Florence Health Services

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who is a certified dietary manager, a certified food service manager, has a national certification for food service management and safety from a national certifying body, or who has an associate's or higher level degree in food service management or hospitality. This practice had the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 48 of 49 residents residing in the facility (1 resident received nutrition via tube feeding.) The facility did not store food in a manner to ensure food safety, including proper food dating. Staff did not test or document parts per million (PPM) of the sanitizing solution.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure residents were given the information to file a complaint, including the name and contact information for the State Survey Agency and a list of names/addresses/telephone numbers of other pertinent state agencies. In addition, the facility did not ensure information regarding resident's rights and how to file a grievance was posted in the facility. This had the potential to affect more than 4 of the 49 residents residing in the facility. During a Resident Council meeting on 4/7/26, R39, R55, R18, R45, and R46 indicated they did not know how to file a complaint with the State Agency. In addition, the residents did not know how to access a list of state agencies, did not know how to file a grievance with the facility, and stated they did not have access to information regarding residents' rights.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 6 residents (R) (R4, R7, R23, R43, R16, and R55) of 16 sampled residents. The facility did not ensure R4, R7, R23, and R43's rooms and/or bathrooms were in clean condition and were cleaned daily. R16's bed did not have a bariatric fitted sheet which caused R16 discomfort. Residents who ate in the dining room at the same table were not served meals together which caused residents (including R55) to watch others eat as they waited for their food.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not follow ordered diets and menus to ensure nutritional needs were met for 11 residents (R) (R1, R47, R7, R27, R15, R41, R20, R11, R17, R14, and R4) of 11 sampled residents. Residents with pureed diets (R1 and R47) and mechanically-altered diets (R7, R27, R15, R41, R20, R11, R17, and R14) did not receive the ordered serving sizes for breakfast on 4/7/26 or breakfast and lunch on 4/8/26. Residents with pureed diets (R1 and R47) and mechanically-altered diets (R7, R27, R15, R41, R20, R11, R17, and R14) did not receive parslied noodles for lunch on 4/7/26. The residents received mashed potatoes instead. R7 did not receive mechanically-altered (L3/Advanced) meat for lunch on 4/6/26 and breakfast on 4/8/26. In addition, R7 did not receive Boost for lunch on 4/8/26. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not consistently obtain food temperatures to ensure food was served at safe and palatable temperatures In addition, the facility did not ensure residents on a pureed diet had meals prepared by a method that conserved the nutritive value. This practice had the potential to affect more than 4 of the 49 residents (R) residing in the facility. Kitchen staff did not appropriately temp food served to residents (including R43) and falsified temperature logs. As a result, food was not served at the correct temperatures. Kitchen staff did not follow a recipe during preparation of pureed food items to conserve or ensure the nutritive value.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure meals were served at regular times and per resident preferences for 6 residents (R) (R39, R55, R18, R45, R46, and R43) of 7 sampled residents. During a Resident Council meeting on 4/7/26, R39, R55, R18, R45 and R46 stated they are not offered a snack before bedtime (HS) as preferred. R43 did not receive a diabetic snack at HS on 4/6/26.

Inspectors wroteBased on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 49 residents residing in the facility. During March of 2026, the staff line list indicated one staff had a fever, one staff had vomiting, two staff had diarrhea, and two staff had vomiting and diarrhea. The facility allowed staff to return to work without identifying if or when their symptoms were resolved.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R1) of 2 sampled residents. R1 had a legal Guardian upon admission to the facility on 1/30/26. Protective placement in the facility was not obtained for R1.

Inspectors wroteBased on staff and resident interview and record review, the facility did not report an allegation of abuse/neglect to the State Agency (SA) for 1 resident (R) (R5) of 23 sampled residents. R5 reported that Registered Nurse (RN)-T refused to change R5's wound dressing or cover a pressure injury on R5's buttocks multiple times after R5 was incontinent of stool. The facility did not report the allegation of abuse/neglect to the SA.

Inspectors wroteBased on staff and resident interview and record review, the facility did not thoroughly investigate an allegation of abuse/neglect for 1 resident (R) (R5) of 23 sampled residents. R5 reported that Registered Nurse (RN)-T refused the change R5's dressing or cover a pressure injury on R5's buttocks after R5 was incontinent of stool multiple times. The facility did not thoroughly investigate the allegation of abuse/neglect.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a care plan was revised for 1 resident (R) (R10) of 1 sampled resident. R10's care plan was not revised to include behavioral interventions following resident-to-resident altercations on 3/29/26.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary care and treatment to prevent pressure injuries and/or promote healing for 2 residents (R) (R6 and R5) of 3 sampled residents. R6 had an order for a specialty air mattress set to R6's weight and to monitor the setting every shift. R6's air mattress was not set to the desired firmness to prevent pressure injuries. R5 had a pressure injury on the buttocks. Staff refused to dress R5's pressure injury to keep it free of feces and potential infection during multiple episodes of diarrhea.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R10) of 1 sampled resident. R10 was at risk for falls and had multiple falls in the facility. R10's care plan contained interventions for increased supervision and to ensure R10 had shoes on in the dining room. The interventions were not consistently implemented.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 1 sampled resident received appropriate care and services after removal of a Foley catheter to prevent urinary retention and avoid infection. R9's Foley catheter was removed on 4/1/26. Staff did not monitor R9's urinary output as ordered by the physician.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R4) of 2 sampled residents. Staff did not clean R4's continuous positive airway pressure (CPAP) machine per manufacturer's instructions or facility policy. In addition, R4's medical record did not contain an order for use of a CPAP machine.

Inspectors wroteBased on observation and staff interview, the facility did not ensure nurse staffing was posted daily. This practice had the potential to affect all 49 residents residing in the facility. The facility did not post the nurse staffing for all shifts on 4/6/26 or on 4/7/26 prior to the start of the AM shift.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure toilets were in a clean and home-like condition for 4 residents (R) (R17, R6, R18, and R10) of 18 sampled residents. The toilets in R17, R6, R18, and R10's shared bathrooms contained rusty metal strips. R17, R6, and R18 stated they did not like the rusty metal strips and had reported them to staff.

Inspectors wroteBased on staff interview and record review, the facility did not ensure medical records were complete for 1 resident (R) (R8) of 18 sampled residents. The facility did not ensure communication with medical providers was documented during a change in condition for R8.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the resident environment remained free from abuse for 3 residents (R) (R3, R4, and R2) of 5 sampled residents. On 9/11/25, a resident-to-resident altercation occurred between R3 and R4 and involved verbal and physical aggression. The facility did not put interventions in place to address R3's aggressive behavior or prevent future instances of abuse, including a resident-to-resident altercation between R3 and R2 on 9/13/25.

Inspectors wroteBased on staff and resident interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 2 residents (R) (R3 and R4) of 5 sampled residents. On 9/11/25, an altercation occurred between R3 and R4 that involved verbal and physical aggression. The facility did not report the allegation of abuse to the SA.

Inspectors wroteBased on staff and resident interview and record review, the facility did not thoroughly investigate a resident-to-resident altercation for 2 residents (R) (R3 and R4) of 5 sampled residents. On 9/11/25, a resident-to-resident altercation occurred between R3 and R4 that involved verbal and physical aggression. The facility did not thoroughly investigate the altercation.

Inspectors wroteBased on staff interview and record review, the facility did not develop or implement an individualized comprehensive resident-centered care plan for 1 resident (R) (R2) of 5 sampled residents. R2 was identified as having trauma on quarterly assessments. R2's diagnoses list did not contain a trauma-related diagnosis and R2's care plan did not contain resident-specific trauma interventions.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R1) of 5 sampled residents. R1's hospital discharge summary contained an order for sliding scale insulin and a recommendation to monitor R1's blood sugars closely. R1's Medication Administration Record (MAR) did not reflect the order or recommendation.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy when 1 of 2 medication carts was left unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the 50 residents residing in the facility. On 6/25/25, staff left a medication cart unlocked and unattended on multiple occasions during medication administration.

Inspectors wroteBased on staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of abuse was not reported to local law enforcement for 1 resident (R) (R2) of 6 sampled residents. R2 reported to staff that Certified Nursing Assistant (CNA)-C got in R2's face and would not wash R2 when R2 requested it. R2 reported to staff that R2 felt that was abuse. The facility did not report the allegation of abuse to local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not ensure preventative action was taken following an allegation of misappropriation for 1 resident (R1) of 6 sampled residents. R1's family reported that two $50 bills were missing from R1's wallet. The facility was not able to determine what happened to R1's money and did not provide staff education on misappropriation to prevent recurrence.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 50 of 53 residents residing in the facility. Three residents received nutrition via tube feeding. Staff did not store food in a manner to ensure food safety and did not date food appropriately. Staff did not follow safe microwave safe heating procedures. Staff did not adhere to temperature requirements for testing sanitizing solution.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 53 residents residing in the facility. The facility did not maintain thorough surveillance/tracking documentation for a COVID-19 outbreak in September 2024 and did not report the outbreak to the local health department in a timely manner. In addition, the facility did not maintain thorough surveillance/tracking for a Respiratory Syncytial Virus (RSV) outbreak between 3/19/24 and 3/21/24 and did not report the outbreak to the local health department in a timely manner. [...]

Inspectors wroteBased on staff interview and record review, the facility did not implement their antibiotic stewardship program by ensuring the accurate use of an antibiotic for 1 resident (R) (R261) of 5 sampled residents. R261 was transferred to the hospital on 1/5/24 and prescribed an antibiotic for a urinary tract infection (UTI) that did not meet the facility's criteria for infection. Fourteen doses of the unnecessary antibiotic were administered.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) dedicated a minimum number of part-time hours to adequately manage the facility's infection prevention and control program. This had the ability to affect all 53 residents residing in the facility. Licensed Practical Nurse (LPN)-F was designated as the facility's IP. LPN-F also worked as a full-time floor nurse which resulted in LPN-F's inability to adequately maintain the facility's infection prevention and control program.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R8, R11, and R29) of 5 sampled residents were offered or received a COVID-19 vaccine. R8, R11, and R29's medical records did not indicate R8, R11, and R29 received, were offered, or declined the most recent COVID-19 vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure injuries of unknown origin were reported to Nursing Home Administrator (NHA)-A or the State Agency (SA) for 1 resident (R) (R15) of 6 sampled residents. R15 was transferred to the hospital with a head injury following a fall from A Hoyer lift on 8/6/24. R15 was also hospitalized from [DATE] to 9/10/24 due to aspiration pneumonia. The facility did not report an injury of unknown origin to NHA-A or the SA after hospital staff notified the facility that R15 had a vaginal mucosa tear with dried blood. In addition, the facility did not report bruises on R15's legs and compression fractures to R15's mid and lower back that were documented on R15's hospital discharge summary to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure injuries of unknown origin were thoroughly investigated for 1 resident (R) (R15) of 6 sampled residents. R15 was transferred to the hospital on 8/6/24 with a head injury following a fall from a Hoyer lift. R15 was also hospitalized from [DATE] to 9/10/24 due to aspiration pneumonia. The facility did not investigate an injury of unknown origin after hospital staff notified the facility that R15 had a vaginal mucosa tear with dried blood. In addition, the facility did not investigate bruises on R15's legs and compression fractures to R15's mid and lower back that were documented on R15's hospital discharge summary.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R15) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of one of R15's transfers. R15 was transferred to the hospital on 8/6/24 and 9/4/24. Neither R15 or R15's Power of Attorney (POA) were provided with a written transfer notice for either transfer. In addition, the Ombudsman was not notified of R15's 8/6/24 transfer.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R15) of 2 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R15 was transferred to the hospital on 8/6/24 and 9/4/24. Neither R15 or R15's Power of Attorney (POA) were provided with a written notice of the bed hold policy. In addition, the bed hold policy form was not filled out by the facility.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 1 resident (R) (R31) of 17 sampled residents. The facility did not honor R31's meal preferences during the lunch meal on 11/12/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure meals were prepared by a method that conserved nutritive value for 2 residents (R) (R10 and R38) of 2 residents who received pureed diets. Kitchen staff did not follow a recipe when preparing pureed food items to ensure and conserve the nutritive value of the food. Kitchen staff did not provide R38 all of the items listed on R38's meal ticket.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 2 residents (R) (R29 and R48) of 5 sampled residents. Staff did not offer R29 or R48 the PCV20 (Prevnar 20®) vaccine.

Inspectors wroteBased on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition. This occurred for 1 of 3 residents (R) R1, reviewed for change in condition. R1 presented with symptoms of low blood pressure and weakness on 5/30/24 at 9:43 a.m. R1 had symptoms of vomiting and diarrhea from approximately 3:30-4:00 p.m. to 7:00 p.m. when R1 was transferred to the emergency room. R1's physician was not consulted between when episodes of vomiting and diarrhea occurred.

Inspectors wroteBased on record review, the facility did not ensure that a comprehensive person centered care plan was developed for 1 of 5 sampled residents (R) R1. R1 was admitted to the facility on [DATE] with diagnoses that included in part, malignant neoplasm of esophagus and was undergoing chemotherapy treatment. The facility did not develop a care plan to address R1's increased risk for infection, risk for dehydration or abnormal lab values with increased need for monitoring related to his diagnosis and chemotherapy treatments. This is evidenced by: Surveyor requested and received the facility policy titled Comprehensive Care Plan dated as most recently revised on 9/23/2022. The policy in part reads: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not comprehensively assess resident medical status with a change in resident's clinical condition. This occurred for 1 of 3 residents (R1) reviewed for change in condition. R1 presented with symptoms of low blood pressure and weakness on [DATE] at 9:43 a.m. R1 had new onset of vomiting and diarrhea noted on [DATE] on the p.m. shift without a comprehensive nursing assessment of his clinical condition from 9:43 a.m. until his time of transfer to the hospital at approximately 7:00 p.m.

Inspectors wroteBased on record review and staff interview, the facility did not ensure a safe environment that was free of accident hazards for 1 Resident (R) (R1) of 3 sampled residents. On 9/17/23 at approximately 10:00 AM, Certified Nursing Assistant (CNA)-C transferred R1 using a sit-to-stand lift. R1 passed out for a few seconds during the transfer. CNA-C did not immediately report the change of condition to a nurse. At 10:10 AM, CNA-C transferred R1 a second time. R1 passed out again, slipped out of the mechanical lift support straps, was lowered to the floor by CNA-C, and incurred multiple injuries.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not develop an individualized comprehensive care plan for 2 Residents (R) (R247 and R9) of 13 sampled residents. R247's care plan did not include pain interventions for pain management. R9's care plan did not include arm sleeves to protect R9's skin.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not revise a plan of care in accordance with current care needs for 1 Resident (R) (R32) of 13 sampled residents. R32 had a fall with a fracture. R32's plan of care was not updated with a new intervention following the fall. R32 was changed to a Hoyer transfer after R32's fall with fracture. R32 was observed in a wheelchair sitting on a sling on multiple occasions. R32's plan of care was not updated. R32 was prescribed a PRAFO boot by the wound clinic to protect R32's left heel pressure injury. The intervention was not implemented or added to R32's plan of care. R32 was admitted the facility on dialysis. R32's dialysis ended on 7/13/23. R32's plan of care was not updated to reflect R32 was no longer on dialysis.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not provide the necessary care and services to monitor for fluid retention by ensuring post hospitalization weights were completed as ordered for 1 Resident (R) (R25) of 1 resident reviewed for hospitalization. R25 was weighed daily prior to hospitalization for a change in condition related to an exacerbation of congestive heart failure. R25 had 17.8 kilograms (kgs) or 38.58 pounds (lbs) of fluid removed while hospitalized . R25 returned to the facility with a standard order for weight monitoring.