Every finding on record at Alexander "Sandy" Nininger State Veterans Nursing

Based on observations and interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was observed during 3 of 3 visits conducted in the Main Kitchen. The findings included: 1. A tour of the Main Kitchen was conducted on 05/18/26 at 08:46 AM with the Dietary Manager (DM). The following items were observed: a. In the walk-in refrigerator, a full 6 inch deep, two third-sized hotel pan located on a shelf to the right of the entrance was observed with loosely wrapped raw white mushrooms. The pan was dated 05/08/26 and the mushrooms were observed to be browned and discolored indicative of spoilage. The DM stated mushrooms can be refrigerated for up to 30 days. b. In the food processing area, the convection oven was observed with a large amount of food residue on mainly the interior top and bottom. The bottom of the oven had a metal sheet tray which also had a large amount of food residue that was burnt onto the pan. c. In the cooking prep area, a knife drawer was noted with food residue and debris. There were five knives observed with food residue or buildup in the grooves and handles. d. In the food prep area, a food processor was observed in a corner. Upon disassembling the processor, the blade was observed to have food particles. The DM stated it was not in use. There was no sign or tag identifying the item as not in use. e. In the food prep area, a bug zapper was noted on the wall above a stainless-steel prep table with 2 food processor bases on it. The bug zapper had no collection tray or cover to ensure insects would not fall upon the food prep area and there was a buildup of dust like debris on the appliance. f. In the dish machine area, white dried up liquid splashes and buildup were noted on the shelves above the dish table and the dish table back splash where the clean dishes exited the washer and were placed to dry. g. In the dish machine area, there were broken floor tiles where water accumulated and sat. h. In the steam table area, inside the plate-warmer, two plates were noted with dried food debris and dried up coffee colored liquid stains. 2. Upon returning to the kitchen on 05/18/26 at 10:29 AM to discuss some of the findings from the previous observation that morning with DM, personal items were found on a stainless-steel prep table near the oven. An 8-ounce water bottle and an orange-colored blue tooth speaker were observed next to single use gloves and food equipment. The DM was notified. She acknowledged the findings by stating she would have them removed. 3. On 05/20/26 at 11:10 AM a tray-line observation was conducted. The following was observed: Staff I used plastic-handled portion scoops to serve the food items. Her hands were bare. The scoop for the pureed bread was observed sinking into the food item down to the handle and release mechanism which had been in contact with Staff I's bare hand. This also occurred with the pureed meat, starch, and vegetable food items after it was pointed out by this surveyor. Photographic Evidence was obtained.

Based on observations, interviews, and record review, the facility failed to: 1. Follow the approved menu for the lunch meal served to the residents on 05/18/26 with the potential to affect 63 residents with orders for regular texture foods. 2. Failed to provide all the menu items for 1 of 1 resident observed during the breakfast meal on 05/19/26. (Resident #65) 3. Failed to provide all the menu items for 1 of 1 resident observed during the lunch meal on 05/19/26. (Resident #43) 4. Failed to serve the correct portion size for residents on 05/20/26 with the potential to affect 7 residents with orders for bite sized consistency. The findings included: 1. The approved lunch menu on 05/18/26 documented the residents with regular texture diet consistency were to receive a 4-ounce (oz) portion of Chicken Marinated. During an observation on 05/18/26 at 11:51 AM, in the Delta Blue Dining Room, the portion of chicken served to the residents with a regular texture diet was observed to be smaller than 4 oz. On 05/18/2026 at 12:10 PM an observation of the lunch meal performed by a second surveyor on the Alpha Unit and the Main Dining Room revealed chicken portions for the regular texture diet that appeared to be small. On 05/18/26 at 12:14 PM, the regular texture chicken on the steam table was weighed at 2.7 oz. The DM acknowledged it by advising the server to provide two pieces per plate. 2. Record review for Resident #65 revealed the resident was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #65 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. On 05/19/26 at 09:05 AM an observation was conducted in resident #65's room. The resident was consuming his breakfast meal. The tray ticket read No Added Salt, Regular Texture, Thin Liquids Diet and included Oatmeal on the list of meal items. The approved breakfast menu on that day documented a 1/2 cup serving of Cereal Oatmeal. There was no documentation found on the ticket indicating the resident did not like hot cereal or oatmeal. There was no oatmeal bowl on the resident's tray. When asked, the resident stated he liked oatmeal. On 05/21/26 at approximately 10:30 AM an interview was conducted with the Dietary Manager (DM) who had been employed by the facility for 10 years. She stated hot cereal was not placed on the breakfast trays. The units were provided with bowls of hot cereal which were passed to the residents by the unit staff. 3. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Cancer, Autoimmune Gastrointestinal Disease, Diabetes, and Hyperlipidemia. Review of the Quarterly Minimum Data Set (MDS) for Resident #43 dated 05/08/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. On 05/19/26 at 12:01 PM an observation was conducted during the lunch meal in resident #43's room. The resident's tray ticket read Regular, Regular Texture, Thin Liquids. At the bottom of the ticket, it read no pork. The approved lunch menu on that date documented the main meal for the Regular Diet had pork thus the alternate meal was provided. The approved Regular Diet, alternate meal was documented as beef Swiss steak tomatoes and potatoes parslied. The resident's tray did not have parslied potatoes. The tray ticket did not indicate the resident did not like potatoes. The resident stated he liked potatoes and would have wanted them. On 05/21/26 at approximately 10:30 AM an interview was conducted with the Dietary Manager (DM). She stated it was Resident #43's preference but was unable to provide documentation that the resident did not want potatoes. 4. The approved lunch menu on 05/20/26 documented residents with Soft and Bite Sized Diet consistency orders were to receive a 3 oz portion of fish tilapia herb and lemon. On 05/20/26 at 11:10 AM an observation of the tray line was conducted. Staff I was observed plating the meals using a 3 oz portion scoop to measure the bite sized portion of fish. It was noted the portion provided was with a scoop that was approximately two thirds to half full. This surveyor stopped the dietary staff from passing the tray down to the meal cart. The DM advised Staff I to fully fill the scoop acknowledging the finding. Photographic evidence was obtained.

Based on observations, interviews and record review, the facility failed to provide pureed foods in a form to meet the needs of a total of 17 residents with orders for pureed foods. The findings included: The facility provided the guidelines from the International Dysphagia Diet Standardization Initiative 2.0 (IDDSI) dated July 2019 which were the guidelines used for the consistency of the pureed diets. The standards described pureed consistency as extremely thick and able to retain its shape. It further stated that it cannot be poured. Recipes for Pureed Sauteed Squash and Pureed Garlic Mashed Cauliflower provided by the facility described the consistency as able to hold its shape on a plate, does not flow easily, and cannot be poured. 1. Record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Dementia, Depression, and Chronic Gingivitis. Review of the Significant Change Minimum Data Set (MDS) for Resident #9 dated 02/25/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 01, which indicated the resident had severe cognitive impairment. The resident had a diet order (02/18/26) Puree, Thin Liquids. 2. Record review for Resident #31 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Anxiety, Seizures, and Depression. Review of the Quarterly Minimum Data Set (MDS) for Resident #31 dated 04/07/26 revealed the Resident could not have a Brief Interview for Mental Status (BIMS) due to rarely or never being understood. 3. Record review for Resident #53 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Diabetes and Cerebral Vascular Accident with Hemiplegia. Review of the Quarterly Minimum Data Set (MDS) for Resident #53 dated 04/15/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. On 05/19/26 at about 12:00 PM Residents #9 and #31 were observed eating lunch in the Unit Dining Room. The meal for the pureed diet was pork loin with noodles, sauteed mushrooms, and bread. They were both fed by staff and the meals appeared thin and runny. The food items did not hold their shape and were pooled on the plate. On 05/20/26 at 11:10 AM an observation of the tray line was conducted. The pureed food items were not thick and holding shape. The scoops placed inside the pureed bread, fish, cauliflower garlic mash, and squash medley sank into the food. The pureed items were poured onto the plates, and the scoops were covered in a liquid residue that had an ice cream shake consistency. On 05/20/26 at about 12:00 PM the Dietary Manager, who had been employed by the facility for 10 years, was alerted to the pureed consistency. She stated the year prior, the facility was cited because the pureed food items were too thick. On 5/20/26 12:26 PM Resident #53 was observed eating his meal in the Main Dining Room. The resident's meal ticket read regular, pureed consistency, thin liquids. The pureed meal was fish, garlic cauliflower mashed, and squash medley. The food items did not hold their shape and puddled on the plate. On 05/20/26 at 12:28 PM during a dining room observation in the Main Dining Room, the Dietary Manager and the Speech Language Pathologist approached this Surveyor and provided the IDDSI guidelines. They stated the facility follows these guidelines for pureed food consistency. This surveyor suggested to look at Resident #53's plate to compare it to the guidelines but they chose not to. Photographic evidence was obtained.

Based on Interview and record review, the facility failed to obtain informed consent for the use of Psychoactive medications for 1 of 4 residents reviewed for Dementia Care, Resident #98. The findings included:On 05/21/26 at 11:51 AM, a record review was conducted for the Dementia Care investigation for Resident #98. Resident #98 was determined to have been prescribed the following Psychoactive medications:Quetiapine 25 mg (Seroquel) 25 mg 1 tablet by mouth at bedtime for hallucinations. Duloxetine (Cymbalta) 30 mg 1 capsule by mouth at bedtime for depressionDuloxetine (Cymbalta) 30 mg 2 capsule (60mg) by mouth once a day at 9:00 AM for depression. Psychoactive medications require informed consent prior when ordered by the Physician, Nurse Practitioner, or Physician's Assistant. Resident #98's records only have Informed Consent for Duloxetine (Cymbalta) 30 mg 1 capsule by mouth at bedtime for depression. On 05/21/26 at 3:43 PM, an interview was conducted with the Administrator regarding Quality Assurance Performance Improvement (QAPI) initiatives for the facility. During the meeting a review of Performance Improvement Programs (PIP) was conducted. The facility had developed a PIP for Informed Consent for Psychoactive Medications. This PIP was completed on 5/1/26.

Based on interview and record review, the facility failed to ensure accuracy of diagnoses included on the PASARR (Preadmission screening and record review) for individuals with a mental disorder, for 3 of 4 residents reviewed (Residents #33, #34, and #7). The findings include: 1.) On 05/19/26 at 2:59 PM, during record review for Resident #33 a determination was made that the primary diagnosis for Resident #33 was identified on the PASARR as Dementia. The Admitting Diagnoses listed for Resident #33 included Chronic combined systolic (congestive) and diastolic (congestive) heart failure.Resident #33 had a Psychiatric evaluation after admission which identified the following psychiatric diagnoses:Major Depressive Disorder recurrent moderate;Post Traumatic Stress Disorder unspecified;Insomnia unspecified.None of these diagnoses were identified as a primary admitting diagnosis. On 05/20/26 at 10:41 AM, an interview was conducted with the Social Services Director (SSD) who is a Licensed Clinical Social Worker (LSCW). The SSD explained that when a resident is admitted to the facility from another facility the sending facility is expected to send the completed PASRR at the time of admission. The SSD explained that an admission from home would need to have a PASSR completed by the facility at the time of admission. The SSD stated that she or one of the nurses trained to complete a PASSR is supposed to review the PASSR and correct discrepancies when they are identified. The SSD explained that if a new psychiatric diagnosis is determined then the facility is supposed to update the resident's record to reflect that new diagnosis. The SSD stated that if a new diagnosis is determined to be a Serious Mental Illness or an Intellectual Disability then a PASRR Level two evaluation becomes necessary. The SSD identified examples of when a Level Two PASSR was required. The examples included Schizophrenia, Autism Spectrum and Downs Syndrome. On 05/20/26 at 11:53 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator indicated she collects the diagnoses from the 3008 form, the hospital records, and the doctor's notes. The MDS coordinator explained that she had a conversation with the SSD regarding Resident #33's PASRR. The MDS Coordinator agreed with the conclusion that the PASSRR for Resident #33 was coded incorrectly as dementia was not the primary admitting diagnosis based upon the documentation she used from the hospital. The MDS coordinator stated the SSD was correcting the PASARR as we spoke. 2) Resident #35 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Psychotic Disorder, Hypertension and Depression. A Brief Interview for Mental Status (BIMS) was done, and Resident #25's score was 4 on the quarterly Minimum Data Set, dated [DATE]. This indicated he had severely impaired cognition. Record review of Resident #35's Preadmission Screening and Resident Review (PASARR) dated 08/02/23 prior to the resident's admission revealed no diagnoses were checked on the PASARR Screen Decision Making relating to Mental Illness or suspected Mental Illness. Diagnoses of Depressive Disorder and Psychotic Disorder are listed as examples of Mental Illness. An interview with the Social Service Director on 05/21/2026 at 11:55 AM revealed the Social Service Director or Admissions look to see if the PASARR is a part of the admissions file. If it is not, they request it from the hospital or they do it on admission. If the resident comes from home, they do the PASARR. Social Services and any Registered Nurse can review the PASARR. The PASARR for Resident #35 did not have any diagnoses. The Social Service Director reviewed this PASARR and stated this PASARR was not filled out correctly and it should have been filled out with his diagnoses of Depression and Psychotic Disorder. She stated she will fill out a new PASARR today. 3). Record review for Resident #7 revealed an admission date of 12/20/23. A Level one PASRR with a reference date of 12/14/23 – prior to being admitted to the facility - that was completed by a facility that the resident came from documented diagnoses that included Bipolar disorder and Depressive disorder, with no other diagnoses indicative of MI or suspected MI. Resident #7's face sheet documented diagnoses that included: PTSD - 11/14/24, Anxiety disorder - 11/14/24, Major depressive disorder - 11/06/24, Bipolar disorder - 0/04/25, Dementia - 04/03/25, Psychosis - 03/20/26, Adjustment disorder with mixed anxiety and depressed mood - 01/23/24. Resident #7's most recent complete assessment, a Quarterly MDS with a reference date of 03/18/26, documented diagnoses that included: Anxiety disorder, Depression, Bipolar disorder, Post Traumatic Stress Disorder (PTSD), Vascular dementia, Major depressive disorder, and Dementia. Resident #7's care plan for Mood State, initiated on 01/02/25 and most recent revised on 03/19/26, documented: Resident is at risk for exhibiting symptoms of depression such as crying, tearfulness, worried facial expressions related to diagnosis of Major Depressive Disorder with psychotropic medications treatments. Resident has a history of depression, anxiety, PTSD (Post Traumatic Stress Disorder) and insomnia as per records history of being treated for depression, psychosis and anxiety. Resident is being monitored by Psychologist, Psychiatry ARNP, Pharmacist, nursing staff and Social Services for psychotropic meeting to evaluate current dosages, adverse effects and GDR (Gradual Dose Reduction) if appropriate. Resident #7's Most recent psychiatric note, with a reference date of 04/16/26, documented: Chief complaint: follow up for history of depression, anxiety, PTSD, Bipolar, dementia and insomnia History of present illness: Patient is seen for follow up psychiatric assessment. Patient has hx of depression, anxiety, Bipolar, PTSD, dementia and insomnia per records .Patient reports that she feels depressed sometimes .Duloxetine was reduced in GDR attempt. No self-harm, SI, hallucinations reported. Depakote was d/c due to tremors. Patient has chart hx of violence, paranoia and suspicious behavior. Current meds: Duloxetine 30 mg po once daily Duloxetine 60 mg po qHS Donepezil 10 mg q HS During an interview, on 05/20/2026 at 10:45 AM, with the Admissions Coordinator, when asked about the resident's PASSAR, the Admissions Coordinator stated that the Admissions Nurse does the pre-admission visit when the resident is coming from the home. When the resident is coming from the hospital or another facility, the Admissions Nurse will request the PASSAR and that she (the Admissions Coordinator) reviews it to make sure that it is correct and psychiatrist will come to the facility and find new diagnoses.

Based on observations, interviews and record reviews, the facility failed to develop and implement a care plan with measurable goals and interventions for 1 of 5 residents reviewed for Behavior, Resident #7; and failed to follow care plan interventions for 1 of 2 residents reviewed for falls, Resident #65. The findings included: 1). Record review for Resident #7 revealed an admission date of 12/20/23. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 03/18/26, Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented that the resident displayed behaviors that included little interest in doing things 2-6 times during the 14-day look back period, feeling down, depressed, or hopeless 2-6 days of the 14-day look back period, and feelings of loneliness or isolations 'sometimes'. The assessment documented Resident #7 had psychiatric mood disorders at the time of the assessment that included: Anxiety disorder, Depression, Bipolar, and Post Traumatic Stress Disorder (PTSD). Further review of the resident's record revealed that there were no care plans, with measurable goals and interventions for symptoms related to diagnosis of PTSD, including triggers and behaviors. During an interview, on 05/18/2026 at 1:55 PM, Resident #7 stated that her PTSD was related to witnessing a sibling being abused and beaten by a parent. When asked about triggers, Resident #7 replied, touching me, even just a little. The hospital rule is that only women can provide care to women (referring to not being provided care by male staff). When asked about reactions to the trigger, the resident motioned that it made her feel uneasy and unsafe by shrugging and shivering. During an interview, on 05/20/2026 at 10:41 AM, with the Social Services Director, the Social Services Director was made aware of the findings. 2). Review of the facility's policy titled, Falls and Fall Risk Managing, last revised on 09/05/24, stated the staff will identify interventions and implement a resident-centered fall prevention plan related to the resident's specific risks and causes to try to prevent the resident from falling. Record review for Resident #65 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Dementia, Benign Prostatic Hypertrophy, Chronic Kidney Disease Stage 3, Colon and Prostate Cancer. Review of the Quarterly Minimum Data Set (MDS) for Resident #65 dated 04/07/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. The resident was dependent when toileting and used a wheelchair or walker to ambulate. Per the facility's Report, Resident #65 fell on [DATE] and 03/16/26. As per the event assessment dated [DATE] at 03:48 AM, Resident #65 fell in his room and stated he was coming from the bathroom when he fell. As per the event assessment dated [DATE] at 03:00 AM, Resident #65 was found on the bathroom floor and stated he fell while urinating. Review of the Care Plan for Resident #65 dated 01/07/26 with a focus on falls was updated after a fall on 03/16/26. The approach documented a Toileting Schedule before meals (AC), after meals (PC), at bedtime (HS), and as needed (PRN). This was a minimum of 7 times a day. A review of the Point of Care History Report during the dates of 04/21/26 through 05/21/26 documented how often the resident was offered to use the restroom. The report revealed Resident #65 was offered to use the restroom on average 3 times a day instead of 7 times a day and they were not during the times specified in the approach. On 05/21/26 at 12:12 PM an interview was conducted with the Risk Manager (RM), who had been employed by the facility for about 1.5 years. She stated that when a resident has a fall incident, a full assessment was completed, it was discussed by the Falls Committee to determine the cause, and interventions such as staff education and toileting schedules were put in place. She provided a printout of the Point of Care History Report for the month and acknowledged the resident was not offered assistance to the bathroom [ROOM NUMBER] times daily. She stated it was possibly documented in the physical chart. On 05/21/26 at 2:08 PM, an interview was conducted with Staff G, Senior Licensed Practical Nurse, who had been employed by the facility for 3 years and Staff H, Senior Certified Nursing Assistant who had been employed for 10 years. Both were familiar with Resident #65 since the resident was part of their usual assignment. They were unable to provide any written documentation regarding the resident's toileting schedule. Staff H stated the resident usually needs to use the restroom during morning care and will ask when he needs to use the restroom. She did not state that the resident is offered to use the restroom before and after meals and was unaware of the toileting approach and specific times. Photographic evidence was obtained.

Based on observations, interviews and record review, the facility failed to investigate and update interventions to care plans to prevent additional falls for 1 of 2 residents reviewed for falls (Residents #65). The findings included: Review of the facility's policy titled, Falls and Fall Risk Managing, last revised on 09/05/24, stated the staff will identify interventions and implement a resident-centered fall prevention plan related to the resident's specific risks and causes to try to prevent the resident from falling. Record review for Resident #65 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Dementia, Benign Prostatic Hypertrophy, Chronic Kidney Disease Stage 3, Colon and Prostate Cancer. Review of the Quarterly Minimum Data Set (MDS) for Resident #65 dated 04/07/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. The resident was dependent with toileting and used a wheelchair or walker to ambulate. Review of the Care Plan for Resident #65 dated 01/07/26 with a focus on falls was observed with approaches which included encouraging out of room activities to increase supervision, bilateral 1/4 upper side rails while in bed to assist with bed mobility, keep pathways dry and clear of clutter, keep bed in lowest position and locked, and review of medications. There were no interventions added until 03/16/26 apart from a pommel cushion in wheelchair ordered on 03/03/26. Per the facility's Report, Resident #65 fell on [DATE] and 03/16/26. As per the event assessment dated [DATE] at 03:48 AM, Resident #65 fell in his room and stated he was coming from the bathroom when he fell. As per the event assessment dated [DATE] at 03:00 AM, Resident #65 was found on the bathroom floor and stated he fell while urinating. On 05/21/26 at 12:12 PM an interview was conducted with the Risk Manager (RM), who had been employed by the facility for about 1.5 years. She stated that when a resident has a fall incident, a full assessment was completed, it was discussed by the Falls Committee to determine the cause, and interventions such as staff education and toileting schedules were put in place. She stated Resident #65 had not fully acclimated when his first fall occurred and he was grieving his wife's death and needed more time. The RM later provided the notes for the Falls Committee Meeting dated 01/30/26. Neuro checks and monitoring were ordered for 3 days. No other interventions were ordered. The RM provided a Fall Review form for the fall dated 03/16/26 where the fall action team response was documented but was unable to provide the form for the 01/30/26 fall. The RM agreed that no new approaches were added to address the fall. Photographic evidence was obtained.

Based on observations, interviews and record reviews, the facility failed to provide care and services to meet the needs and prevent re-traumatizing of 2 of 5 residents reviewed for Behavior, (Residents #7, and #9). The findings included:1.) The Facility Assessment, most recently reviewed and revised on 03/27/26, documented:Services and care we offer based on our residents' needs:Mental health and behavior - Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. During an interview, on 05/21/2026 at 9:14 AM, with Staff C, Unit Clerk, when asked about training provided related to providing care to a resident with PTSD Staff C replied, We have in-services and we learn how to remain calm with them. When asked, Staff C could not recall the most recent training provided. During an interview, on 05/21/2026 at 9:51 AM, with Staff L, Nursing Supervisor 7-3 shift, when asked about training related to providing care to a resident with PTSD, Staff L replied, in-service training on FDVA (Florida Department of Veterans Affairs) learning portal a couple of weeks or a couple of months ago. During an interview, on 05/21/2026 at 1:01 PM, with Staff E, CNA, when asked about training related to providing care to a resident with PTSD, the CNA gave no response after several minutes. During an interview, on 05/21/2026 at 12:58 PM, with Staff F, CNA, when asked about training related to providing care to a resident with PTSD, Staff F stated that there was no training for PTSD, mental stress. During an interview, on 05/21/2026 at 3:11 PM, with Staff M, RN/7-3 supervisor, the RN confirmed that she completed competencies of the nursing and CNA staff. Staff M further stated that the assessments did not include providing care to residents with PTSD and behaviors. When asked about training related to providing care to residents with PTSD, Staff M stated that the Staff education nurse does in-services, she had one last year where she showed videos that were about symptoms of PTSD. When asked how it was determined that staff were understanding of the training, Staff M referred to Staff Development Coordinator (SDC). During an interview on 05/21/2026 at 3:21 PM, with the SDC, when asked about training for providing care to residents with PTSD, the SDC replied, they watched a video and signed a sheet. When asked how to ensure that the staff that took the training and watched the videos understood the material, the SDC stated that there was no assessment to ensure understanding. 2). Record review for Resident #7 revealed an admission date of 12/20/23. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 03/18/26, Resident #7 had a Brief Interview for mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The assessment documented that over the 2-week look back period, Resident #7 displayed the following mood symptoms:Little interest or doing things 2-6 days.Feeling down, depressed, or hopeless 2-6 days. Feeling lonely or isolated 'sometimes.' Resident #7s diagnoses included: Anxiety disorder, Depression, Bipolar disorder, PTSD. Psychiatric/Mood disorders at the time of the assessment included: Anxiety disorder, Depression, Bipolar disorder, PTSD. Resident #7's care plan for Mood State, most recently reviewed/revised 03/23/26, documented, Resident is at risk for exhibiting symptoms of depression such as crying, tearfulness, worried facial expressions related to diagnoses of major depressive disorder with psychotropic medications. Has a history of depression, anxiety, PTSD and insomnia as per records history of being treated for depression, psychosis and anxiety. Resident is being monitored by psychologist, Psychiatry ARNP, Pharmacist, nursing staff and Social Services for psychotropic medications. Monthly Psychotropic meeting to evaluate current dosages, adverse effects and GDR if appropriate. A 'Trauma Informed Care Screening' assessment with a reference date of 12/21/23 (upon admission) documented: Did not experience an event that was frightening, horrible or upsetting.Has never served in active combat or in a combat zone. Has never been in a serious accident.Has experience Hurricanes, severe weather in Florida.No trauma during childhood.Has never been attacked, beaten or mugged.Has never been pressured or forced to engage into unwanted sexual activity.Has not had a close family member die violently.Care plan developed yes. During an interview, on 05/18/2026 at 1:55 PM, Resident stated that her PTSD was related to witnessing her sister being abused and beaten by their father. When asked about triggers, Resident #7 replied, touching me, even just a little When asked about reactions to the trigger, the resident motioned that it made her feel uneasy and unsafe by shrugging and shivering. During an interview, on 05/20/2026 at 1:36 PM, with Staff A, CNA, when asked about Resident #7's PTSD, Staff A referred to Physical Therapy. When asked about PTSD, Staff A stated that she was not aware of trauma. During an interview, on 05/20/2026 at 1:47 PM, with Staff B, RN, since 2002, when asked about Resident #7's behaviors and PTSD, Staff B replied, sometimes she gets or has a tendency to get verbally aggressive, sometimes she will burst out crying. Her husband comes and sits with her and watches television and that helps manager her. She said to me in the past that it was from being in the service. When asked about the resident's triggers, Staff B replied, There is no behavior that I do that would trigger her. My actions do not trigger her. On 05/21/2026 at 9:03 AM, Resident#7 was observed in bed with breakfast partially eaten on an overbed table. Resident #7 was crying and appeared to have been for several minutes based on dried tears on her cheek/face. Resident was unable to verbalize why she was crying and motioned that she was hot and needed a fan. During an interview, on 05/21/2026 at 9:10 AM, with Staff K, RN/nurse manager, when asked about the fan, Staff K replied, we had to remove her fan so that Maintenance could make sure that it is grounded and safe. We told her that it would be 15 minutes and that was 8:53 AM. During an interview, on 05/21/2026 at 9:14 AM, with Staff C, Unit Clerk, when asked about Resident #7's behaviors, Staff C replied, she is mostly calm, she likes to be by herself. We get her up as often as we can and her husband is here two times a week and is very supportive of her and he calls her very often - good man. When asked about Resident #7's diagnosis of PTSD, Staff C replied, I don't know, She was in the Miami VA for a long time and we got her after that. During an interview, on 05/21/2026 at 9:51 AM, with Staff L, Nursing Supervisor 7-3 shift, when asked about Resident #7's fan, Staff L replied, Maintenance and Risk manager determined that the fan was not safe as it could very easily fall or be knocked from the headboard as it is a clamp fan. During an interview, on 05/21/2026 at 10:02 AM, with Staff D, LPN providing care to Resident #7, when asked about the resident's behaviors, Staff D replied, she has depression and doesn't like to interact with other people, she lies in her bed and watches TV and listens to music. She states that she would rather be home with her spouse and that adds to her depression. When asked about the resident's PTSD, Staff D replied, I have never heard her complain of nightmares like others do. Another resident has nightmares - he is the only one with PTSD that has nightmares and he is medicated for them. Sometimes she gets upset when we go in and provide care and she is frustrated and she will yell and scream if you go in and she is sleeping and you wake her up. I noticed the fan on Monday, it wasn't there before. During an interview, on 05/21/2026 at 12:36 PM, with Resident #7's spouse, when asked about the resident having PTSD, the spouse replied, not that I am aware of. I have never heard anybody say that about her. When asked about Resident #7's siblings, the spouse replied, There were 3 of them all together and she was the youngest. All girls/sisters. The oldest sister passed from a heart attack 15 years ago. She was born in San [NAME] and then Atlanta and there is no family in South Florida and no kids. When asked about the resident's fan, the spouse replied, about a month or so for the fan, she was always getting so hot. They took one away from her a long time ago and then they said that she could have one again. 3). Record review for Resident #9 revealed an admission date of 08/03/22. According to the resident's most complete assessment, a Quarterly MDS with a reference date of 03/25/26, Resident #9 had a BIMS score of 15, indicating the resident was cognitively intact. The assessment documented that Resident #9 displayed feeling down, depressed or hopeless 2-6 days during the 2-week look back period. Resident #9's diagnoses included: Parkinson's disease, PTSD, Insomnia, Major depressive disorder, Depression, unspecified psychosis. Resident #7's care plan for psychosocial well-being, most recently reviewed/revised 04/28/26, documented, resident experiences symptoms of distress/PTSD related to history of trauma as evidenced by feelings triggered by loud noises and fireworks. The goal of the care plan was documented as, Episodes of distress symptoms will be alleviated quickly without harm to resident or others. Interventions of the care plan included: Acknowledge experiences as trauma and address as such.Identify what triggers stressful episodes and avoid as able. Maintain consistency in daily routine, care givers, and avoid changes when possible. Provide safe environment. During an interview, on 05/18/25 at 11:18 AM, with Resident #9, when asked about his PTSD, Resident #9 replied, Combat in Vietnam, I killed people, I carried the radio and sent information to the platoons. I was the first one in of my platoon. They sent me to a hospital for 6 weeks in Titusville. They gave me instruction on how to react. When asked about triggers to the PTST, Resident #9 stated explosions, loud noises. I gotta close in. I can be very obnoxious. During an interview, on 05/21/2026 at 10:07 AM, with Staff D, LPN providing care, when asked about Resident #9's PTSD, the LPN replied, he has never complained about nightmares. He has never complained to me about his PTSD. He was in the Vietnam war. He gets aggressive when you don't get things done in a certain order. He does not like the lights being left on and doors being left open. During an interview, on 05/21/2026 at 12:58 PM, with Staff F, CNA providing care to Resident #9, when asked about Resident #9's PTSD, the CNA replied, sometimes he will want something, and he will want it right now.

Based on interview, and record review, the facility failed to document behavior monitoring for 1 of 4 residents reviewed for Dementia Care, (Resident #98).The findings include:On 05/21/26 at 11:51 AM, a record review was conducted for Resident #98 related to antipsychotic medications prescribed for a resident with a diagnosis of Dementia. The following medications were ordered for the reason provided:Quetiapine 25 mg (Seroquel) 25 mg 1 tablet by mouth at bedtime for hallucinations. Duloxetine (Cymbalta) 30 mg 1 capsule by mouth at bedtime for depression.Duloxetine (Cymbalta) 30 mg 2 capsule (60mg) by mouth once a day at 9:00 AM for depression.A review of the Medication Administration Record (MAR) for May 2026 revealed monitoring for the antipsychotic medication Quetiapine (Seroquel) but no monitoring was found for the Duloxetine (Cymbalta) an antidepressant. A review of progress notes revealed there were no notes found that identified behavior and/or mood changes related to depression or the use of the antidepressant Duloxetine.On 05/21/26 at 2:17 PM, an interview was conducted with Staff D, a Licensed Practical Nurse (LPN) who works in the Alpha Unit and was assigned to care for Resident #98. Staff D was asked if the facility had a protocol for monitoring antidepressants and to explain the protocol. Staff D stated that the facility had a protocol to monitor behaviors and mood changes for antidepressant medication. Staff D stated that monitoring is included on the MAR. Staff D looked at the orders for Resident #98 and found no orders for monitoring the antidepressant Duloxetine. Staff D stated that the nursing staff is trained to monitor for signs of depression and signs of worsening depression, citing examples that included increased sadness, being withdrawn or seeking to be isolated. Staff D confirmed that behavior monitoring for the antipsychotic Quetiapine was found on the MAR.On 05/21/26 at 2:45 PM, an interview was conducted with Staff J, a Registered Nurse (RN), who works on the Alpha unit where Resident #98 resides.Staff J stated if a resident has dementia and antidepressants, and/or antianxiety medications, and/or antipsychotic medications are ordered then behavior and mood monitoring is supposed to be ordered and documented in the MAR. Staff J stated the nurses do not need to get a doctor's order for monitoring because it is understood that monitoring is required. Staff J stated that even if monitoring was not ordered for a medication, she would at least document mood and behavior in the progress notes. Staff J stated she would document no changes if the resident was stable.

Based on review of policy and procedure, interview and record review, the facility failed to 1) accurately document, assess and report a resident's change in skin condition and; 2) ensure appropriate notification of the resident's representative of a change in the resident's condition for 1 of 2 sampled residents reviewed, Resident #1.The findings included: 1) Review of the facility policy titled Skin Management provided by the Director of Nursing (DON) reviewed effective 04/23/12 documented .Ongoing Skin Checks Daily C.N.A. and/or other direct care giver skin checks: 1. The Certified Nursing Assistant (C.N.A.)/other direct care giver will conduct an inspection of the resident's skin daily when providing care, assisting with or providing bath/shower. 2. The Certified Nursing Assistant (C.N.A.)/other direct care giver will report to the Licensed Nurse any findings/concerns daily. Weekly Licensed Nurse skin checks: 1. The Licensed Nurse will complete full body inspection of the resident, and either: a. document on weekly skin sheet, or: b. document in the resident's electronic health record. 2. Any new concerns/risk factor will be addressed and the care plan reviewed and revised as appropriate. As appropriate, the resident's physician and primary contact will be notified of any new skin concerns. Resident #1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Diabetes Mellitus II, Hypertension, End Stage Renal Disease, Cerebral infarction, Dysphagia, Parkinson's Disease, Seizure, Depression, Anemia, Gastrostomy, Dependence on Renal Dialysis (with AV fistula/shunt to left upper extremity), contracture of the left hand, contracture of right elbow, Osteomyelitis ankle and foot. He had a Brief Interview Mental Status (BIM) score of 1, indicative of severe cognitive impairment.On 05/27/25 at 05:32 AM, Resident #1 was transferred to the hospital for lethargy, shortness of breath, and labored breathing. Vital signs were Blood Pressure 124/52, Temperature 98.3F, Pulse 61, Respiratory rate 28; and Oxygen saturation 90%.During a telephone interview conducted on 07/01/25 at 12:33 PM, with the son, who is the Power of Attorney (POA) and Healthcare Surrogate (HCS), he explained how he had received a call from the Hospital informing him that Resident #1 had been admitted to the Emergency Room, from the facility. The son stated that no one from the facility called to notify him and he said that no call was ever received. The son also stated that when he arrived at the hospital, he discovered that Resident #1 had bruises and swelling on his forehead and chin and he was on a ventilator. The son said that he could not understand how the bruises and swelling got there and why he had not been informed about this, especially since his Dad was bed bound and unable to move. The son went on to say that he was not given any information from the facility regarding Resident #1's being transferred to the hospital, nor the reason why and what happened, when he went back there several days later to gather his Father's belongings. He said that the facility only referred him to speak with the Risk Manager (RM) and with the Social Worker (SW), neither of which was able to provide any further plausible explanation to him.For the dates of 05/08/25 through 05/27/25 the Physician's Order documented, Weekly skin checks once a day on Wednesday.During a computerized record review of the nurses' note dated 05/26/25 at 11:29 PM by Staff D, Licensed Practical Nurse (LPN) she documented and revealed, Resident resting in bed no sign of distress noted . Resident face has redness On 07/02/25 at 4:28 PM an interview was conducted with Staff B, Certified Nurse Assistant CNA (assigned to the resident at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM in which she was working on the 11 PM - 7:30 AM shift), in which she revealed that when she came in that night and did her rounds, after 11 PM that night, both she and the nurse, Staff C, LPN, saw a little red rash on one of the resident's cheeks and on his chin. On 07/02/25 at 4:24 PM a telephone call was attempted, but the message stated that, this number cannot take calls, at this time, Staff A, CNA (was assigned to Resident #1 just before the event occurring on Tuesday 05/27/25 at 4:30 AM, in which she was working on the 3 PM - 11:30 PM shift), was unavailable for interview, during this survey, in order to discuss Resident #1's skin condition, at the time.On 07/02/25 at 4:26 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system, and it is not available to leave a message, Staff D, (was assigned to Resident #1 just before the event occurring on Tuesday 05/27/25 at 4:30 AM and who had been working on the 3 PM - 11:30 PM shift), was unavailable for interview, during this survey, in order to discuss Resident #1's skin condition, at the time.An interview was conducted on 07/02/25 at 4:58 PM with the Facility Registered Nurse (RN)/Risk Manager, in which she acknowledged that Resident #1 did have some type of redness, bruising and swelling on his forehead and chin, to her knowledge, however, she indicated that she did not learn about this until it was brought to her attention (when she was informed) by the resident's son, after Resident #1 had already been transferred out of the facility and to the hospital, after the date of: Thursday 05/29/25 at 6:33 PM---2 days later. She stated that she was not informed of this by the assigned nurse for the resident, at the time in which it had been documented, on Tuesday 05/27/25. The Risk Manager also acknowledged that there had been no further description nor details documented regarding Resident #1's skin condition, in the facility's progress notes. Moreover, the Facility Risk Manager revealed that she had documented, Hospital staff informed the resident's son that the resident was admitted with the above bruises, as documented in the report provided to Agency for Healthcare Administration (AHCA), by the facility's Risk Manager, dated 06/03/25 6:01:45 PM. The Risk Manager also indicated in the AHCA report that, On May 26, 2025, the 3 PM - 11 PM staff stated that upon their initial rounding on the resident, they observed him with redness on the left chin, the redness appeared recent And, the Risk Manager further documented in this same report that, during the interview process, the 11 PM- 7 AM staff expressed that they saw a bruise on the left side of the resident's cheek. And documented this on the resident's transportation form before he was transported to the Hospital. The Risk Manager subsequently described, as documented, the resident's skin abrasions after hospital transfer as: The first skin abrasion was visible approximately an inch above the resident's right brow line approximately the size of a nickel, with pinpoint red bumps visibly around the area, no swelling or rise was observed; the second skin abrasion was visible under the resident's lip towards the left corner of his mouth, the skin abrasion was blotchy/irregular shaped and approximately 2 inches, also with no swelling or skin elevation> The Risk Manager further acknowledged that both of these notations were also in the report that she submitted to AHCA. Record review of the Resident #1's Skin Care plan initiated 10/30/20 and revised 05/08/25 indicated Focus: Status/post Hospitalization on 05/08/25 . Interventions: Dermatology consult as needed . Topical treatments as ordered Goal: Resident #1 will be free of skin breakdown by next review date.There had been no mention or documentation in the record, prior to this time referencing a redness to the resident's face from Thursday 05/01/25 at 6:23 AM, in which Resident #1 was sent out to the hospital, returned to the facility on Thursday 05/08/25 at 9:25 PM until the nurses' notation on Monday 05/26/25 at 11:29 PM. Neither was there any further information describing the exact location on the resident's face that this was noted, whether the skin was intact, bruising, swollen, clean and dry. Furthermore, there was no notation in the record that this had been reported to either the Supervisor or Unit Manager on duty, nor whether any further facial skin assessment or follow-up had been done, for this resident, at the time.2) Review of the facility policy titled Change of Condition provided by the DON effective 05/12/25 documented in the Policy Statement: . II Standard: Identify, report, document and respond to a resident's change of condition to ensure timely and appropriate care. III. Definitions: A. Change of Condition: A new, worsening, or unexpected clinical development that: Threatens life or may lead to hospitalization, or Requires starting, stopping, or adjusting treatment, or Alters the residents' physical, mental, or psychological status. IV. Procedures: A. Detect the Change: All direct-care staff continuously observe deviations from baseline such as but not limited to: New or worsening pain, New changes in vital signs, Acute mental-status change, New skin discoloration or breakdown, New onset/change of mobility or functional decline, Abnormal event or occurrence. B. Notification: Relay observations to LPN/RN/Supervisor/DON to assist as necessary. Contact the primary or on-call MD/NP/PA promptly, for potentially life-threatening situations (e.g. possible Sepsis, Stroke, Uncontrolled pain). a. Provide concise information: vitals, assessment and observation findings, labs, code status, and recommended actions. b. Initiate treatments, diagnostic tests, or transfers as prescribed. Inform the resident (as able) and the designated representative of the change and provider orders. C. Document in the HER, create a comprehensive progress note on the same shift that includes: Assessment details and clinical findings, Provider notification (name, time, information shared), Interventions carried out and resident's response and Follow-up evaluation results.Computerized record review of the nurses' progress note dated Tuesday 05/27/25 at 5:16 AM by Staff C, LPN, on the 11 PM - 7:30 AM shift, revealed that she documented, Call placed to resident family member. Message left on answering machine informing of resident transfer to the hospital. Resident #1 was transferred to the hospital due to lethargy, shortness of breath, and labored breathing.On 07/02/25 at 4:47 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system and it is not available leave a message. Staff F, RN, Part-time Night Supervisor of the entire building (was assigned to Resident #1's unit at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM she will often either work on the 7 AM - 3:30 PM shift or on the 11 PM - 7:30 AM shift), was unavailable for interview, during this survey, in order to discuss whether or not the resident's representative had been contacted.On 07/02/25 at 4:43 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system, and it is not available to leave a message, Staff C, (was assigned to Resident #1 at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM in which she was working on the 11 PM - 7:30 AM shift), was unavailable for interview, during this survey, in order to discuss whether or not the resident's representative had been contacted.During an interview conducted on 07/02/25 at 2:38 PM, with Staff E, RN, (who was assigned to Resident #1 just the time after the event had occurred earlier on Tuesday 05/27/25 at 4:30 AM, in which she was working on the 7 AM to 3:30 PM day shift) she revealed that she had not made any phone calls, at any time during her shift, to Resident #1's family in order to ensure that they had been informed of the resident's hospital transfer.During a subsequent side-by-side record review and interview with the Risk Manager on 07/02/25 at 5:20 PM, it was revealed, according to the progress notes in the facility record, that there was only one (1) note regarding Resident #1's family being notified via voice message only. Subsequently, the Risk Manager acknowledged that there was no additional notation to show that the resident's family ever actually received this information from the facility, nor that the facility made any other attempts to contact and notify the resident's family of the resident's transfer out of the facility to the hospital.There were no other documented follow-up phone call attempts made by the facility to verbally inform the resident's representative of the resident's changed in condition or status, nor of his transfer to the hospital. And, there was no evidence to show that the facility had actually spoken to and informed the son. The DON further recognized and acknowledged on 07/02/25 at 5:45 PM that, Resident #1's facility identified 'face with redness and rash on one of his cheeks and on his chin,' should have been documented in detail to include whether or not the skin was intact, bruising, swollen, clean and dry, size and include a description and exact location on the resident's face along with any further facial skin assessment or follow-ups, reported to the Supervisor, to her and to the Doctor notified, as applicable or as warranted. The DON also acknowledged that the resident's representative should have been notified and ensured that documented attempts or efforts were made to contact them.

Based on observations, interviews, and record review, the facility failed to address a significant weight loss in a timely manner, failed to provide adequate nutritional supplements to prevent further significant weight loss, and failed to have effective communication between the multidisciplinary staff for 1 of 4 sampled residents reviewed for nutrition (Resident #103). The findings included: A review of the facility's policy titled, Dietitian, dated [DATE], showed the following: The Dietitian will work closely with the Interdisciplinary team, assess the nutritional needs of the residents, and collaborate effectively with other direct care staff and practitioners to assess and address nutritional issues with the facility population. A review of the facility's policy titled Facility Nutrition Program/Resident Nutrition Services dated [DATE] showed the following: the Dietitian will help assess the nutritional needs and risk of all residents and ensure that appropriate meals and other nutritional interventions are provided. A review of the facility's policy titled Standards of Care Meetings dated [DATE] showed the following: the facility will conduct a standards of care meeting weekly to address resident at risk related to significant weight changes. Pull report from electronic health for the weight variances for the past 180 days and review prior to meetings. Each significant weight change must be identified and addressed in the documentation and the care plan. Identifying the root cause of the weight loss and working toward identifying interventions as appropriate. Is the Dietitian consulted and documenting timely on the significant weight change? Are recommendations followed up in a timely manner? The meetings will be held weekly and all residents in all care areas should be discussed at least monthly. Record review revealed that Resident #103 was initially admitted to the facility on [DATE]. He was discharged on [DATE] and readmitted again on [DATE]. He was transferred to the hospital on [DATE] and returned on [DATE]. He was transferred to the hospital on [DATE] and returned to the facility on [DATE]. He was transferred to the hospital from [DATE] and returned [DATE]. He was transferred to the hospital again on [DATE]. A progress note dated [DATE] revealed that Resident #103 expired at the hospital. Resident #103 had diagnoses of right Adrenalectomy, bipolar, dementia, and hypertension. The annual Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 10, which was moderate cognitively impaired. A review of the care plan initiated on [DATE] showed that Resident #103 will not experience weight changes and will consume greater than 75% of meals served. It further showed that Rsident #103 was at risk for decline in nutritional status as evidenced by diagnoses. The Quarterly review dated [DATE] showed to continue with plan of care. The approaches were noted to monitor nutritional status and to monitor weights. A review of the weight log for Resident #103 showed the following: [DATE], a weight of 182 pounds. [DATE], a weight of 177 pounds. [DATE], a weight of 174 pounds. [DATE] a weight of 170 pounds. [DATE], a weight of 168 pounds. [DATE], a weight of 166.5 pounds. [DATE], a weight of 168 pounds. [DATE], a weight of 181 pounds. [DATE], a weight of 178 pounds. [DATE], a weight of 176 pounds. [DATE], a weight of 164 pounds. [DATE], a weight of 157 pounds. [DATE], a weight of 154 pounds. [DATE], a weight of 150.8 pounds. [DATE], a weight of 154.2 pounds. [DATE], a weight of 145 pounds. The above weight changes showed that Resident #103 had a significant weight loss of 9.4% from [DATE] to [DATE], a significant weight loss of 6% from [DATE] to [DATE], and an 11.6% significant weight loss from [DATE] to [DATE]. The readmission initial nutritional observation dated [DATE] revealed the following: The Dietitian used a recorded weight of 172.4 pounds taken from [DATE]. No updated weight was taken after Resident #103 was readmitted on [DATE]. Resident #103 estimated calorie needs at ,d+[DATE] a day and ,d+[DATE] grams of protein a day. In this note, the Dietitian deceased the Mighty Shake (nutritional supplements), which the Resident was on from 3 times a day to once daily, stating that Resident #103 ate over 75% of his meals. Monitor intake of meals and weights and follow up as needed. The next follow up nutritional note dated [DATE] showed the following: Resident #103 weight was at 176 pounds and at increased nutritional risk. He was receiving one can on Mighty shake an eating 75% to 100% of his meals. This note did not address that Resident #103 went down from 181 pounds to 176 pounds. No additional nutritional interventions were made at this time. The next nutritional assessment was dated [DATE] which was 17 days after Resident #103 ' s 9.4% significant weight loss was identified. In this note, the Consultant Dietitian stated that Resident #103 had a 7.5% weight change in 90 days and reduced his estimated protein needs between 74 grams to 89 grams and his daily caloric needs to 2337. It further showed that Resident #103 was at nutritional risk due to weight loss and ate ,d+[DATE]% of his meals. No new nutritional interventions were made to address the above significant weight loss and the note stated to continue plan of care. The nutritional follow-up note dated [DATE], which was written about 2 weeks after the 6% significant weight loss, was identified from 164 pounds on [DATE] to 154 pounds on [DATE]. In this note, Staff V, Consultant Dietitian stated Resident #103 eats 76%-100% of his meals and occasionally eats 26% to 50% of his meals. Staff V stated that Resident #103 was at nutritional risk with a history of significant weight loss and recommended increasing the Mighty Shake supplements from once a day to twice a day. This nutritional intervention only provides an extra 200 calories and 9 grams of protein a day to aid with significant weight loss. A review of the Medication Administration Record dated [DATE] to [DATE] did not show that Resident #103 received the Mighty Shake nutritional supplements twice a day. A progress note dated [DATE], which was completed by Staff V, current Consultant Dietitian, revealed the following: Resident #103 Ideal Body Weight was 178 pounds, and his current weight was 155.4 pounds. Resident #103 had a 6.2% significant weight loss in 30 days and a significant 11.7% weight loss in 90 days. Resident #103 eats 76%-100% of his meals, and occasionally, he eats 26% to 75% of his meals, which should be sufficient to meet nutritional needs. It further showed that Resident#103 would benefit from a weight gain of 4.6 pounds in two weeks and 1.2 pounds in one week. No nutritional interventions or changes were made at this time to address the weight loss and provide supplements to aid with weight gain. The next nutritional progress dated [DATE] and completed by Staff V showed the following: Resident #103 had 19.8 pounds in 180 days (the RD wrote this in her note which was a mistake), and 11.5% significant weight loss in 90 days. 51% to 75% of the food intake was noted for the last 30 days, which may not be sufficient to meet nutritional needs. In this note, Staff V added a Med pass (nutritional supplement) once a day to provide an extra 240 calories and 10 grams of protein. This note did not show that Staff V contacted Resident #103 ' s Practitioner regarding the severe weight loss of 19.8% from [DATE] to [DATE]. A progress note written on [DATE] by Staff W, Nurse Practitioner, stated that Resident #103 lost 36 pounds in 6 months post Adrenalectomy. It was recommended to consult an endocrinologist for possible adrenal insufficiency. This note was written 2 weeks after the last nutritional note was written by Staff V on [DATE]. In an interview conducted on [DATE] at 3:05 PM with Staff W, she stated that she was aware that Resident #103 lost some weight, but she did not suspect more than a normal weight loss associated with dementia. She did not worry about the weight loss because she knew that Dietary was following the Resident. The nursing staff told her that Resident #103 had not been eating well for some time, and when she assessed the Resident on [DATE], she noticed the weight loss on his face and body. Staff W was not aware that Resident #103 had a severe weight loss and was never told by the nutrition department or the nursing staff prior to the week of [DATE]. According to Staff W, she did not see the trending weight loss or the overall picture of the weight loss for Resident #103. She ordered some labs after she noticed the weight loss but would have had Resident #103 see an endocrinologist sooner. Staff W said, I depend on the nursing staff to let me know of any significant weight loss or change in conditions. When asked by this Surveyor if the weight loss for Resident #103 was avoidable or nonavoidable, she could not tell. In an interview conducted on [DATE] at 10:20 AM with Staff V, Current Consultant Dietitian stated that she comes into the facility on ce a week and oversees all high-risk residents and residents with significant weight loss. The weights are taken on admission, every week for four weeks, and monthly thereafter. A nutrition observation assessment on all admissions and readmissions is completed as soon as possible. In an interview conducted on [DATE] at 8:00 AM with the facility's Diet Technician, she stated that she has been working in the facility full time and that the Consultant Dietitian comes in once a week. The residents weights are discussed and reviewed in the weekly risk meetings that are held on Thursdays with the Interdisciplinary team. She and the consultant dietitian are required to attend those meetings. The Consultant Dietitian comes in once a week, usually on Thursdays so that she can attend the meetings. They have had some issues with coverage for some time and difficulties with meeting the workload once a week by the Consultant Dietitians. According to her, all initial assessments and significant weight change notes are completed by a Consultant Dietitian. All weights are taken by Restorative staff and recorded in the electronic system. The monthly weights are placed in the system by the 9th of the month and then emailed to her and the Consultant Dietitian for review. For any weight loss, the Diet Technician will contact the Consultant Dietitian to ensure that she follows up on any nutritional recommendations and interventions. The consultant nutritionist oversees the running of a monthly weight report and addresses any significant weight losses as well as weekly weights. In an interview conducted on [DATE] at 9:26 AM with Staff V, Current Consultant Dietitian, she was asked as to why she only recommended Med pass once a day in her note dated [DATE]. She said that Resident #103 was eating about 75% of his meals, and she wanted to make sure he was receiving the nutritional supplements (Mighty Shake) and that it was enough before throwing more supplements on Resident #103. It was only when she noticed the 10-pound weight loss that she went ahead and added the Med pass. Staff V said that she only attended the last risk meeting but has not been attending the prior ones. She was only told recently that she needed to be part of the risk meetings. When asked if she had contacted Staff W prior to [DATE] to address the significant weight loss for Resident #103, she said no. Staff V stated that she did not address the weight loss with the facility ' s Director of Nursing or the nursing staff on the floor. In an interview conducted on [DATE] at 10:00 AM with the Director of Nursing (DON), she stated that at 10:00 AM, the risk meetings are done weekly with the Consultant Dietitian and the Diet Technician. They addressed the weekly and monthly weights and any significant changes. The DON said that she remembered discussing the weight loss on Resident #103 in the risk meeting but could not recall the date. When asked if she had contacted Resident #103's Practitioner to let her know about the severe weight loss, she said no but that the Practitioner had been notified recently by the nursing team. Usually, she speaks to the nursing team and the nurse supervisor, and they contact the Practitioner. In an interview conducted on [DATE] at 10:07 AM with Staff E, Licensed Practical Nurse, she stated that she remembered Resident #103 and had worked with him in the past. She said that Resident #103 was eating well, that he drank all the Mighty shakes daily, and that he liked them. She did not see any poor intake of meals and was aware that he lost weight because she reviewed the weekly and monthly weights. She reported to Staff W, that Resident #103 lost weight but was not sure as to when she reported the weight loss. According to Staff E, Resident #103 could eat independently and needed very little assistance. Only around the end of [DATE] did she start noticing the weight loss on Resident #103's face and body. A review of the clinical chart did not show any nutritional assessments or notes written after the last one was done on [DATE]. In an interview conducted on [DATE] at 3:00 PM with the DON she was informed of the findings.

Based on observations, interviews and record review, the facility failed to follow their own menu for fresh fruit, for 8 of 8 residents observed during dining (Resident #104, Resident #42, Resident #14, Resident #8, Resident #86, Resident #12, Resident #60, and Resident #35). The findings included: 1. Record review revealed that Resident #104 was admitted on [DATE] with diagnoses of Hypokalemia and Hemiplegia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an interview conducted on 01/07/25 at 8:24 AM in the main dining room, Resident #104 was eating his breakfast meal. Resident #104 stated that they only get bananas twice a week if any, and that the rest of the week they do not get any fresh fruits. He then picked up his meal ticket and said, it says here that we are supposed to get fresh fruit for breakfast. 2. Record review revealed that Resident #42 was readmitted to the facility on [DATE] with diagnoses of Depression and Dysphagia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. In an interview conducted on 01/07/25 at 8:32 AM in the main dining room, Resident #42 stated that they only get fresh fruits twice a week and that is usually a fresh banana which they do not have today. 3. Record review showed that Resident #14 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, and Muscle Weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. In an interview conducted on 01/07/25 at 8:32 AM in the main dining room, Resident #14 stated that they are supposed to get a fresh fruit every day for breakfast and that they do not. 4. Record review revealed that Resident #8 was readmitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, and Hypertension. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. In an interview conducted on 01/07/25 at 8:32 AM in the main dining room, Resident #8 stated that they only get bananas but not every day and that it is only given once or twice a week. 5. Record review revealed that Resident #86 was admitted on [DATE] with diagnoses of Muscle Weakness and Depressive Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an observation conducted on 01/07/24 at 8:41 AM, Resident #86 was in his room with the breakfast tray. The breakfast meal ticket dated 01/07/25 showed fresh fruit. The breakfast meal plate provided to Resident #86 did not have fresh fruit. 6. Record review showed that Resident #12 was readmitted to the facility on [DATE] with diagnoses of Muscle Weakness and Dysphagia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an interview conducted on 01/07/24 at 8:50 AM, Resident #12 stated that they do not get fresh fruit for breakfast every day. 7. Resident #60 was readmitted on [DATE] with diagnoses of Parkinson, Dysphagia and Depression. An order dated 12/20/24 for Mechanical Soft (Pureed fruits and vegetables with nectar thick liquids. The Significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #60 is rarely or never understood. In an observation conducted on 01/07/24 at 8:54AM, Resident #60 was in his room with the breakfast tray. The breakfast meal ticket dated 01/07/25 showed fresh fruit. The breakfast meal plate provided to Resident #60 did not have fresh fruit. 8. Record review showed that Resident #35 was readmitted to the facility on [DATE] with diagnoses of Hemiplegia and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an observation conducted on 01/07/24 at 8:39AM, Resident #35 was in his room with the breakfast tray. The breakfast meal ticket dated 01/07/25 showed fresh fruit. The breakfast meal plate provided to Resident #35 did not have fresh fruit. In an interview conducted on 01/09/24 at 11:00 AM with the facility's Diet Technician, she stated that they have bananas coming in on a weekly basis and that they also substitute other fresh fruits. When asked as to why the fresh fruit was not provided to all residents on 01/7/24 for the breakfast meal she did not have an answer.

Based on observations, interviews and record reviews, the facility failed to provide palatable, appetizing and flavorful food for 8 of 8 residents (Resident# 58, Resident# 43, Resident# 59, Resident# 73, Resident# 88, Resident# 17, Resident# 32, Resident# 70). The findings included: 1. A record review showed that Resident #58 was admitted on [DATE] with chronic kidney disease stage 3. The Minimum Data Set (MDS) quarterly dated 11/20/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 13, which indicates mild cognitive impairment. In an interview conducted on 01/06/2025 at 11:45 AM, this surveyor was stopped in the hallway by Resident # 58 who said that the food in the facility is disgusting. He stated that the food did not look appetizing, that he usually asks for his eggs over easy but one day he gets it and the next day he does not. This is because they alternate between pasteurized and unpasteurized eggs. Resident #58 further stated that the unpasteurized eggs are overcooked and have a pancakes texture. The resident said that he doesn't understand what is going on in the kitchen, but the food is terrible. 2. A record review showed that Resident #43 was admitted on [DATE] and readmitted on [DATE] with Amyotrophic lateral sclerosis and muscle wasting and atrophy. The Minimum Data Set (MDS) quarterly dated 10/16/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 12, which indicates moderate cognitive impairment. In an interview conducted on 01/06/2025 at 10:01 AM Resident # 43 stated that his meals are incomplete, and that he never gets what he asks for. 3. A record review showed that Resident #59 was admitted on [DATE]with low vision, atherosclerotic heart disease, and unspecified angina pectoris. The Minimum Data Set (MDS) quarterly dated 12/18/24 revealed that the Brief Interview of Mental Status (BIMS) score is 08, which indicates severe cognitive impairment. In an interview conducted on 01/06/2025 at 10:05 AM Resident # 59 stated that the food is horrible. 4. A record review showed that Resident #73 was admitted on [DATE] and readmitted on [DATE] with cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery and chronic arterial fibrillation. The Minimum Data Set (MDS) quarterly dated10/09/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairment. In an interview conducted on 01/06/2025 at 12:30 PM in the main dining room Resident # 73 stated that breakfast is okay, but lunch and dinner are terrible. Sometimes they serve popcorn shrimp with a very thick coating and some pieces don't have any shrimp under the coating. Resident #73 further stated that when he says he doesn't like the food the staff gets mad and takes his plate away. 5. A record review showed that Resident #88 was admitted on [DATE] with polymyalgia rheumatica and muscle wasting and atrophy. The Minimum Data Set (MDS) quarterly dated 10/16/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 14, which indicates mild cognitive impairment. In an interview conducted on 01/06/2025 at 12:37 PM in the main dining room Resident # 88 stated that the main issue of this facility is that the food is not appetizing and that he does not get what's on the menu even when he orders it. A review of the Fall/Winter week 4, Day 4, lunch showed the following: 3 ounces of baked chicken, sage bread dressing, Harvard beets and black forest cake. At test tray on a Regular consistency diet was conducted on 01/08/24 at 12:10 PM. The following were noted: the baked chicken appeared small and tasted bland with no seasoning. The sage bread stuffing was colorless, with no taste and a dough like texture. The beets had a thick glaze with no taste and tasted like canned beets. The overall lunch plate had a beige and reddish color with no other color variation and lacked any type of colorful garnish. The black forest cake was dry to taste and was served in a plastic throw away container. The lunch meal did no have an appetizing appearance or taste. 50370 6) Record review revealed Resident #17 was admitted on [DATE] with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness, Muscle Weakness, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder, and Malignant Neoplasm of the Prostate. A review of quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C revealed a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. A review of dietary care plan dated 08/29/24, revealed Resident #17's risk for nutritional status decline, with interventions to monitor and document the intake of food, and to offer food preferences. During an interview on 01/07/25 at 11:25 AM, Resident #17 was sitting in a wheelchair, and waiting for a staff to take him to activities. When asked regarding breakfast, he prompted the surveyor to speak louder, while pointing at his left ear. He stated he barely ate the breakfast served him because of bad food taste. He added he had to eat some of it because he had no other choices. When asked if he requested an alternate meal, he seemed confused, pointing at his right ear, then asked this surveyor to repeat the question. When the surveyor explained that he could ask for a different meal in a louder voice volume, he smiled and stated he did not know that. When asked regarding other previous meals served in the facility, he added all foods had bad taste and not good to eat. 7) Record review revealed Resident # 32 was initially admitted on [DATE], and readmitted on [DATE] with diagnoses including Bullous Pemphigoid (a rare skin condition causing large, fluid-filled blisters), Hemiplegia and Hemiparesis following Cerebrovascular Disease (affecting left non-dominant side), Muscle Weakness, Dementia with Agitation and Diabetes Mellitus. A quarterly MDS dated [DATE], revealed a BIMS score of 12, indicating a moderately good cognition. A review of baseline care plan dated 03/02/23, revealed Resident #32 was at risk for nutritional deficit, with the following interventions: dietician to evaluate as needed, provide diet as ordered, assist with meals as needed, and obtain food preferences. Additional review of a quarterly nutrition progress notes dated 09/03/24, revealed the following: Basal metabolic index (BMI) of 27.12, weight of 121 Lbs. (pounds), fluctuating food intake, and known food preferences. During an interview with resident on 01/06/25 at 10:10 AM, when asked regarding meals and food serve by the facility, she responded, Terrible food. When asked to explain what terrible means, she stated, Food does not match menu, and food does not taste good. When asked if she requested a tastier food, she responded All of the foods served here have no flavor. In another interview with Resident #32 on 01/08/25 at 03:49 PM, when asked regarding lunch, she responded, Lunch was tasteless. 8) Record review revealed Resident #70 was admitted on [DATE] with diagnoses including Complete Traumatic Amputation of 2 or more toes, Type 2 Diabetes Mellitus, Essential Hypertension and Depression. A review of quarterly MDS dated [DATE], revealed a BIMS score of 09, indicating moderately impaired mental cognition. Section K revealed no swallowing disorder, while Section L revealed no broken teeth, loose teeth and mouth or facial pain. Additional review of nutrition care plan dated 09/19/24, revealed resident was at risk for nutritional status decline. A quarterly MDS review notes dated 10/29/24, revealed to assist resident with meals as needed, diet as ordered, and monitor food intake. Further review of dietary notes dated 01/08/25 revealed no food intolerances, and resident was at continued nutritional risk. During an interview with Resident #70 on 01/06/25 at 10:36 AM, when asked regarding the meals and food served by the facility, he responded, The food was not flavorful. In another interview on 01/07/25 at 9:30 AM, when asked about his breakfast, he responded, Food was not good. When asked why it was not good, he responded, It had crappy taste. During another interview with resident on 01/08/25 at 9:10 AM, when asked if he is losing weight, because he stated he does not like the taste of food in the facility, he responded his wife brings him food, he is not bothered if he is losing weight but would like to have tasty and flavorful food from the facility. 50895 9) During an interview with the Food Service Director (FSD) on 01/08/25 at 3:50 PM, in the Dietary Manager's office, the FSD mentioned that she eats the foods served at the facility and that she thinks they taste good. She also said that there were many residents on the No Added Salt diet, and for that reason many of the foods tasted bland. The requested test tray was for the lunch meal served to residents on a Regular diet (with no restrictions).

Based on observations, record reviews, interviews, and policy review, the facility failed to provide the correct diet consistency for 9 residents on the Pureed consistency diet (Residents #41, #65, #25, #53, #11, #16, #45, #60 and #22). This had the potential to affect 14 residents that were prescribed the pureed consistency diet. The findings included: 1) During an observation of residents eating lunch in the Delta Blue dining area, on 01/06/25 at 12:10 PM, Resident #16, Resident #45, and Resident #11 were served the pureed entree consisting of ham, brussel sprouts, and corn. The food appeared lumpy. 2) In an observation and interview with the FSD on 01/06/25 at 12:25 PM, the surveyor approached the Food Service Director (FSD) who was behind the steam table in the main dining room. Concerns about the pureed consistency were voiced by the surveyor. The surveyor requested a sample of the pureed lunch meal and the FSD asked a dietary aide to prepare a pureed meal plate. The FSD carried the pureed meal tray to her office accompanied by the surveyor. At the Food Service Director's desk, the surveyor tasted the pureed meal and observed that the pureed corn, the pureed ham, and the pureed brussel sprouts had small pieces in them that required chewing. They were not smooth. The FSD agreed that the consistency of the pureed foods was not smooth. 3) During an observation of residents eating lunch in the Delta Blue dining area on 01/07/25 at 12:14 PM, Resident #16, Resident #45, and Resident #11, received the pureed entree consisting of pureed Goulash, pureed mixed vegetables, and pureed white bread. The Goulash, mixed vegetables, and bread appeared lumpy. The surveyor approached the FSD and expressed concern about the pureed meal plates and requested a written description of the mechanically altered diets that the cooks follow. 4) Observation of the lunch meal served on the Delta [NAME] unit 01/08/25 at 12:03 PM showed that the pureed diet was served to Resident #41, Resident #65, Resident #25, and Resident #53. The pureed chicken had visible strands of chicken. It was not a uniform consistency. 5) A review of the facility's diet roster printed on 01/06/2025 showed that Resident #16, Resident #45, Resident #11, Resident #41, Resident #65, Resident #25, and Resident #53, were on pureed consistency diets. 6) A review of the State of Florida Department of Veteran's Affairs policy on Facility Diets-Food Consistencies, revised 11/07/2017, described the pureed food consistency. The pureed consistency is designed to provide soft smooth foods. The pureed diet is indicated for individuals with chewing or swallowing problems. 7) In an interview conducted on 01/08/25 at 3:39 PM with Staff G, the Speech Language Pathologist (SLP), she stated that for the pureed consistency, the food needs to be cooked in a way that is it not too liquid and that it should have no solids particles. Sometimes when they process the food in the blender it may have some food particles in it. The Pureed food should have a smooth consistency, with one solid uniform consistency. When the Speech Language Pathologist was shown a picture of the strand of chicken on the spoon from the pureed lunch meal served on 01/08/25, she said that if she saw that pureed chicken served to the residents, she would have sent it back to the kitchen and requested that it be pureed until it was smooth. Photographic evidence obtained 40153 8) Resident #60 was readmitted on [DATE] with diagnoses of Parkinson's, Dysphagia, and Depression. An order dated 12/20/24 for Mechanical Soft (Pureed fruits and vegetables) with nectar thick liquids. The Significant Change Minimum Data Set (MDS) dated [DATE] revealed that Resident #60 is rarely or never understood. In an observation conducted on 01/06/25 at 12:09 PM, Resident #60 was in his room with his lunch meal. Closer observation showed a meal ticket: regular mechanical soft diet with pureed fruits and vegetables, mechanical soft baked ham, creamed corn, soy milk, bread, and thick nectar liquids. The lunch plate was noted with mechanical soft ham and pureed corn that was lumpy, with visible pieces of corn that did not have a uniform consistency. 9) Resident #22 was readmitted on [DATE] with diagnoses of Dysphagia and Psychotic disorder. The diet order dated 08/12/24 was for a pureed thin liquids diet. The Quarterly MDS dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 09, which was moderate cognitive impairment. In an observation conducted on 01/06/25 at 12:40 PM, Resident #22 was in his room eating his lunch tray. A closer observation showed a meal ticket noted with the following: pureed diet with pureed ham and pureed buttered corn. The lunch plate was noted with pureed corn that was lumpy, with visible pieces of corn that did not have a uniform consistency.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, sanitary conditions, and to ensure the prevention of foodborne illnesses for 106 of 112 residents. The findings included: During the initial tour of the kitchen on 01/06/25 at 9:30 AM, accompanied by the Food Services Director (FSD): 1. The walk-in refrigerator had a black plastic bag with a knot in it located on a shelf. When asked what was in the bag the FSD opened the bag and revealed that it was someone's personal food. It looked like it was chicken and vegetables in a plastic container. On the shelf below that there was transparent, white plastic wrap crumpled up into a ball. 2. The Arctic walk-in freezer had pieces of rubber on the floor. When asked what it was, a food service employee said that it fell off a pipe. 3. The metal backsplash connected to the Vulcan oven had streaks of black and brown debris on the area rising approximately 14 above the level of the stove top. 4. A clear plastic bin had white dried on residue on the interior walls of the bin. The FSD said it must be cleaning solution. 5. Two frying pans had burned on black debris. 6. A large stock pot had black debris surrounding the areas where both handles were connected. 7. The meat slicer had rusty colored markings and brown residue on the blade and the surrounding areas. A follow-up tour of the kitchen on 01/08/25 at 12:00 PM was conducted. The following was observed: 1. The temperature of chocolate pudding that was taken out of the reach in refrigerator was 48' F. The temperature of the puree Black Forest Cake was 54' F. The temperature should have been 41' F or below to meet professional standards for food safety. The FSD was present during this temperature reading and she agreed with the finding. She said that she didn't know why the temperature was so high. During a tour of the nourishment rooms on 01/08/25 at 4:00 PM, accompanied by the FSD, the following was observed: 1. The Alpha nourishment room refrigerator had brown residue on the highest plastic shelf on the inside of the refrigerator door. Drops of brown colored dried on liquid was on the inside of the freezer close to where the ice packs were stored. There was brown residue on the door handle. 2. The microwave had brown residue on the interior surfaces of the microwave, including the lower and the upper sides of the interior. 3. The temperature of the refrigerator in the Delta Yellow nourishment room was 44' F. The temperature should have been 41' F or below to meet professional standards for food safety. 4. An interview with the nurse supervisor for the Delta Yellow unit, Staff I, on 01/08/25 at 4:32 PM, revealed that to the best of her knowledge, housekeeping does not clean inside the refrigerator. If someone uses the microwave and spills something they should clean it up right then. She added that if someone spills something in the refrigerator, they should clean it up. Photographic evidence obtained.

Based on observations, interviews and record reviews, the facility failed to provide residents' choices consistent with their interest assessments and care plan. Facility failed to honor resident choices regarding scheduled bedtime for 1 of 1 resident (Resident #114). The findings included: A record review showed that Resident #114 was admitted on [DATE] with Quadriplegia, C1-C4 incomplete. The Minimum Data Set (MDS) quarterly dated 12/18/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicated no cognitive impairment. A review of the admission MDS dated [DATE] section E showed that Resident #114 answered that it was very important for him to choose his bedtime. In an observation conducted on 01/06/2025 at 11:35 AM Resident #114 was still lying in his bed undressed. In an observation conducted on 01/08/2025 at 12:05 PM Resident #114 was seen in bed underneath the covers. In this observation Resident #114 said that he was waiting to get dressed and get out of bed. In an interview conducted on 01/09/2025 at 1:15 PM Resident #114 stated that he wished to be out of bed earlier than 12:00 PM. An ideal time for him would be at 10:00 AM. Resident #114 further stated that he talked to the staff regarding getting out of bed at 10:00 AM and not after 12:00 PM, but nothing changed. In his last attempt to address the issue he was answered that they have to do what is best for the nursing staff. In an interview conducted on 01/09/2025 at 1:05 PM with Staff O, Certified Nurse Assistant (CNA) Staff O, stated that Resident #114 did mention wanting to be out of bed earlier than 12:00 PM, but she did not have the power to change that. In an interview conducted on 01/09/25 at 2:00 PM, with the Director of Nursing (DON), she was informed of the findings.

Based on observations, interviews and record reviews, the facility failed to address a grievance regarding hearing aids for 1 of 1 sampled resident (Resident #17). The findings included: A review of facility's policy titled, State of Florida, Department of Veteran's Affairs, Resident Grievances dated 08/04/2009, revised 10/18/2027, revealed the resident has the right to voice grievances to the facility. Number 1under the filing grievances section revealed that any resident, family member, or appointed resident representative may file a grievance concerning care, treatment, behavior of other staff members, theft of property or any other concerns regarding his or her stay in the facility. Number 3 revealed that grievance may be submitted orally or in writing and may be filed anonymously. Number 6 under the investigation and resolution of grievances section revealed that the resident and or resident's representative filing the grievance on behalf of the resident, will be informed of the findings of the investigation within 10 working days of receiving the grievance, and actions taken to correct any identified concerns. Record review revealed Resident #17 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder. Review of quarterly Minimum Data Set (MDS) assessment, dated 11/12/24, revealed a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. Section B revealed hearing aids were used by Resident #17 during the assessment. A review of nursing care plan dated 08/15/23, quarterly reviewed on 11/15/23, 02/14/24, 05/15/24; annually reviewed on 08/14/24 and 11/13/24, revealed to continue the plan of care for communication problem with the Nursing approaches of assisting with hearing aid placement and maintenance prn (pro re nata), or as needed. Additional nursing interventions revealed to check Resident #17's ears for cerumen build up prn, and to refer to Audiologist as indicated. Additional review of Social Worker's notes dated 11/20/24, revealed impaired hearing, bilateral hearing aid used, potential for decline in understanding. A further review of care plan edited on 11/21/24 regarding mood and state problem revealed interventions by Nursing and Social Services to involve Resident #17's family in his care. In an interview on 01/07/25 at 11:19 AM, Resident #17 reported he lost his hearing aids two weeks ago. When asked if he told Staff, he pointed to his right ear and asked this Surveyor to repeat the question. He then responded No! Resident stated he was having a hard time understanding and asked the surveyor to talk louder. When asked how he lost the pair of hearing aids, he responded with a smile, pointed at his right ear and asked to repeat the question. After the surveyor asked the question in a louder voice, Resident #17 responded, I put them in my right short pocket, then my laundry was taken out of my room with the pair of hearing aids. In an interview with Staff Q, a Certified Nursing Assistant (CNA), on 01/07/25 at 11:30 AM, when asked if she had observed Resident #17 was not wearing both hearing aids for the past few weeks, she responded No. When asked if she is aware resident lost his hearing aids, she responded, she was not. She added she will tell the Charge Nurse right away. In an interview with Staff E, a Charge Licensed Practical Nurses (LPN) on 01/08/25 at 11:46 AM , she stated she has never heard of any resident who lost hearing aids. In an interview with Resident #17's daughter on 01/07/25 at 12:16 PM, she revealed she reported the loss of hearing aids two weeks ago to both laundry and nursing staff but failed to get their names. When asked if any of the facility staff had given her an update regarding the hearing aid search, she responded, No, no one called me back and I want to get an update as soon as possible. She was worried that her father might be having difficulty in communicating and expressing his needs. In another interview on 01/07/25 at 2:30 PM, when asked about his lunch, Resident #17 answered with a smile that he is having hearing difficulty. He kept pointing at his right ear and asking the surveyor to repeat the questions. In an interview with Staff S, a Licensed Social Worker (LSW) on 01/08/25 11:56 AM, when asked who can report the loss of personal property in the facility, she responded, Anybody, including staff, visitors and residents may report a loss or missing personal item. She added that there is no time limit for reporting the loss or missing items. When a resident reports the lost or missing items to a facility staff, the staff completes a Care and Concern form. Once filled, the form is submitted to the Social Services department, which initiates the investigation, and discusses the search event during the next day staff meeting. When the entire facility staff is aware, they all participate in the investigation by searching for the lost or missing item. When asked why there was no completed Care and Concern form and investigation started for Resident #17's hearing aids, she responded, I never heard of anybody who lost a pair of hearing aid!. Staff S, a LSW was made aware that Resident #17 told Staff Q, a CNA yesterday about the lost hearing aids. Furthermore, she was informed that Resident #17's daughter reported the loss to the laundry and the nursing staff a few weeks ago. Staff S responded that there is a break in reporting, but she will talk to the Nurse Supervisor and will personally fill out the report. In another interview on 01/09/25 at 9:02 AM, Resident #17 stated no one has updated him about the hearing aids. In an interview with Staff S on 01/09/25 at 10:23 AM, she stated the hearing aids investigation started, and Resident #17's daughter was updated regarding the search.

Based on observations, interviews and record reviews, the facility failed to provide treatment and care, in accordance with professional standards for practice for 3 of 25 sampled residents (Resident #114, Resident #34, Resident #104). The findings included: 1) Record review showed that Resident #114 was admitted to the facility on [DATE] with Quadriplegia, C1-C4 incomplete. The Minimum Data Set (MDS) quarterly dated 12/18/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairment. A review of section GG indicated that Resident #114 needs partial to moderate assistance to roll left and right. In an interview conducted on 01/09/2025 at 1:30 PM Resident #114 stated that 3 weeks ago he was left on his bed for 2 hours in fetal position waiting for a suppository to help with defecation. He further stated Staff O, Certified Nurse Assistant (CNA), who starts her shift at 3:00 PM and came into his room and found him in fetal position on his bed sweating with his heart rushing. The CNA obtained the Hoyer lift from the room across, got him in his wheelchair, pushed him into the bathroom and made the necessary arrangement for him to evacuate. In an interview conducted on 01/09/2025 at 4:05 PM with Staff O, she stated that the incident happened 3 weeks ago. She came in at 3:00PM and started rounding when she found Resident #114 lying on one side sweating saying that he needed to use the bathroom, she ran and went to get the Hoyer lift from the opposite room, got him on the chair and pushed him to the bathroom. She further stated that Resident #114 told her that he had spent two hours waiting for the suppository which never got administrated. 50895 2) At the resident council meeting held on 01/08/2024 at 2:30 pm, Resident #34 complained that at a prior resident council meeting he reported the problem that he waits too long for assistance with toileting. He and two other residents agreed that reported problems are not resolved. When asked to describe what happened in the bathroom, Resident #34 said that he waited on the toilet for one and a half hours before he received assistance. At first, he pulled the call bell, and no one came. When he got too tired of waiting, he phoned the front desk and asked for someone to request that a nursing staff member to go to his room and to provide him with assistance in the bathroom. When the surveyor asked how many times this has happened, Resident #34 stated every day of the week. A record review showed that Resident #34 was admitted to the facility on [DATE] with Other Sequelae of Cerebral Infarction, and Diabetes Mellitus Type 2. This resident's Brief Interview for Mental Status (BIMS) score, per the Minimum Data Set (MDS) assessment dated [DATE], was 15. This indicated that Resident #34 was cognitively intact. 3) At the resident council meeting held on 01/08/2024 at 2:30 pm Resident #104, said that he waited half of an hour to receive assistance when he was on the toilet. He stated that when he called someone to help, a CNA answered that she was unable to assist him because she was assigned to a different section of residents on the unit. Per record review, Resident #104 was admitted on [DATE] with diagnoses that included Hemiplegia/Hemiparesis following Cerebral Infarction affecting left dominant side, and Spinal stenosis. This resident's Brief Interview for Mental Status (BIMS) score, per the Minimum Data Set (MDS) assessment dated [DATE], was 14. This indicated that Resident #104 was cognitively intact. In an Interview with Staff J, on 01/06/25 at 3:00 PM, the CNA said that she worked at the facility for almost 8 years. When asked how many residents she provided care for on that day, the CNA responded that each CNA on her unit provided care for 7 residents. When asked if she felt like they could provide adequate care for the residents, she answered that with love and cooperation, they could manage it. In a follow-up interview with Staff J on 01/08/25 at 10:00 AM, the surveyor asked if there was enough nursing staff to take care of all of the residents on the unit on that day, Staff J answered, we manage.

Based on observations, interviews and record review, the facility failed to provide a left hand splint as per Physician's order for 1 of 1 resident reviewed for Limited Range of Motion (Resident #19). The findings included: Record review revealed that Resident #19 was readmitted to the facility on [DATE] with diagnoses of Hypertension and Muscle Weakness. An order dated 11/30/23 revealed the following: apply left hand splint and left elbow protector for 8 hours (as needed) during AM hours and check skin before and after removal. The Quarterly Minimum Data Set( MDS) dated [DATE], showed that Resident #19 has a Brief Interview of Mental Status (BIMS) score of 13, which is low to moderate cognitive impaired. In an observation conducted on 01/06/25 at 11:00 AM, Resident #19 was observed in bed with a contracture (fingers curled and pulled towards the palm) on his left hand, and no left-hand splint in place. In this observation, Resident #19 stated that the left hand splint has not been placed on his left hand and that the staff will get around to do so when they can. In observations conducted on 01/06/25 at 12:35 PM, at 2:00 PM and 3:00 PM, Resident #19 was observed in bed with a contracture on his left hand, and no left-hand splint in place. In an observation conducted on 01/07/24 at 8:30 AM, Resident noted in bed with a contracture to his left hand, and no left-handed splint in place. In an interview conducted on 01/07/24 at 2:35 PM with the facility's Rehab Director, he said that Resident #19 had an order for left hand splint which was dated 11/30/24. He further stated that Restorative oversees making sure that the splints are placed on Resident #19 on a daily basis. In an interview conducted on 01/07/25 at 2:38 PM with Staff D, Registered Nurse, she stated that the Restorative team, oversees the Restorative program. The Restorative treatment is documented in a Restorative binder located in the nurse's station. If a resident has a splint in place, it will be documented in the electronic system indicating whether the splints are on or off. Staff D said that it will also be documented in the progress notes if a resident has splint in place. If a resident has an order for splint that is not placed as per Physicians' order, she will question the Restorative staff as to why it is not followed. In an interview conducted on 01/07/25 at 2:53 PM, with Staff C, Restorative Certified Nursing Assistant, she stated that she is given a list of residents who have orders for splints by the Restorative Nurse. She follows Physicians orders for splints and documents in the electronic system. Staff C oversees the placement of splints on her unit and will ask for help from other Restorative staff if needed. When asked about the order for splints for Resident #19, she said that he has knee braces every day between 4-8 hours and was not aware of any other orders for splints. She then said Resident #19 has no more splints that I am aware of. In an interview conducted on 01/07/25at 3:30 PM, with the Staff F, Registered Nurse, she stated that Resident #19 is receiving hip and knee splints that are placed by Restorative staff. She further said that she will document in the electronic system for on and off when the splints are placed on the resident or taken off the resident. A review of the last 14-days Administration History in the electronic system did not show any on or off documented for Resident #19. In an interview conducted on 01/09/25 at 3:00 PM with the facility's Director of Nursing, she was informed of the findings.

Based on observations, interviews, record reviews, and policy reviews, the facility failed to provide adequate supervision during a Hoyer lift transfer for 1 of 1 sampled resident (Resident #45). This had the potential to affect 50 residents who used Hoyer lifts. The facility failed to ensure that the oxygen tank was secured for 1 of 1 sampled resident (Resident #44). The findings included: 1) According to the facility's policy and procedure on Safe Resident Handling and Lifting, revised 05/09/2018, employees will use mechanical lifting devices and/or other approved resident handling assistive devices in accordance with instructions and training. At least two people will be present to assist the resident during the use of mechanical lift equipment. Staff should refer to and comply with the resident's care plan prior to transferring or lifting residents. Review of the clinical record for Resident #44 revealed an admitted [DATE]. This resident's diagnoses included Unspecified Dementia, Unspecified Psychosis, Chronic Kidney Disease, Muscle Weakness, Other Lack of Coordination, and Senile Degeneration of the Brain. According to the Minimum Data Set assessment dated [DATE], Resident #44 was rarely/never understood. His functional abilities were coded dependent for chair/bed-to chair transfers. Review of the care plan for Resident #44 showed that he was at increased risk for falls. The care plan revised 12/26/24 listed a goal was to be free of fall related injuries. An intervention listed in the care plan specified the requirement for dependent assistance to be provided with bed/chair to chair transfer. On 01/06/25 at 1:10 PM, Staff J, Certified Nursing Assistant (CNA), was observed using the mechanical lift to lower Resident #45 into his bed. No other nursing staff members were present in the room. Staff J detached the Hoyer pad from the mechanical lift and then she proceeded to answer questions. In an interview with Staff J, on 01/06/25 at 3:00 PM, she stated that she worked at this facility for almost 8 years. When asked how a resident gets transferred from a bed to a wheelchair, Staff J said some residents used a lift and other residents ambulated during the transfer. She explained that nursing and therapy departments communicated about how the resident was to be transferred. When asked how she knew if the resident's transfer required 1 person or 2 people to assist, she answered that when a mechanical lift was used, two people were needed to assist the resident. Staff J was asked if it was easy to find another staff member to provide assistance with mechanical lift transfers. She responded that it was not easy to find someone to help provide assistance, for instance in the morning, at breakfast time, everyone is busy. So, you have to wait. An interview was conducted on 01/06/25 at 2:30 PM, with Staff K, Registered Nurse (RN), who oversees the care planning for residents. She was asked what dependent in transfers meant. Staff K answered that dependent meant the resident depended totally on the staff for transfers. When asked to describe examples of total dependence, the RN said it usually means a mechanical lift. Staff K explained that each resident was screened by the therapy department to determine their needs for transfers and mobility. When asked how the nurses know when to use a mechanical lift, the RN said that it's listed on each resident's care plan. Both of the RNs in the room, Staff K, and Staff L, voiced that always, at least two person assistance is needed for mechanical lift transfers. In an interview with Staff K on 01/09/25 at 12:00 PM, the surveyor requested to know how many people were using mechanical lifts. Staff K said she was unable to print out a list of the residents. She said she would ask each charge nurse how many residents used mechanical lifts on 01/09/25 on their unit. At 1:10 PM, Staff K reported that 50 residents were using mechanical lifts for transfers on that day. 41837 2) Review of the facility's policy titled, Oxygen Concentrators/Oxygen Tanks-Maintenance and Inspection with a revised date of 07/19/23 included in part the following: All portable oxygen tanks that are not in use are to be properly secured and stored in the designated oxygen storage room within the appropriate tank holder. Not in use (empty) portable oxygen carts and hand trucks stored within the stored room are also to have appropriate securing mechanism attached. Record review for Resident #44 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on 08/13/24. Diagnoses included in part the following: Acute Respiratory Failure with Hypoxia, Respiratory Syncytial Virus Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Other Asthma, Unspecified Dementia Moderate with Anxiety. Review of the Minimum Data Set for Resident #44 dated 11/20/24 documented in Section C a Brief Interview of Mental Score of 15, indicating a cognitive response. Documented in Section O for Respiratory Treatments included oxygen therapy. Review of the Physician's Orders for Resident #44 revealed an order dated 08/13/24 to check O2 (oxygen) saturation every shift, give oxygen at 3 L/min (Liters per minute) via n/c (nasal cannula) continuous. Review of the Care Plan for Resident #44 dated 08/07/23 with a problem of resident has diagnosis of COPD with continuous oxygen as ordered via nasal cannula and is susceptible to shortness of breath, labored respirations, URI (Upper Respiratory Infection), and increased congestion. The goals were for the resident to breathe comfortably with intervention thru NRD (next review date), and episodes of congestion and URI will be minimized with interventions in place thru NRD. The Approaches included in part the following: Administer medications, respiratory treatments and oxygen as ordered. Pulmonary consult as ordered. On 01/06/25 at 11:18 AM, an observation was made of Resident #44 sitting up in bed with oxygen on via nasal cannula. Next to the bed was a wheelchair with an oxygen tank in the holder on the wheelchair, behind the wheelchair was an additional oxygen tank standing up next to an empty oxygen holder (Photographic Evidence Obtained). On 01/06/25 at 3:30 PM, an observation was made of Resident #44 sitting up in bed with oxygen on via nasal cannula and an additional oxygen tank standing up next to an empty oxygen holder in same spot as previously observed earlier today. On 01/07/25 at 9:00 AM, an observation was made of Resident #44 sitting up in bed wearing oxygen via nasal cannula. Next to the bed was a wheelchair with an oxygen tank in holder on the wheelchair, behind the wheelchair continued to be an additional oxygen tank standing up next to an empty oxygen holder. During an interview conducted on 01/06/25 at 11:25 AM with Staff A, Registered Nurse (RN) who was asked about the oxygen tanks for the resident, she stated he has an oxygen tank on his wheelchair for when he goes out of his room, she said he also has an additional oxygen tank behind the wheelchair just in case he needs it. Staff A checked both oxygen tanks with a penlight and said yes they both have oxygen in them. During an interview conducted on 01/07/25 at 3:15 PM with Staff B, Certified Nursing Assistant (CNA) who stated she has worked at the facility for 3 years. When asked about oxygen tanks at the bedside, she stated they do not keep additional oxygen tanks at the bedside, if the tank on the back of the wheelchair becomes empty, they take the empty one back to the oxygen room to store it and will get a replacement tank. The oxygen tank is kept in the back of the wheelchair. When asked if there was an additional oxygen tank how it would be stored, she said they are in stored in the holder. During an interview conducted on 01/07/25 at 3:18 PM with Staff C, CNA who stated she has worked at the facility since 2008. When asked about oxygen tanks at the bedside, she stated oxygen tanks are kept in the back of the resident's wheelchair, they do not have extra oxygen tanks at the bedside. She stated that if the oxygen tank becomes empty, they return it to the oxygen room and obtain a full tank. During an interview conducted on 01/08/25 at 8:51 AM with Staff D, RN who stated she has worked at the facility for 7XXX[AGE] years. When asked about oxygen tanks at the bedside, she said they are not supposed to have extra oxygen tanks in the resident's room, if the tank becomes depleted they return the tank to the oxygen room and obtain a new tank. When asked how oxygen tanks are stored, she said in the holder attached to the back of the wheelchair. If there was an extra oxygen tank it would be stored in a roller (stand).