Every finding on record at Westminster Suncoast

Based on record reviews, observations, and interviews the facility failed to ensure wound care was completed as ordered for two (#1 and #6) of three residents sampled for the treatment of non-pressure wounds, failed to ensure accurate and timely assessments were completed for two (#5 and #6) of three residents sampled for skin assessments. Findings included:1.Review of Resident #1's admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to metabolic encephalopathy, repeated falls, and unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident was discharged to an acute care hospital on 6/21/25. Review of Resident #1's progress notes revealed a change in condition on 6/6/25. The note revealed the resident had a skin tear, neuro (checks) and fall protocol were implemented as staff had assisted resident up. Review of Resident #1's Treatment Administration Record (TAR) showed an order instructing:Treatment as follows: Cleanse skin tears on Right Lower Extremity (RLE) with normal saline (NS), pat dry, cover with xeroform and abdominal (ABD) pad, wrap with gauze every 2 days. The order was scheduled to completed on night shifts and started on 6/7/25. The review showed wound care had been completed on 6/7, 6/9, 6/11, 6/13, 6/15, and 6/17/25. Review of Resident #1's Weekly skin evaluations showed on 6/14/25 the resident's skin was not intact and the area(s) were not new. The progress notes dated 6/14/25 did not include information on the resident's skin evaluation and the old area(s). Review of Resident #1's progress notes showed a Change in Condition evaluation was completed on 6/19/25 at 8:32 a.m. by the Director of Nursing (DON). The DON had reported an other change in condition. The nursing observations, evaluations, and recommendations were Reported that Dressing was not done as ordered, reported to MD, reported to Law enforcement, reported to Department of Children and Families (DCF), reported to Agency for Healthcare Administration (AHCA). The note showed family were notified and was awaiting a return call. An order was obtained from the primary care provider to start prophylactic antibiotic, start (liquid protein) twice a day, vitamin c, zinc daily, and treatment was updated. Review of the progress notes did not reveal documentation of the appearance of the wound, the dressing found, and/or notification to the DON. Review of Resident #1's late entry progress note dated 6/19/25 at 8:45 p.m. showed the DON had spoken with family about dressing being missed and reported. Review of Resident #1's late entry progress note dated 6/19/25 at 8:46 p.m. revealed the residents family had returned call to DON and had discussed event in length. During an interview on 2/25/26 at 2:09 p.m. the Director of Nursing (DON) reviewed the incident regarding Resident #1. The DON stated the resident's dressing was supposed to changed every other day and two nurses had signed the change had been completed on 6/13, 6/15, and 6/17 however on 6/19 it was reported to her that the dressing was dated 6/11, which she witnessed. The DON reported the resident had weekly skin checks done but staff were looking for anything new, saw the dressing but didn't pay attention to the date. The DON stated weekly skin checks are done head to toe but the point of the skin checks was to see if there was anything new. Review of Resident #1's TAR showed an order instructing staff to Monitor steri-strips to left (L) hand for signs/symptoms (s/s) of infection every shift for skin tear the order was scheduled for day, evening, and night shifts and was included on the day shift of 6/1/25. The review revealed staff had documented 9 on the day shift of 6/11, and on the evening shift on 6/15, staff had left the night shift on 6/12 blank. According to the TARs chart codes 9 = other/see progress notes. Review of Resident #1's progress notes showed on 6/11/25 at 2:41 p.m. nursing staff had documented wound care provided by wound care nurse in response to monitoring of steri-strips. The notes on 6/11, 6/12, and 6/13 did not reveal why the monitoring of the steri-strips had not been completed during the night shift on 6/12. The progress note on 6/15/25 at 3:48 p.m. revealed staff had not observed the steri-strips to Resident #1s left hand. Review of Resident #1's Fall Risk Evaluation, dated 6/6/25 revealed the resident had intermittent confusion, was chairbound, incontinent, and had a balance problem with standing. Review of Resident #1's care plan showed the resident was at risk for skin breakdown related to needs assistance with bed mobility and repositioning, nutritional risk, 5/5/25 posterior hand skin tear, and 6/9/25 right lower extremity skin tears. The interventions included but not limited to:monitor steri strips to left hand for signs and symptoms of infection, assigned to licensed nursesobserve resident's skin condition during routine care every shift and report any findings to nurse, assigned to Certified Nursing Assistant(s) (CNAs).Treatments as ordered, assigned to licensed nursing staffWeekly skin checks, assigned to licensed nursing staff. The intervention did not instruct staff to only look for new areas. An interview was conducted on 2/25/26 at 11:04 a.m. with Staff E, Restorative CNA. The staff member reported working with the nurses regarding wound care. If a dressing was not dated correctly would get the nurse, if it was dirty and coming off would let the nurse know and they come in with me. 2.On 2/25/26 at 9:37 a.m. an observation was conducted with Staff F, Licensed Practical Nurse/Unit Manager (LPN/UM) of Resident #6's left wrist dressing. The staff member stated the dressing change was every other day. The dressing was dated 2/23(/26). Review of Resident #6's Treatment Administration Record (TAR) showed an order started on 2/13/26 and scheduled for evening shift for Treatment: cleanse left wrist with normal saline (NS) and apply xeroform and dry sterile dressing (dsd) every (q) day until resolved every evening shift for skin tear treatment. The order was completed on 2/13 - 2/18/25 and discontinued on 2/19/25 at 5:32 p.m. The documentation for 2/19 was blank. Review of Resident #6's TAR revealed an order started on 2/20 and scheduled for the day shift for Treatment: cleanse left wrist with normal saline (NS) and apply xeroform and dry sterile dressing (dsd) every (q) day until resolved every day shift for skin tear treatment. The order was completed and discontinued on 2/20/26. Review of Resident #6's TAR showed the treatment to Resident #6s left wrist was not completed on 2/19/26. The TAR revealed the treatment to the resident's left wrist continued every other day with dressing changes completed on 2/21, 2/23, and 2/25/26. Review of Resident #6's Weekly skin inspections, dated 2/14 and 2/21/26 revealed the resident's skin was intact. Review of Resident #6's care plan showed the resident had a potential for skin impairment related to (r/t) decreased mobility, impaired cognition, incontinence, and on 2/16/26 a left wrist skin tear. The interventions showed licensed nursing staff were to provide treatments as ordered but did not include if the resident was to receive weekly skin evaluations. During an interview on 2/25/26 at 3:15 p.m. the Director of Nursing stated the weekly skin check should say skin was not intact and hopefully nurses weren't putting a dressing on a resolved wound, had told staff not to but some nurses want the wound nurse to discontinue the treatment. 3.On 2/25/26 at 9:29 a.m. an observation was conducted with Staff F, LPN/UM of Resident #5's dressing on right wrist. The dressing was dated 2/24/26 and the resident stated they change it frequently. The staff member stated the dressing changes were every other day. Review of Resident #5's summary for provider note, dated 2/19/26 at 4:47 p.m. showed the Assistant Director of Nursing had received an order from the primary care physician for wound care follow up, cleanse with normal saline (n/s), pat dry, apply xeroform, and dry dressing x 4 days. Review of Resident #5's Treatment Administration Record (TAR) revealed the following: skin tear to right fore arm outer aspect cleanse woth [sic] n/s pat dry apply xero form, and boarder fome [sic] x 4 days in the evening for skin tear.The TAR showed the order started on 2/19/26 and the resident had received dressing changes daily for 6 days (2/24/26) and as of 2/25/26 at 5:42 p.m. the treatment did not have an end date. Review of Resident #5's electronic clinical record showed Weekly Skin Inspection: 2 days overdue - 2/23/2026. The notification was a red-colored banner showing the next assessment due. The review showed the last completed weekly skin inspection was done on 2/16/26, nine days prior to the review on 2/25/26. Review of Resident #5's care plan revealed the resident had a Potential for skin breakdown related to episodes of incontinence, history of skin breakdown, needs assistance with bed mobility & repositioning, nutritional risk, 2/20/26 skin tear to right forearm outer aspect, and 2/23/26 excoriation/moisture associated skin damage (MASD) to buttock. The interventions included but not limited to weekly skin checks assigned to licensed nursing staff. During an interview on 2/25/26 at 3:08 p.m. the Director of Nursing stated the weekly skin checks for Resident #5 were going to be scheduled differently because the resident had recently moved from the 100 to 200 hall. The DON acknowledged the record showed the weekly skin check was from Monday and was 2 days overdue. Review of the policy - Wound Treatment Management, revised 5/2025, revealed To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The policy explanation and compliance guidelines included but not limited to:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise, or as wet.7. Treatments will be documented on the treatment administration record or in the electronic health record.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above).

Based on observations, interviews and record review the facility failed to ensure medications were stored securely and not accessible by unauthorized staff, visitors, and residents related to:1. medications left unattended on a medication cart on two (300/400) of three units; 2. medications left unattended in a resident's room for one resident (#7) who was not assessed to self-administer medications out of one resident sampled for self administration of medications.Findings included: 1. An observation on 2/25/26 at 8:05 a.m. showed a bag of Vancomycin 1 gram/200 milliliter (mL) sitting on top of an unattended medication cart parked outside of residents rooms on the 400 hall. The observation showed Staff A, Registered Nurse (RN) was in a resident room on the 300 hall. The staff member returned to the medication cart and reported the medication should not have been left on top of the cart. During an interview on 2/26/26 at 2:09 p.m. the Director of Nursing stated medications should not be left unattended on the carts. 2. On 2/25/2026 at 7:10am Resident #7 was observed with a medication at bedside. Staff G, Registered Nurse (RN) walked into Resident #7's room and abruptly went to the medications at Resident #7's bedside to administer the remaining medication to the resident. Resident #7 stated the medication had been at their bedside for at least 30 minutes and said the staff always leaves their medications at bedside for the resident to be able to take at a later time. Staff G, RN made no comment on the occurrence at hand and took the empty medication cup after the resident finished taking their medication. A review of Resident #7's admission record revealed an admission date of 2/11/2026 with diagnoses to include fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, pain in left hip, hypertensive urgency, other specified anxiety disorders, and major depressive disorder, recurrent, moderate. A review of Resident #7's Quarterly Minimum Data Set (MDS) assessment, dated 2/18/26, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 15, indicating Resident #7 was cognitively intact. In Section N- Medications revealed that Resident #7 is taking antianxiety, antidepressant, anticoagulant, opioids, and antiplatelet medications. A review of Resident #7's orders revealed the following: Buproplon HCI Oral Tablet 100 milligram (MG): 1 Tablet by mouth one time a day for depression Busprione HCI Oral Tablet 5 MG: 1 Tablet by mouth one time a day for anxiety Levotheyroxine Sodium Oral Tablet 88 MCG: 1 Tablet by mouth one time a day for Hypothyroidism Lisinopril Oral Tablet 5 MG: 1 Tablet by mouth one time a day for Hypertension Pravastatin Sodium Oral Tablet 40 MG: 1 Tablet by mouth one time a day for Hyperlipidemia Wallbutrin SR Oral Tablet Extended Release 12 Hour: 1 Tablet by mouth one time a day for depression/anxiety A review of Resident #7's progress notes revealed the following no indication of resident requesting to take medications at a later time or advisory to the physician and family. A review of Resident 7#'s Care Plan revealed no behavior related to Resident #7 having a tendency to want to take medications at a later time than what is prescribed or wanting to hold medications. On 2/25/26 at 11:12am, an interview with Staff H, RN revealed no medications should ever be left unattended with a resident, and the protocol is to stay with the resident till they take all of their medications. If a resident requests to take their medication at a later time, then the process is to take back the medications and hold them with the resident's medication label attached to the medication up till the resident is ready to take the medication. Staff H, RN stated if medications are late, the physician is to be notified. On 2/25/26 at 2:45pm an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed it is not the expectation for medications to be left at residents' bedside at any time unattended by staff. The DON explained the process is for the resident's medication to be removed and for the medication cup to be labeled with the [NAME] pack so it is identifiable, then to attempt the resident at a later time with the medications with the physicians 'OK' and orders. A review of the facility's Medication Administration policy revealed the following: Observe resident consumption of medication. Review of the policy – Medication Storage, revised 5/2025 showed It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/ or medication rooms according to the manufacturers recommendations insufficient to ensure proper sanitation, temperature, light, then relation, moisture control, segregation, and security. The General guidelines included: a. All drugs and biologicals will be stored in compartments (i.e. Medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage area/ cart. (Photographic evidence obtained)

Based on interviews and record review, the facility failed to maintain medical records with accurate documentation for one resident (#4) of three residents reviewed for incontinence care. Findings include:A review of Resident #4's admission record revealed an initial admission date of 8/7/25, with diagnoses to include need for assistance with personal care, difficulty in walking, speech and language deficits following unspecified cerebrovascular disease, and major depressive disorder, recurrent, moderate.A review of Resident #4's Quarterly Minimum Data Set (MDS) assessment, dated 5/22/25 in Section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 9, indicating moderately impaired cognition.A review of Resident #4's Bowel and Bladder tasks revealed incontinent care was not provided on 8/28/25 for the 3-11 shift, 9/8/25 for the 7-3 shift, 9/11/25 for the 11-7 shift, 9/12/25 for the 3-11 shift, 9/30/25 for the 11-7 shift, and 10/5/25 for the 3-11 shift for Resident #4.On 2/25/26 at 2:45 p.m. an interview with the Director of Nursing (DON) revealed none of the resident's bowel and bladder tasks should be blank, and staff should notate No bowel or bladder movement if there is no care needing to be provided. The DON expressed for the end of every shift, every task for residents should be documented on by care staff.A review of the facility's CNA Job Description revealed the following: Preserves residents' dignity, honors resident's rights, provides good customer service, communicates appropriately, and adheres to federal and state compliance regulations. Comply with all applicable rules, policies, standards and guidelines related to employments with Westminster Services and its communities. Practice infection prevention and control measures in compliance with Federal, State and facility requirements. Make routine and frequent rounds to ensure those safety precautions/equipment are in place and in working order. Avoid development of skin problems or skin breakdown by providing timely incontinent care and frequent repositioning of residents that need assistance.Review of the policy - Documentation in Medical Record, revised 6/2025, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation.1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the residence medical record in accordance with state law and facility policy.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.4. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented.ii. Record descriptive and objective information based on first-hand now edge of the assessment, observation, or service provided.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the residence care and/ or responses to care.

Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to ensuring staff members donned appropriate Personal Protective Equipment (PPE) to prevent the transmission of communicable conditions for two (#9 and #10) of five residents with physician orders for contact precautions.On 2/25/26 at 7:39 a.m. an observation showed Staff C, Certified Nursing Assistant CNA) dressed in wine-colored scrubs standing in front of Resident #9 (sitting in wheelchair) and speaking with the resident. The staff member left the room. Staff B, Licensed Practical Nurse (LPN) confirmed a Contact Precautions sign was posted on the resident's door and no Personal Protective Equipment (PPE) was available at the doorway. Review of the Contact Precaution sign posted on Resident #9's door Instructed, STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. The sign was from the United States (U.S.) Department of Health and Human Services - Centers for Disease Control and Prevention (CDC). An interview was conducted on 2/25/26 at 7:49 a.m. with Staff C. The staff member stated Resident #9 did not have any precautions. Staff B stated the facility was attempting to obtain a stool sample for Clostridium difficile (C. diff) due to the resident having loose stools. On 2/25/26 at 7:51 a.m. an observation was conducted with Staff B and Staff C of the sign posted on Resident #9's door. Staff C observed the sign and stated PPE was required when giving care to the resident and confirmed being in the room without PPE. Review of Resident #9's admission Record showed the resident was admitted on [DATE]. The record revealed diagnoses not limited to multiple fractures of ribs left side subsequent encounter for fracture with routine healing, generalized muscle weakness, and unspecified convulsions. Review of Resident #9's active, as of 2/25/26 at 5:31 p.m., physician orders revealed an order dated 2/23/26 for Contact Isolation every shift for possible cdiff for 5 days. The order was to end on 2/28/26. An order dated 2/23/26 showed staff were to obtain stool for cdiff and ova and parasites (O & P) one time only for loose stool for 3 days. 2.On 2/25/26 at 10:51 a.m. an observation showed Staff D, Activity Assistant enter Resident #10's room without donning PPE and shut the door. The observation revealed a Contact Precaution sign was posted on the door and no PPE was available in the hallway directly outside the resident's room. The staff member left the room approximately one minute later. Staff D reported being educated on (transmission-based) precautions and PPE use. Staff D stated they should wear gloves, (face) mask, gown, and face shield for contact precautions. The staff member PPE was used when there are signs on the door so you know. The staff member read the sign posted on Resident #10's door and said it says soap and water. Review of the sign posted on Resident #10's door instructed STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. The sign included handwritten instructions for soap & water. The sign was from the United States (U.S.) Department of Health and Human Services - Centers for Disease Control and Prevention (CDC). Review of Resident #10's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere and hypertensive emergency. Review of Resident #10's active (as of 2/25/26 at 5:32 p.m.) physician orders revealed orders for:-Contact Isolation every shift for staph aureus to wound until 3/31/26 at 2:59 p.m., dated 2/19/26 and ending 3/31/26.-Enhanced Barrier Precautions related to (r/t) intravenous access and coude foley cath: staff to wear gloves and gown while performing high contact care activities. No isolation required, dated 2/24/26 with no end date. Review of the facility-provided list of residents with contact precautions orders showed a total of five residents including Resident #9 and Resident #10. The list showed contact precautions were implemented for Resident #9 for possible C.diff and Resident #10 for staph aureus to wound. Review of the Centers of Disease Control and Prevention (CDC) guidance Transmission-Based Precautions, Infection Control Basics, Healthcare Providers, dated April 3, 2024 revealed Transmission-Based Precautions Are the second tier of basic infection control in RTUB used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. The recommendation details instructed Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission.Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patients environment. Donning PPE upon room entry and properly discarding before exiting the patient room has done to contain pathogens. Review of the CDC guidelines for Isolation Precautions: Appendix A, Healthcare Providers, dated February 7, 2025 (https://www.cdc.gov/infection-control/hcp/isolation-precautions/appendix-a-type-duration.html#C) revealed the types and duration of precautions:Clostridium difficile (See Gastroenteritis, C. difficile) - Type of Precaution: Contact + Standard for the Duration of illness. The guideline did not include additional precautions/comments for this condition.Gastroenteritis - Type of precaution: Standard. Precaution/Comments: Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks for gastroenteritis caused by all the agents below. Gastroenteritis - C. difficle: Discontinue antibiotics if appropriate. Do not share electronic thermometers; [853, 854] ensure consistent environmental cleaning and disinfection. Hypochlorite solutions may be required for cleaning if transmission continues [847]. Handwashing with soap and water preferred because of the absence of sporicidal activity of alcohol in waterless antiseptic handrubs [983]. The guideline did not include directives related to methicillin susceptible staphylococcus aureus (MSSA infection). Review of the policy - Infection Prevention and Control Program, revised 11/20/25, revealed 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 in guidelines.The policy explanation and compliance guidelines included:2. All staff are responsible for following all policies and procedures related to the program.4. Standard Precautions: All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.5. Isolation Protocol (Transmission-Based Precautions):a. A resident with an infection or a communicable disease shall be placed on transmission based precautions as recommended by current CDC guidelines. Review of the policy - Transmission-Based (Isolation) Precautions, revised 6/2025, revealed It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens modes of transmission. For training and quick referencing purposes, a summary of precautions is contained at the end of this policy.The policy defined contact precautions as Refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment.1. Facility staff will apply transmission based precautions coming in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission.Contact precautions:a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment.c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. vancomycin-resistant enterococcus (VRE), C.difficile, noroviruses, and other intestinal tract pathogens, (and) respiratory syncytial virus (RSV)). The recommendations for PPE related to contact precautions included: Gloves: Whenever touching the patients intact skin or surfaces in articles in close proximity to the patient (e.g. medical equipment, bed rails). Done gloves upon entry into the room or cubicle. Gowns: Whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental services or equipment in close proximity to the patient. Down gown upon entry into the room or cubicle.The policy showed type and duration of transmission-based precautions for selected infections and conditions related to Clostridioides difficile was contact precautions for the duration of illness with hand hygiene with soap and water. The selected infections and conditions did not include TBP directives for methicillin susceptible staphylococcus aureus (MSSA infection).

Based on record reviews and interviews the facility failed to provide the services ordered by a physician for one (#1) of three residents sampled for treatment of a non-pressure wound. The facility falsified documentation showing wound care had been completed during that time and failed to recognize wound care had not been completed for 8 days during a weekly skin assessment.Findings included: Review of Resident #1's admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to metabolic encephalopathy, repeated falls, and unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident was discharged to an acute care hospital on 6/21/25. Review of Resident #1's progress notes revealed a change in condition on 6/6/25. The note revealed the resident had a skin tear, neuro (checks) and fall protocol were implemented as staff had assisted resident up. Review of Resident #1's Fall Risk Evaluation, dated 6/6/25 revealed the resident had intermittent confusion, was chairbound, incontinent, and had a balance problem with standing. Review of Resident #1's Treatment Administration Record (TAR) showed an order instructing: - Treatment as follows: Cleanse skin tears on Right Lower Extremity (RLE) with normal saline (NS), pat dry, cover with xeroform and abdominal (ABD) pad, wrap with gauze every 2 days. The order was scheduled to completed on night shifts and started on 6/7/25. Review of Resident #1's TAR showed wound care had been completed to the RLE skin tear on 6/7, 6/9, 6/11, 6/13, 6/15, and 6/17/25. Review of Resident #1's weekly skin evaluation showed on 6/14/25 the resident's skin was not intact and the area(s) were not new. The progress notes dated 6/14/25 did not include further information related to the resident's skin evaluation, the old areas, or the appearance of the areas. Review of Resident #1's progress notes showed a Change in Condition evaluation was completed on 6/19/25 at 8:32 a.m. by the Director of Nursing (DON). The DON had reported an other change in condition. The nursing observations, evaluations, and recommendations were Reported that Dressing was not done as ordered, reported to MD, reported to Law enforcement, reported to Department of Children and Families (DCF), reported to Agency for Healthcare Administration (AHCA). The note showed family were notified and was awaiting a return call. An order was obtained from the primary care provider to start prophylactic antibiotic, start (liquid protein) twice a day, vitamin c, zinc daily, and treatment was updated. Review of the progress notes on 6/18 and/or 6/19/26 did not reveal staff had documented the appearance of the wound, the dressing found, and/or notification to the DON. Review of Resident #1's late entry progress note dated 6/19/25 at 8:45 p.m. showed the DON had spoken with family about dressing being missed and reported. Review of Resident #1's late entry progress note dated 6/19/25 at 8:46 p.m. revealed the residents family had returned call to DON and had discussed event in length. During an interview on 2/25/26 at 2:09 p.m. the Director of Nursing (DON) reviewed the incident regarding Resident #1. The DON stated the resident's dressing was supposed to be changed every other day and two nurses had signed the change had been completed on 6/13, 6/15, and 6/17 however on 6/19 it was reported to her that the dressing was dated 6/11, which she witnessed and had confirmed. The DON reported the resident had weekly skin checks done but staff were looking for anything new, saw the dressing but didn't pay attention to the date. The DON stated weekly skin checks are done head to toe but the point of the skin checks was to see if there was anything new. Review of Resident #1's TAR showed one nurse had documented the RLE wound care had been administered on 6/13 and 6/15/25 and another nurse had documented the wound care had been completed on 6/17/25. The documentation showed two nurses had falsely documented the wound care to the resident's lower extremity had been completed. Review of Resident #1's care plan showed the resident was at risk for skin breakdown related to needs assistance with bed mobility and repositioning, nutritional risk, 5/5/25 posterior hand skin tear, and 6/9/25 right lower extremity skin tears. The interventions included but not limited to: - monitor steri strips to left hand for signs and symptoms of infection, assigned to licensed nurses - observe resident's skin condition during routine care every shift and report any findings to nurse, assigned to Certified Nursing Assistant(s) (CNAs). - Treatments as ordered, assigned to licensed nursing staff - Weekly skin checks, assigned to licensed nursing staff. The intervention did not instruct staff to only look for new areas. An interview was conducted on 2/25/26 at 11:04 a.m. with Staff E, Restorative CNA. The staff member reported working with the nurses regarding wound care. If the dressing was not dated correctly would get the nurse, if it was dirty and coming off would let the nurse know and they come in with me. Review of Abuse, Neglect, and Exploitation, revised 5/2025, revealed It is the policy of this facility to provide protections for the health, welfare, in rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy defined neglect as the Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The compliance guidelines included but not limited to: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written. The prevention of abuse, neglect, and exploitation showed The Facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and expectation that achieves: F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; And providing feedback regarding the concerns that has been expressed. Review of the policy – Wound Treatment Management, revised 5/2025, revealed To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The policy explanation and compliance guidelines included but not limited to: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise, or as wet. 7. Treatments will be documented on the treatment administration record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above). Review of the policy – Documentation in Medical Record, revised 6/2025, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the residence medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 4. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. ii. Record descriptive and objective information based on first-hand now edge of the assessment, observation, or service provided. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the residence care and/ or responses to care.

Based on observation, interview, and record review, the facility failed to report an alleged violation involving abuse immediately or no later than 2 hours for one (#6) out of eight sampled allegations of abuse. . Findings included: On 9/23/24 at 10:15 a.m., Resident #6 was observed sitting in a specialized wheelchair in her room. The resident reported mistreatment considering how she was treated and informed writer you're probably the worst one. The resident would not explain the statement related to mistreatment stating, it's over and done with hopefully. The resident reported being blind. Review of Resident #6's Admission Record revealed the resident had diagnoses not limited to unspecified cerebral infarction, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, recurrent moderate major depressive disorder, and adjustment disorder with other symptoms. Review of Resident #6's progress notes revealed the following: - Late Entry behavior note, dated 9/16/24 at 1:51 p.m. and effective 9/14/24 at 1:49 p.m., Resident sliding out of chair, staff members assisted back up into chair. Resident grabbed staff member by shirt and almost pulled her down. No signs/symptoms (s/s) of distress at this time. Will continue to monitor. - Behavior note, 9/14/24 at 10:14 p.m., Resisting care for transfer to bed and changing clothes and brief. Explained need to have brief changed. Cursing at staff and spitting and resisting care but finally stops resisting and care is completed. Tolerates well and is no longer speaking to staff. An interview was conducted on 9/23/24 at 1:18 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Health Care Director (RHCD). The NHA reported an incident had occurred on 9/14/24 at approximately 10:00 p.m., between Resident #6 and Staff B, Registered Nurse (RN)) as witnessed by Staff A,Certified Nursing Assistant (CNA). The resident had refused and was combative with care while staff were trying to change her shirt and at 10:00 p.m. the resident calmed down. The staff had done multiple follow-ups with the resident and as Staff B, RN was assisting, the resident spat at the nurse. Staff A witnessed Staff B spitting back at the resident and held the resident's hands down during the care. The NHA reported Staff B admitted to holding the resident's hands down and spitting at the resident. The NHA reported, during an interview with Staff B she became aggressive towards the interviewers (NHA, DON, and RHCD) and refused to answer any questions. The NHA reported unfortunately Staff A did not report the incident until 1:29 p.m. on 9/16/24. A telephone interview was conducted with Staff A on 9/24/24 at 12:29 p.m. Staff A reported she needed help with Resident #6 as the resident was a mechanical lift and was in the process of getting changed. Staff A reported witnessing the resident spit at Staff B and then witnessed Staff B spit at the resident might have been 2-3 times. Staff A stated after the incident everyone was calm, the resident allowed to be changed. Staff A said (the resident) was probably shocked too. Staff A reported witnessing Staff B hold the resident's wrists down and thought the resident was trying to hit earlier in the night but not at that time. Staff A reported to Staff D, Nursing Supervisor, that Staff B had spit at the resident, and the supervisor told Staff A to write a statement for the administrator. Staff A stated the statement was written on Monday (2 days after the event). Review of an email from Staff A to the NHA on 9/16/24 at 2:03 p.m. an incident had occurred on 9/14/24 at 10:00 p.m. with Resident #6, Staff A, and Staff B. The description showed on 9/14/24 at approximately 8:00 p.m. [Staff A] was attending [Resident #6] who had been refusing care and exhibiting combative behavior. Despite multiple follow-ups, [Resident #6] remained uncooperative. At 10:00 p.m., [Resident #6] had calmed somewhat, and [Staff B] offered to assist with changing [the resident's] shirt. During the process, [Resident #6] spat at [Staff B]. In response, [Staff B] while standing over[the resident] spat back at her. This exchange occurred again when [the resident] spat at [Staff B] who repeated the action. At this point,[Resident #6] was no longer combative, and I did not require further assistance. [Staff B] was excused from the room. The actions taken showed the Staff B was excused from the room to de-escalate the situation. Review of the statement dated 9/16/24, from Staff B, provided by the NHA on 9/24/24 at 1:32 p.m. showed Staff B had reported assisting Staff A with putting Resident #6 into bed at approximately 10:00 p.m. - 11:00 p.m. (on 9/14/24). The resident was resistive to care, hitting, clawing and spitting at staff. Staff B reported holding the resident's hands so the CNA could put gown on. Staff B confirmed Resident #6 spat at her and she may have spit back during aggressive speaking and made spitting noises. The nurse reported Resident #6 was an angry bitter person. The NHA stated the statement from Staff B was done over the phone and was written verbatim with the NHA, DON, and RHCD. A telephone interview was conducted on 9/24/24 at 2:17 p.m. with Staff D, Licensed Practical Nurse (LPN). The staff member confirmed working on the 11 p.m. - 7 a.m. shift, having the most seniority on shift so guessed that made her the Charge Nurse. Staff D reported walking up on the CNA, who had witnessed the incident on 9/14/24, speaking with someone else (unidentified) about the nurse spitting on the resident. Staff D reported advising the CNA if something had happened it would have to be reported. Staff D reported not saying anything to anyone else (regarding the incident) because she was not the supervisor on duty when it happened. During an interview on 11/12/24 at 12:04 p.m. with the NHA, DON, and RHCD, the management team reported Staff A had not reported the incident for 2 days. The DON stated the staff member should have reported to the weekend supervisor who was in the facility until 11:00 p.m. and the supervisor would have notified the DON. The DON stated if another staff member was aware of the situation they should have reported it also. The DON stated she was unaware of any other staff member being aware of the incident. The NHA stated Staff A had texted him on 9/16/24 at approximately 1:00 p.m., prior to the email. The NHA and DON stated they did not interview any other staff regarding the incident. The RHCD stated Staff A was afraid of retaliation from Staff B due to issues in the past, not related to residents and Staff A did not report informing anyone else of the incident. Review of the timeline provided by the NHA related to an incident involving Resident #6 revealed on 9/14/24 at 10:00 p.m. Staff A, was attending the resident who had been refused care and exhibited combative behaviors. The report showed at 10:10 p.m. Staff B had been asked to assist the staff member in changing the resident's shirt and at 10:15 p.m. Resident #6 spat at Staff B who reciprocated the action back to the resident. The report showed on 9/14/24 at 10:25 p.m., Staff B held the resident's hands down and spit back at the resident a couple of times while trying to provide care then was excused from the situation at 10:30 p.m. The report showed on 9/16/24 at 1:42 p.m. (39 hours and 12 minutes after the incident) Staff A called the Nursing Home Administrator to report the incident between Resident #6 and Staff B. On 9/16/24 at 2:52 p.m., Resident #6's physician and family representative were informed of the incident and at 2:55 p.m., 40 hours after the incident, the facility reported the incident to the state agency and law enforcement. Review of the facility policy - Abuse, Neglect, and Exploitation, revised on 7/23, revealed 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. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse a certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of our residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including the abuse facilitated or enabled through the use of technology. The definition of willful is described as the individual must have acted deliberately, not that the individual must have been intended to inflict injury or harm. Physical abuse includes, but is not limited to hitting, slapping, punching, fighting, and kicking. It also includes controlling behavior through corporal punishment. Alleged violation is defined as 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. The Reporting/Response component of the policy showed: A. The facility we'll have written procedures that includes: 1. reporting all alleged violations to the administrator, state agency, adult Protective Services, into all other required agencies (e.g. Law enforcement when applicable) within specified time frames: a. Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that caused 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 aid 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 healthcare 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 responsibility for implementation of corrective action; e. the expected date for implementation; and f. identification of staff responsible for monitoring the implementation of the plan.

Based on observation, interview, and record review, the facility failed to protect the rights of one (#6) of one resident related to the physical abuse from a staff member. Findings included: On 9/23/24 at 10:15 a.m., Resident #6 was observed sitting in a specialized wheelchair in her room. The resident reported mistreatment considering how she was treated and informed writer you're probably the worst one. The resident would not explain the statement related to mistreatment stating, it's over and done with hopefully. The resident reported being blind. Review of Resident #6's Admission Record revealed the resident had diagnoses not limited to unspecified cerebral infarction, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, recurrent moderate major depressive disorder, and adjustment disorder with other symptoms. Review of Resident #6's progress notes revealed the following: - Late Entry behavior note, dated 9/16/24 at 1:51 p.m. and effective 9/14/24 at 1:49 p.m., Resident sliding out of chair, staff members assisted back up into chair. Resident grabbed staff member by shirt and almost pulled her down. No signs/symptoms (s/s) of distress at this time. Will continue to monitor. - Behavior note, 9/14/24 at 10:14 p.m., Resisting care for transfer to bed and changing clothes and brief. Explained need to have brief changed. Cursing at staff and spitting and resisting care but finally stops resisting and care is completed. Tolerates well and is no longer speaking to staff. Review of an Incident Report statement from Staff A, Certified Nursing Assistant (CNA), dated 9/16/24 at 2:03 p.m., showed on 9/14/24 at approximately 8:00 p.m. the staff member was attending to Resident #6 who had been refusing care, exhibiting combative behaviors, and despite multiple follow-ups the resident remained uncooperative. The report showed at 10:00 p.m. (40 hours prior to the report) the resident had calmed somewhat and Staff B, Registered Nurse (RN) offered to assist with changing the resident's shirt. The report showed during the process, the resident spat at Staff B who in response, while standing over the resident spat back at the resident, the exchange occurred again when the resident spat at the nurse who repeated the action. The resident became no longer combative, the aide did not require any further assistance, and the nurse was excused from the room to de-escalate the situation. A telephone interview was conducted with Staff A on 9/24/24 at 12:29 p.m. Staff A reported she needed help with Resident #6 as the resident was a mechanical lift and was in the process of getting changed. Staff A reported witnessing the resident spit at Staff B and then witnessed Staff B spit at the resident might have been 2-3 times. Staff A stated after the incident everyone was calm, the resident allowed to be changed. Staff A said (the resident) was probably shocked too. Staff A reported witnessing Staff B hold the resident's wrists down and thought the resident was trying to hit earlier in the night but not at that time. Staff A reported to Staff D, Nursing Supervisor, that Staff B had spit at the resident, and the supervisor told Staff A to write a statement for the administrator. Staff A stated the statement was written on Monday (2 days after the event). A telephone interview was conducted on 9/24/24 at 2:17 p.m. with Staff D, Licensed Practical Nurse (LPN). The staff member confirmed working on the 11 p.m. - 7 a.m. shift, having the most seniority on shift so guessed that made her the Charge Nurse. Staff D reported walking up on the CNA, who had witnessed the incident on 9/14/24, speaking with someone else (unidentified) about the nurse spitting on the resident. Staff D reported advising the CNA if something had happened it would have to be reported. Staff D reported not saying anything to anyone else (regarding the incident) because she was not the supervisor on duty when it happened. Review on 9/24/24 at 1:32 p.m. of the facility's transcription from Staff B conducted via telephone, showed the Staff A had requested assistance from Staff B with putting Resident #6 into bed. Staff B reported assisting Staff A at approximately 10-10:30 p.m. with evening care for Resident #6. It was reported the resident was resistive to care, hitting, clawing and spit at Staff B. The statement showed the staff were able to put on a nightgown while the resident sat in the wheelchair and as Staff B was holding [the resident's hands] so CNA could put on gown. Staff B reported the resident did spit at her and I may have spit back during my aggressive speaking. The staff member continued to report making spitting noises and I was upset I just wanted to get her changed. The statement showed Staff B continued to state [resident] was an angry bitter person. The statement showed when the Regional Director of Health Care Services attempted to address how to handle a resident with cognitive impairment Staff B raised voice, asking What do you want me to do?Am I just supposed to leave her like that? During a previous interview the NHA reported the statement was conducted with Staff B over the phone, was written verbatim and attended by the Regional Director, Director of Nursing, and NHA. Review of the staff sign-in sheets for Saturday September 14th and Sunday September 15th, 2024 showed Staff B, Registered Nurse (RN) was assigned to Resident #6's hall. Review of September Medication Administration Record (MAR) for Resident #6 showed Staff B had administered medications and documented the resident's refusals on 9/14 and 9/15/24. On 9/14 and 9/15/24 during the evening shift, Staff B had documented the resident had not exhibited any behaviors related to the use of an antidepressant which included irritable. Review of Resident #6's Treatment Administration Record showed Staff B and applied both barrier cream to the resident's buttocks and peri-area and applied skin prep barrier to bilateral heels during the evening shift on both 9/14 and 9/15/24. During an interview on 9/24/24 at 12:14 p.m., Staff C, Certified Nursing Assistant (CNA) reported Resident #6 did get abusive and staff just walked away. When the resident refused care the aides would let the nurses know. Review of Resident #6's Behavioral Health note, dated 9/14/24 at 10:42 a.m. revealed the patient was referred to psychological evaluation and possible enrollment of behavioral health services with a history of moderate, major depressive disorder (MDD), adjustment disorder, and dementia. The patient had no history of signs/symptoms (s/s) of psychosis or mania, and no outbursts or behaviors had been reported. The note revealed the resident was dependent on staff for Activities of Daily Living (ADLs). The mental status examination showed the resident had poor insight, judgement, short- and long-term memory, and the fund of knowledge was insufficient and unreliable. The resident had a calm mood, congruent affect but did not respond or give short responses. The note showed the resident was likely not psychological appropriate due to level of memory impairment related to dementia. Review of the care plan for Resident #6 included the following focuses and related interventions: - Has self-care deficits and needs assistance completing activities of daily living (ADLs) due to (d/t) recent cerebral vascular accident (CVA), impaired visual function, stability, poor balance, and mobility. The interventions included instructions for staff to encourage and allow residents to do as much for themselves as safely able and to use of task segmentation in verbal cues as needed (PRN) to promote resident participation in completion of task. - Has a behavior problem as evidence of refusing medications and hitting the CNA with call light. A resident has episodes of yelling and cursing at the staff. Residents has episodes of displaying anger towards staff as evidence of stating get the hell out of here. Resident refused blood sugars. This focus was revised on 5/23/24. The interventions instructed staff to provide opportunity for positive interaction, attention. Stop and talk with him/ her as passing by. In addition to explain all procedures before starting and allowing to adjust to changes, if reasonable discuss behavior explain/ reinforce why behavior is inappropriate and/ or unacceptable. During an interview on 9/23/24 at 1:18 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Health Services Director (RHCD), the NHA reported at approximately 10:00 p.m. on 9/14/24 there was an incident of Resident #6 being combative with care while staff were trying to change her shirt. Staff A had asked Staff B to assist as the resident had refused care and was combative. The NHA reported despite multiple follow-ups (with resident), Staff A and B were assisting to change the resident's shirt and the resident spat at Staff B. The NHA reported Staff B spat back at the resident and held the resident's hands down during the care. Staff B was immediately suspended during the investigation. Staff B reported holding the resident's hands down as the resident was in the mechanical lift. Staff A reported Staff B spit back and the resident and Staff B spit again at each other. The NHA stated unfortunately Staff A did not report the incident right away. The NHA reported Staff B had become aggressive with the NHA, DON, and RHCD during the interview and refused to answer questions. The RHCD reported the allegation (of abuse) was verified as Staff B confirmed holding down the hands of the resident and spitting back at the resident. Review of the policy - Abuse, Neglect, and Exploitation, revised 7/23, 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. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The definition of willful per policy was the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The compliance guidelines show the facility will develop and implement written policies and procedures that: A. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; B. established policies and procedures to investigate any such allegations; and C. include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and D. established coordination with the QAPI program. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: - h. Assigning responsibility for the supervision staff on all shifts for identifying inappropriate staff behaviors. The Protection of Resident guidelines reveal the following: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim in resident's; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the residence care plan at the residence medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on observations, interviews, and record review the facility failed to ensure identification and monitoring of a BIPAP (Biphasic positive airway pressure) machine was in place for one resident (#6) out of one resident sampled. Findings included: A review of Resident #6's Admission Record revealed he was initially admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/18/24. His medical diagnoses included encounter for surgical aftercare following surgery on the digestive system, muscle weakness, abnormalities of gait and mobility, repeated falls, heart failure, and Type 2 Diabetes Mellitus without complications. An interview and observation was conducted on 04/22/24 at 10:10 AM. Resident #6 was observed to be lying in bed with his BIPAP mask on. He said he brought the BIPAP machine from home and he puts it on himself. He was observed to remove the BIPAP from his face and place it on his over bed table. Review of Resident #6's medical record on 4/22/24 at 11:15 p.m. did not reveal any orders related to a BIPAP machine. Review of Resident #6's care plan, with a revision date of 3/21/24, revealed the following: BIPAP therapy Obstructive Sleep Apnea. The goal included Resident Will Adhere to CPAP (Continuous Positive Airway Pressure) / BiPAP Regime. The interventions included BIPAP cleaning as scheduled and Encourage Resident's use of CPAP / BiPAP. An interview was conducted with the Director of Nursing (DON) on 4/24/24 at 12:58 PM. She said, We should have an order for the setting for the BIPAP and we would have the Respiratory Therapists come here weekly as well for the resident, and we should confirm the setting with home use or hospital use. Review of the facility's Noninvasive Ventilation (CPAP, BIPAP) policy, with a revision date of 7/23, revealed the following: Policy: It is the policy of this facility to provide noninvasive ventilation as per physician orders and current standards of practice. Definitions: .BiPAP, or bi-level positive airway pressure, is a similar respiratory therapy interventions that delivers an inhale pressure and an exhale pressure to provide a patent airway. It requires a machine that generates the separate pressures through a tube into a mask that fits over the nose or mouth. Policy Explanation and Compliance Guidelines: .2. The facility will obtain an order for the use of a CPAP, BiPAP, device and settings from the practitioner. 3. The CPAP, BiPAP, device must be set up and maintained by______________(specify). 4. Pay personal CPAP/BiPAP device may/may not be brought into the facility for the resident's use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use. 5. The facility will follow the manufacturer's instruction for use of the machine. .7. Document use of the machine, resident's tolerance, any skin, respiratory or other changes and response(s). 8. Follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. Only the supplier may service the machine .

Based on record review and interviews, the facility failed to ensure ongoing assessment and monitoring of the dialysis fistula (dialysis access port) before and after dialysis treatments for one resident (#37) out of three residents sampled. Findings included: On 4/22/24 at 12:19 p.m., during an observation and interview, Resident #37 was sitting in a wheelchair in her room after her dialysis appointment. She said the dialysis access port was recently changed due to bleeding from the left thigh to the right thigh. Review of Resident #37's admission record revealed an admitted [DATE] with diagnoses including End Stage Renal Disease and dependence on renal dialysis, and complication of surgical fistula (dialysis access port), onset date 3/27/24. Review of a physician orders, dated 4/19/24, revealed the following: -Resident #37 was scheduled for 1) dialysis services at a dialysis center on Mondays, Wednesdays, and Fridays; -Completion of the dialysis communication form before the resident leaves the facility for dialysis and on return to the facility after dialysis. A review of Resident #37's care plan, initiated on 7/25/22 and revised on 3/28/24, revealed the following: Focus: Hemodialysis due to renal failure. The goal: Will have immediate intervention should any signs or symptoms of complications from dialysis occur. The intervention listed include: 1) complete the dialysis communication form as ordered; 2) receives dialysis on Monday, Wednesday, and Friday; 3) monitor dialysis catheter site for signs and symptoms of infection; 4) monitor vital signs and notify the medical doctor of significant abnormalities; 5) monitor, document and report as needed any signs or symptoms of infection to access site for example, redness, swelling, warmth or drainage; 6) monitor, document and report as needed signs and symptoms of bleeding, hemorrhage, Bacteremia and septic shock. A review of the Dialysis Communication Inter-Change form dated, 4/3/24, revealed the thrill and bruit assessments, signs of bleeding and or infection, and the nurses' signature were not recorded before leaving the facility for dialysis. The thrill and bruit assessments and signs of bleeding and or infection were not recorded after returning to the facility from dialysis. A review of a physician note, dated 4/3/24, revealed intermittent swelling in the left leg and staff to notify the physician if symptoms become more pronounced. A review of the Dialysis Communication Inter-Change form dated, 4/5/24, revealed the thrill and bruit assessments, signs of bleeding and or infection and the nurses' signature were not recorded before leaving the facility. The thrill and bruit assessments and signs of bleeding and/ or infection was not recorded on return to the facility. A review of the progress note dated, 4/5/24, revealed the thrill and bruit assessments, signs of bleeding and or infection were not recorded. A review of the Dialysis Communication Inter-Change form dated, 4/8/24, revealed pre dialysis thrill and bruit assessments, signs of bleeding and/or infection and the nurses' signature were not recorded on the form for Resident #37 A review of a progress note, dated 4/8/24, revealed Resident #37 was admitted to the hospital from the dialysis center. A review of a hospital consultation report dated, 4/8/24 at 2:12 p.m., revealed a clot was removed from the left thigh dialysis fistula. A review of a progress note, dated 4/10/24 at 11:17 p.m., revealed Resident #37 arrived at the facility by ambulance. An assessment of the fistula was not recorded. A review of progress notes, dated 4/11/24 at 7:20 a.m., revealed Staff C, RN, ADON entered the residents room and observed copious amounts of [NAME] red blood and clots from the left dialysis fistula. A review of the Medical Certification for Medicaid Long-term Care Services and Patient Transfer form, (3008), dated 4/19/24, revealed a primary diagnosis of hemorrhage of hemodialysis fistula of left thigh. A review of the Dialysis Communication form dated, 4/22/24, revealed pre dialysis vital signs, thrill and Bruit assessment, signs of bleeding and or infection and the nurses' signature were not recorded. The post dialysis thrill and bruit assessments, signs of bleeding and or infection and the nurses' signature were not recorded for Resident #37 A review of the progress notes, dated 4/22/24, revealed the dialysis fistula assessment was not recorded. A review of the Dialysis Communication form dated, 4/24/24, revealed pre dialysis vital signs, thrill and Bruit assessment, signs of bleeding/ infection, and nurses' signature were not recorded. The post dialysis, thrill (feel fistula vibrations) and bruit (listen to the fistula with a stethoscope) assessments and signs of bleeding and/ or infection were not recorded for Resident #37 A review of the progress notes, dated 4/24/24, revealed assessment of the dialysis fistula was not recorded for Resident #37. On 4/24/25 at 3:23 p.m. an interview was conducted with the DON and, Staff C, RN, ADON. Staff C, RN, ADON said the facility expects staff to complete fistula thrill and bruit assessments every shift and document in the progress notes. She stated the thrill and bruit assessments should be documented on the dialysis communication form before a resident leaves the facility for dialysis and after returning to the facility from the dialysis center. Staff C, RN, ADON said care plans, medication lists, and a completed dialysis communication form are sent with each dialysis center appointment. She said the nursing staff are expected to complete a dialysis communication form before and after each dialysis treatment. She stated all information should be documented on the form as follows: -Prior to leaving the facility: Resident's name, date and time, name of the dialysis facility, blood pressure, temperature and pulse, bruit and thrill assessment, signs of infection or bleeding, and the nurses' signature. -On return to the facility: time returned, blood pressure, temperature and pulse, bruit and thrill assessment, signs of infection or bleeding, and the nurses' signature. On 4/25/24 at 9:08 a.m. an interview was completed with the DON and Staff C, RN, ADON. The DON said after Resident #37 returned from the hospital on 4/10/24, a dialysis fistula assessment was not recorded before she was transported to the hospital by ambulance. On 4/25/24 10:04 a.m. an interview was conducted with Staff D, Certified Nursing Assistant (CNA). She said some dialysis education has been provided, not a lot. Staff D, CNA, said if bleeding was noted or the bandage was wet the nurse would be notified. On 4/25/24 at 10:07 a.m. an interview was conducted with Staff E, Staff E, LPN said the education the facility provides is primarily web based. She said the dialysis fistula should be monitored every shift and documented in the progress note. Staff E said on 4/11/24 shortly after her shift started, she heard Resident #37 call out help, help. When she entered the resident's room she observed blood around the fistula area. Staff E immediately called the Director of Nursing (DON) and Staff C, Registered Nurse (RN), Assistant Director of Nursing (ADON) to the bedside. EMS was called to transport Resident #37 to the hospital. On 4/25/24 at 2:00 p.m. during an interview Resident #37 said, On 4/11/24 she awoke, felt her left thigh and there was blood on her hand, and her bed sheet and cover were soaked with blood. Review of Nursing education, dated 2023, titled Dialysis revealed the following steps must be completed on dialysis days for every dialysis resident. -Dialysis communication filled out completely pre and post dialysis -Dialysis communication sheet sent with resident to dialysis -Pre and post vital signs taken and recorded in the Electronic Health Record (EHR) and dialysis communication sheet. -Pre and post weights taken and recorded in the EHR and dialysis communication sheet. -Document Pre and post Thrill and Bruit in the EHR and dialysis communication sheet. -Post dialysis ensure the communication sheet is filled out completely. If not, do so now. Call the dialysis center if needed. -Make sure a nurse's note is written when the resident leaves and returns. -Skin assessment completed pre and post dialysis transportation and documented in PCC. -Care Plan and dialysis order is up to date and includes: --Transportation, Center name, location, phone number; times and days of dialysis; fistula dressing is in place, clean and intact; check thrill and bruit; vital signs pre and post; dialysis emergency procedures if bleeding is present (apply pressure).

Based on observations, interviews, and record review, the facility failed to ensure pressure relieving boots were applied to prevent the worsening of a pressure wound for one resident (#101) out of one resident sampled for pressure wounds. Findings included: Review of Resident #101's Admission Record revealed he was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] from an acute care hospital. His diagnoses included dysphagia following unspecified cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, repeated falls, speech and language deficits following a cerebrovascular disease. An observation was conducted on 04/22/24 at 10:16 AM. Resident #101 was observed to be in bed eyes closed, feet resting on the mattress, with his green air boots on the chair next to his bed, not in use. An observation was conducted on 4/23/24 at 10:41 AM. Resident #101 was observed to be lying on his right side, in bed, with the sides of both feet resting on the air mattress, with his eyes closed, with his green air boots in the chair next to his bed, not in use. Review of Resident #101's physician orders revealed a start date of 4/21/24 with no end date for Air boots to heels while in bed. every shift for Wound/Prevention. A physician's order with a start date of 3/20/24 and no end date to float heels while in bed every shift for Pprevention [sic]. Review of Resident #101's Treatment Administration Record (TAR) revealed on 4/22/24 the day, evening, and night shift nurses signed off as administered on Resident #101's physician order for Air boots to heels while in bed. every shift for Wound/Prevention. On 4/23/24 the day and evening documented the air boots were administered. Review of Resident #101's April Medication Administration Treatment (MAR) and TAR did not reveal documentation related to float heels while in bed every shift for Pprevention [sic]. Review of Resident #101's Wound Assessment Report, dated 4/22/24, revealed the following: Location: left lateral heel: measurements: Length:1.07cm width: 1.00 cm LxW: 1.07cm2 Depth: 0.00cm Etiology: Pressure stage/severity: unstageable acquired in house: No date wound acquired 3/30/24 wound status: stable .Periwound: Fragile, Denuded, Macerated Exudate Amount: Moderate Exudate Description: Serosanguineous Odor Post Cleansing: None Treatment Dressing Change Frequency: Daily, and PRN [as needed] Clean Wound With: Cleanse with normal saline Primary Treatment: Betadine Other Dressings: float heels, Bordered foam, LAL [low air loss]/Heel Boots . Review of Resident #101's care plan, revised on 4/5/24, revealed the following: [Resident #101] has Coccyx and left lateral heel pressure related areas requires assist with bed mobility & repositioning, nutritional risk continues, and he continues to be at risk for further breakdown. The goals included Will not have further breakdown on coccyx. Will not develop additional skin breakdown/pressure injuries. The interventions included: air boots to heels while in bed with a creation date of 4/22/24. apply house lotion to dry skin PRN assist resident as needed with bed mobility & repositioning on rounds during cares & PRN check Braden scale encourage good nutritional intake float heels while in bed OLO air loss alternating pressure air mattress observe resident's skin condition during routine care every shift and report any findings to nurse ooh cushion in wheelchair treatments as ordered weekly skin checks An interview was conducted on 4/24/24 at 1:18 p.m. with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON said the facility does not have a restorative nursing program. It is the responsibility of the staff to put on pressure-relieving boots. She said staff is either the nurse, Certified Nursing Assistant (CNA), or therapy. An interview was conducted on 4/24/24 at 1:45 p.m. with Staff G, CNA. She said the CNA's are responsible for putting on air boots and they are trained by therapy on how to do it. Review of the facility's Assistive Devices policy, revised on 7/23, revealed the following: Policy: The Purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: .2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care. 3. The facility will provide assistive devices for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement. .5. Direct care staff will be trained on the use of the devices as needed to carry out there roles and responsibilities regarding the devices. Training will also include when to refer to other departments for changes in condition or problems with the device. 6. A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed .

Based on observations, interviews, and record review, the facility failed to ensure a paid caregiver for one resident (#205) out of 40 sampled residents had specific competencies and skill sets necessary to care for the resident's care needs. Finding included: Resident #205 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following a cerebrovascular disease affecting the right dominant side, abnormalities of gait and mobility, and muscle weakness. An interview was conducted on 04/22/24 at 10:54 AM with Resident #205's private caregiver. The private caregiver was observed to have gloves on and said she had just taken the resident to the bathroom. She said the resident arrived at the facility last Thursday after having a stroke and went to the hospital. She said the resident had weakness on her right upper and lower extremities. The private caregiver said she had been transferring the resident to the bathroom, giving the resident showers, and helping get her dressed because when she put the call light on it would take 20-30 minutes for anyone to answer the light and when she would ask the staff if they can take the resident to the bathroom or give her a shower the staff told her the other private caregivers were doing the care so she could provide the care too. She asked the staff if they needed to see her transfer the resident and they said no they didn't need to see her do it. The private caregiver said she is a home health aide who works for a private agency and has not had any formal training as a Certified Nursing Assistant (CNA) or nurse. An interview/observation was conducted on 04/23/24 at 10:50 AM with Resident #205 and her private caregiver. The private caregiver was observed to have gloves on and said the resident was in the bathroom. The private caregiver said this morning when she arrived, she got the resident up, cleaned her up, dressed her and brought her to bathroom. The private caregiver said she arrives in the morning and leaves at 4:00 p.m. then the family comes. The private caregiver said yesterday (4/22/24) she provided all the activities of daily living (ADL) care the resident required without help from the staff until she left at 4:00 p.m. An interview was conducted on 04/23/24 at 10:50 AM with Staff H, CNA. He said this is his first time working with Resident #205. He said the resident has a private person in the room who comes after breakfast and gets the resident up, dressed, cleaned up and takes the resident to bathroom. He said he was not sure how many people the resident requires to transfer but he Would assume one person. An interview was conducted on 4/24/24 at 12:55 p.m. with the Director of Nursing (DON). She said our staff should be providing the residents care but the residents do have the opportunity to have a private caregiver. The DON said she was not aware Resident #205 had a private caregiver and she would have to follow up to find out if the private caregiver has had any training on how to perform care. An interview was conducted on 4/24/24 at 1:05 p.m. with the Nursing Home Administrator (NHA) who said he was aware Resident #205 had a private caregiver, but he did not know if the private caregiver had any formal training to provide ADL care. He said the facility staff should be performing ADL care. An interview was conducted on 4/24/24 at 1:45 p.m. with Staff G, CNA. She said Resident #205 has a private aide and the private aide provides the resident with all the ADL care, so she doesn't have to. A phone interview was conducted on 4/25/24 at 3:30 p.m. with Resident #205's family member. He said Resident #205 has had four strokes and the most recent one was a month ago which lead her to the facility after a hospital stay. He said since the stroke Resident #205 had become very weak and was unable to get up. He said he has a private caregiver come for seven hours during the day and four hours at night. He said the number one reason for the private caregivers is to provide hygiene to Resident #205. He said his only concern with the facility is the staff are supposed to provide the care to Resident #205, but the private aides are providing the ADL care when the facility staff do not provide the care. An interview was conducted on 4/25/24 at 3:33 p.m. with the NHA. He said he spoke to the private caregiver and asked if she had been pushing the call light, she said she had not been using the call light since the first day when it took a long time for the staff to come. He said he also found out she had been working out of her scope and our staff should be providing care. He said, so the private caregiver was educated that she is essentially a companion, and our staff should be providing all the care. The NHA interpreted the facility's policy titled Home health services CCRC's guidelines on limitations of service dated 02/05and said Resident #205 caregiver would be considered a Non-certified Personal Assistant (3) and her duties are limited to Provides domestic services such as: light housework, assistance with grooming, letter writing, companionship and assistance with transportation.

Based on observations, interviews, and record review, the facility failed to ensure one resident (#72)with Post Traumatic Stress Disorder (PTSD) was assessed to identify triggers which may re-traumatize the resident out of 40 residents sampled. Findings Included: On 04/25/2024 at 2:00 and 3:00 p.m., Resident #72 was observed sitting with a group of residents attending an activity. Review of the Admission Record for Resident #72 showed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Type 2 Diabetes Mellitus without complications, and post-traumatic stress disorder, unspecified. Review of a Minimum Data Set assessment, dated 03/1/2024, showed a Brief Interview for Mental Status (BIMS) score of 09 indicating Resident #72 was moderately cognitively impaired. Review of Resident #72's care plan showed the following: Focus: The resident has a history of Trauma related to a traumatic event as a child related to verbal and physical abuse, requires ongoing intervention to maintain psychosocial well-being. Resident # 72 is followed by Huntington Behavioral Services as needed. Dated initiated 02/13/2024, revised dated 02/13/2024. Interventions: Administer medications as ordered arrange for Licensed Mental Health Providers/ Psych services as indicated, encourage resident to expression of feelings and concerns in a safe space, encourage involvement in care planning decisions, encourage supportive relationships with family and friends, keep informed about changes to care, life at the facility, etc., observe for possible signs and symptoms of depression, anxiety, sleep disturbance substance abuse. Date initiated 02/13/2024. The care plan did not identify triggers specific for the resident which could potentially re-traumatize the resident. During an interview on 04/25/2024 at 3:30 p.m., with the Social Services Director, SSD, she stated Trauma Screening is part of the resident's admission assessment. She stated the resident or their representative are asked questions to determine if the resident has a history of trauma. Based on the assessment a Trauma care plan is created and then the resident is referred to psychiatric services. She stated they can identify what the resident triggers are when they ask the resident or their representatives to provide the resident trauma background information. She stated the resident triggers are then documented so staff would know how to properly assist the resident with their care needs. She stated Resident # 72 was verbally abused by a family member, but we did not ask her or her daughter if the resident had any triggers. The SSD stated she would have to reassess the resident to find out what triggers the resident. During an interview on 04/25/2024 at 3:45 p.m., with the Director of Nursing., she stated the Social Services Director reports to her, and she did not know much about Trauma Informed Care. She stated If we need any information about Trauma Informed Care, she would have to refer to her Social Services Director. She stated her expectations are residents with Post Trauma Stress Disorder triggers should be identified during their initial assessment so staff can be informed and provide better care for their residents. During an interview on 04/25/2024 at 3: 45 p.m., with the Nursing Home Administrator, he stated he will have the Social Services Director reassess all their residents who have Post Traumatic Stress Disorder, PTSD. He stated they will update the resident care plans and provide education to their staff related to trauma informed care. Review of facility policy titled, Trauma Informed Care, revised 6/2023, showed the following: Policy: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and /or re-traumatization. 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Triggers- specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identity ways to mitigate or decrease the effort of the trigger on the resident and will be added to the resident care plan.

Based on interviews and record review, the facility failed to ensure an accurate care plan was in place related to Advanced Directives for one resident (#101) out of 40 sampled residents. Findings included: Review of Resident #101's Admission Record revealed he was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] from an acute care hospital. His diagnoses included dysphagia following unspecified cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, repeated falls, and speech/language deficits following a cerebrovascular disease. A review of Resident #101's physician orders revealed an order, dated 4/21/24, for Do Not Resuscitate (DNR). Review of Resident #101's medical record revealed a State of Florida's Do Not Resuscitate Order, dated 3/29/24, completed by Resident #101's Durable Power of Attorney (POA) and signed by the physician on 3/30/24. Review of Resident #101's care plan, dated 4/5/24, revealed the following: Residents Advanced Directives have been reviewed and include: Full Code. The goal revealed, Resident's wishes will be honored. The interventions revealed: Assist resident/family as needed for completion of Advanced Directive documents where applicable. Educate resident/family regarding Advanced Directives. Make resident's wishes known through care continuum. Notify physician if any change in condition. Review resident's advanced directives quarterly. An interview was conducted on 04/23/24 at 09:10 AM with Staff F, Assistant Social Worker. She said upon admission Advanced Directives are obtained by the social services department and after hours the nurses obtain the Advanced Directives, then the social services department follows up. She stated the social services department develops Advanced Directive care plans and the care plans should be accurate and reflective of the information obtained. An interview was conducted on 4/24/24 at 1:20 p.m. with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON and the NHA confirmed Advanced Directive care plans should be reflective of the physician order. The NHA said staff are to go to the physician order in the electronic medical record and in the hard chart to obtain the physician ordered code status. The care plan is not where the staff go to determine code status. Review of the facility's Comprehensive Care Plans policy, revised date 7/23, revealed the following: Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. .Policy Explanation and Compliance Guidelines: .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment .

Based on observations, interviews and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and eighteen errors were identified for three residents (#130, #79, #131) observed. These errors constituted a 66.67% medication error rate. Findings included: 1. On 2/14/22 at 10:28 a.m., an observation of medication administration with Staff J, Registered Nurse (RN), was conducted with Resident #79. Staff J. was observed dispensing the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Loratadine 10 milligrams (MG) tablet orally -[MEDICATION(S)] Prop 50 micrograms (MCG) Spray 1 spray each nostril -[MEDICATION(S)] 20 mg. 1 tablet orally -Tumeric 1 capsule orally -[MEDICATION(S)] 2.5 MG 1 tablet orally During the dispensing of the medications for Resident #79, Staff J said the [MEDICATION(S)] 1,000 microgram (MCG)/milliliter (ML) was not in the medication cart. Staff J confirmed the medication was not administered. She confirmed the medication pass was late and not within the 6-10 a.m. window. She stated, I am not sure of the policy. Review of Resident #79's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 1,000 MCG/ML VL inject 1ML intramuscular (IM) Every 14 days marked 'N' indicating Not Given -Loratadine 10 MG tablet give 1 tablet by mouth for allergies AM -[MEDICATION(S)] 20 MG tablet 1 tablet by mouth daily for Hypertension AM, -[MEDICATION(S)] 2.5 MG Tab 1 Tablet by mouth Twice a Day for Hypertension -[MEDICATION(S)] Prop 50 MCG Spray 1 Spray each nostril Twice Daily -Tumeric give 1 capsule by mouth daily for deficiency AM A review of Nurses Notes dated 2/14/22 at 1:09 p.m. entered by Staff J for Resident #79 identified the following, Resident medication were late this morning, MD [physician] and resident aware. 2. On 2/14/22 at 10:43 a.m., an observation of medication administration with Staff J (RN) was conducted with Resident #131. Staff J was observed dispensing the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)]-HCTZ 37 5-25 MG 1 tablet orally -Probiotic 10 billion cell cap 1 capsule orally -[MEDICATION(S)] 50 MG tablet 1 tablet orally On 2/14/22 at 10:50 a.m., during an interview Staff Member J stated, Medications were late for 6-10 AM window for Resident #131. The medication pass is completed for hallway 300. A review of Resident #131 February Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)]-HCTZ 37.5-25 MG 1 tablet by mouth daily in AM for Hypertension -Probiotic 10 billion cell cap 1 capsule by mouth daily in AM for colon health -[MEDICATION(S)] 50 MG tablet 1 tablet by mouth every morning DX Hypertension AM 3. On 2/14/22 at 10:50 a.m. during an interview, Staff J requested to review and confirm medication administration for Resident #130. Staff J stated, I missed Resident #130 and did not see she did not receive her medications for 6:00 AM-10:00 AM. On 2/14/22 at 10:53 a.m., an observation of medication administration with Staff J (RN) was conducted with Resident #130. Staff J was observed dispensing the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] ER 50 MG 1 orally -[MEDICATION(S)] 20 mg 1 tablet orally -[MEDICATION(S)] 50 MG tab 1&1/2 tablets (75mg) orally -[MEDICATION(S)] 2.5 MG tablet 1 tablet orally -[MEDICATION(S)] 200 mg 1 tablet orally -[MEDICATION(S)] 400 MG tablet 1 tablet orally -Vitamin D3 400 unit tablet 1 tablet orally -Ocular Vitamin 1 tablet orally -[MEDICATION(S)]-[MEDICATION(S)] 2%-0.5% instill 1 drop Right Eye On 2/14/22 at 11:00 a.m. following dispensing of medication to Resident #130, Staff J stated, Since I am new I do not know the policy for here. I should have shared with the residents they received the medication late today and I will need to check the policy to contact the Physician's for the residents. A review of Resident #130 February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] ER 50 MG tablet Give 1 tablet by mouth one daily AM -[MEDICATION(S)] 400 MG tablet 1 tablet by mouth daily for infection AM -[MEDICATION(S)] 200 MG tablet 1 tablet by mouth daily for [CONDITION(S)] -[MEDICATION(S)]-[MEDICATION(S)] 2%-0.5% Instill 1 drop in Right Eye twice daily for [CONDITION(S)] AM, HS -[MEDICATION(S)] 2.5 MG tablet give 1 tablet by mouth twice daily for A Fib AM, HS -[MEDICATION(S)] 20 MG tablet give 1 tablet by mouth twice daily for [CONDITION(S)] -Calcium Carb 500 MG tab Chew 1 tablet by mouth twice a day for vitamin deficiency AM, HS -Vitamin D3 400 Unit Tablet 1 tablet (400 Units) by mouth twice a day for risk for malnutrition -[MEDICATION(S)] [MEDICATION(S)] Tablet 1 tablet by mouth twice a day for risk for malnutrition AM, HS -[MEDICATION(S)] 50 MG tab 1 & ½ tablets (75 MG) by mouth twice a day for hypertension Review of a facility provided policy titled Medication Errors Policy and dated 7/20 identified: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. 2. The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. 5. Medication timing errors will be determined by utilizing the facility's policy relating to dosing schedules. Review of The Facility's Medication-time guidelines document, undated, indicated: #a. medication time for AM medication administration as 06h00-10h00 (6-10am), #d. identifying AM for BID30, (twice a day) medication times as 6AM-10AM for medication schedules. In an interview conducted on 2/14/22 at 3:28 p.m. with Staff J, she confirmed the medications were administered outside the facility's identified range for morning medications and would be considered administered late. An interview with the Director of Nursing (DON) was conducted on 2/15/22 at 1:10 p.m. She stated, Medication schedule for AM order at this facility is currently 6:00-10:00 AM window, if medications are administered outside that timeframe for AM medications they would be untimely. On 02/16/22 10:13 AM an interview was attempted with the facility's Consultant Pharmacist via phone. A voicemail was left; however, a return call was not received by completion of the survey.

Based on observation, interview, and policy review the facility failed to provide a safe environment related to ensuring two of thirteen egress fire exit doors were secured, locked, and monitored to prevent a possible unwitnessed resident exit. Findings included: 1. An interview on 02/15/2022 at 2:34 p.m. with the Nursing Home Administrator (NHA) regarding an unwitnessed exit event in August 2021, and an unwitnessed exit event in September of 2021, involving Resident #7, revealed the resident exited the facility through the egress fire exit door located by the employee time clock. Resident #7 was found in the area directly outside of the egress fire door by staff uninjured. An observation on 02/14/2022 at 1:17 p.m., revealed an egress fire exit door, located by the employee timeclock in between the kitchen and the therapy gym, was alarming. No employee or resident was observed outside of the egress door, nor were any employees or residents observed in the hallway at the time of door alarming. Upon pushing the alarming egress door, the door immediately opened to the outside of the building. A kitchen aide was observed to exit from the kitchen area with a meal cart and did not address the alarming egress door. A second staff member was observed walking past the alarming egress door towards the activities area. The staff member did not stop to address the alarming door. Photographic evidence was taken of the alarming door, and the pathway outside of the door leading to a parking lot area. At 1:20 p.m. on 02/14/2022, the Admissions Coordinator walked up to the alarming egress door and said, I heard the alarm and am going to turn it off. Upon the first attempt at entering in the egress alarm code, it did not work. The Admissions Coordinator walked away into the side office area and returned at 1:21 p.m., entering in a code and turning off the door alarm. The Admissions Coordinator stated that employees would use this exit to go on lunch break. The door functioned by pushing on the door handle. After 15 seconds the door would unlocked, and the alarm would sound. The door would not automatically re-lock until the keycode was put in. During this interview the Admissions Coordinator confirmed the expectation was any staff member alerted to the alarm door would address the alarm. She stated she thinks a staff member walked out of the egress door. 2. An interview on 02/14/2022 at 1:44 p.m. with the Director of Nursing revealed the expectation was that staff would respond to a door alarming and verify if a resident exited through the alarming door by going outside. Staff were to only enter and exit from the front entrance door. The DON stated she thinks that an employee exited from the side door that was alarming because . saw the employee standing outside by the door. On 02/14/2022 at 2:59 p.m. an observation of an employee exiting from the fire egress door by the employee time clock occurred. The employee walked through the door outside, and the door alarm began sounding. The employee was observed walking away from the unlocked door towards the parking lot. At 3:01 p.m. two additional employees were observed walking up to the alarming door and exiting. A staff member entered a keycode to lock the alarming door after the two additional employees walk through it. On 02/14/2022 at 3:45 p.m. the Nursing Home Administrator (NHA) confirmed that the egress fire exit door by the employee time clock should not be used by employees to exit the facility. However, staff would sometimes use it because it was a direct path to the employee parking lot. 3. A walk-through of the facility with the Maintenance Director to verify the functionality and security of the facility egress fire exit doors occurred on 02/16/21 at 8:41 a.m. During the walk-through an egress fire exit door located by room 112 on the rapid recovery unit was found to be unlocked, and not alarming. When pushed, the egress door immediately opened to back of the facility without alarming. The Maintenance Director stated the pathway outside of the egress door lead around the building to the security guard entrance area. The Maintenance Director stated there was no reason for the door to be unlocked and not sounding. 4. A document review of How to check Nursing Care Doors, dated 02/2022, revealed five steps to check an egress door. 1. Push the door to ensure that it is locked. 2. Start a timer at the same time that you press against the door. 3. The door should release at 15 seconds. 4. Reset the door alarm. 5. Check that the Maglock has engaged. A policy review of Safe and Homelike Environment, dated 07/2020, revealed In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the residents 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 . Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' room, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.

Based on observation, record review, and interview, the facility failed to treat residents with respect and dignity related to one (Resident #230) of six residents with an indwelling catheter who did not have a privacy cover on the urine drainage bag, on two (02/13/2022 and 02/15/2022) of four survey days. Findings included: On 02/13/2022 at 10:49 a.m., an observation of Resident #230 revealed the resident had an indwelling urine catheter, with the drainage bag not covered by a privacy cover, and the bag was visible from the room door and hallway. On 02/15/2022 at 9:49 a.m., an observation of Resident #230 revealed the resident had an indwelling urine catheter, with the drainage bag not covered by a privacy cover, and the bag was visible from the room door and hallway. During an interview on 02/15/2022 at 9:54 a.m. with Staff A, Certified Nursing Assistant (CNA), she confirmed the drainage bag did not have a privacy cover. In an interview with Staff B, Registered Nurse (RN) on 02/15/2022 at 10:05 a.m., he said it was the facility's policy to ensure a urine catheter drain bag was covered. Review of the clinical record for Resident #230 showed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, dated 01/31/2022, did not reveal an intervention related to the preservation of the resident's dignity and placement of a privacy cover on the catheter drain bag. On 02/15/2022 at 1:02 p.m. during an interview with the Director of Nursing (DON), she stated it was her expectation the indwelling catheter drain bag was covered with a vanity cover to preserve the resident's dignity. A facility-provided policy titled 'Catheter Care' and dated '7/20' was reviewed; it did not address the use of a privacy cover for the catheter drain bag. A facility-provided policy titled 'Resident Rights' and dated '7/20' was reviewed; it revealed, the resident has the right to be treated with respect and dignity. It did not address the use of a privacy cover for the catheter drain bag.

Based on record review, interviews, and policy review, the facility did not ensure the advance directive wishes were implemented for one resident (#35) of eighty-three residents reviewed for advance directives. Findings included: A review of the face sheet in the admission record for Resident #35 revealed he was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (minimum data set) assessment dated [DATE] reflected a BIMS (brief interview for mental status) score of thirteen, indicating his cognition was relatively intact. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record located at the nurses' station on the unit where Resident #35 resided on 2/14/22, revealed a laminated bright green paper in the front of the record with FULL CODE marked on it. On 2/14/22 at 10:11 a.m., an interview was conducted with Resident #35's nurse, Staff K, LPN (licensed practical nurse). Staff K, LPN said you could locate the residents' code status on the computer or in the chart. It says code status and it will tell you if they are a DNR or full code. Staff K, LPN checked Resident #35's electronic medical record and said he was a full code. Staff K also checked the paper record located at the nurses' station and presented the laminated bright green sheet of paper in the front of the chart indicating full code. During the interview the electronic medical record was reviewed with Staff K, LPN who confirmed there was an order dated 2/8/22, which read patient wishes to sign DNR. Staff K, LPN said on paper he is a full code. Technically he is a full code. She said she would do full resuscitation. On 2/14/22 at 10:26 a.m., an interview was conducted with Staff F, ADON (assistant director of nursing), unit manager. Staff F said he probably put the order in the computer. The nurse practitioner was in and ordered the DNR. She had the resident sign the form. She had a conversation with him and had him sign. The resident signed it on 2/8 and the doctor signed it on 2/11. Staff F presented the State of Florida Do Not Resuscitate Order form with Resident #34's signature on it, dated 2/8/22. Further review of the document reflected the physician had signed the form on 2/11/22. Staff F, ADON unit manager said until it was approved by the physician it was not in effect. We have to have the completed form. Staff F said he spoke to the nurse practitioner. She told him about it on 2/8. We have folders here for physician communication with anything the physician needs to sign. Staff F, ADON unit manager confirmed there was an order in the medical record located at the nurses' station that indicated patient wishes to sign DNR. The order was signed by a PA (physician's assistant). Staff F said the order should be followed pretty quick. It should be faxed to notify the physician it was here and that he needed to sign it. The order was the eighth, and the physician signed it on the eleventh. Staff F said he was not sure what the delay was. The order would have been faxed. He did not know if the physician got it on the eighth. He may have come in on the eleventh and signed it. On 2/14/22 at 10:30 a.m., an interview was conducted with Staff L, case manager RN (registered nurse). Staff L said if there was a result or anything the doctor needed to know, telephone orders, or anything that needed a physician signature, it went in their folder for a signature. The nurse notified them if there was an abnormal lab or X-ray finding. The nurse wrote on the result that the doctor was notified, with the date, time, and what the doctor said. The DNR's were faxed immediately if there was a need. At 10:45 a.m. on 2/14/22 an interview was conducted with the DON (director of nursing). She said, We should notify the doctor we have a resident that wishes to have a DNR so that they can also sign it, which I believe the ADON did. I think they faxed it to him. The resident's physician was the medical director. He signed the DNR on the eleventh when he was here. He might have wanted to have a discussion with the resident first before he signed it. I would hope that they would call him. The DON said she was not sure if the nurse practitioner for [Insurance Company Name] would have called his doctor. The resident's doctor was here every week. On 2/14/22 at 12:41 p.m., a telephone interview was conducted with Resident #35's attending physician. He explained that the process was to handle those requests the same day. He said he did not recall if the facility reached out to him. He assumed they did. He believed they faxed it to him. He said he should have signed it that day. He believed the policy was to sign it that same day. He heard about this this morning. He said he should have signed it. On 2/14/22 at 12:54 p.m. a follow up interview was conducted with the DON. The DON said she wrote down a note that Resident #35's physician was going to sign it on Thursday. That was 2/9. She said she always wrote notes on things to follow up on. Resident #35's physician usually came in on Thursdays. He did not come to sign it until Friday. The DON said she would assume the ADON would follow up on it. He sent the fax and he was the nurse manager. That DNR snuck in Friday, most likely after we left. A review of the policy, Residents' Rights Regarding Treatment and Advance Directives, dated 7/20, reflected 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. Policy Explanation and Guidelines: 6. The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate. 7. 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 advance directives. 8. 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. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record ands communicated to the interdisciplinary team and staff responsible for the resident's care. 11. Should the resident refuse treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] a. what the resident refused. b. The reason for the refusal. c. The advice given to the resident about the consequences of refusing. d. the offering of alternative treatments. e. The continuation of providing all other services.

Based observation, interview, and record review, the facility failed to implement the care plan for one (Resident #34) of two residents sampled for vision and hearing. The facility staff failed to offer Resident #34 their eyeglasses on three of three observed days. The failure of the staff to offer Resident #34 their eyeglasses per the care plan, resulted in a failure to identify Resident #34's eyeglasses were missing. Findings included: On 02/13/22 at 12:45 p.m., Resident #34 was observed lying in bed under the covers saying help . is someone going to help? Upon interviewing the resident, Resident #34 stated her stomach hurt and assistance was needed. The resident's call light was within reach, however, Resident #34 said I can't see [it] . The location of the call light for the resident was explained and the resident pressed the call light button for assistance from staff. Resident #34 said, I hate this thing [referring to the call light button], I can't hear it. Further observation of the resident revealed her without eyeglasses. An observation of the resident's direct vicinity revealed no eyeglasses within the resident's reach. A review of Resident #34's Facesheet revealed current medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #34's minimum data set (MDS), dated [DATE], revealed the resident had a brief interview for mental status score of 8, indicating moderate cognitive impairment without behaviors of inattention or disorganized thinking. Resident #34 had moderately impaired vision and used corrective lenses. A review of Resident #34's Care Plan, revealed a problem onset date of 07/22/2020 with a goal and target date of 03/16/2022 for Decreased vision related to [CONDITION(S)], [CONDITION(S)] and vision loss to left eye. Approaches for this problem area included ensuring that eyeglasses are in place/being worn by the resident during waking hours and ensuring that eyeglasses are appropriate strength/type for resident's needs. A follow-up interview on 02/14/2022 at 10:13 a.m. with Resident #34 revealed she had eyeglasses but had not worn them in a while, stating that . things go missing for me a lot. Resident #34 stated she had notified someone a while ago that her eyeglasses were missing. An observation of Resident #34 on 02/15/2022 at 10:00 a.m. revealed the resident not wearing eyeglasses. An interview on 02/15/2022 at 10:26 a.m. with Staff C, Registered Nurse (RN) revealed the certified nursing assistants (CNAs) were responsible for offering and putting a resident's glasses on if they had them. An interview on 02/15/2022 at 10:44 a.m. with Staff D, CNA revealed she had worked with Resident #34 before but was unsure if the resident had glasses or not. Staff D, CNA stated if the resident did have glasses, they would be inside the nightstand drawers. Staff D, CNA looked inside the resident nightstand drawers and was unable to find eyeglasses. During this observation Resident #34 said, my glasses have been missing for a while. Staff D, CNA stated she was unsure where the eyeglasses would be. An interview on 02/15/2022 at 10:52 a.m. with Staff E, CNA revealed she had worked with Resident #34 for a while, and had not seen the resident wearing eyeglasses. An interview on 02/15/2022 at 1:15 p.m. with the Nursing Home Administer (NHA) and the Director of Nursing (DON) confirmed the plan of care should be implemented and followed. Both the NHA and DON stated they were unaware the resident was missing her eyeglasses. The NHA and DON confirmed that if the plan of care had been followed, facility staff would have identified the resident's eyeglasses were missing. A policy review of Hearing and Vision Services, dated 07/2020, revealed It is the policy of this facility to ensure that residents have access to and received proper treatment and assistive devices to maintain vision and hearing abilities . 1. the facility will utilize the comprehensive assessment process for identifying and assisting a resident's vision and hearing abilities in order to provide person-centered care. This process includes: resident's vision and hearing abilities in order to provide person-centered care. This process includes: a. Obtaining history from medical records, the family, and the resident regarding hearing and vision abilities; b. MDS and care assessments; c. Ongoing monitoring of sensor problems; d. Care plan development and implementation, and e. Evaluation . 5. Employees will assist the resident with the use of any devices or adaptive equipment needed to maintain vision or hearing. A policy review of Comprehensive Care Plans, revised 07/2020, revealed It is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residence medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally- competent and trauma-informed . 3. The comprehensive care plan will describe, at a minimum, the following a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 5. the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the residents needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review, the facility failed to obtain and verify laboratory results for a physician ordered urinalysis (U/A) for one (Resident #6) of two residents sampled for urinary tract infections. Findings included: Resident #6's minimum data set (MDS), dated [DATE], revealed the resident was severely cognitively impaired, required extensive assistance for toilet use, and had occasional urinary incontinence. A review of Resident #6's Department Notes, dated 01/19/2022 at 12:36 p.m. revealed CNA [certified nursing assistant] reports resident weeps upon urination. ARNP [advanced registered nurse practitioner] visited and order received for UA, C&S [urinalysis culture and sensitivity]; straight cath [catheter] if needed. A review of Resident #6's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed on 01/19/2022 at 10:00 p.m. a check mark; which indicated the urinary sample was collected to complete the physician order. In an interview on 02/14/2022 at 11:07 a.m., with Staff C, Registered Nurse (RN), she stated once a laboratory (lab) service was ordered, and the results were received, it was uploaded into the online medical chart. If the lab result was not in the online medical chart, it could also be found in the resident's hard paper chart, the physician folder awaiting review, or in the online lab result file. A review of the online lab result system revealed the last lab result for Resident #6 was on 01/04/2022. Staff C, RN stated there were no other lab results available after 01/04/2022 for Resident #6 related to a urinalysis. On 02/14/2022 at 2:26 p.m., Staff F, Assistant Director of Nursing (ADON) stated during an interview that laboratory services were ordered by the physician, a nurse would input the order into the online system, and the laboratory sample was obtained and sent to a lab by a nurse. The results of the labs were reviewed by the physician for further guidance. The ADON reviewed Resident #6's online medical chart and hard paper chart. The ADON confirmed a lack of lab results related to Resident #6's physician ordered urinalysis. On 02/14/2022 at 2:55 p.m., an interview with both Staff F, ADON and Staff C, RN confirmed Resident #6's online medical chart indicated a urinalysis sample was collected on 01/19/2022, however, there was no indication within the resident's medical files that the lab was completed, nor the results obtained and reviewed. On 02/14/2022 at 2:56 p.m. the Director of Nursing (DON) confirmed the facility process for ordering, obtaining, and reviewing a physician ordered laboratory service. The DON stated even if a resident's lab result did not indicate abnormal findings, the results should still be confirmed and filed into the resident's medical chart. A follow-up interview on 02/14/2022 at 4:22 p.m. with the DON confirmed Resident #6's urinalysis lab was not completed. The facility was unable to verify if the urinalysis lab sample was . even collected and done. The DON spoke with the nurse who signed off on collecting the urinalysis lab sample and the nurse was unable to verify if the lab was collected. A policy review of Provision of Physician Ordered Services, dated 07/2020, revealed The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . 1. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless they report fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the residence clinical record. A policy review of Laboratory Services and Reporting, dated 07/2020, revealed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialists in accordance with state law . 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services . 6. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record. 7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.

Based on interviews, record reviews, and review of facility policy, the facility failed to provide completed documentation related to consent and administration of pneumococcal and influenza vaccinations for 5 out of 5 sampled residents (#1, #2, #3, #4, #5) Findings included: Resident #1 was admitted on [DATE], per the Admission Record. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] Vaccine Administration Record showed pneumonia checked and a signature of a person authorizing the vaccine. The signature was not dated. It showed it was received on 12/19/2017 and the pneumonia vaccine was administered on 12/19/2017. The Resident Flu Vaccine Administration Record, showed influenza checked. The signature showed a verbal consent with a family member, but the signature was not dated. The form showed the flu vaccine was given on 10/23/20. Resident #2 was admitted on [DATE], per the Admission Record. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] Vaccine Administration Record showed pneumonia was not checked and a signature of a person authorizing the vaccine. The signature was dated 10/28/2019. The Resident Flu Vaccine Administration Record, showed influenza checked. The signature showed a verbal consent with a family member, but the signature was not dated. The form showed the flu vaccine was given on 10/23/20. Resident #3 was admitted on [DATE], per the Admission Record. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] Vaccine Administration Record showed pneumonia was not checked and showed declined as resident was current. A signature of a person authorizing the vaccine was present. The signature was not dated. The Resident Flu Vaccine Administration Record, showed influenza vaccine was not checked. A signature was present, but the signature was not dated. The form showed the flu vaccine was given on 10/21/20. Resident #4 was admitted on [DATE], per the Admission Record. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] Vaccine Administration Record showed pneumonia check was noted and a signature of a person authorizing the vaccine via verbal consent. The signature was dated 10/23/20. The Immunization List showed the Pneumococcal vaccine was given on 12/19/2013. The Resident Flu Vaccine Administration Record, showed influenza checked. The signature showed a verbal consent with a family member, but the signature was not dated. The form showed the flu vaccine was given on 10/23/20. Resident #5 was admitted on [DATE] with an original admitted [DATE], per the Admission Record. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] Vaccine Administration Record showed pneumonia was not checked and was declined by the resident. The signature was not dated. The Resident Flu Vaccine Administration Record, showed influenza checked. The signature showed a consent from the resident, but the signature was not dated. The form showed the flu vaccine was given on 10/21/20. During an interview on 08/09/21 at 2:45 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) verified that the [MEDICATION(S)] Vaccine Administration Record and the Resident Flu Vaccine Administration Record were not filled out completely and lacked dates as to when the forms were actually signed for consent. The NHA stated that it did not occur on their watch (NHA and DON). NHA state that it would be part of the QAPI. The Corporate Regional Nurse stated at 2:55 p.m. that they as a company were reviewing the forms and these for flu and pneumonia vaccines would be on the list to review. She stated that she understood there was not a date to show when the signature occurred. The question was asked if they knew if they had permission to give the vaccinations since there were no dates on the consents, no answer was given. Record review of the facility's policy, Pneumococcal Vaccine (Series, dated 7/20 showed it is our policy to offer our residents, staff, and volunteer workers immunization against Pneumococcal disease in accordance wit current CDC guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for Pneumococcal immunization upon admission. 2. Each resident will be offered a Pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. 3. Prior to offering the Pneumococcal immunizations, each resident or resident's representative will receive education on regarding the benefits and potential side effects of the immunization. 4. The resident / representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. 7. The resident's medical record shall include documentation that indicates at a minimum, the following: a. the resident or resident's representative was provided education regarding the benefits and potential side effects of Pneumococcal immunization. B. the resident received the Pneumococcal immunization or did not receive due to medial contraindication or refusal. Record review of the facility's policy, Influenza Vaccination, dated 7/20 showed Policy Explanation and Compliance Guidelines: 1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against influenza disease in accordance with national standards of practice. 2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated. 4. Following assessment for potential medical contraindications, influenza vaccinations may be administered accordance with physician-approved standing orders. 5. Prior to administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative will be provided a copy of CDC current vaccine information statement relative to influenza vaccination. 7. Individuals receiving the influenza vaccine or their legal representative, will be required to sign a consent form prior to administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record. 9. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal.