**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review facility failed to follow a nutritional care plan for one (Resident #95) out of one sample resident, as evidenced by it was observed that Resident #95 was provided with a ham and cheese sandwich before leaving for dialysis. This meal was not consistent with the prescribed pureed diet, posing potential risks to Resident #95's health and wellbeing. There were 20 residents receiving pureed diets at the time of survey. The findings included: On 9/26/25 at 4:22 AM Resident #95 was observed in bed with no apparent distress.Observation on 9/26/25 at 4:25 AM at the first-floor nursing station revealed a transparent bag labeled with Resident #95's name and room number that contained a ham and cheese sandwich and applesauce (photo evidence).Interview on 9/26/25 at 4:33 AM Staff B, Registered Nurse (RN) was asked about Resident # 95 ‘s snack of ham and cheese sandwich and applesauce provided for the resident to take to dialysis; Staff B replied: This resident has been assessed, is waiting for pick up and always goes with a snack of sandwich and applesauce. On 09/26/25 at 4:58 AM, transportation arrived to pick up Resident#95.On 9/26/25 at 5:11 AM, the Assistant Director of Nursing (ADON) and Staff B, RN, were asked if it is okay for Resident #95 to leave with a sandwich despite the ordered pureed diet. The ADON replied: It is okay for the resident [Resident #95] to eat a ham and cheese sandwich because it can be mechanical soft.On 9/26/25 at 5:15 AM Resident #95 had already left the facility with the ham and cheese sandwich and applesauce that was provided.Interview on 9/26/25 at 6:30 AM, the Director of Nursing (DON) was asked if it is okay for Resident #95 who has an ordered pureed diet to be provided with a sandwich to take to dialysis; the DON replied: I will get back to you on that. On 9/26/25 at 6:45 AM, the Dietician was notified about identified diet concern and stated, A sandwich is not considered pureed.[Resident #95] used to be on a regular diet, and I will check with the Speech therapist to see if it is ok to send a sandwich.On 9/26/25 at 6:56 AM, the DON presented a transparent bag with Resident #95's name that contained a ham and cheese sandwich and applesauce and stated: We got the snack from the Dialysis center and replaced it with applesauce.Observation on 9/26/25 at 10:40 AM, Staff C, Speech therapist (ST), conducted a trial feeding of a ham sandwich with Resident #95. After some difficulty in following directions the therapist placed a small piece of bread into Resident #95's mouth and the resident began chewing. The therapist encouraged Resident #95 to swallow . After failing attempts to swallow, the Speech Therapist concluded that it was not safe for Resident #95 to eat sandwiches due to impaired cognition or physical tiredness from dialysis.Record review of a demographic sheet revealed Resident #95 was admitted on [DATE] with diagnosis that included: End Stage Renal Disease.Record review revealed the 5-day Medicare Minimum Data set (MDS) reference dated 9/11/25 revealed Resident #95 had a Brief Interview of Mental Status score of 8, indicating moderate cognitive impairment, required partial/moderate assistance for eating, received a mechanically altered and therapeutic diet, and held food in mouth/cheeks or had residual food in mouth after meals.Record review of a Care Plan initiated on 10/07/23 and revised on 09/08/25 revealed Resident #95 was at risk for altered nutrition and hydration status, had a goal to show no signs or symptoms of dehydration and the interventions included: Provide and serve diet as ordered. Pureed texture, Nectar Thick consistency, and provide snacks and supplements as ordered.Record review of Resident #95's September 2025 physician's order sheet revealed a diet order for Pureed texture and nectar thick consistency.Record review of a Nutrition/Dietary Note dated 9/10/25 revealed Pureed/Nectar diet.An interview with The Registered Dietician on 9/25/25 at 12:09 PM revealed Resident #95 was on a pureed nectar diet with low sodium and low sugar. Record review of Speech therapy addendum dated 9/15/25 indicated to continue with swallow precautions and compensatory strategies at mealtimes. Record review of a policy titled, Care Plans, Comprehensive Person-Centered revised December 2021, reviewed January 2025 revealed policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observations, interviews and record review facility failed to provide an environment free from potential accident hazards on one (2nd floor storage room) out of nine storage rooms in the facility as evidenced by an unmarked, unlocked storage room with a door that locks from the inside. There were 90 residents residing in the facility at the time of survey.The findings included:Observation of the facility's Second Floor on 9/23/25 at 3:25 PM, an unmarked door; the Surveyor opened the door, which revealed a small room with enteral feeding supplies stacked on shelves. The door could be locked from the inside and there was no call light observed. (photo evidence).On 9/23/25 at 3:30 PM, the Nursing Home Administrator was notified about the identified concern, acknowledged the door was unlocked and locked the door from the inside.Interview on 9/23/25 at 3:40 PM Staff A, Central Supply was asked about the unmarked, unlocked room Staff A stated: This is the storage room, and it is kept locked. Only Maintenance staff, Administration, the Assistant Director of Nursing and myself have a key. When nursing staff needs anything from this room, they tell me, and I retrieve it for them.During an interview on 9/23/2025 at 3:48 PM, the Maintenance Director stated: I am responsible for posting signs on doors in the facility. I am not sure why there is no sign posted.On 9/24/25 at 12:45 PM, the Second Floor Infection Preventionist was interviewed about the identified concern and stated, I am the supervisor; the storage door is kept locked for the safety of our residents because we have residents with Dementia who can wander into the room.Interview on 9/25/25 at 1:36 PM, regarding the identified concerns, the Risk Manager stated: I am part of the Quality Assurance team, and I discuss any issues concerning resident safety. If there is an identified issue with safety, I come up with a plan to prevent it from happening again. The storage door is normally kept locked and labeled. Normally the maintenance staff checks the doors twice a day and the supervisor checks on the weekends. The possibility does exist for a resident to wander into an open storage room and get locked in.Record review revealed the Second-Floor storage room was 28 square feet in dimension.Record review of Policy entitled, Storage Doors effective date: 04/01/2024 review date: 01/03/2025 revealed Policy Statement: All storage room doors containing medical supplies, cleaning agents, maintenance tools, resident records, personal belongings, or hazardous materials must remain closed and locked when not in immediate use. Only authorized personnel shall have access. Procedure: 1. Access Control: All storage areas must be equipped with locks. 2. Door Security: Storage doors must be closed and locked after use. 3. Daily Monitoring: Unit supervisors and department heads must perform daily checks to ensure all storage doors are locked.

Based on observations, interviews and record review facility failed to properly store and label medications on one (2nd floor east) out of two medication carts sampled as evidenced by an observation of an eye drop bottle with an open date of 8/9/25. There were 90 residents residing in the facility at the time of survey.The findings included:On 9/26/25 at 5:36 AM, a medication storage check was completed with Staff D, Licensed Practical Nurse (LPN) on the 2nd floor east medication cart revealed a Brimonidine eye drop with an open date written on bag of 8/9/25, the dispensed date from pharmacy was 8/8/25.Interview on 9/26/25 at 6:06 AM, Staff D, LPN stated: The eye drops last 28 days after opening. I check every day to make sure there are no expired medications. When I open an eye drop bottle, I write the open date. I did not open this eye drop bottle.On 9/23/25 at 7:01 AM, the Director of Nursing (DON) was notified about the identified concern.Record review of a policy titled, Storage of Medications Revised April 2019, Reviewed January 2025 revealed Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Class III

Based on observations, interviews, and record reviews revealed that the facility did not maintain accurate records for one (Resident #99) out of two sampled residents. As evidenced by a review of the September 2025 Medication Administration Record (MAR) showed that staff signed off on all medications as administered, even though no medications were available for Resident #99. There were 90 residents residing in the facility at the time of the survey. The findings included: Observation on 9/23/25 at 12:17 PM while on the second floor, Resident #99 observed standing in the hallway with oxygen in progress via nasal cannula. Resident #99 stated to Staff E, Registered Nurse (RN) I have not received my medication, and it is becoming difficult to breathe.” Staff E, RN replied, “The medication has not arrived from the pharmacy yet.” Resident #99 then went back into room. Surveyor asked Staff E, RN which medications were missing and if an assessment would be completed and Staff E, RN replied, “Resident #99 vitals were within a normal range, and the medications were ordered last night.” Interview on 9/23/25 at 12:25 PM, Resident #99 stated: “I can breathe but had been waiting on the medication, and I will have difficulty breathing if I don't get it. I was admitted last night.” Record review of the September Medication Administration Record (MAR) for Resident #99 revealed all medications were signed administered at 9:00 AM for the date 9/23/25. On 9/23/25 at 4:40 PM, the Director of Nursing entered the conference room and revealed all medications for Resident #99 had arrived and the physician was notified and stated it was okay to give meds upon arrival. Further revealed Staff E, RN signed the MAR due to being nervous. On 9/23/25 at 4:51 PM Staff E, RN (translated by another surveyor) was interviewed about identified concern and stated, “I sign the MAR after I give the medication. There is not a time I would sign before. If the medication is not here, I mark no and write in the progress notes and call the doctor and pharmacy. I did not give [Resident #99] any medication this morning because it was not here. I signed The MAR as administered in error.” Record review of Resident #99's demographic sheet revealed an admission date of 9/22/25 with Diagnosis that included: Acute and chronic respiratory failure with hypercapnia. Record review revealed the admission Minimum Data set (MDS) reference dated 9/22/25 was in progress. Record review of a Care Plan initiated and revised on 09/23/2025 revealed Resident #99 was at risk for altered respiratory status/difficulty breathing related to: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Acute on Chronic Respiratory Failure, Alkalosis, Hypo-osmolality and Hyponatremia, Hypoxemia, had a goal to maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date and interventions that included: Administer medication/inhalers/nebulizers as ordered and monitor Oxygen saturations as ordered and as needed, and teach resident/family/caregivers appropriate breathing, coughing, and splinting techniques. Record review of Resident #99's September 2025 physician's order sheet revealed orders included: Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 microgram per actuation (MCG/ACT) two puffs every 12 hours related to Acute and chronic respiratory failure with hypercapnia, Ipratropium Bromide Nasal Solution 0.03 % two sprays in both nostrils one time a day for Bronchodilator, Aclidinium Bromide Inhalation Aerosol Powder Breath Activated 400 MCG/ACT one inhalation two times a day for Bronchodilator related to COPD with Acute Exacerbation, and Fluticasone Propionate Nasal Suspension 50 MCG/ACT two sprays in both nostrils one time a day for Congestion, Azelastine hydrochloric acid (HCl) Nasal Solution 137 MCG per spray directions: 1 spray in both nostrils every six hours for congestion, Prednisone oral tablet 20 milligrams (MG) tablet by mouth one time a day for COPD exacerbation, and Montelukast Sodium Oral Tablet 10 MG tablet by mouth in the evening for Bronchodilator related to COPD. Record review of a pharmacy packing slip revealed medications for Resident #99 were delivered to facility and signed received by Supervisor on 9/23/25 at 2:43 PM. Record review of a policy titled, Charting Errors and/or Omissions/Accuracy of Medical Records revised January 2025 revealed Policy Statement: Accurate medical records shall be maintained by this facility.

Based on observations, record review and interview the facility failed to ensure pharmacy procedures were followed as per facility policy for two out of four carts in use. The findings included: On initial entrance to the facility on 5/19/2023 at 06:07 AM; the 1st floor's [NAME] Medication cart assigned to Registered Nurse (Staff A) was observed unlocked in the hallway, Staff A was observed in a resident's room taking care of the resident. Staff A came out of the resident's room, greeted the surveyor and proceeded to lock the unlocked medication cart. During an observational tour on 05/20/24 at 08:12 AM the 1st floor [NAME] Medication Cart assigned to Licensed Practical Nurse (Staff C) was observed with Two (2) round white pills in a medication dosage cup sitting on top of the cart, at the time of the observation, Staff C was in room a resident's room administering medications to a resident. Interview on 05/20/24 at 08:13 AM Licensed Practical Nurse (Staff C) reported that the pills fell on the floor and she needs to discard them, she is not allowed to leave pills on the cart unattended and will put the pills in the drug buster, she checked the medication cart and no drug buster was available on cart at the time and she will have to go get the drug buster from the medication storage room. Interview on 05/21/24 at 03:36 PM Director of Nursing (DON) stated: I will of course do an in-service with all the nurses to educate them on correct medication storage . Review of the facility policy and procedures titled Storage of Medications revision date April 2024 states: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Review of the undated facility policy and procedures titled Medication storage states: medications will be stored in a manner that maintains the integrity of the product and that ensures the safety of the residents and is in accordance with Florida Department of Health Guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement a comprehensive care plan for an upper extremity device as ordered by the physician for one (Resident #36) out of 19 residents sampled. There were 75 residents residing in the facility at the time of this survey. The findings Included: During observation on 02/13/2023 at 09:08 AM Resident #36 was observed on the hallway in a wheelchair, coughing and stated he is ok. Review of Resident #36's medical records revealed the resident was re-admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing. Muscle Weakness (Generalized). Review of the Physician's Orders Sheet for February 2023 revealed Resident #36 had orders that included but not limited to: 1/12/2023-Device: Right upper extremity, non-weight bearing (NWB) wear sling at all times-every shift. On 02/13/2023 at 12:29 PM, Resident #36 was observed in his room having lunch, no sling was noted on right side. 02/14/2023 11:00 AM Resident# 36 was observed in the facility's therapy room, sitting in wheelchair, no sling noted to upper right side. On 02/15/2023 at 08:53 AM Resident #36 was observed in his room sitting in bedside chair finishing his breakfast. The surveyor asked Resident # 36 where his right shoulder sling was, the resident stated they took it, I guess I don't need it. Record review of Resident # 36's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for cognitive pattern documented Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating the resident is moderately impaired cognitively. Section E for Behaviors documented the resident exhibited no behaviors and had no potential indicators of psychosis. Section G for Functional status documented extensive assistance required for Activities of Daily Living (ADLs). Section J for Health Conditions documented resident received no scheduled or as needed pain medications in the last 5 days, had a fall prior to admission to the facility and experienced no shortness of breath in the last 5 days. Section O for Special Treatments documented resident received 191 minutes of Occupational Therapy and 162 minutes of Physical Therapy in the last 7 days. Review of Resident #36's Care Plans Reference Date 1/11/2023 revealed: The resident requires use of device: Sling right upper extremity NWB. Interventions Include: Monitor sight for device application daily and take off to clean extremity, monitor for pain, moaning, removal of device and report to nurse, notify Medical Doctor (MD) of any adverse sign and symptoms related to device usage, notify to MD resident device use preference, and educate resident on consequences of not following assistive device use. Review of February 2023 Treatment Administration Record (TAR), revealed from 2/1/2023 to 2/14/2023 -every shift (7 AM-30PM, 30PM-11 PM, 11 PM-7 AM) nurses signed off that the resident is always wearing right upper extremity NWB sling. Review of progress notes dated 2/15/2023, timestamped 09:50 AM written by the Assistant Director of Nursing (ADON) documented: Nurse on shift reported that patient not wearing the sling device. When patient interviewed, he reported that he was told by our psychiatrist that he doesn't need anymore . called resident's MD and confirmed about comment from the patient. Physician will submit his progress notes. Phone order obtain to discontinue device. Physical therapy and restorative nurse informed. During an interview on 02/15/2023 at 08:59 AM Registered Nurse (Staff A) when asked about the resident's right shoulder sling, Staff A stated that she will have to ask the Certified Nursing Assistant (CNA) assigned to the resident about the sling. Staff A stated; this resident used the sling before, but I need to know what is going on with the resident's sling now. The surveyor told Staff A to check the TAR which revealed that the nurses have been signing off on the right sling being used every shift. Staff A confirmed that nurses on all shifts have been signing off on resident having the right shoulder sling on. The surveyor and Staff A went to Resident #36's room, Staff A questioned Resident #36 about the upper extremity sling. The resident stated; the sling is in my drawer, and I do not need it, therapy told me I do not need it. Staff A located the right extremity sling in resident's bedside drawer. Staff A stated she will speak to therapy, her supervisor and the resident's doctor and get back with the surveyor afterwards. During an interview on 02/15/2023 at 01:07 PM, the Director of Nursing stated (DON) reported that the resident has an order from the MD to discontinue the upper extremity device. The surveyor requested a copy of the physician note, progress note, care plan, Treatment Administration Record (TAR) for February 2022, face sheet, current and discontinued orders, facility policy and procedure on positioning devices. On 02/15/2023 at 03:16 PM, the Administrator (NHA) brought documentation for the resident's discontinued order related to the right upper extremity sling dated 2/15/2023 at 10:48 AM and a consultation note dated 1/23/2023 from the MD that documented-Findings/Diagnosis: Right proximal humerus fracture, right shoulder pendulum exercise and passive range of motion 0-90 degrees. Patient may feed self if able. Otherwise non weight bearing (NWB) to right upper extremity., 2/15/2023 progress note, February 2023 TAR, care plans, and orders. During an interview on 2/16/2023 at 9:49 AM the Director of Nursing (DON) stated he will be educating the nurses on documentation, which they have done in the past and will continue to do. He stated, we have a nursing dashboard on the units for nurses to use as a quick guide to know which residents have devices, oxygen, peg tube, wounds etc. and the dashboard is updated every Monday. On 02/16/2023 at 03:54 PM the DON brought surveyor a Physiatrist follow up note, the date of service noted was 02/09/2023, follow up care-documented continue with NWB of right upper extremity pending ortho follow up for weight bearing status changes. May remove sling according to orthopedics' recommendations. Review of the facility's policy and procedures titled, Contractures Prevention revision date 8/22/2017 states: Each resident must be evaluated for need of contracture prevention procedure on admission, readmission and as needed. Positioning: Some residents may have braces or splints to prevent or help release contractures-be sure to follow the physicians order regarding the schedule of when to put these on and when to remove them.

Based on record review and interviews, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area, as evidenced by repeated deficient practice during consecutive annual surveys. Cross reference F 656 develop/implement Comprehensive Care Plan. There were 75 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during an annual survey with exit dated 10/15/2021, deficient practice was cited related to F 656-Develop Implement Comprehensive Care Plan related to due to the facility's failure to implement the activities care plan for one (Resident #62) out of 20 sampled residents. During this survey with exit date of 02/16/2023 the facility was cited F 656-Develop Implement Comprehensive Care Plan related to the facility's failure to implement a comprehensive care plan for an upper extremity device as ordered by the physician for one (Resident #36) out of 19 residents sampled. Review of the facility's plan of correction for the last annual survey with an exit dated 10/15/2021 related to F 656- Develop/Implement Comprehensive Care Plan indicated as part of the correction measures revealed: The Activity director and/or designee will conduct an audit of residents' activity care plan to ensure that they are followed and documented, random weekly x 4 weeks, then random monthly, thereafter. Findings will be discussed at the monthly QAA meeting to maintain compliance. During an interview with the Administrator, Director of Nursing (DON), and Admissions Director on 02/16/2023 at 2:37 PM it was revealed that the issues identified and discussed in the in previous meetings were missing items and grievances procedure, dietary issues, pandemic management, staffing issues, and Cyber breach. The administrator stated that they do Quality Assurance meetings daily and that they have not done a general meeting for February. They did not identify any concern with the tag F 656 as they run audits every day. The administrator stated that when it comes to assessments, one thing is for late assessment even though they were completed and submitted on time, they show as not submitted. We have tickets open with IT departments as we have had issues with connectivity, Minimum Data Set (MDS) coordinator and her assistant are on point with everything. The Director of Nursing stated that when it comes to Physician Orders, they hold clinical meetings every morning, and that they do 24-hour orders check. They do audits and he noted; I have never noticed that there is a pattern for not following physician orders. For the subject of this survey in particular, the doctor educated the patient, and he did not put a physician order in the record therefore the nurses kept using the splint, and the resident wanted to keep using the splint. The DON explained that audits are done for everything through a CRO (Conversion Rate Optimization audit also known as a conversion audit). The DON stated, we get audits every morning and especially for the new admission we check anything the nurses documented and whatever it needs to be looked at, we get a full report daily then I personally go one by one and try fixing it, this is consistent, and we also do 24-hour review after new admission. We are on top of everything, and we are going to be auditing physician orders specially for orthopedic patients for adaptive devices. Record review of the facility's Policy and Procedure documented : Subject Quality Assessment & Assurance Committee. POLICY: The QAA Committee shall consist of a minimum of the Director of Nursing, a physician designated by the facility and three (3) other members of the facility staff. Procedure: The Committee shall: 1. Review the following items to identify current and ongoing issues for committee action: a. Quality Indicator Report b. Accident/Incident Tracking Log c. Adverse Incident Tracking Log d. Regulatory Agency Reports e. Grievance Log f. Customer satisfaction results g. Consultant Reports h. Staff Meeting minutes. i. Resident Council Meeting minutes 2. The committee shall implement a CQI or quality review to investigate trends, patterns, positive or negative outcomes related to the topic. 3. The committee will determine an action plan needed to address any concerns. 4. The committee will implement and revise appropriate corrective actions.