Advanced Care Center

involving the resident b.

Discovery of injuries of an unknown source.2. A significant change of

b. impacts more than one area of the resident's health status; c. requires interdisciplinary review

will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form.8.

The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2011 showed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exportation. 8.

Identify and investigate all possible incidents of abuse, and neglect, mistreat or misappropriation of resident property. 9e.

Investigate and report any allegations within time frames required by federal regulations. 10.

Protect residents from any further harm during investigations.

105478 10/23/2025

Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

did have an admission checklist, but it depended on the nurse if they used it or not.A follow-up

everything is in the record and match what came from the hospital.

The DON said she was not there

if they reviewed them.An interview was conducted on 10/15/25 at 6:48 p.m. with the Assistant Director of Nursing (ADON).

She said when reviewing new admission in the clinical meetings the Unit Manager (UM) reviewed the admission paperwork and the resident's electronic medical record if pulled up on the big screen.

She said the UM goes through the paperwork from the hospital and they all make sure the orders were entered correctly.

She did not recall if Resident #1 and #2's records were reviewed.An interview was conducted on 10/15/25 at 6:55 p.m. with Staff F, LPN/UM.

Staff F said she did admission record reviews and in that process, she made sure batch orders were in place, she checked medications on the discharge paperwork and ensured correct doses were ordered.

Staff F said she did not recall Resident #1 or #2's review.

She said seeing stop insulin on the hospital discharge paperwork wouldn't necessarily make her question it because some residents are on insulin temporarily in the hospital, but if a resident and/or RR said the resident was on insulin she would call the doctor or expect the nurse to call and get orders for insulin and/or blood glucose checks.Residents #1 and #2 primary care provider could not be reached.

Review of the facility admission Checklist included but not limited to: -Add/Verify Attending Physician-Input Diagnosis and review H&P (history and physical)-Review hospital discharge orders-Add/Verify MD (medical doctor) orders from discharge med reconciliation ensure appropriate diagnosis, route, parameters.

Ensure each diagnosis is covered in medication regimen if applicable.On 10/15/25 at 7:04 p.m. the DON stated the facility did not have a policy on medication reconciliation or diabetes management or the admission process.Review of a facility policy titled Physician Services, revised February 2021, showed: Policy Statement - The medical care of each resident is supervised by a licensed physician.Policy Interpretation and Implementation showed:1. A physician must recommend in writing that an individual be admitted to the facility.

This can be accomplished through:a. hospital transfer summary completed by a physician;b. admission paperwork completed by the resident's physician in the community:c. other written form completed by a physician; ord. a physician 's admission orders for the resident's immediate care.2.

Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).

105478 10/23/2025

Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

Review of an order summary dated 10/23/2025 showed:Consult Urology for urinary retention, verbal active order, dated 10/23/2025.

Review of a progress note dated 10/08/2025 created by Staff G, Advanced Registered Nurse Practitioner (ARNP) noted to start a voiding trial on Resident #5. If voiding trial fails reinsert indwelling foley and consult urology.

Review of a progress note dated 10/13/2025 created by Staff G, ARNP showed Staff G gave verbal orders previously on Friday for voiding trial, but it was not done for unknow reasons.

Staff G noted she spoke with nursing and the Director of Nurses (DON) about the plan and requested voiding trial to be done and if voiding trial fails, consult urology.

Review of a progress note dated 10/20/2205 created by Staff G, ARNP showed on 10/20/2025, Resident #5 did not pass voiding trial despite electronic record documentation indicating otherwise.

Staff G noted Resident #5 had not voided with need for straight cath (catheterization) and greater than 400 mls [milliliters] output with urinalysis with culture and sensitivity obtained and + yeast, see labs and plan. On 10/23/2025 at 2:00 p.m. an interview was conducted with the Director of Nurses, DON.

The DON said the ARNP put Resident #5 on a voiding trial because she did not have justification for the use of a foley catheter.

The DON stated the ARNP wanted Resident #5 to start a voiding trial.

The DON said, When we conducted the trial, the resident failed.

The DON said the Nurse Practitioner noted to consult urology if Resident #5 failed the trial, but she did not put an order in the system.

The DON said when she reached out to the ARNP she told them to just leave the foley in.

The DON said the ARNP could have put the urology consult order in the system if she wanted Resident #5 to be seen by urology. On 10/23/2025 at 3:30 p.m. an interview was conducted with Staff G, ARNP.

The ARNP said she wrote in her progress notes to start a voiding trial on Resident #5 because she had a diagnosis on her 3008 for acute retention.

She said she told the nurse and the director of nurses twice if the resident failed the voiding trial to consult urology.

She said the director of nurses reached out to tell her the resident was not voiding, and they only obtained 2000 milliliters of urine.

The ARNP said she told the DON they needed to get a consultation from urology.

The ARNP said once she gave the facility a verbal order they should have put the urology consult order in the system.

She said she told the Unit Manager and the DON both to consult urology if the resident did not pass the voiding trial.

She said the told the Unit Manager on Friday and told the DON again on Monday to consult urology for Resident #5.

She said she told them to leave the foley in and consult urology The facility did not have a policy/procedure regarding care consultation and referral.

105478 10/23/2025

Advanced Care Center 401 Fairwood Ave Clearwater, FL 33759

depended on the nurse if they used it or not.A follow-up interview was conducted with the DON on

from the hospital.

The DON said she was not there when Resident #1 and #2's records would have

conducted on 10/15/25 at 6:48 p.m. with the Assistant Director of Nursing (ADON).

She said when reviewing new admission in the clinical meetings the Unit Manager (UM) reviewed the admission paperwork and the resident's electronic medical record if pulled up on the big screen.

She said the UM goes through the paperwork from the hospital and they all make sure the orders were entered correctly.

She did not recall if Resident #1 and #2's records were reviewed.An interview was conducted on 10/15/25 at 6:55 p.m. with Staff F, LPN/UM.

Staff F said she did admission record reviews and in that process, she made sure batch orders were in place, she checked medications on the discharge paperwork and ensured correct doses were ordered.

Staff F said she did not recall Resident #1 or #2's review.

She said seeing stop insulin on the hospital discharge paperwork wouldn't necessarily make her question it because some residents are on insulin temporarily in the hospital, but if a resident and/or RR said the resident was on insulin she would call the doctor or expect the nurse to call and get orders for insulin and/or blood glucose checks.Residents #1 and #2 primary care provider could not be reached.

Review of the facility admission Checklist included but not limited to: -Add/Verify Attending Physician-Input Diagnosis and review H&P (history and physical)-Review hospital discharge orders-Add/Verify MD (medical doctor) orders from discharge med reconciliation ensure appropriate diagnosis, route, parameters.

Ensure each diagnosis is covered in medication regimen if applicable.On 10/15/25 at 7:04 p.m. the DON stated the facility did not have a policy on medication reconciliation or diabetes management or the admission process.Review of a facility job description titled Licensed Practical Nurse/Registered Nurse, revised 1/1/15, showed: Purpose of Your Position - 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 CNAs/GNAs and other nursing personnel. To monitor the performance of CNAs/GNAs, nursing and non licensed personnel, provide education and counseling, perform disciplinary action as necessary, and complete performance evaluations.

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 Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times.Charting and Documentation Complete and file required recordkeeping forms or charts upon the resident's admission, transfer, and/or discharge.

Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.

Receive telephone orders from physicians and record on the Physician's Order Form.Transcribe physician's orders to resident charts, cardex, medication cards, treatment or care plans, as required.

Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.

Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor and/or Unit Manger.Drug Administration Functions Review medication cards for completeness of information,) accuracy in the transcription of the physician's order, and adherence to stop order policies.

Notify the attending physician of automatic/stop/orders prior' to the last dosage being administered.Nursing Care Functions Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary.

Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary.

Maintain established nursing objectives and standards.