Every finding on record at Windsor Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to secure medications when unattended for 3 of 5 hall rooms observed. Findings include: 1) During an observation on 8/24/2026 at 10:25 AM of Resident #117's room on the bedside table there was an unattended tube of clotrimazole cream 1% (an antifungal cream used to treat skin infections). During an observation on 8/25/2026 at 1:18 PM of Resident #117's room there was an unattended tube of clotrimazole cream 1% on the bedside table. 2) During an observation on 8/24/2026 at 10:50 AM of Resident #6's room there was one unattended vial of ipratropium bromide and albuterol sulfate 0.5mg (milligram)/ 3 mg per 3 ml (milliliters) solution (relaxes and opens the air passages) on the bedside table. During an interview on 8/25/2026 at 1:30 PM Staff D, License Practical Nurse (LPN) stated medications cannot be left at the bedside During an interview on 8/25/2026 at 1:55 PM the Director of Nursing stated, Medications are not allowed to be left at the bedside. Review of the policy and procedure titled, Medication Storage with a last review date of 1/20/2026 read, 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 manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. General guidelines: a. All drugs and biologicals will be stored in locked compartments 9. i.e. (example), medication carts, cabinets, drawers, refrigerators, medication rooms). 2) During an observation on 8/24/26 at 9:21 AM of Resident #5's room unattended Antifungal Powder (used to treat fungal and yeast infections) was observed on the bedside table. During an observation on 8/24/26 at 9:52 AM of Resident #31's room unattended Dermal Wound Cleanser (used to stop of slow the growth of microorganisms and prevent infection) was by the resident's television. During an observation on 8/25/26 at 12:43 PM of Resident #75's room unattended Dermal Wound Cleanser was on the bedside table. During an interview on 08/25/2026 at 12:23 PM the Director of Nursing (DON) stated, Medications are not allowed at bedside. During an interview on 8/25/26 at 12:46 PM Staff A, Registered Nurse stated, The Dermal Wound Cleanser should be stored in the med cart. 3.) During an observation on 08/24/2026 at approximately 1:00 PM of Resident #10's room there were two unattended tubes of cream in a plastic bag, the bag had a prescription label attached. Review of Resident #10's physician orders dated 07/17/2026 read, Calcipotriene External Cream 0.005% (Calcipotriene) (used to treat plaque psoriasis on the skin). Apply to affected areas topically one time a day for psoriasis may mix with betamethasone cream (used to reduce redness, swelling, itching, and discomfort from various skin conditions). Dated 07/10/2026 Betamethasone Dipropionate External Cream 0.05 % (Betamethasone Dipropionate (Topical), Apply to Affected area topically one time a day to affected area for psoriasis. During an interview on 08/25/2026 at 12:23 PM the DON stated, Medications are not allowed at bedside. During an interview on 08/25/2026 at 2:55 PM Staff A, Registered Nurse stated, I go in [Resident #10's name] room every two hours for her feedings every 4 hours. I did not apply the cream today; we had a treatment nurse today. I have not applied the creams since the last time I worked. Review of Resident #10's MAR (Medication Administration Record) for August 2026 Staff A had documented Calcipotriene application at 0900 on 08/19/2026, 08/20/2026, and 08/25/2026. Review of the policy and procedure titled, Medication Storage with a last review date of 01/20/2026 read, Policy: 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 manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation moisture control, segregation, and security. a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on interview and record review, the facility failed to ensure the resident's formulation of a Do Not Resuscitate (DNR) directive was accurately maintained for 1 of 3 residents, Resident #49, reviewed for advanced directives. Findings include: Review of Resident #49's physician orders documented Resident #49 had a DNR [do not resuscitate] order dated 07/23/2026 with an end date of 08/10/2026. Review of Resident #49's State of Florida Do Not Resuscitate Order form was dated 12/20/2012 and was signed by Resident #49 and the physician. Review of Resident #49's care plan dated 05/26/2026 read, [Resident #49's name] has an established DNR (DO NOT RESUSCITATE) order in place. Review of Resident #49's hospital record documented the resident returned to the facility on [DATE]. Review of Resident #49's 3008 transfer form from the hospital, dated 08/17/2026 read, Advanced Care Planning Advanced Directive was checked yes. Living will was checked yes and Do Not Resuscitate (DNR) was checked yes. Review of Resident #49's physician order dated 08/16/2026 read, FULL CODE. During an interview on 08/24/2026 at 12:27 PM, the Director of Social Services stated, [Resident #49's name] went out to the hospital on August 8th and returned on August 16th. I was out on vacation at that time. Resident #49 was a DNR when she went out. I see an order for full code now. I just looked at the 3008 and Resident #49 should be DNR. During an interview on 08/27/2026 at 9:47 AM, the Director of Nursing stated, We review admissions every morning and go over the 3008 to make sure the code status is correct. There is no one that really covers for [Social Services Director's name] when she is off. That Monday when [Resident #49's name] returned from the hospital, we had several people that were out, and I was not here either. Review of policy and procedure titled, Standards and Guidelines: Advanced Directives Code Status review date 01/20/2026 read, Standard: It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations. Admission/readmission: Code Status verified upon admission with Resident/Resident Representative by admitting nurse. Nurse reviews code status with the resident/resident representative and confirms decision with the attending physician (MD), osteopathic physician (DO) autonomous nurse practitioner (NP) or physician assistant (PA).

Based on observation, interview, and record review the facility failed to ensure the development and implementation of a care plan to meet the residents' medical needs for 2 of 8 residents, Residents #72 and #10, reviewed for care plans.Findings Include: Review of Resident #72's medical record documented diagnosis to include urinary tract infection, chronic kidney disease, and dementia.During an observation of Resident #72 on 08/24/2026 at 9:22 AM a 1000 ml (milliliter) bag of IV (intravenous) fluids solution 0.9% was hanging on a pole in the room. Resident #72 was not observed with an IV insertion site.During an interview on 08/26/2026 at 9:07 AM Staff M, LPN (Licensed Practical Nurse) stated I am aware Resident #72 is to be encouraged to drink water. The night shift is responsible for getting fresh cups each night. Resident #72 is continent and does not need to call for assistance to the bathroom, so I am not aware if she is urinating and how often. Review of Resident #72's Care Plan did not include a Focus for Hydration to include goals and interventions.During an interview on 08/26/2026 8:45 AM Staff J, RN (Registered Nurse) from MDS (Minimum Data Set) department stated she had recently updated the care plan in preparation for a care plan meeting with Resident #72's family tomorrow. Staff J, RN stated the resident does not have a hydration focus on her care plan.Review of Resident #72's progress note authored by Staff D, LPN dated 08/11/2026 at 22:20 (10:20 PM) read, peripheral IV was placed to residents left arm, when she pulled it out within about 10 min (minutes). Resident refused to let this nurse place another peripheral IV. Resident was not able to receive fluids via IV, pushing fluids PO (by mouth). MD (Medical Doctor) notified.Review of Resident #72's progress note authored by Staff N, RN dated 08/12/2026 at 10:22 AM read, Resident drank 90 cc (cubic centimeters/approximately 1/3 cup) of water at this time. Review of Resident #72's Change in Condition form dated 8/11/2026 Summarize: Noted elevated BUN (blood urea nitrogen) 52, creatinine 1.60 GFR (glomerular filtration rate) 30 (results indicate a moderately to severely decreased kidney function). Recommendation from Primary - IVF (intravenous fluids) and follow up labs.Review of Resident #72's physician order dated 04/15/2026 read, Encourage Fluid Intake every shift for CKD (chronic kidney disease).Review of Resident #72's Change in Condition form dated 03/25/2026 at 0000 (12:00 midnight) read, Abnormal labs BUN 36 Creatine 1.58 (results indicate reduced kidney filtration efficiency) Start 2 L (2 liters) Normal Saline. Insert Midline (peripheral intravenous catheter inserted into a large vein in the upper arm, with the tip resting near the armpit instead of the heart). Recommendation of Primary - Start 2 L Normal Saline. Insert Midline.During an observation on 08/24/2026 at 9:15 AM of Resident #10's room, on the entrance door there was a sign that read, Contact (the room is under contact precautions, with rules used to stop the spread of infection). Outside of the room by the closed door was a container holding PPE (personal protective equipment).Review of Resident #10's Care Plan did not include a Focus for Contact Precautions with goals, and interventions.During an interview on 08/26/2026 at 11:07 AM Staff J, RN/MDS stated, typically contact precaution residents are care planned for contact precaution. C. Aureus (Candida Aureus - an emerging fungus that can cause severe, often multidrug-resistant, infections) is a fungus that patients with poor immune systems get and is very contagious.Review of Resident #10's physician orders dated 05/07/2026 read, Contact Precautions every shift for C. Auris.Review of the policy and procedure titled, Care Plans, Development, Baseline and Comprehensive with a last review date of 01/20/2026 read, Standard: To ensure a resident has a baseline care plan to meet immediate needs within forty-eight (48) hours of admission and to further ensure a comprehensive person-centered care plan is developed and implemented to include measurable objectives and timetables to meet the needs of the resident. Comprehensive Care Plan: 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.6. The comprehensive, person-center care plan will: g. Incorporate identified problem areas.

Based on observation, interview, and record review the facility failed to ensure necessary assistance with activities of daily living (ADL), specifically bathing and personal grooming for 2 of 3 residents, Residents #1 and #82, sampled for ADL care for dependent residents. Findings include: 1) Review of Resident #85's clinical record documented the resident was admitted on [DATE] with diagnosis to include quadriplegic (paralysis of all four limbs). During an observation on 8/24/2026 at 10:14 AM, Resident #85 was observed lying in bed. The resident's beard was overgrown and unkempt. During an interview on 8/24/2026 at 10:14 AM Resident #85 stated, I'm supposed to receive a bed bath three times weekly. I would be fortunate if I received a bed bath every few weeks. Staff have told me at times that linen was unavailable and therefore the bath could not be provided. I am supposed to be shaved when I get a bed bath, now my beard is so long that it rubs against my chest and is uncomfortable. During an observation on 8/25/2026 at 12:10 PM, Resident #85's facial hair remained unkempt and overgrown. During an observation on 8/26/2026 at 8:50 AM, Resident #85 was lying in bed. A family member was in the room visiting the Resident. The resident's beard remained visibly stubbled and overgrown. During interview on 8/26/2026 at 08:50 AM Resident #85 stated he received a bed bath the previous evening but was not shaved. He stated that the CNA (certified nursing assistant) told him she would return to shave him but did not return. The resident further stated that the beard caused discomfort to his chest. During an interview on 8/26/2026 at 12:30 PM Staff E, CNA stated, No, I did not shave him (Resident #85) last night I thought the barber did it. During interview on 8/26/2026 at 1:55 PM, the Director of Nursing (DON) stated, [Resident #85's name] should receive a shave when he gets his bed baths. A request was made for documentation related to Resident #85 provided shaving, none was received. Review of Resident #85's care plan read, Focus: [Resident #85's name] is non-compliant with Plan of Care aeb [as evidenced by] Refuses to get out of bed for showers but accepts bed baths. Refuses to get showers outside of the hours of 3 PM to 5 PM and the latest he will take it is at 8 PM. Goal: [Resident #85's name] will accept at least two bed baths weekly. Interventions: Offer bed baths on [Resident #85's name] shower days. Review of Resident #85's August 2026 ADL (activities of daily living) bathing task report bathing was documented as not applicable on 8/1/2026, 8/8/2026, and 8/13/2026 and documented on 8/11/2026 and 8/20/2026 the resident refused. The form does not provide documentation for shaving. 2) Review of Resident #1's medical record documented the resident was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (a condition that causes impairment to one side of the body) following cerebral infarction (stroke) affecting right dominant side. During an observation on 08/25/2026 at 2:30 PM, Resident #1 was lying in bed. The Resident was wearing a brace on the right hand for right hand contracture. The fingernails of the right hand were touching the resident's palm and had a brown substance underneath the nail bed. The resident's fingernails on both hands were long and extended approximately three (3) centimeters past the fingertips. During an interview on 08/25/2026 at 2:30 PM, when the resident was asked if she would like her nails trimmed, and the resident nodded yes. Review of Resident #1's dermatology note dated 07/13/2026 read, Educated patient at length on importance of proper management of skin when dealing with pruritus [an irritating sensation that makes you want to scratch your skin]. Reviewed importance bathing or showering with lukewarm water, using mild hypoallergenic soaps, moisturizing skin while it is still damp, avoiding harsh fabrics, avoiding fabric softeners, and keeping nails short. Review of Resident #1's care plan dated 07/24/2026 read, [Resident #1's name] has an ADL [activities of daily living] self-care performance deficit r/t [related to] CVA [stroke] w/ [with] hemiplegia, right upper extremity flaccid [limp], cerebrovascular disease, arthritis and HF [heart failure]. Interventions: PERSONAL HYGIENE: sub [substantial] /max assistance with personal hygiene. During an interview on 08/25/2026 at 2:35 PM, the Assistant Director of Nursing observed Resident #1's fingernails and stated that nail care should be completed every Sunday. The Resident's nails should have been trimmed. During an interview on 08/27/2026 at 9:37 AM Staff I, APRN [Advanced Practice Registered Nurse] stated, [Resident #1s name] has been evaluated by dermatology a couple of times for pruritus. I have noticed that her nails are really long when I have seen her. I don't recall if I have spoken to the staff about it. Review of the policy and procedure titled, Activities of Daily Living (ADLs) with a last review date of 01/20/2026 read, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.

Based on interview and record review the facility failed to ensure physician orders for the administration of hypertensive medication were followed as prescribed for 1 of 3 residents, Resident #23, sampled for unnecessary medications.Findings Include:Review of Resident #23's physician order dated 07/27/2026 read, Carvedilol Tablet 3.125 mg (milligrams). Give 1 tablet by mouth two times a day for hypertension [high blood pressure] HOLD IF SBP [systolic blood pressure] LESS THAN 110/HR [heart rate] LESS THAN 60.Review of Resident #23's MAR (Medication Administration Record) for August 2026 read, Carvedilol 3.125 mg. Give 1 tablet by mouth two times a day for hypertension. HOLD IF SBP LESS THAN 110/HR LESS THAN 60. Start Date: 02/27/2026 at 2100 [9:00 PM]. The MAR provided for the documentation of the blood pressure results and pulse; there was no documentation of the blood pressure or heart rate/pulse for 08/01/2026 through 08/26/20-26 at 0900 (9:00 AM]. There was documentation on 08/26/2026 at 2100 with results of the blood pressure documented as 104/69 and the heart/pulse rate as 70; with a chart code of 4 = Vitals Outside of Parameters for Administration. During an interview on 08/25/2026 at 2:28 PM Staff M, LPN (Licensed Practical Nurse) stated she does the vitals every time she gives Carvedilol for Resident #23. It will pop up and I can't click off the medication without entering the blood pressure.During an interview on 08/26/2026 at 3:30 PM the ADON (Assistant Director of Nursing) stated there is no documentation that is consistent with the administration of Carvedilol. It must have been an oversight [not completing the vital signs]. The meds have been given without checking the parameters. Review of the policy and procedure titled, Medication Administration with a last approval date of 01/20/2026 read, Policy: Medication are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 8. Obtain and record vital signs, when applicable or per physician orders. When applicable hold medications for those vital signs outside the physician's prescribed parameters. Example guidelines for Medication Administration (unless otherwise ordered by physician) this list is not all-inclusive. Medications requiring vital signs prior to administration - Digitalis, Lanoxin, Digoxin, Anti-Hypertensives.

Based on record review and interview, the facility failed to ensure pain medication was administered per physician orders for 1 of 3 residents, Resident #2, reviewed for pain management. Findings include: During an interview on 8/24/2026 at 10:20 AM Resident #2 stated she did not know exactly when, but this weekend that she did not receive her oxycodone 30 milligrams which she gets normally every 6 hours and additional pain medications for chronic pain. She has arthritis, back pain, and knee pain. I have increase pain all over my body when I do not get my scheduled dose and I will have abnormal sensation in my upper extremities. I know they should order my medication before I run out, not wait until they are giving me the last pill.Review of Resident #2's clinical record documented an admission date of 1/10/2024 with diagnosis to include chronic pain syndrome, long term use of opiate analgesic, and opioid dependence.Review of Resident #2's physician order dated 9/11/2025 read, Oxycodone HCL (hydrochloride) oral tablet 30 mg [milligrams] controlled drug level 2. Give 30 mg by mouth every 6 hours for chronic pain, non-acute.Review of Resident #2's care plan dated 2/28/2024 read, Has acute/chronic pain r/t [related to] chronic pain syndrome, DM [diabetes mellitus], obesity, hx [history] of CVA [cardiovascular accident] left sided weakness, muscle spasms, nerve pain, heartburn/gas, spasticity. Interventions: Administer analgesia as per orders. Receives opioid analgesicsReview of Resident #2's Medication Administration Record (MAR) for August 2026 documented Oxycodone has a blank space for August 23, 2026, for the 6:00 AM dose and is coded as 9 [held code reads see nurses note] for 00:00 (12:00 AM midnight) dose on August 24, 2026. During an interview on 08/26/2026 at 4:34 PM the Director of Nursing stated that if we run out of oxycodone or any narcotic, we can get a pull code and if we have that amount in our (name of medication dispensing machine) we can pull it out of the (name of the medication dispensing machine). If it is not in the (name of the medication dispensing machine - the ordered dosage amount) it is a little more complicated because then you have to get a provider to give a one-time code for the medication to be pulled in a different milligram to equal the dosage that is prescribed. (Resident #2's name) needs 2 - 15 mg pills to equal the prescribed order, which is 30 mg. The process that is followed to make sure that we do not run out of medication is to order at least three days in advance. So, let's say she gets it three times a day then that would be when the pack gets to 9 pills. The staff would call the pharmacy . The pharmacy, if the pharmacy already has the script on file they will send the medication. If there is no script on file, then the nurse has to call the doctor, and the physician has to send another script to the pharmacy. The resident (Resident #2) should never run out of oxycodone.During an interview on 8/27/2026 at 08:46 AM Staff H, Licensed Practical Nurse (LPN) stated [Resident #2] had ran out of her oxycodone and it was coded 9 because I did not have the medication. I called the physician; I don't remember who I talked to. The oxycodone was on its way, and it was going to be delivered. We need a code to pull the narcotics from the (name of medication dispensing machine) because there was only fifteens [15 mg oxycodone] in there and her dose is 30 mg which doesn't match. So, I could not pull it from the pyxis. I received her delivery that morning [August 24th] and she was medicated.During an interview on 8/27/2026 at 09:45 AM Staff I, Advance Practice Registered Nurse (APRN) stated he was not on call this weekend, so he did not receive a call about [Resident #2's name]. The staff can get medication out of the contingency machine if they run out on the cart. Missing that one dose [August 24th, at midnight] would not cause her harm but she could have increased pain by missing just one dose. She needs to be medicated as ordered. If she was without it [oxycodone] for several days, then she could start having withdrawal symptoms.Review of the policy and procedures titled Pain Management with a last review date of 1/20/2026 read, The intent of this policy is that each resident receives necessary care and services that is in accordance with professional standards of practice, the resident's care plan, and the resident's choice. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Review of policy and procedures titled Pharmacy Services with a last review date of 1/20/2026 read, 1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. 6. The facility will maintain a limited supply of medications for emergency or after-hours situations in accordance with facility policy and applicable state laws.

Based on observations and interviews, the facility failed to repair or replace broken floor tiles in 3 of 6 residents' rooms reviewed for a safe, comfortable and homelike environment.Findings Included During an observation on 12/30/2025 at 9:25 AM in room [ROOM NUMBER], there were four cracked floor tiles with brown discoloration adjacent to the doorway on the interior of the room, with one of the tiles raised slightly above the floor level. (Photographic evidence obtained). During an observation on 12/30/2025 at 9:38 AM in room [ROOM NUMBER], one cracked floor tile was observed adjacent to the doorway in the interior of the room (Photographic evidence obtained). During an observation on 12/30/2025 at 9:42 AM in room [ROOM NUMBER], there were four broken floor tiles adjacent to the interior doorway of the room, with two chipped sections, and extensive cracking to the outer edges of the tiles. (Photographic evidence obtained). During an interview on 12/30/2025 at 4:30 PM the Maintenance Director stated, I complete a monthly patient room inspection. Due to the fact the facility is over [AGE] years old, it is difficult to find a vendor that has these specific tiles in stock, however, I think I have a few tiles left to fix the floors. During an interview on 12/30/2025 at 6:05 PM, with the Administrator, the photographic evidence was reviewed. The Administrator acknowledged the tiles were in disrepair.

Based on observations, interviews, and record reviews, the facility failed to implement a person-centered comprehensive plan of care for 2 of 4 residents reviewed for respiratory care services. (Resident #212 and #24) Findings include: 1.) Review of Resident #212's admission record documented diagnoses that included chronic respiratory failure, disease of pulmonary vessels, and chronic obstructive pulmonary disease (COPD). During an observation on 4/14/25 at 10:45 AM, Resident #212 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an observation on 4/15/25 at 8:30 AM, Resident #212 was observed sitting up in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an interview on 4/15/25 at 8:32 AM, Resident #212 stated, I have not changed my oxygen level. I need it to breath; it is my lifeline. Review of the resident centered comprehensive plan of care for Resident #212 read, [Resident name] is at risk for respiratory complications r/t [related to] chronic respiratory failure and COPD. Administer oxygen as ordered. Review of Resident #212's physician order dated 4/3/25 reads, Oxygen at 4 liters / min via Nasal Cannula. Humidification every shift for COPD. During an interview on 4/15/25 at 8:45 AM, Staff A, Licensed Practical Nurse stated, The oxygen is set at 3[liters], it should be 4 [liters], we check the levels throughout the day, I just haven't gotten to her yet. 2.) Review of Resident #24's admission record documented a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During an observation on 4/14/25 at 11:15 AM, Resident #24 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. During an observation on 4/15/25 at 7:30 AM, Resident #24 was observed lying in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. Review of Resident #24's physician order dated 3/18/24 reads, Oxygen at 3 liters/minute via nasal cannula every shift related to Chronic Obstructive Pulmonary Disease. Review of the comprehensive plan of care for Resident #24 dated 4/4/25 reads, Resident is at risk for respiratory complications r/t [related to] chronic respiratory failure and COPD. Administer oxygen as ordered. During an interview on 4/16/25 at 9:05 AM, the Director of Nursing stated, We should always follow the physicians orders, and the care planned interventions when running oxygen. Review of the policy titled, Oxygen Administration with a review date of 1/21/2025 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency.

Based on observations, interviews, and record reviews, the facility failed to ensure that respiratory care and services were provided consistent with professional standards of practice for 2 of 4 Residents (Resident #212 and Resident #24). Findings include: Review of Resident #212's admission record documented a diagnosis that included chronic respiratory failure, disease of pulmonary vessels, and chronic obstructive pulmonary disease (COPD). During an observation on 4/14/25 at 10:45 AM, Resident #212 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an observation on 4/15/25 at 8:30 AM, Resident #212 was observed sitting up in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an interview on 4/15/25 at 8:32 AM, Resident #212 stated, I have not changed my oxygen level. I need it to breath; it is my lifeline. Review of Resident #212's physician order dated 4/3/25 reads, Oxygen at 4 liters / min [minute] via Nasal Cannula. Humidification every shift for COPD. During an interview on 4/15/25 at 8:45 AM, Staff A, Licensed Practical Nurse, stated, The oxygen is set at 3 [liters], it should be 4 [liters], we check the levels throughout the day, I just haven't gotten to her yet. 2) Review of Resident #24's admission record documented a primary diagnosis of chronic obstructive pulmonary disease. During an observation on 4/14/25 at 11:15 AM, Resident #24 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. During an observation on 4/15/25 at 7:30 AM, Resident #24 was observed lying in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. During an interview on 4/15/25 at 8:32 AM, Resident #24 stated, I do not know how to change my O2 [oxygen] level. If I have trouble breathing, I call the nurse. Review of Resident #24's physician order dated 3/18/24 reads, Oxygen at 3 liters/minute via nasal cannula every shift related to chronic obstructive pulmonary disease. During an interview on 4/17/25 at 8:30 AM, the Director of Nursing stated, Oxygen should be running at the physician ordered rate. Nurses should check the levels when giving meds [medications]. Review of a policy titled, Oxygen Administration with a review date of 1/21/2025 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency.

Based on record review and interview, the facility failed to ensure the resident's physician and resident's representative were notified of a change in condition for 1 of 3 residents reviewed for change in condition, Resident #1. Findings include: Review of Resident #1's admission record showed the resident was admitted on [DATE] with the diagnoses to include encephalopathy, muscle weakness, anemia, dementia, and osteoporosis. During an interview on 10/3/2024 at 10:47 AM with the Director of Nursing (DON), review of the facility's documentation showed on 9/15/2024 at 11:30 AM Resident #1 was found on the floor with a knot on the left side of head, and the resident had previous fall on 9/13/2024 at around 3:00 PM. Review of nursing progress notes for 9/15/2024 did not contain documentation that Resident #1's physician or representative was notified of the resident's fall and injury. Review of Resident #1's hospital transfer form dated 9/16/2024 at 7:45 AM read, s/p [status post] fall x 2. During an interview on 10/3/2024 at 3:07 PM, Staff A, Registered Nurse (RN), stated, I was taking care of the resident [Resident #1] and I thought that [Staff B, LPN's name] called the doctor and family member. I did not call the doctor or the family. During an interview on 10/3/2024 at 3:20 PM, Staff B, LPN, stated, I was getting off of shift and did not call the doctor or the family. [Staff A, RN's name] was the resident's nurse and I thought he called the doctor and family. During an interview on 10/3/2024 at 3:44 PM, the DON stated, The doctor and the family are to be notified of any change in condition and an additional fall is a change in condition. No call was placed to the doctor or to the family to inform of the fall on 9/15/2024. Review of the facility policy and procedure titled Notification of Changes revised in January 2024 read, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notifications. Circumstances requiring notification include: 1. Accidents a. Resulting in injury, b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . 4. A transfer or discharge of the resident from the facility.

Based on observations, interviews and record review, the facility failed to ensure foods and beverages were stored in a safe and sanitary manner in 2 of 2 nourishment areas. Findings Include: A tour of the facility nourishment rooms was completed on [DATE] beginning at 9:48 AM with the Certified Dietary Manager (CDM). On [DATE] at 10:15 AM in the east nourishment room freezer there was an opened, unlabeled, undated container of Mystic Bahama Blueberry drink, an unlabeled, undated ,d+[DATE] eaten bar of a chocolate [NAME] Daz Ice cream on a stick, 3 bags of unlabeled, undated brown frozen bananas, 1 unlabeled, undated cheddar broccoli casserole, 2 unlabeled Styrofoam cups filled with an unidentifiable substance, and there was a reddish-brown sticky substance on the interior of the freezer bottom shelf. On [DATE] at 10:30 AM in the west nourishment room there were 11 pudding cups with an expiration date of [DATE] written in blue ink on the lid, there were 10 applesauce cups with an expiration date of [DATE] written in black ink on the lid, there was one unlabeled, undated piece of Chocolate pie with whipped topping on the top shelf of the refrigerator. In the bottom left drawer of the refrigerator there was 1 Taco Bell paper bag undated and unlabeled with an unidentifiable substance inside. There was a brownish sticky substances on the top and bottom glass shelves of the refrigerator, and on the bottom shelf of the refrigerator door (Photographic Evidence Obtained). On [DATE] at 10:45 AM during an interview Staff C, Licensed Practical Nurse, Unit Manager stated, It is the certified nursing assistant's responsibility to keep the nourishment rooms clean. Sometimes the house keepers will tidy it up, and Dietary is responsible for the cleaning of the refrigerators and freezers. On [DATE] at 10:15 AM during an interview, the CDM stated, The nursing staff is responsible for cleaning the nourishment rooms, dietary will stock the items, and remove the expired items. I expect the Dietary staff to go and check those rooms daily, and wipe down anything that needs it. Review of the policy and procedure titled Use and Storage of Food Brought in by Family or Visitors with a reviewed date of [DATE] reads, Policy: It is the right of the resident of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Policy Explanation and Compliance Guidelines: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and date. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. B. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff. Review of the policy and procedure titled Refrigerators and Freezers with a review date of [DATE] reads, Policy Statement. This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation. 10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Pantry refrigerators/freezers should be monitored by all facility staff and cleaned at least daily and more often as necessary. A cleaning schedule for the nourishment rooms was requested, information was not provided.

Based on observations, interviews, and record reviews, the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 1 (Resident #31) of 4 residents reviewed for respiratory care and 1 (Resident #96) of 4 residents reviewed for discharge. Findings include: During an observation on 1/29/24 at 12:00 PM, Resident #31 had a C-PAP [continuous positive airway pressure] machine at her bedside. During an observation on 1/30/24 at 8:00 AM, Resident #31's face was reddened around the nose and cheeks. During an interview on 1/30/24 at 8:00 AM, Resident #31 stated she had just taken her C-PAP off from wearing it during the night. During an interview on 1/31/24 at 10:10 AM, Resident #31 stated that she does not know how long she has been using a C-PAP, but the staff come in the evening and put water in the C-PAP and help her get in on her face and she sleeps with it every night. Review of Resident #31's admission record documented an admitted [DATE] with diagnoses that included congestive heart failure and obstructive sleep apnea. Review of Resident #31's physician's orders dated 11/14/23 read, CPAP setting 8.0 cmH20 [centimeter of water] at bedtime related to obstructive sleep apnea. Review of Resident #31's care plan dated 9/22/23 and revised on 11/16/23 documented Resident exhibits or is at risk for respiratory complications R/T (related to) respiratory distress due to OSA (obstructive sleep apnea) with interventions that include C-Pap as ordered for OSA. Review of Resident #31's Minimum Date Set (MDS) Quarterly assessment dated [DATE], Section O, Special Treatments, Procedures, and Programs documented Resident #31 used a non-invasive mechanical ventilator but the type of ventilator support [CPAP] was left unchecked. During an interview on 1/31/24 at 9:43 AM, the MDS Coordinator, RN, stated, the coding was a mistake due to incorrectly documenting non-invasive mechanical ventilator which disabled further questioning for a CPAP. She confirmed that the Quarterly MDS assessment dated [DATE] was inaccurate. Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual reads O0110G3. C-PAP. Check if the non-invasive mechanical ventilator support was CPAP. 40559 2.) Review of the admission record for Resident #96 documented the most recent admitted was 9/10/23 and discharged date was 11/5/23 to another nursing facility. Review of Resident #96's Minimum Data Set (MDS) Assessment Homepage documented Next Trckng/Dschrg (Tracking/Discharge): Discharge - ARD (Assessment Reference Date) 11/5/2023. Complete by: 11/19/2023 - 73 days overdue. There was no documented discharge assessment completed. Review of Resident #96's facility census report documented stop billing on 11/5/23. Review of Resident #96's discharge summary documented discharge date of [DATE] to a long-term care facility located closer to family. During an interview on 1/31/24 at 9:30 AM, Staff B, RN, MDS Coordinator, stated, The discharge MDS was not completed, and I see he [Resident #96] discharged on [DATE]. Review of the policy and procedure titled MDS 3.0 Completion, last reviewed on 1/23/24 read, Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. f. Discharge Assessment - completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD.

Based on interviews and record reviews the facility failed to ensure that residents who required blood glucose monitoring receive treatment in accordance with professional standards of practice for 1 of 3 residents review for insulin administration (Resident #77) and failed to promptly notify a physician for critical high laboratory results for 1 of 3 resident reviewed for laboratory results ( Resident #108) Findings include: Review of the admission record for Resident #108 documented diagnosis that include essential primary hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, hypothyroidism, unspecified atrial fibrillation, unspecified protein calorie malnutrition, dysphagia, adult failure to thrive, and chronic kidney disease. Review of the physician's order dated [DATE] reads, CBC (complete blood count), CMP (complete metabolic profile), serum magnesium, prealbumin every night shift for failure to thrive for 1 day. Review of the Lab results report for Resident #108 dated [DATE] reads, Collection date [DATE] at 6:35 AM, received date [DATE] at 11:19 AM, reported date [DATE] at 1516 (3:16 PM) Comprehensive Metabolic Panel: Critical result called to [Staff name] on [DATE] 3:04 PM by [Laboratory Staff name] Results were read back to caller. Sodium 156 meq [milliequivalent/l (liter)]. Review of the nursing progress notes for Resident #108 from [DATE] through [DATE] documented no progress notes indicating call to physician or nurse practitioner for notification of critical lab results. Review of the physician's order for Resident #108 dated [DATE] reads, Stat BMP (basic metabolic profile), CBC for hypernatremia (high sodium levels). Review of the physician's order for Resident #108 dated [DATE] reads, May insert IV (intravenous catheter). Review of the physician's order for Resident #108 dated [DATE] reads, Dextrose Intravenous Solution 5% use 2 liters intravenously every shift for abnormal labs d/c (discontinue) when complete. During an interview on [DATE] at 9:55 AM the Director of Nursing (DON) stated, I don't know why the critical lab wasn't called. I was not aware of this. All critical labs should be called immediately. I was not told that the nurse practitioner had any concerns about him or that we didn't call him about these. I don't see documentation that anyone was informed of these results before the 27th [[DATE]]. We should have called them immediately. During an interview on [DATE] at 10:19 AM, the Advanced Nurse Practitioner (APRN) stated, I was not called about these lab results, they were not called to anyone. I expect all critical labs should be called. I was displeased that was not dealt with. In hypernatremia you would expect progressive altered mental status declines and that is what I was seeing on that day. I saw him [Resident #108], I wanted the labs immediately rechecked and it [the sodium level] was the same and so I started the fluids. It is unlikely that it would have corrected itself. But I still wanted to recheck it. His diagnosis was failure to thrive, I spoke to nephew as POA (power of attorney), his sister [the resident's] had recently died and he was declining and got very depressed and was giving up. The hypernatremia was likely a result of dehydration and insufficient intake. They gave the 2 liters of fluid. I should have been notified on the 25th when the critical lab came in. It was a delay in his treatment, but I can't say whether it would have altered his course. I know with the recheck of the sodium it had not worsened; it was still 156. 2. Review of the admission record for Resident #77 documented diagnosis that included type 2 diabetes mellitus, essential primary hypertension, diverticulosis, neoplasm of ovary, cholelithiasis, fatty liver, acute kidney failure, and hyperlipidemia. Review of the physician's order for Resident #77 dated [DATE] reads, Humalog KwikPen 100 units/ml (milliliter) solution pen injector. Inject as per sliding scale; if ,d+[DATE] = 0 units, ,d+[DATE] = 2 units, ,d+[DATE] = 4 units, ,d+[DATE] = 6 units, ,d+[DATE] = 8 units, ,d+[DATE] = 10 units, ,d+[DATE]= 12 units. Notify provider if greater than 450, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for [DATE] through [DATE] documented on [DATE] at 4:30 PM a blood sugar of 488 with a chart code 9. Chart code 9 = Other / See progress notes. Review of the nursing progress notes for [DATE] document no progress note or physician notification of the elevated blood sugar. During an interview on [DATE] at 9:30 AM, the Director of Nursing (DON) stated, All physician orders should be followed, and they all should be documented correctly. They should have called the 488 [blood sugar to the doctor] and documented that they did. During an interview on [DATE] at 10:15 AM, the APRN stated, I was not aware that the blood sugar was 488 and was not called about it. I may have added additional insulin had I been called. During an interview on [DATE] at 8:45 AM, the Medical Director stated, I was not notified of a blood sugar of 488. They should have done that. Review of the policy and procedure titled Notification of Changes last review date of [DATE] reads, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial conditions such as deterioration and health, mental or psychosocial status. This may include: a. Life threatening conditions or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment.

Based on observations, interviews, and record reviews, the facility failed to administer oxygen according to physician's orders and professional standards of practice for 2 of 4 residents reviewed for respiratory care. (Resident #82 and #30) Findings include: Review of Resident #82's admission record documented diagnosis that included acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease, emphysema, nicotine dependence, non ST elevation myocardial infarction, fibroblastic disorder, and rheumatoid arthritis. Review of Resident #82's physician's order dated 11/22/2023 reads, Oxygen at 6 L (liters) N/C (nasal cannula) continuous with humidification. During an observation on 1/29/2024 at 12:46 PM Resident #82 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 4 liters per minute. During an interview on 1/29/2024 at 12:46 PM Resident #82 stated, I have not changed my oxygen level. I need it set at 6 liters and don't change it myself. During an observation on 1/31/2024 at 8:36 AM Resident #82 was observed sitting up in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 4 liters per minute. During an interview on 1/31/2024 at 2:10 PM Staff D, Registered Nurse stated, The oxygen is set at 4, it should be 6 liters, maybe he changed it. I should check on the amount running when I give meds [medications]. During an interview on 1/31/2024 at 4:05 PM the Director of Nursing stated, Oxygen should be running at the physician ordered rate. Nurses should check when giving meds. 2. Review of Resident #30's admission record documented diagnosis that include chronic obstructive pulmonary disease, age related osteoporosis, iron deficiency anemia, major depressive disorder, and anxiety disorder. Review of the physician's order for Resident #30 dated 7/16/2023 reads, Oxygen at 2 liters/minute via nasal cannula every shift related to COPD (chronic obstructive pulmonary disease). During an observation on 1/29/2024 at 9:31 AM, Resident #30 was observed sleeping in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters per minute. During an observation on 1/30/2024 at 7:43 AM, Resident #30 was observed sleeping in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters per minute. During an interview on 1/31/2024 at 2:15 PM, Staff D, RN stated, Her oxygen should be at 2 liters. I think maybe she turned it up. I have not checked it until now. No oxygen policy and procedure was provided prior to exit from facility.

Based on observations, interviews, and record review, the facility failed to label and store medications according to professional standards of practice in 2 of 4 medication carts. Findings include: During an observation of medication cart #1 with Staff E, Licensed Practical Nurse (LPN) on 1/29/2024 at 9:05 AM, there was one medication cup that contained 11 medications which had no resident identifier and no indication of what the medications were. One opened bottle of artificial tears with no opened date or expiration date. During an interview on 1/29/2024 at 9:10 AM, Staff E, LPN stated, I just left those pills in the cart because the resident was not in their room. The eye drops should be dated. During an observation of medication cart #3 with Staff F, LPN on 1/29/2024 at 9:22 AM, there was one medication cup in the drawer that contained 13 pills which had no resident identifier and no indication of what the medications were. There was one opened bottle of Dorzolamide ophthalmic solution with no opened date or expiration date. During an interview on 1/29/2024 at 9:28 AM, Staff F, LPN stated, That resident was not available right now, I shouldn't have left them, they should be labeled. I can't tell when the eye drops were opened. During an interview on 1/29/2024 at 1:30 PM, the Director of Nursing stated, All medications should be labeled. Review of the policy and procedure titled, Labeling of Medications and Biologicals last reviewed date 1/23/2024 reads, Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 2. Medication labels must be legible at all times. 4. Labels for individual drug containers must include: a. The resident's name; c. The medication name. h. The expiration date when applicable.

Based on interview, record review and review of the facility policy and procedure the facility failed to accurately and completely document within the medical record for 2 out of 3 residents reviewed for insulin administration (Resident #77 and #95). Findings include: Review of the admission record for Resident #77 documented diagnosis that included type 2 diabetes mellitus, essential primary hypertension, diverticulosis, neoplasm of ovary, cholelithiasis, fatty liver, acute kidney failure, and hyperlipidemia. Review of the physician's order for Resident #77 dated 9/26/2023 reads, Humalog KwikPen 100 units/ml (milliliter) solution pen injector. Inject as per sliding scale; if 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 352-400 = 10 units, 401-450= 12 units. Notify provider if greater than 450, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. Review of the physician's orders for Resident #77 dated 12/7/2023 reads, Lantus Solostar subcutaneous solution pen-injector 100 unit/ml (milliliter) (insulin glargine) inject 30 unit subcutaneously one time a day for T2DM (type 2 diabetes mellitus). Review of the Medication Administration Record (MAR) for Resident #77 dated 12/1/2023 through 12/31/2023 documented no blood sugar recorded on 12/23/2023 at 6:30 AM and 12/25/2023 at 6:30 AM. Both of these dates and times were blank. Review of the MAR for Resident #77 dated 1/1/2024 through 1/31/2024 Staff B, LPN documented on 1/16/2024 at 9:00 PM chart code 4 and no blood sugar was documented. Chart code 4 = Vitals outside parameters for administration. During an interview on 2/1/2024 at 8:15 AM, the Director of Nursing (DON) stated, All blood sugars should be documented. I don't know why they aren't. All documentation should be accurate. The nurse did call the doctor and got orders to hold the insulin. During an interview on 2/1/2024 the Medical Doctor (MD) stated, I was called each time that the insulin was held. 2. Review of the admission record for Resident #95 documented diagnosis that included unspecified open wound, left foot, occlusion stenosis of right anterior cerebral artery, hemiplegia affecting left dominant side, essential primary hypertension, unspecified atrial fibrillation, osteomyelitis, hyperlipidemia, cerebral infarction, and type II diabetes mellitus with hyperglycemia. Review of the physician's order for Resident #95 dated 8/11/2023 reads, Lantus Solostar 100 unit/ml (milliliter) solution pen-injector Inject 20 unit subcutaneously one time a day related to type 2 diabetes mellitus with hyperglycemia. Review of the MAR for Resident #95 dated 12/1/2023 through 12/31/2023 staff documented on 12/19/2023 at 6:30 AM 'chart code 4 for Lantus 20 Units subcutaneously. Blood sugar was documented as 134. Chart code 4 = Vitals outside of parameters for administration. Review of the nursing progress notes for Resident #95 documented no progress notes related to holding insulin or physician notification on 12/19/2023. Review of the MAR for Resident #95 dated 1/1/2024 through 1/31/2024 staff documented on 1/7/2024 at 6:30 AM chart code 4 for administration of Lantus 20 units subcutaneously. Blood sugar was documented as 108, on 1/8/2024 at 6:30 AM Staff documented chart code 4 with no blood sugar documented, and on 1/11/2024 at 6:30 AM Staff B, LPN documented chart code 9 with no blood sugar documented. Chart code 4 = Vitals outside of parameters for administration, Chart code 9 = Other/see progress notes. Review of the nursing progress notes for Resident #95 from 1/7/2024 through 1/12/2024, there were no progress notes related to holding insulin or physician notification. During an interview on 2/1/2024 at 8:15 AM, the Director of Nursing (DON) stated, All blood sugars should be documented. I don't know why they aren't. All documentation should be accurate. The nurse did call the doctor and get orders to hold the insulin. During an interview on 2/1/2024 the Medical Doctor (MD) stated, I was called each time that the insulin was held. Review of the policy and procedure titled Medication Administration last reviewed date of 1/23/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination for infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 11. Compare medication source (bubble pack, vial, etc). with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. 14. Administer medication as ordered in compliance with manufacturers specifications.

Based on observations, interviews, and record review the facility failed to perform hand hygiene during medication administration in 2 out of 5 observations consistent with accepted standards of practice. Findings include: During an observation of medication administration for Resident #78 conducted on 1/31/2024 at 8:31 AM, Staff D, Registered Nurse (RN) did not perform hand hygiene when returning from room and returning to the medication cart. Staff D unlocked medication cart, poured medications, entered Resident #78's room, checked blood pressure, and administered all medications. Staff D, RN exited the resident's room without performing hand hygiene and returned to the medication cart. During an observation of medication administration for Resident # 82 conducted on 1/31/2024 at 8:36 AM, Staff D, RN did not perform hand hygiene and prepared the residents medications, locked the medication cart, entered Resident #82's room without performing hand hygiene and administered medications. Staff D, RN exited the room and without performing hand hygiene began preparing medications for another resident. During an interview on 1/31/2024 at 12:30 PM Staff D, RN stated, Oh, I did not use hand sanitizer or wash my hands. I should have. During an interview on 1/31/2024 at 12:55 PM, the Director of Nursing (DON) stated, All staff should perform hand hygiene when giving medications. Review of the policy and procedure titled Medication Administration last reviewed date of 1/23/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination for infection. Policy Explanation and Compliance Guidelines: 4. Wash hands prior to administering medications per facility protocol and product. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Review of the policy and procedure titled Hand hygiene last reviewed date of 1/23/2024 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table. Hand hygiene table: before preparing and handling medications.

Based on observations, interviews, and record review, the facility failed to maintain equipment to be in a safe operating condition for 1 reach in refrigerator in the main kitchen. Findings include: On 1/29/24 at 9:30 AM during the initial tour of the main kitchen with the Certified Dietary Manager (CDM), an observation of the seal (gasket) was noted to be falling off of the top right-hand corner, and down the right side of the reach in refrigerator. The refrigerator was noted to have 8 oz milk cartons, Ensure nutritional supplements, vanilla pudding, and various juices sitting on the shelves. There was a thermometer that read 40 degrees in the back of the refrigerator. During an interview on 1/29/24 at 9:30 AM with the CDM, she stated, I'm not gonna [going to] hide it, the seal had just come off a couple of days ago, and the new one is on order I think. Review of a purchase order for an Arctic Air Refrigerator was obtained on 1/30/24 that showed an order was submitted on January 29, 2024 at 4:49 PM by the Maintenance Director. The purchase is pending approval. During an interview on 1/31/23 at 10:30 AM the Maintenance Director stated, I only keep work logs relating to the compressors on the refrigerators. The dietary department would keep the logs on the upkeep of the gaskets. On 1/31/23 at 12:30 PM, a request was made for the logs relating to gasket condition of the facilities refrigerators. The information was not provided. Review of the policy and procedure titled Refrigerators and Freezers with a review date of 1/23/24 reads, Policy Statement. This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation. 9. Culinary Service Manager will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene during medication administration in 5 of 6 observations of medication administration. Findings include: During an observation of medication administration on 8/9/2022 at 8:19 AM Staff A, Licensed Practical Nurse (LPN) prepared medication for Resident #67 without performing hand hygiene, donned personal protective equipment (PPE), and put on gloves without performing hand hygiene, entered the resident's room and administered the medications. Staff A did not perform hand hygiene after removing PPE, returned to the medication, and began preparing medications for another resident. During an interview on 8/9/2022 at 10:25 AM Staff A, LPN stated, I should have used the hand sanitizer before I got the PPE and gloves on, I should have washed my hands when I took it [PPE] off. During an observation on 8/9/2022 at 8:28 AM Staff C, LPN was observed in hallway checking Resident #56's blood pressure, staff was observed removing gloves and without performing hand hygiene began preparing medications for Resident #56 and administered the medications in the hallway. After administering the medications Staff C did not perform hand hygiene and began preparing medications for another resident. During an observation of medication administration on 8/9/2022 at 8:33 AM Staff C, LPN began preparing medications for Resident #54 without performing hand hygiene. Staff C administered the medications to the resident at the medication cart per resident request and did not perform hand hygiene after administering medications and beginning to prepare medications for another resident. During an observation of medication administration on 8/9/2022 at 8:55 AM Staff C, LPN began preparing medications for Resident #11 without performing hand hygiene. Staff C entered the resident's room without performing hand hygiene, assisted Resident #11 to reposition in bed and administered the medications. Staff C, left the room, returned to the medication cart, and began preparing medications for another resident without performing hand hygiene. During an observation of medication administration on 8/9/2022 at 10:40 AM Staff C, LPN completed an accucheck on Resident #25, staff assembled all equipment and entered the resident's room without performing hand hygiene, donned gloves, performed the accucheck, removed gloves, and without performing hand hygiene returned to the medication cart, obtained the medications from the cart, and returned to the resident's room. Staff C donned gloves without performing hand hygiene administered insulin subcutaneously in the right abdomen, pulling up the resident's shirt with a gloved hand. After administering the insulin, Staff C opened the 0.9% normal saline syringe, cleaned the resident's right midline catheter needleless connector for 2 seconds and administered 0.9 % normal saline, without changing gloves or performing hand hygiene between the administrations. During an interview on 8/9/2022 at 10:55 AM Staff C, LPN stated, I should have cleaned the needleless connector for longer. I should have changed my gloves and washed my hands before I flushed the midline dressing. I should use hand sanitizer before I poured meds [medications] and when I go in or out of the resident's rooms to give them meds. Review of the policy and procedure titled Hand Hygiene approval date of 1/11/2022 reads Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations in the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your tasks requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the policy and procedure titled Medication Administration approval date of 1/11/2022 reads Policy. Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 4. Wash hands prior to administering medications per facility protocol and product.

Based on record review and interview, the facility failed to conduct and submit a discharge Minimum Data Set (MDS) assessment within 14 days after completion to the Centers for Medicare Services System, including a subset of items upon a resident's transfer, or discharge for 2 (Resident #1 & Resident #2) out of 3 residents sampled for MDS assessment completion. Findings include: Review of the Admission Record for Resident #1 documented an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's progress notes documented on 04/21/22, [Resident #1's Name] will discharge home accompanied by son . Review of Resident #1's Minimum Data Set (MDS) assessments documented an Admission Medicare - 5 Day Assessment completed on 4/19/22 and accepted on 04/25/22. There was no discharge MDS Assessment located in Resident #1's electronic file. Review of the Admission Record for Resident #2 documented an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note dated 4/25/22 at 2:00 PM documented Recommendations of Primary Clinicians- send out to hospital. Review of Resident #2's Minimum Data Set (MDS) assessments documented an Admission Medicare - 5 Day Assessment completed on 4/20/22 and accepted on 04/25/22. There was no discharge MDS Assessment located in Resident #2's electronic file. During an interview conducted on 08/09/22 at 01:42 PM with the MDS coordinator she confirmed that Residents #1 and #2 did not have a discharge MDS in their electronic files. Review of the facility policy titled MDS 3.0 Completion undated and reviewed on 01/11/22 read, .f. Discharge Assessment - completed using the discharge date as the ARD (Assessment Reference Date). Must be completed within 14 days of the discharge date /ARD.

Based on record review and interview, the facility failed to implement policies and procedures for the verification of identification, licensure and background screenings for all agency nursing staff prior to having access to the residents, allowing an unlicensed agency staff person to work as a Licensed Practical Nurse providing nursing care and services to 52 residents, including Residents #4, #5, and #6, during two work shifts for the period from [DATE] through [DATE]. Findings include: Review of an invoice generated by the nurse staffing agency dated [DATE] revealed that Staff A, Unlicensed Agency Staff, had worked in the facility from 7:00 PM on [DATE] through 7:30 AM on [DATE] and from 7:00 PM on [DATE] through 7:30 AM on [DATE]. During an interview on [DATE] at 11:48 AM, the Director of Nursing (DON) stated Staff A, Unlicensed Agency Staff, had worked in the facility two nights as a Licensed Practical Nurse. The Director of Nursing stated she then completed a reportable. The DON stated the nurse staffing agency initially stated they had not sent the facility a nurse but the facility found text messages that verified the nurse staffing agency had sent a nurse to the facility. During an interview on [DATE] at 1:24 PM, the Staff Development Coordinator stated that the facility had trusted nurse staffing agencies to send qualified credentialed staff prior to the incident with Staff A. She stated the facility had not verified or maintained a record of the identification, background screenings or credentials of agency staff prior to the incident with Staff A. Record review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed Staff A (Agency Staff Member) was not licensed as a Licensed Practical Nurse in the State of Florida. Review of the facility records did not reveal a nursing license and a background screening result for Staff A. Review of the job description titled Licensed Practical Nurse reads, Required Qualifications: A Nursing Degree from an accredited college or university or a graduate of an approved LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse] program. Prior experience in long-term care preferred but not required. Current unrestricted license as a Licensed Practical Nurse (LPN) in practicing state. Current CPR [Cardiopulmonary Resuscitation] certification. During an interview on [DATE] at 10:01 AM, the Administrator stated the facility had not verified Staff A's background screening, identity, or license before allowing Staff A to work with facility residents as a Licensed Practical Nurse. The facility had a contract with the nurse staffing agency that stated the nurse staffing agency would conduct their business practices in an ethical manner, would recruit, test and screen their staff and ensure compliance with legal obligations. The facility trusted the agency to honor the contract. Review of Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Abuse, Neglect, Exploitation, last reviewed on [DATE], reads, The components of the facility abuse prohibition plan are discussed herein: I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the facility document titled 5 whys Root Cause Analysis revealed the root cause of the event that resulted in an unlicensed individual working as a nurse in the facility on [DATE] through [DATE] as, Licensed verification was not conducted before shift began and License verification was not being conducted by facility at that time. Review of the ADHOC Quality Assurance Performance Improvement committee meeting minutes revealed the facility convened an ADHOC quality assurance performance improvement meeting attended by the Administrator, Director of Nursing, Medical Director, Clinical Nurse Manager, Staff Developer, Nurse Manager and Schedule Coordinator on [DATE]. The meeting minutes documented on [DATE] the facility began an audit of all the residents Staff A had been assigned the two days she worked at the facility, started a new audit of all current nurses and certified nursing assistants, initiated verification of agency nurses that worked in the facility and certified nursing assistants' professional licenses and driver's licenses to verify their identities and educated staff who grant access to residents' computerized records to new agency personnel related to verifying professional licenses and checking driver's license to verify identity. On [DATE], the facility audited all residents with the potential to have been under Staff A's care for adverse effects and assessed the residents had not suffered adverse effects related to being under Staff A's care. On [DATE], the facility audited the licenses, photographic identification and background screening for 162 agency staff to ensure those staff were licensed or certified. On [DATE], the facility audited the licenses and photographic identification for all facility staff to ensure those staff were licensed or certified. On [DATE], the facility developed a tracking document for agency staff that verified the status of non-facility staff (agency, student, volunteer, other) and whether the staff members' licensure/certification, photographic identification, background screening has been verified. The facility maintains a document that shows verification of identity, licensure/certification, and background screening of 162 agency staff that worked at the facility [DATE] through [DATE]. On [DATE], the facility implemented a Process for New Agency Staff for verification of the licensure and background screening status of the new staff. The process includes electronic verification of the picture of employee on the agency website, verification of a current and clear nursing license by name, verification of the person's identity from a driver's license and from picture on background document upon arrival, and granting access to PCC (Point Click Care) in order for care to be provided during shift after verification. Review of the agency staff records for 10 sampled employees from 4 different staffing agencies revealed they have been verified for licensure/ certification status, and level II background screening results. Review of the sign-in record dated [DATE] revealed the Administrator, the Director of Nursing, Staffing Coordinator, Staffing Development Coordinator on verifying identification and confirming picture matches person, background screen, and licenses. During an interview on [DATE] at 11:48 AM, the DON stated, What we did was go through all of our own staff and verified their license and are using agencies that have uploaded the driver's license and nursing license. We verify that before they are given access to the residents. She was charting under [Staff A's name]. We completed audits of staff, pulled all their licenses, and also checked all agency staff. As a new agency person comes, we verify them before we give them access to the patients. Staff have been educated related abuse/neglect/exploitation and verification of staff identity. Quality Assurance Performance Improvement meeting was held to address this situation. During an interview on [DATE] at 1:24 PM, the Staff Development Coordinator stated, Regular staff identities are verified upon application. They have to present their driver's license and social security card. Identity is verified by looking at picture on driver's license. Then, we run a background screening. We normally check their license/certification during initial interview. For agency staff, we can pull them up on the web. We run information as soon as the agency staff is scheduled. Once they are in the building, the nurse manager will obtain a picture. If information is not online, we have the agency send the information through the agency system or email. During an interview on [DATE] at 10:01 AM, the Administrator stated, We immediately changed the procedure and started auditing all our and agency staff background and license. We checked all agency staff screens to verify identities. We would look at the agencies portals and make sure the picture matched the person. During the interviews conducted on [DATE] through [DATE] with Agency Staff C, Registered Nurse (RN), Agency Staff D, RN, Agency Staff O, LPN, and Agency Staff P, LPN, they confirmed that their credentials, identification and background screening were verified by the facility before starting to work in the facility.

Based on record review and interview, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility by not verifying identification, licensure and level II background screening for agency nursing staff prior to granting access to the residents, allowing an unlicensed agency staff person to work as a Licensed Practical Nurse providing nursing care and services to 52 residents including Residents #4, #5, and #6, during two work shifts for the period from [DATE] through [DATE]. Findings: Review of the job description titled Administrator reads, Position Purpose: Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents . Major Duties and Responsibilities: Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations . Knows and understands general nursing practices and procedures, OBRA [Omnibus Budget Reconciliation Act] regulations, Code of Federal Regulations, Appendix PP State Operations Manual, reimbursement processes, Life Safety Code Regulations, applicable labor relations laws, and all other regulatory entities that may apply . Ensures delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover, general cleanliness, physical plant condition, and optimal resident functioning-physically and psychosocially. Review of the job description titled Director of Nursing reads, Position Purpose: Planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents . Major Duties and Responsibilities: Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services Department, as well as, its programs and activities, in accordance with current state and federal laws and regulations . Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units, general cleanliness and maintaining optimal resident functions . Oversees nursing schedules to ensure resident needs, regulatory and budget standards are met . Participates in the recruitment, hiring and termination of nursing personnel. Review of an invoice generated by the nurse staffing agency dated [DATE] revealed the Staff A, Unlicensed Agency Staff, had worked in the facility from 7:00 PM on [DATE] through 7:30 AM on [DATE] and from 7:00 PM on [DATE] through 7:30 AM on [DATE]. During an interview on [DATE] at 11:48 AM, the Director of Nursing (DON) stated Staff A, Unlicensed Agency Staff, had worked in the facility two nights as a Licensed Practical Nurse. The Director of Nursing stated she then completed a reportable. The DON stated the nurse staffing agency initially stated they had not sent the facility a nurse but the facility found text messages that verified the nurse staffing agency had sent a nurse to the facility. During an interview on [DATE] at 1:24 PM, the Staff Development Coordinator stated that the facility had trusted nurse staffing agencies to send qualified credentialed staff prior to the incident with Staff A. She stated the facility had not verified or maintained a record of the identification, background screenings or credentials of agency staff prior to the incident with Staff A. Record review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed Staff A (Agency Staff Member) was not licensed as a Licensed Practical Nurse in the State of Florida. Review of the facility records did not reveal a nursing license and a background screening result for Staff A. Review of the job description titled Licensed Practical Nurse reads, Required Qualifications: A Nursing Degree from an accredited college or university or a graduate of an approved LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse] program. Prior experience in long-term care preferred but not required. Current unrestricted license as a Licensed Practical Nurse (LPN) in practicing state. Current CPR [Cardiopulmonary Resuscitation] certification. During an interview on [DATE] at 10:01 AM, the Administrator stated the facility had not verified Staff A's background screening, identity, or license before allowing Staff A to work with facility residents as a Licensed Practical Nurse. The facility had a contract with the nurse staffing agency that stated the nurse staffing agency would conduct their business practices in an ethical manner, would recruit, test and screen their staff and ensure compliance with legal obligations. The facility trusted the agency to honor the contract. Review of Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Abuse, Neglect, Exploitation, last reviewed on [DATE], reads, The components of the facility abuse prohibition plan are discussed herein: I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the facility document titled 5 whys Root Cause Analysis revealed the root cause of the event that resulted in an unlicensed individual working as a nurse in the facility on [DATE] through [DATE] as, Licensed verification was not conducted before shift began and License verification was not being conducted by facility at that time. Review of the ADHOC Quality Assurance Performance Improvement committee meeting minutes revealed the facility convened an ADHOC quality assurance performance improvement meeting attended by the Administrator, Director of Nursing, Medical Director, Clinical Nurse Manager, Staff Developer, Nurse Manager and Schedule Coordinator on [DATE]. The meeting minutes documented on [DATE] the facility began an audit of all the residents Staff A had been assigned the two days she worked at the facility, started a new audit of all current nurses and certified nursing assistants, initiated verification of agency nurses that worked in the facility and certified nursing assistants' professional licenses and driver's licenses to verify their identities and educated staff who grant access to residents' computerized records to new agency personnel related to verifying professional licenses and checking driver's license to verify identity. On [DATE], the facility audited all residents with the potential to have been under Staff A's care for adverse effects and assessed the residents had not suffered adverse effects related to being under Staff A's care. On [DATE], the facility audited the licenses, photographic identification and background screening for 162 agency staff to ensure those staff were licensed or certified. On [DATE], the facility audited the licenses and photographic identification for all facility staff to ensure those staff were licensed or certified. On [DATE], the facility developed a tracking document for agency staff that verified the status of non-facility staff (agency, student, volunteer, other) and whether the staff members' licensure/certification, photographic identification, background screening has been verified. The facility maintains a document that shows verification of identity, licensure/certification, and background screening of 162 agency staff that worked at the facility [DATE] through [DATE]. On [DATE], the facility implemented a Process for New Agency Staff for verification of the licensure and background screening status of the new staff. The process includes electronic verification of the picture of employee on the agency website, verification of a current and clear nursing license by name, verification of the person's identity from a driver's license and from picture on background document upon arrival, and granting access to PCC (Point Click Care) in order for care to be provided during shift after verification. Review of the agency staff records for 10 sampled employees from 4 different staffing agencies revealed they have been verified for licensure/ certification status, and level II background screening results. Review of the sign-in record dated [DATE] revealed the Administrator, the Director of Nursing, Staffing Coordinator, Staffing Development Coordinator on verifying identification and confirming picture matches person, background screen, and licenses. During an interview on [DATE] at 11:48 AM, the DON stated, What we did was go through all of our own staff and verified their license and are using agencies that have uploaded the driver's license and nursing license. We verify that before they are given access to the residents. She was charting under [Staff A's name]. We completed audits of staff, pulled all their licenses, and also checked all agency staff. As a new agency person comes, we verify them before we give them access to the patients. Staff have been educated related abuse/neglect/exploitation and verification of staff identity. Quality Assurance Performance Improvement meeting was held to address this situation. During an interview on [DATE] at 1:24 PM, the Staff Development Coordinator stated, Regular staff identities are verified upon application. They have to present their driver's license and social security card. Identity is verified by looking at picture on driver's license. Then, we run a background screening. We normally check their license/certification during initial interview. For agency staff, we can pull them up on the web. We run information as soon as the agency staff is scheduled. Once they are in the building, the nurse manager will obtain a picture. If information is not online, we have the agency send the information through the agency system or email. During an interview on [DATE] at 10:01 AM, the Administrator stated, We immediately changed the procedure and started auditing all our and agency staff background and license. We checked all agency staff screens to verify identities. We would look at the agencies portals and make sure the picture matched the person. During the interviews conducted on [DATE] through [DATE] with Agency Staff C, Registered Nurse (RN), Agency Staff D, RN, Agency Staff O, LPN, and Agency Staff P, LPN, they confirmed that their credentials, identification and background screening were verified by the facility before starting to work in the facility.

Based on record review and interview, the facility failed to ensure nursing staff employed at the facility were licensed in accordance with applicable State laws by not verifying the licensure and level II background screening for agency nursing staff prior to granting access to the residents, allowing an unlicensed agency staff person to work as a Licensed Practical Nurse providing nursing care and services to 52 residents including Residents #4, #5, and #6, during two work shifts for the period from [DATE] through [DATE]. Findings include: Review of an invoice generated by the nurse staffing agency dated [DATE] revealed the Staff A, Unlicensed Agency Staff, had worked in the facility from 7:00 PM on [DATE] through 7:30 AM on [DATE] and from 7:00 PM on [DATE] through 7:30 AM on [DATE]. During an interview on [DATE] at 11:48 AM, the Director of Nursing (DON) stated Staff A, Unlicensed Agency Staff, had worked in the facility two nights as a Licensed Practical Nurse. The Director of Nursing stated she then completed a reportable. The DON stated the nurse staffing agency initially stated they had not sent the facility a nurse but the facility found text messages that verified the nurse staffing agency had sent a nurse to the facility. During an interview on [DATE] at 1:24 PM, the Staff Development Coordinator stated that the facility had trusted nurse staffing agencies to send qualified credentialed staff prior to the incident with Staff A. She stated the facility had not verified or maintained a record of the identification, background screenings or credentials of agency staff prior to the incident with Staff A. Record review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed Staff A (Agency Staff Member) was not licensed as a Licensed Practical Nurse in the State of Florida. Review of the facility records did not reveal a nursing license and a background screening result for Staff A. Review of the job description titled Licensed Practical Nurse reads, Required Qualifications: A Nursing Degree from an accredited college or university or a graduate of an approved LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse] program. Prior experience in long-term care preferred but not required. Current unrestricted license as a Licensed Practical Nurse (LPN) in practicing state. Current CPR [Cardiopulmonary Resuscitation] certification. During an interview on [DATE] at 10:01 AM, the Administrator stated the facility had not verified Staff A's background screening, identity, or license before allowing Staff A to work with facility residents as a Licensed Practical Nurse. The facility had a contract with the nurse staffing agency that stated the nurse staffing agency would conduct their business practices in an ethical manner, would recruit, test and screen their staff and ensure compliance with legal obligations. The facility trusted the agency to honor the contract. Review of Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Abuse, Neglect, Exploitation, last reviewed on [DATE], reads, The components of the facility abuse prohibition plan are discussed herein: I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the facility document titled 5 whys Root Cause Analysis revealed the root cause of the event that resulted in an unlicensed individual working as a nurse in the facility on [DATE] through [DATE] as, Licensed verification was not conducted before shift began and License verification was not being conducted by facility at that time. Review of the ADHOC Quality Assurance Performance Improvement committee meeting minutes revealed the facility convened an ADHOC quality assurance performance improvement meeting attended by the Administrator, Director of Nursing, Medical Director, Clinical Nurse Manager, Staff Developer, Nurse Manager and Schedule Coordinator on [DATE]. The meeting minutes documented on [DATE] the facility began an audit of all the residents Staff A had been assigned the two days she worked at the facility, started a new audit of all current nurses and certified nursing assistants, initiated verification of agency nurses that worked in the facility and certified nursing assistants' professional licenses and driver's licenses to verify their identities and educated staff who grant access to residents' computerized records to new agency personnel related to verifying professional licenses and checking driver's license to verify identity. On [DATE], the facility audited all residents with the potential to have been under Staff A's care for adverse effects and assessed the residents had not suffered adverse effects related to being under Staff A's care. On [DATE], the facility audited the licenses, photographic identification and background screening for 162 agency staff to ensure those staff were licensed or certified. On [DATE], the facility audited the licenses and photographic identification for all facility staff to ensure those staff were licensed or certified. On [DATE], the facility developed a tracking document for agency staff that verified the status of non-facility staff (agency, student, volunteer, other) and whether the staff members' licensure/certification, photographic identification, background screening has been verified. The facility maintains a document that shows verification of identity, licensure/certification, and background screening of 162 agency staff that worked at the facility [DATE] through [DATE]. On [DATE], the facility implemented a Process for New Agency Staff for verification of the licensure and background screening status of the new staff. The process includes electronic verification of the picture of employee on the agency website, verification of a current and clear nursing license by name, verification of the person's identity from a driver's license and from picture on background document upon arrival, and granting access to PCC (Point Click Care) in order for care to be provided during shift after verification. Review of the agency staff records for 10 sampled employees from 4 different staffing agencies revealed they have been verified for licensure/ certification status, and level II background screening results. Review of the sign-in record dated [DATE] revealed the Administrator, the Director of Nursing, Staffing Coordinator, Staffing Development Coordinator on verifying identification and confirming picture matches person, background screen, and licenses. During an interview on [DATE] at 11:48 AM, the DON stated, What we did was go through all of our own staff and verified their license and are using agencies that have uploaded the driver's license and nursing license. We verify that before they are given access to the residents. She was charting under [Staff A's name]. We completed audits of staff, pulled all their licenses, and also checked all agency staff. As a new agency person comes, we verify them before we give them access to the patients. Staff have been educated related abuse/neglect/exploitation and verification of staff identity. Quality Assurance Performance Improvement meeting was held to address this situation. During an interview on [DATE] at 1:24 PM, the Staff Development Coordinator stated, Regular staff identities are verified upon application. They have to present their driver's license and social security card. Identity is verified by looking at picture on driver's license. Then, we run a background screening. We normally check their license/certification during initial interview. For agency staff, we can pull them up on the web. We run information as soon as the agency staff is scheduled. Once they are in the building, the nurse manager will obtain a picture. If information is not online, we have the agency send the information through the agency system or email. During an interview on [DATE] at 10:01 AM, the Administrator stated, We immediately changed the procedure and started auditing all our and agency staff background and license. We checked all agency staff screens to verify identities. We would look at the agencies portals and make sure the picture matched the person. During the interviews conducted on [DATE] through [DATE] with Agency Staff C, RN, Agency Staff D, Registered Nurse (RN), Agency Staff O, LPN, and Agency Staff P, LPN, they confirmed that their credentials, identification and background screening were verified by the facility before starting to work in the facility.