Every finding on record at Baldomero Lopez Memorial Veterans Nursing Home

Based on observations and staff interviews, the facility failed to maintain the required hot holding temperatures for ready to serve food items during meal service related to multiple bowls of soup held below the minimum required temperature of 135 Fahrenheit, during one of one meal services observed.Findings included: During a kitchen tour on 06/24/2026, at 11:33 a.m., an interview was conducted with the Certified Dietary Manager (CDM). The CDM stated all lunch food items had been fully cooked, prepared, placed in metal pans on the steam table, and were ready to be served to residents. Before demonstrating temperature checks, the CDM stated that hot foods must be held at 140 F or above and confirmed that staff were trained on required holding temperatures. At 11:35 a.m., Staff A, the cook, described the hot holding process. She stated hot foods should be maintained at 140 F on the steam table. Staff A confirmed her digital thermometer had been calibrated using an ice water mixture to 32 F and was ready for use. At 11:37 a.m., Staff A began taking temperatures of all items on the steam table. When checking the pan containing more than fifteen pre portioned bowls of soup, the tomato soup measured 130 F. A bowl of pureed chicken noodle soup measured 132 F, and another large bowl of pureed chicken noodle soup measured 129 F. Staff A and the CDM confirmed these temperatures did not meet the required minimum of 135 F. At 11:47 a.m., the soups were tested again. Staff A confirmed that the steam table was functioning properly and set to its highest heat level. The CDM explained that he had microwaved the bowls of soup to bring them up to temperature. At 11:49 a.m., the CDM used his thermometer to check a randomly selected bowl of pureed chicken noodle soup. The temperature was 132 F. The CDM stated he did not know why the temperature was below requirement after reheating. On this second check, the soup again did not meet the minimum required hot holding temperature of 135 F. On June 25, 2026, at 11:00 a.m., the CDM confirmed during interview that the facility did not have a written policy specifying required hot holding temperatures for food items.

Based on observations, record review and interviews the facility failed to store food under sanitary conditions by not labeling and dating prepared food items in three of four reach in refrigerators and by failing to maintain kitchen equipment and walls in a clean and sanitary manner, in one of one kitchen observed.Findings included: On 06/22/2026, at 9:40 a.m., a tour of the kitchen was conducted with Staff B, Assistant Dietary Manager. During the tour of the dishwashing room, three dietary aides-Staff C, Staff D, and Staff E were observed rinsing soiled dishes and operating the dish machine. A large area of the wall measuring approximately three feet by three feet, located on the soiled dish side directly in front of Staff C, was covered with black biogrowth. Staff C stated she was unaware of the condition of the wall. The Certified Dietary Manager (CDM) arrived shortly afterward and reported he had been in the facility less than two months and did not know the cause of the biogrowth or whether a work order had been submitted. Staff D and Staff E also reported not knowing who was responsible for cleaning the wall. The reach-in refrigerator was then observed with multiple unlabeled prepared food items stored inside. Two bowls containing chopped food were wrapped in plastic but lacked both labeling and dating. The CDM confirmed the items should have been labeled and stated he believed they had been prepared the morning of June 22 or possibly June 21 but was uncertain. The tray holding the bowls was also not labeled. A second reach in refrigerator contained five large metal trays of approximately fifteen to twenty Styrofoam cups with plastic lids. Neither the cups nor the trays were labeled or dated. The CDM stated the cups contained shrimp cocktail; however, he did not know when the items were prepared. A large pool of standing water was observed on the bottom shelf of the refrigerator. The CDM stated he was unsure if there was an existing work order but confirmed standing water should not be present in a unit containing ready to eat foods. On 06/24/2026, at 11:49 a.m., the steam table was observed during a hot holding temperature check. The water inside the steam table basin was dark brown. Staff A, [NAME] stated the water turns that color, and the CDM attributed the discoloration to scaling. The CDM confirmed the steam table required cleaning. A second tour of the kitchen was conducted on 06/25/2026, at 9:52 a.m. The same three foot by three foot section of black biogrowth remained on the wall near the dish machine. The CDM and the Registered Dietitian stated they had submitted a work order but were unable to recall when it had been submitted. During the tour, a dietary aide rinsing dishes rubbed her gloved hand along the wall and black residue transferred to the glove. The aide confirmed she was aware of the wall's condition but did not know how it would be cleaned. Additional observations revealed three steam tables containing dark brown or grey water with visible scaling at the bottom. A satellite steam table located in an adjacent service area was also observed containing discolored water and scaling. The CDM confirmed the discoloration and stated that the equipment required cleaning. Both nourishment rooms were toured with the CDM and the Registered Dietitian. In the Alpha nourishment room, the refrigerator contained approximately fifteen pre made sandwiches. All sandwiches were dated 06/21/2026. The CDM stated prepared sandwiches must be discarded after three days and confirmed the items should have been discarded on 06/24/2026. In the Delta nourishment room, approximately twenty pre poured yogurts were observed. Three were dated 06/21/2026. The CDM confirmed those yogurts should also have been discarded on 06/24/2026 and acknowledged that he had not audited the nourishment refrigerators during the current week. Review of the facility's policy titled Food Receiving and Storage, updated January 2026 revealed: Foods shall be received and stored in a manner that complies with safe food handling practices.The Procedure section of the policy showed:1.Food Services, or other designated staff, will maintain clean food storage areas at all times.7 . All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by or best by date) and shelved to allow adequate air circulation. 12 . Food items and snacks kept on the nursing units must be maintained as indicated below: (a) All food items are to be kept below 41 degrees F must be placed in the refrigerator located at the nurses' station and labeled with a use by or best by date. (Photographic Evidence Obtained)

Based on observation, record review, and interview, the facility did not ensure residents remained free from the use of physical restraints for one resident (#3) out of one resident observed. Resident #3 was repeatedly observed with pillows placed underneath the fitted sheet on both sides of the resident's body in a manner that restricted movement.Findings included: On 06/22/2026, at 9:52 a.m., Resident #3 was observed lying in bed with pillows placed underneath the fitted sheet on both sides of the body, extending from the shoulders to the waist. The resident was asleep and did not respond to knocking. Later that day, at 3:38 p.m., Resident #3 was again observed with pillows positioned beneath the fitted sheet from shoulders to waist. Staff K, Certified Nursing Assistant (CNA) stated the pillows were placed to prevent the resident from falling over. The resident was lying on top of the right-side pillow, with both pillows secured beneath the sheet.On 06/23/2026, at 9:22 a.m., the resident was observed in bed with the head of the bed elevated approximately 45 degrees. Pillows were tucked beneath the fitted sheet from the shoulders to the waist under both arms, and the bedside table was positioned over the bed without any items on it. Further observations on June 24, 2026, at 10:14 a.m., and on June 24, 2026, at 10:27 a.m., again showed Resident #3 lying in bed with pillows tucked underneath the fitted sheet, positioned beneath the arms from the shoulders to the waist.On 06/24/2026, at 2:19 p.m., the Director of Rehabilitative Services (DOR) observed the resident with pillows placed under the fitted sheet on both sides. The Director stated being unaware of any clinical purpose for the pillows and confirmed that the physical therapy screening completed on June 21, 2026, did not include recommendations for placing bilateral pillows underneath the sheet or under the resident's arms.On 06/24/26 at 2:33 p.m., Staff L, CNA reported providing care for Resident #3 for approximately three months and stated being unaware of the purpose of the pillows. Staff L stated the pillows were present a few weeks ago and were left in place without inquiry. Staff L reported not having observed Resident #3 independently remove or adjust the pillows.On 06/24/26 at 2:43 p.m., Staff M, Licensed Practical Nurse (LPN) stated nurses make safety observations but confirmed seeing pillows under Resident #3 during morning medication pass. Staff M stated the resident was not supposed to have pillows under the arms and believed night shift staff may have placed them.On 06/25/26 at 8:57 a.m., the resident's Health Care Durable Power of Attorney stated they were not notified of pillows being used in the resident's bed.On 06/25/26 at 10:15 a.m., Staff J, registered Nurse (RN)/ Supervisor stated supervising nursing staff and ensuring care plans and orders are implemented as part of their role but was unaware of pillows being placed under the resident's arms or under the sheet.On 06/25/26 at 1:00 p.m., Staff N (LPN) and Staff O (CNA) reported regularly caring for Resident #3 and did not know why pillows were positioned underneath the resident's arms. Staff N reported not observing the resident move the pillows independently. Staff O stated the pillows could have been used to prevent the resident from getting out of bed.On 06/25/26 at 10:15 a.m., the Director of Nursing (DON) stated staff are not supposed to place pillows underneath a resident's sheets behind their body because it is a restraint. The DON stated pillows may only be used on top of the sheets for positioning. The DON reported uncertainty about whether Resident #3 could remove the pillows independently.Record review revealed no documentation authorizing the use of pillows underneath the fitted sheet or positioned bilaterally from the shoulders to the waist. The care plan, physician orders, and progress notes from May and June included no references to such positioning. Resident #3 had a BIMS score of 03, indicating severe cognitive impairment. Section P of the MDS did not document any restraint use.A review of a facility policy titled Restraint Protocol, effective 03/15/2015 revealed, the facility will ensure the right of each resident to be free from any restraint imposed for any purpose other than to treat the resident's medical symptoms. A restraint is defined as any manual method or any physical or mechanical device, material, or equipment attached to or adjacent to the body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body and environmental.

Based on observations, interviews, and record review, the facility failed to implement its process for inventorying and safeguarding resident personal belongings, resulting in missing items for two residents (#22 and #67) of two residents sampled.Findings included: On 6/24/26 at 9:39 a.m., Resident #67 stated he lost books and clothing during a move from the Delta Unit to the Alpha Unit. Record review showed he was admitted on [DATE] to the Delta Unit and transferred to the Alpha Unit on 10/11/24. Review of his quarterly Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of 11, indicating moderate cognitive impairment. No inventory of personal effects was found in his medical record.On 6/24/26 at 9:40 a.m., Resident #22 reported missing flashlights, blankets, and additional belongings, totaling 19 items. Review of the resident's record showed an admission date of 11/25/24. His quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition. The inventory of personal effects in his chart included only his name, room number, and patient number with no items listed.On 6/24/26 at 2:48 p.m., an interview and observation were conducted with Staff F, Certified Nursing Assistant (CNA). She verified that Resident #67 had no personal effects inventory in the chart and that Resident #22's inventory sheet contained no listed belongings. Staff F stated, If it isn't in the chart, then it wasn't done, and acknowledged that completing personal effects inventories is a known issue among staff.On 6/24/26 at 2:49 p.m., Staff G, CNA, stated that when belongings are reported missing, she asks the resident what is missing and attempts to locate the items. If unsuccessful, she refers to the resident's personal effects inventory and reports findings to the nurse or unit supervisor.On 6/24/26 at 2:50 p.m., Staff H, Registered Nurse (RN), reported that she assists residents in locating missing items and reviews the personal effects inventory as part of her process. She stated that inventories for long term residents go missing and confirmed that nursing staff are responsible for completing the inventory at admission and maintaining it in the physical chart.On 6/25/26 at 10:59 a.m., Staff I, Licensed Clinical Social Worker (LCSW), stated that an inventory of personal effects must be completed on admission, updated whenever families bring items, and must always remain in the chart.On 6/25/26 at 11:20 a.m., Staff J, RN Unit Supervisor, confirmed the requirement for staff to complete personal effects inventories at admission. She stated that family members sometimes bring items that are not documented.On 6/25/26 at 12:12 p.m., the Director of Nursing (DON) confirmed the expectation that nursing staff complete personal effects inventories at admission and that unit secretaries ensure the documents are placed in the chart. The DON was unable to explain how she audits or monitors compliance with this process.On 6/25/26 at 2:00 p.m., the DON confirmed that no personal effects inventory existed for Resident #67, and that Resident #22's inventory sheet contained no listed items.Review of the facility's policy titled Personal Property (Residents), revised 6/14/2012, showed the following: Nursing is required to inventory all resident items at admission and update the inventory as needed, with documentation retained in the medical record. Inventory updates must occur whenever personal items are added, removed, transferred, replaced, or reported missing. The facility is responsible for taking precautions to prevent misuse or loss of resident property.

Based on observations, interviews, and record review the facility failed to ensure the development, revision, and/or implementation of comprehensive care plans was completed for four (Resident #1, #2, #4, and #7) of seven sampled residents.Findings included:1.Review of the resident face sheet for Resident #1 revealed an admission date of 2/20/2025 and a recent admission of 4/1/2026 with diagnoses to include: Alzheimer's disease, dementia without mood disturbance, adjustment disorder with mixed anxiety and depressed mood, post-traumatic stress disorder (PTSD), hypertension, and other co-morbidities. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS revealed the resident had no identified moods or behaviors. During an interview on 4/8/2026 at 2:05 p.m. the facility Risk Manager (RM) stated on 2/24/2026 Resident #1 was involved in a verbal altercation where he was pushed to the floor and hit his head and had skin tears on both hands. The RM stated during the investigation it was determined that Resident #1 was yelling at another resident from his room. Resident #1 routinely yells at other residents who push on the exit door and the alarm on the door beeps. Resident #1 will yell at the other residents for this. There have been a couple of episodes of this verbal exchange, on 2/24/2026, 3/30/2026 and again on 4/2/2026. The RM stated requesting the care plan approaches to be updated on each of these occasions.Review of Resident #1's Care Plan revealed a problem area Behavioral Symptoms dated with a start date of 4/22/2025 and edited date 2/27/2026 revealing: Behavior: Resident #1 is noted with problematic behaviors such as refusing care at times. Resident #1 verbally resists needed assistance from staff to shower and/or assist with incontinence care and peri-care. The goal reviewed Resident #1 will have fewer episodes of problematics by the next review. Approaches to accomplish this goal are as follows: 4/22/2025 as cognitively able to understand, discuss behaviors with Resident #1. Reinforce why behavior is inappropriate and/or unacceptable. Praise, any indications of progress/improvement in behavior. 4/22/2025 assist Resident #1 in developing appropriate methods of coping and interacting. Encourage him to express his feelings appropriately, letting staff know when he is upset or agitated. 4/22/2025 if Resident #1 becomes resistant/combative to cares, stop and attempt a slower or different approach. Return at a later time as safety and hygiene allows or ask another care giver to attempt approach when possible.4/22/2025 intervene as needed to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and assist to another location as needed. 4/22/2025 Resident is ordered psychotropic medication: Administer as ordered and as appropriate for condition. Monitor for side effects, effectiveness and appropriateness of continued administration.4/22/2025 Monitor behavior episodes and attempt to determine underlying causes. Consider pain, personal beliefs, location, time of day, persons involved and situations. Document behavior and potential causes. 4/22/2025 Monitor for and document presence of mood and behaviors. If noted, document triggers, need for control and outcome of behaviors. 4/22/2025 Problematic behaviors are often noted to occur/worsen with presence of infection: Monitor for signs and symptoms of infection. Obtain/Monitor labs and diagnostic testing as ordered. Report results to the physician as indicated. 4/22/2025 Referral to psychiatry as indicated.4/22/2025 Social services to complete a trauma informed care assessment annually and as needed. No other updates were located related to behaviors in Resident #1's care plan. Review of Resident #1's Care Plan revealed a problem area Falls dated with a start date of 3/6/2025 and edited date 4/9/2026 revealing: Safety: Resident #1 is at risk for injury related to potential falls due to unsteady gait related to diagnosis Alzheimer's Dementia and chronic low back pain. He also has history of stroke, bilateral ankle pain and falls prior to admission. He is at further risk for falls/injury due to daily administration of psychotropic medications and is at risk for excessive bleeding due to daily administration of antiplatelet therapy. Prior to survey entrance no approaches were listed after 3/6/2026 for falls. 2. Review of the resident face sheet for Resident #2 revealed an admission date of 10/24/2025 and a recent admission of 10/30/2025 with diagnoses to include: Alzheimer's disease with early onset, dementia with psychotic disturbance and mood disturbance and anxiety, and other co-morbidities. Review of the MDS dated [DATE] revealed Resident #2 had a BIMS score of 3 out of 15, indicating severe cognitive impairment. The MDS revealed the resident had physical behavioral symptoms directed toward others occurred at one to three days of the seven day period and the resident wanders daily. Review of the progress notes for Resident #2 the following was revealed: 4/2/2026 at 7:38 p.m. wife notified that resident was involved in altercation with another resident.3/31/2026 at 4:22 p.m. resident continues to have excessive wandering and exit seeking behaviors. Not easily redirected. During an interview with the facility RM on 4/8/2026 at 2:05 p.m. the RM stated Resident #2 has been involved in five resident to resident altercations from 2/24/2026 to 4/2/2026. The altercations were all related to Resident #2's wandering. Review of Resident #2's Care Plan revealed a problem area Behavioral Symptoms dated with a start date of 11/11/2025 and edited date 2/11/2026 revealing: Wandering/Elopement secured Unit: Resident #2 has wandering behavior and is at risk for elopement. He is noted with excessive pacing behaviors. No resident to resident behaviors are mentioned in this care plan. Review of Resident #2's Care Plan revealed a problem area Behavioral Symptoms dated with a start date of 11/11/2025 and edited date 3/13/2026 revealing: Behavior: Resident #2 is noted with problematic behaviors such as constant pacing and wandering the secured unit. He has cognitive impairment related to dementia an demonstrates impaired awareness of personal space. He may enter other resident's rooms or crowded areas and becomes anxious or agitated when in close proximity to others, placing him at risk for resident to resident conflict or altercations. Approaches to accomplish this goal are as follows: 3/10/2026 edited 3/13/2026 Staff will provide frequent observation when Resident #2 is in common areas and will redirect him away from other resident room or crowded areas. If he enters a confined or crowded space and becomes anxious, staff will provide calm reassurance and assist him to exit the area safely and redirect to another area or activity.11/18/2025 provide and encourage the use of a sensory chew for redirection and safety.11/11/2025 as cognitively able to understand, discuss behaviors with Resident #2. Reinforce why behavior is a risk. Praise, any indications of progress/improvement in behavior. 11/11/2025 Assist in developing appropriate methods of coping and interacting. Encourage him to express his feelings appropriately, letting staff know when he is upset or agitated. 111/11/2025 if Resident becomes resistant/combative to cares, stop and attempt a slower or different approach. Return at a later time as safety and hygiene allows or ask another care giver to attempt approach when possible.11/11/2025 intervene as needed to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and assist to another location as needed. 8/29/2024 Resident #4 is ordered psychotropic medication: Administer as ordered and as appropriate for condition. Monitor for side effects, effectiveness and appropriateness of continued administration. 11/11/2025 Monitor behavior episodes and attempt to determine underlying causes. Consider pain, personal beliefs, location, time of day, persons involved and situations. Document behavior and potential causes. 11/11/2025 Monitor for and document presence of mood and behaviors. If noted, document triggers, need for control and outcome of behaviors. 11/11/2025 Problematic behaviors are often noted to occur/worsen with presence of infection: Monitor for signs and symptoms of infection. Obtain/Monitor labs and diagnostic testing as ordered. Report results to the physician as indicated. 11/11/2025 Referral to psychiatry as indicated.11/11/2025 Social services to complete a trauma informed care assessment annually and as needed. No other updates were located related to behaviors in Resident #2's care plan. 3. Review of the resident face sheet for Resident #4 revealed an admission date of 8/28/2024 and a recent admission of 2/12/2026 with diagnoses to include: Alzheimer's disease, dementia with mood disturbance, adjustment disorder, hypertension, atrial fibrillation, and other co-morbidities. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The MDS revealed the resident had no identified moods or behaviors. Review of the progress notes for Resident #4 the following was revealed: 3/27/2027 at 11:25 a.m. resident to resident noted. 3/25/2026 at 11:58 a.m. Resident sitting in open area watching television (TV) when writer witnessed this resident stick his foot out in attempt to trip another resident. Redirected resident to please no stick his foot out like that. Resident advised this writer that resident keeps pacing in front of his view of the TV. Redirected the other resident. 3/16/2026 at 9:31 a.m. altercation occurred between this resident and another resident. Resident was redirected by staff. No injury was noted. 1/8/2026 at 7:49 p.m. resident standing over another resident (his roommate) yelling at roommate you better stop making all that noise. Review of Resident #4's Care Plan revealed a problem area Behavioral Symptoms dated with a start date of 8/29/2024 and edited date 2/18/2026 revealing: Behavior: Resident #4 has diagnosis of dementia and adjustment disorder. He is noted with increased confusion and agitation at the end of the day that may lead to verbal aggression. The goal revealed Resident #4 will have no episodes of problematic behaviors by the next review date. Approaches to accomplish this goal are as follows: 8/29/2024 as cognitively able to understand, discuss behaviors with Resident #4. Reinforce why behavior is inappropriate and/or unacceptable. Praise, any indications of progress/improvement in behavior. 8/29/2024 assist Resident #4 in developing appropriate methods of coping and interacting. Encourage him to express his feelings appropriately, letting staff know when he is upset or agitated. 8/29/2024 if Resident becomes resistant/combative to cares, stop and attempt a slower or different approach. Return at a later time as safety and hygiene allows or ask another care giver to attempt approach when possible.8/28/24 intervene as needed to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and assist to another location as needed. 8/29/2024 Resident #4 is ordered psychotropic medication: Administer as ordered and as appropriate for condition. Monitor for side effects, effectiveness and appropriateness of continued administration. 8/29/2024 Monitor behavior episodes and attempt to determine underlying causes. Consider pain, personal beliefs, location, time of day, persons involved and situations. Document behavior and potential causes. 8/29/2024 Monitor for and document presence of mood and behaviors. If noted, document triggers, need for control and outcome of behaviors. 8/29/2024 Problematic behaviors are often noted to occur/worsen with presence of infection: Monitor for signs and symptoms of infection. Obtain/Monitor labs and diagnostic testing as ordered. Report results to the physician as indicated. 8/29/2024 Referral to psychiatry as indicated.8/29/2024 Social services to complete a trauma informed care assessment annually and as needed. No other updates were located related to behaviors in Resident #4's care plan. 4. Review of the resident face sheet for Resident #7 revealed an admission date of 5/13/2021 and a recent admission of 12/12/2024 with diagnoses to include: Alzheimer's disease, dementia with agitation and other behavioral disturbance and psychotic disturbance and anxiety, psychotic disorder with delusions due to known physiological condition - PTSD related psychosis, hypertension, and other co-morbidities. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a BIMS score of 0 out of 15, indicating severe cognitive impairment. The MDS revealed the resident had physical behavioral symptoms directed towards others four to six days per week and verbal behavioral symptoms towards others one to three days per week. Review of the progress notes for Resident #7 the following was revealed: 4/1/2026 at 10:57 p.m. resident observed on floor. 3/27/2026 at 5:23 p.m. resident was pushed by another resident when resident took off another resident's hat and this resident was trying to push another resident out of his wheelchair. 3/18/2026 at 6:34 p.m. resident observed on floor2/21/2026 at 6:03 p.m. observed on floor2/18/2026 at 5:31 p.m. resident had fall in common area.Review of Resident #7's Care Plan revealed a problem area Falls dated with a start date of 6/4/2021 and edited date 4/3/2026 revealing: Safety: Resident #7 is at risk for falls due to expected continual declines in physical function, and daily administration psychotropic medication related to diagnosis of PTSD. He is at further risk for falls/injury due to resistance/combativeness. Resident #7 is also at risk for excessive bleeding due to daily administration of antiplatelet therapy. Approaches to accomplish this goal were updated on 5/9/2025, 11/6/2024, 4/12/2024. No recent updates had been made to Resident #7's care plan. During an interview on 4/9/2026 at 11:46 a.m. MDS Registered Nurse (RN) confirmed responsibility for updating and developing care plans along with the MDS for each resident. MDS RN stated the care plan for Resident #1, #4 did not reveal being updated with any new approaches after the problem behavior(s) occurred. The MDS RN stated Resident #4's care plan should have been reviewed and revised. The MDS RN stated an internal note is entered into the electronic record attached to the incident resulting from the problematic behavior. During an interview on 4/8/2026 at 2:05 p.m. the Director of Nursing (DON) stated the care plan should be updated and adjusted as needed. Review of the facility's policy and procedure titled: Care Plan Development with a revised date of 11/28/2017 revealed: The care plan will be reviewed and revised as needed, when a significant change in condition is noted, when outcomes were not achieved or when outcomes are completed. All team members are responsible for reporting any changes to the resident's condition to the primary/charge nurse and of any goals or objectives not being met. Any changes must be reported to the MDS coordinator for review. Documentation must be consistent with resident's plan of care and revisions will be done on an as needed basis and can be done by any member of the Interdisciplinary team.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a resident to resident altercation for 6 of 7 residents reviewed (Resident #s 1, 2, 3, 4, 5, 6, and 7). This failure resulted in eight resident-to-resident physical altercations on one of two units. Cross reference F656Findings included:1. During an interview on 4/8/26 at 2:05 p.m. the facility Risk Manager (RM) stated on 2/24/26 Resident #1 was involved in an altercation with another resident (Resident #2) where he was pushed to the floor and hit his head and had skin tears on both hands. The RM stated Resident #1 has been involved in three altercations with Resident #2 (3/30/26 and again on 4/2/26). Review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including Alzheimer's disease, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood.Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], showed a brief interview for mental status (BIMS) score of 12, moderately impaired cognition.Review of Resident #1's Care plan showed a problem area of:Psychiatric: Resident #1 is at risk fluctuations in mood and behavior related to Alzheimer's dementia and post-traumatic stress disorder (PTSD).An interview was conducted on 4/8/26 at 3:25 p.m. with Staff A, CNA. He said when the resident-to-resident incident occurred with Resident # 1 and #2 on 4/2/26, he was across the hall in another resident room with the door shut providing care. Staff A said he was the only staff member on the hall at the time and tried to keep an eye on everyone but had to close the door of the room he was in for privacy. He said he heard screening from another room, so he dropped everything and ran out. He said he went into Resident #1's room and Resident #1 had Resident #2 pinned to the bed and had his hands around his neck. Staff A said he had to convince Resident #1 to let so of Resident #2. He said Resident #2 was visibly shaking and trembling. Staff A said he could only imagine how Resident #2 felt at the time.Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including Alzheimer's disease with early onset, major depressive disorder, recurrent, mild, other mixed anxiety disorders, and dementia in other diseases classified elsewhere, severe with psychotic disturbance, mood disturbance and anxiety.Review of Resident #2's MDS dated [DATE], showed a BIMS score of 3, indicating severely impaired cognition The MDS revealed the resident had physical behavioral symptoms directed toward others occurred at one to three days of the seven-day period and the resident wanders daily. Review of Resident #2's care plan showed a problem area of:Behavior: the resident is noted with problematic behaviors such as constant pacing and wandering the secure unit. He has cognitive impairment related to dementia and demonstrated impaired awareness of personal space. He may enter other resident's rooms or crowded areas and become anxious or agitated when in close proximity to others, placing him at risk of resident-to-resident conflict or altercations. Dated 3/13/26.Review of the resident supervision list showed Resident #2 was on every 15-minute checks.During an interview on 4/8/2026 at 2:05 p.m. the RM stated Resident #2 wanders all the time and invades other residents' personal space, including touching them. This sometimes leads to issues. The RM stated Resident #2 has been involved in five resident-to-resident altercations (2/24/26, 3/7/26, 3/27/26, 3/30/26 and 4/2/206). 2. During an interview on 4/8/2026 at 2:05 p.m., the RM stated Resident #3 was in the common area watching television and had another resident hit him with a walker. Both residents were examined and no injuries were noted.Review of admission Records showed Resident #3 was admitted on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder and other co-morbidities.Review of Resident #3's MDS dated [DATE], showed a BIMS score of 4, indicating severely impaired cognition.Review of Resident #3's care plan showed a problem area of:Behavior: the resident is noted with problematic behaviors expected continual declines in cognition and physical function due to dementia by rejection of care; combative with staff; refuses to get out of bed or attempts to get out of bed without assistance at times. He has been noted to be sexually inappropriate at times. Dated: 5/18/21.3. Review of the resident face sheet for Resident #4 revealed an admission date of 8/28/24 and a recent admission of 2/12/26 with diagnoses to include: Alzheimer's disease, dementia with mood disturbance, adjustment disorder, hypertension, atrial fibrillation, and other co-morbidities.Review of the MDS dated [DATE] revealed Resident #4 had a BIMS score of 4, indicating severe cognitive impairment. The MDS revealed the resident had no identified moods or behaviors.Review of Resident #4's Care Plan revealed a problem area Behavioral Symptoms dated with a start date of 8/29/24 and edited date 2/18/26 revealing: Behavior: Resident #4 has diagnosis of dementia and adjustment disorder. He is noted with increased confusion and agitation at the end of the day that may lead to verbal aggression. During an interview on 4/8/26 at 2:05 p.m. the RM stated Resident #4 and Resident #7 were in the common area watching television and had a resident-to-resident altercation. Resident #4 pushed Resident #7 and tried to pull him out of his wheelchair.Review of the resident face sheet for Resident #7 revealed an admission date of 5/13/21 and a recent admission of 12/12/24 with diagnoses to include: Alzheimer's disease, dementia with agitation and other behavioral disturbance and psychotic disturbance and anxiety, psychotic disorder with delusions due to known physiological condition - PTSD related psychosis, hypertension, and other co-morbidities.Review of the MDS dated [DATE] revealed Resident #7 had a BIMS score of 0, indicating severe cognitive impairment. The MDS revealed the resident had physical behavioral symptoms directed towards others four to six days per week and verbal behavioral symptoms towards others one to three days per week.4. Review of admission Records showed Resident #6 was admitted on [DATE] with diagnoses including Alzheimer's, cognitive communication deficit, PTSD, and mild neurocognitive disorder due to known physiological condition with behavior disturbances.Review of Resident #6's 1/23/26 MDS, showed a BIMS score of 4, indicating severely impaired cognition.Review of Resident #6's Care Plan revealed a problem area Behavioral Symptoms dated with a start date of 1/29/26 and edited date 2/6/26 revealing: Behavior: Resident #6 is at risk for disturbed sensory perception due to trauma triggers, resistive/combativeness, impaired social interaction related to anxiety and hypervigilance due to diagnosis of PTSD. He has been noted wandering into other residents' rooms thinking it is his own and or looking for the toilet.An interview was conducted on 4/9/26 at 11:15 a.m. with Staff B, LPN. He said for the incident with Residents #5 and #6 on 2/3/26 he was the first one to arrive in the room. He said he witnessed Resident #6 wander into Resident #5's room and he thought Resident #5 would tell Resident #6 would leave and he would exit the room. Staff B, LPN said he heard Resident #5 tell Resident #6 to leave but they got into it like to macho guys and he ran into the room. He said the two residents were full on punching each other and it was like a [NAME] in the jungle. Staff B said Resident #6 ended up being pushed to the floor and kicked by Resident #5. He said he yelled for Staff A, CNA to help him and they were able to separate the two residents. Staff B said Resident #6 had redness around his eye where he was hit right after the incident happened and later it turned purple.Review of admission Records showed Resident #5 was admitted on [DATE] with diagnoses including Alzheimer's, dementia, and a history of mental and behavioral disorders.Review of Resident #5's MDS dated [DATE], showed a BIMS score of 8, indicating moderately impaired cognition.Review of Resident #5's Care Plan revealed a problem area Behavioral Symptoms dated with a start date of 7/22/24 and edited date 2/6/26 revealing: Behavior: Resident #5 is noted with problematic behaviors such as paranoia and delusions. He occasionally incorporates information heard on television into his own life. He has a history of verbal behaviors when informed he is wrong and during times of correction/redirection. He is territorial, has poor impulse control and does not like loud noises.5. An interview was conducted on 4/8/26 at 2:05 p.m. with the Director of Nursing (DON) and Risk Manager (RM). The DON said residents tend to gravitate toward certain rooms and it isn't something staff encourage. The RM said, we redirect them constantly, but they continue to do it. The DON said residents also gather in the common area and some get mad when others walk in front of the television. She said, there is always somebody there at the nurses' station to observe residents in the common area.An observation was conducted on the locked unit on 4/8/26 at 10:05 a.m. upon entrance to the locked unit a group of four residents were sitting watching television in the common area. No staff were insight of the area. Residents were seen wandering up and down hallways, staff were in and out of resident rooms providing care. An observation was conducted on the locked unit on 4/8/26 at 5:09 p.m. dinner was being served in the dining room to 10 residents. One staff member was in the far corner of the dining room sitting in a chair observing the room and another staff member was delivering trays to the residents. An observation was conducted on the locked unit on 4/8/26 at 5:14 p.m. of three residents in the common area and no staff were at the nurses' station or insight of the area. At 5:19 p.m. it had increased to five residents in the common area with no staff in sight providing supervision.During an interview on 4/8/26 at 5:37 p.m. Staff H, Certified Nursing Assistant (CNA) stated working in the locked unit on a regular basis. Staff H said the residents can get very physical at times with each other. We (the staff) try our best to watch everyone, but it is just so busy, especially around mealtimes and in the afternoon the residents can become more confused. During an interview on 4/8/26 at 5:40 p.m. with Staff I, CNA stated mealtimes are especially difficult, everyone is everywhere, the residents' eat at different times and in different places, we (staff) are trying to pass out the meals, provide care, and try to keep an eye on everyone it is just a lot. During an interview on 4/8/26 at 5:47 p.m. with Staff J, CNA stated the residents on the locked unit do get physical with each other. The residents are everywhere it is hard to keep an eye on them and get what you need to get done accomplished. An interview was conducted on 4/9/26 at 9:40 a.m. with Staff F, Registered Nurse (RN). Staff F said locked unit needs 6 or more CNAs on each shift plus the CNAs that are one to one with residents. She said most days they have enough put not really on weekends. Staff F said the unit had several residents with increased supervision and she would provide a list.Review of the provided supervision list showed on the locked unit there are five residents with every 15-minute checks, five residents with every 30-minute checks, and one resident that is 1:1 supervision.An interview was conducted on 4/9/26 at 11:21 a.m. with Staff G, CNA. Staff G confirmed her resident assignment and said she did not have any residents on increased supervision that she was checking on more frequently or documenting checks on. Comparing Staff G, CNA's assignment to the supervision list, it revealed she had two residents that should have been on every 30-minute checks.An interview was conducted on 4/9/26 at 1:15 p.m. with Staff E, CNA. Staff E confirmed her resident assignment and said she had one resident on increased supervision that she was checking on every 30 minutes and documenting checks on.Comparing Staff E, CNA's assignment to the supervision list, it revealed she had two residents on every 30-minute checks.An interview was conducted on 4/9/26 at 12:57 p.m. with Staff D, CNA. Staff D confirmed her assignment and said she had one resident on increased supervision that she was checking and documenting every 15 minutes. Staff D said during change of shift the CNAs should have been given the supervision documenting sheet for each resident with increased supervision. Staff D was observed pulling out the sheet for her resident and noting she had documented every 15 minutes from the start of her shift at 7:00 a.m. She said the CNAs documented the time of the check and what the residents were doing or where they were at the time. Staff D showed that from 4/9/26 at 12:00 a.m. until 7:00 a.m. there was no documentation completed for her resident. She said when she came on shift, she asked the CNA and nurse, but no one had a sheet that had been completed for her resident, and she had to start a new one.An interview was conducted on 4/9/26 at 2:38 p.m. with the DON. The DON said all staff should know which residents are on increased supervision. She said that information if given at change of shift and each resident had a sheet that needed to be documented on every 15 or 30 minutes depending on their supervision level. The DON said she expected the supervision sheets to be completed and did not understand how staff were not aware they had residents on increased supervision. The DON confirmed Resident #2 was on every 15-minute checks on 4/2/26 when the incident occurred with Resident #1. She said there were always more than one staff member on a hall and she had not heard Staff A, CNA was the only staff member on the hall at the time of the incident between Residents #1 and #2.During an interview on 4/8/26 at 2:05 p.m. the RM stated this is a very busy unit and as we are not able to restrain them due to regulations, these incidents are still going to happen.During an interview on 4/9/26 at 2:00 p.m. the RM stated she had not tracked or trended the incidents on the unit to see if there was a pattern.

Based on interviews and record review, the facility did not ensure a complete and thorough investigation for two resident-to-resident abuse incidents (Resident #1/Resident #2 and Resident #5/Resident #6) out of nine resident-to-resident incidents reviewed.Findings included: 1.An interview was conducted on 4/8/26 at 3:25 p.m. with Staff A, Certified Nursing Assistant. He said when the resident-to-resident incident occurred with Resident # 1and #2 on 4/2/26, he was across the hall in another resident room with the door shut providing care. Staff A said he was the only staff member on the hall at the time and tried to keep an eye on everyone but had to close the door of the room he was in for privacy. He said he heard screening from another room, so he dropped everything and ran out. He said he went into Resident #1's room and Resident #1 had Resident #2 pinned to the bed and had his hands around his neck. Staff A said he had to convince Resident #1 to let so of Resident #2. He said Resident #2 was visibly shaking and trembling. Staff A said he could only imaging how Resident #2 felt at the time. Review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including Alzheimer's disease, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a brief interview for mental status (BIMS) score of 12, indicating moderately impaired cognition. Review of Resident #1's Care plan showed a problem area of:Psychiatric: Resident #1 is at risk fluctuations in mood and behavior related to Alzheimer's dementia and post-traumatic stress disorder (PTSD). Review of Resident #1's progress notes showed:4/2/26 7:50 p.m. by Staff B, Licensed Practical Nurse (LPN). Resident involved in resident-to-resident altercation during shift. Immediate staff interventions was implemented, and resident separated without further escalation. Post-incident observations revealed no visible injury or outward sign of acute distress at time of entry. Resident was redirected and remained in stable condition thereafter. Responsible party was notified. RN supervisor and risk manager were notified in accordance with facility protocol. Ongoing monitoring and safety interventions continue. Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including Alzheimer's disease with early onset, major depressive disorder, recurrent, mild, other mixed anxiety disorders, and dementia in other diseases classified elsewhere, severe with psychotic disturbance, mood disturbance and anxiety. Review of Resident #2's MDS dated [DATE], Section C, Cognitive Patterns, showed a BIMS score of 3, indicating severely impaired cognition. Section E, Behavior showed resident wandered daily and resident had physical behavioral symptoms directed towards others on one to three of the previous seven days. Review of Resident #2's care plan showed a problem area of:Behavior: the resident is noted with problematic behaviors such as constant pacing and wandering the secured unit. He has cognitive impairment related to dementia and demonstrated impaired awareness of personal space. He may enter other resident's rooms or crowded areas and become anxious or agitated when in close proximity to others, placing him at risk of resident-to-resident conflict or altercations. Dated 3/13/26. Review of Resident #2's progress notes showed:4/2/26 7:38 p.m. by Staff C, LPN. Wife and POA [power of attorney] notified that resident involved in Altercation [sic] with another resident. Resident evaluated by this nurse. No bruising, skin tears or redness noted to resident skin. Resident denies pain or discomfort at this time. An interview was conducted on 4/8/26 at 2:05 p.m. with the Risk Manager (RM) and a follow-up interview was conducted on 4/9/26 at 2:00 p.m. She said Staff B, LPN called her on 4/2/26 around 8:00 p.m. and told her there had been a resident-to-resident abuse incident with Residents #1 and #2. She said she was told Resident #1 had his hands around Resident #2's neck. The RM said she was not always in the building and depending on where she was at, she told staff to get her the allegations and the information. The RM said for this incident she didn't have statements but was still investigating it. She confirmed she typically got statements immediately when an event occurred. The RM said, we [staff] aren't good about painting the picture. If I am not here I have to rely on them [staff] to tell me what is going on. She said she only had a verbal statement from Staff B, LPN about what happened with Residents #1 and #2. She said Staff B told her a CNA informed him about the incident, but the RM didn't know who the CNA was. She said she thinks it was Staff A, CNA that said something about witnessing Resident #1 having his hands around Resident #2's neck. The RM said she did not get a statement from Staff A, CNA. She said the way she visualized it the incident happened in front of the bed by the door. She said Resident #1 was up and he met Resident #2 at the door and started screaming at him and then Resident #2 got in Resident #1's personal space and Resident #2 put his hands on Resident #1's neck. The RM said she was assuming this happened by the door but did not get a written statement or clarification from Staff A, CNA to figure out what happened. The RM said she had not heard anything about Resident #2 being pinned to the bed by Resident #1. She confirmed she had already completed the required investigation reports and submitted them. The RM said she could have dug into the incident further and there were no excuses. 2. An interview was conducted on 4/9/26 at 11:15 a.m. with Staff B, LPN. He said for the incident with Residents #5 and #6 on 2/3/26 he was the first one to arrive in the room. He said he witnessed Resident #6 wander into Resident #5's room and he thought Resident #5 would tell Resident #6 would leave and he would exit the room. Staff B, LPN said he heard Resident #5 tell Resident #6 to leave but they got into it like to macho guys and he ran into the room. He said the two residents were full on punching each other and it was like a [NAME] in the jungle. Staff B said Resident #6 ended up being pushed to the floor and kicked by Resident #5. He said he yelled for Staff A, CNA to help him and they were able to separate the two residents. Staff B said Resident #6 had redness around his eye where he was hit right after the incident happened and later it turned purple. Review of admission Records showed Resident #5 was admitted on [DATE] with diagnoses including Alzheimer's, dementia, and a history of mental and behavioral disorders. Review of Resident #5's MDS dated [DATE], Section C, Cognitive Patterns, showed a BIMS score of 8, indicating moderately impaired cognition. Review of Resident #5's progress notes showed;2/3/26 at 9:43 p.m. Staff reported to this writer that resident had pushed [Resident #6] to the ground. Staff heard yelling and investigated the yelling they observed both residents exchanging punches. According to staff, resident [Resident #6] walked into [Resident #5] room doorway. Then [Resident #5] became agitated at this and began the physical altercation. As staff were walking over to intervene, they observed [Resident #5] push [Resident #6] to the ground. [Resident #6] fell backward and then onto his buttocks with his back against the open door. [Resident #5] cursed at [Resident #6] and then kicked him while on the ground. CNA intervened and redirected [Resident #5] into his room and shut his door. CNA went to get the hall nurse. Hall nurse assessed both residents and no visible injuries were noted to either resident. Both denied pain. [Resident #6] was assisted up into his wheelchair by the hall nurse and 2 CNAs. This writer placed a stop sign on [Resident #5] door and contacted Risk Manager. Review of admission Records showed Resident #6 was admitted on [DATE] with diagnoses including Alzheimer's, cognitive communication deficit, PTSD, and mild neurocognitive disorder due to known physiological condition with behavior disturbances. Review of Resident #6's 1/23/26 admission MDS, Section C, Cognitive Patterns, showed a BIMS score of 4, indicating severely impaired cognition. Review of Resident #6's progress notes showed: 2/3/26 at 9:43 p.m. Staff reported to this writer that resident was pushed to the ground by Resident #6. Staff heard yelling and investigated the yelling, when they observed both residents' exchanging punches. According to staff, Resident #6 walked into Resident #5's room doorway. Then, Resident #5 became agitated and began the physical altercation. As staff walked over to intervene they observed Resident #5 pushed Resident #6 onto his buttocks with his back against the open door. Resident #5 cursed at Resident #6 then kicked him while he was on the ground. CNA intervened and redirected Resident #5 into his room and shut the door. Hall nurse assessed both residents and no visible injuries were noted to either resident. Resident #6 was assisted up into this wheelchair. A stop sign was placed on Resident #5's door. RM was notified of the incident. Resident #6 verbalized that he went into the room not knowing it was not his own. An interview was conducted on 4/8/26 at 2:05 p.m. with the Risk Manager (RM). She said Resident #6 was on every 15-minute checks as he was very aggressive and can change mood in a heartbeat. The RM said it was reported to her that Resident #6 went into Resident #5's room and Resident #6 fell on his buttocks after being pushed by Resident #5 then Resident #6 was kicked. The RM said Staff A, CNA was the first person in the room when the incident occurred and he called Staff B, LPN in to help. The RM said she did not have written statements from all staff, but what it sounded like to her was Staff A, CNA walked in and saw Resident #6 on the floor and Staff B, LPN was called into help. She said when she talked to Staff B, LPN the only altercation he mentioned was Resident #5 kicking Resident #6 on the ground. The RM said she had a statement from Staff B that said the residents were in an altercation and then Resident #6 fell on the ground and was kicked. She said she assumed the altercation was Resident #6 being pushed to the floor and kicked. The RM said, I guess I could have probed a little more of what happened. The RM read the nursing progress note in Resident #5's medical record and said she had not read it previously. She said she didn't know about punches being thrown. The RM said, it is like herding cats to them [staff] to give a statement and I should have probed more. An interview was conducted on 4/9/26 at 2:48 p.m. with the Nursing Home Administrator (NHA). The NHA said she expected statements to be taken, and each incident fully investigated. The NHA said the facility policy for investigating resident-to-resident abuse was to follow the federal regulations. Review of a facility policy titled Adverse Incident Investigation and Reporting Guideline, effective 1/8/26, showed:StandardAs part of the facilities risk management and quality assurance program, the Risk Manager or designee will initiate an internal investigation of incidents/accidents within I business day after the Risk Manager or designee has received a report.

Based on observations, interviews, and record review the facility failed to maintain and promote a resident's dignity related to not providing a privacy bag for a urinary catheter drainage bag for one (#63) of three sampled residents with urinary catheters. Findings included: On 01/11/22 at 10:19 a.m., Resident #63 was observed sleeping in bed. The resident's urinary catheter drainage bag was visible from the door. The catheter drainage bag was observed hanging at the end of the bed with bright yellow urine, and no privacy bag covering it (photographic evidence obtained). On 01/12/22 at 9:11 a.m., Resident #63 was again observed sleeping in bed, and his urinary catheter drainage bag was visible from the door. The catheter drainage bag was observed with bright yellow urine, and no privacy bag covering it (photographic evidence obtained). 01/13/22 at 8:42 a.m., Resident #63 was observed watching television in bed. An attempt was made to interview the resident, however, he was unresponsive to all questions. On 01/13/22 at 11:00 a.m., Staff H, Certified Nursing Assistant (C.N.A.), stated she helped provide care for the resident and emptied his catheter bag if it was full in the morning and again after lunch. Staff H reported the catheter drainage bag was always supposed to be in the blue bag (privacy bag). On 01/13/22 at 11:05 a.m., Staff I, Licensed Practical Nurse (LPN), stated the catheter bag should always be in a privacy bag that hangs at the end of the bed. Staff I indicated this had to do with dignity issues. She reported that she noticed the catheter drainage bag out of a privacy bag on the morning of 01/12/22 during medication pass around 8:30 a.m.-9:00 a.m. On 01/13/22 at 11:09 a.m., the Director of Nursing (DON) stated the catheter bag should always be covered. Review of Resident #63's Admission Record revealed this long term resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the significant change Minimum Data Set (MDS) assessment, dated 12/15/21, revealed a Brief Interview for Mental Status score of 3 indicating severe cognitive impairment, the presence of an indwelling catheter, and no improvement to a trial toileting program. Record review of the facility's policy titled, Urinary Catheter Indication and Maintenance (Urethral and Supra-pubic), revealed the catheter tubing and drainage bag should be maintained off the floor with a privacy bag as appropriate. On 01/13/22 at 12:21 p.m., the DON stated the supervisor does rounds daily and makes sure that everything listed on the [Provider Name] Surveillance Rounds document has no issues. The DON stated the supervisor makes note of the issue and immediately does education with the staff, but no documentation was kept when education was provided. A review of the Surveillance Rounds document revealed resident rooms are checked daily for privacy practices to include catheter privacy bags.

Based on record review and interview the facility failed to establish a communication process to ensure hospice services were provided in accordance with the hospice agreement and plan of care for one (#56) of one resident sampled for hospice services out of three facility residents receiving hospice care. Findings included: Review of Resident #56's medical record revealed that current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on [DATE] at 8:35 AM with Staff A, Certified Nursing Assistant (CNA), revealed that the resident was on hospice and that hospice comes in about 2 times a week. Interview on [DATE] at 8:38 AM with Staff B, Licensed Practical Nurse (LPN), revealed that the resident was on hospice and that hospice comes in 2 times a week. She was not sure if they had come yet this week, but stated they also call routinely to check on the status of the resident. She reported that if there are any changes with the resident, the hospice nurse was notified. She reported that there was a hospice book kept at the nurses station and provided the book. Interview on [DATE] at 9:09 AM with Staff C, Registered Nurse (RN)/Unit Supervisor, confirmed that hospice comes in at least 2 times a week and that the facility communicates any concerns with the hospice team. Review of the hospice book located at the nurses station revealed a Patient Sign-In and Patient Care Log. This form documented vital signs, weights, arm circumference and date of the resident's last bowel movement. Continued review of the form for Resident #56 revealed that hospice staff last documented on this form over 8 months ago, on [DATE], by Staff E, Hospice RN. Continued review of the hospice book revealed that it contained a document titled Hospice Visit Summary. The last Hospice Visit Summary form noted to be in the book was dated over 10 months ago, on [DATE] and completed by Staff E, Hospice RN. Closer review of the [DATE] Hospice Visit Summary revealed that Staff E had included a hand written note which documented a completed visit on [DATE]. The last clinical note present in the hospice book for Resident #56 was dated [DATE]. Phone interview on [DATE] at 9:42 AM with Staff E, Hospice RN, revealed that she was in the facility to see the resident last week, and she comes to see the resident once within a 14 day period. She reported that although the frequency in the plan of care is ,d+[DATE] times a week that was only for when there was a change in status. If no change in status occurs, she comes once within a 14 day period. She reported that she does complete progress notes for each visit, but they are in her computer. She reported that she gets too busy so the paperwork does not get filed, but she does speak to the resident's nurse during each visit. Interview on [DATE] at 10:25 AM with the Director of Nursing (DON) revealed that hospice typically does not leave a note at the time of the visit but will send a note once it is completed. She reported that she will check with medical records for documentation. She was not aware that hospice was not providing their notes. Interview on [DATE] at 11:10 AM with Staff F, the Social Worker for Hospice, revealed that she writes a progress note for every visit. She stated that the progress notes were shared with the facility. In addition, she will do a report on the phone with the facility and document that in the clinical notes held by hospice. She reported that nurses notes were kept at the nurses station in a folder. Follow-up interview on [DATE] at 12:09 PM with the DON revealed that Social Services was responsible to complete audits of the hospice books. If there were missing notes, they (Social Services) should reach out to hospice and get the notes. Interview [DATE] on 12:29 PM with Staff G, Social Work Service Program Manager, revealed that the facility has two social workers in the building and that they are both assigned to audit hospice books. She reported that when the hospice books are audited they make sure that there is a recertification, a current care plan, a contact sheet, a contract, and notes. She reported that typically they should be leaving the notes. Staff G reported that audits were done quarterly, and if there were missing items then they request the missing items from hospice. Review of the audit dated [DATE] revealed a note indicating request under Question #7, Visit reports completed when hospice services provided. There was no documentation or supporting documentation that would indicate that the request was made for the missing notes. Review of an audit dated [DATE] revealed a check mark indicating a yes response to Question #7, Visit reports completed when hospice services provided. Review of an audit dated [DATE] revealed Question #7, Visit reports completed when hospice services provided had a hand written note in the box of ,d+[DATE]. Review of an email from the facility social worker dated [DATE] revealed the first request to get hospice paperwork. Review of the email revealed the last recertification and plan of care on file in the facility for Resident #56 was expired and dated [DATE] and the nurses's last log in date was [DATE]. On [DATE] at 12:09 p.m., the DON provided the notes that were sent over from hospice. Review of the provided notes revealed they were dated from [DATE] to [DATE] and had a print date of [DATE]. The DON reported that she was not sure why the facility audits did not consistently reveal missing notes. Review of the hospice plan of care provided revealed the the patient was being recertified in the hospice program from [DATE] to [DATE]. Treatments included Skilled Nursing (SN) ,d+[DATE] times per week for 9 weeks and 4 PRN: [as needed] weekly for change in status. Review of the Hospice Agreement signed and dated February 2021 revealed that in section 4.1 Compilation of Records revealed (a) Preparation. FACILITY and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Hospice Patient receiving services under this agreement in accordance with prudent record keeping procedures, their own policies and procedures, and applicable federal and State of Florida laws and regulations.

Based on observation, interview and record review, the facility failed to monitor medication administration of an inhalation medication for one Resident #50 of 3 Residents on inhalation medication. Findings Included: During observation of Resident #50 on 10/8/20 at 8:15 a.m. the resident was sitting up in his wheelchair with a nebulizer mask covering his face. The resident was observed moving the mask with his hands. The door to his room was open and the curtain was closed between the two beds. The resident was looking out into the hallway and mumbling. Staff member B, RN was observed going into another resident room across the hall with the door shut from 8:22 a.m. to 8:25 a.m. Staff member B, RN peeked into Resident #50's room and partially shut the door to the room and stayed in the hallway talking to a resident until 8:37 a.m. when she removed the mask and rinsed with water, dried and placed in the bag. Staff member B, RN stated she does not listen to Residents' lungs before or after inhalation treatment and stated Resident #50 has to be watched with the nebulizer as he will rip the mask off. An interview with Staff member B, RN on 10/8/20 at 8:40 a.m. revealed Resident #50 gets nebulizer treatments every 4 hours. Staff member B, RN said the resident will tell you when he is done on occasion and sometimes will just take the mask off. Review of the physician orders [REDACTED]. Review of the self-administration of medication informed consent and assessment dated [DATE] revealed Resident #50's box checked as I wish to have the med nurse administer my medications. Review of the Resident #50's minimum data set (MDS) section C revealed a Brief interview for mental status (BIMS) of 6 indicated severe cognitive impairment. Review of the care plan revealed the resident's family elected to pursue palliative care due to severe cognitive declines, initiated on 8/20/20, edited on 9/8/20. The approach documented was to administer medications for shortness of breath as needed and ordered by physician. Monitor for side effects and effectiveness created 8/21/20. Provide total nursing care as needed dated 8/20/20. Review of the policy for Self-administration of medication effective date 7/10/19, page one of three, revealed: A resident may self-administer medications if the interdisciplinary team has determined that the practice is safe. The resident will be assessed fro their cognitive, physical and visual ability to self-administer medications based on the attached form Self Administration of Medication Informed Consent and Assessment. If the interdisciplinary care team determines that the resident cannot safely self-administer medications, medications will be administered by the staff nurse. Review of the procedure guidelines for Administering nebulizer therapy (not dated, page 240 from unknown document) one page revealed: Nursing action 1. Auscultate breath sounds, monitor the heart rate before and after the treatment for [REDACTED]. 4. Instruct the patient to exhale. 7. Observed expansion of chest to ascertain that patient is taking deep breaths. 8. Instruct the patient to breathe slowly and deeply until all the medication is nebulized. 9. On completion of the treatment, encourage the patient to cough after several deep breaths.

Based on record review and interview, the facility did not ensure that 1 (Resident #76) out of 5 residents reviewed for unnecessary medications had a [DIAGNOSES REDACTED]. Findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to acute [MEDICAL CONDITION], pneumonia, and primary [MEDICAL CONDITION]. Review of the resident's active orders revealed that the resident had an order for [REDACTED]. The resident also had an order for [REDACTED]. On 10/09/20 at 1:16 PM in an interview with the Director of Nursing (DON), she said that there should be a [DIAGNOSES REDACTED]. When asked what [MEDICATION NAME] was used for, she said it was used as a sleep aide. When asked what [MEDICATION NAME] DM was used for, she said it was for a cough. The DON acknowledged that there was no [DIAGNOSES REDACTED]. She said that she didn't know why there wasn't a [DIAGNOSES REDACTED]. On 10/09/20 at 1:27 PM in an interview with Staff F, pharmacist, she said that she was not the normal pharmacist, so she could not speak to a specific resident, but that she could give her expectations as a pharmacist. She said that she would expect every medication to have at least one [DIAGNOSES REDACTED]. On 10/09/20 at 1:29 PM, during a phone interview with Staff G, the facility's full-time pharmacist she said that all medications should have a diagnosis. She asked if the order list we had received from the facility had diagnoses printed with it. Staff F, who was present for the telephone interview, told Staff G that yes, the version we had did include diagnoses. Staff F also relayed to Staff G that there were no diagnoses or indication for use for either of the medications in question. Staff G said that it is her expectation that all medications have a diagnosis. Review of a facility policy Verbal and/or Telephone Physicians' Orders effective on 5/30/2009 revealed under the heading II. PROCEDURES . 4. The verbal or telephone order shall be documented by the professional who accepts the order and shall include: . e. Purpose or indication for a medication

Based on interview and record review, the facility did not ensure 1. that 2 (Resident's #76 and #3) out of 5 residents reviewed for unnecessary medications were being monitored for behaviors related to the use of [MEDICAL CONDITION] medications; and 2. that a care plan related to monitoring the effectiveness of [MEDICAL CONDITION] medications was implemented for 2 (Resident #76 and #3) out of 5 residents reviewed for unnecessary medications. Findings included: 1. On 10/09/20 at 1:16 PM in an interview with the Director of Nursing (DON), she said that behaviors for [MEDICAL CONDITION] medications are documented on the eMAR (electronic medication administration record). She said that behaviors should be monitored for [MEDICAL CONDITION] medication every shift. When she was asked if anti-depressants were considered [MEDICAL CONDITION] medication, she said I don't think so. When asked if nurses should be monitoring behaviors for residents who are taking anti-depressants, she said we only monitor anti-psychotics every shift. With residents who are taking anti-depressants, we go by the PHQ-9 tool (section D of the Minimum Data Set (MDS) assessment) done by our Social Services (SS) Department quarterly. SS monitors all residents quarterly with the PHQ-9 tool, and nurses document in the notes if the resident has any behaviors. She was asked to clarify what the PHQ-9 was and told us that the PHQ-9 is a tool to determine if there is any indication of depression for all residents. On 10/09/20 at 1:27 PM Staff F, pharmacist said that she was not the facility's full-time regular pharmacist, but that she was in the facility covering the regular pharmacist's vacation. She said that she could give her expectations as a pharmacist, but not about a resident specific. She said that she would expect to see behaviors monitored, even if there were no behaviors that should be documented. She believes that the monitoring should be done when the nurse gives the medication, not every shift. On10/09/20 at 1:29 PM, during the interview with Staff F, the facility's regular pharmacist Staff G, by request of the DON, called to answer surveyor questions. Staff G said that behaviors should be monitored every shift, and that there are questions on each eMAR about behaviors. She said the nursing staff should be monitoring residents if they are having behaviors and documenting how many times the residents are having those behaviors. If a resident has no behaviors, that should be documented as well. Behavior monitoring is part of a standard nursing order set that should go along with all [MEDICAL CONDITION] medication ordered. If the resident gets an order for [REDACTED]. Those behaviors don't change shift to shift, so we use the PHQOV or PHQ-9 (filled out) by social services every quarter. Resident #76 was initially admitted to the facility on [DATE] for a [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Resident #76's most recent quarterly MDS dated [DATE] the resident was assessed to have a BIMS (brief interview for mental status) of 14, indicating the resident had intact cognitive responses. The resident was assessed to feel tired or have little energy 7-11 days during a 14-day assessment period, and to refuse or reject care 4-6 days of a 7-day assessment period. The resident was assessed to receive an antidepressant daily. The resident had orders that included, but were not limited to: [MEDICATION NAME] 200mg tablet oral every 12 hours for [MEDICAL CONDITION] disorder dated 5/23/2019 [MEDICATION NAME] 20mg one tablet orally at bedtime for depression dated 5/17/2019 [MEDICATION NAME] 100mg one tab orally at bedtime for depression dated 5/17/2019 Anti-depressant medication side effect monitoring dated 6/1/2020 Review of the residents eMAR revealed that the resident had been given [MEDICATION NAME] and [MEDICATION NAME], both for depression, daily for the past 3 months and was being monitored for side effects only every shift and not for the effectiveness of the medication. Part of the resident's care plan included to be at risk for complications and side effects from daily administration of [MEDICAL CONDITION] medications. One of the approaches to this problem area included monitor for effectiveness. Another approach was Monitor resident frequently for mood or behaviors. Review of the residents eMAR (electronic medication administration record) revealed that the resident was not being monitored for effectiveness or behaviors, only side effects. 2. On 10/09/20 at 10:50 a.m., Resident #3 was observed sitting in the wheelchair next to the bed in his room. He was well groomed and dressed for the day. A review of the Resident Face Sheet for Resident #3 revealed that he was initially admitted into the facility on [DATE] with a primary [DIAGNOSES REDACTED]. A review of Section C of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was rarely/never understood. Section D indicated that the resident was rarely/never understood. The section related to feeling down, depressed, or hopeless was blank. Section N revealed that Resident #3 received an antidepressant for 7 days per week. A review of the Physician order [REDACTED].#3 had the following orders: Memantine- 10 mg twice per day for dementia [MEDICATION NAME]- 50 mg once per day for depression There was no order for Behavior Monitoring found on the Physician order [REDACTED]. A review of the Medications Administration History for 08/01/20-08/31/20, 09/01/20-09/30/20, and 10/01/20-10/09/20 did not reflect that Resident #3's behaviors were monitored. A review of the Treatment Administration History for 08/01/20-08/31/20, 09/01/20-09/30/20, and 10/01/20-10/09/20 did not reflect that Resident #3's behaviors were monitored. A review of the Resident Progress Notes for August, September, and October did not reflect daily documentation for non-verbal signs of anxiety, mood and behavior monitoring. The care plan for behavioral symptoms had a start date of 01/16/19. Interventions included but were not limited to monitor behavior episodes and attempt to determine underlying causes, document behavior and potential causes, and monitor for and document presence of mood and behaviors. The care plan for [MEDICAL CONDITION] drug use had a start date of 01/16/19. Interventions included but were not limited to monitor for non-verbal signs of anxiety and monitor Resident #3 frequently for mood and behaviors. On 10/09/20 at 10:24 a.m., the MDS Coordinator stated that behavior monitoring should be documented in progress notes. On 10/09/20 at 10:48 a.m., Staff A, Nursing Supervisor, reported that Resident #3 did not have any behaviors, but can be resistive to care often. Staff A reported that he was not combative or anything. She reported that behaviors would be monitored if a resident was taking [MEDICAL CONDITION] medications. If a resident was monitored for behaviors, it would pop up on the Medication Administration Record [REDACTED]. If they are not on a [MEDICAL CONDITION], then behaviors would be documented in the progress notes. Staff A reported that she was not sure what medications Resident #3 was ordered. At 10:54 a.m., she looked up the resident's orders. She stated that he had an order for [REDACTED]. The policy [MEDICAL CONDITION] Medication Clinical Guidelines revised on 10/06/17 revealed the following: Standard [MEDICAL CONDITION] Drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to drugs in the following categories: Antipsychotics Antianxiety Antidepressants Hypnotics Nursing 1. Daily monitoring of the resident for presence of target behaviors and any adverse effects of the medication (charting behaviors/adverse effects when present) 2. Review the use of the [MEDICAL CONDITION] medication with the interdisciplinary team on a quarterly basis to include presence of target behaviors and/or adverse effects of the medication. Pharmacist 1. Monitors [MEDICAL CONDITION] drug use in the facility to ensure appropriate use/monitoring of medications.

Based on observation and interviews with facility staff, the facility failed to ensure that proper isolation of positive COVID-19 residents was maintained for 1 (Room A 101) of 4 isolation rooms on a wing of 10 rooms. Findings included: During a co-visit with the Department of Health, occurring on 04/30/2020 beginning at 2:30 p.m., the Administrator confirmed facility residents and staff had been tested for COVID-19 on 04/22/20. The facility had been notified on 04/29/20 of a positive result for five residents and one nurse. The Administrator reported that the facility had isolated the five residents to one wing in the facility. Sixteen residents lived on the wing identified as the isolation wing. Of the sixteen residents, two had refused to be tested for COVID 19, nine had tested negative and five had tested positive. Observation of the isolation wing began on 04/30/20 at 3:00 p.m. The fire doors leading to the wing were in the open position. Staff from the day shift and the evening shift were observed huddled together in the hall endorsing resident status. All staff were noted to be wearing surgical masks. A 'bump-out' made of a plastic material was noted at the second door on the left side of the A 100 hall just past the nurses station. There was no sign indicating the reason for the isolation or what protection staff should take. The plastic material was identified as Visqueen, and described by the Administrator as providing isolation for the resident in the private room (A 101). She reported that inside the bump-out were the PPE (Personal Protective Equipment) supplies required to be worn by anyone who entered the resident's room, as the resident had tested positive for COVID 19. Further observation of the area behind the Visqueen, which was secured closed with a zipper but outside of the resident's room, revealed a table that held masks: N95 and surgical, gloves, gowns, head coverings, goggles and sanitizer. The Infection Preventionist (IP) pointed out a poster on the wall with instructions on donning and doffing PPE. She confirmed that each staff member that entered the isolation room had their own N95 mask . (photo evidence obtained) The plastic sheeting creating the isolation area was kept shut with a zipper. It was confirmed by the IP that the room was not under negative pressure and air from the room could be felt leaving the isolated area when the zipper was opened. There were 5 rooms on either side, of the hall including the isolation rooms. Two aides were noted to walk into a room, past the first isolation room, without having to open the door first, and then returned to the hall. Other aides were noted to enter resident rooms, again without opening the doors to the rooms. The Administrator confirmed during the observation that when the aides or nurse provided care to the residents not in isolation, they only had to wear the surgical mask and gloves. At the end of the hall another sheet of the Visqueen was noted to go diagonally across the hall, isolating three resident rooms (Rooms A 108, A 109, A 110) with the hall ending in double doors leading to the outside. (photo evidence and map obtained) The isolated rooms were approached at the end of the hall. Residents could be observed in their rooms, either in bed or in chairs next to their beds, most without masks on, but easily observed as their doors were open. The isolated end of the hall was noted with a shelving unit tucked into a niche in the hall with PPE supplies in three columns. (photo evidence obtained) The IP explained that the columns represented the three shifts with dedicated PPE for each shift and the aide who worked that shift. The Administrator confirmed during the observation that an aide was assigned to work with the five residents who had tested positive and those aides had N95 masks to wear when they cared for the residents. It was unclear whether the aide wore the same N95 mask while caring for each resident. The Administrator reported that there was one nurse assigned to the wing who administered medications and completed assessments on all the residents, including the residents who had tested positive. She confirmed that the nurse would don her PPE inside of the isolation barrier prior to seeing to the resident. Two of the three rooms isolated at the end of the hall were occupied and had a total of four residents, who shared one bathroom. The IP reported that all of the four residents had cognitive concerns. All four residents required assistance with toileting. She also reported that the four residents needed some assistance at meals and required the aide to remain with them at meals. After the visit to the isolation wing, at 4:00 p.m., the COVID 19 Focused Survey for Nursing Homes (self assessment), was provided to the IP for reference. When asked if the facility had completed the Focused Survey/self assessment the IP reported, after confirming with the Administrator, that since it wasn't required they hadn't completed it nor submitted it to the state agencies. She reported that the areas of concern (the critical elements) included in the self assessment were all areas that they had discussed, but hadn't used the self assessment to make notes or 'check off' each area as completed. Attention was drawn to the first section of the Focused Survey document which discussed Standard and Transmission Based Precautions. Under the section discussing Transmission - Based Precautions, the fifth bullet point included guidance that read, When COVID-19 is identified in the facility, staff wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility wide based on the location of affected residents), regardless of symptoms.

Based on medical record review and staff and resident/representative interview, the facility failed to ensure one of forty-four sampled residents' (#23's) representative was called and notified of a change of condition which occurred between the resident and another resident. Findings included: On 5/13/2019 at 10:29 a.m., the responsible party for Resident #23 was called. The responsible party answered the phone and confirmed that she was Resident #23's responsible party and made his decisions at the facility and participated along with his wife in care planning. She further indicated that Resident #23's wife required care and could not make decisions for herself and she was also her responsible party. The responsible party was asked if she was notified of an incident that occurred between Residents #23 and #75, which occurred on 4/9/2019. She indicated she had not received communication about anything from anyone regarding Resident #23 and another resident. She was asked if anyone told her of an incident related to a random resident entering Resident #23's room, when he asked Resident #75 to leave, only for Resident #75 to lunge at him and try to punch him. This resulted in Resident #23 grabbing his finger and twisting it. She replied, No, I was not at all made aware of that situation. She also confirmed that his wife was not made aware either. She further explained that she had been in Resident #23's room while visiting and has had, on occasion, other residents come in the room and then leave. However, there had not been any verbal or physical contact between the residents. She asked if Resident #23 was hurt in the incident? The surveyor indicated that that staff would discuss that with her. She had no other issues or complaints regarding the facility or staff, or residents, but did have an issue as to why she was not made aware of the contact between Resident #23 and Resident #75. Review of Resident #23's medical record revealed the resident was admitted to the facility for long term care on secured unit on 6/28/2018, per the Admissions Record. Review of the advanced directives revealed the resident had a POA in place, who was his wife, but currently at this time the friend was becoming the contact person and she would pass that information along to the spouse. This was noted in the face sheet. Review of the nurse progress notes from 4/1/2019 to current 5/16/2019 did not indicate anything reflecting any incident between him and Resident #75. The medical record of event history, to include dates from 4/1/2019 to current, did not reveal any resident-to-resident event with Resident #75. Review of Resident #23's advance directive revealed A Durable Mental Health Care Surrogate, dated and signed 2/23/2019, to include resident's wife as DPOA. However, the face sheet under the contact information revealed the friend was to be contacted with information and would then relay information to the spouse, as she resided with the spouse. The face sheet also indicated wife was DPOA and Family member was responsible party. The physical record also contained a sheet of white paper placed in the advanced directives/face sheet portion. The sheet revealed in large bold letters, Please do not give resident his wife's phone number. He may contact family friend, who is the primary emergency contact. She resides with spouse and will relay information to her. There was also a permission to discuss or disclose resident information sheet, which was signed by the legal representative/spouse, and friend on 8/7/2017. The chart also contained an incapacity statement related to dementia signed and dated by the MD on 8/10/2017. On 5/14/2019 an attempt to call the spouse (DPOA/Health Care Surrogate) found she had cognitive impairments and would not be able to answer any questions related to her husband. On 5/14/2019, the family friend was interviewed and she indicated she was the HCS for the resident's spouse and she would not be able to answer any questions about her husband Resident #23. The friend indicated the spouse had declined mentally recently, and therefore, she (Friend) requested the facility call her when there was a change of status for Resident #23 and she would tell the spouse. On 5/15/2019 at 10:30 a.m. an interview was conducted with the Risk Manager, who explained the incident between Residents #23 and #75, which occurred on 4/9/2019. She indicated that Resident #75 self-propelled into Resident #23's room on the secure unit. Resident #23 told Resident #75 to leave the room and then Resident #75 leaned forward and tried to strike Resident #23. Resident #23 grabbed the middle finger of Resident #75 and twisted it. They were both immediately separated, & MD notified. Both residents were placed on close supervision. MD and family of Resident #75 were notified. All state agencies were notified as per interview. On 5/14/2019 at 9:20 a.m., an interview with the Activity Assistant revealed she knew of both Residents #23 and #75 and had not seen them being combative or showing behaviors with one another. She was aware that they did have an incident, but was not made aware of the specifics. She further said that when she had been doing activities, she had not noticed anything between them. She did say she and other staff had received an inservice and education related to resident-to-resident interaction within the past few weeks. On 5/15/2019 the Risk Manager was interviewed and confirmed by reading her investigation for the 4/9/2019 incident between Residents #23 and #75, it could not be determined if the contact person was called for Resident #23. She confirmed because of the nature of the incident, both contacts of parties involved should have been contacted.

Based on observation, resident record & policy review and staff interview, the facility failed to develop and/or failed to implement care plan interventions related to falls for two of forty-four residents (#20 and #37). Findings included: 1. The policy titled Care Plan Development, effective 8/1/2010 and revised on 11/28/17, identified the care plan is integral to the provision of care to the resident and will be available to team members who are responsible for providing care and services. 2. Resident #20 was admitted on [DATE] and 11/22/18, per the admission record. The facesheet included [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) indicated a Brief Interview of Mental Status (BIMS) score of nine, reflecting that the resident was moderately cognitively impaired. An observation, on 5/13/19 at 9:48a.m., found Resident #20 lying in a bed, in the low position, with one fall mat on the floor between the bed and privacy curtain, and a floor mat leaning against the wall, beside a reclining chair. Photographic evidence obtained. The resident admitted to falling and hurting hip. On 5/15/19 at 9:40a.m., Resident #20 stated, falls all the time. Bilateral floor mats were laying on each side of the bed. A dressing was observed on the right elbow of the resident. Staff Member D, Licensed Practical Nurse (LPN), stated, on 5/15/19 at 11:42a.m., Resident #20 falls often. The staff member revealed the resident was ambulatory to a certain extent and makes bad decisions. The LPN identified the resident was on a two-hour toilet prompting at night. An observation on 5/16/19 at 9:25a.m., found Resident #20 lying in bed; two floor mats were leaning, however, against the wall between the reclining chair and wall. Staff Member D stated the resident had already been to therapy. Staff Member K, Certified Nursing Assistant (CNA), entered the room and stated the resident must have gotten back into bed. The CNA then placed floor mats on each side of the bed. A review of the facility matrix identified Resident #20 suffered a fall with injury. The electronic summary of an event revealed that on 5/9/19 the resident suffered a fall with a skin tear to the right elbow. The details of the fall identified the resident slid out of chair to the floor in the activities room. The details of an event identified Resident #20 fell in shower, on 4/29/19, while the CNA (Certified Nursing Assistant) was in the resident's room retrieving a clothing item. The details indicated the resident fell out of the shower chair and staff were advised to stay in the bathroom with the resident due to poor safety awareness. On 3/21/19, Resident #20 suffered a fall transferring self from bed to wheelchair. The event details indicated the resident was encouraged to use the call bell and a Fall Prevention Program was initiated. According to the summary of the event, dated 1/12/19, Resident #20 was observed laying on the floor mat beside the bed. The evaluation notes revealed PT (Physical Therapy) to screen resident, the care plan was updated, and Falls Prevention Program was initiated. During an interview, on 5/16/19 at 7:47a.m., the DON stated there was not a specific Fall Prevention Program. The facility was restraint-free and utilized the use of safety devices. The facility monitored and discussed any falls and if any, new interventions were needed. The root causes of falls were looked at and the facility may put a resident on prompted voiding or 1:1, and then the interventions are put in the point of care for the CNA's to know if any safety devices are used. The Physician order [REDACTED]. -5/6 - 6/4/19: PT (Physical Therapy) to eval and treat: Resident to be seen by PT 5x per week for 30 days for therapeutic exercise, activity, and gait training. -4/27/18 - open ended: Floor mats while resident is in bed for safety. Every shift: Day, Eve, Night. A review of Resident #20's care plan found the resident was at risk for falls (Start date of 5/9/2017) due to unsteady gait, expected continual declines in cognitive and physical function due to dx (diagnosis) of [MEDICAL CONDITION] and dementia, hx (history) of falls, and daily administration of mood stabilizing medication r/t (related to) dx depression. (MONTH) use a wheelchair or a walker while out of bed and requires staff assistance for safe transfers and ambulation. Was noted to report unwitnessed falls to staff. 10/17 was noted with hx of falls during transfers while attempting to self-toilet, problem start date 5/9/17, edited 5/7/19. The approaches included but were not limited to: -Maintain floor mats as ordered, approach start date 4/27/18, created 5/3/18. -Prompt Resident #20 to toilet as tolerates. Assist with transfers as needed for safety. Document as indicated, start date 4/27/18, created 10/6/17. -Receiving physical therapy. See therapy goals and plan of treatment, start date 5/6/19, created 5/7/19. -Therapy screening after each fall and as indicated to assess for potential functional decline, start 5/9/17, edited 5/10/17. The Care Plan did not include approaches that started after Resident #20's falls on 3/21/19 or 5/9/19. During an interview, on 5/16/19 at 9:00a.m., Staff Member J, RN, MDS, stated the department was trying to streamline the care plans. The staff member explained MDS received green sheets (physician telephone orders) from staff and the care plans were updated then, every three months, and with a significant change. Staff Member J stated care planning was done by exception, not the rule, and staying with a resident in the shower would be a rule, basic care, and after the fall on 5/9/19, the staff member did not know what else we could attempt, as resident was receiving therapy. Staff Member J stated the facility had done so many approaches in the past, and did not feel there was anything else to do. 3. Resident #37 was admitted on [DATE], per the Admission Sheet. The quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status score of 10, moderately cognitive impairment. The MDS revealed Resident #37 required extensive 2-person assist with transfers. On 5/14/19 at 8:40a.m., an observation of Resident #37's room revealed bilateral floor mats next to the bed. On 5/15/19 at 9:37a.m., when asked about the fall on 4/17/19, the resident stated the wheelchair was unlocked, reached down and the wheelchair moved. The resident stated the only thing hurt was pride. On 5/15/19 at 11:40a.m., Staff Member D, Licensed Practical Nurse (LPN), stated the fall happened several months ago, the spouse was present, and Resident #37 attempted to transfer self into the bed. The staff member stated Resident #37 was unrealistic after an amputation and was trying to do things without assistance. An observation on 5/16/19 at 9:29a.m., of Resident #37's room revealed bilateral floor mats beside the bed. The electronic Event tracking log revealed Resident #37 suffered a fall on 4/17/19 while trying to self-transfer. The Care Plan for Resident #37 (Start date 5/21/2018) indicated the resident was at risk for falls . The problem summary did not include information regarding the fall on 4/17/19 and was last edited on 3/6/19. The approaches related to the problem of falls did not indicate any interventions were implemented after the fall and did not include the use of bilateral floor mats. An interview was conducted, on 5/16/19 at 9:17a.m., with Staff Member J, RN, MDS, regarding Resident #37's fall. The staff member asked if the fall was an isolated incident. The physician orders [REDACTED]. The staff member stated another staff member might have felt floor mats were a good idea so took it upon themselves to add them without notifying the Risk Manager or MDS. Staff Member J stated a physician order [REDACTED]. The policy titled, Fall and Fall Risk Management, effective 5/15/17, revealed based on a resident's assessment, the facility will identify interventions related to the resident's specific risks and behaviors and develop a plan of care to try to prevent the resident from falling and to minimize complications if a fall does occur. The facility staff will identify appropriate resident specific interventions to reduce the risk of falls, and if falling recurs despite initial interventions, staff will implement additional interventions or document why current approaches remain relevant.

Based on observations, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections related to observation of an employee cooling a resident's meal by blowing on the food, a resident observed eating from another resident's tray during lunch, inappropriate storage of oxygen equipment, cleaning of the glucometer, and administration of eye drop medication, affecting five (33, 73, 83, 88, and 101) of forty-four sampled residents. Findings included: 1. On 05/15/19 at 11:48 a.m., Resident #73 was observed in the dining room on the secured unit. The resident was sitting in a high back wheelchair at the table with one other resident. At 11:50 a.m., Staff A, Certified Nursing Assistant (CNA), was observed assisting Resident #73 with a bowl of soup while standing. Staff A stated, I know it is hot and started blowing the soup on the spoon before inserting the spoon of soup into the resident's mouth. This was observed by two surveyors. Starting at 11:52 a.m., Staff A was observed continuously dishing out a spoon of soup, blowing the soup, and inserting the spoon of soup into the resident's mouth. Staff A finished assisting Resident #73 with the soup at 11:58 a.m. Resident #73 ate the entire bowl of soup. Staff A assisted the resident with the entire bowl of soup while standing. On 05/16/19 at 12:02 p.m., Staff A reported that she assists the resident when she is scheduled to work with his meals. If you do not assist him, then he will stick his fingers in his food instead of using utensils stated Staff A. The surveyor reported to Staff A that she was observed blowing on the soup and inserting the spoon of soup into the resident's mouth. The surveyor asked Staff A was the soup hot and if Resident #73 told her that the soup was hot? Staff A reported that she knew the soup was hot because Resident #73 started spitting it out. She reported that the soups are always hot. Staff A was asked if she normally cools the resident's food by blowing it and she stated if I put it to the side, he will reach for it. She stated that it comes in a container and it is very hot. Staff A stated, I blow it because if I put it to the side, he will put his hand in it and burn himself. Staff A reported that sometimes she would put an ice cube in the food to cool it. At 12:07 p.m., Staff A assisted Resident #73 with a bite of watermelon with the fork while standing up. At 12:10 p.m., Resident #73 was observed using his fork and eating food from the plate of the resident that was sitting at the table with him. Resident #73 ate spoons of the cornbread stuffing from the resident's plate that was seated at the table with him. After about 3 minutes, Staff A came over and stated, No, you can't eat from his plate he has a different diet from you. Staff A asked the other resident if he was done with his meal. A record review of the Resident Face Sheet form for Resident #73 indicated that he was admitted into the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Section C of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #73 was rarely/never understood. Section G revealed that the resident needed supervision with one person physical assistance with eating. The care plan related to ADL Functional for Resident #73 indicated to set up and assist him with meals as needed. Monitor for difficulty chewing or swallowing. Document and Notify Physician if noted. On 05/15/19 at 2:23 p.m., the Director of Nursing (DON) reported that staff should be sitting and not standing when assisting residents with meals. The DON reported that her expectations for cooling foods during meal service was to move it to the side and let it cool or add ice to the food. There should be supervision during meals so that the residents are not taking food from other resident's trays stated the DON. At 3:51 p.m., the DON reported that she did not have a policy related to how to cool food for the residents and supervision during meals. 2. On 5/14/19 at 3:45p.m., Staff Member E, Licensed Practical Nurse (LPN), was observed obtaining a blood glucose level from Resident #33. The staff member utilized an Assure Platinum glucometer to obtain the level after removing it from a small plastic bag in the top drawer of the medication cart. After obtaining the blood glucose level, Staff Member E, placed a paper tissue on top of the medication cart and laid the glucometer on it. The staff member proceeded to don gloves and with another paper tissue wiped the top of the glucometer and place the meter back in the plastic bag. Per Staff Member C, LPN, the facility provided individual glucometers for each resident. At 3:57p.m., Staff Member E stated normally the glucometers are cleaned with an alcohol pad before and after use but did not do it this time. Staff Member E admitted to using a dry paper tissue to clean the glucometer. The policy titled, Blood Glucose Monitoring, effective 5/30/2012, identified to clean/disinfect the blood glucose meter before and after each use per the manufacturer's instructions, and to store the blood glucose meter after cleaning appropriately. According to http://www.arkrayusa.com/diabetes-management/sites/arkrayusa.com.diabetes-management/files/Platinum_Cleaning-and-Disinfecting_EN.pdf, if a blood glucose meter was assigned to an individual, the meter needs to be cleaned and disinfected. Cleaning of a glucometer could be accomplished with soap and water or [MEDICATION NAME] alcohol, however soap and water or [MEDICATION NAME] alcohol would not disinfect the glucometer. To disinfect the glucometer, the manufacturer recommended the use an EPA-registered disinfectant wipe or to use a lint-free cloth dampened with a 1:10 bleach solution. The cleaning of disinfection of the glucometers minimize the risk of transmitting blood-borne microorganisms and should be performed as recommended. 3. An observation was made, on 5/14/19 at 3:42p.m., of Resident #83 sitting in the common area of the Delta unit. The resident was sitting in a wheelchair with an emergency tank (e-tank) of oxygen attached to the back of the chair. Attached to e-tank was oxygen tubing with nasal cannula, the tubing was wrapped around the tank with the cannula lying against a black knob located above the regulator of the tank. A plastic clear bag was hanging from the handle of the wheelchair. During an interview, on 5/14/19 at 4:06p.m., Staff Member E, LPN, stated oxygen tubing was to be stored in a plastic bag. An observation with Staff Member E was made at the time of interview, the staff member stated the oxygen tubing would be changed and the storage of the tubing, was wrong. An interview was conducted, on 5/16/19 at 7:47a.m., with the DON. She stated when oxygen tubing and nebulizer equipment was not in use, they were supposed to be stored in a bag. 4. On 5/14/19 at 8:30a.m., during an observation and an attempted interview of Resident #88, the resident's nebulizer inhalation mask was observed standing upright against the nebulizer machine and on the edge of the bedside dresser. A continued observation did not reveal the nebulizer mask and tubing was dated, or a storage bag for the nebulizer mask. Photographic evidence was obtained. The facility provided education, undated, that identified when nebulizer/breathing treatment was completed, the equipment was to be stored in a clean, labeled bag. On 5/16/19, the DON provided a policy for storage of oxygen emergency tanks and staff education regarding oxygen use safety, neither addressed the storage of oxygen tubing. 5. During the mandatory task of Medication Administration, on 5/15/19 at 8:56a.m., with Staff Member B, Licensed Practical Nurse (LPN), an observation was made of the staff member administer eye drops to Resident #101. The staff member washed hands and donned gloves, assisted in opening the resident's left eye, and placed one drop of Refresh eye lubricant. The staff member opened the resident's right eye, observed crusty mucous substance attached to the resident's eyelashes, and stated the resident's eye needed to be cleaned. The staff member placed one drop of Refresh in the resident's right eye. Staff Member B, turned from the resident, wet a washcloth, handed it to the resident and the resident wiped left eye then the right. Staff Member B placed the washcloth, after use, on a paper towel on the resident's over-the-bed table, then left the room. At 9:04a.m., Staff Member B stated the crusty should have been cleaned before administering the eye drops. The policy titled, Medication Administration - Eye Drops, revised 03/07, included the following instructions: - 3. Position resident on back or sitting with head held back. - 4. Cleanse eye gently with a tissue or wash cloth. - 5. Read medication label. - 6. Draw medication into dropper. - 7. Retract lower lid using a tissue under finger. Ask resident to look forward. - 8. Instill medication onto conjunctiva of lower lid. The policy identified staff members were to always handwash with soap and water, not alcohol. The policy did not indicate the use of gloves during administration. An interview was conducted, on 5/16/19 at 7:47a.m., with the DON. She stated when oxygen tubing and nebulizer equipment was not in use, they were supposed to be stored in a bag. The DON identified glucometers are patient-specific and cleaned before and after use then stored in a baggie. The glucometers are to cleaned with an alcohol pad or a Sani-wipe, which are located on each hallway near the medication carts. An interview with the Infection Control Coordinator (ICC), on 5/16/19 at 10:40a.m. was conducted regarding the facility infection control protocols. The ICC stated nebulizer equipment located at the bedside are to be stored in a plastic bag and dated, either the bag or the tubing, and oxygen tubing should be stored in a plastic bag and the tubing with cannula should be placed in a plastic bag when staff notice it, as some residents remove it themselves. She reported patient-specific glucometers should be cleaned/disinfected before and after each use with a Sani-wipe. A dry paper tissue was not appropriate to clean a glucometer. The ICC stated if an eye was crusty she would have cleaned the eye prior to administrating eye drops and stated if the policy did not indicate the use of gloves during eye drop administration she would expect nurses to do so if there was an ongoing infectious process. During the description regarding a staff member blowing on a residents' food, the ICC stated she would not blow on a resident's food.

Based on observations, staff interview and medical record review, the facility failed to maintain resident dignity to include: 1. Staff referring to residents as feeders in populated dining rooms, 2. A nurse preparing and passing medications to groups of residents in a television lounge, while residents were watching a movie, 3. Two of sixteen residents (# 91 and #58), while seated in a dining room were not served, set up and assisted with their meals in a timely manner, 4. Staff not knocking and or announcing prior to entering resident rooms, 5. Staff shaving multiple residents in other resident's rooms during four of four days observed (2/12/2018, 2/13/2018, 2/14/2018 and 2/15/2018), in two of two units (Alpha unit and Delta unit). Findings included: 1. On 2/13/2018 at 11:32 a.m. the Alpha unit Bistro was entered and there were seven residents seated at tables and with three aides in the room. One aide, (employee V) observed another aide (employee W) bring in a resident and she said to him aloud, He's a feeder, yeah he's a feeder. She was in the middle of the room and said this aloud and all other residents could hear. The resident that she was referring to was not interviewable and could not make his own needs known. Employee V. was overheard telling employee W again, for a third time that the resident was a feeder. On 2/14/2018 at 7:58 a.m. an aide, employee X, walked into the secured unit Bistro and said, hello, I'm here to the other staff in the room. She went to a resident in the room and repositioned him and another staff member asked her a question and she said aloud, while in the middle of the room, He's a feed. Employee X. walked to the sink and then said aloud to another staff member while seated in the other side of the room, He's a feed. All residents in the room could over hear the employee, as she said it aloud. 2. On 2/14/2018 at 9:20 a.m. the secured locked/dementia unit was observed with eight residents seated in the television/sitting lounge approximately fifteen feet across from the nurse station. During this time, a nurse (employee A) was observed at her medication cart in the corner of the room and preparing and passing medications to four of eight residents in this area. Most were watching a movie that was playing on the television. At times the nurse was standing in front of the television passing medications to a resident, and blocking the view of other residents watching. Medications included cups of pills/tablets and cups of apple sauce with spoons in it. Employee A. was observed to assist with providing medications to the residents in this area and to include spoon feeding meds with spoon and apple sauce. Employee A. continued to prepare and pass medications to residents, in front of other residents and visitors from 9:20 a.m. through to 9:42 a.m. when she walked away with her cart. On 2/15/2018 at 9:09 a.m. the secured Delta unit was observed during the medication pass. At this time there was one nurse (employee B), who was standing at her medication cart in the corner of the television/activity room. There were seven residents seated in their wheelchairs and parked in a line fashion near the nurse and her medication cart. The television was playing a movie for residents to watch. At 9:09 a.m. through to 9:16 a.m. Employee B. was observed pouring and preparing medications in various cups. At 9:16 a.m. she brought a cup of medications to one resident seated in the room, who was seated next to two other residents. Employee B. returned to the medication cart and prepared more medications. At 9:19 a.m. she brought cups of medications to one resident seated in front of the television and who was seated next to one other resident. She then returned to her medication cart at 9:21 a.m. Also, Employee B was observed taking vital signs with residents in this area. At 9:24 a.m. she was again observed to bring a cup of medications and passed them to a resident, who was seated in the line of residents in the television/activities room. At 9:33 a.m. Employee B. removed her medication cart from this room and proceeded to move down the 300 hall to prepare and pass medications to residents while in their rooms. On 2/15/2018 at 11:40 a.m. an interview with the Delta unit manager indicated that it is normal routine for nurses to pass medications out in the activities/television lounge, as that is the area where most residents are at during that time of morning. She confirmed that the medication pass is out in the open and that they could try and do a better job not passing medications in an assembly type of fashion, and not pour and prepare meds and pass meds while in front of the television. 3. On 2/14/2018 at 11:50 a.m. the Alpha Bistro dining room was observed for a dining meal service. At this time the room was observed with sixteen residents with fourteen who had already been served, set up and some being assisted with eating by staff. There were six staff members in the room and all were seated and assisting residents with eating. However, there were two residents (#91 and #58), who were seated in either their Broda chair or wheelchair at a table in the back corner by themselves. Both were observed not interviewable and had clothing protectors positioned around their neck and hanging down over their shirts. Resident (#91) was observed with his eyes closed and the other resident, (#58) was observed looking at residents seated at other tables while they were eating or being assisted with eating from staff. It was determined at this time that they have not been served or assisted with their meal. Further, neither #91or #58 had hydration, soup or etc. At 12:10 p.m., fifteen minutes after first observed time, this surveyor walked up to another table and spoke with two staff members (Employee C. and B.), who were assisting with two other residents. They were asked about residents (#91 and #58), and aide (employee C) replied, they have not eaten yet due to there is not enough staff in the room at this time. Nurse (employee B) confirmed. They both confirmed that both residents had been brought into the room at the same time as all they others and that they are usually assisted with their meals last after the others, when there is not enough staff in the room. It was evident that all six employees in the room were assisting other residents with eating, and could not assist residents (#91 and #58). Randomly at 12:12 p.m. an aide (employee D) walked into the room and went to various aides and offered them to leave and she would assist in their place for the residents that were already being assisted. Nurse (employee B) pointed over to residents (#91 and #58) and indicated that they needed to be assisted as they have not eaten yet. (Employee D.) washed her hands, went over to the meal tray cart, where both doors have been all the way open since, leaving the unused trays exposed, at least since 11:55 a.m., then grabbed a tray and brought it to the table where residents (#91 and #58) were seated. She assisted resident (#91) and began to set up the tray at 12:16 p.m. At 12:18 p.m. resident (#91) was finally assisted with eating. He was observed to accept bites of food that were brought up to his mouth. At 12:16 p.m. another staff member (employee E) walked into the room and asked if she could help. The nurse (employee B) pointed over at resident (#58) and explained that he needed to be assisted with his meal. (Employee E) went to the tray cart and tried to find his tray. However, the tray was not in the cart. She left the room at 12:18 p.m. to go find it or retrieve another one from the kitchen. However, at this time and from 12:16 p.m., resident (#58) was now watching his table mate (#91) eating, as he had nothing. At 12:22 p.m. (employee E) brought in a tray and placed it in front of resident (#58) and she set up the meal. At 12:25 p.m., resident (#58) was finally assisted with his meal and he accepted bites of food that were brought up to his mouth. It was determined that resident (#91) was brought in the dining room at same time as others. All other residents were served by 11:55 a.m. He was not assisted and served his meal until twenty-six minutes after all others were assisted. The table mate, (#58) was not assisted and served his meal until thirty minutes after all others were assisted. Further, a confidential interview with one family member confirmed that the room needs more staff to assist the residents with eating. On 2/15/2018 at 7:48 a.m. the Alpha unit Bistro was observed. There were six staff members seated at various tables already assisting residents with eating. They were bringing forkfuls of food to residents' mouths. There were sixteen residents in the room at this time. One table was observed with two residents and staff assisting with eating and one resident who was not served his tray yet. There was another table with two residents who had not been served their tray or assisted with, while the third resident at the table was being assisted with eating from a staff member. There was one table in the back with one resident who was not served or set up with his meal yet. At 7:48 a.m. all staff in the room were already seated and assisting with feeding the residents at the tables. At 7:58 a.m., ten minutes later, three other staff came in the room and then began to get trays from the meal cart and then served, set up and began to assist with eating for the three residents who had not been served yet. Interview with (employee D) indicated that it's different every day with who comes in this Bistro to assist with meal set up and eating assistance. Review of resident #91's medical record revealed he was admitted to the facility on [DATE] for long term care services. Review of the Advanced Directives revealed the resident had a POA in place. Review of the current Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed the resident had a short term/long term memory problems and was severely impaired with decision making skills. Therefore resident #91 would not be able to be interviewed related to his dining experience. Review of resident #58's medical record revealed he was admitted to the facility for long term care on 7/2/2010. Review of the Advanced Directives revealed the resident had a POA in place and who was involved with his care and services. Review of the current MDS Quarterly assessment dated [DATE] revealed he had short term/long term memory problems and severely impaired decision making skills. Therefore resident #58 would not be able to speak related to his dining experiences. On 2/15/2018 at 11:45 a.m. the Director of Nursing was interviewed. She indicated that the expectations area that residents who are seated at a table are to be generally served at the same time. She confirmed that with the example of resident #91 and #58, that it was not satisfactory that they were not assisted and served for over thirty minutes after others. 4. The following observations were made during the survey of staff not knocking or asking permission before entering a residents' room: On 2/12/18, random staff members were observed to enter resident rooms in the Alpha Unit without knocking or without asking permission to enter. The following staff was observed on 02/12/18 at 10:01 AM on the 300 hall staff member (A): On 02/14/18 at 4:00 PM staff member (F) CNA went in to take vitals in room [ROOM NUMBER]. The staff member knocked did not ask for permission to enter. On 02/14/18 at 4:01 PM CNA staff member (G) knocked on the residents' door without asking permission to enter room. On the 200 hall room [ROOM NUMBER] & 207 staff member (N) CNA was observed to enter the rooms without knocking. On 02/14/18 at 4:08 PM staff member, (H) CNA was observed entering resident rooms without knocking on the 300 hall. On 02/15/18 at 9:04 AM staff member (I) CNA, was observed entering in and out of resident rooms without knocking, asking permission or introducing herself. In addition, at 9:29 AM staff members J, K and O were also observed to enter residents' room without knocking. 5. An observation was conducted on 2/12/2018 at 9:15 a.m. with two residents in another resident's room being shaved by Staff L and M. At 9:17 a.m. the two residents inside of the room were escorted out into the hall by Staff L and M and then Staff M was observed to bring another resident into the same room to be shaved. During an interview with Staff M on 2/12/2018 at 10:08 a.m. she said when we shave the residents we normally bring two residents at a time into Resident #49's room to shave them. During an interview with Staff L on 2/13/2018 at 11:22 a.m. she said we normally bring the resident into Resident #49's room and do all the shaving in there. We do that so we can stay on the hall and continue to watch the other residents for their safety rather than going to the shaving room. But, today (2/13/2018) I went to the shaving room to shave the residents During an interview on 2/15/2018 at 11:00 a.m. with Staff P, Nursing Supervisor, she said residents should not be shaved in one particular resident's room. They should be shaved in the barber shop room that's on the unit or in their individual rooms

Based on observation, record review and interview the facility failed to ensure that one of four Hospice residents (#30) had a complete medical record for care related to hospice services. Information related to hospice services was not included in the record and/or filed in medical records and not readily available to staff. Findings included: Resident #30 was originally admitted on [DATE], per the face sheet. The face sheet reflected [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of resident was rarely / never understood. Resident required extensive assistance of two for bed mobility, transfers, and toileting. Resident was on Hospice. Medical Verification of Capacity or Incapacity to give informed consent and / or make medical decision upon admission or form a change in condition. The Attending Physician for the resident evaluated Resident #30 at the nursing home on 05/17/11 and determined he lacked the capacity to make informed consent and / or medical decisions due to dementia. Certificate of Terminal Illness, end stage, or persistent vegetative state signed due to end stage dementia on 09/19/17. A Do Not Resuscitation signed and dated 05/17/11. An observation on 02/12/18 at 02:10 p.m. found Resident #30 was frail and elderly, sleeping in bed after lunch. His urinary catheter tubing was observed touching the floor in excess of about two inches. It was also noted that the urinary catheter bag in a privacy bag was also touching the floor. Record review of physician orders, dated 8/23/17, showed the resident admitted to hospice due to end stage dementia. Record review of Hospice Care Plan, updated 11/29/17, showed the family requested Hospice services related to end of life process due to end stage [DIAGNOSES REDACTED]. Goals included resident and his family will be supported and comforted in a manner that complies with his wishes and beliefs. Approaches included but were not limited to administer medications for anxiety, congestion, fever, pain and shortness of breath as needed and physician, monitor for side and his physician of unresolved conditions as indicated; coordinate care and services with Hospice service provider; notify physician and Hospice and the family of further declines in resident ' s condition. Assist as needed with his end of life process; Notify the family of crisis care status as indicated; provide an area for the family for privacy as requested; assist resident and his family in meeting their spiritual needs; provide emotional support to the family; provide interventions to increase comfort; provide total nursing care as needed. Record review of Resident #30's record produced no documentation related to Hospice. During an interview on 02/14/18 at 2:34 p.m. Staff T, Registered Nurse (RN) supervisor, verified there was no Hospice paperwork on the unit or in Resident #30 ' s record. There was a binder with an Agency Visit Report dated 02/02/18, 02/09/18 and 02/14/18 at the nursing station. The Medication Profile 09/20/2017 was located on the secure unit, where the resident previously resided. Staff T stated that Hospice does not give us anything. Staff P, RN supervisor for the Secure Unit also stated that Hospice does not leave us anything. During an interview on 02/14/18 at 2:50 p. m. the Director of Nursing (DON) provided Hospice Care IDT Reports which were dated 02/07/18 from through 08/30/17. The DON stated that the forms were found in medical records, not in the resident's record. She also provided a Nursing Home Reimbursement form which she stated was located in the billing department. The DON stated that her expectation was to find the care plans from Hospice and for them to be updated as needed. She stated that she would also expect to have the Hospice notes as well as the admission paperwork. During an interview on 02/15/18 at 10:26 a.m. the DON stated that they did not have the information from Hospice as to what services they were visiting or the frequency of their visits. She verified the facility did not have the Election Form or any information regarding Advanced Directive from Hospice. She verified they did not have the physician certification or recertification of terminal illness. She stated that they did not have the specific information regarding who was case managing the resident in the facility. She stated that they would call the main Hospice number, if needed. She stated that they did not have the service notes from the Hospice visits. She stated that they called Hospice yesterday and asked for the Plan of Care and received a Plan of Care with a fax date of 02/14/18. During an interview on 02/15/18 at 10:47 a.m. with the Hospice clinical manager, she stated that they provide a joint plan of care and a medication list to the facility. She stated that on admission the facility was provided a binder with a brief overview of services, as well as the contact information and on-call information. She stated that she was told the binder was going to the medical records department for some reason. She stated that they have not been providing the physician certifications or re-certifications of terminal illness to the facility. She stated that their visit notes are electronic and they have not been asked to provide a copy, only to write on the Agency Visit Report in the binder at the desk. She stated that the services and frequency of those services provided was in their electronic record. She stated that she had not been asked to print that information either. She stated that the nurse as well as the aide was visiting the resident twice a week. She stated that the chaplain was at the facility this week. She stated that the social worker was not ordered for Resident #30. She stated that she was not aware of the facility calling Hospice for anything. She stated that she made a visit to the facility to introduce herself. She stated that she educated the Hospice nurse and aide to check in at the facility nursing station and then give report to the facility staff and write on the Agency Visit Report. She stated that the facility requested the Agency Visit Report documentation in case the facility nurse had not seen the Hospice nurse or aide, they could read the Agency Visit Report for an update. During an interview on 02/15/18 at approximately 11:05 a.m. the Nursing Home Administrator (NHA) stated that the medical records department had requested documentation from Hospice, but had not followed up to verify it had been received. She stated that they should have followed up. Record review of facility's policy, Skilled Nursing Facility Services Agreement Hospice, dated December 8, 2015, reflected services to be provided by Hospice, at a minimum, Hospice shall provide the following information to Facility for each Hospice Patient: (a) Hospice Plan of Care, Medications and Orders. The most recent Hospice Plan of Care, medication information and physician orders [REDACTED]. The hospice election form and any advanced directives; (c) Certifications. Physician certification and recertification of terminal illness; (d) Contact Information. Name and contact information for Hospice personnel involved in providing Hospice Services; and (e) On Call Information. Instructions on how to access Hospice's 24 hour on-call system. 1.7 page 2, The Hospice Plan of Care a detailed statement of the scope and frequency of services necessary to meet the Hospice Patient ' s and Hospice Patient ' s family ' s needs. 2.2 page 4, Hospice shall develop and maintain a written Hospice Plan of Care. The Hospice Plan of Care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care. Hospice shall provide services to the Hospice Patient in accordance with the Hospice Care Plan. Hospice shall review and update the Hospice Plan of Care at least every 15 calendar days, or sooner when there are changes in the Hospice Patient ' s condition. 2.13 page 6, Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of services under this Agreement is in accordance with the Hospice Plan of Care, assessments, and treatment planning and care coordination. 4.1 page 12, Facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Hospice Patient receiving services under this Agreement in accordance with prudent record keeping procedures, their own policies and procedures, and applicable federal and state of Florida laws and regulations. Records include all documents that are necessary to certify the nature and extent of the costs of services provided.

Based on observation , record review, and interview the facility failed to operationalize their infection prevention and control program for three (Residents #30 , #40, and #49) of 31 residents to help prevent the development and transmission of communicable diseases and infections related to catheter tubing, oxygen equipment and eye drop administration. Findings Included 1. Resident #30 was admitted on [DATE]. The face sheet showed [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of resident was rarely / never understood. Resident required extensive assistance of two for bed mobility, transfers, and toileting. Resident had a urinary catheter. Resident had an active [DIAGNOSES REDACTED]. Record review of Urinary Incontinence dated 11/29/17 showed resident had recurrent and chronic Urinary Tract Infection [MEDICAL CONDITION]. Approaches included but were not limited to assess, document and report to physician as indicated signs and symptoms of UTI; provide indwelling catheter care following facility protocol. See indwelling catheter care plan for additional approaches to care. Indwelling Care Plan dated 11/29/17 showed resident was admitted with a supra pubic catheter related to [DIAGNOSES REDACTED]. Resident was at risk for UTI. Approaches included but were not limited to keep drainage tube free from kinks. Maintain the drainage bag below the level of the bladder and cover to promote privacy as resident allows. Maintain a closed system at all times. Monitor catheter tubing / drainage bag for side effects of medications. Monitor urine output for changes in characteristics, i.e. sediment, amount, color, etc. Secure catheter to resident's abdomen or leg to avoid tension on the supra-pubic entry site. May be secured by means of tape and / or catheter strap per his wishes. Observation on 02/12/18 at 02:10 p.m. found Resident #30 was frail and elderly, sleeping in bed after lunch. His urinary catheter tubing was observed touching the floor in excess of about two inches. It was also noted that the urinary catheter bag in a privacy bag was also touching the floor. Blankets were covering the resident. During an interview on 02/12/18 at 2:26 p.m. both Staff R, Licensed Practical Nurse (LPN) and Staff S, Certified Nursing Aide (CNA) confirmed that both the urinary catheter tubing and urinary catheter bag were on the floor. They stated that the tubing and bag should not be on the floor due to an infection control issue. They stated that the resident was on fall precautions which was why his bed was in the low position. Record review of facility's policy, Urinary Catheter Indication and Maintenance (Urethral and Supra-pubic), revised on 06/09/2017 showed maintenance / care of indwelling urinary catheters: monitor resident for signs / symptoms of urinary tract infection and [MEDICAL CONDITION]. Notify physician as appropriate. Maintain catheter tubing and drainage bag off the floor with privacy bag as appropriate. 2. On 2/14/2017 at 1:00 p.m , a medication administration pass conducted by the Registered Nurse (Staff B) for Resident #40 was observed. The resident had orders for Artificial Tears ([MEDICATION NAME] alcohol) -Over the Counter (OTC) drops 1.4%: amount 1 drop Ophthalmic. 1 drop each eye four times a day for dry eyes. The nurse obtained the eye drops from the in-house pharmacy, washed her hands and donned gloves. She pulled two tissues from the tissue box and explained to the resident what she was about to do. The resident was non-verbal. The nurse administered one eye drop into the right eye and with both tissues; she wiped the right lower eyelid, including the eyelash to remove the excess fluid. She then administered one drop into the left eye and with the same two tissues, she wiped the left lower eyelid, including the eyelash to remove the excess fluid. On 2/14/2017 at 1:30 p.m. and interview was conducted with the Registered Nurse (Staff B). She verified that she should have used one tissue for each eye. Per the facility's policy: Number 4901.3, Effective Date 1/18/2013, Subject Instillation of Eye Medications, Section III. Procedure, Number 12. Clear any excess medication from each eye with separate gauze/tissue. 3. Record review for Resident #49 indicated he was admitted to the facility with [DIAGNOSES REDACTED]. He had a medication order for [MEDICATION NAME] Solution (start date 2/7/18 - end date 2/17/18) 0.5-2.5 (3) mg/3ml ([MEDICATION NAME]-[MEDICATION NAME]), 1 vial; inhalation for a [DIAGNOSES REDACTED]. This medication was ordered to be given every six hours. Review of the Medication Administration Record [REDACTED]. An observation on 2/12/2018 at 9:50 a.m. revealed that Resident #49's nebulizer machine was lying on the bedside table. The nebulizer tubing and mask was attached, uncovered, and hung on top of the resident's chair next to the bed. On 2/12/2018 at 2:15 p.m. an observation revealed Resident #49's nebulizer was on the seat cushion of the chair next to the resident's bed. The tubing was attached to the nebulizer machine and wound up with the mask uncovered lying on the seat cushion of the resident's chair. The resident's mask was observed to have a clump of a brown and white substance on the rim. On 2/13/2018 at 9:30 a.m., an observation revealed the resident's nebulizer machine was sitting on the resident chair. The tubing to the nebulizer machine was partially wound up with the mask uncovered lying in between two pillows on the resident's chair (picture available). On 2/13/2018 at 3:04 p.m., an observation revealed the resident's nebulizer machine was lying on the seat cushion of the chair next to the resident's bed with the tubing and mask uncovered placed under two pillows on the chair. During an interview with Staff U on 2/13/2018 at 3:10 p.m., she said Oh, his (Resident #49) mask and tubing should be in a bag. All the residents' oxygen masks and tubing are supposed to be in a clear bag with a date on it. Review of the facility's Nebulizer Treatment Administration competency check off list revealed that nebulizer equipment should be labeled and stored in a clean manner and nursing staff should ensure that medication is completed and nebulizer reservoir and tubing is placed back into a clean bag. Review of the facilities Infection Control Program policy with an effective date of 10/17/2011 and a revision date of 9/26/2017, revealed that the facility shall develop, implement, and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and the onset and spread of infection within the facility.

Based on observation, interview and record review, the facility failed to assess one (#41) resident for self-administration of medication out of 11 residents observed during the medication administration observation task. Resident #41 was observed to self-administer his nebulizer treatment without an assessment by the interdisciplinary team of his ability to safely administer medications independently. Findings included: Observation on 01/25/17 at 4:25 p.m. showed Staff B, Licensed Practical Nurse (LPN) preparing Ipat-Albut 0.5-3 (2.5) mg for Resident #41. Staff B, LPN cleansed her hands, donned gloves and checked the resident's armband. She poured the medication into the nebulizer cup and handed the nebulizer mask to the resident. At 4:27 p.m., the nebulizer medication was turned on to begin administration of the medication. Staff B, LPN removed her gloves and washed her hands. At 4:28 p.m. Staff B, LPN left the resident's room to go answer the phone across the hallway. Resident #41 was sitting in a recliner and was unable to be seen from the door by Staff B, LPN. At 4:29 p.m. Staff B, LPN went into another resident's room to speak with them. She then returned to the phone in the hallway. Staff B, LPN then gathered the medication for Resident #41's roommate. Following this, Staff B then returned to the medication cart and moved to the next room to continue passing medications. She passed medications for both residents in that room. At 5:05 p.m., Resident #41 was observed sitting in the recliner without the nebulizer mask on his face. Resident #41 had laid the nebulizer mask on the bed and was talking on the telephone. At 5:05 p.m., Staff B was observed going to the nurses' station to speak with the supervisor. As of 5:15 p.m. Staff B, LPN still had not returned to check on Resident #41 since beginning the breathing treatment at 4:27 p.m. An interview on 01/25/17 at 5:15 p.m. with Resident #41 revealed he does his nebulizer himself. He stated that when he was done with his nebulizer treatment he throws the mask on the bed. He stated that the nurses do not stay with him during the treatment. During an interview on 01/26/2017 at 2:48 p.m. the DON was asked her expectation regarding performing nebulizer treatments, she stated she expected the nurse to set the medication up and put the mask on the resident. She stated she expected the nurse to periodically check on the resident. When asked if the nurse was allowed to leave the room, she stated the nurse could leave the room, they do not have to stay with the resident. When asked about the facility's policy last revised 3/07 titled Administrating Medications which documented that all drugs will be administered in a manner compliant with the prescribed procedures included in this manual. More specifically, the nurse shall remain with the resident until medication has been administered and/or taken (regardless of dosage form). The DON had no comment. When asked if the facility evaluates the residents for self-administering of medications, she stated rarely do they have residents that self-medicate. She stated if the resident wants to self-medicate, the resident must sign a consent, be evaluated by the nurse, than have the evaluation presented to the team, and obtain a physician order. She stated she did not know if Resident #41 was able to self-medicate, but she did not believe so. The DON then reviewed Resident #41's clinical record and verified the resident had not signed a self-administration consent form, received an evaluation for self-administration of medication or received a physician order [REDACTED].>Record review of the facility's policy, Self-Administration of Medications, effective 5/15/2009 showed a resident may self-administer medications if the interdisciplinary team has determined that the practice is safe. If a resident requests to self-administer medications, the interdisciplinary team will assess the resident's ability to safely administer medications before the resident may exercise this right. The resident will be assessed for their cognitive, physical and visual ability to self-administer medications based on Self Administration of Medication Informed Consent and Assessment. If the interdisciplinary care team determines that the resident is able to self-administer medication, the facility will provide the resident with a place to safely store the medications or provide the medication container to the resident upon request. Provide coordination with the attending physician for those medications being self-administered by the resident. The resident who self-administers medications will be reevaluated quarterly and as needed for their ability to continue to self-administer medications.