Does AVIATA AT THE BAY have any serious inspection findings?

Yes, AVIATA AT THE BAY has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 33 total deficiencies from recent inspections.

What are the staffing levels at AVIATA AT THE BAY?

AVIATA AT THE BAY has a three-star staffing rating from CMS with 0.85 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is AVIATA AT THE BAY located?

AVIATA AT THE BAY is located in TAMPA, FL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does AVIATA AT THE BAY have?

AVIATA AT THE BAY has 150 certified beds.

Who owns AVIATA AT THE BAY?

AVIATA AT THE BAY is a for profit - limited liability company facility and is part of the AVIATA HEALTH GROUP chain.

What questions should families ask when visiting AVIATA AT THE BAY?

Families visiting AVIATA AT THE BAY should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does AVIATA AT THE BAY compare to other nursing homes?

AVIATA AT THE BAY has a 1-star overall rating, which is below average compared to other nursing homes in FL. Families should carefully review inspection findings and consider alternatives.

AVIATA AT THE BAY

Name: AVIATA AT THE BAY
Address: 2916 HABANA WAY, TAMPA, FL, 33614, US
Telephone: (813) 876-5141
Rating: 1.0

2916 HABANA WAY, TAMPA, FL 33614 · (813) 876-5141

For profit - Limited Liability company 150 Beds AVIATA HEALTH GROUP Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

0/100

#610 of 690 in FL

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Last Inspection: June 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Aviata at the Bay has received a Trust Grade of F, indicating significant concerns about the facility's overall care and management. Ranking #610 out of 690 facilities in Florida places them in the bottom half, and #24 out of 28 in Hillsborough County shows that there are only a few local options that perform better. The situation appears to be worsening, with the number of issues increasing from 8 in 2022 to 22 in 2024. Staffing is rated as average with a 3/5 star rating, but the turnover rate is concerning at 54%, which is higher than the state average. Although the facility has good RN coverage, more than 83% of Florida facilities, there have been serious incidents, such as a resident being allowed to leave unsupervised, exposing them to potential harm, and another resident expressing distress over lack of assistance with basic needs. Families should weigh these strengths and weaknesses carefully when considering this nursing home.

Trust Score: F
In Florida: #610/690
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $152,565 in fines. Lower than most Florida facilities. Relatively clean record.
Skilled Nurses: Each resident gets 51 minutes of Registered Nurse (RN) attention daily — more than average for Florida. RNs are trained to catch health problems early.
Violations: 33 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2022: 8 issues

2024: 22 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

1-Star Overall Rating

Below Florida average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 54%

Near Florida avg (46%)

Higher turnover may affect care consistency

Federal Fines: $152,565

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: AVIATA HEALTH GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 33 deficiencies on record

2 life-threatening 2 actual harm

Jun 2024 20 deficiencies 1 Harm

SERIOUS (H) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an observation and interview on 06/25/2024 at 10:15 a.m. Resident #126 was in bed, dressed for the day. Resident #126's hair was matted and unkept and she stated that she was not able to brush her hair on her own, so she got knots in her hair. Resident #126 stated she really would like to go outside and get some sun, but she was always in bed, which caused her neck and back to hurt. She said she did not ask the CNAs for help because they were short staffed and there was no point. During an interview on 06/27/2024 at 4:50 p.m. Resident #126 was lying in bed crying. Her hair was noted to be visibly unkept and matted and she stated no one had offered to help her out of bed, or to brush her hair. Resident #126 stated, I would just like to go outside for a little while, so I can see something other than these walls. 3. During an observation on 06/25/24 at 9:30 a.m., Resident # 124 was observed lying down in her bed. She was dressed in her night gown with her call light within her reach. Resident #124 said the staff had not assisted her with her ADLs, they would not get her out of bed. She said she had asked staff to put her on the toilet when she had to have a bowel movement, but she was told to go in her brief. She said she would like to go to activities or even get up out of bed to visit with other residents, but staff would not get her up out of bed. Resident #124 started crying as she was expressing her frustration about the lack of assistance she received from the staff. She said she had told her nurse, but they had not done anything about it. During multiple observations on 6/25/2024 and 6/26/2024 at 11:00 a.m., 1:45 p.m., and 5:00 p.m., Resident # 124 was observed dressed in her night gown, with her call light within reach. She continued to express her frustration about staff not getting her up out of bed. During an interview on 6/27/2024 at 1:45 p.m., Resident #124 was observed lying down in bed, dressed in her nightgown with her call light within reach. Staff E, Registered Nurse (RN)/Weekend Supervisor and Staff J, Licensed Practical Nurse (LPN)/Unit Manager came to Resident #124's room for an observation. Resident #124 stated that she wanted to say something. She began to express to the weekend supervisor and the unit manager about how she had repeatedly asked staff to get her out of bed so she could participate in activities and socialize with other residents. Resident #124 began to cry as she was expressing how she felt about being left in bed all the time. She stated she had not been out of her bed for three months. She said she felt like she was declining due to not being able to get up out of the bed. She stated that she did not want to turn crippled due to her not getting up out of the bed. Review of a Resident Information Record dated 06/28/2024 showed Resident #124 was admitted to the facility on [DATE] with diagnoses to included but not limited to Muscle weakness (generalized), difficulty in walking, not elsewhere classified, other lack of coordination, cerebral palsy, unspecified. Review of a Minimum Data Set (MDS) dated [DATE] showed Resident #124 had a Brief Interview Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Review of a care plan dated 3/29/2024, revealed a care plan focus showing Resident #124 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Review of a care plan goal showed Resident #124 would maintain involvement in cognitive stimulation, social activities as desired through review date. Review of a care plan intervention showed to invite the resident to scheduled activities. Date initiated: 04/10/2023, date revised on 04/10/2024. During an interview on 06/27/24 at 9:33 a.m., with the Advanced Registered Nurse Practitioner, ARNP. The ARNP stated that she was assigned to all the residents at this facility. She said she had spoken with the staff about residents not getting out of their beds. She said the staff told her most of the residents did not have access to wheelchairs so they could not get out of bed. During an interview on 6/27/2024 at 2:00 p.m., with Staff E and Staff J, Staff J stated her expectations were that staff assisted their residents with their ADLs and got them out of bed, unless the resident refused to get up. If a resident refused, staff should report it to the nurse so the situation could be documented. She stated it was not acceptable that so many residents were in their beds but some of the residents did not have wheelchairs so they could not get up. She said, her and Social Services were supposed to do an audit to see which resident did not have wheelchairs, but it was not done. She said she was not able to conduct the audits because of her workload with being responsible for the lower part of the 300 hall and the 400 unit located upstairs. She stated everyone in the facility knew they did not have enough wheelchairs to get residents up. Staff E and Staff J stated that they had reported residents did not have enough wheelchairs to get out of the bed to the Director of Nursing and the Nursing Home Administrator during their meetings and nothing had been done about it. During an interview on 6/27/2024 at 2:30 p.m., with Staff G, Certified Nursing Assistant (CNA). She stated that she assisted residents with their ADLs. She only got residents up and dressed them if they asked her to. Some residents could not get out of bed because they did not have wheelchairs. During an interview on 6/27/2024 at 5:30 p.m., with the Nursing Home Administrator. She stated if a resident needed a wheelchair, she or the Director of Nursing could have a wheelchair to the resident by the next day. Her expectations were for all residents to be assessed for what type of chair they needed. She stated she was not aware that there were residents without wheelchairs. She stated she did an audit a couple of times a week on the 4 floors and no one including staff and residents had reported residents not having a wheelchair. She stated had not observed residents dressed in gowns all day. If residents were dressed in gowns all day that would be the preference of the residents. She would expect residents to ask for assistance if they would like to get out of bed or would like to change their clothes. Once the question was clarified she stated her expectation was for the CNAs to ask the resident if they would like to get out of bed or to get dressed. During an interview on 06/28/24 at 11:50 a.m. with the Director of Rehab, he stated when a patient was admitted to the facility Occupational Therapy or Physical Therapy would evaluate the resident for mobility. After the evaluation, it would determine if the resident needed a wheelchair if they were non-weight bearing. When a resident was assigned a wheelchair, they labeled the wheelchair with an ID bracelet to show that the wheelchair was assigned to that resident. Staff have not told the therapy that residents did not have wheelchairs. He said the administrator told him today to start evaluating all the residents to determine their type of mobility. He said he had noticed that there were a lot of residents who remained in their beds and dressed in gowns all day. He said he had mentioned during a Utilization Review (UR) meeting that residents should get out of bed more. He said he explained the risks of residents lying down in bed all the time and how it could cause their skin to breakdown and cause them to have poor circulation. He restated that he was told by the administrator today to re- evaluate all the residents for their wheelchair. He said he did not know what could have happened to the wheelchairs that were assigned to the residents when they were first admitted to the facility. During an Interview on 6/28/2024 at 6:00 p.m., with the Director of Nursing, DON, she stated she had worked at the facility for a year. She stated she was aware that some residents were in bed a lot, but that was because they had refused staff to get them out of the bed. Some residents refused to get up out the bed and some residents did not have wheelchairs. She stated they were aware that residents had not had wheelchairs for a long time, but there was not much they could do about it. They reached out to corporate, and they were denied permission to purchase more wheelchairs. They were told they could only rent about 5 chairs a month. She stated she did not put any interventions in place for those residents who did not have access to wheelchairs. Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect for four residents (#47, #114, #124, #126) out of thirty-one sampled residents related to no access to wheelchairs, no assistance getting out of bed, and residents not receiving proper ADL (activities of daily living) care including hair care and dressing. Findings included: 1. An interview was conducted on 6/26/24 at 2:17 p.m. with a family member for Resident #114. He said when he brought the resident to this facility, he was looking for a place with more interaction. He said she was only staying in her bed. He said he brought Resident #114's custom wheelchair to the facility for them to use. He said he was told therapy would have to evaluate her before she could use it. He said next, he was told she was not getting up because the chair did not have a seat belt. He said if someone had just lifted the cushion, they would have seen the seatbelt was there. He said when Resident #114 got angry enough she would shake the bed to get staff attention. He said he would like her to get out of bed and have some interaction. Review of admission Record showed Resident #114 was admitted on [DATE] with diagnoses including aphasia, multiple sclerosis, bipolar disorder, quadriplegia, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, post-traumatic stress disorder, and autistic disorder. Resident #114 was observed to be in her bed with a hospital style gown on throughout the day on 6/25/24, 6/26/24, 6/27/24 and 6/28/24. Her wheelchair was observed in the closet in her room. Review of Resident #114's quarterly MDS, dated [DATE], Section C, Cognitive Patterns, was not able to be completed due to resident rarely/never being understood. Section GG, Functional Abilities and Goals, was not completed due to the questions being disabled. Review of Resident #114's care plan showed a focus area of ADL self-care deficit related to decreased mobility, incontinence, cerebral vascular accident with aphasia, multiple sclerosis, spinal cord injury, and quadriplegia. Interventions included: resident was totally dependent for bathing/showering, dressing, and transfers. 2. An interview was conducted on 6/26/24 at 5:10 p.m. with Resident #47. She said she would like to get out of bed, but no one would help her. During a follow-up interview on 6/27/24 at 3:23 p.m., the resident said she had been in her bed for a long time and just wanted to get up. She said she had asked staff multiple times for a wheelchair. Resident #47 said she did not know if she was getting depressed or senile. She said she was surprised she is not in a deep depression from just sitting in her bed all the time. She said her television (T.V.) was the only thing that saved her. Resident #47 said she would love to get up and be involved in life because she could not last another several years lying in her bed. Review of the admission Record showed Resident #47 was admitted on [DATE] with diagnoses including non-Hodgkin lymphoma, anxiety disorder, low back pain, and seizures. Review of Resident #47's care plan showed a focus area of ADL self-care deficit related to limited mobility and musculoskeletal impairment. Interventions included: resident is totally dependent on staff for transferring. Requires assist of 2 staff with mechanical lift.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility did not ensure the confidentiality of Protected Health Information (PHI) was maintained for one resident (#395) of 42 residents on the 200 Unit. Findings included: During a facility tour on 06/25/24 at 10:03 a.m. an observation was made of an IV (intravenous) label thrown into a trash can by Resident #395's bed. The IV label included PHI for the resident to include Resident #395's name, name of the medication, prescription number and the medication administration schedule. Review of the admission Record showed Resident #395 was admitted to the facility on [DATE] with a diagnosis of sepsis. On 06/25/24 at 10:12 a.m. an interview was conducted with Staff F, Registered Nurse (RN). She stated resident's PHI should not be disposed of in the trash. She stated they should maintain the resident's confidentiality and HIPAA (Health Insurance Portability and Accountability Act) per their policy. An interview was conducted on 06/25/24 at 10:28 a.m. with Staff I, Licensed Practical Nurse (LPN). She observed the resident's information inside the trash can. She said, It's his IV information. It should not be in the trash. I believe the nurse who removed it was probably in a hurry. I'll remove the information from the trash can. On 06/25/24 at 10:31 a.m. an observation was made of Staff Q, Certified Nursing Assistant (CNA) removing trash from Resident #395's room. The trash bag was all tied up as she was observed leaving the room. Staff I, LPN stopped her in the hallway and proceeded to retrieve the IV information from the bagged trash. She stated she would dispose of it accordingly. Review of a facility policy titled, Confidentiality and Privacy, dated 11/30/2014, showed the confidentiality and privacy policy is implemented for the purpose of complying with the privacy/security regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPPA or the Privacy/Security Rule). It is the policy of The Company, LLC to protect the confidentiality of Protected Health Information of its residents. The Procedure showed to never throw sensitive information in the trash. Shredding documents is the only acceptable method of destruction for health or financial information.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to act upon a resident's grievance for one (#394) resident out of 42 residents on the 200 Unit. Findings included: During a facility tour on [DATE] at 10:13 a.m. Resident #394 was observed in bed. He stated he was constantly hot because the air conditioning (A/C) wall unit in this room did not work. He said, I have provided my own fan. The batteries died. They told my [family member] I can't have a fan that plugs in the wall because there was nowhere to plug it. He stated the family member brought another desk fan and the batteries were dead again. He stated he had notified facility staff. He said, The CNAs [certified nursing assistants] and the nurses know. I have requested a fan if they can't move me. The A/C wall unit was observed to be turned off. The resident stated his roommate turns it off. Review of the admission Record showed Resident #394 was admitted to the facility on [DATE] with a primary diagnosis of wedge compression fracture of the fourth lumbar vertebra, sequela. Review of the facility's Grievance Log, dated [DATE] to [DATE], showed there was no documented grievance for Resident #394. An interview was conducted on [DATE] at 1:36 p.m. with the Director of Maintenance (DOM). He stated the A/C unit worked, but Resident #394's roommate did not want the AC turned on. He stated he notified the staff of the conflict between the two residents. He said, I don't know if there is anything we can do. On [DATE] at 1:40 p.m. an interview was conducted with Staff I, Licensed Practical Nurse (LPN). She stated she worked in this hall (200) on a regular basis and was familiar with the two residents. She stated Resident #394's roommate did not want the A/C turned on. She said, I know, he turns it off immediately after you turn it on. She stated to the DOM, What are we going to do. Maybe I can speak to the Social Services Director (SSD) for advice. Staff I, LPN confirmed Resident #394's roommate had this problem with every roommate he had. On [DATE] at 3:07 p.m. an interview was conducted with Staff R, Certified Nursing Assistant (CNA). She stated Resident #394's roommate did not like the A/C unit turned on. She stated he turned it off. She stated Resident #394 had been complaining because his roommate would not let him turn on the A/C unit. Staff R said, This morning [Resident #394] said again he was unhappy because it was too hot. She stated a family member brought a fan but there was nowhere to plug it in. Staff R stated the resident had complained to everyone. An interview was conducted with Staff L, LPN/Unit Manager on [DATE] at 3:12 p.m. She confirmed Resident #394's roommate would not let them turn it on. Staff L said, It (the A/C) works. We have spoken to him multiple times. He won't agree. [Resident #394] has requested a room change. I told him I do not have a room right now. Staff L stated she spoke to Admissions regarding roommate compatibility. She stated the owner wanted beds to be filled. She said, I have to wait until we find a place for him. During an interview on [DATE] at 3:32 p.m. Staff S, Assistant SSD stated on [DATE] nursing submitted a grievance related to ADLs (activities of daily living), but not about the room being hot or the request for a room change. She stated their procedure was a resident, family member or staff could initiate a grievance. She stated if the resident notified staff of the room concern, a grievance should be initiated as soon as possible. She stated nursing had not notified the Social Services department. She said, If the roommate did not want the A/C on; then we would initiate a room change. On [DATE] at 4:03 p.m. an interview was conducted with the Director of Nursing (DON). She stated the staff should have initiated a grievance for this resident. She said, Somebody should have documented his concerns. The DON confirmed the expectation was to initiate a grievance to document the resident's concern. On [DATE] at 4:18 p.m. an interview was conducted with the SSD. She stated she had not received any grievances related to this resident's A/C unit or a request for a room change. She stated if the resident had expressed an issue, it should be documented. Review of a facility policy titled, Complaint/Grievance, dated [DATE], showed the intent of this guideline is to support each resident's right to voice grievances and to assure that after receiving a complaint/grievance, the center actively seeks a resolution and keeps the resident appropriately appraised of its progress towards resolution. Prompt efforts by the center to resolve grievances the resident may have, including those with respect to the behavior of other residents. Under Process, the policy showed an employee receiving a complaint/grievance from a resident, family member, and/or visitor shall initiate a complaint/grievance form or electronic equivalent.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An interview was conducted on 6/25/24 at 10:18 a.m. with Resident #75. He said he received glasses, but they do not work. He said he cannot see very well, can't read menus, and people are just shadows. Review of the admission Record showed Resident #75 was admitted on [DATE] with diagnoses including malignant neoplasm of the brain, hemiplegia and hemiparesis following cerebral infarction, and chronic migraine. Review of Resident #75's Annual Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns, showed he had a BIMS score of 13, indicating he is cognitively intact. Section B - Hearing, Speech, and Vision showed he had highly impaired vision. Review of Resident #75's care plan did not show any focus areas or interventions related to vision loss. An interview was conducted on 6/28/24 at 9:47 a.m. with Staff FF, Certified Nursing Assistant (CNA). She said she frequently cares for Resident #75. She said he can see about 50% of things and can see if they are close to him. She said she sometimes reads his mail to him when he asks for help. Staff FF said sometimes activities brings the resident crossword puzzles, but he can't see to do them. An interview was conducted on 6/28/24 at 9:57 a.m. with Staff EE, Licensed Practical Nurse (LPN). She said Resident #75 had vision issues and wears glasses, but she doesn't know how much he can see. She said sometimes he will ask staff to read things to him and will ask for the room light to be off so he can try to see the TV better. An interview was conducted on 6/28/24 at 10:17 a.m. with the MDS Coordinator. She said normally when the MDS is done for a resident, the care plan is revised by the person doing the MDS. She said the care plan is updated with current information from the new assessment. She said she does not know Resident #75, but if someone had vision issues the system would trigger to do a care plan. She reviewed Resident #75's Annual MDS and confirmed it noted highly impaired vision. She confirmed he had no care plan in place and said his needs are not being accommodated if he can't read or see things. 3. Review of the admission Record showed Resident #114 was admitted on [DATE] with diagnoses to include bipolar disorder, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, post-traumatic stress disorder (PTSD), and autistic disorder. Review of Resident #114's care plan did not show any focus area or interventions in place related to autistic disorder. An interview was conducted on 6/28/24 at 10:17 a.m. with the MDS Coordinator. She said she had only been in the facility a couple of months and did not know all the residents, including Resident #114. She reviewed Resident #114's diagnoses and care plan. She stated that every diagnosis does not require a care plan, but anything that would be psychological and/or effect behavior should have one. She said autism effects everything and should be care planned. Review of a facility policy titled Plans of Care, revised 9/25/17, showed the following: Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: -Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . -The Individualized Person-Centered plan of care may include but is not limited to the following: . Resident's strengths and weaknesses. . Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements. . Other state and federal services, which are not being provided due to respecting a resident's right to refuse care. . Resident's goals for admission and desired outcomes, as well as preferences and potential for future discharge. . Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals. . Interdisciplinary approaches that maintain and/or build upon resident abilities, strengths, and desired outcomes. . Alternative treatments as applicable. Based on observation, record review, and interview the facility failed to develop and/or implement an effective care plan for three (#57, #75, and #114) out of 53 sampled residents. Findings included: 1. On 6/25/24 at 10:44 a.m. Resident #57 was observed with matted hair on the front left side of her head. The resident reported not allowing staff to comb hair because she does it by herself. On 6/28/24 at 11:57 a.m. Resident #57 reported combing her own hair. The observation of the resident showed her hair was matted to the front of her head. At this time, Staff U, Certified Nursing Assistant (CNA) stated the family doesn't want to cut it. Review of Resident #57's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record revealed diagnoses not limited to unspecified encephalopathy, mood disorder due to known physiological condition with mixed features, and dementia in other diseases classified elsewhere severe without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #57's June 2024 Medication Administration Record (MAR) showed the staff documented the resident was combative 6 out of 54 shifts and did not have any other behaviors. Review of Resident #57's care plan revealed the following: - Has an Activities of Daily Living (ADL) self-care performance deficit r/t (related to) decreased mobility, morbid obesity, Diabetes Mellitus (DM), hx (history) of falls, (and) right leg pain. The interventions revealed the resident required supervision for personal hygiene. - Has behaviors r/t refusal of personal care from males, refusal of UA C&S (Urinalysis Culture & Sensitivity), non-compliant with skin sweeps, she speaks not so nice to staff who enter her room, tells staff she doesn't like them or to get out of her room, fabricates stories, 2 staff to go into room when providing care, refusal of meds, refusal to go to ER (Emergency Room), refusal to be straight cathed, yelling at staff, refusal of incontinence care, (and) refusal of med (medication) neb (nebulizer) treatments. During an interview on 6/28/24 at 5:14 p.m. the Director of Nursing (DON) stated Resident #57 does refuse staff to comb her hair and the facility has asked the spouse to cut her hair, which is refused. Review of the care plan for Resident #57 did not reveal the facility had developed a care plan or interventions related to the resident's matted hair and the resident/family refusal to assist with the resident's hair.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement an effective discharge planning process to assist one resident (#72) with a discharge to another facility out of eight residents sampled. Findings included: During an observation made on 06/25/24 at 9:30 a.m., Resident #72 was observed lying down in bed dressed in her night clothes. Resident #72 was not able to verbally answer interview questions. She pulled out her phone to write her responses down. She wrote the staff at the facility was not treating her good. Staff will not assist her with her ADLs (activities of daily living). She said she was supposed to be up right now for her therapy, but she was not able to go because the aide from the 11:00 p.m. to 7:00 a.m. shift did not get her up. She said her and her [family member] requested that she be transferred to another facility but the person in social services will not assist them. Review of the admission Record showed Resident #72 was admitted originally on 2/16/24 and readmitted on [DATE] with diagnoses to include acute embolism and thrombosis of left femoral vein, bipolar II disorder, major depressive disorder recurrent, unspecified, anxiety, adjustment disorder with mixed anxiety and depressed mood. Review of a Minimum Data Set (MDS), dated [DATE]. Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #72 was cognitively intact. Review of a care plan, initiated 2/20/24, showed a focus of: [Resident #72] wished to return/be discharged home. Review of the care plan goal showed [Resident #72] will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date. The interventions showed: established a pre-discharge plan with the resident/resident's representative/ caregivers and evaluate progress and revise plan; make arrangements with required community resources to support independence post-discharge homes [sic], PT (physical therapy), OT (occupational therapy), MD (medical doctor), wound nurse. During an interview on 6/26/24 at 2:00 pm. with Resident #72's family member, she stated she spoke with the Social Services Director (SSD) at the facility to see if they could assist them with trying to move [Resident #72] to another facility. She said the SSD told her that another facility will not take [Resident #72] at this time because she is Medicaid pending. She said [Resident #72] has been Medicaid pending since March. During an interview on 06/27/24 at 5:00 pm. with the SSD, she stated when a resident wants to transfer to another facility, she would help them by providing a list of facilities they could choose from. Sometimes the resident or their representatives may have a facility that they have already selected. Then she would reach out to the facility of their choice to coordinate the discharge between the resident and the facility. Some facilities may not take residents based on their payor source, for example if a resident is Medicaid pending then some facilities may not want to take the resident until their Medicaid is fully processed. She said the resident and her family member came to her to tell her that the resident wanted to go home but then they changed their mind and wanted her to transfer to another facility. [Resident #72's family member] reached out to her about wanting [Resident #72] to be transferred to another facility. I told her that [Resident #72] is Medicaid pending and most facilities will not take her until her Medicaid has been processed. The SSD said she did not assist the resident with looking for another facility because she knows, based on her own experience, that another facility would not take the resident because she is Medicaid pending. An interview was conducted with the Business Office Manager (BOM) following the interview with the SSD. The BOM stated the facility has a Medicaid specialist who does the Medicaid applications. The BOM stated 0n 6/18/2024 they reviewed Resident #72's file and saw the resident's application was not pulled from the system, meaning no one has pulled her application to work on it. The facility did not provide a policy related to discharge planning by the last day of the survey on 6/28/24.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation made on 06/26/24 at 9:22 a.m. Resident #97 was observed lying down in bed dressed in her night clothes. She was not able to verbally communicate. She was observed pointing at different things and hitting on herself trying to communicate. During an observation made on 06/26/24 at 3:00 p.m. Resident #97 was observed lying down in bed dressed in a night gown. The resident was not able to communicate her needs. Resident #97 was observed trying to express herself with moving her hands around. Review of the admission Record showed Resident #97 was admitted to the facility on [DATE] with diagnoses to included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and depression unspecified. Review of Resident #97's medical record showed she did not have a communication care plan in place to assist her with her communication needs. During an interview on 06/27/24 at 6:00 p.m. Staff Y, CNA stated he can communicate with Resident #97. He stated when he enters her room, he calls her mom and asks her what she wants. Staff Y called out mom to Resident #97 and he was not able to understand what Resident #97 was trying to tell him. He stated she has a board that she can write on if she wanted to tell him something. During an interview on 06/28/24 at 9:55 a.m. the MDS Coordinator/RN stated care plans are created by the information triggered from the MDS. For a resident that is nonverbal, Section B on the MDS for hearing communication would be checked as rarely or never understood. This would then trigger for a communication care plan to be created. Resident #97's care plan was done in April (2024). She was coded as usually understood, which may have been coded wrong. She stated she was not here at the facility when the resident care plan was done. This was her first time even seeing the resident. No one told her about this resident's communication needs. She stated what she can see is that Resident #97 should have a communication care plan in place. She stated she will get therapy to see what she can do as far as getting the resident assessed and she will create a communication care plan with the appropriate intervention for the resident. The Director of MDS asked Resident #97 if she can write on the board that is next to her. Resident #97 was not able to write on the board that was given to her. Based on observation, interview and record review the facility did not ensure a functional communication system implemented for two (#393 and #97) of three residents sampled. Findings included: 1. On 06/25/24 at 10:19 a.m., and on 06/25/24 at 12:47 p.m. observations were made of Resident #393 laying on her bed. The resident did not respond to the interview attempts. During the observations, it was noted there were no alternate communication tools to enable this resident to interact with anyone. On 06/25/24 at 1:02 p.m. an interview was conducted with Staff I, Licensed Practical Nurse (LPN). She stated this resident was non-verbal following a stroke. She stated she observes her body to know what she needed. She stated it was hard to know what she really needed. Review of the admission Record showed Resident #393 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of cerebrum, unspecified without loss of consciousness, subsequent encounter, acute respiratory failure, aphasia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of a document titled, Baseline Care Plan and Summary, showed Resident #393 will be able to communicate desires/needs. The section titled Other, was noted blank. On 06/26/24 at 2:30 p.m. an interview was conducted with Staff R, Certified Nursing Assistant (CNA). She stated she does not speak with the resident. She said, The resident cannot speak. I go in and take care of her . I let the nurse know if I don't know what is going on. On 06/28/24 at 11:50 a.m. an interview was conducted with Staff L, LPN/Unit Manager. She stated this resident was non-verbal. She communicates through text messaging. She stated the resident could squeeze your hand to answer to yes and no questions. On 06/28/24 at 11:58 a.m. an interview was conducted with Staff Q, CNA and Staff Z, CNA. They stated they communicate with this resident by observing her face to see if she was happy or if she was sad. They confirmed they did not know this resident's preferred method of communication. On 06/28/24 at 12:31 p.m. an interview was conducted with the Director of the Nursing (DON). She stated if a resident was non-verbal, there should be a communication board in their room. She stated the resident was able to text using her phone. She stated the Unit Manager should share the unit cell phone with Resident #393 so she can communicate with them. She stated this should be documented in the care plan so all staff know how the resident communicated. The DON stated in the resident's care plan under the section Other, the MDS (Minimum Data Set) nurse should have entered alternate measures; such as use of a cell phone or a communication board. She stated all staff should be informed on how to interact with this resident. On 06/28/24 at 1:00 p.m., an interview was conducted with the MDS Coordinator/Registered Nurse (RN). She stated Resident #393 communicated via text message. She stated she had not spoken to the resident, but she created the baseline care plan after reviewing her admission paperwork. She said, Regarding the care plan, it should say the resident was non-verbal and include this resident's appropriate communication style. The MDS Coordinator/RN confirmed the baseline care plan showed the resident's non-verbal status was not identified. An interview was conducted with Staff AA, Speech Therapist (ST) on 06/28/24 at 2:01 p.m. She stated Resident #393 was non-verbal and they were working on hand squeezes. She stated the resident nodded yes and no, responded to eyebrow raises, blinking and visual picture boards. She stated they were working on pointing. Staff AA stated the most effective method of communication was to use her left hand and left eyebrow. Staff AA, ST stated they should have put this information in a place where everyone knew how to interact with Resident #393. She confirmed the care plan should be updated to include the appropriate communication methods. Review of a facility policy titled, Plans of Care, dated 11/30/14, showed an individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and or resident representative to the extent practicable and updated in accordance with state and federal regulatory requirements. Under procedure the policy showed to develop and implement an individualized person-centered baseline plan of care within 48 hours of admission that includes but not limited to initial goals on the admission orders physician orders ., if applicable the other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the comprehensive plan of care is completed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure activities of daily living (ADLs) were completed and maintained for two (#126 and #97) out of two residents sampled. Findings included: 1. During an observation and interview on 06/25/2024 at 10:15 a.m. Resident #126 was in bed, dressed for the day. Resident #126's hair was matted and unkept, she stated that she is not able to brush her hair on her own, so she gets knots in her hair. Resident #126 stated she really would like to go outside and get some sun, but she is always in bed, which causes her neck and back to hurt. She stated she does not ask the CNAs (certified nursing assistants) for help because they are short staffed and there is no point. During an interview on 06/27/2024 at 4:50 p.m. Resident #126 was lying in bed crying, and her hair was noted to be visibly unkept and matted. She stated no one has offered to help her out of bed, or to brush her hair. Resident #126 stated, I would just like to go outside for a little while, so I can see something other than these walls. Review of Resident #126's admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of pain in left shoulder, muscle wasting and atrophy, weakness, unspecified abnormalities of gait and mobility, and unsteadiness on feet. Review of Resident #126's Quarterly Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Shows resident cognitive level is intact. Functional Abilities and Goals, Section GG revealed Resident #126 has an impairment to her upper and lower extremity on one side and requires substantial/maximal assistance for Toileting hygiene, and Shower/bathe care, upper body dressing, lower body dressing, and putting on/taking off footwear. Resident #126 requires Partial/Moderate assistance for personal hygiene. According to the Self-Care Coding Substantial/maximal means the helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort and Partial/Moderate assistance means helper does less than half the effort. A helper lifts or holds trunk or limbs and provides less than half the effort. During an interview on 06/28/2024 at 5:00 p.m. Staff BB, CAN stated she needed a translator to answer questions and at this time another CNA on the floor translated for her. She stated she was not familiar with Resident #126 since this was the first time she has worked with her. She stated she typically provides residents with showers, diaper changes, and provides water and ice. She stated she had not offered to help Resident #126 to brush her hair or to get out of bed since being assigned to her. During an interview on 06/28/2024 at 5:00 p.m. Staff CC, CNA stated he is typically assigned to the other end of the hall and was not familiar with Resident #126's care. He stated part of his job as a CNA is to help residents with showers, diaper changes and provide them with water and ice. He stated he has not offered Resident #126 help with getting out of bed because it is too difficult for him to do. During an interview on 06/28/2024 at 8:55 a.m. Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM) stated Resident #126 can be confused at times. She stated that she has a lot of new CNAs and she has to remind them they should be offering personal hygiene care to include brushing hair and shaving the residents. She stated she used to get a lot of care concerns with her 3:00 p.m. to 11:00 p.m. shift nurses, but it has really turned around. She stated she noticed residents, who do not speak Spanish, are not getting as good of care as residents who do speak Spanish. 2. During an observation made on 06/26/24 at 9:22 a.m. Resident #97 was observed lying down in bed dressed in her night clothes. She was not able to verbally communicate. She was observed pointing at different things and hitting on herself trying to communicate. During an observation made on 06/26/2024 at 3:00 p.m Resident #97 was observed lying down in bed dressed in the same night gown all day. The resident was not able to communicate her needs. Resident #97 was observed trying to express herself with moving her hands around. Observations were made multiple times during the survey on 06/26/2024, 06/27/2024, and 6/28/2024 during multiple times and revealed Resident #97 in bed dressed in her night gown all day and evening. Review of a admission Recordshowed Resident #97 was admitted to the facility on [DATE] with diagnoses to included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus due to underlying condition with diabetic autonomic (Poly) neuropathy, depression unspecified, and other lack of coordination. Review of a Quarterly Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status, (BIMS) score of 03, which indicated Resident #97 is severely cognitively impaired. Reivew of a care plan, dated 4/17/2024, showed a care plan Focus of Resident #97 has an ADL self- care performance deficit related to decreased mobility, cerebral vascular accident with hemiparesis/aphasia, liver injury, chronic obstructive pulmonary disease, hypertension, Diabetes Mellitus, paroxysmal atrial fibrillation. Date initiated 10/30/2023 and revised on 10/30/2023. Review of the care plan goal showed Resident #97 will improve current level of function in through the review date. Review of the care plan interventions showed Resident #97 requires substantial assist for upper body dressing and dependent for lower body dressing. Further review of the care plan interventions showed the resident requires substantial assist x1 for bathing/ showering. Date initiated 10/30/2023 and revised on 11/06/23. During an interview on 6/27/24 at 2:00 pm. Staff H, Certified Nursing Assistant (CNA) stated some residents are still in bed dressed in their gowns because they have not requested to get up out of bed. She said if her residents ask her to get up then she will assist them. During an interview on 6/27/24 at 2:30 p.m. with Staff J, License Practical Nurse/Unit Manager (LPN/UM) she stated her expectations are that staff dress and get their residents up out of bed. If residents refuse care, then the aides should make sure they report it to their nurse, so that we can address the situation. During an interview on 6/28/24 at 6:00 p.m. the Director of Nursing (DON) stated that her expectation is that staff assist their residents with ADL care. She said she was told by her staff that residents are in their beds and dressed in gowns because the residents refused staff assistance. She stated some residents don't have wheelchairs to get up in, but staff should assist with their care, dressing and get them up if they can.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure trauma informed care was provided for one (#114) out of three residents with post-traumatic stress disorder (PTSD). Findings included: Review of admission Record showed Resident #114 was admitted on [DATE] with diagnoses including bipolar disorder, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, post-traumatic stress disorder (PTSD), and autistic disorder. Review of Resident #114's Quarterly Minimum Data Set (MDS), dated [DATE], Section I, Active Diagnosis, noted yes for post-traumatic stress disorder. Section C, Cognitive Patterns, was not able to be completed due to resident rarely/never being understood. Review of Resident #114's care plan did not show a focus area or interventions in place related to post-traumatic stress disorder. An observation was conducted on 10/25/24 at 10:40 a.m. of Resident #114 lying in bed and yelling out repeatedly. Staff EE, Licensed Practical Nurse (LPN) was in the hall and said, is she still crying? An interview was conducted on 6/28/24 at 10:17 a.m. with the MDS Coordinator. She said she had only worked in the facility a couple of months and did not know all the residents, including Resident #114. She said if a resident had a PTSD diagnosis there isn't a specific PTSD care plan, but there is a trauma informed care focus area. She reviewed Resident #114's diagnoses and care plan. She said the resident should have a care plan for trauma informed care. An interview was conducted on 6/28/24 with the Nursing Home Administrator (NHA). She reviewed Resident #114's medical record and said the resident is not being followed by psychiatry or psychology. She said Resident #114's primary care nurse practitioner has mental health training and managed the resident's medications. Review of the policy - Trauma Informed Care, document N-1580 and effective 10/24/22, showed Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident- centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re- traumatization. The procedure included: -1. Residents are evaluated for trauma, triggers and cultural preferences on admission/re- admission, quarterly, and annually. -2. Develop resident- centered interventions based on trauma triggers and resident cultural preferences. -3. Develop a care plan and add interventions to the nurse aide [NAME]. -4. Review and update care plan and interventions quarterly and as needed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medications were administered as ordered for one resident (#393) of 42 residents on the 200 Unit. Findings included. Review of the admission Record showed Resident #393 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of cerebrum, unspecified without loss of consciousness, subsequent encounter, acute respiratory failure, aphasia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of the June 2024 Medication Administration Record (MAR) for Resident #393 revealed on 06/06/24 the resident was ordered Cephalexin Oral Tablet 500 mg (milligram), Give 500 mg enterally four times a day for infection (urinary tract infection) for 7 days. Review of the MAR showed Resident #393 received the Cephalexin antibiotic as follows: * On 06/07/24 at 2:50 p.m., Cephalexin 250 mg, 2 tablets were administered. Record review showed no other doses were administered on 06/07/24. * On 06/08/24 at 5:34 a.m., Cephalexin 250 mg, 2 tablets were administered. On 06/08/24 at 9:54 a.m., Cephalexin 250mg, 2 tablets were administered. Record review showed no other doses were administered on 06/08/24. * On 06/09/24 at 6:44 a.m., Cephalexin 250 mg, 2 tablets were administered. On 06/09/24 at 8:22 a.m., Cephalexin 250 mg, 2 tablets were administered. On 06/09/24 at 12:47 p.m., Cephalexin 250 mg, 2 tablets were administered. Record review showed no other doses were administered on 06/09/24. Review of the MAR for Resident #393 showed the resident did not receive the Cephalexin antibiotic as ordered from 06/10/24 to 06/13/24, which was the end of the 7 days. On 06/27/24 at 2:15 p.m. an interview was conducted with Staff L, Licensed Practical Nurse (LPN)/Unit Manager and the Director of Nursing (DON). The DON reviewed the resident's record and confirmed they had pulled the medication from the EDK (Emergency Drug kit). She stated they ran out of the Cephalexin that was in the EDK kit. The DON stated the nurse should have called the pharmacy to follow-up on the delivery of Resident #393's medications. She confirmed the missed doses. The DON said, She should not have missed her antibiotics. The expectation was for the nurse to contact the doctor and to notify the unit manager and DON if they did not have the antibiotics. During an interview with the Regional Nurse Consultant (RNC) on 06/27/24 at 2:35 p.m., the RNC stated the nurse should have followed up on the original order and called pharmacy. She said, Yes, the EDK should be used for an emergency; not on an on-going basis. She confirmed the nurse should have contacted the pharmacy to obtain the antibiotics. An interview was conducted on 06/27/24 at 9:24 a.m. with the Advanced Registered Nurse Practitioner (ARNP). She reviewed Resident #393's MAR and stated it looked like they did not follow-up regarding the antibiotics. She said, They should have called the pharmacy. It seems to be a timeliness issue. They may have pulled from their EDK stock. The nurse should have notified someone if the resident did not have medications. Antibiotics are critical meds. The resident already had critical labs. It did not help her situation. Review of a facility policy titled, Physician Orders, dated 11/30/24, showed the center will ensure physician orders are appropriately and timely documented in the medical record. The procedure showed: information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure critical labs were reported to the ordering physician in a timely manner for one resident (#393) of 53 residents sampled. Findings included: Review of the admission Record showed Resident #393 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of cerebrum, unspecified without loss of consciousness, subsequent encounter, acute respiratory failure, aphasia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of laboratory results for Resident #393 showed: On 6/10/24 at 6:15 a.m. labs were collected. On 6/10/24 at 8:55 a.m. labs were received. On 6/10/24 at 1:44 p.m. lab results were reported to the facility. Review of the lab results showed the following high readings that were flagged. Glucose serum 193; Reference range 70-105; Flagged high results. BUN (Blood Urea Nitrogen) 59; Reference range 7-25 Flagged high results. Sodium Serum 155; Reference range 135-145; Flagged high results. Chloride 113; Reference range 98-108; Flagged high results. Osmolarity Calculated 343.9; Reference range 275.0-295; Flagged high results. Review of Resident #393 progress notes and assessments showed there were no progress notes documented on this day to confirm the resident's physician was notified. Review of a hospital document titled, History and Physicals, Final Report, dated 06/13/24, showed the patient presented to the emergency room (ER) with abnormal labs. The resident was previously discharged to a facility. She returned to the ER secondary to having abnormal labs. Upon evaluation the patient was lethargic. When her labs were drawn, she had an increase in her white count of 18,000. Her BMP (Basic Metabolic Panel) showed her sodium was 160 and Potassium was 6. Her BUN was 134 and creatine was 2.76, which were previously normal. Patient received IV fluid per Sepsis protocol and broad- spectrum antibiotics. Patient was admitted to the Intensive Care Unit (ICU) for further evaluation and work up. On 06/27/24 at 09:09 a.m., an interview was conducted with the facility's ARNP (Advanced Registered Nurse Practitioner). She stated she had to send the resident out due to critical labs on June 13th. She stated the resident's sodium level was 155 and her BUN (kidney function) was 59. The ARNP stated she had re-ordered labs on the 13th because she had critical labs that were not addressed on the 10th. The ARNP said, I don't know why the physician was not notified. I don't know that they notified anyone. The ARNP stated if the lab results were critical, they should be reviewed STAT, meaning without delay. She said, Typically when I come in, I review the labs myself because most of the time they do not call. They also don't answer the phone. The ARNP stated the facility nurse should call with any critical labs. She stated a delay of 24 hours can make a significant difference for a resident. The ARNP said, I have told the administration they can call me. It is a problem that they don't call when the resident has a change in condition. The ARNP stated communication was a problem at this facility. On 06/27/24 at 11:16 a.m. an interview was conducted with the Director of Nursing (DON). The DON said, She [Resident #393] had critical labs. The nurse should notify the physician, put in orders and notes as soon as they receive the labs. The DON stated there should be a progress note if the physician was notified. The DON stated the laboratory provider called the facility, but it was a hit or miss process. The DON stated the laboratory provider sent a fax too. The DON confirmed the facility had access to the laboratory results. She said, We can log in and look. The DON stated the expectation was for the nurse to call the doctor as soon as the results were received, obtain orders, and document. She said, That is Nursing 101. The DON stated the resident should not have waited 24 hours for a response to critical labs. On 06/27/24 at 11:34 a.m. an interview was conducted with Staff L, Licensed Practical Nurse (LPN). She stated the nurses should notify the doctor of any critical labs and immediately put it in a progress note. She stated the physician should be called as soon as they review the labs. Review of a facility policy titled, Laboratory, Diagnostic and X-ray, dated 11/30/2014, showed an expectation to provide guidance on ordering, obtaining, documenting and reporting laboratory, diagnostic and X-ray results. Under procedure: *Critical values to be called to the center. * The center to notify the ordering practitioner (or the covering physician if after hours) of values outside the reference range or per physician order. * Document any new orders. * Document notification of the practitioner and resident/resident representative of lab work results, diagnostic testing and X-rays to be filed in the electronic medical record.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to promptly provide dental services for one (#79) out of one sampled resident complaining of chewing difficulties related to tooth pain. Findings included: On 6/25/24 at 10:53 a.m. Resident #79 was observed lying in bed. The resident reported having no teeth, having a problem chewing, and had told everybody about the chewing problem. Review of Resident #79's admission Record revealed the resident was originally admitted on [DATE] and re-admitted on [DATE] and 11/29/22. The record included diagnoses not limited to unspecified Type 2 diabetes mellitus with unspecified complications, mild protein-calorie malnutrition, and gastro-esophageal reflux disease without esophagitis. The admission Record revealed the primary payer source for the resident was Medicaid (MCD) Long Term Care (LTC) [provider name]. Review of Resident #79's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating a severe cognitive impairment. The assessment revealed the resident was not edentulous, did not have any abnormal mouth tissues (ulcers, masses, oral lesions), no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums, or any mouth or facial pain, discomfort or difficulty with chewing. Review of Resident #79's medical record revealed a note, dated 5/28/24, showing the resident reported pain in a tooth, the Nurse Practitioner was notified, and an order was obtained for a dental consult and Acetaminophen. Review of Resident #79's progress notes showed the resident received two tablets of 325 mg (milligram) Acetaminophen on 6/4/24 at 11:18 p.m., 6/21/24 at 9:07 a.m., and 6/27/24 at 7:20 a.m., per an order for every 6 hours as needed for pain. The note did not reveal the location of the resident's pain. An interview was conducted with the Social Service Assistant (SSA) on 6/26/24 at 5:13 p.m The SSA reported having to check if dental had been in. The SSA stated the dentist comes in once a month, and the hygienist comes in once a month. The SSA stated she would have to check if dental had been in the facility twice during the month of June. The SSA stated dental services are supposed to write a note if the resident refuses and it gets uploaded (into the resident's clinical record). The SSA reviewed records and stated the dentist was at the facility on 5/29/24 (the day after Resident #79 had reported tooth pain) and the facility had to request an appointment. A request was made for any dental notes and information if Resident #79 had been seen on 5/29/24. On the morning of 6/27/24 the Director of Nursing was asked for the dental information requested of the SSA on 6/26/24. On 6/27/24 at approximately 5:00 p.m. a request was made to the Regional Nurse Consultant (RNC) for the previously requested dental information related to Resident #79. The RNC stated they were trying to get a dental appointment for the resident. On 6/27/24 at 5:28 p.m. another request was made to the DON regarding Resident #79's dental information (notes, appointments) and she stated the hygienist had been in the facility. On 6/27/24 at 6:15 p.m. a request was made to the DON asking if Resident #79 had been seen by dental services. Review of Resident #79's progress notes revealed a note written by the DON, dated 6/27/24 at 6:36 p.m., showing the resident had a 10 a.m. dentist appointment at an outside dental vendor. The note did not reveal a date of the appointment. Review of Resident #79's progress note, dated 6/27/24 at 7:09 p.m., showed the resident refers [sic] to continue with dental pain, the physician was notified with orders for Acetaminophen and labs obtained. The note revealed the resident had a dental consult appointment scheduled. An interview was conducted on 6/28/24 at 8:35 a.m. with the DON. The DON stated they attempted to reach out to the dental vendor yesterday but it had been after 5:00 p.m., so they were closed; and the hygienist should have given a list (of residents seen) to Medical Records but did not know what happened. On 6/28/24 at 9:10 a.m. Resident #79 was observed dressed, sitting in a wheelchair, and waiting to leave the facility for a dentist appointment. The resident reported not having any teeth, opening mouth and revealing 4-5 blackened broken teeth on the bottom. The resident stated her mouth continued to hurt. The facility did not provide supporting documentation to show Resident #79 had been seen by dental services during the month of May or June. The facility did provide documentation that the resident had been seen at an outside the facility dental vendor on 6/28/24, 32 days after the resident complained of tooth pain on 5/28/24. Review of the Policy and Procedure titled, Dentist Services, revised 11/27/17, showed The center will contract with a dentist licensed by the board of dentistry to provide routine and 24- hour emergency dental services. The procedures instructed: - Obtain order for dental consult. - The nurse or designee will if necessary or if requested assist the patient/ resident in making the appointment and arranging for transportation to and from the dentist's office. - Residents with lost or damaged dentures will be referred promptly within three days to the dentist. - If a referral does not occur within three days the nurse will evaluate and document changes inability to eat and drink. Review ability with physician and obtain orders as indicated. - Medicare and private pay residents may be charged for the services. The facility will provide Medicaid resident services in routine services covered under the state plan at no charge. If any resident of the facility is unable to pay for needed dental services, the facility will attempt to find alternative funding sources or alternative service delivery systems to ensure the resident maintains his/ her highest practicable level of well- being.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure the medical record of one (#90) out of fifty-three sampled residents was accurate related to the application and removal of an orthotic device. Findings included: On 6/25/24 at 10:27 a.m. Resident #90 was observed lying in bed with his right arm bent at the elbow, right hand and wrist were visible and lying on the resident's chest. The observation showed the resident's right wrist was bent and the fingers were in a fixed fist-like position, and the thumbnail extended approximately 0.25 inches past the fingertip. The resident stated staff try to open my hand to clean underneath (the clenched fingers). On 6/26/24 at 11:20 a.m. Resident #90 was observed lying in bed and not wearing a splint/brace and/or holding a hand roll in his right hand. The resident reported not wearing a splint or hand roll. On 6/26/24 at 2:37 p.m. Resident #90 was observed lying in bed and was not wearing either a splint/brace or holding a hand roll. On 6/26/24 at 3:16 p.m. Resident #90 was observed lying in bed and was not wearing either a right-hand splint/brace or holding a hand roll. On 6/27/24 at 11:53 a.m. Resident #90 was observed lying in bed and not wearing a splint/brace on right hand. Review of Resident #90's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of right hand, right knee, and right hip, and not elsewhere classified stiffness of right and left knee. Review of Resident #90's active physician orders as of 6/27/24 at 6:47 p.m. revealed the following orders: - Restorative Passive Range of Motion (PROM)/Active-assisted Range of Motion (AAROM) to bilateral lower extremities 2x (times)10, 3x/week for 6 weeks as tolerated, active as of 11/8/23. - Right hand splint on AM and off PM, every day shift for muscle strength related to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, active as of 4/27/22. Review of Resident #90's physician orders showed the order for the resident's application and removal of the right-hand splint was listed on the June 2024 Treatment Administration Record (TAR). Review of the TAR showed the licensed nursing staff documented the order had been administered daily, except for 6/20/24. Review of Resident #90's June 2024 Medication Administration Record (MAR) did not reveal the resident had exhibited any behaviors from 6/1/24 to 6/26/24 day shift. Review of Resident #90's Restorative Nursing Program documentation, dated 5/29/24, showed under Problems/Needs: the right upper extremity (RUE) was painful especially elbow & hand, severe right (R) hand contracture, and Refuses to trial any right splints. The Recommendations/Approaches included: staff to perform Left (L) UE AROM (active range of motion) 10 reps 2 sets for shoulder flexion, elbow ext (extension)/flexion, wrist & finger extension 5 repetitions 2 sets and Gentle PROM right shoulder, elbow & hand within tolerance every (q) pain. The Precautions revealed: Patient may refuse any ROM to right arm. Review of Resident #90's Visual/Bedside Report revealed the Restorative care areas: - Nursing Rehab/Restorative: Splint/Brace Right hand on a.m. (AM) and off p.m. (PM) daily. - Restorative: PROM/AAROM to bilateral lower extremities (BLE) 2x 10, 3x/week for 6 weeks as tolerated. - Restorative: Right hand splint on a.m. and off p.m. every day shift for muscle strength related to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. - Right hand splint to be worn daily as follows: On in a.m. and off in p.m., Check skin for redness or breakdown. Review of Resident #90's care plan, revised on 10/23/23, revealed the resident had an Activity Daily Living (ADL) self-care performance deficit related to Hemiplegia, Impaired balance, Limited ROM, (and) Stroke. The interventions associated with the focus included: Restorative - Right-hand splint on AM and off PM every day shift. An interview was conducted on 6/27/24 at 2:25 p.m. with Staff T, Restorative Certified Nursing Assistant (RCNA). Staff T reported doing restorative over 15 years at the facility. Staff T stated Resident #90 did not have a splint, received ROM when the resident allowed, the Director of Rehabilitation ordered ROM for the (right) arm but the resident refuses. Staff T reported not thinking the hand ROM (orders) were in the computer so does only the resident's legs. Staff T stated the resident had a splint at one time, but it had been discontinued. Staff T returned to the interview on 6/27/24 at 2:31 p.m., and reported after reviewing the Restorative Record for Resident #90, she performed lower extremity ROM only and did it for 5 minutes. Staff T stated if the resident had a splint she would be the one who applied it. An interview was conducted on 6/27/24 at 3:24 p.m., with Staff V, Registered Nurse (RN), the floor nurse for Resident #90. Staff V reported Resident #90 did have a right-hand splint/brace and received therapy. An observation was conducted of Resident #90 with Staff V at this time. The resident was not wearing a splint/brace and/or hand roll. Resident #90 reported Restorative had not come and Staff V stated therapy applies the splint/brace then said, not today. Staff V reviewed Resident #90's admission Record showing the resident had a diagnosis of hemiplegia and stated yes she put the splint on the resident, who wears it 1-2 hours then takes it off. Staff V reported taking Resident #90's splint off at 2:00 p.m. (prior to the interview). The interview continued at the bedside of the resident and Staff V reported putting the splint on the resident and when it wasn't available she put it (right hand) on a pillow. Resident #90 shook head and stated he did not have a splint. Staff V reviewed the TAR and confirmed signing the TAR showing she put the splint on. Review of Resident #90's Minimum Data Set (MDS) assessment, dated 4/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. The resident was observed and interviewed throughout the survey process and answered questions appropriately. The review showed during the 7-day period prior to 4/4/24 the resident did not receive any PROM, AROM, or splint/brace assistance. During an interview on 6/27/24 at 5:28 p.m. the Director of Nursing (DON) reviewed Resident #90's physician orders and stated the splint/brace (orders) should be discontinued if the resident did not have it and staff should not be documenting the resident does have it. Review of the job description for Clinical Nurse I (RN) revealed, As the company Clinical Nurse I-RN, you are entrusted with the responsibility of caring for our residents, families, co-workers, visitors, and all others. The primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the director of clinical services to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible health care with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. The Duties and Responsibilities (of the Clinical Nurse I) included: - 4. Conduct and document a thorough assessment of each resident's medical status upon admission and throughout the resident's course of treatment. - 6. Comply with the evaluation, treatment, and documentation of the company guidelines. - 8. Complete required documentation in an accurate and timely manner. - 14. Monitor compliance with resident record documentation, as directed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation was conducted on 6/25/24 at 10:00 a.m. during a tour of the fourth floor of rooms 409, 410, 412, and 415, all with contact precaution signs on the door. room [ROOM NUMBER] had a precaution sign on the door in Spanish but did not have a sign in English. (Photographic evidence obtained) An interview was conducted on 6/25/24 at 10:07 a.m. with Staff EE, LPN. She said the only rooms on contact precautions were room [ROOM NUMBER] and 413; the other rooms had enhanced barrier precautions. An observation was conducted on 6/25/24 at 12:53 p.m. of a lunch tray being delivered and set up in room [ROOM NUMBER]. There was a contact precaution sign on the door and the staff member delivering the lunch tray did not don personal protective equipment (PPE) when entering the room. An interview was conducted on 6/25/24 at 1:00 p.m. with Staff P, RN. She reviewed the orders for the residents in room [ROOM NUMBER] and said the room should not have a contact precaution sign; the room was standard precautions. A list of transmission-based precautions (TBP) provided by the Director of Nursing (DON) showed four rooms in the facility on TBP, all of which were contact precautions. Those rooms were 220, 409, 413, and the room of Resident #77. An observation was conducted on 6/25/24 at 2:10 p.m. of Resident #77's room with no contact precaution sign posted. An enhanced barrier sign was posted on the door. room [ROOM NUMBER] had an English enhanced barrier sign and a Spanish contact precaution sign. (Photographic evidence obtained) Review of admission Records for Resident #77 showed he was admitted on [DATE] with diagnoses including paraplegia and multiple contractures. Review of Resident #77's labs, showed a wound culture collected on 6/21/24, was reported to the facility on 6/24/24 as having Methicillin Resistant Staphylococcus Aureus (MRSA). Review of orders showed an order for contact precautions was not put in the computer until 6/25/24 at 1:30 p.m. by the Assistant Director of Nursing (ADON). An observation was conducted on 6/25/24 at 2:10 p.m. and again on 6/26/24 at 11:05 a.m. and 3:15 p.m. of Resident #77's room continuing to only have an enhanced barrier precaution sign and no contact precaution sign. An interview was conducted on 6/25/24 at 3:50 p.m. with the DON. She said the ADON or nurse that admits the resident or receives lab results should place the correct precaution sign on a resident's door if it is required. The DON said if the sign in not correct staff wouldn't know what to do and it would cause confusion. She said, If the sign is there, staff should be following what is on the sign, even if the sign is not correct per the orders. The DON said no resident in the facility is on airborne precautions because the facility does not accept those residents. She said she will have the ADON check the precaution signs and make sure they are correct. She said it sounds like someone was just grabbing signs and putting them up. An interview was conducted on 6/26/24 at 3:16 p.m. with Staff GG, RN. She said when a resident is on contact precautions, PPE should be worn anytime a staff member enters the room. She said for enhanced barrier staff wear gloves, gowns, and masks when working directly with the resident. Staff GG said administration staff place the correct precaution signs on the door. She reviewed the orders for Resident #77 and confirmed he should be on contact precautions and only had an enhanced barrier sign posted on his door. Staff J, LPN/Unit Manager (UM) joined the interview confirming Resident #77's order and that the incorrect sign was posted. Staff J said the ADON, who is the infection preventionist, does all the precaution signs. A follow-up interview was conducted on 6/26/24 at 3:37 p.m. with the DON. She reviewed Resident #77's record and said when the lab results were reported on 6/24/24 an order for contact precautions should have been entered in the computer and a sign put on the door. The DON said she teaches staff that it doesn't matter if the room is on contact or enhanced barrier precautions, they should wear PPE anytime they enter the room. An interview was conducted on 6/28/24 at 5:24 p.m. with the ADON. She said when a resident is on contact precautions, she puts an enhanced barrier precaution sign in English and in Spanish and she puts a contact precaution sign in English and in Spanish. She said she could see how that might cause some confusion. She reviewed Resident #77's record and confirmed he should have been placed on contact precautions when the lab results were reported on 6/24/24. She said she put the order in on 6/25/24 and does not know why the sign didn't get put up. The ADON said she conducts rounds every morning and checks all precaution signs. When asked about a resident having an airborne precaution sign she said I saw that the other day. I don't know where that came from. Review of a facility policy titled Policies and Practices-Infection Control, revised October 2018, showed the following: Policy Statement This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. 2. The objectives of our infection control policies and practices are to: . c. Establish guidelines for implementing Isolation Precautions, including standard and transmission-based precautions. d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission-based precautions. . 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Based on observations, record reviews, and interviews the facility failed to post correct infection control signage in resident rooms on 2 (3rd and 4th) of 3 facility floors including for Residents #37, #77 related to not correctly informing staff necessary precautions to take to prevent cross contamination of infections between residents. Findings included: An observation was conducted on 6/25/24 at 2:06 p.m. of Resident #37's open door. The door was posted Airborne Precautions, Everyone must: Clean their hands, including before entering and when leaving room, Put on a fit tested N-95 or highest level respirator before room entry, Remove respirator after exiting the room and closing the door, Door to room must remain closed. A container hanging from the doorway contained yellow isolation gowns, a package of surgical masks and a box of non-latex gloves. On 6/25/24 at 2:15 p.m., an observation was made from the open door of a Staff G, Certified Nursing Assistant (CNA) in the room, near the resident's bed wearing a yellow gown, surgical mask and gloves. The staff member left the room and went into the unit's common area to sanitize hands. Review of Resident #37's admission Record revealed the resident was admitted on [DATE] and re-admitted on [DATE]. The physician orders for the resident showed an order, dated 5/15/24, for Enhanced Barrier precautions every shift for Colonized Candida Auris. During an interview on 6/25/24 at 3:51 p.m., the Director of Nursing (DON) stated the facility did not have anyone under Droplet or Airborne precautions. The DON stated staff wouldn't know the type of precautions, staff should follow what the (posted) sign said, and the facility would not be able to admit anyone with Airborne precautions. An interview was conducted on 6/25/24 at 4:04 p.m. with Staff A, Registered Nurse (RN). The staff member reported Resident #37 was on Contact precautions and they wear a gown, gloves, and a procedure mask for the resident. Staff A reported not wearing a N-95 and the resident was currently on Contact due to a wound. The staff member stated the resident had previously been on Airborne precautions due to Candida Auris (C. Auris). Staff A reviewed Resident #37's physician orders which contained an order for Enhanced Barrier precautions. The staff member stated previously the resident had both contact and enhanced precautions due to a wound infection. An interview was conducted on 6/25/24 at 4:13 p.m., with Staff B, CNA. The staff member reported relying on the sign on door to show what type of Personal Protective Equipment (PPE) to wear. An interview was conducted on 6/25/24 at 4:14 p.m., with Staff C, RN/Assistant Director of Nursing (ADON). The ADON reported not knowing why the Airborne sign was posted (on the door to Resident #37's room) and would definitely expect staff to question why room was posted with Airborne precautions.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a facility tour of the 200 Hall on 06/25/24 at 10:13 a.m. an observation was made of small flying gnat like insects in room [ROOM NUMBER]. The resident stated this has been an ongoing problem. On 06/25/24 at 1:38 p.m. the Director of Maintenance observed the flying insects on the resident's bedside table and on the cups. He stated, This is not good at all. The gnats have been an ongoing problem. He stated one of the residents in room [ROOM NUMBER] liked to hold on to food. The Director of Maintenance said, There are quite a few gnats here. I will call pest control. On 06/25/24 at 2:20 p.m. during an interview with the Nursing Home Administrator (NHA) small flying gnat like insects were observed in the facility's conference room. She stated they hold care plan meetings in this room. She stated they have had problems with gnats. She stated in response they have increased pest control visits. The NHA stated they had received complaints in April 2024 and May 2024. She stated they addressed the grievances. She stated the Ombudsman had voiced concerns. Review of the Grievance Logs for April - June 2024 revealed ongoing concerns related to pest sightings. On 05/14/24 the Ombudsman filed a grievance to have the pest control company spray all rooms and the kitchen for fruit flies and roaches. On 06/26/24 at 3:20 p.m. an interview was conducted with Staff L, Licensed Practical Nurse (LPN)/Unit Manager. During the interview small flying gnat like insects were observed in the 200 Hall. Staff L was observed swishing the pests off her face. She said, They have these annoying flies everywhere. It is worse in room [ROOM NUMBER] because the resident hides food. Staff L, LPN/Unit Manager stated the Director of Maintenance had installed light fixtures to catch the flies. She said, I don't know if they are working, but I see a few gnats inside the trap. During a tour of the kitchen on 06/27/24 at 12:07 p.m. an observation was made of standing water on the floor around missing tiles in the kitchen. The water was noted with an odor and flies were observed hovering on the trash can, around the standing water and on food carts at the dishwashing station. An immediate interview was conducted with the Certified Dietary Manager (CDM)/Kitchen Manager. He stated they had an ongoing problem of flies because of the standing water. He stated maintenance was supposed to fix the tiles and spray the drains. He observed the flies and stated this was not proper sanitation. The CDM stated sometimes they pour vinegar down the drain to ease the smell and keep away the fruit flies. He stated maintenance had been notified. On 06/28/24 at 9:37 a.m. the Director of Maintenance stated the contractor came in weekly. He stated he sprayed all areas where there were sightings. He stated they sprayed fly traps. He stated the problem in the kitchen was that staff were turning off the fly lights. He stated he sprayed bacteria eater, whenever he saw gnats and roaches. The Director of Maintenance stated the residents' wellness was his priority. Review of a document titled, Pest Sighting Log showed entries documented for the month of May 2024 for sightings of gnats and roaches in halls 200, 300, 400 and Kitchen (100 hall). Page 2 of the log showed between 12/19/23 to 03/21/24 there were seven sightings of gnats, roaches, fleas, and bugs documented. On 06/28/24 at 9:43 a.m. the Director of Maintenance stated the staff were inconsistent with reporting sightings. He stated this was a struggle. He said, They are not doing a good job. Review of a facility policy titled, Pest Control, dated 11/30/2014, showed the facility will maintain a pest control program which includes inspection, reporting and prevention. Procedure: 1. A pest control contract will be maintained with a licensed exterminator. 2. The contract will include routine quarterly inspections. 3. Treatment will be rendered as required to control insects and vermin. 4. Any unusual occurrence of sighting of insects should be reported immediately to the supervisor. Proper action will be taken. Based on observation, record review, and interview the facility failed to provide a pest-free environment on two of four residential units (Hall 200 and Hall 300) and the kitchen of the facility. Findings included: An observation was conducted on 6/25/24 at 10:17 a.m. of numerous small flying black gnat like insects sitting on the bedside dresser in room [ROOM NUMBER]. (Photographic Evidence Obtained) One of the two residents currently in the 4-person room, nodded his head up and down when was asked if the facility had flying insects. An observation was conducted on 6/27/24 at 8:38 am., during the task of medication administration on the 300 Hall, of a black flying insect flying around the cart. On 6/28/24 at 9:02 a.m. the Director of Maintenance stated the facility had installed bug zapping lights that have blue lights if they are on. The Director of Maintenance stated he noticed the breaker for the 2nd and 3rd floors had been tripped. The observation showed the bug light on 3 High was unplugged, the Director of Maintenance stated staff unplug the light to plug in their phones, and plugged the light back in.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An observation of room [ROOM NUMBER] on 6/25/24 at 10:35 a.m. revealed a wall under the window was bare and unpainted. (Photographic Evidence Obtained) An observation on 6/25/24 at 10:45 a.m. of room [ROOM NUMBER]'s bathroom revealed: *A toilet seat with a brown stain, *A brown residue around the bottom of the toilet on the floor, and *Under the sink there was a bare unpainted wall near the pipes of the sink. (Photographic Evidence Obtained) During a tour of room [ROOM NUMBER] and the bathroom on 6/28/24 at 9:00 a.m. the Maintenance Director stated he started with the company in October of 2023 and went through the building and made a list of everything that needed to be completed. He was in the process of getting everything done. He stated the wall had to be patched due to holes. He stated this was not his expectation for a home like environment for residents. 2. During an observation made on 6/27/24 at 2:00 p.m. Rooms 301, and 307 were observed with stains on the privacy curtains. During an interview on 6/28/24 at 6:24 p.m. the Director of Housekeeping stated his cleaning process is that he deep cleans residents' rooms Monday through Friday. He knows that some residents need new curtains, but he cannot change them out because the facility doesn't have enough curtains. He said he has been aware of the shortage of curtains for five months. He stated he reached out to the Nursing Home Administrator (NHA) to inform her about the facility needing more privacy curtains. Based on observation and interview, the facility failed to provide a safe and homelike environment on three units of three units and one shower room (3rd Floor) out of three shower rooms related to soiled privacy curtains, unpainted/unfinished wall repairs, foul odors, unclean bathroom, disrepair of closets, furniture and light fixture, and a shower chair. Findings included: 1. An observation was conducted on 6/25/24 during a facility tour from 10:00 a.m. until 10:35 a.m. of dirty privacy curtains with gray staining in rooms [ROOM NUMBERS], paint/plaster peeling and cracking around the window and air conditioning unit in room [ROOM NUMBER], an unpainted wall repair was observed above the air conditioning unit in room [ROOM NUMBER] and behind the bed in room [ROOM NUMBER]. These items remained in this condition through the end of the survey on 6/28/24. (Photographic Evidence Obtained) Review of a procedure titled, Cleaning Cubicle Curtains, revised 9/5/17, showed the following: Timing & Method -Examine curtains while doing QCI (Quality Control Inspection) or at discharge. -If curtain is stained, remove immediately. If curtain is torn-replace. -If curtains are off hooks, repair . Additional Information -Have spare curtains on hand to immediately replace dirty or torn curtains. 4. On 6/25/24 at 10:04 a.m. a strong odor of stale urine was noticed in room [ROOM NUMBER]. On 6/25/24 at 10:23 a.m. a very strong urine smell continued in room [ROOM NUMBER]. On 6/25/24 at 10:59 a.m. an observation revealed a section of the vinyl cove base was unattached from the bathroom wall in room [ROOM NUMBER] and was lying on the floor. (Photographic Evidence Obtained) On 6/25/24 at 11:26 a.m. an observation revealed in room [ROOM NUMBER] the dresser veneer was torn and the surface underneath was uncleanable. On 6/25/24 at 2:13 p.m. the strong pungent smell of urine continued outside (in the hallway) of room [ROOM NUMBER], which was confirmed by another state agency survey team member. On 6/25/24 at 10:05 a.m. an observation revealed a wire shelf in the closet of room [ROOM NUMBER] had fallen and was lying across the resident's personal items. (Photographic Evidence Obtained) On 6/25/24 at 11:16 a.m. an observation of the third-floor shower room revealed a shower chair with four rusty and uncleanable caster wheels. (Photographic Evidence Obtained) On 6/25/24 at 3:18 p.m. an observation revealed the ceiling light in room [ROOM NUMBER]'s entrance was missing the shade exposing the light bulbs. (Photographic Evidence Obtained) On 6/25/24 at 4:24 p.m. an observation revealed the Packaged Terminal Air Conditioner (PTAC) unit for room [ROOM NUMBER] was plugged into an electrical outlet that did not have a receptacle cover. (Photographic Evidence Obtained) On 6/26/24 at 11:22 a.m. in the hallway outside of room [ROOM NUMBER] there was a strong chlorine-like smell and inside room [ROOM NUMBER] smelled of stale urine. On 6/26/24 at 3:19 p.m. an observation was made of the closet in room [ROOM NUMBER]. The observation showed the closet did not have closet doors and a wire shelf continued to lie on top of the resident's personal items. (Photographic Evidence Obtained) On 6/28/24 at 9:02 a.m. a tour was conducted with the Director of Maintenance (DOM) of the third floor. The DOM observed the missing ceiling light shade in room [ROOM NUMBER] and stated this should have been reported. The DOM observed the missing receptacle cover in room [ROOM NUMBER] and confirmed it should have been reported. The DOM confirmed the closet wire shelf had been fixed and it had fallen three days ago (6/25/24), parts had to be ordered versus going to a neighborhood store to purchase the parts to rehang the shelf due to the facility not having any petty cash. The DOM stated the rusty shower chair wheels were rusty, uncleanable, and could be replaced. During the tour, an observation revealed the metal sheathing used to cover one side of the ice machine motor was on the floor leaning against the ice bin. The DOM stated this was a safety issue as wires were exposed and the DOM was able to replace the sheathing. The DOM observed room [ROOM NUMBER]'s over-bed table's plastic covering was flaking off and confirmed the odor of urine. An interview was conducted on 6/28/24 at 6:40 p.m. with the Housekeeping Director (HD). The HD reported there were two residents in room [ROOM NUMBER] who would urinate on the floor and the urine has moved under the tile. The HD stated housekeeping cleans the room twice a day and has informed the NHA about two weeks ago. A request was made for a policy regarding providing the residents with a homelike environment, the facility did not provide the policy by the exit of the survey team on 6/28/24. A review of the policy titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, showed: Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) bloodborne Pathogens Standard. The interpretation and implementation portion of the policy included the following: 9. Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis(e.g. daily, three times per week) and when surfaces are visibly soiled.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During an interview on 06/25/2024 at 10:45 a.m. Resident #122 stated that she is happy with her care. Resident #122 was observed lying in bed dressed in a hospital gown. Review of Resident #122's admission Record showed an admission date of 03/01/24 with diagnoses of major depressive disorder, and anxiety. Review of the Level I PASRR, dated 02/23/2024, showed in Section I-Part A MI (Mental Illness) or suspected MI was blank. Part B. ID (Intellectual disability) or suspected ID was blank. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was marked no. 6. During an observation and interview on 06/25/24 at 10:15 a.m. Resident #53 sated he was really upset with this facility and feels the care is lacking. Resident #53 was observed to be greasy looking with his hair disheveled. Review of Resident #53's admission Record showed an admission date of 04/18/24 with diagnoses to include major depressive disorder, and schizophrenia. Review of the Level I PASRR, dated 04/12/24, showed in Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness) that schizophrenia was not marked. Part B. ID (Intellectual disability) or suspected ID (Intellectual disability) was blank. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was marked no. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 3. Review of admission Record showed Resident #114 was admitted on [DATE] with diagnoses to include bipolar disorder, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, post-traumatic stress disorder, and autistic disorder. Review of Resident #114's PASRR Level I Screen, dated 10/17/23, did not show the diagnoses of depressive disorder, autism, or intellectual disabilities. The screening showed it was not a provisional admission and documented, Individual may not be admitted to an [sic] Nursing Facility. Use this form and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of (check one of the following): Serious Mental Illness. No PASRR Level II was found in Resident #114's medical record. Review of Resident #114's care plan showed a focus area of PASSR [PASRR]: [Resident #114] is a PASSR [PASRR] level 2. Initiated 10/30/23. Interventions included: Follow up with community partners as needed in regard to PASRR updates and ensure Brief Interview for Mental Status (BIMS) is in place and up to date at each review. An interview was conducted on 6/27/24 at 10:25 a.m. with the Nursing Home Administrator (NHA). She confirmed they did not have a Level II PASRR for Resident #114. An interview was conducted on 6/27/24 at 10:33 a.m. with the Social Services Director (SSD). She said the unit mangers and herself are responsible for the PASRRs once residents are admitted . She said she started working at the facility in August 2023 and did not have access to the PASRR system until 2-3 weeks ago. She said they did an audit and there was a lot of residents from 2018-2019 that need to be fixed and the plan was to fix those. The SSD said they audited residents on the third and fourth floors. She said if the resident was recently admitted or if they are on the second floor they should have a correct PASRR. The SSD reviewed Resident #114's PASRR and confirmed it documented Resident #114 should not be admitted . She said she cannot say why Resident #114 was admitted to the facility. She said the NHA and DON (Director of Nursing) decides who is admitted . The SSD stated she only reviews them after admission. An interview was conducted on 6/27/24 at 11:08 a.m. with the admission Director. She said she received the PASRR from the hospital and uploaded them into the system. She said once the resident is in the facility, the PASRR is reviewed by the team members trained to look at them to make sure it is correct; it does not get reviewed pre-admission. She said all she does is make sure the facility name is on the PASRR screening form and the date is correct. The admission Director reviewed Resident #114's PASRR and said she had not been trained on PASRRs and did not know there was a section on the back saying an individual may not be admitted to a nursing facility. An interview was conducted on 6/27/24 at 4:27 p.m. with the DON. She said the facility admissions department is who should review PASRRs for residents prior to admission; to see if a resident needed a Level II completed. She reviewed Resident #114's PASRR and said the admission Director should have been trained, and she should have called the hospital about the Level II prior to the resident being admitted . The DON confirmed Resident #114 should not have been admitted to the facility based on her PASRR Level I screen. 4. Review of admission Records showed Resident #75 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including major depressive disorder, seizures, and bipolar disorder. Review of Resident #75's PASRR Level I Screen, dated 3/24/23, did not include the diagnosis of seizures, which was present on admission, bipolar disorder, which was added on 5/4/23, or major depressive disorder, which was added 8/18/23. The facility was unable to provide an updated PASRR Level I Screen completed after the new diagnoses or prior to re-admission on [DATE]. Based on record review and staff interview, the facility failed ensure the Level I Preadmission Screening and Resident Review (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses were accurate for six residents (#394, #135, #122, #75, #114, and #53), and failed to initiate a Level II PASRR for one resident #53 of 31 residents sampled. Findings included: 1. Review of Resident #394's admission Record revealed an admission date of 06/21/24 with diagnoses to include depression. Review of a Level I PASRR for Resident #394, dated 06/07/24, revealed a blank PASRR and the qualifying diagnoses were not checked. 2. Review of Resident #135's admission Record revealed an admission date of 05/21/24 with diagnoses to include major depressive disorder and seizures. Review of a Level I PASRR for Resident #135, dated 04/06/24, revealed a blank PASRR and the qualifying diagnoses were not checked. An interview was conducted on 6/27/24 at 10:33 a.m. with the Social Service Director (SSD). The SSD stated the facility started a Performance Improvement Program (PIP) in early June (2024) regarding the resident's PASRRs. The SSD reported it was the responsibility of the unit managers and social services to review PASRRs, and no one in the facility had access until 2-3 weeks ago (to resubmit the screenings). The SSD reported the facility identified a lot of patients needed changes, some needed Level II evaluations or did not have one in the system. On 6/27/24 at 10:45 a.m. the SSD provided lists that she identified as a full house audit of all resident's PASRR status, which showed if the screenings were correct, action was needed, missing, or a Level II was needed. Review of the list revealed it did not include Residents #394, #135, #122, #75, #114 and #53. On 6/27/24 at 10:53 a.m. the SSD stated the facility did not audit the PASRRs of the residents on the second floor because they were short-term residents, and they would have already gone home. The SSD confirmed that herself and the unit managers review the PASRRs and diagnoses. The SSD stated they check to see if everything is correct and if the resident needs a Level II determination. The SSD stated right now the facility was working on follow up to get PASRRs and the Regional Director had begun working on it, and 2-3 weeks ago they had someone else (working on it). The SSD stated the completion date of the PIP had been 6/20/24. She stated since it had not gotten done the facility decided last week to extend the timeline. The SSD stated PASRRs should be accurate and believed the Regional Director started them two weeks ago. Review of the policy titled, Preadmission Screening and Resident Review (PASRR), revised 11/8/21, revealed, The center will assure that are Seriously Mental Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to federal/ state guidelines. The purpose is to ensure that the residents with SMI or ID receive the care and services they need in the most appropriate setting. 1. It is the responsibility of the center to assess and assure that the appropriate pre-admission screenings, either Level 1 or Level 2, are conducted and results obtained prior to admission and placed in the appropriate section of the residence medical record. 2. If an individual is declared exempt from a PASRR screening, the center should make sure that the appropriate documentation is on the chart upon admission. Individuals who are exempted from this assessment include: - a. Those who are admitted after a release from an acute hospital for a period not to exceed 30 days as part of a medically prescribed period of recovery. -b. Those who are certified by a physician asked to be terminally ill with a 6-month prognosis and are not a danger to self or others. - c. Those who are comatose, ventilator dependent, functions at significantly disabling Parkinson's disease, Huntington's disease, Amyotrophic Lateral Sclerosis, Congestive Heart Failure (CHF), or Chronic Obstructive Pulmonary Disease (COPD). - d. Those with a diagnosis of dementia or its related disorders with detailed documentation supporting this diagnosis. 3. There are no exceptions for Intellectually Disabled (ID) screenings. 4. If it is learned after admission that a PASSR Level 2 screening is indicated, it will be the responsibility of social services to coordinate and/ or inform the appropriate agency to conduct the screening and obtain the results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed. 6. Recommendations will be incorporated in the individual residents plan of care and approaches/ interventions developed to meet the identified needs of the individual. 7. Social services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in appropriate sections of the resident's records.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 6/25/24 at 9:30 a.m. Resident #124 was observed lying down in her bed. She was dressed in her night gown. She said she would like to go to activities or even get up out of bed to visit with other residents, but staff will not get her up out of bed. Review of a admission Record showed Resident #124 was admitted to the facility on [DATE] with diagnoses to include to muscle weakness (generalized), difficulty in walking, not elsewhere classified, other lack of coordination, cerebral palsy, unspecified. Review of a Minimum Data Set (MDS), dated [DATE], showed Resident #124 had a BIMS score of 14, which indicated she is cognitively intact. Review of a care plan, dated 3/29/24, showed a care plan Focus of Resident #124 is dependent on staff for meeting emotional, intellectual, physical, and social needs. The Goal showed Resident #124 will maintain involvement in cognitive stimulation, social activities as desired through review date. The interventions included to invite the resident to scheduled activities. Date initiated: 04/10/23, date revised on 04/10/24. During an interview on 06/28/24 at 1:30 p.m. the Activities Coordinator stated that she is responsible for the unit Resident #124 resides on. She stated last week when she went to Resident #124's room; the resident told her that she would like to get up out of bed so that she could socialize with other residents, and she wanted to get her hair done. She said she did not do any activities with the resident. She stated she just went to her room to deliver a meal tray. She stated she did not report to anyone that Resident # 124 wanted to get up for activities. She said Resident #124 has not been out of bed for a while. Review of the facility policy titled, Social Activities, effective date 11/30/24, showed: Policy: The Social Activities are modified to meet the basic needs of love and belonging in residents who experience deficits in judgment, reasoning and perception. The activities focus on acceptance of the individual and the stimulation of learned social responses. Purpose: To provide opportunities for socialization regardless of one's cognitive limitations. To provide an atmosphere of acceptance through strategic grouping of residents. To encourage the development of friendships. Procedure: 1. Social Activities shall be offered 3-4 times per day. Review of the facility policy titled, Individual Activities, effective date 11/01/21, showed: Residents who are unwilling and/or unable to attend scheduled group activities are provided with one-to-one individual recreational and Community Life based on their needs, interests and functional ability. Based on observation, record review, and interview the facility failed to provide life-enriching activities for three residents (#79, #57, and #124) out of 53 sampled residents. Findings included: 1. Review of the posted Community Life Calendar posted outside of the main dining room, in the unit dining rooms revealed the following scheduled activities: 6/25/24: 10 a.m. - Room Visits, 12 p.m. - Taco Tuesday, and 2 p.m. - Ice Cream Social. 6/26/24: 10 a.m. - Trivia with [NAME], 12 p.m. - Room Visits, and 2 p.m. - Bingo. 6/27/24: 10 a.m. - Coffee, Tea, and Me, 12 p.m. - Outdoor Social, and 2 p.m. - Lemonade Stand. 6/28/24: 10 a.m. - Sip & Paint, 12 p.m. - Fish Fry and June Birthday Party, and 2 p.m. - Resident Council Follow Up. Review of Resident #79's admission Record revealed the resident was admitted on [DATE], 10/18/21, and readmitted on [DATE]. The admission Record included diagnoses not limited to unspecified low back pain, unspecified recurrent major depressive disorder, unspecified anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. During an interview on 6/25/24 at 10:48 a.m. Resident #79 stated nobody reads the activity calendar to her. During a review of the activity calendar, which was posted on the wall behind and to the side of the resident , it was noted the upcoming activity of an Ice Cream Social. Resident #79 reported liking ice cream and would get up if she had a wheelchair. On 6/26/24 at 3:58 p.m. Resident #79 was observed lying in bed with the television on the dresser next to her bed and a television remote in front of the television. The remote was not within reach of the resident who was lying flat in bed. Staff W, Registered Nurse (RN) arrived in the room stating she had come to answer Resident #79's call light (the resident's call light was on). Staff W stated Resident #79 asked to get up and go smoke but the resident didn't smoke. The resident asked if Staff W could get her a wheelchair. An interview on 6/26/24 at 4:01 p.m. was conducted with Staff W, RN. Staff W reported working with Resident #79 three days a week and was not sure if the resident had a wheelchair. Staff W did not think the resident had ever gotten out of bed. Review of Resident #79's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 7 out of 15, indicating a severe cognitive impairment. The MDS showed the resident required substantial/maximal assist with bed mobility and transfers. Review of Resident #79's Comprehensive MDS, dated [DATE], showed the resident was interviewed regarding Activity Preferences. The resident voiced keeping up with the news and doing favorite activities were Somewhat important. Review of Resident #79's Community Life Progress Review, dated 1/2/24, showed the resident was content with their activity pursuits, individual/independent activities participation were as needed/wanted. The assessment revealed the resident had the needed supplies to pursue their interests, participated in small and large group activities and outside the center events as needed/wanted. The resident's physical reaction during programming and emotion expressed was Smiling and laughing with the other residents, expresses happiness. The resident has made friends in the facility, did not have any new hobbies or changes to likes or dislikes, no interests/talents that the resident can share, does not actively participate in Resident Council, or have any interest in forming a club. Review of Resident #79's care plan showed the resident was independent of staff for meeting emotional, intellectual, physical, and social needs, revised on 11/17/21. The goals of this focus were the resident would maintain involvement in cognitive stimulation, and social activities as desired through review date, revised on 10/25/23 and a target date of 7/9/24. The interventions included: - Introduce the resident to residents with similar background, interests, and encourage/facilitate interaction. - Invite the resident to scheduled activities. - Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. - Provide with a Community Life calendar. Notify resident of any changes to the calendar of activities. During an interview with the Activities Coordinator (AC) on 6/28/24 at 10:44 a.m., the AC reported being independent (with activities) meant they did not need staff to assist with social needs. The AC stated she would not consider Resident #79 as independent and reported going to the resident's room to talk, and the resident does not get out of bed. She stated Resident #79 doesn't have a wheelchair; it disappeared. The AC reported seeing Resident #79 twice yesterday (6/27/24) because the call light was on and had to speak to the resident because she was yelling. The AC reported not documenting 1:1 visits but did visit with the resident. The resident has a television and can verbalize what channel she wants to watch. The AC stated the resident liked to socialize with other residents. She stated, been over a month since (the resident) has been out of bed, previously the resident would come down and socialize. A continued interview was conducted on 6/28/24 at 11:39 a.m. with the Activity Coordinator. The AC stated, for an ice cream social she would go floor to floor with a cart and offer it to people who can have a few scoops in a bowl. The AC reported offering ice cream on Resident #79's floor at 10:30 a.m. on 6/25/24. 2. An observation and interview was conducted with Resident #57 on 6/25/24 at 10:40 a.m. The resident reported not knowing about any activities and would go if asked; depending on the activity. The observation did not show the resident had a viewable activity calendar. The observation revealed the television for the resident was on a bedside dresser at the resident's head of bed, which was behind the resident when the head of bed was elevated. The television was not turned on. Review of Resident #57's admission Record revealed an admit date of 7/21/23 and re-admission on [DATE]. The admission Record included diagnoses not limited to unspecified recurrent major depressive disorder, dementia in other disease classified elsewhere severe without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and mood disorder due to known physiological condition with mixed features. Review of Resident #57's Comprehensive Minimum Data Set (MDS), dated [DATE], showed the resident was interviewed regarding daily and activity preferences. The interview showed being around animals and doing favorite activities were very important and doing things with groups of people and going outside for fresh air was somewhat important. Review of Resident #57's Community Life Progress Review, dated 4/5/24, revealed Resident #57 was content and happy about activity pursuits. The resident participated in individual/independent, small group, large group, and outside the center events as needed/wanted. The review showed the resident required minimal assistance to complete activities. The resident's reaction to programming was Smiling and laughing during programming, expresses happiness. The resident had made friends in the center, did not have any new hobbies or changes in likes/dislikes, did not have any interests or talents to share with other residents, and was not interested in forming a club. Review of Resident #57's Quarterly MDS assessment, dated 4/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. The assessment showed the resident did not utilize any mobility device at admission or currently and required substantial/maximal assistance with chair/bed-to-chair transfers. Review of Resident #57's care plan revealed the following: - Resident has little or no Community Life involvement r/t poor adjustment to the facility/unit, resident wishes not to participate, initiated 7/26/23. The interventions instruct staff to explain to the resident the importance of social interaction, leisure activity time and encourage the resident's participation with daily room visits), revised 11/6/23, remind the resident that the resident may leave activities at any time and is not required to stay for the entire activity. Additional interventions included the resident needs assistance/escort to Community Life functions and to invite/encourage the resident's family members to attend activities with resident in order to support participation. An interview was conducted with the Activity Coordinator (AC) on 6/28/24 at 11:08 a.m. The AC reported she considered Resident #57 was independent for emotional and social needs but dependent with Activities of Daily Living (ADLs). She stated the resident's participation depended on the resident's mood, and she has not seen the resident out of bed and does not provide the resident with any activity. The AC stated a calendar is provided to the resident. She stated depending on the corkboard location she does not know if the resident would be able to read it. She reported there was an activity cart in the dining room of each unit containing crayons, crosswords, and magazines, I will pass out if they ask. She stated the resident does not have a wheelchair to get out of bed. During the continued interview on 6/28/24 at 11:08 a.m. the AC explained that Taco Tuesday on 6/25 was scheduled for noon. She reported buying taco supplies for the independent residents and taking the supplies to the floor, but it did not occur because the facility did not have any petty cash. The AC reported she was supposed to pick up the birthday cake at 9:00 a.m. for the activity of fish fry and birthday party, scheduled for noon on 6/28, but had to participate in the survey. She wasn't able to pick up the cake, and no one else was able to pick up the cake because she had to pay for it out of her pocket. The AC stated she understood about quality of life. The AC stated, All of Us have discussed that the resident's don't have wheelchairs or Geri chairs to get out of bed, and was expected to do a job but didn't have the stuff to do the job. The AC reported not knowing why the activity, Trivia with [NAME], scheduled for 10 a.m. on 6/26 had not occurred. The AC reported she did not document 1:1 room visits, had been coordinator for a year and had received very little training for the job. The AC reported not knowing what time the fish fry on 6/28 was scheduled for and it was not part of the resident's lunch (menu: cornflake-crusted tilapia filet). In regard to the activity of popcorn and movie that had been scheduled for noon on Sunday 6/23, she stated she didn't think popcorn and a movie at noon interfered with nutrition (the noon meal). Review of the Community Life calendar revealed an activity was scheduled at noon every day and no activity started later than 2:30 p.m. (church service on Saturday 6/29). Review of the facility mealtimes showed lunch in the main dining room was served at 12:15 p.m. and residents on the third floor did not receive lunch trays till 1:30 p.m. and 1:45 p.m.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure residents with limited mobility received restorative services to maintain or improve mobility and/or range of motion (ROM) for three (#129, #31 and #102) of four residents reviewed. Findings included: 1. On 06/25/24 at 10:33 a.m. Resident #129 was observed in his room sitting on his bed. The resident said, I came off from rehab, they said I'm cut off. I'm not on any restorative services. The resident stated he was trying to keep the exercises going by himself. He stated he did not want to lose the momentum. He stated he wished he could receive some kind of therapy. Review of the admission Record showed Resident #129 was admitted to the facility on [DATE] with diagnoses to include difficulty in walking and encounter for orthopedic aftercare. Review of a document titled, Therapy Communication to Restorative Nursing Program showed on 06/04/24 Resident #129 was assessed for the facility's restorative program for bed mobility. The Problems/Needs section showed to maintain BLE (Bilateral Lower Extremities) strength/endurance and joint flexibility. The Recommendations showed AROM (Active ROM) to BLE 3X15 reps and ambulation 100-200 with 2WW (2 wheeled walker). Perform 3 times a week for 6 weeks. 2. Review of the admission Record showed Resident #31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of polyneuropathy. Review of a document titled, Therapy Communication to Restorative Nursing Program, showed on 06/20/24 Resident #31 was assessed for the facility's restorative program for feeding, upper body dressing, lower body dressing, shoes and CGA (Contact Guard Assistance) for toilet transfers (SGA). The Problems/Needs section showed Resident #31 was legally blind. The recommendations showed to 1. Raise arms towards the ceiling. 2. Raise arms out to the side, 3. Bend and strengthen elbows and 4. Make a fist and strengthen fingers for 3 times a week for 6 weeks. 3. Review of the admission Record showed Resident #102 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include chronic pain syndrome. Review of a document titled, Therapy Communication to Restorative Nursing Program, showed on 05/27/24 Resident #102 was assessed for the facility's restorative program for moderate assistance for transfers and assistance for bed mobility. The section Problems/Needs showed to maintain functional mobility tissue flexibility and strength. The Recommendations showed to perform Active ROM to BLE in all joints available 2X15. Perform 3 times a week for 6 weeks. On 06/27/24 at 1:02 p.m. an interview was conducted with Staff T, Certified Nursing Assistant (CNA)/ Restorative Aide. She stated she provided restorative therapy to the residents assigned to her. She stated she was familiar with all the residents on her case load but not Resident #129. She said, He is not on my assignment. If he was, I would be seeing him per therapy orders. Staff T shared her restorative Tracking Form for review. It did not include Residents #129, #31, and #102. On 06/27/24 at 1:09 p.m. a follow-up interview was conducted with the Director of Rehabilitation (DOR). He stated he previously worked with Resident #129. He said the resident was no longer on case load because he had reached his maximum potential. He stated he had transitioned him to restorative therapy and put in orders. He stated nursing may have dropped the ball. The DOR said, It is a very simple thing. Nursing did not communicate after the previous ADON [Assistant Director of Nursing] left. We did our part on our end. It should not have taken this long to execute the program. The residents should have transitioned to the restorative program right away. The DOR stated the transition should happen within a couple days to ensure continuation of therapeutic goals, so the resident does not lose their abilities. The DOR confirmed six residents had been affected. On 06/27/24 at 1:15 p.m., an interview was conducted with Staff C, Assistant Director of Nursing (ADON). She stated she was supposed to schedule orientation for herself and the restorative aides to understand her new role. She stated the restorative orders were stored in a binder in her office. Review of the order confirmed therapy orders had been in place. She said, We have not set up the training on the procedures of how to manage the restorative program. I did not know I was supposed to input the orders for the aides to carry out the restorative program. On 06/27/24 at 1:22 p.m. an interview was conducted with the Director of Nursing (DON). She confirmed the restorative program had not been implemented for newly assigned residents since the previous ADON left. An interview was conducted with the Nursing Home Administrator (NHA) on 06/27/24 at 02:15 p.m. She stated the residents requiring restorative should transition to the program easily. She stated the previous ADON was entering the orders. The new ADON has not learned the process yet. The NHA stated the residents should not have gone without restorative therapy. She stated they would educate the new ADON. Review of a policy titled, Restorative Nursing Services, dated 08/24/17 showed restorative nursing will be provided to residents as indicated upon evaluation to assist in achieving the highest practicable level of physical functioning as possible. The procedure showed therapy may refer a resident to restorative upon discharge from therapy services as deemed appropriate. When being referred by a therapist, therapist will complete a communication form to restorative nursing. Therapist will review with the restorative aide. After review the therapist restorative nurse and restorative aid was signed the form. The designated restorative nurse will determine appropriate programs and treatment utilizing information provided by various disciplines and in accordance with the residents plan of care. Restorative programs provided by restorative nursing assistants will be documented each time the program is provided on the restorative tracking form.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure medication was stored properly for three residents (#129, #141 and #142) related to medications in resident rooms and medications on the floor, and in three medication carts (400 Low, 300 High and 200 Low) out of four medication carts audited related to undated insulin, and an unlocked medication cart. Findings included: 1. An observation was conducted on 6/27/24 at 3:20 p.m. of an unlocked medication cart on the 4th floor resident hall. No staff were in the hallway at the time. At 3:34 p.m. the cart remained unlocked with no staff around. At that time an interview was conducted with Staff J, Licensed Practical Nurse (LPN)/Unit Manager (UM). She said the medication cart should not be unlocked and she would try to find the nurse assigned to that cart. At 3:39 p.m. Staff DD, LPN returned to the floor and said he didn't know his cart was unlocked and knew it shouldn't be. An interview was conducted on 6/27/24 at 5:10 p.m. with the Director of Nursing (DON). She said she would expect medication carts to be locked when the nurse is not with the cart. An observation was conducted on 6/28/24 4:57 p.m. of a pill on the floor of room [ROOM NUMBER]. (Photographic Evidence Obtained.) Staff EE, LPN was brought into the room and was observed picking up the pill. She said she did not know why the pill was on the floor as both residents in that room take their pills crushed. She said it is dangerous for it to be on the floor in the resident room. An interview was conducted on 6/28/24 at 5:11 p.m. with the DON. She said she would not expect there to be pills on the floor in resident rooms. 2. On 6/25/24 at 10:33 a.m. an observation was made of three bottles of medications at the bedside in Resident #129's room. The three bottles of medications were: Zinc, Wild Omega, and Quercetin immune formula. The resident stated a family member had brought the medication in. He stated he took them on his own every day. (Photographic Evidence Obtained). On 6/25/24 at 10:34 a.m. an observation was made of three tablets on the floor in Resident #141's room. The resident did not have any idea there was medication on the floor. (Photographic Evidence Obtained). On 6/25/24 at 1:24 p.m. an observation was made of an Albuterol Sulfate inhaler on Resident #142's walker which was positioned by the side of his bed. The resident stated he used it every 6 hours for shortness of breath (Photographic Evidence Obtained). On 6/25/24 at 10:40 a.m. Staff X, Certified Nursing Assistant (CNA) observed medication on the floor in Resident #141's room. She stated that was not good. Staff X stated if she saw medications on the floor, she would not touch them. She stated she would notify the nurse. Staff X said, The resident must have refused to swallow them. At this time an interview was conducted with Staff I, Licensed Practical Nurse (LPN). She proceeded to remove medications from the floor in Resident #141's bedside. She stated she would call the doctor. She confirmed the three tablets were two Senna tablets and one vitamin D. She stated they were not from her shift. She said, They must have been from last night. The nurse should have stayed with the resident. Staff I, LPN removed the medications from Resident #141's room. She stated she would call the doctor. An interview was conducted on 6/25/24 at10:46 a.m. with the Advanced Registered Nurse Practitioner (ARNP). She stated the resident should not have medications at bedside without orders. She stated they should be removed, and the nurse should notify the doctor to get a script if needed if the medications were not offered. She stated there should be no tablets on the floor. She said, That is not good. On 6/25/24 at10:42 a.m. Staff L, LPN U/M observed the bottles of medications removed from Resident #129's room. She stated she did not know the medications were in the room. She confirmed she worked this hall every morning and conducted room rounds throughout the day. She stated she would call the doctor to obtain orders for the medications at bedside. She confirmed the resident's medications should not be unsecured in the resident rooms. She stated nurses should supervise residents during medication administration. Review of a facility policy titled, Medication and Medication Supply Storage and Disposal, dated 11/30/14, showed central storage of medications is required for prescription, prescribed over the counter medications and CAM (Complementary and Alternative Medicine), will be kept in a locked area in their original labeled container, and may not be removed more than two hours prior to the scheduled administration time. Medications will be kept in a medication cart that locks, and keys are only accessible to the licensed personnel distributing medications. Only current medication for individuals living in the residence will be kept in the residence. 3. Observation of the 300 High medication cart was conducted on 6/28/24 at 4:34 p.m. with Staff D, Registered Nurse (RN). The observation revealed a medication cup containing crushed medications mixed with applesauce located in a plastic tray in a drawer of the cart. The observation revealed three undated vials of Novolog insulin, 1 undated vial of Lantus insulin, 1 undated vial of Fiasp insulin, 1 undated Novolin 70/30 Flexpen, and an undated vial of Latanoprost Ophthalmic 0.005% solution. (Photographic Evidence Obtained) Observation of the 200 Low medication cart was conducted 6/28/24 at 5:03 p.m. with Staff F, RN. The observation revealed an unopened bottle of Insulin Glargine stored with other opened insulin containers. The bag holding the unopened vial showed the vial was opened on 6/25/24. An opened undated vial of Insulin Glargine and an opened undated vial of Insulin Aspart were observed in the medication cart. (Photographic Evidence Obtained) Review of the manufacturer website, https://www.novomedlink.com/, showed the medication Fiasp, once opened can be stored for a maximum of 4 weeks (28 days). The manufacturer website, novomedlink.com, showed Novolog should be disposed of 28 days after opening. The website, lantus.com, revealed opened vials of Lantus should be thrown away after 28 days, even if it still has insulin left in it. The Mayo Clinic, www.mayoclinic.org, showed Latanoprost Ophthalmic solution can be stored in the refrigerator or at room temperature for up to 6 weeks. An interview was conducted on 6/28/24 at 5:07 p.m. with the Director of Nursing (DON). The DON stated insulin should be dated on the tag attached to the vial, Lantus (unopened) should be refrigerated, and crushed medications should have been destroyed. Review of the policy titled, Medication and Medication Supply Storage and Disposal, effective 11/30/2014, document ALF-935, showed medications would be kept in a locked area, in their original labeled container, and may not be removed more than 2 hours prior to the scheduled administration. Meds will be kept in a medication cart that locks and keys are only accessible to the licensed personnel distributing medications. Medication will be stored in a(n) organized manner under proper conditions and in accordance with manufacturer's instructions.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on record review, observation and interview the facility failed to ensure the kitchen was clean and free of expired food(s) of one kitchen. Findings included: An initial tour of the kitchen on 06/25/24 at 9:45 a.m. revealed: *A blue lighter on the top of the handwashing sink; *A silver pan with a brown substance along the enteral edges and sudsy water located on a basket under the hand washing sink; *The first compartment of the three-compartment sink had dirty dishes in it, the second compartment had frozen chicken defrosting with a silver pan and a cutting board located underneath, and the third compartment had dirty dishes soaking in it. (Photographic Evidence Obtained) Further observations during the tour with the Certified Dietary Manager (CDM) on 06/25/24 at 10:00 a.m. revealed: *In the reach-in cooler: a silver pan filled with a red thick liquid and was covered with a plastic wrap with a white label that showed sauce with a use by date of 6/22, a white block of an unknown food item with a white label that documented 6/14 (there was no indication if this was the open date or use by date a bag of open instant mashed potatoes with no date, and two desert bowls with plastic lids and filled with a food item and no date; *A water heater located under the dish machine and with the front panel missing and exposed wires and insulation; *Two dish racks on their side, on the ground with a white bucket in the middle underneath the dish machine and next to the water heater with exposed wires; and *A brown rust likes substance on the outer front bottom corner of the dish machine. (Photographic Evidence Obtained) On 06/27/24 at 12:00 p.m. the kitchen was toured with the Regional CDM and revealed: *A yellow mop bucket with a mop and gray water touching the white plastic piping of a clean dish rack with clean plate covers; *An unlabeled, opened bag of mashed potatoes mix was on top of the window air conditioning (AC) unit; *An opened bag of grits located under the stove on a shelf; *An AC vent with black bio growth on it and located over clean dishes; *A maroon windbreaker jacket was touching a green wired shelf that contained cups and lids on the green wire shelf; *On a shelf under the food preparation station, an opened blue bag had a pair of shoes that were exposed and next to a jar of peanut butter and two jars of seasoning. (Photographic Evidence Obtained) During an interview on 06/27/24 at 2:00 p.m. the photographic evidence was shared with the Nursing Home Administrator, Regional CDM, and CDM. The Regional CDM stated he thought the pan under the hand washing sink was from breakfast and was put under the sink to be washed. He stated it was not his expectation for dirty dishes. He stated food that was opened or left over and put into the reach-in cooler has a 5-day shelf life. He stated he was not sure why the water heater had the panel removed. It was requested to be put back on this week and they are working on getting it removed from the kitchen. The CDM stated he was not sure where the lighter came from, and he does not expect to find lighters near the handwashing station. He stated when chicken is being thawed, he would expect it to be in a pan in the refrigerator and not in the sink with dirty dishes. He expected any outdated food to be removed by the use by date or expired date. He stated food was labeled with dates of when the items were opened or put in the fridge. Review of the Kitchen Cleaning Schedule, dated June 2024, revealed: Week 1 (June 3rd-7th ) Monday, Thursday, and Friday there were no entries. For Week(s) 2, 3 and 4 there were no entries in any day. Review of the policy titled, Receiving, Procedures, dated 02/2023, revealed: 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 6. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principles of first in-first out (FIFO) inventory management. Review of the policy titled, Food Storage: Cold Foods, Procedures, dated 02/2023, revealed: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the policy titled, Equipment, dated 09/2017, revealed the policy statement as, All foodservice equipment will be clean, sanitary, and in proper working order. 1. All equipment will be routinely cleaned and maintained in accordance with manufactures directions and training materials All non-foods contact equipment will be cleaned and free of debris.

Jan 2024 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of 10 residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits and history of dementia, epilepsy, and confusion before admission to the facility. In addition, the facility failed to provide meals, shelter and ordered medical treatment during Resident #1's absence. The facility staff failed to ensure the medical care and safety of Resident #1; on 12/31/2023 at approximately 2:30 PM, Resident #1 ambulated from the second floor of the facility, entered the facility elevator, and rode the elevator down to the first floor of the facility. Resident #1 exited the facility through the front door, which was equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and was opened by reception staff who thought Resident #1 was a visitor at the facility. Resident #1 was able to walk out the front door of the facility, travel approximately 0.2 miles, along a 4-lane road and was found more than 24 hours later at a nearby apartment complex in a vacant apartment by a member of the community. Resident #1 was discovered by a member of the community on 1/1/2024 at approximately 7:00 PM in a vacant apartment and was returned by facility staff at approximately 7:30 PM. The facility failed to take action to prevent the resident from exiting the facility by not determining and providing the necessary level of supervision, and not distinguishing the resident from visitors of the facility. The resident was not located for approximately 28 hours and 30 minutes. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 12/31/2023. The findings of Immediate Jeopardy were determined to be removed on 1/12/2024 and the severity and scope was reduced to a D. Findings included: A review of the facility policy titled Abuse, Neglect, Exploitation, & Misappropriation, last revised on 11/16/2022 revealed under the section titled Policy it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and/or misappropriation of property. The policy defines neglect as the failure of the center, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also revealed examples of neglect including failure to take precautionary measures to protect the health and safety of the resident and failure to adequately supervise a resident known to wander from the facility without the staff knowledge. A review of the facility policy titled Missing Patient/Resident, last revised on 8/1/2020, revealed under the section titled Overview, staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. The policy also revealed the following facility procedure under the section titled Procedure: - Check the Leave of Absence (LOA) book and medical record to ensure the patient/resident is not on an authorized leave or medical appointment. - Announce (resident name) please return to your room, over the public announcement (PA) system. Repeat three times to alert staff of a missing patient/resident. - Assign staff to search the Center and grounds. - If the patient/resident is not located after an initial search, the point person will notify the Nursing Home Administrator (NHA), the Director of Nursing (DON), the resident representative, and the Primary Care Physician (PCP). The NHA and/or DON or designee will notify local law enforcement. A review of Resident #1's hospital history and physical (H&P), dated 12/13/2023 revealed Resident #1 arrived at the emergency department with a critically high blood pressure of 233/151, a heart rate of 101, and was unresponsive with active convulsions. Resident #1 was determined to be in critical condition with a risk of worsening seizures, stroke, or death. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 12/29/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section S: Physical Function, Resident #1 ambulated with standby assistance and required no assistive devices to ambulate. The transfer form revealed under Section U: Mental/Cognitive Status at Transfer, Resident #1 was alert and disoriented but could follow simple instructions. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of epilepsy, unspecified, intractable, with status epilepticus, difficulty walking, essential hypertension, other symptoms and signs involving cognitive functions and awareness, diabetes mellitus, occlusion and stenosis of the right carotid artery, non-ST elevation (NSTEMI) myocardial infarction, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and history of falling. A review of Resident #1's Admission/readmission Data Collection assessment dated [DATE] and completed by Staff B, Registered Nurse (RN), revealed under Section B: Cognition, Resident #1 was alert and oriented to person, place, and time. The assessment also revealed under Section N2: Elopement Risk Evaluation, Resident #1 was not cognitively impaired, was not independently mobile (either ambulatory or in a wheelchair), did not have poor decision-making skills, did not have the ability to exit the facility, and was not at risk for elopement. A review of the facility policy titled admission Assessment, last revised on 8/22/2017 revealed at the time of admission or readmission, the nurse shall initiate the admission Data Collection Form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with resident and family, and review of the resident's available medical records. A telephone interview was conducted on 1/10/2024 at 12:02 PM with Resident #1's Primary Care Physician (PCP). The PCP stated he evaluated Resident #1 on 12/30/2023 and the resident appeared stable but was confused, disoriented to time, and did not give appropriate responses to questions. Resident #1 had a history of stroke and new onset seizures. The PCP stated he was notified of Resident #1's elopement from the facility on 12/31/2023 and of the resident's return on 1/1/2024. The PCP ordered lab work for Resident #1 upon his return to the facility and no abnormalities were found. The PCP stated Resident #1 was in danger during his elopement from the facility because he does not know what's fully going on and the resident had a possibility of increased seizure risk without his seizure medications. A review of Resident #1's physician's orders showed the resident missed evening and morning doses of his two medications for seizures and missed his three morning medications for hypertension: - An order dated 12/30/2023 for Lacosamide 100 milligrams (mg) by mouth in the morning and at bedtime for a diagnosis of seizures. - An order dated 12/30/2023 for Levetiracetam 1000 mg by mouth in the morning and at bedtime for a diagnosis of seizures. - An order dated 12/30/2023 for Lisinopril 5 mg by mouth once daily for a diagnosis of hypertension. - An order dated 12/30/2023 for Hydralazine Hydrochloride (HCl) 25 mg by mouth once daily for a diagnosis of hypertension. - An order dated 12/30/2023 for Amlodipine Besylate 10 mg by mouth once daily for a diagnosis of hypertension. - An order dated 1/1/2024 for an electronic elopement device to the right lower extremity. - An order dated 1/1/2024 to verify placement of the electronic elopement device to the resident's right lower extremity every shift. - An order dated 1/1/2024 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. A review of Resident #1's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 12/31/2023 at 7:41 PM and authored by Staff A, Licensed Practical Nurse (LPN) and Unit Manager (UM), revealed under the section titled Situation Resident #1 could not be located in the facility. The note also revealed under the section titled Appearance Staff A, LPN UM looked for Resident #1 on the first floor of the facility after the resident did not return to the unit for the dinner meal. Staff A, LPN UM was not able to locate Resident #1 and the facility's elopement protocol was initiated. Resident #1's Primary Care Physician (PCP) was also notified of Resident #1's elopement at 9:00 PM and a recommendation was made to call 911. A review of Resident #1's care plan revealed a problem, dated 1/1/2024, indicating Resident #1 was a risk for elopement/wanderer related to a history of attempts to leave the facility unattended and impaired safety awareness. Listed interventions included the following: distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, or a book; applying an electronic elopement device to the resident's right lower extremity; monitor the resident's location frequently; and identify patterns of wandering. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/2/2024 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. The assessment also revealed under Section E - Behavior, Resident #1 displayed behaviors of wandering 1 to 3 days of the assessment period, which placed Resident #1 at significant risk of getting to a potentially dangerous place. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. An interview was conducted on 1/9/2024 at 12:59 PM with Staff A, LPN UM, who was Resident #1's assigned nurse on 12/31/2023 for the 3:00 PM to 11:00 PM shift. Staff A, LPN UM stated she was called in to work the 3:00 PM to 11:00 PM shift on 12/31/2023 due to a call off and arrived at the facility around 4:00 PM. Staff A, LPN UM usually worked as the Unit Manager on Resident #1's floor but she was not familiar with Resident #1 because she was off at the time Resident #1 was admitted to the facility. When she arrived to the unit, Staff A, LPN UM did a shift-to-shift report with Staff B, RN, who told her Resident #1 was participating in an activity in the downstairs dining room. Neither staff member verified Resident #1 was at the activity at the time of the report. Staff A, LPN UM stated around 6:00 PM, she noticed Resident #1 did not return to the unit for dinner and his dinner tray in his room was untouched. Staff A, LPN UM went downstairs to the dining room to check on Resident #1 and he was not at the activity. Staff A, LPN UM stated she also checked the smoking porch off of the downstairs dining room and Resident #1 was not found. Staff A, LPN UM asked Staff C, Receptionist, if she had seen Resident #1 because she did not know what the resident looked like and Staff C, Receptionist responded, no. Staff A, LPN UM also checked with the other floor staff in the facility but was not able to locate Resident #1 on any floor. Staff A, LPN UM stated around 7:00 PM, she went to the reception desk and called the DON and told her Resident #1 could not be located in the building. During her telephone conversation with the DON, Staff A, LPN UM heard Staff C, Receptionist tell her she saw a group of people leaving the facility earlier in the day and was not able to state a time, but she was not certain Resident #1 was part of the group because she did not know what the resident looked like. Staff A, LPN UM stated after speaking with the DON, she initiated a code silver and notified Resident #1's representative. Staff A, LPN UM also stated the DON called her around 7:30 PM and told her to call 911. Staff A, LPN UM was connected to local law enforcement and informed them Resident #1 was missing from the facility. Staff A, LPN UM stated she went outside and searched the surrounding area for the resident, but no other staff members assisted her with the search on the outside perimeter of the facility. Staff A, LPN UM also stated local law enforcement arrived at the building around 10:00 PM and she provided Resident #1's information to them. After speaking with local law enforcement, Staff A, LPN UM completed some paperwork and documentation and left the faciity on 1/1/2024 around 12:15 AM. Staff A, LPN UM arrived back at the facility on 1/1/2024 around 7:30 AM and assisted with staff in-services for the 7:00 AM to 3:00 PM staff, related to Resident #1's elopement. Around 2:00 PM, Staff A, LPN UM went to a local gas station Resident #1 frequently visited prior to his admission to the facility and spoke with members of the community in an attempt to locate Resident #1, but the resident was not found at that time. Staff A, LPN UM stated she received a phone call from the NHA around 6:00 PM on 1/1/2024, stating Resident #1 was found and was being returned to the facility. An interview was conducted on 1/9/2024 at 1:38 PM with Staff B, RN, who was Resident #1's assigned nurse on 12/31/2023 for the 7:00 AM to 3:00 PM shift. Staff B, RN stated she was familiar with Resident #1, and she was his nurse when he arrived at the facility on 12/29/2023. Staff B, RN also stated she completed Resident #1's admission assessment on 12/29/2023 and the resident was alert, but a little bit confused. Staff B, RN stated Resident #1 was able to appropriately answer questions, had knowledge of his surroundings, able to state where he was, and was able to state his name. Staff B, RN also stated at the time of his admission assessment, Resident #1 did not seem cognitively impaired and did not have any diagnoses to indicate cognitive impairment. Staff B, RN addressed Resident #1 did have a diagnosis of dementia and was independently mobile but was not able to state why Resident #1's admission assessment revealed the resident was cognitively intact, was not independently mobile, and did not have the ability to leave the facility. Staff B, LPN UM stated she observed Resident #1 on 12/31/2023 around 2:45 PM go onto the facility elevator wearing a jacket and Resident #1 stated to her he was going downstairs to participate in an activity. Staff B, LPN UM also stated around 3:00 PM, she did a shift-to-shift report with Staff A, LPN UM and told her Resident #1 was downstairs participating in an activity, but neither staff member verified Resident #1 was downstairs. After giving the shift-to-shift report, Staff B, RN left the facility. Staff B, RN stated she returned to the facility on 1/1/2024 and was told by Staff A, LPN UM Resident #1 was missing from the facility. Staff B, RN also stated Resident #1 was returned to the facility by local law enforcement on 1/1/2024 around 7:00 PM. Staff B, RN completed a skin assessment for Resident #1 and the resident had no injuries. Staff B, RN stated Resident #1 appeared more confused upon his arrival and was wearing different clothing than the previous day. An interview was conducted on 1/9/2024 at 11:06 AM with Resident #1 in the resident's room. Resident #1 was observed sitting on the side of the bed in his room and was able to get up from the bed and walk to the door without difficulty and without the use of assistive devices. Resident #1 spoke clearly during the interview but was not able to appropriately answer questions. Resident #1 was not able to state where he was, what day it was, or why he was at the facility but was able to state his name, which he repeated several times during the interview. Resident #1 was not able to recall his elopement from the facility on 12/31/2023. An interview was conducted on 1/9/2024 at 2:02 PM with Staff F, Certified Nurse Aide (CNA). Staff F, CNA stated he was familiar with Resident #1 during previous interactions with the resident on 12/30/2023 and stated the resident was in and out when describing the resident's cognition. Staff F, CNA also stated the resident was able to hold a conversation, but only some things made sense, and Resident #1 was not aware of his surroundings. Staff F, CNA stated he worked on Resident #1's floor on 12/31/2023 during the 7:00 AM to 3:00 PM shift and saw the resident dressed to leave around 2:10 PM, but he did not see Resident #1 get onto the elevator or go downstairs during the shift. Staff F, CNA also stated he did not see the resident again before his shift ended at 3:00 PM because he was not assigned to the resident during the shift. Staff F, CNA stated he did not see Resident #1 until 1/2/2024 during the 7:00 AM to 3:00 PM shift. Staff F, CNA also stated he asked Resident #1 about his elopement from the facility but Resident #1 was not able to respond appropriately. An interview was conducted on 1/9/2024 at 2:23 PM with Staff D, Activity Coordinator (AC). Staff D, AC stated she worked at the facility on 12/31/2023 and she set up a football party activity in the first-floor dining area. Staff D, AC also stated she was not familiar with the resident and did not know what the resident looked like prior to his elopement on 12/31/2023. Staff D, AC stated she was assisting residents with a smoke break around 2:15 PM on 12/31/2023 and went to the reception desk to retrieve the smoking supplies when she saw a group of about 3 or 4 people leaving the facility through the front entrance. Staff D, AC was not able to state if Resident #1 was with the group of people exiting the facility because she was not familiar with the resident at the time. Staff D, AC left the facility around 3:15 PM and was told upon her return to the facility on 1/1/2024 Resident #1 was missing from the facility. Staff D, AC stated she assisted several other facility staff members in looking for the resident in the community on 1/1/2024 around 8 or 9 AM, but they were not able to find the resident. A telephone interview was conducted on 1/10/2024 at 10:27 AM with Staff C, Receptionist. Staff C, Receptionist stated she worked at the facility from 8 AM to 8 PM on 12/31/2023 and works mostly weekends. Staff C, Receptionist also stated she was not familiar with Resident #1 prior to the elopement and had never seen the resident before. Staff C, Receptionist stated on 12/31/2023 around 1:30 PM or 2:00 PM, she observed a group of people exiting the facility through the front entrance. Staff C, Receptionist stated she just clicked the buzzer to open the door and let the group out because she assumed it was just a group of visitors leaving the facility and did not think a resident was with them. Staff C, Receptionist stated on 12/31/2023 around 7:00 PM, she noticed Staff A, LPN UM downstairs looking for the resident. Staff C, Receptionist told Staff A, LPN UM she saw a group of people leaving the facility around 1:30 PM or 2:00 PM but she was not sure if the resident was with the group because she did not know what the resident looked like. Staff C, Receptionist stated a code silver was initiated and she assisted Staff A, LPN UM with calling Resident #1's family members in an attempt to notify and locate the resident. Staff C, Receptionist also stated she assisted in searching for Resident #1 outside of the facility for about 10 or 15 minutes but had to leave the facility at 8:00 PM. Staff C, Receptionist returned to the facility at 10:00 PM to assist staff in trying to locate Resident #1 and left the facility around 11:00 PM. Staff C, Receptionist stated she returned to the facility on 1/1/2024 around 8:00 AM and joined several other facility staff for a good hour in trying to find Resident #1 out in the community, but Resident #1 was not found. A telephone interview was attempted on 1/10/2024 at 11:46 AM with Staff E, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 7:00 AM to 3:00 PM shift. Staff E, CNA did not answer the phone call and a message was left for call back by Staff H, Social Services Aide (SSA), who assisted with translation. The phone call was not returned by Staff E, CNA. A telephone interview was conducted on 1/10/2024 at 11:50 AM with Staff G, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 3:00 PM to 11:00 PM shift. Staff G, CNA stated she was not familiar with Resident #1 and had not seen the resident before his return on 1/1/2024. Staff G, CNA also stated she arrived at the unit on 12/31/2023 around 3:00 PM and conducted shift-to-shift rounds with Staff E, CNA. Staff G, CNA stated she only did a verbal shift-to-shift report with Staff G, CNA and neither staff member verified where Resident #1 was at the time of the shift change. Staff G, CNA assisted another CNA with resident care at the beginning of the shift and noticed Resident #1 was not in his room when she brought his dinner tray to the room. Staff G, CNA stated she reported to Staff A, LPN UM Resident #1 was missing from the unit and a code silver was initiated. Staff G, CNA also stated she assisted in searching the facility for Resident #1 for about 15 to 20 minutes before returning to the unit to provide care for the other residents, but Resident #1 was not found. Staff G, CNA left the facility around 11:00 PM and returned on 1/1/2024 around 3:00 PM. Staff G, CNA stated Resident #1 returned to the facility 1/1/2024 and she provided a dinner tray for the resident upon his return. A review of a law enforcement report dated 12/31/2023 at 10:48 PM revealed Resident #1 eloped from the facility at approximately 2:00 PM and local law enforcement dispatched several units in the community to locate Resident #1. Local law enforcement spoke with Resident #1's representative, who told law enforcement Resident #1 recently suffered a seizure due to not taking his seizure medications and staff feared for the resident's safety. The local law enforcement report dated 12/31/2023 at 10:34 PM also revealed an interview with the NHA, who stated Resident #1 walked out of the facility at approximately 2:00 PM due to staff assuming the resident was a visitor at the facility. Local law enforcement obtained a description of Resident #1 and were told by the NHA Resident #1 had confusion and was unable to care for himself. A Local law enforcement interview with Resident #1's representative (RR) on 12/31/2023 at 10:43 PM revealed the following: - [Local law enforcement] spoke to the [RR] via phone The [RR] stated she is the [RR] of the missing party [Resident #1] and that he suffered a stroke [approximately] 5 [years] ago. [Resident #1] recently suffered a severe seizure which resulted in brain injury and was recently transferred from the hospital to the [facility] on Friday. [RR] stated that [Resident #1] cannot speak and his English [is] garbled and that he is easily confused and cannot take care of himself. [RR] stated that it is likely that [Resident #1] has no former knowledge of the area and would not attempt to go back to local address or friends' home (as he cannot recall them). [RR] stated that [Resident #1] can move with a crowd of people if they were crossing a cross walk but would have difficulty on his own. [RR] stated [Resident #1] has no money and no cellphone and no means of contacting family or friends. [RR] is concerned for [Resident #1's] safety. [RR] stated that the [Resident #1] suffered from the earlier seizure due to his not taking his meds and fears that without said medication he could have further incidents. A local law enforcement report dated 1/1/2024 at 7:22 PM revealed local law enforcement responded to an apartment complex at approximately 6:40 PM after a member of the community reported possibly seeing the resident through the window of an abandoned apartment. The report also revealed Resident #1 was standing near a stairway outside and identified himself to local law enforcement. Resident #1 was incoherent and was not able to answer any questions, but appeared in good physical condition and did not require medical attention. Resident #1 was returned to the facility by local law enforcement. A review of Resident #1's psychiatry evaluation dated 1/5/2024 revealed Resident #1 was alert and oriented only to self and was not able to answer questions appropriately. The evaluation also revealed Resident #1 was independently mobile, had disjointed thought process, and had poor short- and long-term memory. An interview was conducted on 1/8/2024 at 3:00 PM with the facility's NHA and DON. The NHA stated on 12/31/2023, Resident #1 eloped from the facility. During the investigation into Resident #1's elopement, the facility developed the following timeline of events through staff interviews: - On 12/31/2023 around 2:00 PM, Staff F, Certified Nursing Assistant (CNA) and Staff B, RN observed Resident #1 standing next to his room door, which was located across the hallway from the unit elevator, wearing a jacket, hat, and shoes. - On 12/31/2023 around 2:30 PM, Staff F, CNA and Staff B, RN observed Resident #1 getting onto the unit elevator and both staff assumed Resident #1 was going to the downstairs dining room to participate in an activity. - On 12/31/2023 at 3:00 PM, Staff G, CNA arrived to the unit for the 3:00 PM to 11:00 PM shift and did shift-to shift rounding with Staff F, CNA. Staff F, CNA informed Staff G, CNA Resident #1 was downstairs participating in an activity. Neither staff member verified Resident #1 was downstairs in the activity at the time of the shift-to-shift report. - On 12/31/2023 around 5:30 PM, food trays arrived for the dinner meal and Staff G, CNA dropped off a dinner tray to Resident #1's room. Resident #1 was not in the room, and it was assumed by staff he was downstairs participating in an activity in the downstairs dining room. - On 12/31/2023 around 6:00 PM, Staff A, LPN UM observed Resident #1's dinner tray was untouched, and Resident #1 did not return to his room for the dinner meal. Staff A, LPN UM went downstairs to the dining area to check if Resident #1 was participating in the activity. Staff A, LPN UM was not able to find Resident #1 in the first-floor dining room or on the first floor of the facility. Staff A, LPN UM initiated the facility's code silver protocol and facility staff began searching other floors in the facility for Resident #1 as well as outside of the facility. Staff A, LPN UM notified the DON, NHA, PCP, and resident representative of Resident #1's elopement. The facility staff conducted a 100% head count of every other resident in the facility and all other residents were accounted for at the time. - On 12/31/2023 around 7:40 PM, Staff A, LPN UM notified local law enforcement of Resident #1's elopement from the facility and contacted nearby hospitals to attempt to locate Resident #1. Resident #1 was not found. - On 12/31/2023 around 8:40 PM, The NHA drove to Resident #1's previous residence to see if Resident #1 was there and spoke to Resident #1's family member around 9:00 PM. Resident #1 was not at his previous address. - On 12/31/2023 around 10:00 PM, local law enforcement arrived at the facility and gathered information from the facility about Resident #1 to assist in finding the resident. Local law enforcement advised the facility a search in the local community would be conducted to find Resident #1. - On 1/1/2024 around 8:16 AM, Staff A, LPN UM contacted local hospitals in an attempt to locate Resident #1. Several facility staff conducted searches throughout the community in an attempt to locate Resident #1. Resident #1 was not located at any surrounding hospital and was not found in the community. - On 1/1/2024 at 6:28 PM, the NHA was notified by facility staff a member of the community may have located Resident #1 at a nearby apartment complex approximately 0.2 miles from the facility in a vacant apartment. Local law enforcement was notified, and facility staff went to the apartment complex. Resident #1 was discovered inside of the vacant apartment and was brought back to the facility around 7:00 PM. The NHA stated following Resident #1's return to the facility, a skin assessment was performed, and Resident #1 had no injuries from the elopement. Nursing staff also applied an electronic elopement device to Resident #1's right ankle following the elopement, in preparation for the installation of the system the next day. During the facility's investigation, interviews were conducted with Staff C, Receptionist and Staff D, AC, who stated they observed a group of four or so people exiting the facility on 12/31/2023 around 1:30 PM to 2:00 PM and they thought Resident #1 may have been in the group of people without staff knowledge at the time. The facility conducted a root cause analysis of the elopement and determined Resident #1 left with the group of visitors without staff knowledge due to not being recognized as a resident of the facility, facility staff not conducting proper shift-to-shift rounding to verify Resident #1's whereabouts at shift change, staff failing to recognize signs of elopement as e[TRUNCATED]

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 10 residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits and history of dementia, epilepsy, and confusion before admission to the facility. The facility staff failed to ensure the safety of Resident #1; on 12/31/2023 at approximately 2:30 PM, Resident #1 ambulated from the second floor of the facility, entered the facility elevator, and rode the elevator down to the first floor of the facility. Resident #1 exited the facility through the front door, which was equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and was opened by reception staff who thought Resident #1 was a visitor at the facility. Resident #1 was able to walk out the front door of the facility, travel approximately 0.2 miles along a 4-lane road and was found more than 24 hours later at a nearby apartment complex in a vacant apartment by a member of the community. Resident #1 was discovered by a member of the community on 1/1/2024 at approximately 7:00 PM in a vacant apartment and was returned by facility staff at approximately 7:30 PM. The facility failed to take action to prevent the resident from exiting the facility by not determining and providing the necessary level of supervision, and not distinguishing the resident from visitors of the facility. The resident was not located for approximately 28 hours and 30 minutes. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 12/31/2023. The findings of Immediate Jeopardy were determined to be removed on 1/12/2024 and the severity and scope was reduced to a D. Findings included: A review of Resident #1's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 12/31/2023 at 7:41 PM and authored by Staff A, Licensed Practical Nurse (LPN) and Unit Manager (UM), revealed under the section titled Situation Resident #1 could not be located in the facility. The note also revealed under the section titled Appearance Staff A, LPN UM looked for Resident #1 on the first floor of the facility after the resident did not return to the unit for the dinner meal. Staff A, LPN UM was not able to locate Resident #1 and the facility's elopement protocol was initiated. Resident #1's primary care physician (PCP) was also notified of Resident #1's elopement at 9:00 PM and a recommendation was made to call 911. A review of the facility policy titled Missing Patient/Resident, last revised on 8/1/2020, revealed under the section titled Overview, staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. The policy also revealed the following facility procedure under the section titled Procedure: - Check the Leave of Absence (LOA) book and medical record to ensure the patient/resident is not on an authorized leave or medical appointment. - Announce (resident name) please return to your room, over the public announcement (PA) system. Repeat three times to alert staff of a missing patient/resident. - Assign staff to search the Center and grounds. - If the patient/resident is not located after an initial search, the point person will notify the Nursing Home Administrator (NHA), the Director of Nursing (DON), the resident representative, and the Primary Care Physician (PCP). The NHA and/or DON or designee will notify local law enforcement. A review of Resident #1's hospital history and physical (H&P), dated 12/13/2023 revealed Resident #1 arrived at the emergency department with a critically high blood pressure of 233/151, a heart rate of 101, and was unresponsive with active convulsions. Resident #1 was determined to be in critical condition with a risk of worsening seizures, stroke, or death. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 12/29/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section S: Physical Function, Resident #1 ambulated with standby assistance and required no assistive devices to ambulate. The transfer form revealed under Section U: Mental/Cognitive Status at Transfer, Resident #1 was alert and disoriented but could follow simple instructions. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of epilepsy, unspecified, intractable, with status epilepticus, difficulty walking, essential hypertension, other symptoms and signs involving cognitive functions and awareness, diabetes mellitus, occlusion and stenosis of the right carotid artery, non-ST elevation (NSTEMI) myocardial infarction, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and history of falling. A review of Resident #1's Admission/readmission Data Collection assessment dated [DATE] and completed by Staff B, Registered Nurse (RN) revealed under Section B: Cognition, Resident #1 was alert and oriented to person, place, and time. The assessment also revealed under Section N2: Elopement Risk Evaluation, Resident #1 was not cognitively impaired, was not independently mobile (either ambulatory or in a wheelchair), did not have poor decision-making skills, did not have the ability to exit the facility, and was not at risk for elopement. A review of the facility policy titled admission Assessment, last revised on 8/22/2017 revealed at the time of admission or readmission, the nurse shall initiate the admission Data Collection Form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with resident and family, and review of the resident's available medical records. A review of Resident #1's physician's orders revealed the following: - An order dated 1/1/2024 for an electronic elopement device to the right lower extremity. - An order dated 1/1/2024 to verify placement of the electronic elopement device to the resident's right lower extremity every shift. - An order dated 1/1/2024 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. - An order dated 12/30/2023 for Lacosamide 100 milligrams (mg) by mouth in the morning and at bedtime for a diagnosis of seizures. - An order dated 12/30/2023 for Levetiracetam 1000 mg by mouth in the morning and at bedtime for a diagnosis of seizures. - An order dated 12/30/2023 for Lisinopril 5 mg by mouth once daily for a diagnosis of hypertension. - An order dated 12/30/2023 for Hydralazine Hydrochloride (HCl) 25 mg by mouth once daily for a diagnosis of hypertension. - An order dated 12/30/2023 for Amlodipine Besylate 10 mg by mouth once daily for a diagnosis of hypertension. A review of Resident #1's care plan revealed a problem, dated 1/1/2024, that Resident #1 was a risk for elopement/wanderer related to a history of attempts to leave the facility unattended and impaired safety awareness. Interventions included to distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, or a book, applying an electronic elopement device to the resident's right lower extremity, monitor the resident's location frequently, and identify patterns of wandering. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/2/2024 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. The assessment also revealed under Section E - Behavior, Resident #1 displayed behaviors of wandering 1 to 3 days of the assessment period, which placed Resident #1 at significant risk of getting to a potentially dangerous place. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. An interview was conducted on 1/9/2024 at 12:59 PM with Staff A, LPN UM, who was Resident #1's assigned nurse on 12/31/2023 for the 3:00 PM to 11:00 PM shift. Staff A, LPN UM stated she was called into work the 3:00 PM to 11:00 PM shift on 12/31/2023 due to a call off and arrived at the facility around 4:00 PM. Staff A, LPN UM usually worked as the Unit Manager on Resident #1's floor but she was not familiar with Resident #1 because she was off at the time Resident #1 was admitted to the facility. When she arrived to the unit, Staff A, LPN UM did a shift-to-shift report with Staff B, RN, who told her Resident #1 was participating in an activity in the downstairs dining room. Neither staff member verified Resident #1 was at the activity at the time of the report. Staff A, LPN UM stated around 6:00 PM, she noticed Resident #1 did not return to the unit for dinner and his dinner tray in his room was untouched. Staff A, LPN UM went downstairs to the dining room to check on Resident #1 and he was not at the activity. Staff A, LPN UM stated she also checked the smoking porch off of the downstairs dining room and Resident #1 was not found. Staff A, LPN asked Staff C, Receptionist if she had seen Resident #1 because she did not know what the resident looked like and Staff C, Receptionist responded no. Staff A, LPN UM also checked with the other floor staff in the facility but was not able to locate Resident #1 on any floor. Staff A, LPN UM stated around 7:00 PM, she went to the reception desk and called the DON and told her Resident #1 could not be located in the building. During her telephone conversation with the DON Staff A, LPN UM heard Staff C, Receptionist tell her she saw a group of people leaving the facility earlier in the day and was not able to state a time, but she was not certain Resident #1 was part of the group because she did not know what the resident looked like. Staff A, LPN UM stated after speaking with the DON, she initiated a code silver and notified Resident #1's representative. Staff A, LPN UM also stated the DON called her around 7:30 PM and told her to call 911. Staff A, LPN UM was connected to local law enforcement and informed them Resident #1 was missing from the facility. Staff A, LPN UM stated she went outside and searched the surrounding area for the resident, but no other staff members assisted her with the search on the outside perimeter of the facility. Staff A, LPN UM also stated local law enforcement arrived at the building around 10:00 PM and she provided Resident #1's information to them. After speaking with local law enforcement, Staff A, LPN UM completed some paperwork and documentation and left the faciity on 1/1/2024 around 12:15 AM. Staff A, LPN UM arrived back at the facility on 1/1/2024 around 7:30 AM and assisted with staff in-services for the 7:00 AM to 3:00 PM staff, related to Resident #1's elopement. Around 2:00 PM, Staff A, LPN UM went to a local gas station Resident #1 frequently visited prior to his admission to the facility and spoke with members of the community in an attempt to locate Resident #1, but the resident was not found at that time. Staff A, LPN UM stated she received a phone call from the NHA around 6:00 PM on 1/1/2024, stating Resident #1 was found and was being returned to the facility. An interview was conducted on 1/9/2024 at 1:38 PM with Staff B, RN, who was Resident #1's assigned nurse on 12/31/2023 for the 7:00 AM to 3:00 PM shift. Staff B, RN stated she was familiar with Resident #1, and she was his nurse when he arrived at the facility on 12/29/2023. Staff B, RN also stated she completed Resident #1's admission assessment on 12/29/2023 and the resident was alert, but a little bit confused. Staff B, RN stated Resident #1 was able to appropriately answer questions, had knowledge of his surroundings, able to state where he was, and was able to state his name. Staff B, RN also stated at the time of his admission assessment, Resident #1 did not seem cognitively impaired and did not have any diagnoses to indicate cognitive impairment. Staff B, RN addressed Resident #1 did have a diagnoses of dementia and was independently mobile but was not able to state why Resident #1's admission assessment revealed the resident was cognitively intact, was not independently mobile, and did not have the ability to leave the facility. Staff B, LPN UM stated she observed Resident #1 on 12/31/2023 around 2:45 PM go onto the facility elevator wearing a jacket and Resident #1 stated to her he was going downstairs to participate in an activity. Staff B, LPN UM also stated around 3:00 PM, she did a shift-to-shift report with Staff A, LPN UM and told her Resident #1 was downstairs participating in an activity, but neither staff member verified Resident #1 was downstairs. After giving the shift-to-shift report, Staff B, RN left the facility. Staff B, RN stated she returned to the facility on 1/1/2024 and was told by Staff A, LPN UM Resident #1 was missing from the facility. Staff B, RN also stated Resident #1 was returned to the facility by local law enforcement on 1/1/2024 around 7:00 PM. Staff B, RN completed a skin assessment for Resident #1 and the resident had no injuries. Staff B, RN stated Resident #1 appeared more confused upon his arrival and was wearing different clothing than the previous day. An interview was conducted on 1/9/2024 at 11:06 AM with Resident #1 in the resident's room. Resident #1 was observed sitting on the side of the bed in his room and was able to get up from the bed and walk to the door without difficulty and without the use of assistive devices. Resident #1 spoke clearly during the interview but was not able to appropriately answer questions. Resident #1 was not able to state where he was, what day it was, or why he was at the facility but was able to state his name, which he repeated several times during the interview. Resident #1 was not able to recall his elopement from the facility on 12/31/2023. An interview was conducted on 1/9/2024 at 2:02 PM with Staff F, CNA. Staff F, CNA stated he was familiar with Resident #1 during previous interactions with the resident on 12/30/2023 and stated the resident was in and out when describing the resident's cognition. Staff F, CNA also stated the resident was able to hold a conversation but only some things made sense and Resident #1 was not aware of his surroundings. Staff F, CNA stated he worked on Resident #1's floor on 12/31/2023 during the 7:00 AM to 3:00 PM shift and saw the resident dressed to leave around 2:10 PM, but he did not see Resident #1 get onto the elevator or go downstairs during the shift. Staff F, CNA also stated he did not see the resident again before his shift ended at 3:00 PM because he was not assigned to the resident during the shift. Staff F, CNA stated he did not see Resident #1 until 1/2/2024 during the 7:00 AM to 3:00 PM shift. Staff F, CNA also stated he asked Resident #1 about his elopement from the facility but Resident #1 was not able to respond appropriately. An interview was conducted on 1/9/2024 at 2:23 PM with Staff D, Activity Coordinator (AC). Staff D, AC stated she worked at the facility on 12/31/2023 and she set up a football party activity in the first floor dining area. Staff D, AC also stated she was not familiar with the resident and did not know what the resident looked like prior to his elopement on 12/31/2023. Staff D, AC stated she was assisting residents with a smoke break around 2:15 PM on 12/31/2023 and went to the reception desk to retrieve the smoking supplies when she saw a group of about 3 or 4 people leaving the facility through the front entrance. Staff D, AC was not able to state if Resident #1 was with the group of people exiting the facility because she was not familiar with the resident at the time. Staff D, AC left the facility around 3:15 PM and was told upon her return to the facility on 1/1/2024 Resident #1 was missing from the facility. Staff D, AC stated she assisted several other facility staff members in looking for the resident in the community on 1/1/2024 around 8 or 9 AM, but they were not able to find the resident. A telephone interview was conducted on 1/10/2024 at 10:27 AM with Staff C, Receptionist. Staff C, Receptionist stated she worked at the facility from 8 AM to 8 PM on 12/31/2023 and works mostly weekends. Staff C, Receptionist also stated she was not familiar with Resident #1 prior to the elopement and had never seen the resident before. Staff C, Receptionist stated on 12/31/2023 around 1:30 PM or 2:00 PM, she observed a group of people exiting the facility through the front entrance. Staff C, Receptionist stated she just clicked the buzzer to open the door and let the group out because she assumed it was just a group of visitors leaving the facility and did not think a resident was with them. Staff C, Receptionist stated on 12/31/2023 around 7:00 PM, she noticed Staff A, LPN UM downstairs looking for the resident. Staff C, Receptionist told Staff A, LPN UM she saw a group of people leaving the facility around 1:30 PM or 2:00 PM but she was not sure if the resident was with the group because she did not know what the resident looked like. Staff C, Receptionist stated a code silver was initiated and she assisted Staff A, LPN UM with calling Resident #1's family members in an attempt to notify and locate the resident. Staff C, Receptionist also stated she assisted in searching for Resident #1 outside of the facility for about 10 or 15 minutes but had to leave the facility at 8:00 PM. Staff C, Receptionist returned to the facility at 10:00 PM to assist staff in trying to locate Resident #1 and left the facility around 11:00 PM. Staff C, Receptionist stated she returned to the facility on 1/1/2024 around 8:00 AM and joined several other facility staff for a good hour in trying to find Resident #1 out in the community, but Resident #1 was not found. A telephone interview was attempted on 1/10/2024 at 11:46 AM with Staff E, Certified Nurse Aide (CNA), who was Resident #1's assigned CNA on 12/31/2023 during the 7:00 AM to 3:00 PM shift. Staff E, CNA did not answer the phone call and a message was left for call back by Staff H, Social Services Aide (SSA), who assisted with translation. The phone call was not returned by Staff E, CNA. A telephone interview was conducted on 1/10/2024 at 11:50 AM with Staff G, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 3:00 PM to 11:00 PM shift. Staff G, CNA stated she was not familiar with Resident #1 and had not seen the resident before his return on 1/1/2024. Staff G, CNA also stated she arrived at the unit on 12/31/2023 around 3:00 PM and conducted shift-to-shift rounds with Staff E, CNA. Staff G, CNA stated she only did a verbal shift-to-shift report with Staff G, CNA and neither staff member verified where Resident #1 was at the time of the shift change. Staff G, CNA assisted another CNA with resident care at the beginning of the shift and noticed Resident #1 was not in his room when she brought his dinner tray to the room. Staff G, CNA stated she reported to Staff A, LPN UM Resident #1 was missing from the unit and a code silver was initiated. Staff G, CNA also stated she assisted in searching the facility for Resident #1 for about 15 to 20 minutes before returning to the unit to provide care for the other residents, but Resident #1 was not found. Staff G, CNA left the facility around 11:00 PM and returned on 1/1/2024 around 3:00 PM. Staff G, CNA stated Resident #1 returned to the facility 1/1/2024 and she provided a dinner tray for the resident upon his return. A telephone interview was conducted on 1/10/2024 at 12:02 PM with Resident #1's PCP. The PCP stated he evaluated Resident #1 on 12/30/2023 and the resident appeared stable but was confused, disoriented to time, and did not give appropriate responses to questions. Resident #1 had a history of stroke and new onset seizures. The PCP stated he was notified of Resident #1's elopement from the facility on 12/31/2023 and of the resident's return on 1/1/2024. The PCP ordered lab work for Resident #1 upon his return to the facility and no abnormalities were found. The PCP stated Resident #1 was in danger during his elopement from the facility because he does not know what's fully going on and the resident had a possibility of increased seizure risk without his seizure medications. A review of a law enforcement report dated 12/31/2023 at 10:48 PM revealed Resident #1 eloped from the facility at approximately 2:00 PM and local law enforcement dispatched several units in the community to locate Resident #1. Local law enforcement spoke with Resident #1's representative, who told law enforcement Resident #1 recently suffered a seizure due to not taking his seizure medications and staff feared for the resident's safety. The local law enforcement report dated 12/31/2023 at 10:34 PM also revealed an interview with the NHA, who stated Resident #1 walked out of the facility at approximately 2:00 PM due to staff assuming the resident was a visitor at the facility. Local law enforcement obtained a description of Resident #1 and were told by the NHA Resident #1 had confusion and was unable to care for himself. A Local law enforcement interview with Resident #1's representative (RR) on 12/31/2023 at 10:43 PM revealed the following: - [Local law enforcement] spoke to the [RR] via phone The [RR] stated she is the [RR] of the missing party [Resident #1] and that he suffered a stroke [approximately] 5 [years] ago. [Resident #1] recently suffered a severe seizure which resulted in brain injury and was recently transferred from the hospital to the [facility] on Friday. [RR] stated that [Resident #1] cannot speak and his English [is] garbled and that he is easily confused and cannot take care of himself. [RR] stated that it is likely that [Resident #1] has no former knowledge of the area and would not attempt to go back to local address or friends' home (as he cannot recall them). [RR] stated that [Resident #1] can move with a crowd of people if they were crossing a cross walk but would have difficulty on his own. [RR] stated [Resident #1] has no money and no cellphone and no means of contacting family or friends. [RR] is concerned for [Resident #1's] safety. [RR] stated that the [Resident #1] suffered from the earlier seizure due to his not taking his meds and fears that without said medication he could have further incidents. A local law enforcement report dated 1/1/2024 at 7:22 PM revealed local law enforcement responded to an apartment complex at approximately 6:40 PM after a member of the community reported possibly seeing the resident through the window of an abandoned apartment. The report also revealed Resident #1 was standing near a stairway outside and identified himself to local law enforcement. Resident #1 was incoherent and was not able to answer any questions, but appeared in good physical condition and did not require medical attention. Resident #1 was returned to the facility by local law enforcement. A review of Resident #1's psychiatry evaluation dated 1/5/2024 revealed Resident #1 was alert and oriented only to self and was not able to answer questions appropriately. The evaluation also revealed Resident #1 was independently mobile, had disjointed thought process, and had poor short- and long-term memory. An interview was conducted on 1/8/2024 at 3:00 PM with the facility's NHA and DON. The NHA stated on 12/31/2023, Resident #1 eloped from the facility. During the investigation into Resident #1's elopement, the facility developed the following timeline of events through staff interviews: - On 12/31/2023 around 2:00 PM, Staff F, Certified Nursing Assistant (CNA) and Staff B, RN observed Resident #1 standing next to his room door, which was located across the hallway from the unit elevator, wearing a jacket, hat, and shoes. - On 12/31/2023 around 2:30 PM, Staff F, CNA and Staff B, RN observed Resident #1 getting onto the unit elevator and both staff assumed Resident #1 was going to the downstairs dining room to participate in an activity. - On 12/31/2023 at 3:00 PM, Staff G, CNA arrived to the unit for the 3:00 PM to 11:00 PM shift and did shift-to shift rounding with Staff F, CNA. Staff F, CNA informed Staff G, CNA Resident #1 was downstairs participating in an activity. Neither staff member verified Resident #1 was downstairs in the activity at the time of the shift-to-shift report. - On 12/31/2023 around 5:30 PM, food trays arrived for the dinner meal and Staff G, CNA dropped off a dinner tray to Resident #1's room. Resident #1 was not in the room, and it was assumed by staff he was downstairs participating in an activity in the downstairs dining room. - On 12/31/2023 around 6:00 PM, Staff A, LPN UM observed Resident #1's dinner tray was untouched, and Resident #1 did not return to his room for the dinner meal. Staff A, LPN UM went downstairs to the dining area to check if Resident #1 was participating in the activity. Staff A, LPN UM was not able to find Resident #1 in the first-floor dining room or on the first floor of the facility. Staff A, LPN UM initiated the facility's code silver protocol and facility staff began searching other floors in the facility for Resident #1 as well as outside of the facility. Staff A, LPN UM notified the DON, NHA, PCP, and resident representative of Resident #1's elopement. The facility staff conducted a 100% head count of every other resident in the facility and all other residents were accounted for at the time. - On 12/31/2023 around 7:40 PM, Staff A, LPN UM notified local law enforcement of Resident #1's elopement from the facility and contacted nearby hospitals to attempt to locate Resident #1. Resident #1 was not found. - On 12/31/2023 around 8:40 PM, The NHA drove to Resident #1's previous residence to see if Resident #1 was there and spoke to Resident #1's family member around 9:00 PM. Resident #1 was not at his previous address. - On 12/31/2023 around 10:00 PM, local law enforcement arrived at the facility and gathered information from the facility about Resident #1 to assist in finding the resident. Local law enforcement advised the facility a search in the local community would be conducted to find Resident #1. - On 1/1/2024 around 8:16 AM, Staff A, LPN UM contacted local hospitals in an attempt to locate Resident #1. Several facility staff conducted searches throughout the community in an attempt to locate Resident #1. Resident #1 was not located at any surrounding hospital and was not found in the community. - On 1/1/2024 at 6:28 PM, the NHA was notified by facility staff a member of the community may have located Resident #1 at a nearby apartment complex approximately 0.2 miles from the facility in a vacant apartment. Local law enforcement was notified, and facility staff went to the apartment complex. Resident #1 was discovered inside of the vacant apartment and was brought back to the facility around 7:00 PM. The NHA stated following Resident #1's return to the facility, a skin assessment was performed, and Resident #1 had no injuries from the elopement. Nursing staff also applied an electronic elopement device to Resident #1's right ankle following the elopement, in preparation for the installation of the system the next day. During the facility's investigation, interviews were conducted with Staff C, Receptionist and Staff D, AC, who stated they observed a group of four or so people exiting the facility on 12/31/2023 around 1:30 PM to 2:00 PM and they thought Resident #1 may have been in the group of people without staff knowledge at the time. The facility conducted a root cause analysis of the elopement and determined Resident #1 left with the group of visitors without staff knowledge due to not being recognized as a resident of the facility, facility staff not conducting proper shift-to-shift rounding to verify Resident #1's whereabouts at shift change, staff failing to recognize signs of elopement as evidence by Resident #1 getting on the facility elevator with his hat and jacket on, and Resident #1's elopement assessment not being properly completed upon his admission to the facility on [DATE]. The NHA said on 1/1/2024, a third-party vendor was contacted to install an elopement management system for the facility's front door and the unit was installed on 1/2/2024. The elopement management system works with the resident's electronic elopement device to prevent elopement by locking the door as the resident approaches it and sounding an audible alarm. The DON stated the facility now has a staff member in place on the first floor on a 24 hour basis by the facility elevator to ensure no residents at risk for elopement attempt to leave the facility. The DON also stated all facility staff had in-service education related to elopement and the elopement policy, abuse, neglect, and exploitation, the leave of absence (LOA) policy, and identification of wandering/elopement behaviors, which was completed on 1/4/2024. The DON also stated all nursing staff have been educated on the admission assessment process in order to properly identify elopement risks upon admission to the facility. The DON stated CNA staff have been educated on shift-to-shift reports and ensuring

Apr 2022 8 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure weight loss was monitored and assessed timely, as evidenced by lack of weekly weights and lack of food consumption documentation, which resulted in a significant weight loss for one (Resident #67) out of seven residents sampled for nutrition. Findings included: On 3/29/22 at 1:02 p.m., Resident #67 was observed sitting in the bed in his room. He was alert and able to answer questions related to his care. He stated he really dislikes the pureed food he is getting and cannot eat it. He stated he has had no upper teeth for a long time, and he can eat regular food just fine. He stated he just wants regular food so he can eat. He stated he has to rely on what he can get to eat from the outside, and it is not enough. A review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with a diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), opioid dependence, Congestive Heart Failure (CHF), dysphagia, underweight, and anemia. A review of the Order Summary Report on 3/30/22 for Resident #67 indicated the following orders were active: -Regular diet dysphagia mechanical soft texture, regular/thin liquids consistency. Add fortified foods (started on 11/11/21). -Med Pass put amount ordered oral in add directions three times a day for supplements 240 milliliters (ml) (started on 11/10/21). -Speech Therapy (ST) evaluate and treat as indicated (started on 11/09/21). A review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #67 revealed in Section C-Cognitive Function, a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment revealed in Section G-Functional Status the resident was independent for eating with assistance for set up only. The assessment revealed in Section K-Swallowing/Nutritional Status, the resident had no swallowing disorder, a weight loss of more than 5% in a month or 10% in the last six months and not on a prescribed weight loss regimen. A review of the Weight Summary for Resident #67 revealed the following: Height 65 inches BMI (Basal Metabolic Index) 17.6 11/9/21 106.0 lbs. (pounds)Standing 12/3/21 105.2 lbs. Wheelchair 1/14/22 107.8 lbs. (no indication of method) 1/26/22 100.2 lbs. Wheelchair 2/2/22 86.9 lbs. Standing 3/3/22 99.4 lbs. (no indication of method) Resident #67 had a 13.3% weight loss in one month from 1/26/22 to 2/2/22. Resident #67 had a 6.23% weight loss in less than three months from 11/19/21 to 3/3/22. Review of the Comprehensive Care Plan for Resident #67 revealed the following: Focus: The resident has an activities of daily living self-care performance deficit related to disease processes. (initiated 3/1/22) Goal: Resident will maintain current level of function through review date. Interventions included but not limited to: The resident is able to feed self with setup. Focus: Resident #67 has a nutritional problem related to significant weight loss. (initiated 2/8/22) Goal: Resident will maintain adequate nutritional status as evidenced by maintaining at least 76-100% meal portions and supplements consumed ongoing through next review as well as weight stability/increase. Interventions: Provide and serve diet as ordered; Provide, serve diet as ordered. Monitor intake and record each meal. RD to evaluate and make diet change recommendations as needed. A review of the Nutrition Evaluation Initial, Annual and Significant Change record dated 11/12/21 indicated Resident #67 was on a dysphagia mechanical soft solid diet with thin liquids, had missing teeth, and no chewing or swallowing concerns. The document indicated Resident #67 had an Ideal Body Weight (IBW) of 142 lbs. and a current weight of 104.6 lbs. No history of weights was available. The meal intake level was reported as 76-100%. The document indicated the resident was at risk for malnutrition as evidenced by need for continued strong oral intake, limited oral intake documentation thus far, limited oral intake available, and a goal for the resident to continue to consume at least 76-100% meal portions daily. A review of the Nutrition Evaluation Initial, Annual and Significant Change record dated 2/8/22 indicated Resident #67 was on a dysphagia mechanical soft solid diet with thin liquids, had missing teeth, and no chewing or swallowing concerns. The document indicated Resident #67 had an IBW of 136 lbs. and a current weight of 100.2 lbs. The evaluation indicated a significant weight change of -5% since 1/14/22 with a BMI of 16.7. The meal intake level was reported as 76-100%. The document indicated the resident was at risk for malnutrition as evidenced by inadequate calorie and protein intake, inadequate food and beverage intake, significant weight loss with a goal to consume at least 51-100% meal portions daily as well as supplements provided, fortified foods, med pass 240 ml three times a day, weekly weights. On 3/30/22 at 1:00 p.m., Resident #67 was observed in the hallway on the second floor of the facility walking with his meal tray and yelling I can't eat this [expletive], as he brought the tray to staff members who were in the hallway. On 3/31/22 at 12:30 p.m., Resident #67 was observed seated in his room with his lunch tray on the overbed table. The resident stated he cannot eat that pureed [expletive]. He had finely chopped meatloaf, brown gravy, pureed seasoned green peas, mashed au gratin potatoes, sliced peaches, pureed dinner roll/bread, and margarine on his tray. The resident had only eaten the fruit. He was picking at the meat. The rest of the tray had been untouched. He stated there was no reason he could not get normal food, and he cannot get anyone to listen to him so he can eat. He stated he has had no teeth for a long time and has never eaten pureed food. He stated he has no problems eating and drinking. A review of the eating percentages documented in the tasks section of the medical record revealed only one day (3/18/22) of meal percentages had been recorded for Resident #67 between 3/16/22 and 3/31/22. On 4/1/22 at 10:25 a.m., an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated an evaluation was completed for Resident #67 by speech therapy for swallowing due to weight loss. He stated at the time the resident had no concerns with the diet. On 4/1/22 at 11:09 a.m., an interview was conducted with the Registered Dietician (RD) and the Risk Manager, RN (RM). The RD stated he had been working at the facility for a year doing all the assessments. He stated he is physically in the facility three times a week. He stated he has one remote dietician who assists with quarterly assessments. He stated the nursing staff are responsible for the weekly weights and nursing is responsible for making sure all recommendations are carried out. The RD stated there is a weekly meeting on Fridays to discuss weights and determine gains or losses for the residents. The RD stated he was not aware the weekly weights were not completed as planned for Resident #67. The RD stated he was not aware Resident #67 had not been consuming his diet. The RD stated he was not aware the diet percentages had not been recorded as planned for Resident #67. The RD stated he noticed a significant weight loss for Resident #67 when he did his evaluation on 2/8/22 and he put in recommendations at that time. He stated all likes and dislikes for a resident are to be reported and the Certified Dietary Manager can make changes as needed. The RD confirmed meal percentages and weekly weights had not been completed for the resident or reported to him and stated he would evaluate the residents needs right away. The RM had nothing to add related to a lack of follow up by the RD. A policy was requested for Nutritional Assessment/Management for residents, and it was not supplied by the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to allow a resident's guardian to participate in the care planning process for one resident (Resident #329) out of 27 residents reviewed for care plans. Findings included: A review of the admission Record revealed Resident #329 was admitted into the facility on [DATE] with diagnosis to include vascular dementia without behavioral disturbance. The admission Record indicated that Resident #329 was his own responsible party, and his wife was listed as an emergency contact. Review of the resident's electronic medical record revealed a legal court document with an upload date of 02/02/22 indicating that Resident #329 was an incapacitated person, and his wife was appointed as guardian. The legal document was dated 09/29/20 Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating moderately impaired. Section Q of the MDS- Participation in Assessment and Goal Setting revealed Resident #329 participated in the assessment. This section indicated the family or significant other did not participate in the assessment. This section also indicated the guardian or legally authorized representative did not participate in the assessment. Resident was marked as the information source in Section Q0300A. On 04/01/22 at 10:54 a.m., MDS Coordinator, Licensed Practical Nurse (LPN), stated that she would contact the responsible party to complete the assessment if a resident was incapacitated. She confirmed that Resident #329's family and/or guardian did not participate in the care planning process per the MDS. On 04/02/22 at 4:00 p.m., the Director of Nursing (DON) reported if a resident was incapacitated, the family should be involved in the care planning process. She confirmed that Resident #329's family and/or guardian did not participate in the care planning process per the MDS. The policy and procedure provided by the facility Care Plan Invitation with an effective date of 11/30/2014 revealed the following: Policy - The resident and/or resident representative shall be invited to attend each of the Interdisciplinary Care Planning Conferences for a specified resident. Procedure - Request that the resident and/or resident representative contact the facility designee to confirm or reschedule the date/time for the resident's conference.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to review and revise the Resident Centered Care Plan related to 1) adding interventions after a fall for one (Resident #50) of three residents sampled for falls, and 2) adding a focus area with interventions implemented for range of motion for one (Resident #50) of three residents sampled for range of motion. Findings included: On 3/29/22 at 10:47 a.m., Resident #50 was observed lying in the bed in his room. Resident #50 was unable to speak but could understand and nod yes or no to questions. A hand splint was noted sitting on the nightstand next to the resident's bed. Photographic evidence was obtained. Resident #50 indicated the splint was not his and he was not supposed to have it on. Resident #50 was noted to have a contracture to his right hand. A review of the medical record for Resident #50 revealed the resident was admitted on [DATE] with a diagnosis of Cerebral Vascular Accident (CVA) with right (R) hemiplegia and hemiparesis, R hand contracture, abnormalities of gait and mobility, and muscle weakness. A review of the Order Summary Report for Resident #50 on 3/30/22 revealed an order for Occupational Therapy (OT) to evaluate and treat as indicated dated 1/15/22, there were no orders for treatment or therapies related to a splint. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed under Section C-Cognitive Patterns, Resident #50 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The assessment revealed under Section G-Functional Status, Resident #50 required extensive assistance by one to two persons for Activities of Daily Living (ADL). A review of the progress notes for Resident #50 revealed a note dated 2/1/22, indicating: Fall risk score of 55, High Risk. Patient found lying on floor next to bed. Assisted back to bed. Resident stated he only had pain in left knee which appeared to have a skin tear. Resident stated he did not hit his head on anything. MD (medical doctor) notified will monitor. A Change of Condition dated 2/16/22 revealed Resident #50 had an unwitnessed fall and was found on the floor. The resident showed no signs of pain or distress and was placed back in bed. Neurological checks were begun. A review of the Comprehensive Care Plan for Resident #50 revealed the following: Focus area-The resident is at risk for falls related to CVA with Hemiparesis and Hemiplegia, gait/balance problems, hypertension, incontinence, psychoactive drug use. (Initiated 1/26/22, Revised 1/26/22) Goal-Minimize the risk of sustaining a serious injury through the review date Interventions related to fall incidents, included but not limited to: Actual fall 2/16/22 0400 IDT (interdisciplinary team) reviewed MD (Medical Doctor) ordered CBC (Complete Blood Count), BMP (Baseline Metabolic Profile), and UA (Urinalysis), C&S (Culture and Sensitivity) to be completed. There was no indication of a fall on 2/1/22 or an intervention added related to the fall that occurred on 2/1/22. The care plan did not reflect a focus area related to Resident #50 having a contracture of the right hand or a range of motion focus area related to the diagnosis of CVA and use of a splint. On 3/31/22 at 11:39 a.m. Resident #50 was observed lying in the bed in his room. A splint was noted on his right hand securely in place. Resident #50 indicated by nodding his head the splint had been put in place by staff. On 4/1/22 at 10:11 a.m. an interview was conducted with the Director of Rehabilitation (DOR) and the Risk Manager (RM). The DOR stated Resident #50 had a splint from OT and the resident was being trialed on it for a few weeks to increase the range and wearing schedule. The DOR stated there should be an order for the splint and the therapist or the nurse should make sure the order is in the record. The DOR stated he did attend all care plan meetings and all residents are discussed as far as current therapies go. The DOR stated the splint was being trialed due to the contracture of the right hand for Resident #50. The DOR stated contractures should be on the care plan and he does up date resident therapies and treatments in the care plan meetings. On 4/1/22 at 10:33 a.m. an interview was conducted with the MDS Case Manager. She stated range of motion with a contracture would be a focus area on the care plan. She confirmed the contracture for Resident #50 should be included in the care plan and verified it was not there. She stated the process of care planning is done by reviewing the history and physical and observing and interviewing the resident. She stated social services, activities, therapy, and nursing all play a role in making sure the assessment is correct and areas of concern get on the care plan. She stated the process is completed within the first 14 days and additions to the care plan are done every morning in the meetings when all residents are discussed. She indicated the DOR attends the meetings to give updates to the care plan. The Case Manager stated when a resident has a fall it is placed on the care plan with any interventions added as a result of the fall review. She indicated new interventions should be added after a fall. She stated falls are also part of the morning meeting discussions and interventions are added at the time of the meeting. A review of the Order Summary Report for Resident #50 supplied by facility on 4/1/22, revealed a late entry order dated 4/1/22 as follows: 3/16/22 for Occupation Therapy (OT) five times a week for four weeks. Treatment may include: orthotic training and management for right hand, orthotic training subsequent encounters, therapeutic exercise, neuromuscular reeducation, self-care management, group therapy, ultrasound, and therapeutic activities. A review of the policy entitled Plans of Care, with an effective date of 11/30/2014 and a revision date of 09/25/2017 revealed the following: Policy: An individual person-centered plan of care will be established by the interdisciplinary team with the resident and/or resident representative to the extent practicable and updated in accordance with state and federal regulatory requirements. Procedure: Review, update and /or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident in in response to current interventions after the completion of each MDS assessment, and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintain the highest practicable physical, mental, and psychosocial well-being.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy reviews the facility failed to ensure proper care for activities of daily living (ADLs) related to nail care and incontinence care for two (Resident #95 and Resident #63) out of four residents sampled for activities of daily living. Findings included: 1. Medical record review for Resident #95 revealed an admission date of 7/13/2021 with diagnoses to include end stage renal disease, dependence on renal dialysis, legal blindness, muscle weakness, type 2 diabetes mellitus without complications, wedge compression fracture of first lumbar vertebra, and subsequent encounter for fracture with routine healing. A review of Resident #95's quarterly Minimum Data Set (MDS) assessment completed on 2/14/2022 indicated a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section C-Cognitive function of his MDS indicated no concerns with memory or mental status. Section G-Functional abilities of the MDS indicated the resident needs extensive assistance with toilet use, personal hygiene, bed mobility, dressing and transfers. The resident required limited assistance for walking in his room and corridor. A review of the care plan revealed a focus care area dated 11/24/2020 for ADL self-care performance deficit related to impaired balance. Interventions included: prefer all meals to be served in bowls, restorative ambulation/locomotion, gait training, bathing/showering check nail length and trim and clean on bath day and as necessary, toilet use, resident requires assistance by one staff member for toileting, encourage resident to use bell to call for assistance. A focus area was in place for Bladder incontinence, interventions included clean peri-area with each incontinence episode and monitor/document for signs and symptoms of UTI (urinary tract infection). An observation and interview was conducted for Resident #95 on 03/30/22 at 08:48 AM. Resident #95 was resting in bed with the call bell within reach. Observation of the resident's fingernails revealed they were untrimmed and had dark matter underneath the nail beds. The resident stated he must sit soiled for a long time waiting for assistance with incontinence care. Resident #95 stated when he pressed his call bell Staff G, Certified Nursing Assistant (CNA) has laughed and told the resident he, is bossy. The resident stated sometimes when he rings his bell, the CNAs will turn the light off and tell him they will be back, but it takes a while. Resident #95 stated he just wants to be changed. The resident stated he would do things himself if he could. The resident reported his bath days were Tuesday, Thursday and Saturday. An observation and interview was conducted for Resident #95 on 4/1/2022 at 12:45 PM. Resident #95's nails were still long, untrimmed, and soiled with dark matter underneath the nail beds. The resident stated he has asked for his nails to be trimmed and has been told they will get to it. The resident stated it was a while ago that he asked, not in the last week. Resident #95 stated the foot doctor comes and does his feet, but no one does his fingernails. He stated he would like his nails to be cut. An interview was conducted with Staff F, CNA on 4/1/2022 at 2:40 PM. Staff F was assigned to Resident #95 for her shift on 4/1/2022. She stated when residents are showered, they also clip their nails and shave them if they want it. She stated the central supply on the floor is out of nail clippers this week and she doesn't get to trim nails. She stated she has only worked at the facility for one week. Staff F was observed going to the supply closet and searching for clippers with no nail clippers being located. An interview was conducted with Staff G, CNA on 4/1/2022 at 2:45 PM. Staff G said the supply closet on the second floor is out of nail clippers sometimes. He calls downstairs to central supply and can usually get clippers from them. Review of policy and procedure revised 9/1/2017 titled Care of Nails indicates an emery board, orange stick and nail clippers be used for nail care. Procedures include trim fingernails and clean nails. 2. An interview was conducted with Resident #63 on 3/31/2022 at 12:27 PM. The resident stated she has had several problems with not getting changed when soiled. The resident stated she calls, and someone will come and say, I will be back then they don't come back for at least 30 mins. Resident #63 stated she has had to wait 2 hours before when soiled. A medical record review indicated Resident #63 was admitted on [DATE] with diagnoses including chronic kidney disease. A review of Resident #63's admission MDS assessment dated [DATE] revealed a Brief Interview for Metal Status (BIMS) score of 15, indicating intact cognition. Section H-Bowel and Bladder of the resident's MDS indicated she was always incontinent of bowel and bladder. A review of the orders for Resident #63 indicated the following: UA/CS (urinalysis/culture and sensitivity) every night shift for recurrent UTI for 1 day on 4/1/2022. A nursing note dated 3/16/2022 reported urine results positive for ESBL (extended spectrum beta-lactamase). The physician gave orders for Amoxicillin 875/125mg (milligrams) by mouth every 12 hours for 7 days. Nurse notified of new orders. Nursing to continue to monitor. A care plan (Initiated 2/16/2022) was in place for bowel and bladder incontinence. The interventions included clean peri-area with each incontinence episode, wash, rinse and dry perineum. change clothing prn after incontinence episodes, monitor/document for signs and symptoms of UTI, monitor/document/report as needed any possible causes of incontinence. An interview was conducted with Staff L, CNA on 3/31/2022 at 6:00 PM. Staff L stated when a call light goes off it should be answered as soon as possible. She added, sometimes CNAs are in another room taking care of patients and it takes a few minutes. Staff L stated she continually goes from room to room during her shift checking on her residents, especially those who are more dependent on staff for incontinence care. She stated, They need to be changed as quick as possible. Staff L stated she was responsible for them and doesn't want anything to happen to them. She said there was not enough staff for the number of residents. She stated the agency staff come in to assist and usually cannot be found anywhere. She stated they are smoking or go get food and are not around. An interview was conducted with Staff G, CNA on 4/1/2022 at 2:45 PM. Staff G stated he is often assigned to the same hall as Resident #95 and Resident #63 but doesn't always have them on his assignment. Staff G stated when call lights go off, he goes as quick as possible and if he is doing something with another resident, he will go tell the resident who called he will be back when he is finished. He stated he finishes what he was doing and then returns to assist the resident with incontinence care. Staff G stated he does not forget to go back to the resident who called for help.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, policy review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice during a recertification survey that was conducted on 03/29/2022 through 04/01/2022 and was cited F692 and F761. On 05/18/2022 the facility was recited for F692 and F761. The facility had developed a POC with a compliance date of 05/01/2022. Findings include: 1. Ongoing non-compliance was identified during the revisit survey related to nutritional supplement interventions with appropriate documentation in the medical record. The facility had developed a POC that included: DCS [Director of Clinical Services]/designee re-educated current licensed nurse 04/20/2022 on the components of this regulation with emphasis on ensuring appropriate documentation of a registered dietitian assessment, nutritional supplement interventions, physician/responsible party notification and weights obtain timely with appropriate documentation in the medical record for residents with a weight loss. DCS/Designee to conduct quality monitoring of residents with weight loss to ensure appropriate documentation of a registered dietitian assessment, nutritional supplement interventions, Physician/responsible party notification and weights obtain timely with appropriate documentation in the medical record 2 times weekly x [for] 4 weeks, then weekly x 2 months and PRN [as needed] as indicated. Review of Resident #12's admission record revealed she was readmitted to the facility on [DATE] with diagnoses that include but are not limited to Dementia with Behavioral disturbance, anxiety disorder, major depressive disorder, and stage 3 chronic kidney disease. Review of Resident #12's physician orders revealed an order to start on 4/23/22 with no end date: MedPass put Amt [amount] ordered PO [by mouth] in add direc. [additional directions] three times a day supplement. The additional directions were reviewed with no indication of how much MedPass to administer to Resident #12. Review of Resident #12's dietary note dated 4/23/22 revealed Resident w/16% wt [weight] loss since 12/8/21. BMI [body mass index] = 25.8 (WNL) [within normal limits]. s/p [status post] hospital stay. Intake 76-100% thus far. Receiving regular diet w/ fortified foods w/ pureed solids . Adding medpass 120ml TID [three times daily]. Will con't [continue] to monitor weekly wts [weights] and discuss at weekly SOC [standards of care] and provide additional recc's [recommendations] as indicated. Review of Resident #12's interdisciplinary team (IDT) note dated 4/23/22 revealed met to discuss resident weight loss post hospital stay. Resident was noted in restraints and combative at hospital. Resident is on weekly weights. Resident 76-100% po [by mouth] intake. Resident has orders for MVI [multivitamins], regular diet pureed solids, zinc, vitamin C. orders to add fortified foods, Medpass 120ml TID. IDT will continue to monitor. Review of Resident #12's medication administration record revealed from 4/23/22 at 5:00p.m. to 5/18/22 at 1:00 p.m. the resident received MedPass three times a day. There was no indication of how much MedPass to give and there was no documentation of how much MedPass was given. An interview with Staff D, Registered Nurse (RN) was conducted on 5/19/22 at 2:40 p.m. she stated she was Resident #12's nurse and she said, I give her 30ml's [milliliters] I think it is, a whole cup full of MedPass. Staff B, Licensed Practical Nurse (LPN), Unit Manager was next to Staff D, RN at the time of the interview, and she said she believes a full cup is 240ml's. Staff B, LPN, Unit Manager reviewed Resident #12's orders and she confirmed the order does not specify how much to give. An interview was conducted with the Director of Nursing (DON) on 5/18/22 at 2:18 p.m. She stated Resident #12's MedPass order should indicate how much of the MedPass to give. A nutritional assessment/management policy was requested, and the facility indicated they did not have one. Review of the facility's Physician Orders policy revised on 3/3/21 revealed Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record. 2. Ongoing non-compliance was identified at the revisit related to storage of resident medications and biologicals in refrigerators with proper temperature controls. The facility developed a POC that included: Current Licensed Nurses re-educated by the DCS/designee on 4/20/2022 regarding the components of this regulation with emphasis on ensuring the facility must store all drugs and biologicals in locked compartments under proper temperature controls. Quality monitoring of medication rooms to be completed by the DCS/designee to ensure the refrigerator is maintained under proper temperature controls 5 times weekly x 4 weeks, 3 times weekly x 4 weeks then twice weekly and PRN as indicated. An observation was conducted on 5/18/22 at 10:30 a.m. of the 4th floor medication storage fridge. The thermometer was observed to be at 50 degrees Fahrenheit. Staff A, Registered Nurse (RN) confirmed the fridge thermometer was 50 degrees. She stated she was unsure what the temperature was supposed to be set at (Photographic evidence was obtained). An interview was conducted on 5/18/22 at 10:33 a.m. with the 4th floor unit manager, Staff B, Licensed Practical Nurse (LPN). She stated the night shift does the documenting of the fridge temperatures. She stated the fridge temperature should be 40 degrees and said she will call maintenance to fix the fridge. A second observation of the 4th floor medication storage fridge was conducted on 5/18/22 at 2:47 p.m. the thermometer in the medication storage fridge read 50 degrees Fahrenheit. Staff C, RN confirmed the thermometer read 50 degrees and also confirmed there were resident medications stored in the fridge. Observation of the medication storage fridge located on the 2nd floor was conducted on 5/18/22 at 10:02 a.m. The 2nd floor medication storage fridge was observed to be crowded with medication. Inside the fridge was wet with dripping water. The thermometer was observed at 50 degrees Fahrenheit. Staff D, RN confirmed the thermometer read 50 degrees. Staff E, RN also confirmed the fridge was too warm and all the medications needed to be moved to another fridge for proper storage. She stated she will contact maintenance to fix the fridge (Photographic evidence obtained). A second observation was conducted of the 2nd floor medication storage fridge on 5/18/2 at 2:45 p.m. The fridge was observed still be overcrowded with medications and the thermometer was observed to be at 48 degrees Fahrenheit. Staff B, RN confirmed the thermometer read 48 degrees. On 5/18/22 at 3:02 p.m. the Maintenance Director and the Nursing Home Administrator (NHA) were interviewed, and the Maintenance Director said this morning he looked at the 2nd floor medication storage fridge and it was packed full of medications. He stated he was going to check the fridges. An interview was conducted with the Director of Nursing (DON) on 5/18/22 at 12:15 p.m. She indicated the medication storage fridges should not be above 46 and not below 36 degrees Fahrenheit. She said she tasked the Unit Managers to check the fridge temperatures. Review of the facility's Temperature Log for Refrigerator-Fahrenheit undated revealed: Danger! Temperatures above 46 [degrees Fahrenheit] are too warm! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately! Danger temperatures below 36 [degrees Fahrenheit] are too cold! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately! Review of the facility's policy Storage and Expiration Dating of Medications, Biologicals Revised on 1/1/22 revealed: Procedure -3. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. -11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the Unit States Pharmacopeia guidelines for temperature ranges . -11.2 Refrigeration 36 degrees - 46 degrees F [Fahrenheit]. -12. Facility should monitor refrigerated storage for evidence of moisture and condensation (humidity) and may consult with pharmacy regarding medication integrity. -12.1 when moisture is observed in the refrigerator, facility staff should evaluate how often the refrigerator door is opened, and consider a faulty door, broken thermostat, or blocked vent. -12.2 allowing air to circulate around the items stored (i.e., not overcrowding item) will promote low humidity. An interview was conducted on 5/18/22 at 4:56 a.m. with the NHA and the Risk Manager (RM). They indicated the facility's Quality Assurance and Performance Improvement team met several times to develop and review their POC. The NHA and the RM said they discovered some audits were not being completed. The RM indicated losing a unit manager, using agency staff, and trying to complete all the audits between herself and the DON was hard to get done. The RM also indicated the POC audits were reviewed during the clinical morning meetings, but the Quality Assurance and Performance Improvement team had not met to do a complete review of the audits. Review of the facility's Performance Improvement Committee (Quality Assurance) policy revised on 8/19/2020 revealed: Policy: The Performance Improvement Committee will meet to review, recommend, and act upon activities of the facility, performance improvement teams and/or department activities. The committee shall direct all activities including approving proposed monitoring, evaluating and review of services. The committee will assure QAPI activities have indicators and standards/thresholds for evaluation, that appropriate actions are implemented, and that such correction has been evaluated by subsequent monitoring.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of policy and maintenance logs, the facility did not ensure the transportation services were adequate related to the air conditioning not cooling residents during transport in the facility's van for two residents (Resident #380 and Resident #77) of two residents transported in the facility's only van during the week of March 28, 2022. Findings included: An interview was conducted with Resident #380 on 3/31/2022 at 12:30 PM. The resident stated she was transported in the facility van on 3/30/2022 to a doctor's appointment and the van was very hot. She stated she was sitting in the back of the van in her wheelchair. She stated she was fanning herself and she started feeling sick from overheating. She stated she threw up as soon as she reached the doctor's office and in the van when she was returning to the facility. A review of Resident #380's Minimum Data Set (MDS,) dated 2/7/2022, has a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section C of the MDS showed no mental, memory or cognitive concerns. She needs extensive assistance for mobility, transport and locomotion. The resident stated her appointment was at 3:30 PM. An interview was conducted with Staff C, Transport Van Driver on 3/31/2022 at 12:45 PM, he stated the facility has only one van. It is a 2007. Staff C stated he is the primary driver and responsible for ensuring the van works properly. He stated the air conditioning works in the van, but it takes a little bit for it to cool off, maybe 20-30 minutes. He stated there is only one vent in the rear of the van, so it does not get as cool as the front. He stated he tries to go out and start the van before loading the resident and can do it most of the time, however, he did not start it prior to the transport of Resident #380 yesterday. Staff C stated the van is always running when a resident is in it. While transporting Resident #380 on 3/30/2022 he noticed she was fanning herself with papers and she said it was hot. He stated he had the air conditioning on maximum cooling. He stated the resident did vomit on the way back to the facility. He stated upon return to the facility he did not report the heat concerns to anyone or notify the resident's nurse she had gotten sick. He stated her son followed them to and from the appointment in his vehicle and the son went back up to her room with her. An observation was conducted on 3/31/2022 at 12:45 PM with Staff C. He went outside and turn the van on at 12:47 PM with the air conditioning on maximum cool. The temperature was taken with a thermohygrometer. The starting temperature inside the back of the van measured to be 80.9 degrees Fahrenheit (F). After ten minutes the temperature reading inside the van was 79.7 degrees F in the back, where residents are seated. The air temperature decreased 1.2 degrees in ten minutes of running the air conditioning on maximum cooling. The air temperature when tested directly coming from the vent, in the middle of the van, was 70.7 degrees F. There was one vent in the back section of the van observed with limited air flow in the area where wheelchairs would be positioned for transport. The vehicle has very little to no tint on the windows. (Photographic evidence obtained) The weather in [NAME], Florida (FL) on 3/31/2022 at time of testing was 83 degrees F and mostly cloudy. The weather in [NAME], FL at time the of transport on 3/30/2022 at 3:00 pm was 88 degrees F and sunny, with a few clouds. Reference: https://www.weather.gov. An interview was conducted with Resident #77 on 3/31/2022 at 2:40 PM, resident stated she was transported on 3/28/2022. She stated sat in the back of the van in her wheelchair for transport. She stated it was a little bit hot. Resident 77's transport was 3/28/2022 at 11:00am. An interview was conducted with Staff D, Registered Nurse (RN) 04/01/2022 at 04:33 PM. Staff D indicated he was the nurse taking care of Resident #380 when she returned from transport on 3/30/2022. He stated no one told him the resident had gotten sick or had any concerns. He said when a resident is transported back, the transport driver usually puts the resident in their room and tell staff they are back. He stated there was no report to him of resident's change in condition. Staff D stated later in the evening the resident mentioned in passing to him the van was hot. He stated he had no idea she had gotten sick. He said he would expect to be told if the resident had a change of condition while they were gone so he could check on the resident and follow up. A review of the van's maintenance log showed the van was last in for regular service on 8/13/2021. Air conditioning problems for the van were previously diagnosed and serviced on 9/8/2020, 5/31/2019, and 4/17/2018. A review of the facility policy titled Motor Vehicle Safety (effective 11/30/2014) indicated the following It is the facility policy to ensure motor vehicle safety in providing and maintaining a safe working environment. The facility considers the use of automobiles as part of the working environment. Procedures showed 4. Accident recordkeeping, reporting, analysis 6. Vehicle inspection and maintenance. The Transportation Request for Resident #380 shows the transport was from the facility to the doctor's office. This was a distance of 19 miles and approximately 28 minutes. The Transportation Request for Resident #77 show transport was from the facility to a doctor's appointment. This was a distance of 10 miles and approximately 23 minutes. According to the Health in Again Foundation When the temperature climbs above 80°F, older adults need to be proactive and take precautions to avoid ailments due to excessive heat. The Health in Aging Foundation is the official foundation of the American Geriatrics Society. https://www.healthinaging.org

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) During a facility tour on 03/29/22 at 10:28 AM an observation was conducted for Resident #95. Resident #95's oxygen tubing was on the floor with the oxygen concentrator running. The resident was out of the facility at the time (Photographic evidence obtained.) A medical record review indicated Resident #95 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, legal blindness, muscle weakness, Type 2 Diabetes Mellitus without complications, wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing. The resident's orders included: Oxygen as needed (PRN) 2 liters if oxygen levels <93%. Start date 3/3/2022, Change tubing, mask and/or nasal cannula weekly, may change sooner as needed for hygiene and every night shift Thu for hygiene, Pulse Ox every day shift for monitoring. Start date 3/4/2022 Resident #95's Minimum Data Set (MDS) review completed on 2/14/2022 and indicated a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G-Functional Abilities of the MDS indicated resident needs extensive assistance with toilet use, personal hygiene, bed mobility, dressing and transfers and for walking in his room and corridor, resident needs limited assistance. 5) During a facility tour on 3/29/2022 at 10:29 AM an observation was conducted for Resident #381. Resident was in bed sleeping with nasal cannula in place. His nebulizer tubing and mouthpiece were lying on the bedside table, uncovered (Photographic evidence obtained.) Medical record review indicated Resident #381 was admitted on [DATE] with diagnoses including encephalopathy, sepsis, dementia without behavioral disturbances, muscle weakness, chronic pain, dysphagia. The resident's orders included: Oxygen via nasal cannula at 4 liters/min to maintain oxygen sats (saturation) above 90% as needed for treatment. Start date 3/27/2022; Ipratropium-Albuterol Solution 0.5-2.5 milligrams(mg)/3 milliliters(ml). 3ml inhale orally every 12 hours as needed for SOB (shortness of breath) and wheezing. Start date 3/7/2022. A MDS review on 3/11/2022 indicated a BIMS should not be conducted. Section C of the MDS indicated Resident #381's cognitive skills for daily decision making are severely impaired. Resident in totally dependent or needs extensive assistance for all activities of daily living (ADLs.) 6) During a facility tour on 03/29/2022 at 11:44 AM Resident #378's oxygen tubing was observed lying on the floor, resident was not in his room at the time (Photographic evidence obtained.) A review of medical records indicated Resident #378 was admitted on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, hypokalemia, other pulmonary embolism without acute COR pulmonale. The resident's orders included: Respiratory oxygen- continuous at 2L Revision date 3/27/2022, Change tubing, mask and/or nasal cannula weekly, may change sooner if needed. As needed for hygiene and every night shift every Friday. Start date 3/27/2022. MDS review is in progress from admission. BIMS score was indicated to be 15, indicating intact cognition. No respiratory/oxygen care plans were in place. Review of the electronic medication administration record (eMAR) documented breath sounds are being checked and vital signs taken as ordered. An interview was conducted with Staff E, Registered Nurse (RN) and Infection Preventionist on 3/30/2022 at 10:15 AM. Staff E stated the expectation would be for respiratory equipment such as oxygen tubing and nebulizer masks to be stored in a plastic bag. She stated the equipment should not be on the floor or uncovered. Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to storage of oxygen, and nebulizer tubing's and supplies, consistent with professional standards of practice for six residents (#56, #69, #95, #178, #378, #381) of ten facility residents receiving respiratory treatments. Findings included: 1) On 3/29/22 beginning at 10:00 am a tour of the facility was conducted. Resident #56 was observed lying in her bed in the room. An oxygen tubing with nasal cannula was observed on the floor next to the resident's bed. Photographic evidence was obtained. The resident stated she does use oxygen sometimes. A review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with a diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), anxiety, shortness of breath, nicotine dependence, and asthma. A review of the orders for Resident #56 revealed an order dated 3/3/22 for Oxygen as needed at 2 liters/minute. The order was discontinued on 3/25/22. A review of the Treatment Administration Record (TAR) dated March 2022 revealed the following: Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. Every night shift every Thursday. (signed off by nursing as completed on 3/24/22) Oxygen as needed 2 liters/minute (start date 3/3/22-discontinue date 3/25/22) 2) On 3/29/22 at 10:15 a.m., Resident #69 was observed in her room. An oxygen tubing with nasal cannula was observed draped over a cord and on the floor in the room. Photographic evidence was obtained. The resident stated the concentrator and oxygen was for her. A review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure, asthma, and CHF. A review of the Order Summary Report revealed the following: Oxygen as needed at 2 liters if oxygen saturation less than 90% (start date 3/3/22). Change tubing, mask and/or nasal cannula weekly. May change sooner as needed for hygiene (start date 3/3/22). 3) On 3/29/22 at 12:00 p.m., Resident #178 was observed walking down the hallway coming from the shower room towards her room. An interview was conducted with the resident when she reached her room. An oxygen tubing was observed draped over the resident's bed. Photographic evidence was obtained. A nebulizer machine, tubing and mask was observed sitting on the nightstand. The tubing and mask were not stored in a plastic bag. Photographic evidence was obtained. The resident stated she is on oxygen and does get respiratory treatments at the facility. A review of the medical record for Resident #178 revealed the resident was admitted to the facility on [DATE] with a diagnosis of carcinoma in situ of bronchus and lung, COPD, and CHF. A review of the Order Summary Report for Resident #178 revealed the following: Respiratory oxygen 2 liters continuous every shift (started on 3/17/22). Ipratropium-Albuterol solution 0.5-2.5 milligrams/milliliter 3 milliliter inhale orally every eight hours as needed for shortness of breath. A review of the Medication Administration Record (MAR) for March 2022 revealed the last nebulizer treatment of Ipratropium-Albuterol was given on 3/19/22 and signed off by nursing. The document revealed nursing was signing off the oxygen order daily each shift. On 3/30/22 at 10:15 a.m., an interview was conducted with the Infection Control Nurse (ICN), RN. The nurse stated all oxygen and nebulizer tubing, and supplies should be cleaned and kept in a clean plastic bag for continued use. The nurse stated the tubing and supplies are changed every Friday for sanitary reasons. A review of the policy titled Oxygen Therapy with an effective date of 11/30/14 and a revision date of 8/28/17 indicated the following: Policy: Oxygen therapy is the administration of a FiO2 (oxygen concentration) greater than 21% by means of various administration devices to: raise the resident's PaO2 (percent arterial oxygen) to an acceptable baseline using the lowest FiO2, to treat arterial hypoxemia, to decrease work of breathing, to reverse and prevent tissue hypoxia, and to decrease myocardial work. Procedure: .Gather necessary equipment, follow infection control procedures, as appropriate A review of the policy titled Nebulizer with an effective date of 11/30/14 and a revision date of 3/20/18 indicated the following: Note: Small volume nebulizers are used to deliver medication aerosols to the respiratory tract to relieve bronchospasm, to deliver medications, to improve the effectiveness of the cough and to relieve mucosa edema. Small volume nebulizers create a mist from a liquid medication solution that can be inhaled into the bronchial tree. Droplets of mist are delivered through a facemask or mouth piece and absorbed into the bloodstream through alveoli with in the lung tissue. Procedure: Disassemble device and rinse the mouthpiece and nebulizer cup with water and air dry. Place entire unit in a bag to be maintained in the resident's room.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observations, interviews and record review the facility failed to ensure proper storage of drugs and biologicals as evidenced by: 1) not maintaining refrigerator temperatures within reference range for three of three medication refrigerators, and 2) not storing four vials of Lorazepam 2 mg (milligrams)/ml (milliliter), a Schedule IV medication, in a permanently affixed compartment in the refrigerator for one of three medication storage rooms. Findings included: On 3/31/22 at 12:15 p.m., a medication storage room observation on the second floor of the facility was conducted with Staff H, Registered Nurse (RN). The refrigerator inside of the storage room was locked and a log of temperature checks was observed on the outside of the refrigerator. Photographic evidence obtained. The log indicated the temperature range for the refrigerator was to be between 35 degrees Fahrenheit and 46 degrees Fahrenheit. The document indicated the aim was to be at 40 degrees Fahrenheit and alerted staff to take immediate action to correct a temperature that was out of range. A check of the temperature gauge in the refrigerator indicated the temperature was reading 50 degrees Fahrenheit. The refrigerator was noted to be dripping water from the small freezer area. Photographic evidence obtained. The nurse indicated the temperature was too high and she would call maintenance to get it looked at. The refrigerator contained medications at the time of the observation. On 4/1/22 at 2:15 p.m., a medication storage room observation on the fourth floor of the facility was conducted with Staff I, RN. The refrigerator inside the storage room was locked and a log of temperature checks was observed on the outside of the refrigerator. Photographic evidence obtained. A check of the temperature gauge in the refrigerator indicated the temperature was reading 51 degrees Fahrenheit. The refrigerator was noted to be dripping water from the small freezer area. Photographic evidence obtained. The nurse indicated the temperature was too high and he would call maintenance to get it looked at. The refrigerator contained medications at the time of the observation. The refrigerator contained a clear plastic box on the top shelf, it was unlocked and able to be removed from the refrigerator for inspection. The box contained two plastic sleeves. The first plastic sleeve was labeled for Resident #40 and contained two vials of Lorazepam 2 mg/ml, a Schedule IV medication. The second plastic sleeve was labeled for Resident #43 and contained two vials of Lorazepam 2 mg/ml, a Schedule IV medication. Photographic evidence obtained. The nurse stated the drawer just broke yesterday and it should be secured and locked. On 4/01/22 at 02:45 p.m., a medication storage room observation on the third floor of the facility was conducted with Staff J, RN. The refrigerator inside the storage room was locked and a log of temperature checks was observed on the outside of the refrigerator. Photographic evidence obtained. A check of the temperature gauge in the refrigerator indicated the temperature was reading 24 degrees Fahrenheit. Photographic evidence obtained. The nurse indicated the temperature was too low and she would call maintenance to get it looked at. The refrigerator contained medications at the time of the observation. On 4/1/22 at 3:15 p.m., the Director of Nursing was notified of the findings related to medication storage. The DON indicated the refrigerators were to be checked on the night shift and the narcotics are to be kept in the clear box with a lock and secured to the refrigerator on the inside. She stated she would have this corrected.

Feb 2021 3 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to provide required written beneficiary notifications (Skilled Nursing Facility Advance Beneficiary Notice Form Centers for Medicare and Medicaid Services 10055 [SNF ABN Form CMS-10055]) to three (Resident #7, Resident #68 and Resident # 83) of three sampled residents. Findings included: On 2/11/21 at 9:30 a.m., written notices for Resident #7, Resident #68 and Resident # 83 were reviewed. There was no documentary evidence of completed SNF ABN Form CMS-10055 for all three sampled residents. 02/11/21 1:51 p.m., the Interim Executive Director, Staff A and the Director of Social Services, Staff B were interviewed. Staff A and Staff B stated the facility had not been providing eligible residents copies of completed SNF ABN Form CMS-10055. Both stated the facility had not been completing the documents. Staff A stated the facility social workers had not been trained on the required beneficiary notice. On 02/12/21 9:57 a.m., Staff B was interviewed. Staff B stated she was not familiar with the required SNF ABN Form CMS-10055. Staff B stated since she started in May 2020, We have not been completing them and therefore had not been informing eligible residents of what is covered and not covered by Medicare Part A. Review of the facility policy and procedure titled Advance Beneficiary Notice - ABN last revised 11/10/2015, indicated, An ABN will be utilized to notify residents of the possibility that medicare will not pay for the item(s) that are described on the form. The facility will place their name, address, and telephone number on the top of the notice header; and may elect to include their logo. The form cannot otherwise be modified other than the additional information that is required. Information added to the form must be in at least 12 font and legible. The form will be reviewed with the residents or authorized representatives .The facility will give a completed copy of the ABN far enough in advance that the beneficiary or the representative has the time to consider the options and make an informed choice .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and policy review the facility failed to ensure that the confidential medical information for one (Resident # 109) of six residents reviewed during the facility task of Medication Administration, was secured when he left the computer screen displaying Resident #109's record unattended on his cart on multiple occasions during a medication pass. Findings included: During the evening medication pass of 02/11/21 at 4:45 p.m. Staff C, Registered Nurse (RN) stepped away from his medication cart to verify that a glucometer was stored in Resident #109's room. Staff C, locked his cart when he stepped away but neglected to lock the screen or close the computer that sits atop the cart and displayed the confidential medical information for Resident # 109. Staff C returned to the cart and proceeded to prepare his supplies when he noticed that he did not have any gloves, he locked the cart but did not close the computer leaving the private confidential information pertaining to Resident #109's medication in full view on the computer screen. Once Staff C, RN had gathered all the necessary supplies, he locked his cart but did not close the computer, he entered Resident # 109's room. Staff C left the computer screen displaying Resident # 109's private medical information. Several residents and other employees were seen in the hallway. When he returned to the cart, he confirmed that the computer screen should be closed to ensure the privacy of resident records when the cart was unattended. He confirmed that education related to confidentiality of the medical record was provided to him during orientation. Staff C stated, As a nurse, I know that this medical information is private and I should have locked the screen. A request was made to the Director of Nursing (DON) and a Regional Clinical Resource for the policy pertaining to ensuring that the private confidential information of the residents was not at risk during medication administration, but review of the provided policy did not provide any additional information.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observations, interviews and record review the facility failed to maintain drugs and biological's used in the facility in a safe, secure, and orderly manner in three of five inspected medication carts and one of two inspected medication storage rooms. Findings include: On 2/11/21 at 4:25 p.m., an observation of the second-floor low side medication cart was conducted with Staff G, Registered Nurse (RN). The nurse was asked to open the narcotic drawer to verify the narcotic count. Staff G opened the narcotic drawer without a key. Photographic evidence was obtained. The nurse was asked how long the narcotic drawer had been broken and the lock propped with a straw. The nurse stated it had been like that for a while maybe two years. In the top drawer of the medication cart, an Insulin pen had no open date or expired date on the packaging or the pen. Photographic evidence obtained. A second Insulin pen was observed to be expired (opened on 1/8 and expired on 2/6). Photographic evidence obtained. An interview with Staff G was conducted. Staff G stated she was responsible for making sure all medications in the cart were not expired and when Insulin was removed from the refrigerator and placed in the cart it was the policy to date it with an open and an expire date. On 2/11/21 at 4:45 p.m., an observation of the second-floor medication storage room was conducted with Staff G. A small refrigerator located inside the storage room was opened for inspection by the nurse. Seven vials of Lorazepam 2 mg/ml, a schedule II medication, in two bags were observed in a non-affixed small metal box sitting on the shelf and able to be removed from the refrigerator for inspection. Photographic evidence obtained. An interview with Staff G was conducted. The nurse stated the medications had always been kept that way to her knowledge. On 2/11/21 at 5:15 p.m., an observation of the second-floor high side medication cart was conducted with Staff C, RN. In the top drawer of the medication cart an Insulin vial was observed with no open or expiration date on the label or the bottle. Photographic evidence obtained. A second vial of Insulin was observed to be expired (opened on 1/7, expired on 2/5). Photographic evidence obtained. A third vial of Insulin was observed with no open or expiration date on the label or the bottle. Photographic evidence obtained. Loose pills were observed in the second drawer of the medication cart. Photographic evidence obtained. In the bottom drawer of the medication cart a large bag of Perforomist 20 mcg/2 ml with two stickers on the bag stating REFRIGERATE. Photographic evidence obtained. An interview was conducted with Staff C. The nurse indicated he was not aware of why the medication would be in the medication cart when it was labeled to refrigerate. The nurse confirmed expired medications should not be in the medication cart and should be disposed of. The nurse stated when Insulin was removed from the refrigerator, they were to label it with an open date and an expiration date per policy. On 2/12/21 at 12:50 p.m., an observation of the third-floor low side medication cart was conducted with Staff H, RN. On the top drawer of the medication cart a vial of Insulin was observed to have no open or expired date on the packaging or the vial. Photographic evidence obtained. An interview was conducted with Staff H. The nurse confirmed that all Insulin was to be dated with an open date and an expired date once removed from the refrigerator and placed in the medication cart according to policy. On 2/12/21 at 2:21 p.m., a telephone interview was conducted with the facility Consulting Pharmacist. She indicated the facility was to keep all Schedule II-V medications in a separate locked area and in a fixed compartment that could not be removed. She indicated there were fixed drawers in some of the refrigerators. The Consulting Pharmacist stated all Insulin were to be dated with an open date and an expire date once it was removed from the refrigerator and stored in the medication carts. She stated the Perforomist should also be dated once it was removed from the refrigerator to assure it did not expire. A review of the facility policy entitled Storage and expiration dating of medications, biologicals, syringes, and needles (revised 10/28/2019) indicated the following: Applicability: This policy 5.3 sets for the procedures relating to storage and expiration dates of medications, biological, syringes and needles. Procedure: 2 Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. 3.1 Facility should store Schedule II-V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key to access device 3.1.1 Store all drugs and biologicals in locked compartment, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. 5 Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. 11 Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the Untie States Pharmacopeia guideline for temperature ranges. 17 Facility should destroy or return all discontinued, outdated/expired, or deteriorated medication or biologicals in accordance with Pharmacy return/destruction guidelines.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 2 harm violation(s), $152,565 in fines. Review inspection reports carefully.
• 33 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $152,565 in fines. Extremely high, among the most fined facilities in Florida. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Aviata At The Bay's CMS Rating?

CMS assigns AVIATA AT THE BAY an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Florida, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Aviata At The Bay Staffed?

CMS rates AVIATA AT THE BAY's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 54%, compared to the Florida average of 46%. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Aviata At The Bay?

State health inspectors documented 33 deficiencies at AVIATA AT THE BAY during 2021 to 2024. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 29 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Aviata At The Bay?

AVIATA AT THE BAY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AVIATA HEALTH GROUP, a chain that manages multiple nursing homes. With 150 certified beds and approximately 142 residents (about 95% occupancy), it is a mid-sized facility located in TAMPA, Florida.

How Does Aviata At The Bay Compare to Other Florida Nursing Homes?

Compared to the 100 nursing homes in Florida, AVIATA AT THE BAY's overall rating (1 stars) is below the state average of 3.2, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Aviata At The Bay?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.

Is Aviata At The Bay Safe?

Based on CMS inspection data, AVIATA AT THE BAY has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Florida. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Aviata At The Bay Stick Around?

AVIATA AT THE BAY has a staff turnover rate of 54%, which is 8 percentage points above the Florida average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Aviata At The Bay Ever Fined?

AVIATA AT THE BAY has been fined $152,565 across 10 penalty actions. This is 4.4x the Florida average of $34,605. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Aviata At The Bay on Any Federal Watch List?

AVIATA AT THE BAY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 150
Avg. Residents: 142
Occupancy: 94.7%
Ownership: For profit - Limited Liability company
Chain: AVIATA HEALTH GROUP
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
2 Immediate Jeopardy citations: -24
2 Actual Harm citations: -10
33 Deficiencies: -10
Fines ($152,565): -15
Abuse Finding: -15
Final Score: 0/100

Nearby Alternatives

EXCEL CARE CENTER 5-star SUN TERRACE HEALTH CARE CENTER 4-star CANTERBURY TOWERS INC 4-star

View all in TAMPA →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 105417