**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 25 sampled residents to meet the residents nursing needs that are identified in the comprehensive assessment. (Resident #31 & #2) The findings include: Resident #31 On 04/21/25 at approximately 11:05 AM, Resident #31 was seen sitting in his wheelchair wearing a cardiac Life Vest (The LifeVest is a wearable cardiovascular defibrillator designed to protect individuals at risk of sudden cardiac death). A record review for Resident #31 revealed no orders for the cardiac Life Vest, and no mention of the cardiac Life Vest in the cardiac care plan. (photographic evidence obtained) On 04/23/25 at approximately 03:25 PM, an interview the Director of Nursing (DON) was conducted. The DON was asked what documentation is expected from nursing for a resident with a cardiac Life Vest. The DON stated there should be a cardiac care plan that would include the cardiac Life Vest. However, when shown that the cardiac care plan for Resident #31 did not contain language regarding the cardiac Life Vest, the DON stated, It should have been in the care plan. Resident #2 On 4/22/2025, a record review was conducted for Resident #2. The record indicated that Resident #2 was hospitalized on [DATE]-[DATE] with acute chronic respiratory infection. The physicians' orders included an order for Cefdinir Oral Capsule 300 MG (an antibiotic), give 300 mg by mouth two times a day for infection, ordered 3/28/25 and stopped 4/23/25. The care plan for Resident #2 did not include infection or antibiotic use. A review of Resident #2's diagnosis list included, ACUTE RESPIRATORY FAILURE WITH HYPOXIA and PNEUMONIA DUE TO METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS. The quarterly minimum data set (MDS) were positive for Infections (Pneumonia) and antibiotic use. On 04/23/25 at approximately 02:16 PM, an interview with Staff E, a registered nurse (RN)/MDS coordinator, was conducted about Resident #2's infection and if there should be a care plan for infection/antibiotic use. The RN/MDS coordinator stated Resident #2 has been in and out of the hospital lately for respiratory infections. She stated, Yes, she should have a care plan for infection, I must have missed this.

Based on family interview, record review, and staff interview, the facility failed to provide appropriate physician ordered services to increase range of motion or prevent further decrease in range of motion for 1 of 3 residents sampled for limited range of motion. (Resident #19) The findings include: A telephone interview was conducted with Resident #19's sister on 4/21/25 at 2:12 PM. She stated the resident had limited range of motion in his knees and was not receiving any services for the issue. A review of Resident #19's electronic medical record revealed a current physician order dated 1/28/25 stating to provide a functional maintenance program to provide stretching exercises to the bilateral knees while in bed to maintain knee extension. The current plan of care for Alteration in activities of daily living and Reduced range of motion with a diagnosis of bilateral knee contractures (revised 1/30/25) indicated that a functional maintenance program for knee stretches was started on 1/27/25 with a nursing intervention of range of motion to bilateral knees.A review of the task menu for April 2025 revealed no documented entries of the functional maintenance program and stretching exercises being performed as ordered. A review of the facility's Functional Maintenance Programs form for Resident #19, dated 1/10/25, revealed staff should stretch the resident's knees while in bed to maintain knee extension and prevent further contractures and verbally cue resident to improve standing posture when upright. An interview was conducted with Employee A (Registered Nurse) on 4/23/25 at 1:31 PM. Employee A stated she was in charge of the functional maintenance program. She stated that care is documented in the task menu. She reviewed the task documentation for Resident #19 and confirmed the care had not been documented as completed in the last 30 days. She then stated if it is not documented, the care had not been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility policy review, the facility failed to provide medications at a timely manner for 1 of 3 residents receiving antibiotic medications via intravenous route. (Resident # 156) The findings include: On 4/21/25, Resident #156 had a pump used for intravenous therapy inside his room. On 4/21/25, Resident #156's medical records were reviewed. He was admitted to the facility on [DATE] following a stay at a hospital. Hospital records dated 4/4/25 indicated a physician discharge order to receive Ceftriaxone (a medication given to treat bacterial infections) 2 Grams (GM) daily for 14 days. admission medication orders dated 4/4/25 stated to start Ceftriaxone 2 GM. Medication Administration Records (MAR) revealed Ceftriaxone's first dose was administered on 4/8/25. A progress note dated 4/5/25 explained that the medication was not at the facility. On 4/7/25, a progress note stated the pharmacy sent intravenous medications but was waiting for the pump to be delivered. On 4/23/25, a late note was entered into the electronic medical record indicating the reasons that antibiotic medication was delayed, due to the pharmacy needing clarification and pharmacy not delivering a pump for administration. On 4/23/25 at 9:42 AM, an interview was conducted with the Director of Nursing (DON). She reviewed Resident #156's medical records. She verified the resident did not receive the ordered antibiotics until 4/8/25, three days after the physician's orders. The DON stated she did an audit and asked Staff B, a Licensed Practical Nurse (LPN), about this. Staff B had told her that the person that had placed the first order had written to give 1 GM instead of 2 GM, and the pharmacy had requested clarification, delaying the delivery and subsequent administration. On 4/23/25 at 10:25 AM, an interview was conducted via telephone with the Pharmacy. They verified that the order for Ceftriaxone was received on 4/4/25, but the order read to use 1 GM and clarification was requested. They stated the clarification was received on 4/6/25. On 4/23/25 at 4:00 PM, an interview was conducted with the Medical Director. He stated it was unfortunate that the antibiotics were delayed for 3 days. The facility policy named Medication Delivery Expectations (dated October 2019) stated that the purpose was to ensure all residents will receive their medications as ordered and to ensure if medications was not received, center immediately intervene and medication is received within 4 hours.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 medication carts. The findings include: On 4/21/25 at approximately 11:47 AM, an observation was made of an unlocked and unattended medication cart. Four staff members walked by the unlocked medication cart between 11:47 AM and 11:49 AM, at which time the licensed practical nurse (LPN), Staff C, came out of a resident's room and acknowledged that he left the medication cart unlocked. On 04/24/25 at approximately 09:56 AM, the Assistant Director of Nursing (ADON) stated that the expectation is to lock the medication cart and computer screen when the nurse leaves the medication cart.

Based on record review and staff interview, the facility failed to designate a single code status in the medical record for 1 of 1 residents sampled for Advance Directives. (Resident #44) The findings include: On 2/7/24, a record review was conducted for Resident #44. The resident's record contained an active order for a Full Code dated 8/21/23 and an additional active Do Not Resuscitate (DNR) order dated 8/15/23. On 2/7/24 at approximately 1:17 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked who is responsible for entering the code status into the medical record. The DON indicated that the admitting nurse is responsible for entering the initial code status during admission and Social Services is responsible for verifying and updating the code status if necessary. On 2/7/24 at approximately 2:56 PM, an additional interview was conducted with the DON regarding active advance directive orders for Resident #44. The DON retrieved the medical record hard copy chart and reviewed the DNR yellow State of Florida form executed on 2/23/23. The DON indicated that Resident #44 is currently a DNR. The DON indicated the Full Code physician order should have been made inactive when Resident #44's code status changed from full code to DNR.

Based on observation, staff interview, and policy review, the facility failed to ensure staff perform appropriate hand hygiene in accordance with facility policy during 1 of 1 wound care observations. (Resident #101) The findings include: An observation of wound care for Resident #101 was conducted on 2/7/24 at 10:35 AM with the Assistant Director of Nursing (ADON). The ADON was observed to don a disposable gown, wash her hands, and apply clean gloves. She then removed the soiled dressing from the resident's sacrum and disposed of the dressing. She then cleansed the wound with the same gloves she used to remove the soiled dressing. She then washed her hands, applied new gloves, and applied the new wound dressing. Employee A did not wash or sanitize her hands after removing the soiled dressing and before cleansing the wound. An interview was conducted with the ADON on 2/7/24 at 11:37 AM. She stated she should have washed her hands and changed gloves after removing the soiled dressing and before cleansing the wound. Review of the facility policy for Non-Sterile Dressings (April 2019) revealed staff should wash or sanitize hands with alcohol based hand rub (ABHR), put on disposable exam gloves, loosen tape and remove soiled dressing, pull glove over dressing and discard into appropriate receptacle, wash hands or sanitize hands with ABHR (if not visibly), put on clean gloves, observe the wound and surrounding skin, cleanse the wound, use dry gauze to pat the wound dry, wash hands or sanitize hands with ABHR and apply new gloves, apply the ordered dressing and secure with tape.

Based on observation, interviews and record review, the facility failed to provide routine medications to meet the needs of 1 of 7 (#17) residents sampled for medication administration observation. The findings include: On 9/21/22 at approximately 1:50 PM, during a medication administration observation of Nurse A, a Licensed Practical Nurse (LPN), Resident #17 asked Nurse A about his inhaler medication and when it would be available. The nurse responded that the pharmacy stated it would be that evening. On 9/21/22 at approximately 1:50 PM, an interview was conducted with Resident #17 who reported he has not received his inhaler for almost a month now. On 9/21/22 at approximately 1:55 PM, an interview was conducted with Nurse A. Nurse A stated that the medication Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH (a steroid inhalation medication used to treat Chronic Obstructive Pulmonary Disease) has been out for several days. She further stated that she notified the pharmacy, and when it did not come in, notified the Assistant Director of Nursing (ADON). When asked if the physician had been notified that Resident #17 had been without his medication for several days, Nurse A stated No. On 9/21/22 at approximately 2:00 PM, an interview was conducted with the ADON, a Registered Nurse. The ADON stated that she had called the pharmacy the other day to re-order the medication, and the pharmacy stated it would be delivered that night. She continued that, when it did not arrive, she called the pharmacy again the next day. When asked if the physician had been notified that the medication was out, the ADON stated that the primary nurse would have notified the physician, and confirmed that she had not done so. When asked about the facility's policy on re-ordering medication and notifying the physician, she stated she was not sure and would have to get back to the surveyor later with an answer to the question. A record review was conducted of Resident #17's electronic medical record. Review of the electronic medication administration record (EMAR) revealed that on the following dates, the medication Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH was documented as not given, 9/1/22, 9/3/22, 9/4/22, 9/8/22, 9/9/22, 9/12/22, 9/13/22, 9/14/22, 9/15/22, and 9/17/22. The EMAR revealed that the medication was documented as given on 9/2/22, 9/5/22, 9/6/22, 9/7/22, 9/10/22, 9/11/22, 9/16/22, 9/19/22, and 9/20/22. Review of the progress notes revealed no documentation that the physician was notified that the medication had not been given on 10 days. Further review of progress notes revealed that a progress note entered on 9/21/22 as a late entry for 9/19/22 revealed the pharmacy was notified of the medication not being delivered and the pharmacy reported it would be in that night. The note further indicated that on 9/20/22 the medication did not arrive and the resident requested the pharmacy be called again. On 9/21/22 at approximately 2:15 PM, an interview was conducted with the Nurse Consultant and the Director of Nursing (DON). When asked about the expectation for re-ordering medications from the pharmacy, the Nurse Consultant responded that if the medication is out, they need to notify the physician and obtain a hold order, then notify the DON to contact the pharmacy, and if needed have the back up pharmacy fill the prescription to be picked up by the facility. The DON stated that she was not notified of the medication being out. On 9/21/22 at approximately 3:30 PM, a telephone interview was conducted with the Pharmacy Manger and Pharmacist who stated that the last time the inhaler medication was delivered to the facility was on 8/19/22, and the medication was a 7-day supply. They stated they did not have any record of it being re-ordered prior to today, but that the medication is on the run tonight. A review was conducted of the document titled Medication Delivery Expectations. Under the Protocol subtitle, section E. states, if pharmacy refuses to deliver or pharmacy does not respond to call, immediately notify the Director of Nursing or Administrator. Section F. states, Administrator, DON, or designee to immediately notify pharmacy of any medication availability issues. If pharmacist does not respond to needs notify pharmacy manager. Do not stop until medication is received, even if that involves further escalating the situation. Section H. states, Notify physician if medication will be given late or obtain order for different start times if appropriate or request medication to be held until available or ask for a change in equivocal medication to one that is available.