Every finding on record at Ybor City Center for Rehabilitation and Healing

Based on observations, record reviews, and interviews, the facility did not maintain required communication with the dialysis center and did not accurately assess residents before and after dialysis treatments for two of three sampled residents (Residents #1 and #2). As a result, important clinical information was missing or incorrect, scheduled evaluations of dialysis access sites and vital signs were not completed as ordered, and the facility did not provide the dialysis center with the information needed to ensure safe and coordinated care. Findings included: Record review showed Resident #1 was admitted on [DATE], with multiple diagnoses including end stage renal disease, dependence on dialysis, polycystic kidney disease, and anemia. The Minimum Data Set, dated [DATE] showed the resident received hemodialysis before admission and while living at the facility and scored 15 out of 15 on the Brief Interview for Mental Status. Review of Resident #1's care plan showed the resident needed hemodialysis relate to end stage renal disease and had a left chest dialysis catheter. The interventions included instructions to observe/document/report as needed (PRN) any signs/symptoms (s/sx) of infection to access site (left chest): redness, swelling, warmth or drainage. Review of the resident's physician orders on July 14, 2026, at 4:40 p.m., showed the resident was scheduled for dialysis every Tuesday, Thursday, and Saturday, with a pickup time of 11:45 a.m. Orders required staff to obtain vital signs before and after dialysis, obtain vital signs again 24 hours after treatment, and remove the pressure dressing if there was no active bleeding from the left chest catheter. Review of the American Association of Kidney Patients, located at aakp.org - Protecting Your Hemodialysis Vascular Access, a central venous catheter (CVC) is an external vascular access - a tube inserted into a large vein (often in the neck or chest) and extending into the heart, unlike an internal vascular access (fistula or graft) which are under the skin. The CVC does not create the whooshing sound of a bruit and buzzing feel of a thrill. The association describes a kidney patients access as their lifeline and due to so much of the CVC being external could lead to many complications. Review of Resident #1's Dialysis Center - Facility Communication forms revealed the following:6/18/26: The resident left the facility at 10:30 a.m. and did not receive pre dialysis medications. The post dialysis section stated the access site was a central venous catheter (CVC) and documented a bruit and thrill were present.6/20/26: The resident left at 11:05 a.m. and received pre dialysis medications. The facility did not complete the post dialysis section, and nursing notes did not document the resident's return.6/23/26: The facility did not complete any pre or post dialysis documentation. The dialysis center sent instructions to the facility, and the only nursing note documented the resident's return without assessment. The instructions were to increase protein, take phosphorus binders with meals, renal diet, and fluid restrictions.7/4/26: Staff did not record the resident's name or physician on the form and did not complete post dialysis vital signs or an access site assessment.7/7/26: The form did not show who completed the pre dialysis section, and the post dialysis section was not completed. Record review showed the resident returned from dialysis on June 26, 2026, but no communication form was completed. The record also showed the resident missed dialysis on July 11, 2026, because transportation did not arrive. Nursing notes did not show staff notified transportation, the dialysis center, or the physician, or assessed the resident's condition. Review of scheduled dialysis dates and communication forms showed staff did not complete forms on six additional treatment dates: June 25, 26, 27, 30, July 2, and July 9, 2026. Review of the Dialysis Center assessment dated [DATE] and received by the facility by fax on 7/14/26 at 11:47 a.m. showed this patient (pt) always removes this CVC dressing and allows his dirty beard lay all up in and on top of the cvc [sic] stoma. Review of Resident #1's July Medication and Treatment Administration Records and nursing notes did not show staff removed pressure dressings as ordered or assessed the catheter site after dialysis. The care plan instructed staff to monitor for redness, swelling, warmth, or drainage at the catheter site, but such documentation was not present. On July 14, 2026, at 12:13 p.m., Resident #2 was not in their room. Staff A, Certified Nursing Assistant (CNA), stated the resident was at dialysis. Record review showed Resident #2 was admitted on [DATE], with diagnoses including diabetes with complications, dependence on dialysis, obesity, and post traumatic stress disorder. Review of Resident #2's active physician orders as of 7/14/26 at 4:24 p.m. revealed showed multiple dialysis related orders requiring staff to assess the right upper extremity arteriovenous fistula for infection, circulation changes, and the presence or absence of bruit and thrill every shift, and to notify the physician if absent. Orders also required pre and post dialysis vital signs, removal of pressure dressings when there was no active bleeding, and documentation of pre and post dialysis weights. Review of Resident #2;s July Medication and Treatment Records revealed staff were obtaining pre- and post- dialysis vital signs and removing pressure dressing on Tue, Thu, and Saturday's after dialysis. The review revealed licensed nursing staff were documenting the following regarding physician orders to check for right subclavian arteriovenous shunt/fistula bruit and thrill. The order instructed nursing to notify the physician of the absence of either:7/6/26, 7 a.m. - 3 p.m. and 3 p.m. - 11 p.m. (same nurse): - for both presence + and absence - of bruit and thrill. 11 p.m. - 7 a.m.: + for both presence and absence of bruit and thrill.7/7/26, 7 a.m. - 3 p.m., 3 p.m. - 11 p.m. and 11 p.m. - 7 a.m. (different nurses): + for presence and absence of bruit and thrill.7/8/26, 3 p.m.: - 11 p.m. and 11 p.m. - 7 a.m.: + for presence and absence of bruit and thrill.7/9/26, 7 a.m.- 3 p.m. and 11 p.m. - 7 a.m.: + for presence and absence of bruit and thrill.7/11/26, 3 p.m. - 11 p.m.: not applicable n/a for the presence and absence of bruit and thrill.7/12/26, 3 p.m. - 11 p.m.: not applicable n/a for the presence and absence of bruit and thrill.7/13/26, 11 p.m. - 7 a.m.: documentation of + for the presence and - for the absence of bruit and thrill. The treatment record revealed an inaccurate evaluation of the absence or presence of the resident's bruit and thrill thirteen out of twenty-five opportunities. For July 6, 2026, nursing notes did not show physician notification, even though the treatment record documented the absence of bruit and thrill. Review of Resident #2s Dialysis Center - Facility Communication forms revealed:One form was undated and missing the treatment date, departure time, last weight, pre dialysis medications, and arrival time back to the facility. Staff did not document vital signs, pain, access site assessment, or whether a bruit, thrill, or bleeding were present.7/9/26: Staff did not complete any part of the form.7/11/26: The form listed a departure time but did not document whether pre dialysis medications were given, although the medication record showed the resident had received several morning medications. Review of the July 2026 calendar showed the resident was scheduled for four treatments (July 4, 7, 9, and 11). One communication form was completely missing, and three were completed incorrectly. During an interview on 7/14/26 at 3:09 p.m., the Director of Nursing (DON) stated staff should be filling out pre-dialysis (dialysis communication forms), send book (dialysis binder), and fill out post-dialysis (communication form). The documentation of pre- and post-dialysis include vitals signs (temperature, weight, heart rate, and pulse) and anything that happened. Dialysis documents their happenings and post-dialysis included weight and vital signs. The DON reported there should be documentation if a resident did not go to dialysis. Review of the policy - Care of the resident receiving Dialysis, undated, revealed The facility will provide care to the resident receiving dialysis to maintain the patency of the arteriovenous shunt, prevent complications such as infections, bleeding and trauma, and identify specific measures to follow if complications occur. The care will be directed by licensed nurses. The procedure instructions included:Pre-dialysis care:a. Nurse will complete top section of dialysis communication form and sign/date.b. The dialysis communication will be sent with the resident to the dialysis clinic.Post dialysis care:a. Nurse will evaluate residence condition upon return from dialysis clinic.b. Document evaluation by completing bottom section of the dialysis communication form. Sign/ date the form. File the completed form in resident's medical record.d. Take vital signs upon return from dialysis and every shift for the 1st 24 hours.e. Inspect the area around the shunt sight dressing for color, warmth, redness, and edema every shift.f. Notify MD of any changes in color, warmth, redness, edema or any drainage noted.g. Leave the outer pressure dressing in place according to instructions given by the dialysis Center for this resident. Once the outer pressure dressing is removed, inspect the inner dressing for evidence of drainage every shift. Documents finding in the medical record. Change the inner dressing only when ordered by physician.h. If bleeding is apparent, [NAME] gloves and apply direct pressure over the shunt puncture site. When applying pressure, be sure that the pulsation can be felt. Notify the physician immediately. Review of the Long Term Care Facility Outpatient Dialysis Services Coordination Agreement between the facility and the dialysis center where Resident #1 and Resident #2 receive treatment, signed by the facility administrator and the centers clinic manager on 6/29/26, revealed: Interchange of information. The long term care facility shall provide for the interchange of information useful or necessary for the care of the End Stage Renal Disease (ESRD) residents, including a contact person at the long term care facility whose responsible these include assisting with the coordination of renal dialysis services for ESRD residents. The Preparation of ESRD Residents showed The long term care facility shall ensure that ESRD residents are prepared to spend an extended length of time at the ESRD dialysis unit and have received proper nourishment in any medications prescribed for reasons other than the treatment of ESRD, as appropriate, before coming to the ESRD dialysis unit.

Based on observation, interview, and record review, the facility failed to provide medically related social services by not ensuring transportation was arranged for three of three residents (Residents #1, #2, and #3) who required outpatient dialysis. This failure resulted in missed or delayed dialysis treatments, early discontinuation of treatment, and residents experiencing uncertainty or fear about whether they would receive their scheduled dialysis. Findings Included:During an interview on 07/14/2026 at 1:00 p.m., Resident #3 stated she was scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. She reported that on 07/13/2026 transportation did not arrive, although she was ready for her appointment. She stated her son helped her locate another transportation service, and the dialysis center moved her chair time so she did not miss treatment. Resident #3 stated the facility informed her that her insurance would no longer cover transportation, and the facility was speaking with her son to find an affordable alternative. Resident #3 reported she was afraid she would not be able to attend her dialysis appointment on Thursday because she had not been told whether transportation had been arranged. Review of Resident #3's admission record showed she was admitted on [DATE] with diagnoses including end stage renal disease (ESRD), atherosclerotic heart disease, dependence on renal dialysis, and hypertension. The Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The care plan dated 07/06/2026 included a focus on the need for dialysis and an intervention to encourage the resident to attend scheduled dialysis appointments. On 07/14/2026 at 2:10 p.m., Staff G, Licensed Practical Nurse (LPN), stated Resident #3 had transportation issues on 07/13/2026 because her insurance would no longer pay for transportation. Staff G stated the nursing staff arranged transportation, and one company had stopped picking up residents. Staff G stated they called alternate companies when needed, and used the facility van when available. She stated the facility van was currently in the repair shop. Staff G reported she was working with admissions staff and Resident #3's son to arrange transportation for Thursday but had not yet received confirmation. On 07/14/2026 at 4:03 p.m., the Nursing Home Administrator (NHA) stated transportation companies used by dialysis residents had been late or had failed to show up at scheduled times. The NHA stated staff contacted other vendors when this happened and notified the dialysis center to determine whether treatment could still occur that day. The NHA stated resident insurance determined transport vendors and the facility did not control vendor selection. The NHA stated the facility was responsible for ensuring transportation for dialysis residents and would arrange transport if insurance did not cover it. On 07/14/2026 at 11:52 a.m., Resident #1 stated transportation did not show up and said this happened periodically. Observations at that time showed his bilateral lower extremities were edematous. Review of Resident #1's admission record showed admission on [DATE] with diagnoses including end stage renal disease, polycystic kidney disease, dependence on dialysis, and anemia. Review of the MDS dated [DATE] showed Resident #3 received dialysis before and during his stay and had a BIMS score of 15, indicating intact cognition. Review of Resident #1's physician orders on 07/14/2026 at 4:40 p.m. showed he may go to dialysis on Tuesdays, Thursdays, and Saturdays with a pickup time of 11:45 a.m., ordered 06/17/2026. Review of Resident #1's care plan showed he required hemodialysis on Tuesdays, Thursdays, and Saturdays at 11:45 a.m. with an intervention for staff to encourage attendance. Review of the June and July monthly calendars revealed the resident was to receive dialysis treatments at an outpatient clinic on 06/18, 06/20, 06/23, 06/25, 06/27, 06/30, 07/02, 07/04, 07/07, 07/09, 07/11, and 07/14/2026. Review of the Dialysis Center – Facility Communication forms revealed no communication forms for 06/25, 06/27, 06/30, 07/02, 07/07, 07/09, and 07/11/2026. Review of a rounding report completed by the dialysis center on 06/30/2026 showed Resident #1 missed treatment on 06/27/2026 and did not receive treatment on 06/25/2026 as scheduled but received treatment on 06/26/2026. Review of the dialysis center documentation dated 07/09/2026 at 1:48 p.m. showed Resident #1 discontinued treatment early due to transportation issues and signed Against Medical Advice (AMA). Documentation dated 07/11/2026 showed Resident #1 missed treatment because transportation did not arrive. Review of Resident #1's nursing notes did not show documentation explaining why dialysis scheduled for 06/25/2026 was moved to 06/26/2026 or that the physician was notified of the schedule change. Notes dated 07/09/2026 did not show he returned to the facility after discontinuing treatment early or that the physician was notified. Notes dated 07/11/2026 stated Resident did not go to dialysis today transport never showed up, but did not show whether the transport provider was contacted, whether alternate transportation was arranged, whether the dialysis center was notified, or whether the physician or administrative staff were notified. On 07/14/2026 at 12:13 p.m., Staff A, Certified Nursing Assistant, stated Resident #2 was at dialysis and stated transportation was a problem the prior week. Staff A stated Resident #2 was transported by stretcher. Resident #2's admission record showed admission on [DATE] with diagnoses including type 2 diabetes mellitus, dependence on dialysis, obesity, and post traumatic stress disorder. Review of Resident #2's physician orders on 07/14/2026 at 4:24 p.m. showed dialysis scheduled on Tuesdays, Thursdays, and Saturdays with a 10:00 a.m. pickup time and 11:20 a.m. chair time, ordered 07/10/2026. Review of the July Medication Administration Record showed he previously had a pickup time of 2:20 p.m. and a chair time of 3:20 p.m., discontinued 07/10/2026. The July calendar showed dialysis scheduled on 07/04, 07/07, 07/09, 07/11, and 07/14/2026. Nursing notes dated 07/08/2026 showed Resident #2 refused make up dialysis arranged for that day but did not show he missed treatment on 07/07/2026 or why make up dialysis was scheduled. No Dialysis Center–Facility Communication form was present for 07/07/2026. A grievance filed on 07/08/2026 at 5:30 p.m. stated transportation was late taking and picking up Resident #2 and he was transported by wheelchair instead of stretcher. The investigation showed the facility van picked him up, and the grievance was not resolved to satisfaction. A physician order dated 07/10/2026 showed a revised chair time. A grievance dated 07/11/2026 at 9:52 a.m. showed continued transportation concerns including uncertainty about transport availability and stretcher transport. Documentation did not show the resident or family was satisfied with changes. On 07/14/2026 at 12:17 p.m., Staff E, Licensed Practical Nurse, stated the facility driver arranged transportation with support from admissions staff. Staff E stated one transportation company underwent management changes and did not pick up Resident #2; the facility contacted another company to avoid a missed appointment. On 07/14/2026 at 12:50 p.m., Staff F, Van Driver, stated she arranged transportation for most appointments. She stated one contracted company did not pick up Resident #2 on time and did not pick up Resident #1 on 07/11/2026. Staff F stated the facility contacted an outside company for Resident #1 and the dialysis center agreed to see him; however, nursing notes did not show the dialysis center was contacted. On 07/14/2026 at 3:09 p.m., the Director of Nursing stated staff should document when residents miss dialysis, contact transportation providers to determine whether transport could still occur, contact the dialysis center to determine whether treatment could still occur, reschedule when needed, and notify the physician. The Director stated Resident #1 reported transportation had not arrived on 07/14/2026. The Director stated she contacted the transportation company and the Assistant Director of Nursing contacted the dialysis center. The Director stated Resident #1 declined dialysis once alternate transportation was arranged and requested to go to the hospital instead. Review of the undated facility transportation policy showed transportation was described only as services provided in a facility owned vehicle. The policy did not address the use of outside transportation vendors.

Based on interviews and record review, the facility failed to address a change in condition in a timely manner for one Resident (#1) out of three residents sampled. Findings included: On 03/03/2026 at 12:53 PM an interview was conducted with Resident #1's Resident Representative (RR). The RR stated after the initial X-ray the facility called him letting him know the Xray came back clear, so he was thinking everything was fine. The RR stated after a week or so he went to visit the resident and noticed swelling on her arm and her hand looked to be hanging in a weird position, like hanging down, so he reached to feel the arm to see if it was warm because he was concerned about a possible blood clot. The RR stated when he barely touched the arm right above the wrist Resident #1 screamed out in pain. He stated he notified the nurse and they said they would address it. The RR stated he called the facility 4 or 5 times, asking for the Director of Nurses (DON) to see what the plan was for Resident #1. He stated he was told they'd give her the message and have her call him back. The RR stated he was never contacted by the DON after those attempts were made. The RR stated he finally went into the facility and found the DON himself to show her Resident #1's arm. The DON went into the room with him and the physician, and she again screamed out in pain when her arm was touched. He said at that point he insisted Resident #1 be transferred to the hospital. He said the DON kept trying to keep her at the facility stating they could try other things, but he told the DON the resident needed to go to the hospital. The RR stated the hospital called him that evening letting him know that Resident #1's shoulder was dislocated and looked like it was that way for a long time. The RR stated the physician told him he estimated at least a month. After that the RR decided not to return the resident to the facility. Review of Resident # 1 admission record revealed she was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, muscle weakness (generalized), chronic kidney disease. Review of a Minimum Data Set (MDS). dated 11/25/25, Section C- Cognitive Patterns revealed a Brief Interview of Mental Status (BIMS) score of 06 which indicated Resident #1 was severely cognitively impaired. Review of a progress note, dated 1/7/26, revealed Staff A, License Practical Nurse (LPN) spoke to Resident #1's RR to inform him about the resident complaints of left hand and wrist pain. Doctor ordered X-ray. Staff A noted Resident #1 RR thanked her for calling to inform him. Review of a change in condition report, dated 1/7/2026, revealed the following: nursing observations, evaluation, and recommendations are: Resident yelling out her hand hurts. Advance Registered Nurse Practitioner (ARNP) notified new orders received for x-ray and as needed (PRN) Tylenol. Review of a X-Ray report, dated 1/7/2026, revealed: Findings--The osseous structures are unremarkable. There is no fracture or periosteal reaction. There is no focal bone lesion. Alignment is anatomic. There is no soft tissue swelling or foreign body identified. Mild degenerative changes and osteopenia noted. Review of a therapy screen, dated 1/9/2026, created by Staff B, Physical Therapy Assistant, [PTA] read: Staff B noted Resident #1 reported left wrist pain during screening process. Staff B reported Resident #1 concern to the unit nurse. On 3/3/2026 at 10:19 AM, an interview was conducted with Staff B, PTA. Staff B stated she has worked at the facility since 2011. Staff B stated therapy was not conducting a screening on Resident # 1 because of a referral from nursing for her wrist. Resident #1 was due for her quarterly screening. Her mobility had not changed. She had no contractures and was able to move her legs properly. Resident #1 complained about her wrist. When she was on her side, she kept saying she didn't want to give me her hand. Staff B stated she understood the resident hand was hurt. So she reported Resident #1's concerns to nursing and documented her concerns on a communication form.Review of the medical record showed no nursing assessment completed by an LPN after Staff B reported Resident #1's wrist pain. Review of a progress note, dated 2/3/2026, created by the Advanced Registered Nurse Practitioner (ARNP), revealed Resident #1 was seen for a routine visit. Review of the progress note showed no range of motion or left hand and wrist assessment completed by the ARNP. On 3/2/2026 at 3:21 PM, an interview was conducted with the ARNP. She stated she was notified Resident #1 had pain and discomfort in her left hand and wrist. The ARNP stated she ordered an x-ray. The results was negative. It did not show any fracture. She stated she ordered the x-ray and as needed Tylenols. She saw Resident #1 on the 3rd of February. She stated Resident #1 was comfortable, did not have pain or discomfort. She was able to raise her arms and move her hands without any concerns. The ARNP said she doesn't know why she did not document her assessment. Resident #1 had no discoloration on her hand. She stated she would make an addendum to her notes. Review of a nursing note, dated 2/10/2026. revealed: Resident {RR} at the facility requesting resident to be sent to the emergency room for evaluation related to left hand/wrist edema and pain. The {RR} spoke with the Doctor via phone. All results and orders are provided to the {RR}, however the {RR} still requested Resident #1 go to the emergency room. The {RR} arrived at the bedside, requesting Medical Doctor change. The Medical Director in the facility and in agreement to accept Resident #1. The Medical Director willing to treat in house with available resources, educated Resident #1 {RR}, however the resident {RR} still requested resident to go to the hospital. Orders received from residents to the hospital for a Computed Tomography Scan (CT). Review of a physician progress note, dated 2/10/2026, revealed the following: Chief Complaint: new admission from skilled nursing facility. Main complaint: left arm swelling of over 4 weeks of evaluation {RR} present during visit as well as the Director of Nursing. She has been moved to our services today so we can examine her left arm. She has swelling on that arm for over 4 weeks of evaluation and does not let anybody lift her arm, but she uses it on her own. At the moment of exam, she refuses to do any range of motion on the exam no visual openings in the arm but unable to examine her axilla. Assessment/plan-1 left arm swelling and pain sent to the emergency room for arm scanning as patient does not let us examine the arm and x-ray of the hand is negative as per staff the venous Doppler was also negative but is not in her chart. So venous thrombosis is not ruled out at this point in time. Agreed with {RR} to send patient to emergency room for immediate imaging and addressing any issue that is now 4 weeks and elevation. Review of a hospital history and physical, dated 2/10/2026, revealed: Chief Complaint left arm pain and swelling x 3 days. She was found to have a left shoulder dislocation in the emergency room which was unable to be reduced, and patient was admitted for further evaluation with orthopedic X-Ray shoulder showed signs of left shoulder dislocation. On 03/02/2026 at 12:37 PM an interview was conducted with Staff C, Certified Nursing Assistant, (CNA). Staff C stated she has worked at the facility for 8 years. She stated she usually works in restorative, but she is pulled to the floor often. She stated she took care of Resident #1 often. Staff C stated she remembers one day she was passing out trays and she heard Resident #1 yelling that she was in pain. Staff C stated she reported the resident complaint to the nurse. They took an X-ray, and that's all she had heard about it. Staff C stated Resident #1 would always yell that she was in pain. On 03/02/2026 at 1:02 PM. an interview was conducted with Staff A, LPN. Staff A stated she has worked at the facility for 21 years. She said she did not take care of Resident #1 often because the resident moved to a different hall. Staff A stated about a month ago the CNA brought it to her attention Resident #1's hand was hurting. Staff A stated she did not remember the aides name. Staff A stated she touched Resident #1's hand, asked her if her hand hurt, and the resident said yes. She stated the resident's hand looked a little swollen at the time. Staff A stated she notified the Advanced Registered Nurse Practitioner, ARNP. An X-ray and Tylenol were ordered as needed. X-ray was completed on 1/7/26 with no negative findings. Staff A stated she notified the ARNP, and the resident RR about the results. Staff A stated at the time she went into the resident room to give her medication the resident did not complain about pain. She said after the resident was put in her chair the staff came to her to notify her that the resident was in pain. On 03/02/2026 at 1:35 PM an interview was conducted with the Director of Nursing. The DON stated a change in condition was completed by the nurse on 1/7/26 for the hand edema for Resident #1. They notified the Advanced Registered Nurse Practitioner. She ordered an X- ray and as needed Tylenol for Resident #1. On 1/9/2026 therapy screened her for pain and swelling in her hand. Pain management saw her on 1/17/2026 for left wrist pain. Pain Management put her on a Topical gel and continue the extra strength Tylenol. When therapy saw her on 1/9/26. Resident #1 reported left wrist pain. Therapy reported pain to unit nurse. The unit nurse gave the resident Tylenol. The DON said they kept the residents on the Tylenol. On 1/13/26 she was checked for a urinary tract infection (UTI), due to Resident #1 complaining about pain when she urinates. She was started on Antibiotic for a Urinary Tract Infection. On 1/17/26 they had Resident #1 Tylenol changed from as needed to routine. On 1/21/26 she was seen by Palliative Care. Noted no complaints of pain. On 2/3/26 the ARNP saw Resident # 1 for a routine visit. No pain noted at the time of visit. On 2/10/2026 her son came in wanting the resident to be sent to the hospital. She had swelling in her hands and fingers. They had the medical director see the resident that day to conduct an assessment. Family wanted a provider change. The DON stated the family did not bring the resident back to the facility because they felt the facility did not address Resident #1's pain. She said her expectations are when another discipline notifies a nurse about a resident change in condition. The nurse should notify the doctor and family and put a change in condition in. If it is something new. It should be a followed up note that the doctor was made aware and the family. She stated that on 2/10/2026 was the first time she assessed the resident and was able to see that the resident was in pain and could not move her arm. On 3/2/2026 at 3:21 PM, an interview was conducted with Pain Management. He stated he saw the resident from 1/17/26 to 2/8/26 for pain. He said the resident has dementia but able to verbalize pain. He stated he ordered the resident routine Tylenol. He said, He did not remember everything about her. He was asked to see her for left wrist swelling. When he did his initial assessment, he did not do any range of motion on the resident because she was in too much pain when he moved her wrist. He said he would just check in with the resident every now and then because nursing was not reporting the resident had further pain. Review of a policy titled, Nursing - Change on a Residents Condition or Status, undated, revealed the following: Policy--the facility shall promptly notify the resident, his or her attending physician, and representative of change in the resident's medical/metal condition and /or status (e.g. change in level of care, billing/payments, resident rights, etc). Procedure: 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status. The facility was asked to provide an assessment change in condition policy but it was not provided.

Based on observations, interviews and record review, the facility did not ensure the prevention and development of pressure wounds for one resident (#1) out of three residents reviewed.Fundings included: Review of Resident #1's admission history and physical, dated 11/26/25 showed under chief complaint: R (right) foot infection. History of present illness: [Resident #1] is an [AGE] year-old patient with Alzheimer's, dementia, hx. (history of CVA (Cerebrovascular Accident) with R lower and upper contracture, RLE (right Lower Extremity) osteomyelitis, . who presents for worsening right foot wound. Pt. unable to contribute to history due to underlying dementia and fatigue. History obtained from [family member] over the phone. Reportedly patient was put in an ALF (adult Living Facility) on 11/18 as [family member} was out of state. When she returned yesterday she visited [Resident #1]. she noted an infected R foot with open wounds on R foot, R heel and R knee. Prior to the ALF, Pt. reportedly had no ulcers whatsoever. His foot was completely normal.Patient was neglected and sitting on his foot (due to contractures) for most of the week.In the ED (emergency Department) Pt. was febrile to 101.2 HR (heart rate 120, BP Pt admitted to medicine for severe sepsis due to a R foot infection.Assessment plan:Severe sepsis 2/2 R footLactic acidosis, resolved.Hx. of R foot osteomyelitisMeets severe sepsis criteria with T 101.2S/P (Status Post) Vancomycin, cefepime and 2L IVF in ED.Plan:Vancomycin and Zosyn750 ml (milliliters) IVF ordered for 30cc/kg sepsis level fluids.F/U (follow -up) foot X-ray.CT RLE (Right Lower Extremity) with contrast ordered.RLE arterial NIVS (Non-invasive Vascular Study) ordered for poor chronic wound healing.Podiatry consulted,F/U blood culturesPT/OT (physical Therapy/Occupational Therapy)wound care consulted.Review of a physician order for Resident #1 dated 12/8/25 revealed resident #1's R foot was amputated with orders to use pas on skin every day for wound care, apply povidone /betadine paint to incision line, wrap amputation site in Kerlix loosely to prevent soiling, change as needed to keep clean and dry. Review of a physician note for Resident #1 dated 11/21/25, signed by the facility's MD on 12/17/25 showed an assessment plan:3. Frailty Clinical Frailty Score =7 severely frail, at very high risk of unavoidable wounds due to bedbound status, PVD (peripheral vascular disease), senile purpura and frailty. Patient is completely dependent for personal care, but prognosis greater than six months Patient has increased vulnerability and functional impairment due to cumulative declines among multiple body systems. Increased risk of adverse health outcomes including falls, hospitalization and death. Risk factors include advanced age, medications, lack of regular exercise, poor nutrition, weight loss, cognitive impairment and CAD, dementia senile purpura , frail skin peripheral vascular disease. Needs close monitoring for medication reviews, fall prevention strategies, nutritional interventions etc.-Daily wound care as recommended, wound care physician following ,notes reviewed today-Turn and reposition every 2 hours if patient is unable to turn self.-Use positioning supports including positioning wedge and heel protectors as needed.-Foam chair cushion when sitting up if needed.-Keep head of bed less than 30 degrees if not contraindicated.-Float heels off of bed with pillows under calves if needed.-Pressure redistributing mattress or specialty bed.-Barrier creams with incontinence care .-Use white incontinence pads in lieu of adult diapers.-Daily moisturizers after bath.-Nutritional support. Review of Resident #1's medical record revealed these assessment plan recommendations were not transcribed for follow -up. On 12/17/2025 at 10:42 a.m., an interview was conducted with the Resident Representative (RR) for Resident #1. The RR stated she had Resident #1 in the facility for respite care for a planned two- weeks stay. The respite care started on 11/18/2025. The RR stated she was gone for one week to then returned to her home and she went to visit Resident #1 on 11/26/2025 and requested the assistance of his nurse who was at the medication cart, to straighten his right leg. The RR stated Resident #1's right foot was positioned under the resident's bottom. The RR stated she observed black spots on both sides of Resident #1's foot. The RR stated on the right side of his foot, the pinky toe and the toe next to it were black and the black discoloration was going down towards the top part of his foot. The RR stated on the inside of his right foot was an opening of his skin. The RR stated she immediately went to her car to obtain supplies for dressing changes and requested the nurse to attend to his wounds with the provided dressings. The RR stated Resident #1 had a breakdown on his foot a year ago during respite care at another facility and the same breakdown occurred then. The RR stated she was able to take the resident home where she was able to treat and resolve the wound herself. The RR stated the resident, under her care, required a pillow to be placed between his legs and under his feet to offset pressure. The RR stated she did not see Resident #1 on an air mattress, pillows for offloading, socks on feet nor a heel boot. The RR stated she immediately knew she wanted Resident #1 removed from the facility. The RR called the preferred hospital, and had emergency medical service (EMS) transfer the Resident #1. The RR stated she was afraid of this situation reoccurring and stated she had taken pictures of Resident #1, just prior to leaving on 11/18/2025. The RR stated having taken pictures of the right foot on 11/26/2025. The RR stated she tried calling the facility multiple times, but the phone would ring and ring without answer. The RR stated when she did speak with Resident #1's nurse she informed her EMS was coming to transfer the resident to the hospital. The RR stated the following morning at 7:20 a.m., she received a call from the DON who apologized and stated she was away on vacation and had not met Resident #1. The RR stated, due to Resident #1's new wounds to his feet, the RR was advised by the medical staff to amputate his leg above the knee, the healthiest point due to his contractures and former total knee replacement. On 12/17/2025 at 10:07 a.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN)/wound care nurse and the Director of Nursing (DON). Staff A, LPN/wound care nurse stated, when she starts her shift, she views the [electronic software medical record] dashboard for newly admitted residents and adds these residents to her current list/log of residents with wounds/treatments to be assessed for any skin concerns. Staff A, LPN/wound care nurse stated after she had completed a head -to-toe assessment of newly admitted residents, if the residents required wound care treatments/management, she would document in the electronic medical records her assessment and treatments as completed in the Treatment Administration Record (TAR) and relay her findings to the admitting physician for a treatment plan as well as notify the resident's representative to inform them of the treatment plan. Staff A, LPN/wound care nurse, stated every Monday, the wound care physician will make official wound care rounds with the residents on the wound care/treatment log. The DON stated, as of December 04,2025, the wound care physician had included new admits onto the list for skin assessments, but this did not include Resident #1 who was admitted on [DATE]. The DON stated the list would have included residents with stage 1 non-blanchable skin concerns. The DON stated Staff A, LPN/wound care nurse was a good about communicating to her about residents requiring heel boots or air mattresses. The DON was unaware of Resident #1's condition prior to the family member's visit on 11/26/2025. A record review of Resident #1's Baseline Plan of Care with an initiation date of 11/18/2025 showed the following:At risk for skin breakdown with a goal: Will not develop new or have decline in existing wounds unless clinically avoidable. Interventions checked: Inspect skin daily during care for s/s (signs/symptoms) of breakdown Encourage, remind assist in position change regularly and frequently Moisturize skin with lotion especially bony prominences, but avoid massaging skin Encourage and assist with food and fluid to promote nutrition.The plan of care did not include previously recommended physician orders related to turning and repositioning every 2 hours if patient is unable to turn self and use positioning supports including positioning wedge and heel protectors as needed. On 12/17/2025 at 9:50 a.m., during the initial tour of the facility, an interview was conducted with Staff B, CNA/staffing coordinator/central supply and Staff C, van driver. Staff B and Staff C opened an outside shed filled with bed mattresses, large black garbage bags and various other equipment Staff B stated the black garbage bags contained air mattress overlays for beds. Staff B stated she has not had an issue with a request for an overlay air mattress when requested by the nurses. Staff B stated they have air mattress always overlays available and anyone can go into the shed to obtain one if needed. Staff B was unaware why Resident #1 did not have the pressure relief mattress on his bed.A record review of Resident #1 showed an admit date of 11/18/2025 with a discharge date of 11/26/2025 with the following diagnoses: Idiopathic gout, multiple sites Hemiplegia and hemiparesis following cerebral infarction affecting right dominant site Dysphagia following cerebral infarction Type 2 diabetes mellitus without complications Mild protein calorie malnutrition Tinea unguium Major depressive disorder, recurrent, moderate Alzheimer's disease, unspecified Essential hypertension Atherosclerotic heart disease of native coronary artery without angina pectorisA review of physician orders include but not limited to: House barrier cream to peri areas/buttocks/sacrum q (every) shift for 14 days for prevention, ordered 11/19/2025 Skin prep bilateral heels q shift for 14 days for prevention, ordered 11/19/2025 Vital signs every shift , ordered 11/19/2025. Zinc oxide ointment to groin and sacrum area every shift for wound care, ordered 11/21/2025A record review of the Treatment Administration Record (TAR) for the month of November 2025 showed the following documentation in relation to physician orders: House barrier cream documented as completed starting 11/19 through 11/25-day shift as last entry (three times a day administration opportunities) Skin prep bilateral heels documented as completed starting 11/19/2025 through 11/25-day shift as last entry (three times a day administration opportunities) Zinc oxide ointment documented as completed starting 11/21 through 11/25-day shift as last entry (three times a day administration opportunities)A record review of the Minimum Data Set (admissions) dated November 25,2025 showed: Section GG-Functional Abilities, Section GG0100-Prior Functioning : Everyday Activities showed Self-Care and Functional Cognition as Needed some help, resident needed partial assessment from another person to complete any activities. Section GG-Functional Abilities, Section GG0110-Prior Device Use showed manual wheelchair and mechanical lift Section GG- Functional Abilities, Section GG 0115- Functional Limitation in Range of Motion showed impairment on one side to upper extremity and lower extremity. Section GG- Functional Abilities- Admission, Section GG0170- Mobility showed substantial /maximal assistance for roll left to right, lying to sitting on side of bed, and dependent for chair to bed-to chair transfer Section H- Bladder and Bowel, Section H0300 showed resident as always incontinent for urinary and bowel continence Section I- Active Diagnoses showed other orthopedic conditions, anemia, coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's disease, cerebrovascular accident, hemiplegia or hemiparesis, depression, with idiopathic gout, dysphagia tinea unguium added to diagnoses. Peripheral Vascular disease (PVD) was not checked or added as a diagnosis. Section M- Skin Conditions Section M0210- Risk for Pressure Ulcers/Injuries showed resident is at risk for developing pressure ulcers/injuries. Section M- Skin Conditions Section M0210- showed resident does not have one or more unhealed pressure ulcers/injuries Section M-Skin Conditions Section M1030 Number of Venous and Arterial Ulcers showed zero total number of arterial/venous ulcers present. Section M- Skin Conditions M1200- Skin and Ulcer/Injury Treatments showed the following items checked: Pressure reducing device to chair, pressure reducing device to bed, applications of ointments, medications (other than to feet On 12/17/2025 at 12:46 p.m., an interview was conducted with Staff D, LPN. Staff D, LPN stated she had Resident #1 on 11/26/2025 during the 3-11 p.m. shift. Staff D, LPN stated she had Resident #1 the day he was admitted on [DATE] but stated she was off for a full week before she was assigned to him again on 11/26/2025. Staff D, LPN stated she was at her medication cart when the RR approached her and asked for her assistance in repositioning the resident. Staff D, LPN, stated the resident had his right foot under his buttocks. Staff D, LPN stated when she assisted moving the resident's right leg was when they both saw the resident's right foot. Staff D, LPN stated, Resident #1 appeared to have new pressure wounds in which she described them as a combination of dark to light red wounds. Staff D, LPN stated she was shocked and said, [Resident #1's] foot was not like this before he was admitted . Staff D, LPN stated the RR left to go to her car and returned with materials to address the wounds. Staff D, LPN stated, She asked me to clean it up and bandage it. Staff D, LPN stated the RR asked her to make sure his foot did not go under his bottom and to keep a pillow under. Staff D, LPN stated she agreed to her request. Staff D, LPN stated the RR left and she called the DON to notify her of the new wound. Staff D, LPN stated the RR called back about 30 minutes later requesting for Resident #1 to be transferred via EMS to the resident's preferred hospital. Staff D, LPN notified the DON regarding the RR requesting the transfer. Staff D, LPN stated thirty minutes later, EMS service arrived to take Resident #1 to the preferred hospital. A record review of the Change in Condition dated 11/25/2025 showed: a change in condition for: skin color or condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 120/78 - 11/25/2025 20:12 Position: Lying r/arm - Pulse: P 78 - 11/25/2025 20:12 Pulse Type: Regular - RR: R 20.0 - 11/24/2025 15:57 - Temp: T 97.2 - 11/25/2025 20:13 Route: Tympanic - Weight: W 180.8 lbs. - 11/22/2025 12:31 Scale: Mechanical Lift - Pulse Oximetry: O2 99 % - 11/25/2025 20:13 Method: Room Air - Blood Glucose: [blank] Nursing observations, evaluation, and recommendations are: resident noted with unstageable wound to right medial foot. approximately 10cmx7cm area noted to medial foot, eschar noted throughout wound bed, with areas of deep red discoloration surrounding. scabbed area to medial malleolus, and medial great toe. Right heel noted with open area approximately 5cm x 5cm, moderate amount of serosanguinous drainage noted to heel wound. Lateral foot noted with area of impairment, discoloration with apparent shearing.Review of a Wound Care consultation note signed by a [wound nurse] showed a progress note dated 11/25/2025 at 8:28 p.m., revealing the following: Resident was discharged via AMA (against Medical Advice) per [RR]'s request. [RR] visited the facility around 6:15 p.m. When accessing [Resident#1's]body she noticed his right foot was under his buttocks when she pulled his foot from underneath him she discovered pressure ulcers on multiple areas of his right foot the she stated to me [sic] were not there at the time of his admission on [DATE], she left some supplies to dress is foot with, so I cleaned & dressed his foot. Around 8 p.m. [RR] called the facility stating that she wanted [Resident #1] to be sent to the [hospital] immediately. I informed her he will be AMA (against medical advice) she stated that was fine paramedic arrived at 9:10 p.m. to have resident transferred to the [hospital] Staff D, LPNA record review titled, Daily Medicare A/Managed Care Nursing Notes SC4 a-V 5 under section K- Skin/Wounds pg.6 showed: 11/22/2025 : No new changes to skin integrity noted. 11/23/2025: No new changes to skin integrity noted 11/24/2025: No new changes to skin integrity noted A record review of the wound therapy nurse's progress note (Skin/Wound note) dated 11/21/2025 showed the following: Resident skin assessed by writer/wound care nurse, no open areas seen at time of assessment, redness to groin and sacrum area seen at time of assessment, resident denies pain at time of assessment, wound care provider notified, new orders given, resident incontinent to bowel and bladder call light left within reach, will continue to monitor. Staff A, LPN/wound nurse. On 12/17/2025 at 2:15 p.m., an interview was conducted with the DON, Assistant Director of Nursing (ADON), and Risk Manager. The DON stated all admits will receive a standard order for skin prep to heels for a minimum of a 14-day period. A review of Resident #1's TAR for November showed documentation related to skin prep to heels as complete per shift by the nursing staff. The DON stated the nursing staff should have made an observation of Resident #1's heels during the application of the skin prep and to notify immediately of any skin concerns. The November 2025 TAR documentation did not show any records of turning and repositioning every two hours, floating heels off bed with pillows and use of wedges and heel protectors as assessed by the facility's MD. A record review of the facility's policy titled, Skin Care & Wound Management-Manage Wound Care, no date initiated or revised, showed the following policy statement: The facility will manage wound care based upon current standards of practice. The policy showed the following procedures but not limited to:1) When skin impairment is identified, the nurse will review and select the appropriate treatment protocol for the wound.6) The Interdisciplinary Team will develop a Care Plan to address identified skin impairment(s) which will include at a minimum, effort to stabilize, reduce or remove risk factors and describe treatment protocol.A record review of the facility's policy titled: Skin Care & Wound Management-Regular skin inspections and prompt interventions to address change, no date initiated or revised, showed the following policy statement: The facility will inspect the resident's skin on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted. The policy showed the following procedures but not limited to:1) Skin inspections will be conducted by the licensed nurse using the Skin Sweep form for documentation at the time of admission and weekly.2) In addition, the Certified Nursing Assistant assigned to the resident will note the condition of the resident's skin during daily routine care and will report changes or areas of concern to the nurses assigned to the resident.3) Any identified skin impairment will be documented by the nurses at the time of discovery and weekly thereafter until healed using the appropriate wound log .If the skin impairment is pressure related, use the wound log. All non-pressure related skin impairments such as surgical wounds, etc. should be documented on the wound log.

Based on observations, record reviews, and interviews, the facility failed to implement an effective pest control program related to live pests found in two rooms (210 and 350) located in two halls (200 and 300) out of 4 halls observed.Findings included: An observation of room [ROOM NUMBER] on 10/21/2025 at 9:40 A.M. revealed several roaches on the wall behind Bed 2's nightstand and under and around the floor of Bed 3's armoire/closet. An observation of the outside of the maintenance area on 10/21/2025 at 11:20 A.M. revealed a resident nightstand. The Housekeeping Supervisor (HS) was spraying the nightstand with a red can of ant and roach pesticide. The nightstand had three drawers that were partially pulled out and each drawer contained personal resident items. A record review of the pest sighting logbooks on each nursing station revealed an entry dated 10/20/2025 and read, 200 Nurse Cart Roach. The entry was made by the Nursing Home Administrator (NHA). A record review of the exterminators invoice dated 10/10/2025 read, No activity was reported today. I need to note that out pest sighting logbooks are not being utilized by the nurses. None of the stations reported any activity for this week's treatment. Please ask the nurses to use the logbook correctly to help record and monitor pest activity. An interview was conducted on 10/21/2025 at 9:34 A.M. with Staff A, Housekeeping. Staff A said she always saw roaches in room [ROOM NUMBER]. She said the roaches are behind bed 2's nightstand and the roaches are under bed 3's armoire/closet. Staff A said the exterminators spray the room and outside the room, but they always come back. She said she thinks the roaches are living inside the wall. Staff A said she tells the maintenance department. She said she doesn't write anything in the pest sighting logbooks. An interview was conducted on 10/21/2025 at 9:46 A.M with the resident in room [ROOM NUMBER]. There were several flies in the room and a food tray sitting on the resident's bed. The resident (#2) said once the facility started construction he saw several roaches in his room and hallways. The resident said he asked for maintenance to come and no one from maintenance or housekeeping had come to the room to see the pests. The resident said he had talked to the staff about the pests, but the staff always say they were working on it. An interview was conducted on 10/21/2025 at 10:50 A.M. with Staff E, Van Driver/Maintenance assistant. Staff E said she helps with maintenance often. Staff E said the pest control company comes to the facility twice per month. Staff E said if the staff see pests inside, she will spray them with the red can of ant and roach pesticide. Staff E said when pests are seen in the facility, staff should be writing the sighting in the pest sighting logbooks at each nursing station. An interview was conducted on 10/21/2025 at 11:21 A.M with the Housekeeping Supervisor (HS). The HS said he had pulled the nightstand out of room [ROOM NUMBER]-2 and sprayed it with the red can of ant and roach pesticide. The HS said he would put it back in room [ROOM NUMBER]-2 later in the day. An interview was conducted on 10/21/2025 at 11:35 A.M. with the Director of Maintenance (DOM). The DOM said the staff do not spray for pests; the facility uses a pest control company. The DOM said if there are pests inside the furniture, that furniture should be pulled out of the resident's room. The DOM said staff are not supposed to use the red can of roach and ant pesticide. The DOM said he was trying to correct some of the old maintenance habits. The DOM said staff are supposed to document any pests sightings in the pest sighting logbooks at each nursing station. The DOM said the exterminators come and spray the facility every two weeks and they review the pest sighting logbooks at that time. The DOM said the exterminators spray the areas indicted in the pest sighting logbooks. The DOM said pesticides are not sprayed inside the building. He stated he uses wasp spray outside the building. An interview was conducted on 10/21/2025 at 1:03 P.M. with the NHA. The NHA said the facility uses a pest control company and they come once per month to spray. The NHA said if the staff see pests, they are supposed to put the sighting in the pest sighting logbooks. The NHA said there was a grievance filed a few days ago regarding flies. The NHA said the grievance had not been resolved. The NHA said the staff are not supposed to spray pesticides in the facility. The NHA said she saw a roach in her office yesterday and noted that in the pest sighting logbook. The NHA said staff should be removing food trays from the rooms as soon as the residents are finished eating. The NHA said it is not appropriate to have roaches in the residents rooms. A review of an undated facility's policy titled, Environmental Services - Pest (Insect) Control showed: The facility will maintain an ongoing pest control program. Pest control services are provided by a licensed pest exterminator on no less than a monthly basis and as needed. The contracted Post Control Services will include both interior and exterior pest control. 1: Food items in resident rooms should be kept in air-tight containers. 3: Staff will report any evidence of insects in resident's rooms or common areas to the maintenance/housekeeping staff. During regular business hours, the report can be logged into the maintenance request log and/or the log provided by the pest control company, if applicable. 4: Live insects in resident rooms or care areas should be reported as soon as possible to the Maintenance or Housekeeping Supervisor and the Administrator. 6: Residents will be removed from the area where live insects are noted until control measures are provided. Only pest control measures that are approved by the licensed pest exterminator will be used.

Based on observations, interviews, and record review, the facility failed protect a residents right to be free from abuse for one resident (#2) out of four residents sampled. Findings included: During an observation on 06/09/2025 at 10:40 a.m., Resident #2 was observed dressed for the day sitting in a wheelchair on the back patio. Review of Resident #2's admission record revealed an admission date of 03/25/2025. Resident #2 was admitted to the facility with diagnoses to include vascular dementia, unspecified severity, with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder, recurrent, moderate. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 03 out of 15, indicating severe cognitive impairment. Review of Resident #2's Care Plan, dated 04/01/2025, revealed the following: Focus: The resident has a behavior problem related to refusing to allow vital signs to be taken, refusing medications at times, throwing plate up against the wall and combative during care diagnosis: Dementia Goal: The resident will have no evidence of behavior problems of resisting vital signs, medication and care by review date Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness, explain all procedures to the resident before starting and allow the resident time to adjust to changes, If resident resists care, leave and return later to try again, and Psych (psychiatric) eval as needed. Focus: Resident #2 has impaired communication secondary to dementia. She sometimes understands others, and sometimes expressing ideas and wants, she has disorganized thinking. She is at risk for missing communication r/t impaired cognition. Goal: The residents will maintain current level of communication function through the review date. Interventions: Anticipate and meet needs, communication: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, Refer to speech therapy for evaluation and treatment as ordered. Speak on an adult level, speaking clearly and slower than normal. Focus: Resident #2 has impaired cognitive function/dementia or impaired thought processes r/t Dementia short- and long-term memory loss and is moderately impaired in decision making. Unaware of where about's Goal: Resident #2 will be able to communicate basic needs on a daily basis through the review date. All of resident needs will be met and anticipated by staff Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs, communicate with the resident/family/caregivers regarding residents capabilities and needs. Cue, reorient and supervise as needed. Discuss concerns about confusion, disease process, nursing home placement with resident/family/caregivers). Explain all procedures. Use simple, one-word requests if possible. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Observe for signs of frustration and anxiety and change activity if observed. If the resident is having an episode of anxiety or agitation, gently attempt to calm resident and refocus attention. Provide cueing and prompting for personal care. Review of Resident #2's Psych Note, dated 06/05/2025, revealed the following: .female with a history psychotic disorder, dementia and comorbid stroke currently overall at baseline in terms of her mood and behaviors. Nursing reports resident can be resistive to care at times. Resident with an expressive aphasia with resultant difficulty communicating. Nursing reports that a nurse pinched her nose in the process of medications administration to encourage the patient to take her medication. This was witnessed and reported. The medication nurse admitted the incident. Patient noted having no change in her mood and behaviors after the incident. Met with the resident in her room. She is awake and alert to person. Difficult to fully assess her cognition due to her aphasia. She does respond appropriately to most yes/no questions, other times appears confused. She shakes her head yes within asked if she is comfortable with her care partners and in the facility. She shakes her head no when asked if she feels depressed. She denies urgent concerns. Physically the patient appeared their stated age, awake and alert. Emotionally the patient appeared calm and less guarded. The patient showed no signs of psychomotor agitation, retardation or bizarre behavior. The patient presented with non-fluent speech. Mood was normal. During an interview on 06/09/2025 at 2:07 p.m., Staff B, Certified Nursing Assistant (CNA) stated she was helping Staff C, CNA provide care to Resident #2. She stated, while providing care Staff D, Licensed Practical Nurse (LPN) came in Resident #2's room to give Resident #2 her medications. She stated, the first time Staff D, LPN gave the medication to Resident #2 she spit it out. She stated, the nurse tried again, and Resident #2 spit the medication out again. Staff B stated, the third time Staff D, LPN left the room and came back with a syringe, and while giving Resident #2 the medication from the syringe the nurse held Resident #2's nose and mouth closed until Resident #2 swallowed the medication. Staff B stated, Resident #2 kept saying, I don't want it, I don't want it. [Staff D, LPN] told us you don't need to go tell on me because I'm going down there myself. I told [Staff C, CNA] if you ever get a chance to be a nurse do not do that because that is abuse. During an interview on 06/09/2025 at 2:59 p.m., Staff C, CNA, stated she was in Resident #2's room getting her ready to give her a bath. Resident #2 looked a little agitated, so I asked Staff D, LPN to give her something. Staff D, LPN left the room and returned with medication for Resident #2. The first time Staff D, LPN gave Resident #2 the medication with a spoon and Resident #2 spit it out. Staff D, LPN tried again with the medication on the spoon and Resident #2 spit it out again. Staff D, LPN said Wait don't touch her I have something for her. Staff D, LPN left the room and came back with a syringe. When she gave Resident #2 the medication this time, She held Resident #2's nose and mouth closed. Staff D, LPN told me that's how I get my kids to take their medicine. During a phone interview on 06/09/2025 at 4:27 p.m., Staff D, LPN stated last Monday (06/02/2025), she walked into give Resident #2 her morning medication and saw Staff C, CNA holding Resident #2's hands and wrestling with the resident. She told Staff C, CNA she had Resident #2's medications. Resident #2 takes her medication crushed with pudding. She tried giving Resident #2 the crushed medication and pudding twice and Resident #2 spit it out both times. She left the room and mixed what was left in the medicine cup with water and put it in a syringe. I gave her the medication with the syringe and held her nose so that she would swallow the medication. I did not do it maliciously. [Resident #2] has a history of being combative when she does not get her medicine. That is the reason she is on the medications. During an interview on 06/10/2025 at 12:30 p.m., the Director of Nursing (DON) stated neither Staff B, CNA or Staff C, CNA reported to her Resident #2 was being combative at the time of the incident. When the CNA's notified her of the incident, she immediately removed the nurse from the assignment. She stated, if a resident is refusing their medications nurses should try to redirect the resident or try to notify family. Resident families can get them to take their medications. She said the resident ultimately has the right to refuse and it is even more important for the residents who are not alert and oriented for those rights to be honored. Review of the facilities undated policy titled Abuse Neglect Exploitation And Misappropriation revealed the following: Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of federal and or state laws are reported immediately to the administrator, the risk manager, the social service director, and the director of nursing.

Based on observations, interviews, and record review, the facility failed to ensure medications were properly stored and secured on two units (300 and 400) out of four units in the facility. Findings included: An observation was conducted on 6/9/25 at 9:25 a.m. at the 400-unit nurses' station. The door to the nurses' station was open, no staff were in sight, and the medication refrigerator in the station was observed to be unlocked. There were floor to ceiling cabinets next to the refrigerator that were also unlocked, and the top cabinet was full of over-the-counter (OTC) medications. The medications were accessible to residents, visitors, or unlicensed staff. An observation was conducted on 6/9/25 at 9:32 a.m. in the 300-unit common area. There was a treatment cart sitting in the resident common area unlocked. No staff were in sight at the time. The treatment cart was observed to contain prescription medications and wound care supplies. A follow-up observation was conducted on 6/9/25 at 12:46 at the 400-unit nurses' station. The medication refrigerator and cabinet with the OTC medications remained unlocked. The nurses' station door was open, and a resident was sitting just outside the door with no staff members in sight. An observation and interview was conducted on 6/9/25 at 3:15 p.m. with Staff A, Licensed Practical Nurse (LPN). The medication refrigerator and cabinet at the 400-unit nurses' station remained unlocked. Staff A was sitting at the nurses' station and confirmed she was the nurse working on the 400 unit from 7:00 a.m. to 3:00 p.m. Staff A said a nurse had just gotten something out of the OTC cabinet. She said it should be locked and any key works to lock it. In reference to the medication refrigerator being unlocked, she said, There isn't anything in there but insulin, but it should be locked. Staff A stated, I just haven't gotten to it. Staff A agreed both the refrigerator and the cabinet with OTC medication should have been locked at all times so they were not accessible. An interview was conducted on 6/10/25 at 11:28 a.m. with the Director of Nursing (DON). She stated medication should not be left unsecured for any reason. The DON said it is her expectation the medication refrigerator and the cabinet with OTC medications would be locked when not being accessed by the nurse. She stated treatment and medication carts should remain locked when not being used by the nurse. Review of a facility policy titled Medication Storage, undated, showed: Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL Department of Health guidelines. Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. . (Photographic evidence obtained.)

Based on observations, interviews, and record review, the facility failed to honor a residents right to refuse medications for one resident (#2) out of four residents sampled. Findings included: During an observation on 06/09/2025 at 10:40 a.m., Resident #2 was observed dressed for the day sitting in a wheelchair on the back patio. Review of Resident #2's admission record revealed an admission date of 03/25/2025. Resident #2 was admitted to the facility with diagnoses to include vascular dementia, unspecified severity, with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder, recurrent, moderate. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 03 out of 15, indicating severe cognitive impairment. Review of Resident #2's Care Plan, dated 04/01/2025, revealed the following: Focus: The resident has a behavior problem related to refusing to allow vital signs to be taken, refusing medications at times, throwing plate up against the wall and combative during care diagnosis: Dementia Goal: The resident will have no evidence of behavior problems of resisting vital signs, medication and care by review date Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness, explain all procedures to the resident before starting and allow the resident time to adjust to changes, If resident resists care, leave and return later to try again, and Psych (psychiatric) eval as needed. Focus: Resident #2 has impaired communication secondary to dementia. She sometimes understands others, and sometimes expressing ideas and wants, she has disorganized thinking. She is at risk for missing communication r/t impaired cognition. Goal: The residents will maintain current level of communication function through the review date. Interventions: Anticipate and meet needs, communication: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, Refer to speech therapy for evaluation and treatment as ordered. Speak on an adult level, speaking clearly and slower than normal. Focus: Resident #2 has impaired cognitive function/dementia or impaired thought processes r/t Dementia short- and long-term memory loss and is moderately impaired in decision making. Unaware of where about's Goal: Resident #2 will be able to communicate basic needs on a daily basis through the review date. All of resident needs will be met and anticipated by staff Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs, communicate with the resident/family/caregivers regarding residents capabilities and needs. Cue, reorient and supervise as needed. Discuss concerns about confusion, disease process, nursing home placement with resident/family/caregivers). Explain all procedures. Use simple, one-word requests if possible. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Observe for signs of frustration and anxiety and change activity if observed. If the resident is having an episode of anxiety or agitation, gently attempt to calm resident and refocus attention. Provide cueing and prompting for personal care. Review of Resident #2's Psych Note, dated 06/05/2025, revealed the following: .female with a history psychotic disorder, dementia and comorbid stroke currently overall at baseline in terms of her mood and behaviors. Nursing reports resident can be resistive to care at times. Resident with an expressive aphasia with resultant difficulty communicating. Nursing reports that a nurse pinched her nose in the process of medications administration to encourage the patient to take her medication. This was witnessed and reported. The medication nurse admitted the incident. Patient noted having no change in her mood and behaviors after the incident. Met with the resident in her room. She is awake and alert to person. Difficult to fully assess her cognition due to her aphasia. She does respond appropriately to most yes/no questions, other times appears confused. She shakes her head yes within asked if she is comfortable with her care partners and in the facility. She shakes her head no when asked if she feels depressed. She denies urgent concerns. Physically the patient appeared their stated age, awake and alert. Emotionally the patient appeared calm and less guarded. The patient showed no signs of psychomotor agitation, retardation or bizarre behavior. The patient presented with non-fluent speech. Mood was normal. During an interview on 06/09/2025 at 2:07 p.m., Staff B, Certified Nursing Assistant (CNA) stated she was helping Staff C, CNA provide care to Resident #2. She stated, while providing care Staff D, Licensed Practical Nurse (LPN) came in Resident #2's room to give Resident #2 her medications. She stated, the first time Staff D, LPN gave the medication to Resident #2 she spit it out. She stated, the nurse tried again, and Resident #2 spit the medication out again. Staff B stated, the third time Staff D, LPN left the room and came back with a syringe, and while giving Resident #2 the medication from the syringe the nurse held Resident #2's nose and mouth closed until Resident #2 swallowed the medication. Staff B stated, Resident #2 kept saying, I don't want it, I don't want it. [Staff D, LPN] told us you don't need to go tell on me because I'm going down there myself. I told [Staff C, CNA] if you ever get a chance to be a nurse do not do that because that is abuse. During an interview on 06/09/2025 at 2:59 p.m., Staff C, CNA, stated she was in Resident #2's room getting her ready to give her a bath. Resident #2 looked a little agitated, so I asked Staff D, LPN to give her something. Staff D, LPN left the room and returned with medication for Resident #2. The first time Staff D, LPN gave Resident #2 the medication with a spoon and Resident #2 spit it out. Staff D, LPN tried again with the medication on the spoon and Resident #2 spit it out again. Staff D, LPN said Wait don't touch her I have something for her. Staff D, LPN left the room and came back with a syringe. When she gave Resident #2 the medication this time, She held Resident #2's nose and mouth closed. Staff D, LPN told me that's how I get my kids to take their medicine. During a phone interview on 06/09/2025 at 4:27 p.m., Staff D, LPN stated last Monday (06/02/2025), she walked into give Resident #2 her morning medication and saw Staff C, CNA holding Resident #2's hands and wrestling with the resident. She told Staff C, CNA she had Resident #2's medications. Resident #2 takes her medication crushed with pudding. She tried giving Resident #2 the crushed medication and pudding twice and Resident #2 spit it out both times. She left the room and mixed what was left in the medicine cup with water and put it in a syringe. I gave her the medication with the syringe and held her nose so that she would swallow the medication. I did not do it maliciously. [Resident #2] has a history of being combative when she does not get her medicine. That is the reason she is on the medications. During an interview on 06/10/2025 at 12:30 p.m., the Director of Nursing (DON) stated neither Staff B, CNA or Staff C, CNA reported to her Resident #2 was being combative at the time of the incident. When the CNA's notified her of the incident, she immediately removed the nurse from the assignment. She stated, if a resident is refusing their medications nurses should try to redirect the resident or try to notify family. Resident families can get them to take their medications. She said the resident ultimately has the right to refuse and it is even more important for the residents who are not alert and oriented for those rights to be honored. Review of the facilities undated policy titled Resident Rights revealed the following: .A. Resident rights. The resident has a right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility, including those specified in this section. 1. A facility must treat each resident with respect and dignity and care for each resident in a manner of and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident B. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and a citizen or resident of the United States. 1. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

Based on observation, interview, and record review. the facility failed to provide Activities of Daily Living (ADLs) related to showering for two (#2, #4) of three residents sampled and related to incontinence care for two (#2, #3) of three residents sampled. Findings included: 1. Review of Resident #2's Admission Record showed diagnoses included but not limited to acute respiratory failure with hypoxia, Urinary Tract Infection (UTI), Chronic Obstructive Pulmonary Disease (COPD), anemia, diabetes, hypertension, myocardium infarction sleep apnea, and muscle weakness. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Under Section GG - Functional Abilities showed the resident needed moderate assistance for toileting hygiene and maximal assistance for toilet transfer. Section O, Special Treatments, Procedures and Programs showed Occupational Therapy (OT) started on 10/14/2024 and Physical Therapy (PT) started on 10/12/2024. Review of Resident #2's care plans showed a care plan for an Activities of Daily Living (ADL) self-care performance deficit related to that decline in health status. She was admitted from the hospital for respiratory failure with hypoxia, collapsed lung, COPD, obstructive sleep apnea, neoplasm of left lung, and obesity. She had a port to the right chest for chemotherapy. She was at risk for further decline secondary to muscle weakness and unsteadiness on feet. Skilled therapy is in progress as scheduled to improve level of function initiated on 10/17/2024. Interventions included but not limited to bathing / showering: provide sponge bath when a full bath or shower cannot be tolerated as of 10/17/2024; PT/OT evaluation and treatment as per MD orders date initiated 10/17/2024. Review of a Care plan for Resident #2 revised on 10/17/2024 showed the resident was incontinent of bladder function related to impaired mobility, history of UTI and endometrial cancer. The resident was at risk for complications associated with incontinence and dehydration. The goal for the resident was to remain free from skin breakdown due to incontinence and brief use through the review date of 1/20/2025. Interventions included but were not limited to brief use: the resident uses adult disposable briefs. Check for incontinence change as needed initiated on 10/17/2024; clean Peri-area with each incontinence episode initiated on 10/17/2024; incontinent: check for incontinence. Wash rinse and dry perineum. Change clothing PRN after incontinence episodes initiated on 10/17/2024. Review of the Documentation Survey Report for Bladder Elimination log for Resident #2 for dates 10/07/24 to 10/24/24 showed 29 out of 52 opportunities or 56% Bladder Elimination documentation was not documented. Review of the Documentation Survey Report for ADL - Toilet Use log for Resident #2 dates 10/07/2024 to 10/24/2024, showed 34 out of 52 opportunities or 65% Toilet Use was not documented Review of the 30 days look back Bath/Shower log for the month of October 2024 showed Resident #2 received only two showers on 10/12/2024 and 10/21/2024. During an interview on 11/07/2024 at 2:00 p.m., Staff A, CNA stated, You document providing incontinence care by pulling up assignment on the computer and it gives you options. Under toilet-use you document incontinence care was provided. The documentation shows if they are dependent or independent and if bladder care for incontinent or not. Staff A stated every shift should be documenting this information. Staff A verified that the documentation was not present on every shift. Staff A stated Resident #2 was to have showers 3 times a week or as requested. She was to have showers on Tuesday, Thursday, and Saturday on the 3 p.m. to 11 p.m. shift. Staff A verified Resident #2 received showers on the 12th and the 21st only. Staff A stated they should have documented she was refusing showers if she was. She confirmed documentation was not there. Staff A stated when the aide came in for their shift, they were given a shower sheet for the shift. During an interview on 11/07/2024 at 3:45 p.m. with the DON, she stated there was to be documentation every shift from the CNAs. The CNA was to document ADL care. The DON stated the residents got showered three times a week, ideally, and could have more. The DON stated, If they want, we offer bed bath in the mornings. The residents were scheduled for showers 3 times a week. If a shower was not given, it should be documented as bed bath, if given. The DON stated there should be some documentation daily about bathing. If the resident refused a shower, they should notify the nurse and document refusal. The DON verified ADL care was not documented on Resident #2. During an interview on 11/07/2024 at 4:20 p.m. with the Nursing Home Administrator (NHA) and Social Services Director (SSD), the NHA stated the DOR (Director of Rehabilitation) was out ill. The NHA verified incontinence care and showers documentation was missing. She stated the residents got showers three times a week and if refused it should be documented. Review of an undated facility policy titled, Perineal Care, showed the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident skin condition. Reporting and documentation: The following information should be reported to the staff / charge nurse and should be documented in the residence medical record. 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. Any skin care problems noted. 7. If the resident refused the treatment and the reasons why. 8. The signature and title of the person recording the data. 2. Review of the Admission Record for Resident #3 showed diagnoses not limited to encounter for other orthopedic aftercare, presence of left artificial knee joint, and difficulty in walking not elsewhere classified. Review of the Admission/Readmission Screening/History evaluation for Resident #3 dated 11/01/2024 revealed Resident #3 was admitted for rehab, was alert and oriented x 4, spoke Spanish. The form did not show the resident was incontinent of bladder (urine) or of bowel and had steri-strips on left leg and was able to bear weight to this extremity. The ADL evaluation revealed bed mobility, transfers, walking, locomotion, and toilet use was not assessed and for dressing, personal hygiene and bathing the resident required assistance of staff. Review of a Continence Evaluation for Resident #3 dated 11/01/2024 showed under mobility status, the resident required assist with transfer/standing. Under Bladder, the assessment showed the perception of the need to void was present, able to tell of need to void, did not wear a pad to keep undergarments clean, and was continent of urine. The evaluation for bowel function had not been completed. Review of the Physical Therapy (PT) evaluation and Plan of Treatment, with a start of care date of 11/02/2204 showed Resident #3's baseline was partial/moderate assist for chair/bed-to-chair transfers, lying to sitting on side of bed, was weight bearing as tolerated status post (s/p) left knee total arthroplasty. The Functional Mobility Assessment showed a toilet transfer had not been attempted due to medical conditions or safety concerns, with partial/moderate assistance resident could walk 10 feet, with substantial/maximal assistance could walk 50 feet with 2 turns, and used a manual wheelchair or scooter. The reason for therapy showed the patient presented with balance deficits, strength impairments, pain, (and) postural alignment/control and decreased dynamic balance. Review of Resident #3's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 10/31/24 showed the resident was weight-bearing as tolerated (WBAT) with a walker. Review of the November 2024 Documentation Survey Report for ADL - Toilet Use log for Resident #3 did not show any bladder or bowel elimination during the 3 p.m. - 11 p.m. shift on 11/01/2024 or 11/02/2024 or on the 11 p.m. - 7 a.m. shift on 11/01/2024 or 11/02/2024. The record did not show the resident received any assistance for toilet use during the period of 3 p.m. to 7 a.m. on 11/01/2024 or 11/02/2024 or if the resident had been incontinent/continent of bowel and/or bladder during those same shifts. An interview was conducted on 11/07/2024 at 12:19 p.m. with the Director of Rehabilitation (DOR). The DOR stated the facility generally knew who was coming in/(admitted ) and new admissions were evaluated the next day. The DOR stated residents who had a total knee replacement should be evaluated, but staff did not necessarily have to wait for residents to be evaluated if they had already been receiving PT in the hospital, if they had documentation from the hospital, and were continent and wanted to get up for the bathroom. An interview was conducted on 11/7/24 at 2:10 p.m. with Staff A, CNA/Medical Records. The staff member reported CNAs enter documentation in the electronic record. Staff A said they logged into the resident's name, pull up the assignment, bowel and bladder elimination should be under toilet use. Staff A stated staff would document the resident's performance, if they were continent/incontinent, and they should document every shift as to what type of care they provided to the resident. Staff A reviewed the CNA documentation for Resident #3 and confirmed the resident had not received assistance from staff during five of seven shifts. During an interview on 11/07/2024 at 3:44 p.m., the Director of Nursing (DON) reported Resident #3 was not at the facility very long, was Spanish-speaking but thought the resident was able to understand a little English. The staff member reported CNAs should document every shift anything that fell under the plan of care (POC). The DON stated she did not know whether the resident was continent or incontinent and reported she had worked the cart during the 11 p.m. - 7 a.m. shift on 11/02/2024 (Saturday into Sunday morning). 3. On 11/7/24 at 12:05 p.m., Resident #4 was observed sitting on edge of bed, wearing a hospital gown, eating the noon meal. The resident reported not being bathed since getting to the facility. Review of the Admission Record for Resident #4 showed the resident was admitted with diagnoses included but not limited to generalized muscle weakness, unspecified altered mental status (AMS), unsteadiness on feet, and unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the admission Minimum Data Set (MDS) for Resident #4 dated 9/17/24, showed a Brief Interview of Mental Status (BIMS) score of 11 of 15, which indicated a moderate impairment of cognition. The review of section F0800 Staff Assessment of Daily and Activity Preferences, showed the resident preferred to receive showers and bed baths. Review of the care plan for Resident #4 showed a focus revised on 09/23/2024, the resident required total assistance with Activities of Daily Living (ADLs), transfers, and bed mobility related to (r/t) muscle weakness, AMS (Altered Mental Status), cerebral vascular accident (CVA) with poor prognosis, and impaired mobility. Skilled therapy is ongoing to improve level of function. The interventions included instructions for CNAs to assist with bathing, dressing, personal hygiene daily and as needed (prn). Review of the 100 & 200 Hall Shower List showed Resident #4 was to receive showers on Tuesday, Thursday, and Saturdays during the 11 p.m. - 7 a.m. shift. The schedule instructed CNAs to provide showers as scheduled (and as needed (prn)) and sign after each shower is given. Review of the September 2024 Documentation Survey Report for ADL - Bathing log for Resident #4 showed the resident received three bed baths on 09/10/24, 09/11/2024 and 09/25/2024. The record showed the resident missed 6 shower/bath opportunities. The documentation did not reveal the resident had any other bathing type (shower) during the month of September 2024. Review of the October 2024 Documentation Survey Report for ADL - Bathing log for Resident #4 showed the resident had not received any showers and had received five bed baths. The record showed the resident missed 10 shower/bath opportunities. The documentation did not reveal the resident had any other bathing type (shower) during the month of October 2024. Review of the November 2024 CNA documentation for Resident #4 bathing task showed the resident had missed a shower/bath on 11/05/2024. The documentation revealed self-performance (how (the) resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) was NA = not applicable. An interview was conducted on 11/07/24 at 2:24 p.m. with Staff A, CNA. The staff member reported Resident #4 was to receive a bath three times a week. Staff A reviewed the CNA documentation for November and confirmed the resident had missed a bath/shower on the previous Tuesday. An interview was conducted on 11/07/2024 at 3:44 p.m. with the DON. The DON stated residents could shower when they want, and the facility scheduled showers three times a week and bed baths daily. She stated she knew Resident #4, and the resident could answer yes or no questions appropriately. The DON stated staff should document a resident's refusal (of care). Review of the Documentation Survey Report for ADL - Bathing log for Resident #4 from 09/10/2024 to 11/06/2024 did not show the resident had refused any bathing/showering. Review of the Certified Nursing Assistant (CNA) job description showed the basic function was To provide routine daily nursing care and services that support the care delivered to patients/ residents requiring long-term or rehabilitative care, in accordance with the established nursing care procedures and directed by your supervisor. The essential functions included: 1. Provides care as directed by the professional nurse to patients/ residents requiring long-term, rehabilitative care or restorative care. 3. Documents objective information related to patient/resident care. 4. Provides services that support the care delivered to the patient/ resident. 10. Performs other related duties as assigned or requested. Review of an undated facility policy titled, Restorative Nursing - ADL's assistance (Bathing, Dressing, and Grooming), revealed The facility will provide restorative programming to assist residents in attaining and maintaining the highest practicable level of function. A resident/patient will be eligible for restorative ADL programming if he/she demonstrates interest in improving or participating in self-performance of activities of daily living and requires skill practice and/or training and dressing, bathing, or grooming. The policy revealed the following under documentation: 1. All entries on charts, notes, flow sheets, etc. (etcetera), are recorded in an informative and descriptive manner. 5. Nursing care flow sheet (if applicable) is maintained. 37999

Based on observation, record review. and interview. the facility failed to maintain the medical record of one (#3) of three residents sampled in an appropriate manner related to complete and accuracy of the records. Findings included: Review of the Admission Record for Resident #3 showed the resident was admitted on [DATE] following a hospital stay. The Admission Record revealed diagnoses not limited to presence of left artificial knee joint, unilateral primary osteoarthritis of left knee, difficulty in walking not elsewhere classified, unspecified anxiety disorder, and recurrent unspecified major depressive disorder. The record revealed the resident's primary language was English. Review of the Nursing Admission/ Readmission Screening/ History, effective 11/1/2024 at 12:04 p.m. for Resident #3 revealed the other language spoken by resident #4 was Spanish. The screening did not reveal the resident spoke English. Review of the Continence Evaluation for Resident #3 showed the resident was oriented x 3 (person, place, and time) for cognition and required assistance with transfers/standing. The evaluation revealed the resident was continent of bladder and the bowel assessment was not completed. Review of the Certified Nursing Assistant (CNA) documentation for Resident #3 showed no documentation had been completed for the resident's Activities of Daily Living (ADLs) during the 3 p.m. - 11 p.m. shift on 11/1 and 11/2, and the 11 p.m. - 7 a.m. shift on 11/1/ and 11/2/24. Review of the progress notes for Resident #3 showed no nursing documentation was completed for the resident from 11/1 at 8:06 p.m. to 11/3/24 at 1:11 p.m. The record did not include any skilled nursing or progress notes for 11/2/24. The one note on 11/3/24 revealed a family member had requested to take resident home Against Medical Advice (AMA), this writer notified the MD on call Services and left voicemail to return call to our facility. The family member (who was not listed as the responsible party or Emergency Contact) signed the AMA paperwork. The record did not reveal if the physician had returned the call, if the Director of Nursing and/or Administrator had been contacted, or if any conversation had happened between the resident, family member, and staff member(s). Review of the facility's Grievance/Concern log for November 2024 revealed no concerns had been voiced by either a resident of the facility or a resident representative. Review of the facility's Incident logs for November 2024 did not reveal Resident #3 had an incident at the facility. During an interview on 11/7/24 at 3:44 p.m., the Director of Nursing (DON) revealed Resident #3 had not been in the facility very long. She stated she had worked the cart on the 11 p.m. - 7 a.m. shift, Saturday to Sunday on 11/2/24. The DON reported Resident #3 seemed to be pleasant, did not ask for much, CNAs offered water, and asked if changing was needed. The DON stated she had given the resident medications during the shift but could not remember which ones. The DON reported not knowing why the resident had left AMA, however had asked the nurse and was told the resident or family believed there was going to be a Spanish-speaking staff member 24 hours a day to translate for the resident. She stated she believed the resident could understand a little English. An interview was conducted on 11/7/24 at 4:20 p.m. with the Nursing Home Administrator (NHA) and Social Services Director (SSD). The SSD reported not being at the facility from 10/18 to 11/4/24 and had a lot piled up. She reported she would not have made a follow up call to Resident #3, the Risk Manager (RM) would have. The NHA reported the RM was let go on Monday (11/4) and a new one started on 11/5/24. The NHA reviewed the progress notes and evaluations confirming there was no note or evaluation completed for Resident #3 on 11/2/24 and there should be a skilled nursing note. The NHA read the note on 11/3/24 regarding Resident #3's AMA discharge and stated it was a pretty generic note. An interview was conducted on 11/7/24 at 4:58 p.m. with the NHA and DON. The NHA reported the facility did not have a skilled nursing policy and the DON stated it would be a follow physician orders policy.

Based on interview and record review, the facility failed to provide therapy services in a timely manner for one (#2) of three sampled residents. Findings included: 1. Review of the Admission Record for Resident #2 showed she was admitted to the facility on ,d+[DATE] with diagnoses included but not limited to acute respiratory failure with hypoxia, Urinary Tract Infection, Chronic Obstructive Pulmonary Disease (COPD), myocardial infarction, and muscle weakness. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Section GG Functional Abilities showed she needed moderate assistance for toileting hygiene and maximal assistance for toilet transfer. Section O, Special Treatments, Procedures and Programs showed Occupational Therapy (OT) started on 10/14/2024 and Physical Therapy (PT) started on 10/12/2024. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 10/7/24, showed treatments and frequency: PT 5 times a week OT 5 times a week Ambulates with assistive device (4 wheeled bariatric walker) and required assistance with transfers Review of the physician orders showed Therapy: Physical Therapy to evaluate and treat as indicated as of 10/12/20204 Therapy: Occupational Therapy to evaluate and treat as indicated as of 10/14/20204 Physical Therapy clarification order: 5 times a week for 4 weeks for unsteadiness on feet, weakness, with focus on therapeutic activity, therapeutic exercise, neuromuscular re-education, gait training, group treatment / concurrent /individual whichever is applicable and discharge planning as of 10/12/2024. Occupational Therapy clarification order, 5 times a week for 4 weeks for weakness with focus on therapeutic activity, therapeutic exercises, neuromuscular re-education, and self-care training, group treatment / concurrent /individual whichever is applicable and discharge planning as of 10/14/2024. Review of the APRN (Advanced Practice Registered Nurse) note written on 10/08/2024 showed Assessment / Plan included Physical deconditioning: admit to SNF, Continue PT/OT as indicated, Fall precaution, Skin assessment per facility protocol and Supportive care; ADL assistance. Review of the PT evaluation dated 10/12/24 showed the reason for therapy: based on examination pt's body regions, systems and structures, patient presents with balance deficits, strength impairments, unilateral weakness, pain, proximal instability, body awareness deficits and gross motor coordination deficits and in consideration of history, personal factors, and functional limitations documented in this eval summary, patient requires skilled PT services to increase LE ROM (Lower Extremity range of motion) and strength, increase independence with gait, increase functional activity tolerance, facilitate independence with hall functional mobility and enhance rehab potential, in order to safely return home, decrease level of assistance from caregivers and facilitate safe transition to next level of care. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for pneumonia, limited out of bed activity, falls, immobility, decreased skin integrity, anxiety and pulmonary insufficiency. Review of the OT evaluation dated 10/14/2024 showed clinical impressions / reason for skilled services: patient exhibits new onset of fall / fall risk, reduced dynamic balance, reduced static balance and reduced ADL participation: patient is a [AGE] year old female who has admitted to ED (Emergency Department) after suffering a fall. Patient has also collapsed lung and COPD. Patient presents to current facility with aforementioned deficits and could benefit from skilled services at this time. Review of Resident #2's care plans showed a care plan that the resident was a new admission to the facility and was here for short term rehab therapy and plans to discharge back to home when able with home health services, if indicated initiated on 10/18/24. The goal was for the resident to attend therapy as scheduled and participate in the treatment program to enable discharge back to home with a target date of 01/2025. Interventions included but not limited to encourage resident to attend therapy to regain strength as of 10/18/2024. The Care plan showed: resident denied history of fall prior to admission. She was at risk for falls related to muscle weakness, unsteadiness on feet as of 10/17/2024. Interventions included but not limited to PT evaluate and treat as ordered or PRN (as needed) as of 10/17/2024. During an interview on 11/07/2024 at 12:19 p.m., the Director of Rehabilitation (DOR) stated Resident #2 had therapy, PT and OT. The DOR reviewed the evaluations, for PT on the 10/12/2024, and OT on the 10/14/2024. DOR stated she made the schedules but was out ill. DOR stated it was possible Resident #2 was missed, she could not say. The DOR stated the normal time frame for evaluating a new resident was the next day in the p.m. She stated she had a PRN therapist which worked in the evening and did the evaluations. The DOR stated she had a PRN therapist in the evening and a part-time therapist that came in during the day. She stated mainly in the p.m. The DOR stated residents were normally evaluated the next day (after admission). The DOR stated, unless (admission) was on the weekend, if I can get a therapist to come in on the weekend. I have COTAS (Certified Occupational Therapy Assistant[s]) and a stand-by therapist for the weekend, not routinely. DOR stated, I was not here, the regional may have been covering. I did not have anyone covering for me. Generally, what happens I know ahead of time for a 'total knee' and will schedule ahead of time. I would say we slipped through the cracks with it. The DOR verified the physician orders. The DOR stated, Under Medicare guidelines it (evaluation) should be within 48 hours. I had a therapist here on the 12th and they noticed she (Resident #2) was not on the schedule. The DOR stated the negative outcome for not receiving therapy during that timeline, don't know, she should have been seen more timely. During an interview on 11/07/2024 at 3:45 p.m. with the DON. When asked if it was acceptable for a resident to go 5 days without ordered therapy, the DON stated, she was not a therapist. She did not put anyone in charge while she (DOR) was gone. When asked as the DON was it acceptable to her for a resident to not get ordered therapy timely? She stated, I understand what you are getting at, and exited the interview. During an interview on 11/07/2024 at 4:20 p.m. with the Nursing Home Administrator (NHA) and Social Services Director (SSD), the NHA stated the DOR typically scheduled while she was out. The NHA stated they only had therapy which work with us part time. The NHA stated, When she (DOR) was out, the NHA covers or regional comes and helps. The NHA stated she was not aware Resident #2 did not get her therapy for 5 days. Review of the facility's policy, Therapy: Physician Orders, not dated showed therapy services require physician orders validated by therapists prior to initiating therapy services and for any interventions. The licensed therapist may request written or verbal orders. Additional circumstances if there is a physician order for evaluation, and in order to trade must be obtained. Components of the order 1. Specific description of services being ordered. 2. Treatment orders to include the following frequency, duration, treatment interventions and modes of treatment; 3. Ensure steps were taken based on EHR to ensure validation have orders by the physician or NPP.

Based on observations, record reviews, and interviews the facility failed to ensure four (#5, #6, #9, and #10) residents of seventy-three had access to the call light system as evidence by call light pull strings were not within their reach. Findings included: On 11/7/24 at 9:30 a.m. Resident #5 was observed lying in bed wearing a hospital gown. The resident's head of bed was raised greater than 45 degrees. The observation revealed the resident's call light pull string was lying on the bedside dresser, which was pushed up against the wall behind and next to the resident's bed, the end of the cord was observed under boxes sitting on top of dresser. Photographic evidence was obtained. On 11/7/24 at 9:30 a.m. Resident #6 was observed lying in bed, curled up and facing the door. The resident's call light pull string was at the resident's head of bed and dropped through the mattress holder onto the floor. The resident would have had to reach behind and above him to reach the cord/string. An interview and observation was conducted with Staff B, Licensed Practical Nurse (LPN) on 11/7/24 at 9:39 a.m. The staff member confirmed Resident #5 and #6 could not reach their call light pull string/cords. Review of the Admission Record for Resident #5 revealed the resident had diagnoses not limited to need for assistance with personal care, unspecified cataract, and mild dementia in other diseases classified elsewhere without behavioral disturbance, psychotic disturbance mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) for Resident #5 dated 8/12/24 showed a Brief Interview of Mental Status (BIMS) score of 13 of 15, which indicated intact cognition. Review of the Admission Record for Resident #6 showed the resident had diagnoses not limited to need for assistance with personal care, Parkinson's disease without dyskinesia without mention of fluctuations, and unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance mood disturbance and anxiety. Review of the quarterly MDS for Resident #6 dated 7/1/24 showed a BIMS score of 6 of 15 which indicated severe cognition impairment. On 11/7/24 at 10:00 a.m., Resident #9 was observed lying in bed with head of bed slightly raised. The observation revealed the resident's call light pull string/cord was lying on the floor behind the resident, near the wall. The end of it was wrapped around the bed control cord. On 11/7/24 at 10:02 a.m. Resident #10 was observed lying with the head of the bed raised higher than 45 degrees. The call light pull string/cord was observed lying on the bedside dresser located to the side of the resident's bed and against the wall. The resident reported being blind and needing it. On 11/7/24 at approximately 10:05 a.m. the Director of Nursing (DON) observed the location of Resident #9 and #10's call lights, confirming they were not within reach of the residents. The DON confirmed call light strings/cords should be within reach. Review of the Admission Record for Resident #9 revealed the resident had diagnoses not limited to other lack of coordination, unspecified chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and generalized muscle weakness. Review of the Comprehensive MDS for Resident #9 showed a BIMS score of 13 of 15, which indicated intact cognition. Review of the Admission Record for Resident #10 revealed the resident had diagnoses not limited to unspecified glaucoma, unspecified cataract, and unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance mood disturbance, and anxiety. Review of the quarterly MDS for Resident #10 showed the resident's vision was severely impaired and the resident's BIMS score was 14 of 15 which indicated intact cognition. Review of the facility's job description for Certified Nursing Assistant's showed the basic function was to provide routine daily nursing care and services that support the care delivered to patients/ residents requiring long-term or rehabilitative care, in accordance with the established nursing care procedures and as directed by your supervisor. The minimum performance standards showed patient/ resident call lights are promptly answered. Appropriate responses to requests are provided.

Based on observations, interviews and record review, the facility failed to provide a safe, clean, and homelike environment for four (250, 310, 330, and 350) of eight rooms observed during four (03/25/2024, 03/26/2024, 03/27/2024, and 03/28/2024) of four days. Findings included: On 3/25/24 at 09:35 a.m., during the initial tour, an observation was made of room [ROOM NUMBER]. Loose wires were noted between two residents' beds (photographic evidence obtained). Continuing with the initial tour at 10:00 a.m. on the 300 hallway, room [ROOM NUMBER] had privacy curtains with brown and red spots and black streaks at the bottom of one set of curtains, and a dirty floor (photographic evidence obtained). In room [ROOM NUMBER] loose wires we observed between residents' beds, a dirty and dusty AC (air conditioning) Vent, cluttered furniture without access to light cord for resident and/or staff to reach, and the hot water knob for the sink would not turn off (photographic evidence obtained). The main shower room for the 300 hallways was noted with a foul smell of urine and around the toilet was loose yellow toilet paper debris (photographic evidence obtained). room [ROOM NUMBER] was observed with dirty privacy curtains, a rusty IV (intravenous) pole, a dirty urinal and a dirty floor (photographic evidence obtained). On 3/26/24 at 7:30 a.m., during an observation no changes were noted. The 300 hallways shower room had yellow stained toilet paper on the floor by the toilet. room [ROOM NUMBER] had loose wires between the residents' beds. Further observation of room [ROOM NUMBER] noted the same wires tangled between two residents' beds and cluttered furniture remained impeding access to light switch/cord. room [ROOM NUMBER] and room [ROOM NUMBER] were noted with dirty privacy curtains and a dirty floor. On 3/27/24 at 07:40 a.m. observations were made of room [ROOM NUMBER] with loose wires between two residents' beds. room [ROOM NUMBER] was noted with loose wires between two residents' beds and a dusty/dirty AC vent. room [ROOM NUMBER] was observed with dirty privacy curtains, and a garbage can with no liner and overflowing, used Personal Protective Equipment (PPE). On 3/28/24 at 10:00 a.m., observations were made of rooms 250, 310, 330 and 350; no changes were observed from previous observations. On 3/28/24 at 1:00 p.m., an interview was conducted with the Housekeeping/Linen Manager. The Housekeeping/Linen Manager (HKM) stated rooms are cleaned everyday with an emphasis on high touch spots. The floors will be mopped but when the opportunity presents itself a strip and wax will be done to the floors. Curtains will be cleaned out along with the deep cleaning of floors and when dirty. The HKM manager stated, We clean our curtains on site. The Housekeeping/Linen Manager was presented with photographic evidence and stated she was aware of dirty curtains in room [ROOM NUMBER] but was not aware of rooms [ROOM NUMBER]. On 3/28/24 at 4:30 p.m., an interview was conducted with the Maintenance Director (MD). The MD said currently, there is no system in place for the Maintenance Director to follow up with maintenance requests made by the residents and/or the staff. The maintenance director, prior to the newly hired Maintenance Director was attempting to initiate a maintenance request log on each floor but the system did not do well because staff were not utilizing on a regular basis. Currently, the staff will come to the Maintenance Director verbally with maintenance requests but admitted this is too much and he may forget some of the requests. A review of the facility's policy titled: Cleaning and Disinfecting Residents' Rooms, revised August 2013, states the purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. 1. Housekeeping surfaces will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 4. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled.

Based on observations, interviews, and record review the facility failed to ensure reasonable accommodations were met for one (#19) of thirty-nine residents on four (03/25/2024, 03/26/2024, 03/27/2024 and 03/28/2024) of four days. Findings included: On 3/25/24 at 11:32 a.m. an observation was made of Resident #19 in her room. The resident was lying in her bed with the lights off, requesting to have her overhead light turned on. Resident #19's voice was extremely soft and reading her lips was difficult. The resident cord to pull her overhead light switch on was hanging behind her bed from the light on the wall out of her reach. The pathway to get to the wall behind her bed to reach this cable was blocked with furniture. Resident #19 said no one can get to it. Resident #19 stated she could not use the call light provided to her because her hands can not squeeze tight enough around the yellow cord to call for assistance. Resident #19 was in a room with three other residents on Droplet precautions. An interview was conducted on 3/25/23 at 11:45 a.m., with Staff D, Licensed Practical Nurse (LPN)/ Unit Manager (UM). Staff D, LPN agreed she could not get to the light cord in the back of Resident 19's room because of the furniture in the way and stated she would give maintenance a call. Regarding call light for Resident #19, Staff D, LPN stated, I don't think she is strong enough to use the call light, I'll ask maintenance. On 3/26/24 at 1:00 p.m., an observation and interview were conducted with Resident #19 in her room. Resident #19 was asking for water and noted with dry lips and a dark yellow substance on her teeth. A manual desk bell was placed on her bedside table not within reach of the resident (photographic evidence obtained). Resident #19 stated she could not use it stating she can't lift her arm to hit the bell. The resident spoke in a low soft voice with time needed to read her lips. The resident's furniture was still in the way of reaching the light cord for the resident. A piece of paper was seen on the dresser drawer stating, Gentle reminder: please brush teeth twice daily. [photographic evidence obtained] On 3/27/24 at 10:40 a.m. an observation and interview were conducted with Resident #19 in her room. Resident #19 had the bedside table moved to the other side with the same manual desk bell not within reach of the resident. Resident #19 dresser drawer was moved to allow an access to the back of the bed to reach the resident's light cord. The TV was off with the resident stating she would like the TV on. Resident #19 stated she cannot use the call system currently provided to her. On 3/27/24 at 11:00 a.m., an interview was conducted with Staff D, LPN/UM regarding call light and communication to accommodate Resident #19. Staff D stated the resident had an amplifier but she thinks the family may have it now since she moved into this room for her Droplet isolation. Staff D said she will call the family to see if they have this device. Staff D stated the resident has a speech therapy consult to work with her speech per resident's family request, stating her voice is getting worse but stated she can understand her. A review of the admission face sheet for Resident #19 has an admitted [DATE] with a primary diagnosis of multiple sclerosis (MS). Secondary diagnoses include but are not limited to the following: paraplegia, unspecified atrial fibrillation, contracture of muscle multiple sites, cognitive communication deficit, major depressive disorder, generalized muscle weakness. A review of the current physician orders included but are not limited to: Consult speech therapy dated 3/27/24 three times a week for two weeks. A review of Resident #19's care plan dated 11/20/2023 identified focus area of selfcare deficit; requires total care for all ADL [activities of daily living] needs: Dx [diagnoses] MS, paraplegia, impaired balance/speech; upper and lower extremity contractures. Goal for focus area will have all ADL needs anticipated and met by staff daily through next review. Interventions for focus included but not limited to: Oral care every shift and prn, place voice amplifier on charger at night, and reposition in bed and chair frequently. On 3/27/24 at 11:27 a.m., an interview was conducted with the Director of Nursing (DON) and the Maintenance Director regarding communication and call light assistance for Resident #19. The DON stated the resident had an amplifier at one point and stated the resident's family may have it. The DON stated the amplifier would help staff understand Resident #19 because it would raise the volume of her voice. The DON stated a communication board may be of some benefit and will check with therapy. The Maintenance Director stated currently there are limited options for different call lights in the facility. The only option is a pneumatic pressure bulb but there are only so many in the facility. On 3/28/24 at 10:35 a.m. an observation was made of Resident #19's room. The resident was out of the facility for a doctor's appointment. The same manual desk bell was seen on the bedside table. On 3/28/24 at 1:45 p.m. an interview was conducted with the Rehab Director regarding Resident #19 and her means of communication to staff for assistance. The Rehab Director there are no alternatives for call light but to have frequent checks offered as a suggestion. Review of the admission packet offered to all residents upon entrance into the facility state the following regarding resident rights: (a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. (2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and 3 errors were identified for two residents (#9 and #32) of five residents observed. These errors constituted a 9.38% medication error rate. Findings Include: On 3/26/24 at 8:50 a.m. an observation of medication administration with Staff C, Licensed Practical Nurse (LPN) was conducted for Resident #9. Staff C, LPN dispensed the following medications: -Clonazepam 0.5 milligrams (mg) one tablet -Plavix 75 mg one tablet -Haldol 5 mg one tablet -Paroxetine 40 mg one tablet -D3 50 mg/2,000 International units (IU) one tablet Staff C, LPN was observed continuing medication administration for Resident # 32 with the following medications: -Aspirin 81 mg chewable one tablet -Losartan 50 mg two tablets -Metoprolol 50 mg one tablet -Doxazosin 4 mg one tablet -Spironolactone 25 mg one tablet -B12 100 micrograms (mcg) one tablet -Incruse 62.5 mcg inhaler 1 puff A review of the physician orders for Resident # 9 showed an order for Vitamin D3 tablet 25 mcg/ 1,000 IU one tablet by mouth daily. During administration on 3/26/24, Resident #9 received Vitamin D3 50 mcq /2,000 IU one tablet. A review of the physician orders for Resident #32 showed an order for Incruse Ellipta aerosol powder breath activated 62.5 mcg/INH with the following instructions: one puff orally one time a day for COPD (chronic obstructive pulmonary disease), rinse mouth with water after use. During administration on 3/26/24 after oral tablets were administered, Resident #32 did his inhaler with the assistance of Staff C, LPN but was not offered the opportunity to rinse his mouth with water as ordered. Further review of physician orders for Resident #32 showed an order for Biofreeze external gel 4% with the following instructions: apply to left knee topically two times a day for pain related to muscle weakness. During administration on 3/26/24, Resident #32 did not receive the Biofreeze external gel as ordered nor at the time designated. On 3/27/24 at 1:45 p.m. an interview was conducted with the Director of Nursing (DON) regarding medication administration. The DON stated medications including over-the-counter medications and topical medications should be administered correctly according to physician orders. A review of the facility's policy entitled: Administering Medication (revised April 2019), showed the following policy statement: Medications are administered in a safe and timely manner and as prescribed. The following policy interpretation and implementation include but not limited to the following: . 4. Medications are administered in accordance with prescriber orders, including any required time frame. . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observations, record review and interviews, the facility failed to ensure Side Rail evaluation were conducted prior to installation for two residents (# 10, 24) out of 10 residents sampled Findings Included: 1 During an observation on 03/25/2024 at 03:26 PM Resident # 10 was observed laying down in bed fully dressed, well groomed, with no signs of distress. Resident # 10 was observed with two different types of 1/4 side rails on his bed. During an observation on 03/27/2024 at 10: 00 AM., Resident #10 was observed laying down in bed with 1/4 side rails up on both sides of his bed. Resident # 10 said he did not know why he had side rails on his bed. Residents were observed with no signs of distress. Review of a Admission Record showed Resident # 10 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Parkinson's disease without dyskinesia, without mention of fluctuation, need for assistance with personal care, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Schizophrenia, unspecified, major depressive disorder, recurrent, unspecified. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 06, which indicated severely impaired. Review of an Order Summary Report dated 03/24/2024 showed an active order dated 03/27/2024 for 1/4 siderails x2 for bed mobility. Review of the Electronic Health Record (EHR,) evaluation section on 03/26/2024 showed no evidence a side rail assessment was completed to show appropriate alternatives were utilized prior installation of the side rails. Further review of the (EHR) evaluation section showed no assessment was completed to show Resident # 10 was not at risk for entrapment. Review of Resident #10's care plan date initiated 10/10/2023 and revised 10/10/2023, revealed a care plan focusing on the resident at risk for skin breakdown related to (r/t) decreased mobility and incontinence; requires extensive assist with bed mobility and transfers. Further review of the care plan showed an intervention for 1/4 side rails up x2 as enablers for bed mobility/ transfer and reposition the resident frequently. Date initiated 03/15/2024 and revised 03/18/2024. 2 During an observation on 3/25/2024 at 3: 30 PM., Resident # 24 was observed laying down in his with both side rails up and his call light in reach. During an observation on 03/26/2024 at 10:00 AM., Resident # 24 was observed laying down in bed with both side rails up on each side of his bed. Resident # 24 was observed with no signs of distress. Review of Resident #24's Admission Record dated 03/27/2024 showed he was initially admitted on [DATE] with diagnoses to included but not limited to hereditary and idiopathic neuropathy, unspecified, unspecified osteoarthritis, unspecified site, chronic kidney disease, stage 3 unspecified. Review of a Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 13, which indicated cognitively intact. Review of Section GG0115 functional limitation in range of motion showed Resident # 24 is impaired on both sides of his upper extremities. Review of Resident # 24 care plan date initiated 02/21/2023 and revised on 11/20/2023 revealed a care plan focus showing Resident # 24 requires total assist with Activity Daily Living, (ADL's) diagnoses Parkinson's right knee pain, knee replacement: unsteady balance. Review of the care plan intervention showed 1/4 side rails x 2 for bed mobility and transfer assist as needed. Date initiated 1/22/2024 and revised on 3/12/2024. During an interview on 03/26/2024 at 3:00PM., with Staff I, Certified Nursing Assistant, (CNA) staff I said he had worked at the facility for two months, but he has just started working on 400 halls two weeks ago. He said Resident # 10 and 24 both have had side rails on their beds ever since he has worked on the 400 halls. He said he did not know why either resident had side rails. During an interview on 3/26/2024 at 3:30 PM with Staff C, License Practical Nurse, LPN. Staff C said residents are assessed upon admission for the use of side rails. Residents # 10 and 24 did not have a side rail assessment done because theirs must have been overlooked. We had more than one person completing the side rail assessment at that time. During an interview on 3/26/2024 at 3: 45 PM., with the Director of Nursing (DON). She said they do a screening on admission to see if a resident would benefit from having a side rail. If a resident uses a side rail for bed mobility or they use it when going to a laying down position to a sitting position, then they would be assessed for a side rail. Side rails assessment is completed upon admission, quarterly and if a resident has a change in condition. The nurse who is assigned to the resident would complete a side rail assessment within five to seven days of the resident admission. The DON stated I don't see a side rail assessment completed for Resident # 10 and 24. Both residents should have had a side rail assessment completed and I don't see that it was done. Review of the facility policy titled, Restorative Nursing - Side Rails No dated, showed Policy: The use of side rails by a resident may be considered a restraint or an enabler, depending on the resident's functional status and whether or not the side rail restricts freedom of movement. Prior to the use of side rails, the resident's strengths and needs should be evaluated by the Interdisciplinary Team to determine the reason for the side rail and any alternative devices that may be used to achieve the same goal. The manufacturer's instructions for the use of side rail will be followed. Side rails longer than 1/4 the length of the mattress from the head of the bed will not be used. Procedure. 1. Complete the Side Rail Evaluation upon admission, readmission, quarterly, and with a significant change.

Based on observations, interview and record review, the facility failed to ensure oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen, was provided for one resident (#66) out of thirty-nine residents sampled. Findings include: On 3/25/24 at 1:15 p.m. an observation was made of Resident #66 in his room with his nasal cannula hanging from his side rail next to a urinal, which had thick brown liquid inside. The nasal cannula was unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. On 3/26/24 at 10:45 a.m. an observation was made of Resident #66 in his room with his nasal cannula at the bottom of a garbage can unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. On 3/27/24 at 11:50 a.m. an observation was made of Resident #66 in his room with his nasal cannula on the ground unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. Resident #66 stated he uses oxygen on and off. On 3/28/24 at 10:30 a.m. an observation was made of Resident #66 in his room with his nasal cannula hanging from an IV pole unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. A review of the admission face sheet for Resident #66 has an admitted [DATE] with a primary diagnosis of urinary tract infection. Secondary diagnoses include but not limited to pulmonary embolism without acute cor pulmonale, dyspnea, chronic obstructive pulmonary disease (COPD), emphysema, weakness, unsteadiness on feet, and cachexia. A review of the physician orders has an order dated 01/24/2024 for Oxygen (O2) at two liters/minute continuous inhalation with no discontinue or end date. An order dated 01/24/2024 for oxygen tubing, cannula/mask change weekly and PRN (as needed). A review of Resident #66 care plan dated 01/24/2024 and a revision date of 02/13/2024 showed a Focus area of the resident having emphysema /COPD and receives O2 via NC (nasal cannula) with a new diagnosis of pulmonary embolism. The interventions include but not limited to check O2 saturations as ordered, O2 via NC as ordered (revised 2/13/2024), and to monitor for difficulty breathing on exertion, signs and symptoms of acute respirator insufficiency. A review of the Minimum Data Set Section O-Special Treatments, Procedures and Programs showed resident under section for respiratory treatments C1- Oxygen therapy as checked for continuous. A review of Resident #66's medication administration record for the month of March 2024 showed entries made by staff for every shift of O2 2l/min (liters/minute) and tubing was changed every night shift on Tuesday with a date of March 26th as completed. A review of the facility's policy titled: Nursing Oxygen Administration (no date) showed the following: The purpose of this procedure is to provide guidelines for oxygen administration. . 11. Adjust the delivery device so it is comfortable to the resident and the proper flow of oxygen is being administered. 12. Observed the resident to be sure oxygen is being tolerated. 13.Check the mask, tank, etcetera to be sure they are in good working order and are securely fastened. . 17. Date tubing and humidifier bottle.

Based on observations, record reviews, and interviews, the facility failed to ensure one resident (# 24) was provided with Activity of Daily Living, (ADL's) assistance out of 10 residents sampled. Findings Included: During an observation on 3/25/2024 at 3: 30 PM., Resident # 24 was observed laying down in his bed with his hair disheveled and facial hair. Resident # 24 said he would like to be shaved but staff won't assist him. During an observation on 03/26/2024 at 10:00 AM., Resident # 24 was observed laying down in bed and appeared with no signs of distress. Review of Resident #24's Admission Record dated 03/27/2024 showed he was initially admitted on [DATE] with diagnoses to included but not limited to hereditary and idiopathic neuropathy, unspecified, unspecified osteoarthritis, unspecified site, chronic kidney disease, stage 3 unspecified. Review of a Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 13, which indicated cognitively intact. Review of Section GG0115 functional limitation in range of motion showed Resident # 24 is impaired on both sides of his upper extremities. Review of Resident # 24 care plan date initiated 02/21/2023 and revised on 11/20/2023 revealed a care plan focus showing Resident # 24 requires total assist with Activity Daily Living, (ADL's) diagnoses Parkinson's right knee pain, knee replacement: unsteady balance. Review of the care plan intervention showed 1/4 side rails x 2 for bed mobility and transfer assist as needed. Date initiated 1/22/2024 and revised on 3/12/2024. During an interview on 03/26/2024 at 3:00PM., with Staff I, Certified Nursing Assistant, (CNA), staff I said he has worked at the facility for two months, but he has just started working on 400 halls two weeks ago. He said he assisted Resident # 24 with all his Activity of Daily Living, (ADL's). He did not shave Resident # 24 because he is still learning his job and he was afraid that he would cut the resident. He said he did not tell the nurse, but he would let her know that he needed assistance with shaving the resident. During an interview on 3/26/2024 at 3:30 PM with Staff C, License Practical Nurse, (LPN), Staff C said her expectation is that the aides assist their residents with all their ADL's if that is required. She said Staff I did not tell her that he was having trouble shaving Resident # 24 because she would have assisted him with the resident. Her expectation is that if an aide is having trouble assisting a resident with care, they would tell her so she can step in and provide assistance. During an interview on 3/26/2024 at 3:45 PM., with the Director of Nurses, (DON), the DON said her expectation is that residents are provided with ADL care according to their care plan. She said she would have expected her staff to report any changes they are having with the residents so that they can provide support when needed. A policy related to ADL care was requested; however, none was provided by completion of the survey.

Based on interview and record review, the facility failed to ensure the accuracy of the Level I Pre-Admission Screening and Resident Review (PASSAR) for four (#56, #7, #10 and #32) of eleven residents reviewed. Findings Included: 1. Electronic Medical Record (EMR) review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses that included but not limited to Bipolar Disorder, Alzheimer's, Other Schizophrenia, Major Depressive Disorder, Unspecified Mood Disorder, Anxiety Disorder according to the Face Sheet. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed: -Section C: Brief Interview for Mental Status (BIMS) score 99, indicating resident unable to complete interview. -Section I: Active Diagnosis - Alzheimer's. Anxiety, Depression, Bipolar, Schizophrenia checked. -Section N: Medications administered - Antidepressant and Antianxiety. Review of the Medication Administration Record (MAR) for March 2024 showed: -Lorazepam Tablet 0.5 milligrams (mg) - Give 1 tablet via G-Tube every 8 hours for anxiety disorder -Buspirone HCL oral tablet 7.5mg via G-Tube two times a day for anxiety disorder -Sertraline HCL tablet 50mg via G-Tube one time a day for major depressive disorder. Review of the PASSAR Level I, dated 1/19/2024 revealed: -Section IA, Mental Illness, or suspected Mental Illness checked for Anxiety Disorder, Bipolar Disorder, Depressive Disorder, Psychotic Disorder, Schizoaffective Disorder and Other written in with Unspecified Mood Disorder. -Section I Services, Marked Currently Receiving Services for Mental Illness, based on documented history and medication -Section II 6 secondary diagnoses of Dementia checked Yes. -Section II 7 marked Yes medical/functional history prior to onset -Section IV marked no diagnosis or suspicion of serious mental illness or intellectual disability indicated. During an interview on 3/28/2024 at 1:00 p.m. Staff G, MDS Coordinator reviewed Resident #56 PASARR dated 1/19/2024. The MDS she stated she should have requested a Level II PASARR be completed for Resident #56. 2. EMR review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that include but not limited to, dementia, major depressive disorder, anxiety disorder, drug induced dyskinesia, unspecified psychosis according to face sheet. Review of quarterly MDS dated [DATE] revealed: Section C: showed a BIMS score of 99 indicating resident unable to complete interview. Section D: showed resident mood interview should not be conducted and PHQ9 score of 5 indicating mild depression. Section I: Active Diagnosis - Dementia, Depression, Anxiety, and Psychotic disorder checked. Section N: Medication administered - taking antipsychotic, antianxiety, and antidepressant. Review of MAR for March 2024 showed: -Xanax Oral Tablet 0.5mg (Alprazolam) 1 tablet by mouth every 12 hours for anxiety -Risperdal Oral Tablet 0.5mg (Risperidone) 1 tablet by mouth at bedtime for psychotic disorder -Mirtazapine Oral Tablet 7.5 mg (Mirtazapine) 1 tablet by mouth at bedtime for depression Review of the PASSAR Level I, dated 01/19/2024 revealed: -Section IA, Mental Illness, or suspected Mental Illness checked for Anxiety, Depressive Disorder and Psychotic Disorder. -Section I Services, Marked Currently Receiving Services for Mental Illness, based on documented history and medication -Section II 5 primary diagnosis of Dementia checked yes. -Section II 7 marked Yes medical/functional history prior to onset -Section IV marked no diagnosis or suspicion of serious mental illness or intellectual disability indicated. During an interview on 3/28/2024 at 1:00 p.m. Staff G, MDS Coordinator reviewed Resident #7 PASARR dated 1/19/2024. The MDS Coordinator stated she should have requested a Level II PASARR be completed for Resident #7. 46498 3. Review of an Admission Record showed Resident # 10 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Schizophrenia, unspecified, major depressive disorder, recurrent, unspecified. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 06, which indicated severely impaired. Review of Resident #10's care plan date initiated 10/10/2023 and revised 10/10/2023, revealed a care plan focus showing Resident # 10 has impaired cognitive function/dementia, resident has short/ long term memory impairment and is moderately impaired in decision making. Further review of the care plan intervention showed to administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 10/04/2023 and revised 10/04/2023. Further review of the care plan showed a focus for the use of psychotropic medications related to diagnoses depression and mood disorder. Review of the care plan intervention date initiated 10/4/2023 and revised 10/10/2023 showed to administer psychotropic medications as ordered by physician. Monitor side effects and effectiveness every shift, Q (every) shift. Review of Resident # 10's Preadmission Screening and Resident Review (PASRR) level I assessment dated [DATE] revealed no answered in section II for questions 4, 5, 6 and 7 to indicate resident # 32 has no dementia diagnosis. 4. Review of Resident # 32's Admission Record dated 03/28/2024 showed he was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bipolar disorder, Review of a Minimum Data Set (MDS) dated ,d+[DATE] /2024 showed the resident had a Brief Interview Mental Status (BIMS) score of 11, which indicated moderately impaired. Review of Resident # 32's Preadmission Screening and Resident Review (PASRR) level I assessment dated [DATE] revealed no answers in section II for questions 4, 5, 6 and 7 to indicate Resident # 10 has no dementia diagnosis. Review of the medical record showed that the resident was not assessed for PASRR level II. Review of Resident # 32's care plan date initiated 1/23/2024 and revised on 1/23/2024 revealed a care plan focusing showing Resident # 32 has impaired cognitive function/ dementia or impaired thought processes related to Cerebral Vascular Accident (CVA). Review of the care plan intervention initiated 1/23/2024 and revised 1/23/2024 showed to observed Resident # 32 for changes in cognitive status. During an interview on 3/28/2024 at 1:00 p.m. with Staff G, Registered Nurse (RN)/ Minimum Data Set (MDS) Coordinator. Staff G stated the Preadmission Screening and Resident Review (PASRR) are received from the hospital on admission. MDS reviews the PASRR for accuracy and makes corrections if needed. She completes an updates the PASARR if a resident has a change in behavior or new diagnosis. In monthly psych meetings, the team is made aware of residents with new psych diagnoses. The team attending psych meetings are Social Services, Director of Nursing, Unit Nurse Manager, and MDS. Review of the facility policy titled, Admission/ Social Services - Pre- Admission Screening and Resident Review ( PASRR), no date, showed Overview: The purpose of PASRR is to ensure individuals who are being considered for placement in a Nursing Facility are evaluated for serious mental illness and/ or intellectual disability and are offered the most integrated setting appropriate for their long term care needs ( including determining whether a Nursing Facility is appropriate). 2. Level I PASRR must be fully and accurately completed and distributed in accordance with Rule 59G-1.040, F. A. C. Upon or prior to admission if the facility finds the level I to be incomplete or inaccurate, a correct Level I PASRR must be completed by hospital staff or appropriate Nursing Facility staff (Physician, Registered Nurse Master Social Worker, or License Clinical Social Worker). 4. When Applicable a request for a PASRR Level II evaluation must be made by the Social Services Director / Designee using the FL PASRR Provider Portal at https://portal.kepro,com/.

Based on observations, record review and interviews, the facility failed to ensure a code status was provided upon admission for one resident ( # 228 ) out of 10 residents sampled. Finding Include: Review of the electronic and paper medical record revealed Resident #228 did not have an advanced directive related to the resident code status for six days after being admitted to the facility. Review of Resident # 228 Admission Record dated 03/27/2024 showed the resident was admitted on [DATE] with diagnoses to included but not limited to Acute Kidney Failure, unspecified, hyperosmolality and hypernatremia, major depressive disorder, recurrent, moderate. During an interview on 03/27/2024 at 10:00 AM., with Resident # 228's responsible party. He said that he received a phone call yesterday from someone at the facility to ask him if he wanted his mother to be a full code or a do not resuscitate (DNR). He said he told the person at the facility that he wants his mother to be an DNR because she is [AGE] years old, and she could not handle someone pressing on her chest. During an interview on 03/27/2024 at 10:10 AM., with the Social Service Director (SSD), she said she created a care plan and put the resident as a DNR, but the care plan was not finalized. She reached out to the resident's son yesterday to confirm if he wanted his mother to be a full code or a DNR and he said he wanted his mom to be an DNR. She said the process is whether the resident is admitted to the facility with a DNR paper or not she confirms with the resident or their responsible party to confirm if their code status. Resident # 228 was admitted over the weekend, and she said she doesn't work on the weekend. During an interview on 03/27/2024 at 10: 15 AM., with the Director of Nursing, (DON), she said when a resident is admitted to the facility from the hospital, they come in with a 3008 form that shows whether the resident is a full code or a do not resuscitate). If the resident is a DNR they make a copy of the yellow paper and put it in the DNR binders located at each nurse's station. The Social Service Director speaks with the resident or family regarding their code status to confirm if they want to remain a DNR, full code or make any changes to their code status. The Social Services Director completes this process within one or two days after admission. Then the nurse responsible for that resident should make sure that the code status is posted in the electronic medical record (EMR). We obtain a physician order if a resident is a full code or a DNR and put it into the EMR. Resident # 228's nurse who conducted her admission should have made sure that the code status was posted on the dashboard in the EMR, and I see that it was not done. She said her expectations are that the nurse who is responsible for the residents when they are admitted on the weekend should obtain the code status and put it in PCC so it would show on the dashboard in PCC. This was an oversight on their end. They normally review weekend admission during their interdisciplinary meetings (IDT) on Monday; however, the meeting did not occur on the past Monday. Review of the facility policy titled, Admission/ Social Services - Advance Directives, no date, showed the facility will promote the resident's right to refuse treatment and care, the right to refuse to participate in experimental research and the right to formulate an advance directive. The facility will inform and educate the resident about these rights and provide the facility policy regarding these rights. The facility will assist the resident in exercising these rights and will incorporate the resident's choices regarding these rights into treatment, care, and services. 2. As part of the admission process, the resident and or legal representative will be given a copy of the form entitled, Acknowledgment of Advance Directives. The resident/ legal representative will verify that they acknowledge they received the following from the Admission Department: This form also provided a checklist that gives verification of the resident's wishes regarding advance directives and the receipt of the Living Will; Durable Power of Attorney for Health Care Authority; Durable Power of Attorney for Financial Authority; Health Care Surrogate; and Florida Do Not Resuscitate Order or the resident's refusal to execute Advance Directives at this time. The Acknowledgement of Advance Directive form will be filed under the Advance Directive tab in the resident's medical record.