide concrete details on how he had gotten to the parking lot or where he had been staying or where he had received food. Regarding the parking lot where Resident #1 was found, the NHA and DON stated, From our understanding a lot of homeless people gather there. The NHA and DON confirmed that Staff E had changed his story on 11/24/20 and stated he had brought three residents to the facility on [DATE] from the sister facility as planned. They confirmed that their investigation findings revealed that Resident #1 was sent on the transportation van from the sister facility for readmission to their facility on 11/20 20 but, He never admitted into the building .he was transported in our facility van .we take responsibility as soon as he gets in our van. They reported that Residents #2 and #3 were confirmed as admitted to the facility on [DATE] and that their findings were that Resident #1 never entered the building on 11/20/20. They reported that Resident #1 had been assessed for elopement risk at his previous admission in October and again during his admission on 11/24/20 and was assessed both times not to be at risk for elopement. On 12/03/20 at 2:35 p.m., the facility NHA, DON and Maintenance Director provided the survey team with video surveillance footage recorded on 11/20/20 of the front lobby door entrance area of the facility. The footage was viewed with the NHA, DON, and Maintenance Director. Review of the footage date/time stamped at 12:20 p.m. on 11/20/20, revealed the facility's transport van arrived and parked in the driveway directly outside of the front lobby doors. The cameras were only affixed to be able to view the inside of the lobby area from the front entrance doors to the reception desk and locked doors that led from the lobby to the inside of the facility. There was no view of the area outside of the entrance door. Video footage at 12:20 p.m. showed Staff E, Transportation Aide assisting two residents who were in wheelchairs inside the entrance door. Staff D, CNA was observed arriving to assist with one of the residents and both staff were observed wheeling the residents to the reception desk where the desk clerk entered the code into the key pad to unlock the doors to the main facility. Staff E and Staff D were observed wheeling the residents in through the doors. Per the video time stamp, at 11/20/20 at 12:56 p.m., Staff E was observed arriving back to the lobby area from inside the facility, exited to the outside and then returned with two clear plastic bags. The DON and NHA stated, that the clear plastic bags contained medication for Residents #2 and #3. They confirmed there were only two bags, not three. Staff D was never observed returning to the lobby area. The video footage time stamp revealed that at 1:21 p.m. on 11/20/20, Staff E returned to the lobby from inside the facility pushing a resident in a wheelchair through the lobby and out the door. The NHA confirmed that the resident was scheduled for Staff E to transport to a doctor's appointment. It was determined through viewing the entire video footage on 11/20/2020 from 12:20 p.m. through to at least 3:00 p.m., that it did not reveal Resident #1 ever being escorted into the facility or entering the facility. Because the surveillance cameras did not have a view of the area outside the entrance or of the van, it could not be determined from the footage if Resident #1 was in the van upon arrival. The NHA and DON both confirmed that the front reception desk in the lobby was staffed at all times from 7:00 a.m. to 7:00 p.m. Additionally during those times, there was an employee posted at a screening station related to COVID-19 in the driveway carport directly outside of the entrance or immediately inside the entrance between the front door and the reception desk. The NHA and DON both confirmed that there were no other entrances used for staff or visitors or residents to enter or exit the facility other than the front entrance lobby doors. On 12/04/20 at 9:59 a.m., an interview was conducted with Staff G, Ward Clerk. He confirmed that he was assigned as the COVID-19 screener at the facility entrance and that he typically worked Monday, Wednesday, Friday from 5:00 a.m. to 7:00 p.m. He stated the screening station was always just outside the facility front entrance door unless the weather was too cold or wet and then it was moved just inside the front entrance door. The interview on 12/04/20 took place at the screening station which consisted of a table set up just outside and to the right of the entrance upon approach from the front driveway. The screening station faced the covered driveway and there was full view of the entire covered driveway area, adjacent parking lots to right and left, and of the four-lane street where the facility was located. There were cameras observed posted above the entrance door facing in both directions. Staff G stated that he was required to remain at his post unless on break and that someone was assigned to cover the station during his breaks. He said he had been reminded by the DON that he needed to stay at his post at all times because he did occasionally leave for a few minutes at a time if someone needed something from inside or if there was a message or item to pass to the receptionist. This was observed happening during the interview when a family member arrived at the screening station requesting visitation. Staff G left the screening station and went inside the lobby to speak with the receptionist, leaving his post at 10:20 a.m. and returning at 10:22 a.m. Staff G reported that there used to be a different camera outside and revealed an area on the wall where it had been. He revealed that new cameras had been placed on 11/25/20. Staff G confirmed that he was working at the screening station on 11/20/20 but that he had left early that day between 1:00 p.m. and 2:00 p.m. due to not feeling well. He said that on 11/20/20 between 12:00 p.m. and 1:00 p.m., I remember (Staff E, Transportation Aide) getting here .I think he had two residents with him. He stated that Staff E was often back and forth from the facility and that when he brought or picked up residents he always pulled the van into the driveway with the front of the van facing the same direction so that the side door and back door were completely visible from the front door and the screening station. He confirmed that he could clearly see both doors when Staff E had the van there. He stated he did not see Resident #1 on 11/20/20 and said that if any resident was, out here by themselves I would say something. He reported that on 11/23/20 the facility NHA had taken him to see Resident #1 in his room and asked if he recognized him or ever saw him and that he had told her he did not recognize him. At 11:20 a.m. on 12/4/20 Staff G followed up and said that since the initial interview, I've been updated on my hours by human resources and the NHA. He said, Apparently I was here all day of the event (11/20/20) . I've mixed up the timeline or my days . I'm not sure of my days anymore .I'm sort of confused on my days, I don't know why. He said, What I told you before is not accurate .I'm not sure which dates things happened .she (NHA) told me that it was Wednesday (11/25/20) that she took me to see Resident #1. Staff G confirmed that regardless of having his dates mixed up, he had never seen Resident #1 enter or exit the facility and in fact had not ever seen him before the NHA took him to see him in his room. On 12/04/20 at 10:38 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN) who confirmed that she was the assigned unit nurse on the 100 unit of the facility where Resident #1 resided. She confirmed she worked on 11/20/20 from 7:00 a.m. to 7:00 p.m. and that Resident #1 was not admitted to the facility that day during her shift . not to my recollection. She stated that either the floor nurse, a unit manager, or nursing supervisor was tasked with doing admissions and said, To my recollection he (Resident #1) was admitted on ,[DATE]/ (20). She stated she was not involved in admitting Resident #1, did not know who had done the admission, and said, I can't recall the UM (Unit Manager) or other nurses that day .I don't know who took the handoff that day. Staff H stated she did not see the resident arrive to the unit and did not know where he had come from or who had brought him there. She first became aware of him because he came up on her list and Medication Administration Record [REDACTED]. At 11:00 a.m. on 12/04/20 Staff A, RN and Staff I, LPN, UM were interviewed. Staff I confirmed that she was the unit manager for the 100 and 200 units and that her usual schedule was Monday - Friday. She confirmed she had worked on 11/20/20 from 8:00 a.m. - 4:00 p.m. and on 11/24/20 from 8:00 a.m. - 4:00 p.m. She confirmed that Resident #1 was not admitted to the facility during her shift on 11/20/20 or 11/24/20. She reported that the general process for tracking expected admissions was to check the facility census, perform rounds, and monitor the dashboard in the EHR which updated the day's discharges and admissions. She confirmed that Resident #1 had not appeared in any of those measures during her shift on 11/20/20. Staff A confirmed that he was usually the nursing supervisor during the 3:00 p.m. - 11:00 p.m. shift for the entire facility. He confirmed that he had worked the following schedule: 11/20/20 3:00 p.m. - 11:00 p.m.; 11/22/20 7:00 a.m. - 7:00 p.m.; 11/23/20 3:00 p.m. - 11:00 p.m.; and 11/24/20 3:00 p.m. - 11:00 p.m. He confirmed that he had performed the admission for Resident #1 to the facility on [DATE] at 4:49 p.m. He stated he did not know any details of where the resident had come from or how he had arrived at the facility and said, I was just told 'he's here' by the nurse (Staff H). He stated that he found out after the fact that Resident #1 was supposed to admit to the facility from a sister facility on 11/20/20. He said he found that out on 11/24/20 when the DON questioned him because she was trying to recall a conversation that she had with Staff E, Transportation Aide on 11/20/20. He stated he had provided the DON with Staff E's telephone number on 11/20/20 because the DON wanted to verify Resident #1's whereabouts. Staff A said, We were told patient (Resident #1) was sent to hospital .I believe it was the DON who spoke with him (staff E) and he reported he (Resident #1) went to hospital .DON called (Staff F, Admissions Director) to call and verify .that's the last thing I heard. Staff A stated he had heard nothing more about Resident #1 until 4:49 p.m. on 11/24/20 when Staff H told him the resident was there. Staff A said, I usually do the admissions, and that later in the evening of 11/24/20 the DON, Reported to me he (Resident #1) was found in parking lot .that's when I was questioned about 11/20/(20). He stated that an elopement assessment was part of the admitting process for all residents and that Resident #1 had a score of 8 which was not at risk. Both Staff A, RN and Staff I, LPN described Resident #1 as nice, polite, no complaints, go with the flow, periods of mild confusion. Staff A reported that Resident #1 had never been known to leave the facility unattended or to exit seek. He stated, because of precautions related to COVID-19 the usual leave of absence (LOA) process was limited to appointments only but that the normal LOA process was for a resident to inform a nurse, sign out, and sign back in. Staff A said, I educated him (Resident #1) on LOA process on 11/24/ (20) and showed him the LOA form. On 12/04/20 at 11:32 a.m. a telephone interview was conducted with Staff F, Admissions Director. She confirmed that she was familiar with Resident #1 and that she had physically met the resident on 11/24/20. She confirmed that the facility was expecting three residents to be transferred for re-admission to the facility from a sister facility on 11/20/20: Resident #1, Resident #2, and Resident #3. She stated that she had confirmed scheduling the transportation with Staff E, Transportation Aide. On 11/20/20, Staff E had texted her from the facility at 10:45 a.m. when he arrived at the facility to report that none of the residents were ready. Staff F stated that she texted Staff E at 11:17 a.m. on 11/20/20 with the names and room numbers of who he was picking up. She spoke with Staff E on the telephone later and he confirmed that he had those three residents on the van and was on his way to the facility. Staff F said, I don't know what happened when (Staff E) got to the facility. Staff F stated that later in the day on 11/20/20 the receptionist told her the residents had arrived. She had noted two of the residents on the dashboard in the EHR but could not confirm the names of those residents. She said she did not have any more communication with Staff E on 11/20/20. Regarding the process of tracking admissions to ensure all expected were accounted for, Staff F stated that the general process was that she would round the morning after the expected admission day to find out if they had arrived. She had not worked at the facility on 11/21/20 and 11/22/20 because it was the weekend and said, Normally we don't have someone in house on the weekend to confirm if someone (was) admitted . Staff F stated that on Monday,11/23/20, she went to the DON's office and asked if she was sure that Resident #1 was not in the building because Staff E stated he had brought three residents on 11/20/20 from the sister facility. Staff F reported that the DON responded that Resident #1 was not in the building. Staff F stated that, as she was leaving the DON's office, Staff E was passing by and he confirmed he had brought three residents on 11/20/20. When he was asked why the DON thought one resident went to the hospital, he confirmed that initially that was what he had told the DON. Staff F stated that while speaking with the Admissions Marketing Director (AMD) at the sister facility on 11/24/20, she confirmed that Staff E had picked up three residents from the sister facility on 11/20/20 to transport for readmission to their facility. The AMD checked her roster and confirmed that Resident #1 was not in the hospital. Staff F stated that she called Staff E on another phone while on the phone with the AMD and said, That's when he told me that he took one of them (Resident #1) off the van and sat him on the bench and retrieved the walker and gave it to (Resident #1) and then went and attended to the other two residents. Staff F said, At that moment I went straight to (NHA) .can't recall what time .shortly after 3:30 or 4:00 when I called (Staff E) .she let (DON) know and they walked off to their office .I don't know what happened. Staff F explained that her typical route driving to and from the facility was to cut through the shopping center parking lot where Resident #1 was found and that she regularly drove through the area at least every morning and every evening. She said, I normally see homeless people gathering there .I normally see the same people there. I had seen a guy sitting in a green fold-out chair with a walker .I just noticed it .one time chair and walker was there and the person was not .but Tuesday morning coming to work that person was there sitting in the chair with his leg propped up on the walker so when I left the building (at the end of her work day), I went over there and asked the man if he was (Resident #1) .he asked me if I had something to drink and I gave him a bottle of water. Staff F confirmed she had not recognized him in days prior because she had never met him before. Staff F recounted that she identified Resident #1 in the parking lot of the plaza on 11/24/20 at approximately 4:30 p.m. and that he was dressed in a shirt, pants, and socks with a large hole in the left foot at the heel and had no shoes. She stated his hair looked oily. She stated that the resident had a jar of peanut butter sitting on the ground next to him. She stated he confirmed to her that he knew the facility, had come from there but didn't remember when, said he had walked and just wanted to get away but didn't know where he was going and wouldn't mind going back. Staff F confirmed that she called the facility immediately upon finding the resident. On 12/04/20 at 1:23 p.m., a telephone interview was conducted with Staff E, Transportation Aide. He confirmed he had been the transport driver at facility for 7-8 months and an employee of the facility since 2018. He stated he was the only driver for the facility and said, I was working every day .nobody else to cover .if I couldn't do it then another company would be called. Regarding any training received on supervising residents during transport he said, I just took what I know from the floor from working as a CNA, but stated he had not received any formal training on supervising residents during transport. He confirmed that he was scheduled to pick up three residents from a sister facili (TRUNCATED)