Every finding on record at Boca Circle Rehabilitation Center

Based on interviews and record reviews, the facility failed to ensure the accuracy of Pre-admission Screening and Record Review (PASRR) for 2 of 3 residents reviewed for PASRR (Residents #21 and #99). The findings included:1). Record review for Resident #21 revealed an admission date of 09/11/20. A PASRR completed by facility RN on 05/26/21 documented diagnoses that included: Bipolar Disorder, Depressive Disorder and Substance Abuse. Section II of the PASRR: Other indications for PASRR Screen Decision-Making, Question #5 documented that the resident did not have a primary diagnosis of dementia. For Question #6, Does the individual have a secondary diagnosis of dementia and primary diagnosis is an SMI (Suspected Mental Illness) or ID (Intellectual disability) there was no answer documented. Further review of the resident's record revealed that Resident #21 was diagnosed with dementia on 10/01/22. Resident #21's care plan documented: Resident has impaired cognitive function/dementia or impaired thought processes related to Dementia, Difficulty making decisions, Disease Process sequelae of cerebrovascular disease, bipolar disorder, depressive disorder, Impaired decision making, Short term memory loss, moderately impaired cognition. Date Initiated: 11/24/2023. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), with a reference date of 05/08/26, Resident #21's diagnoses included Dementia. Further review of the resident's electronic health record revealed no additional PASSR due to a new diagnosis of dementia that was identified on 10/05/21. During an interview, on 06/10/26 at 3:36 PM, with the Social Services Director, the Social Services Director acknowledged the findings. 2). Record review for Resident #99 revealed an admission date of 08/13/25. Resident's diagnoses upon admission included Dementia as a secondary diagnosis. Further review of the resident's record revealed diagnoses of Anxiety disorder and Psychotic disorder that were identified on 08/22/25. A PASRR Level I Screen, completed on 07/18/25 by a hospital Social Worker, documented the resident had an MI or suspected MI diagnoses, with findings based on documented history. A PASRR Level I Screen completed on 08/12/25 by the facility's Social Services Director documented the same as the original PASRR completed prior to admission. Another PASRR Level 1 Screen completed on 10/26/25 by an RN in the facility documented the resident had an MI or suspected MI that included Anxiety disorder and Psychotic disorder and that there was no secondary diagnosis of dementia. The resident's most recent Psychology Note documented, with a reference date of 08/25/25 documented a diagnosis of dementia with an onset date of 08/25/25. Further review of the resident's record revealed that there was no PASRR level I completed with all of the pertinent diagnoses and no Level II PASRR. During an interview, on 06/10/26 at 3:36 PM, the Social Services Director acknowledged the findings.

Based on observations, interviews and record review, the facility failed to provide tracheostomy care in accordance with professional standards of practice for 1 of 1 resident reviewed for Tracheostomy (Resident #3). The findings included: Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cerebrovascular Disease, Acute Respiratory Failure with Hypoxia, Cerebral Infarction, Tracheostomy Status. Physician orders showed an order dated 07/28/25 for Trach care every shift and as needed for Trach Status.During a Tracheostomy (Trach) observation conducted on 06/11/26 at 11:30 AM with Staff D, Licensed Practical Nurse (LPN), She stated she has worked at the facility since February 2026. She was assisted by Staff E, Respiratory Therapist (RT), who stated she is part-time and has worked at the facility for the last 2 months. Staff D and Staff E entered Resident #3's room, washed their hands and put on Personal Protective Equipment (PPE) including a mask. Staff D checked the suction tubing, attached the pulse oximeter to the left hand of the resident but was not getting any reading, then Staff E assisted and placed it on the right index finger and was able to get a reading of 96%. Staff D checked respirations with her stethoscope, which she then hung around her neck with the ends dangling in the front of her gown. She turned on the suctioning machine, removed gloves, did a quick wash of hands (less than 10 seconds) and put on clean gloves. She returned to the bedside and opened the suction kit, grabbed the box and poured the normal saline (NS) into it, removed the left glove and put on a sterile glove, grabbed the extended suction tubes from the kit and wrapped it around the left hand; then with the right (non-sterile) hand grabbed the suction tubing attached to the machine and connected it to the sterile extended tubing. Staff D suctioned Resident #3 as per protocol. She disconnected the tubes and wrapped the extended tubing into the sterile glove, removed gloves and discarded in the trash can. She again performed a quick hand wash, put on clean gloves and returned to the bedside. She opened the inner cannula container, twisted open 2 NS tubes and set them aside. Then she removed and discarded soiled dressing around the Trach. Staff D removed her gloves and did a quick hand wash (less than 10 seconds) and put on clean gloves. Then, she opened the Trach kit and removed her clean gloves and with her left hand picked out a sterile glove struggling to put it on all the way; then with her right non-gloved hand picked up the other sterile glove from inside the kit and again was struggling to put it on, then she used her left sterile gloved hand and grabbed the glove from the bottom to adjusted up the right hand, touching the inside of the right hand, contaminating the left hand. She continued to remove the sterile protector sheet which laid on top of the NS tubes; she used her right hand to grab the NS tubes from underneath and poured the solution in the kit container; then while using the left hand as the sterile hand used it to grab 4x4 pads and soaked in the NS and cleaned the right side of the neck, then discarded, returned to the table and grabbed another 4x4 pad soaked with NS and cleaned the left side of the neck and discarded the pad. Then, she used her right hand to hold down the Trach and with left sterile hand removed the soiled inner cannula and discarded; then with the left sterile hand grabbed the new clean inner cannula and inserted it. She then removed her gloves, performed a quick hand wash and put on clean gloves. She returned to the bedside table, discarded all the supplies, removed her PPE and gloves and turned off the suctioning machine and removed the Oximeter, however, did not clean the overbed table. After the Trach care, an interview was conducted with Staff D. She was asked about the technique to apply sterile gloves. She stated she did struggle with getting the gloves on. She stated she used the right hand as the non-sterile to hold the Trach plate and used the left sterile hand to remove the soiled inner cannula. Staff D stated she did not touch the inside of the soiled cannula therefore she was able to use the left sterile glove to insert the sterile inner cannula. On 06/10/26 at 1:09 PM an interview was conducted with the Director of Nursing (DON), who stated that she spoke with Staff D, and she acknowledged that she did use the sterile glove to remove a soiled inner cannula and without changing gloves and put in the clean inner cannula. The DON acknowledged that this is an educational moment.

Based on the observations, interviews and record review, the facility failed to disinfect the reusable vital signs machine between residents' usage for 3 of 5 residents observed for medication administration (Resident #79, #41 and #59); failed to follow infection control protocol during medication administration as evidence by dispensing medication into an ungloved hand observed during tour of the facility. The facility also failed to properly utilize hand hygiene and discard a used lancet after blood glucose check during medication administration observation for 1 of 1 sampled resident reviewed for blood glucose check observation (Resident #25); and failed to provide hand hygiene opportunities for 3 of 27 sampled residents observed during dining (Resident #21, Resident #26, and Resident #98).The findings included: The Director of Nursing (DON) stated the facility follows Centers for Disease Control and Prevention (CDC) guidelines for disinfecting vital signs machine and provided the following: https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html2. Cleaning of Patient-Care Devices: Clean medical devices as soon as practical after use (e.g., at the point of use) because soiled materials become dried onto the instruments. 4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices: Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). Review of the facility's policy titled, Nursing- Infection Control Prevention and Control Program, dated 08/20/25 with revised date 03/05/26, included the following: 7. Equipment Protocol:a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with current facility procedures governing the cleaning and sterilization of soiled or contaminated equipment. Review of the facility's policy titled, Administering Medications, dated 04/01/20 with a revised date 02/20/26, included the following: To ensure that medications are administered in a safe and timely manner, and as prescribed.General Guidelines: 9. The following information is checked/verified for each resident prior to administering medications: a. allergies to medications; and b. Vital signs, if necessary.23. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's policy titled, Hand Hygiene, dated 04/01/25 with revised date 03/04/26, included the following: 4. Additional Consideration: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 1) Record review for Resident #79 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Acute Respiratory Failure with Hypoxia, Pulmonary Fibrosis, Adult Failure to Thrive, Presence of Aortocoronary Bypass Graft. Physician orders showed an order dated 05/18/26 to take vital signs every shift for Monitoring. On 06/09/26 at 9:18 AM a medication administration observation was conducted with Staff B, Licensed Practical Nurse (LPN), who was being trained by Staff C, LPN from a sister facility [name provided]. Staff B stated they are going to administer medications to Resident #79 but first she will get his vital signs. Staff C was observed rolling the vital signs (VS) machine from the other hallway. Both nurses used the Alcohol based hand rub (ABHR) pump, entered Resident #79's room and Staff B took the blood pressure, pulse, temperature and oxygen saturation readings. Staff B then went and washed her hands while Staff C was standing by the door with the VS machine. They both exited the room and placed the VS machine next to the medication cart. Staff B dispensed and administered the medications for Resident #79, all this time the VS machine was by the medication cart and had not been cleaned. Staff B and Staff C returned to the medication cart and had issues with the computer and went to the nurses' station to document the medication administration for Resident #79. During this time, the surveyor waited by the medication cart and the VS machine, which had not been disinfected. Both nurses returned to the medication cart and showed the surveyor the documentation. Staff B was asked if there was another resident to administer medication to, she stated no. At this time, the surveyor moved further down the hallway but had a clear view of the VS machine which was still near the medication cart and neither nurse had disinfected the VS machine. At 10:31 AM Staff C was observed wheeling the VS machine near the nurses' station for charging, then went and sat at the nurses' station. A few minutes later Staff B joined Staff C at the nurses' station. The VS machine remained plugged in for charging with no indication of either staff was going to clean the machine. On 06/11/26 at 1:49 PM an interview was conducted with Staff B, LPN. She stated that the VS machine is to be cleaned using the EPA disinfectant wipes, located in the medication cart, after each use. Staff B was asked if the VS machine was cleaned after they used it on Resident #79; she stated she does not recall. 2) On 06/09/26 at 10:37 AM a tour of the facility was conducted by the 300's room hallway. Observed Staff F, LPN by the medication cart. Further observation revealed Staff F leaning over an opened medication drawer, holding a medication bubble card with her left hand and popped out a tablet into her right ungloved/bare hand then put it in the medication cup that was on top of the cart. She was then observed popping another tablet from the same bubble card and dumped it into the medication cup again. Then, Staff F noticed the surveyor and grabbed the medication cup, placed it under another medication bubble card and popped the tablet into the medication cup. On 06/11/26 at 2:30 PM a phone interview was conducted with Staff F, who confirmed meeting the surveyor. She then denied popping the medications into her hand and then dropping them into the medication cup until she saw the surveyor. She stated she is aware of the procedure of infection control and medication administration. Staff F sounded irritated throughout the phone call and then asked why the phone call. Staff F was told that the phone call was to confirm she was aware of the protocol and procedures. 3) Record review for Resident #25 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Type 1 Diabetes Mellitus and Acute Kidney Failure. Physician orders showed an order dated 05/01/26 for Lispro (Insulin) Injection Solution 100 Unit/ml, to inject subcutaneously as per sliding scale: if 150 - 200 = 2units; 201 - 250 = 4units; 251 - 300 = 6units; 301 - 350 = 8units; 351 - 400 = 10units; BS (blood sugar) greater than 400, give 12 units and call doctor, before meals and at bedtime for Diabetes Mellitus (DM). A Blood Glucose check observation was conducted on 06/10/26 at 4:05 PM for Resident #25 with Staff A, LPN, who stated she has worked at the facility for 18 months. She washed her hands then don on gloves, cleaned the glucometer, then she set the glucometer to the side to dry and removed the gloves. Then, without performing hand hygiene, Staff A removed the following supplies from the medication cart: alcohol wipes, 2 testing strips, 2 lancets, an 8 oz plastic cup and a 2x2 gauze. She set all the supplies next to the glucometer, knocked and entered Resident #25's room. Without performing hand hygiene, Staff A grabbed a pair of gloves from the wall and proceeded to check the resident's blood glucose (BG). Throughout the procedure she would put the used supplies such as alcohol wipe, lancet into the plastic cup. Once she had obtained the BG reading, she discarded the testing strip into the sharps' container located in the bathroom, then returned and discarded her gloves into the plastic cup. Staff A gathered the unused supplies which included the unused lancet and the plastic cup (with the used lancet) and discarded them in the regular trash can in the room. She washed her hands in the bathroom and exited the room. She returned to the medication cart and put on gloves and cleaned the glucometer and set it aside to dry, then removed gloves and proceeded to document Resident #25's BG reading in the computer without again performing hand hygiene. At this time, Staff A was asked about the used lancet. She stated she discarded it in the sharp's container. Staff A and the surveyor returned to Resident #25's room, where the used and unused lancets were found in the regular trash can. Staff A put gloves and removed the lancets and discarded them in the sharp container. She was then asked about what is the protocol for hand hygiene during a blood glucose check. She acknowledged not performing hand hygiene in between glove changes. On 06/10/26 at 4:50 PM the DON and the Assistant Director of Nursing (ADON) were made aware of the infection control concerns. 4) Review of the record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses which included Myocardial Infarction (Heart Attack caused by a partial blockage in one of the heart's arteries), Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes and Glaucoma. Review of the quarterly MDS dated [DATE] documented a BIMS score of 15, indicating the resident was cognitively intact. Review of the record revealed Resident #59 was admitted on [DATE] with diagnoses which included a Concussion with loss of consciousness, Epilepsy, Spastic Hemiplegic Cerebral Palsy and Cerebral Infarction with Hemiplegia and Hemiparesis of the right dominant side (Stroke resulting in paralysis, weakness and numbness of the right side). Review of the quarterly MDS dated [DATE] documented a BIMS score of 12 indicating moderate cognitive impairment. A medication administration observation was conducted for Resident #59 on 06/09/26 at 08:40 AM with Staff F, Licensed Practical Nurse (LPN). Staff F was observed taking the blood pressures of Resident #41 and Resident #59 who shared the same room. She used a vital signs monitor with a detachable blood pressure cuff. After taking the blood pressure for Resident #41, Staff F removed the cuff from the resident's arm and returned it to the monitor. She then used the same blood pressure cuff for Resident #59. Staff F did not disinfect the blood pressure cuff between the residents' use. During an interview conducted with the Director of Nursing and the Assistant Director of Nursing on 06/10/26 at 5:40 PM, they confirmed that using the same blood pressure cuff between residents was not proper practice for infection control. During an interview conducted with Staff F on 06/11/26 at 2:35 PM, when asked the policy for disinfecting equipment for residents' use. Staff F stated she knew the policy to disinfect the cuff between use but did not do it for Resident #41 and Resident #59. 5). During an observation of lunch served to the residents in the Main Dining Room, on 06/08/2026 at 12:38 PM, it was observed that the residents were served sandwiches on hoagie type rolls, with the intention that they would be eating the sandwiches with their hands. During the observation, it was noted that none of the residents were given an opportunity to perform hand hygiene prior to eating the sandwich with their hands and there was no evidence of staff using any type of hand sanitizing wipes. During an interview, on 06/08/2026 at 1:08 PM, Staff I, LPN, when asked about the residents being provided an opportunity to perform hand hygiene prior to eating with their hands, Staff I stated that the residents were cleaned during Activities of Daily Living (ADLs), but could not provide any details as to how long ago that was. 6). During an observation of lunch being served to the residents in their rooms on the 300 unit, on 06/08/2026 1:11 PM, it was observed that the residents were served sandwiches on hoagie type rolls, with the intention that they would be eating the sandwiches with their hands. During the observation, it was noted that none of the residents were given an opportunity to perform hand hygiene prior to eating the sandwich with their hands and there was no evidence of staff using any type of hand sanitizing wipes. During a room by room observation, on 06/08/26 at 1:19 PM, Residents #21, with a Brief Interview for Mental Status (BIMS) score of 11, indicating a moderate cognitive impairment, Resident #26, with a BIMS score of 15, indicating cognitively intact, and Resident #98, with a 15, the residents were asked about being given an opportunity to perform hand hygiene prior to being served the lunch, all stated that they were not provided the opportunity. At the conclusion of the room by room interviews, the DON acknowledged that she did not observe the staff providing residents with opportunities to perform hand hygiene prior to eating with their hands.

Based on interviews and record reviews, the facility failed to provide appropriate Notice of Medicare Non-Coverage (NOMNC) for 2 of 3 residents reviewed for liability notice (Resident #24 and #40). The findings included:1). Review of a NOMNC for Resident #24, on 06/11/26 at 12:15 PM, revealed a telephone notification to the resident's son on 05/15/26, that the last day of Medicare coverage would be on 06/01/26. It was noted that there was no signature on the notice to indicate that the resident's son received and understood the notice and the right to appeal the notice, as well as the instruction to appeal the notice. A Social Services Progress note, dated 05/15/26, documented, Note Text: SW notified Son and Patient that patient has a tentative discharge date of 6/2/26 so son can make any reservations to come down to Florida to assist patient with transportation to home and post discharge care. 2). Review of a NOMNC for Resident #40 revealed a telephone notification was provided to the resident's son on 05/19/26 that the last day of Medicare coverage would be 06/04/26. It was noted that there was no signature on the notice to indicate that the resident's son received and understood the notice and the right to appeal the notice, as well as the instruction to appeal the notice. Further review of the resident's record revealed that Resident #40 had a Brief Interview for Mental Status score of 15, indicating that the resident had no cognitive impairment. A Social Services Progress note, dated 05/19/26, documented, Note Text: SW spoke to Son Grant about confirmed Discharge plan due to Medicare Days running out on 6/4. It was notified that Patient would either go back home with one of the sons or move into Memory Care unit at an Assisted Living Facility. Son stated that he will speak with his brother and will call SW back. A Social Services Progress note dated 05/26/26 documented, Note Text: SW spoke to Son regarding discharge plan. Son stated that he will be taking patient home. During an interview, on 06/11/26 at 12:31 PM, with the Social Services Director (SSD), the SSD was shown the documents and acknowledged that there were no signatures on the notices provided to Residents #24's son and Resident #40's son, acknowledging that they received and understood the notice and the right to appeal the notices. The SSD stated that the Social Services Assistant (SSA) provided the telephone notifications to the families. The SSD acknowledged that there was no documentation that the parties understood the notices and their right to appeal the notices. During an interview, on 06/11/26 at 12:48 PM, with the SSA, when the Surveyor requested documentation that ensured the notices were received and understood by the families, the SSA acknowledged that the notices did not bear signatures of the parties that they were provided to. When asked why the notice was not provided to Resident #40, an alert and oriented resident with the ability to make his own health care decisions, the SSA did not provide an answer.

Based on observations, interviews and record reviews, the facility failed to provide meaningful activities for 1 of 3 residents reviewed for choices (Resident #21). The findings included:Record review for Resident #21 revealed an admission date of 09/11/20. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 05/08/26, Resident #21 had a Brief Interview for Mental Status score of 11, indicating a moderate cognitive impairment. The assessment documented that the resident was dependent upon staff for transfers and ambulation via manual wheelchair. Resident #21's diagnoses at the time of the assessment included: Anemia, Coronary Artery Disease, Orthostatic Hypotension, Cerebrovascular incident, non-Alzheimer's dementia, Seizure disorder, Depression, Bipolar disorder, Chronic lung disease, Hypothyroidism, Xerosis Cutis, Alcohol dependence in remission, Psoriasis Vulgaris, Psoriatic Arthropathy, Osteoarthritis, Gastro-Esophageal Reflux Disease, Cirrhosis of the liver. Resident #21's care plan for activities documented, Resident prefers not to attend group activities/limited group activities)due to: independent Choices: Dx: Cerebrovascular Disease However: Patient enjoyed past activities such as playing bingo, watching movies, sports, cell phone and spending time with family. Patient prefers to stay in bed most of the day. Patient enjoys conversation and snacking during his visits. Date Initiated: 02/17/2021 Revision on: 12/30/2024 The goal of the care plan was documented as, Resident will participate in 1:1 visits daily/weekly independent leisure activities of choice daily such as reading the newspaper, snacking, watching his favorite TV shows, spending time with family and face time visits. Date Initiated: 02/17/2021 Revision on: 03/30/2026 Target Date: 08/06/2026. Interventions to the care plan included: Provide supplies/materials for leisure activities as needed/requested Date Initiated: 02/17/2021 Revision on: 03/03/2022. Respect choice in regard to limited/ no activity participation Date Initiated: 02/17/2021 Revision on: 07/06/2021. An Activities Assessment, with a reference date of 02/09/21, documented: Importance of doing things with groups of people - Somewhat importantFavorite activities - somewhat importantGo outside - Somewhat importantReligious services or practices - not important at all A Psych Services note, dated 03/12/26 documented, BEHAVIOR: He depends on others to get self-care done. VERBAL CONTENT OF SESSION: Enjoyed loved getting to go to activities. Wants to go out again. A Quarterly Care Conference Record with a reference date of 05/28/26, documented, Activities: Continue to do 1:1 bedside/in-room visits and activities, very happy person to talk with. It was noted that there was no documentation of the resident being a part of the Quarterly Care Conference. During an interview, on 06/08/2026 at 11:54 AM, Resident #21 stated, They don't get me out of bed and I want to go to church. I saw the Activities calendar and there is a lot of things that I would like to do or at least watch if they would get me out of bed. A review of the Activities calendar for the current month and the previous month revealed religious services on a weekly basis as well as live entertainment on a weekly basis. During a follow up interview on 06/11/2026 at 11:20 AM, Resident #21 stated that he is Christian, 'They don't get me out of bed and take me to church on Sundays. The resident further stated he has not been out of bed for approximately 2 months. During an interview, on 06/11/2026 at 11:35 AM, with the Activities Director for three months, when asked about Resident #21 participating in religious services and live entertainment, the Activities Director replied, Every time I am on that side, I pick out some songs on my phone and we listen to music. I mentioned that if they would put him in a wheelchair when the weather was nice, he would like to go outside. We keep on encouraging him to get out of bed and we see him 1:1 and offer him books, newspaper and something that he would be interested in. I try to do an assessment quarterly and annually. we ask questions about what he likes or what he wants to do. The Activities Director was unable to provide documentation of Resident #21 being a part of the Activities Assessment or any other assessment for Activities. During an interview, on 06/11/26 at 3:11 PM, with Staff G, RN, when asked about Resident #21 being out of bed, the RN replied, Only to change the sheets. We did them the day before yesterday. He doesn't like to get out of the room and do activities. He is a 2 person mechanical lift. During an interview, on 06/11/26 at 3:14 PM, with Staff H, CNA, when asked about Resident #21 being out of bed, the CNA replied, He refused yesterday. When asked about being out of the bed when changing the bed linens, the CNA stated that after the sheets were changed, the resident was placed back into the bed. The CNA was unable to provide details of the resident being out of bed and attending activities when asked.

Based on observation, interview, and record review the facility failed to implement and have Enhanced Barrier Precaution (EBP) orders for Residents with active wounds for 3 of 4 sampled residents, Residents #2, #3, and #4. The findings included: Review of the policy titled Policy, Procedures, and Information Enhanced Barrier Precautions revised on 04/03/24 documented, Definitions: Enhanced Barrier Precautions refers to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms (MDROs.) . 1. Prompt recognition of need: . B. Clear signage will be posted in the room indicating the type of precaution, requiring personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Selected image/identifier (image of orange) placed above the bed .2. Initiation of Enhanced Barrier Precautions- . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc) regardless of MDRO colonization status .3. Implementation of Enhanced Barrier Precautions- a. Make gowns and gloves available inside the resident's room . e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. 1.Review of the record revealed Resident #2 was admitted to the facility 04/01/25. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS also documented the Resident had an unhealed stage 2 pressure ulcer and was receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly.) Review of Resident #2's active orders documented as followed: Wound Consult for Open Area to Buttocks; Cleanse Sacral Pressure Ulcer (Stage 2) . Dressing Change Daily and PRN (as needed); Hemodialysis- Assess site (right chest) for bruising / bleeding / symptoms of infection. There were no EBP orders reviewed. Review of the care plan dated 04/15/25 documented Resident #2 has pressure injury to sacral area . Intervention/Tasks: . Follow facility policies/protocols for the prevention/treatment of skin breakdown. During an observation and interview on 05/13/25 at 9:09 AM, there were no EBP signs or PPE observed outside or inside Resident #2's room. When asked if staff wear a gown when provided direct care, the Resident stated No, I don't think so. 2.Review of the record revealed Resident #3 was admitted to the facility 02/11/25. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10, on a 0 to 15 scale, indicating the resident was moderately cognitively impaired. This same MDS also documented the Resident had multiple unhealed pressure ulcers and had a suprapubic catheter. Review of Resident #3's active orders documented: Cleanse sacral wound . daily and PRN; Cleanse left heel . daily and PRN; Cleanse left heel . daily and PRN; Cleanse right ankle . three times per week and PRN; Urinary Catheter No EBP orders were revealed upon review. Review of the care plan dated 03/04/25 documents, Resident #3 requires Enhanced Barrier Precautions r/t: Foley Catheter . Goal: will maintain precautions as directed .Interventions/Tasks: . Resident requires Enhanced Barrier Precautions. Follow precaution signage and protocol .Resident #3 has pressure injuries to Left Heel, Right Heel, Sacral pressure injury r/t Impaired mobility . Interventions/Tasks: Follow facility policies/protocols for the prevention/treatment of skin breakdown. During an observation on 05/13/25 at 9:14 AM, there was an EBP sign and PPE inside Resident #3 room. When asked if staff wear a gown when providing direct care Resident #3 stated, No, I haven't seen it. 3. Review of the record revealed Resident #4 was admitted to the facility 12/18/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 07, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This same MDS also documented the Resident had unhealed pressure ulcers. Review of the active orders revealed: Cleanse Rt Heel Pressure Ulcer . Change Daily and PRN; Cleanse Sacral area .keep Sacral clean and dry and as needed. No EBP orders were revealed. Review of the care plan dated 04/10/25 documented, Resident #4 has a pressure injury to Right heel r/t impaired mobility, Impaired cognition . Interventions/Tasks .Follow facility policies/protocols for the prevention/treatment of skin breakdown. During an observation on 05/13/25 at 9:24 AM, an EBP sign and PPE was observed inside Resident #4's room; an interview was not conducted due to the Resident's cognitive abilities. An interview was conducted on 05/13/25 at 12:25 PM with the Infection Preventionist. When asked what residents should be on EBP, the Infection Preventionist stated, Anybody with a hole in their body that god did not create-IVs, Wounds, Catheters, G-tubes, Trachs. During a side-by-side review of Resident #2,#3, and #4's electronic medical record, the Infection Preventionist agreed that all stated Residents should have had an EBP order; she stated she had no additional information to add.

Based on observation, interview, and record review the facility failed to provide nail care to 3 of 4 sampled Residents, Resident #2, #3 and #4. The findings included: Review of their policy titled Nursing-Activities of Daily Living (ADLS) effective 04/01/22 documented Procedure: 1. The facility shall ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living 2. The facility shall provide care and services for the following activities of daily living as needed based on the individual care plan of each resident: . a. Hygiene-bathing, dressing, grooming, and oral care . 3. A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of the record revealed Resident #2 was admitted to the facility 04/01/25. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the care plan dated 04/15/25 documented Resident #2 has an ADL self-care performance deficit r/t Impaired balance, Limited Mobility . Interventions/Tasks . Personal Hygiene/Oral Hygiene: The resident requires (supervision/limited assistance) by (1) staff with personal hygiene and oral care. During an observation and interview on 05/13/25 at 9:09 AM, Resident #2 was seen to have long nails. When asked if the resident received nail care by staff, Resident #2 stated they only cleaned her nails. When asked if she would also like her nails to get cut, she stated Yes, sometimes I want them cut. During an interview on 05/13/25 at 12:20 PM, when asked who is responsible for providing nail care, Staff C, Certified Nursing Assistant (CNA) stated that the CNAs were responsible. When asked how often nail care was provided, Staff C stated, As needed and explained there was no time frame for it. Resident #2 concerns were reported and Staff C agreed; she stated she would provide her with nail care. 2. Review of the record revealed Resident #3 was admitted to the facility 02/11/25. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10, on a 0 to 15 scale, indicating the resident was moderately cognitively impaired. Review of his care plan dated 03/04/25 documented, Resident #3 has an ADL self-care performance deficit r/t: weakness, impaired mobility . Interventions/Tasks .Personal Hygiene: The resident requires set up assistance by 1 staff with personal hygiene and oral care. During an observation on 05/13/25 at 9:14 AM, Resident #3 was observed with dirt-encrusted and unkempt nails. During an interview on 05/13/25 at 12:09 PM, when asked who is responsible for providing nail care to the residents, Staff A stated everyone was responsible including CNAs, Nurses and CNAs in activities. When asked how often she provided nail care, Staff A stated anytime they need it; daily if needed. Staff A was brought into Resident #3's room to observe his nails. Staff B, Certified Nursing Assistant (CNA assigned to Resident #3 care for the day) was seen walking into the Resident's room as well. During an interview on 05/13/25 at 12:15PM, when asked who is responsible for providing nail care and how often, Staff B stated the CNAs were responsible and they provided it when needed and approximately every 3 days. Staff A walked out of Resident #3's room during the observation and stated she had to attend to another Resident. Staff B observed Resident #3's nails and agreed they were dirty and needed to be cleaned. 3. Review of the record revealed Resident #4 was admitted to the facility 12/18/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 07, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. Review of the care plan dated 04/10/25 documented, Resident#4 ADL self-care performance deficit r/t pulmonary fibrosis, dementia, impaired balance, impaired mobility function . Interventions/Tasks: The resident requires dependent assistance by 1 staff with personal hygiene and oral care. During an observation on 05/13/25 at 9:24AM, Resident #4 was observed to have heavy dirt encrusted nails. During an interview on 05/13/25 at 12:20 PM, when asked who is responsible for providing nail care, Staff C, Certified Nursing Assistant (CNA) stated that the CNAs were responsible. When asked how often nail care was provided, Staff C stated, As needed and explained there was no time frame for it. Resident #4's nails were observed alongside with Staff C, she agreed that Resident #4's nails were dirty and needed to be cleaned.

Based on observations, interviews and record review, the facility failed to identify a severe weight loss in a timely manner, and failed to provide adequate nutritional supplements to prevent further severe weight loss, for 2 of 6 residents reviewed for nutrition (Resident #52 and Resident #56). The findings included: A review of the facility's policy titled, Nursing-Weights, revised on 02/21/23, showed that Weight monitoring schedules should be developed upon admission for all residents: Weights should be recorded timely. For Newly admitted residents' weights should be obtained and measured on admission and weekly for 4 weeks. If no weight concerns are noted, weights should be measured monthly thereafter or per Registered Dietician and or physician recommendations. Residents with weight loss should monitor their weight weekly or per physician's order until it is stable, then monthly. A significant change in weight is defined as a 5% change in weight in a month (30 days), a 7.5% change in weight in 3 months (90 days), and a 10% change in weight in 6 months (180 days). A review of the facility's policy titled Medical Nutrition Therapy-Assessment and Care Planning, revised on 09/2017, showed that the Registered Dietitian will be responsible for ensuring follow-up and appropriate documentation of recommended changes in the plan of care. 1. Resident #52 was admitted to the facility on [DATE] with diagnoses of Cognitive Communication Deficit, Muscle Weakness, and Anoxic Brain Damage. The Admission Minimum Data Set (MDS) dated [DATE] showed that Resident #52 had a Brief Interview of Mental Status score (BIMS) of 03, which is severely impaired. Section GG of this MDS showed that Resident #52 needs partial to moderate assistance for eating. A review of the Physicians' orders revealed an order for Regular, Consistent Carbohydrates with thin liquids dated 12/14/24 and a Sugar snack at bedtime for Diabetes support dated 12/19/24. No orders were noted for nutritional supplements. In an observation conducted on 02/03/25 at 1:31 PM, Resident #52 was eating his lunch tray in his room. Resident #52 was in the room with no staff present and was observed attempting to eat his lunch meal but was not able to bring his left hand to his mouth. His left hand was shaking uncontrollably as he tried grabbing his food with his bare hand. In an observation conducted on 02/04/25 at 8:36 AM, Resident #52 was in his room eating his breakfast tray. No staff was noted in the room to help Resident #52 with his breakfast meal. Continued observation at 8:48 AM showed Resident #52 attempting to eat on his own with the utensil but was not able to pick up the food as his hand was shaking uncontrollably. He started using his hands to scoop the eggs on the plate. A large portion of the eggs were noted all over his bedding and clothes. A review of Resident #52's weight history revealed the following: Admission weight of 182.6 pounds on 12/14/24. A weight of 174.6 pounds on 12/30/24. A weight of 174.6 pounds on 01/08/25. A weight of 170.2 pounds on 01/29/25. This showed a 6.7% weight loss in about 6 weeks. The Initial Nutrition Evaluation dated 12/19/24 showed the following: Resident #52 eats independently, with set-up eating recorded. Meal intake is between 51% and 100% of his meals. Goals are in place to monitor weights and encourage meal intake. The next nutrition follow-up note dated 12/31/24 showed the following: Monitoring recently obtained weight for weight loss vs discrepancy. Resident #52's mom indicated that he had a poor appetite in the hospital and believed he lost weight. Resident #52 is consuming between 51% to 100% of his meals since admission and to continue monitoring. No other interventions were put in place. No follow-up nutritional note was completed after 12/31/24 addressing the weight loss of 6.7% from 12/14/24 to 01/29/25. The care plan initiated on 12/27/24 showed the following: Resident #52 has nutritional problems and is at risk for malnutrition. He will maintain adequate nutritional status, as evidenced by maintaining weight within 5% of his Current Body Weight. Interventions included to monitor significant weight loss of 3 pounds in one week, 5% in one month, 7.5% in 3 months or over 10% in 6 months. Registered Dietitian will evaluate and make diet change recommendations. It further showed that Resident #52 has a self-care deficit and that he requires partial to moderate assistance of one person with feeding. In an interview conducted on 02/5/25 at 1:30 PM with Resident #52's mother, she said that she lives out of state and that she comes to visit her son every few months. He had a stroke that damaged his right hand, and he normally uses his left hand, which is his good hand. She arrived this morning after not seeing him for some time and noticed that his left hand was shaking uncontrolled and that he was not able to eat on his own. He was not able to hold his drink, and she had to cut up the food into pieces to make it easier for him to eat. She then said, I watched him struggling, and it broke my heart. Resident #52's mom stated she could tell that her son lost a lot of weight and said, I am mostly upset about the weight loss. Resident #52's mom said that she would speak to the Unit Manager regarding his weight loss. In an interview conducted on 02/05/25 at 1:50 PM with Staff K, Certified Nursing Assistant (CNA), she stated Resident #52 can eat on his own, makes a little mess when eating, and sometimes messes up his clothes. According to Staff K, Resident #52 eats well with little help and reaches for his food on the plate with his bare hands. When asked if his left-hand shakes, she said no. In an interview conducted on 02/05/25 at 1:55 PM, with Staff L, Licensed Practical Nurse, stated that Resident #52 needs supervision when he eats because he tends to make a mess. In an interview conducted on 02/5/25 at 2:15 PM with Staff H, the MDS Coordinator stated that partial to moderate assistance during eating means that Resident #52 always needs a staff member in the room while eating and that the staff would do less than 50% of the work. Staff needs to help Resident #52 with his drink, utensil, and encouragement. In an observation conducted on 02/05/25 at 3:50 PM, Staff J, CNA, was asked to take the weight on Resident #52 by this Surveyor. She used a chair scale to take the weight and calibrated the scale to 0 before placing Resident #52 on the scale. A new weight showed that Resident #52 was at 162.8 pounds. This showed an additional weight loss of 7.2 pounds from 01/29/25 (170 pounds) to 162.8 pounds on 02/05/25. The overall weight loss showed a severe weight loss of 10.8% in less than 2 months. In this observation, Staff J stated that the list of all weekly and monthly weights is written on a piece of paper and given to the facility's Dietitian. A nutritional follow-up note dated 2/05/25, written at 2:49 PM, showed the following: the Registered Dietitian was made aware the Resident's mother had questions about weight status and requested large portions. Weight statuses were reviewed, and the mother was explained that a natural calorie deficit may occur on a standard facility diet, which is about 2000 calories a day, whereas at home the diet may be over 2000 calories a day. In this note, the Clinical Dietitian documented that Resident #52 was trending towards normal Body Mass Index (BMI), which was beneficial to support Resident #52 and current conditions. On this note, new recommendations were made to provide a large portion for the lunch meal and a large portion of vegetables for the dinner meal. No nutritional supplements were added, or weekly weights were ordered to monitor Resident #52's trending weights. An interview was conducted on 02/05/25 at 4:35 PM with the facility's Registered Dietitian. She stated the Certified Nursing Assistants take the weights of the residents they are assigned to. They write the weights on a piece of paper, and it is then given to her to place them in the electronic system. When she receives the weights, she can see the weight loss compared to previous weights or by looking at the residents themselves. For any weight loss, she will provide nutritional interventions on the same day or no later than 48 hours. When asked about Resident #52, she noticed the downward trend when she put the weight of 170.2 pounds into the system. Since she was unsure that his weight was accurate on admission at 182.6 pounds, she was not overly concerned that the weight dropped to 174.6 pounds. When she noticed the additional drop in weight to 170.2 pounds, she made a metal note to follow up on Resident #52 and visited the Resident but did not write a follow up note. According to the Registered Dietitian, Resident #52 was eating well and was eating all his meals, and monthly weights were going to be monitored and reviewed. During this entire interview, the Registered Dietitian was not aware of or told by Staff J that Resident #52's weight was taken earlier at 3:50 PM, which showed a severe weight loss of 10.8%. In an interview conducted on 02/05/25 at 5:10 PM with the Rehab Director, she stated that Resident #52 met his goal of eating with set up only on 01/10/25. He is still receiving occupational therapy (OT), but since eating was not one of his goals, he was not watched during mealtimes. If Resident #52 had tremors or decreased in strength, that would have noticed it. Looking at him today, she noticed he looked more tired than usual and noticed a decrease in overall strength. They have noted the spilling of food before, but not to the extent of what she was hearing today. In an observation conducted on 02/06/25 at 9:00 AM, Staff K was in the room feeding Resident #52's breakfast meal. Resident #52 seemed very receptive to the help and did not object when Staff K was feeding him his breakfast meal. In an interview conducted on 02/06/25 at 9:27 AM with the Registered Dietitian (RD), she stated that she observed Resident #52 eating in the past and did not remember seeing him shaking or spilling his food. The RD noted that the weight loss may be due to the caloric deficit that could have contributed to gradual weight loss since the diet in the facility is around 2000 calories a day, and the diet provided at home could have been over 2000 calories a day. She told Resident #52's mother that next month, they will see what the weight is, and if it continues to decline, she will put Resident #52 on weekly weights and provide him with Health Shakes (nutritional supplements). According to the RD, Resident #52's mom did not tell her that Resident #52 was shaking uncontrollably and unable to eat independently. When asked by this Surveyor why she did not put Resident #52 on weekly weights, she stated that she would weigh him this month and see if there was a further decline in weight. The RD was still not aware of the new weight of 162.8 pounds, which was taken yesterday by Staff J. In an interview conducted on 02/06/25, at 10:18 AM, with Staff N, the Registered Nurse stated that she noticed Resident #52's hand shaking this past Monday and that she had not seen his hand shaking before. He usually eats by himself and does not need assistance with eating. In an interview conducted on 02/06/25 at 10:30 AM with Resident #52's Mother, she stated that she was told by a staff member yesterday that he spilled most of his breakfast meal and his coffee all over himself. She further said that she spoke to the Clinical Dietitian on the phone yesterday and told her she was worried about her son's weight. She told the Dietitian that her son's hand was shaking and that he had spilled half of his food on himself. The Clinical Dietitian told her that she would increase the amount of food and that she would follow up on his weight at the end of the month. Resident #52's mother said to this Surveyor, I was wondering if he lost weight because half of his meals were on his lap. In an interview conducted on 02/06/25 at 11:13 AM with Staff O, Certified Occupational Therapy Assistant, she stated that she has been working with Resident #52 since his admission on 12/14/24. He has always had some tremors on his left hand. She considered it part of his neurological condition but did not have anything interfering with his Activities of Daily Living (ADLs). She saw him yesterday and noticed his tremors, which had gotten worse. This was nothing like before, and these new symptoms impeded his eating abilities. She further stated that Resident #52 had a can of soda and was not able to bring the can of soda to his mouth. In an interview conducted on 02/6/25 at 3:25 PM with Staff J, she told Staff S, Registered Nurse, about the weight of 162.8 pounds but did not report the weight to the Registered Dietitian. She did not see the RD, so she gave the weight report to Staff S. In an interview conducted on 02/6/25 at 3:44 PM with Staff S, she stated that Staff J told her that she took the weight on Resident #52 as per this Surveyor's request. Staff S said that she was told by Staff J that Resident #52 was 162.8 pounds. She further reported that she did not put any weight in the electronic system and did not report the new weight to the RD because it was late in the day when the weight was taken. When asked if she told the RD about the weight this morning, she said no. In an interview conducted on 02/06/25 at 4:00 PM with the facility's Administrator, she was informed of the findings. 51663 2. A record review showed that Resident #56 was admitted on [DATE] with diagnoses that included Alzheimer's disease, Anxiety, Depression and Rhabdomyolysis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 2, which indicated severe cognitive impairment. Review of Resident #56's Care plan, dated 11/1/2024, for nutritional problems related to medical diagnoses, therapeutic restricted and textured consistency diet, history of variable oral intake. The goal was the resident will maintain adequate nutrition/hydration status. Interventions included: -Administer medications as ordered. -Encourage and assist with setup/intake of meals as needed. -Monitor/document/report any signs of dysphagia. -Monitor/record/report to doctor signs of malnutrition: Significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. -RD to evaluate and make diet change recommendations PRN. -Weights per facility policy. A review of the weight log for Resident #56 showed the following: 1/28/2025 16:22 139.8 Lbs 1/21/2025 07:53 140.2 Lbs 1/14/2025 13:47 139.6 Lbs 1/3/2025 12:48 141.2 Lbs 12/11/2024 10:49 145.0 Lbs 11/7/2024 09:30 160.8 Lbs 10/4/2024 15:02 164.3 Lbs 9/6/2024 12:40 162.3 Lbs 8/1/2024 10:06 159.0 Lbs This showed a weight loss of 15.8 pounds, or a 9.8% severe weight loss in one month between 11/7/24 and 12/11/24. Resident #56 had an overall trending weight loss of 12% from 08/1/2024 to 01/28/2025 (past 6 months). A review of the Dietary progress note dated 12/11/2024 (the day the 9.8% weight loss was identified) revealed the Registered Dietitian stated that Resident #56 meal intake was less than 50% per review over the past 30 days. Resident #56 received Eldertonic QD to TID (once a day to three times a day) for appetite support, fortified food QD (once a day) for nutrition support, encouraged extra oral hydration and continue to monitor protocol prn (as needed). A review of the Dietary progress note dated 01/03/2025 (23 days after the 9.8% weight loss was identified) revealed the Registered Dietitian (RD) stated that Resident #56 continues with trigger for weight loss of 23.1 pounds which representant a 14% of weight loss in 3 months. The progress note further revealed that weekly weight monitoring was difficult for staff members due to behaviors and the meal intake was recorded as more than 50% but less than 75-100% for three meals daily. Resident #56 received house shake BID (twice a day) for nutrition. A review of Resident #56's Physician's orders showed the following: House Supplement Shake once a day started on 01/22/2025 and was increased to twice a day on 01/27/2025. No orders were noted from 12/11/2024 to 01/22/2025. In an observation conducted on 02/03/2025 at 1:30 PM Resident #56 tray's consisted of chicken pot pie with 1 biscuit, 1/2 cup of green peas, 1/2 cup of deluxe fruit salad, 6oz of tea and 4oz of apple juice but no 1/2 cup of fortified mashed potatoes as indicated on the meal ticket. In an interview conducted on 02/05/2025 at 4:05 PM, the Registered Dietitian (RD) stated sometimes there is discrepancy between care plans and orders because Point Click Care (PCC) doesn't communicate the order of the shakes with the system. RD further stated, after reviewing the interventions put in place on 01/03/2025, that she forgot to put in the order for the House Shake once a day. It must have slipped her mind to put in the order after the note. The resident started getting House Supplement Shakes on 01/22/2025.

Based on observations, interviews, and record review, the facility failed to follow their posted scheduled mealtime for tray deliveries on 2 out of 2 observations. The findings included: 1. In an observation conducted on 02/03/2025 between 12:00 PM and 2:00 PM this surveyor observed discrepancies between the stipulated lunch tray's arrival time and the actual arrival time. The lunch trays stipulated arrival time were as follow: Main Dining Room: 12:00 PM, Assisted Dining Room: 12:10 PM, 100 Hall: 11:30 AM, 200 Hall: 11:40 AM, 300 Hall: 11:50 AM. The lunch trays actual arrival time were as follow: Main Dining Room: 12:52 PM, Assisted Dining Room: 1:10 PM, 100 Hall: 1:15 PM, 200 Hall: 1:43 PM, 300 Hall: 1:38 PM. 2. In an observation conducted on 02/04/2025 between 11:30 PM and 12:30 PM this surveyor observed discrepancies between the stipulated lunch tray's arrival time and the actual arrival time. the lunch trays stipulated arrival time were as follow: Main Dining Room: 12:00 PM, 500 Hall: 11:50 AM, 600 Hall: 11:40 AM, 700 Hall: 11:30 AM. The lunch trays actual arrival time were as follow: Main Dining Room: 12:25 PM, 500 Hall: 12:00 PM, 600 Hall: 11:53 AM, 700 Hall: 11:50 AM. 40153 3. Resident #7 was admitted on [DATE] with a diagnosis of Parkinson's and muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status Score (BIMS) score of 15, which is cognitively intact. In an interview conducted on 02/03/25 at 12:42 PM, Resident #7 stated that the lunch meals are always late and usually arrive at the Main dining room between 12:30 PM and 1:00 PM and sometimes past 1:00 PM. 4. A record review revealed that Resident #269 was admitted to the facility on [DATE] with diagnoses of Muscle Weakness and Difficulty Walking. The MDS dated [DATE] revealed that Resident #269 had a BIMS score of 15, which is cognitively intact. In an interview conducted on 02/03/25 with Resident #269, at 1:09 PM, it was stated that the food comes late on the 300 Unit all the time, and it is not unusual for the trays to arrive around 1:30 PM. In an interview conducted on 02/05/25 at 11:45 AM with the kitchen District Manager, she stated that the timing of the meals was changed a while ago. She changed them for the breakfast and dinner meals but forgot to change them for the lunch meal on 02/3/35.

Based on observations, interviews, and record review, the facility failed to treat the resident in a dignify manner and provide personal privacy, for 1 of 16 residents observed during the screening process (Resident # 108). The findings included: Record review for Resident #108 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side and Urinary Tract Infection. The admission Minimum Data Set (MDS) assessment entry dated 01/08/2025 revealed that the Brief Interview of Mental Status (BIMS) score is 99, which indicates that resident is unable to complete the interview. A review of the section GG of the MDS revealed Resident #53 is fully dependent regarding the ability to roll from lying on back to left and right side, and return to lying on back on the bed. During an observation conducted on 02/03/2025 at 9:50 AM Resident #108 was seen laying on her bed with the door open. Resident was seen playing with her foley catheter and without underwear or covered with a blanket. During another observation conducted on 02/03/2025 at 12:20 PM Resident #108 was seen laying on her bed with the door open. Resident was still uncovered nor wearing underwear. During an interview conducted on 02/05/2025 at 1:30 PM with Staff I, Certified Nursing Assistant (CNA) she stated that dignity and privacy are very important. She has been working in this facility for [AGE] years. Very important to never expose residents. CNA further stated that the door has to be close when they are providing care or changing a resident. The CNA also said that resident should always wear underwear specially if they are not entirely conscious.

Based on observations, interviews, and record review, the facility failed to monitor behaviors and side effects for a Resident on psychotropic medications in 1 of 5 residents reviewed for Unnecessary Medication (Resident #52). The findings included: A record review showed that Resident #52 was admitted to the facility on [DATE] with diagnoses of anxiety disorder and major depressive disorder. The Admission Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #52 had a Brief Interview of Mental Status score (BIMS) of 03, which is severely impaired. A review of the Physicians'orders showed an order for Lorazepam (anxiety medication) 0.5 milligrams, give 1 tablet by mouth two times a day which was dated 01/17/25. An order for Paroxetine Tablet 20 milligrams, give 1.5 tablet one time a day for depression which was dated 12/14/24. The Care plan dated 12/31/24 revealed the following: Resident #52 uses anti-anxiety medication related to anxiety. Administer medication as ordered and monitor for side effects. Monitor/record the occurrence of target behavior symptoms and document per facility protocol. It further showed that Resident #52 uses antidepressant medication related to depression. Administer antidepressant medicines as ordered by the physician and monitor/document side effects and effectiveness every shift. A review of the Medication Administration Record for the months of December 2024 and January 2025, did not show that Resident #52 ' s behaviors or side effects were being monitored. An interview was conducted on 02/05/25 at 1:55 PM with Staff L, Licensed Practical Nurse. She stated that any residents on anti-anxiety and antidepressant medications they monitor the behaviors and side effects of the medicines. This is documented in the Medication Administration Record of the electronic system. When asked if Resident #52 was being monitored for side effects and behaviors, she said yes. She proceeded to look in the electronic chart but could not show this Surveyor any documentation regarding the side effects and behavior monitoring for Resident #52. In an interview conducted on 02/06/25 at 4:00 PM with the facility's Administrator she was informed of the findings.

Based on observations, interviews, and record review, the facility failed to properly follow hand hygiene protocol during respiratory treatments and failed to handle medications in a sanitary manner while dispensing medications for 2 of 5 sampled residents reviewed for medication administration (Resident #90 and #79). In addition, the facility failed to follow sanitary procedures for disconnecting dialysis treatment for 1 of 1 sampled resident reviewed for dialysis (Resident #101). The findings included: Review of the facility's policy titled, Administering Medications, revision date 02/21/23, included the following: To ensure that medications are administered in a safe and timely manner, and as prescribed. General Guidelines: 3.Medications are administered in accordance with prescriber orders, and current standards of practice. a. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 1) Record review for Resident #90 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Shortness of Breath. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #90 had a Brief Interview for Mental Status of 15, which indicated that she was cognitively intact. During a medication administration observation conducted on 02/04/25 at 8:46 AM with Staff C, Unit Manager and Licensed Practical Nurse (LPN), who stated she would start Resident #90 on the respiratory treatment via nebulizer prior to dispensing the oral medications. Without performing hand hygiene (HH), Staff C gathered the respiratory treatment and entered the room. She did not wash her hands nor don on gloves and went to the nebulizer machine located on the bedside table and grabbed the mask and assisted Resident #90 to put on the mask. Staff C returned to the medication cart without performing HH and opened the cart and began dispensing the medications for Resident #90 including an inhaler. Without performing HH, she again entered the resident's room, gave the inhaler to Resident #90. After the resident finished with the inhaler, Staff C took the inhaler back from the resident and returned to the medication cart, again no HH was observed. Then, Resident #90 mentioned to Staff C that she must rinse her mouth after using the inhaler and needed a cup of water. Staff C handed a cup of water to Resident #90 and the resident rinsed her mouth and spit the water back into the cup. Staff C donned a glove on her right hand and took the cup and discarded the water in the bathroom sink and at that moment washed her hands. During an interview conducted on 02/04/25 at 9:15 AM, Staff C, stated she has worked at the facility for 8 years. She acknowledged she did not sanitize her hands as much as she should during the medication administration for Resident #90. Staff C then stated she did wash her hands once during the observation. 38349 2) Resident #79 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Major Depressive Disorder and Anemia. He had a Brief Interview Mental Status (BIM) score of 14, indicating no cognitive impairment. During a Medication Administration Observation which began on 02/03/25 at 9:37 AM with Staff D, Registered Nurse (RN), she was observed touching four (4) different oral capsule and pill medications (some stored in bottles and some in Bingo paks), directly with her gloved hand for Resident #79. Staff D consecutively prepared all above four (4) of Resident #79's medications with her gloved hands while touching both the pills and capsules directly with her gloved hand, prior to placing them in the medication cup. On 02/03/25 at 9:42 AM the Medication Administration Observation conducted with Staff D, included this medication: 1) Eliquis 5mg one (1) tablet was ordered twice a day (BID). Staff D, was observed preparing this medication. She subsequently dropped this tablet on the top of the 600 hallway medication cart and discarded it. However, Staff D, was then observed touching the tablet directly with her gloved hand after having popped it out of the Bingo pack; instead of first placing the pill medication in the cap and then transferring it to the medication cup. Then, on 02/03/25 at 9:43 AM Staff D, was observed preparing these medications: 2) Fluoxetine 10mg two (2) capsules were ordered daily. Staff D, was observed touching the capsules directly with her gloved hand after having popped them out of the Bingo pack; instead of first placing the capsule medications in the cap and then transferring it to the medication cup. Next, on 02/03/25 at 9:44 AM Staff D, was observed preparing this medication: 3) Folic Acid one (1) tablet ordered daily. Staff D, was observed touching the tablet directly with her gloved hand, and then placing it directly into medication cup; instead of first placing the pill medication in the cap and then transferring it to the medication cup. Finally, on 02/03/25 at 9:45 AM Staff D, was observed preparing this medication: 4) Midodrine 10mg one (1) tablet ordered three times per day (TID). Staff D, was observed touching the tablet directly with her gloved hand after having popped it out of the Bingo pack; instead of first placing the pill medication in the cap and then transferring it to the medication cup. During an interview conducted on 02/03/25 at 9:46 AM with Staff D, she acknowledged that she should not have touched Resident #79's medications directly with her gloved hand. On 02/04/25 at 3:05 PM an interview was conducted with Staff C, Licensed Practical Nurse/Unit Manager/(LPN)/(UM), for the 400, 500, 600 and 700 hallways,, in which she acknowledged that the nurses' gloved hand should not have touched Resident #79's medications. The DON, further recognized and acknowledged on 02/04/25 at 3:17 PM that Resident #79's medications should not have touched the nurses' gloved hand and should have been transferred directly into the medication cup; this was not done. 40153 3. A record review revealed that Resident #101 was readmitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Anemia, and Psychotic Disorder. A review of the Physicians' orders revealed an order for in-house hemodialysis dated 02/01/25. In an observation conducted on 02/5/25 at 12:25 PM, Staff M, Patient Care Technician, was in the dialysis room performing the disconnection of the Central Venous Catheter (CVC) dialysis site on Resident #101. She was observed sanitizing her hands and putting on a pair of cleaned gloves. She then touched the hand sanitizing bottle, moved it from one side to the other, and proceeded to disconnect the dialysis access site with the same gloves. She did not practice hand hygiene and changed gloves after touching the hand sanitizing bottle.

Based on observations, interviews and record reviews, the facility failed to provide the correct diet consistency for the Pureed diet for 3 out of 12 residents observed on pureed diet (Resident #35, Resident #102 and Resident #108). The findings included: A review of the facility's policy titled ASHAWIRE showed the following: National Dysphagia Diet (NDD) published in 2002 proposed four levels of semisolid/solid foods with level 1 being the pureed consistency. NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability). 1. A record review showed that Resident #35 was admitted on [DATE] with diagnoses of Atrial Fibrillation and Gastro-Esophageal Reflux Disease without Esophagitis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score showed that Resident #35 was unable to conduct the interview. During an observation conducted on 02/03/25 at 1:50 PM in the main dining room, the surveyor realized that pureed Chicken Pot Pie was lumpy, and the green beans shell were easily identified. Resident #35 meal ticket consisted of 8 ounces (oz) of Pureed Chicken Pot Pie with #16 scoop (Scp) of Pureed Biscuit, #10 (Scp) of Pureed [NAME] Peas, #10 Scp of Pureed Sliced Peached & Pears, 1/2 Cup of Fortified Mashed Potatoes and 6 ounces of Tea which matched the meal tray. 2. A record review showed that Resident #102 was admitted on [DATE] with diagnoses of Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure and Muscle Wasting and Atrophy. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score showed that Resident #102 was unable to conduct the interview. During an observation conducted on 02/03/25 at 1:57 PM in Resident #102's room, the surveyor observed that pureed Chicken Pot Pie was lumpy, and the green beans shell were easily identified. Resident #102 meal ticket consisted of 8 ounces (oz) of Pureed Chicken Pot Pie with #16 scoop (Scp) of Pureed Biscuit, #10 (Scp) of Pureed [NAME] Peas, #10 Scp of Pureed Sliced Peached & Pears, 1/2 Cup of Fortified Mashed Potatoes and 8 ounces of Nectar Thickened Lemonade which matched the meal tray. 3. A record review showed that Resident #108 was admitted on [DATE] and readmitted on [DATE] with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side. The admission Minimum Data Set (MDS) dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score showed that Resident #35 was unable to conduct the interview. During an observation conducted on 02/03/2025 at 1:54 PM in Resident #108's room, the surveyor observed the pureed Chicken Pot Pie was lumpy, and the green beans shell were easily identified. Resident #102's meal ticket consisted of 8 ounces (oz) of Pureed Chicken Pot Pie with #16 scoop (Scp) of Pureed Dinner Roll/Bread, #10 (Scp) of Pureed [NAME] Peas, #10 Scp of Pureed Sliced Peached & Pears, 1/2 Cup of Fortified Mashed Potatoes and 6 ounces of Tea which matched the meal tray. During an interview conducted on 02/06/2025 at 2:51 PM, the Speech Therapist stated that pureed food should be blended, completely broken down into one uniform consistency. The Speech Therapist further stated that she has been working in this facility since July and hasn't done any training with the kitchen staff yet. She continued explaining that they follow the [NAME] guidelines for the texture of the food they serve. During an interview conducted on 02/06/2025 at 3:00 PM, the District Manager stated that 12 residents are on pureed consistency diet and that she always tries the pureed food in the kitchen before sending it out on the floor to make sure the consistency is adequate.

Based on observation, interviews and record review, the facility failed to ensure the resident's competency when performing respiratory care for 1 of 2 residents sampled for respiratory care (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE] with diagnoses that included Respiratory Failure, Type 2 Diabetes Mellitus, and Tracheostomy Status. Her BIMS (Brief Interview for Mental Status) was 15 on the quarterly Minimum Data Set (MDS) assessment dated [DATE]. This indicated the resident was cognitively intact. On 02/04/25 at 9:32 AM, trach (tracheostomy) care was observed with Staff P, Respiratory Therapist. Staff P wore a gown, face mask, and gloves and cleaned around the area of the stoma and applied a new gauze pad. The surveyor asked Staff P why did she not change the inner cannula and she replied that the resident changes her own inner cannula. Asked if the resident had a competency for this and she replied that she did the competency over a year ago. Observation of the bedside table of Resident #58 revealed a box of disposable inner cannulas and a box of gloves. Interview with the resident was conducted on 02/04/25 at 2:35 PM. She stated she changes her inner cannula sometimes 3 times a day. She has disposable inner cannulas in her room with gloves. She has had the trach for over a year and prefers to do this on her own. She had a box of gloves and a box of disposable inner cannulas at the bedside and she stated she puts on her gloves and pulls out the inner cannula and puts a new one in and hears it snap. She calls the nurse when she changes the trach but at night she sometimes changes it when the nurse is not there. On 02/04/25 at 2:50 PM the surveyor interviewed Staff C, Unit Manager, as to where the competency checklist would be. She called Staff P on the phone and Staff P stated to her that the competencies would have been on paper and she gave the papers to the former Director of Nursing (DON). On 02/05/25 at 9:00 AM the surveyor spoke with the Regional Nurse Consultant. She stated that they could not find any competency because it was probably on paper with the other company. She agreed that there should be a competency in her Electronic Health record (EHR). Review of the EHR revealed a respiratory therapy progress note dated 01/06/25 (Resident) inner cannula is supposed to be changed twice a day. She is supposed to go through 14 inner cannulas in a week. Per (family) 14 is too little and should be changed more. (Resident) is running out of inner cannulas due to frequent changes. (Resident) will change out her own inner cannula despite being told her inner cannula should only be changed twice a day. RT gives (resident) two boxes at a time to prevent from running out. Per the administrator it is ok to double her inner cannula order. Further review of the EHR on 02/06/25 revealed Resident #58 had documentation in the EHR that she was educated on inner cannula change and demonstration was conducted on 02/04/25 at 5:26 PM and 02/05/25 which was after surveyor intervention.

Based on interview and record review, the facility failed to complete a Level 2 Preadmission Screening and Resident Review Process (PASARR) for 1 of 1 resident sampled for PASARR (Resident #50). The findings included: The facility's policy titled, Social Service-PASRR with an effective date of 04/01/22 revealed A Hospital Discharge Exception is given when an individual being admitted into the NF has a Dx of a SMI and/or behavior that accompanies the SMI (Serious Mental Illness) or Suspected SMI and the physician has certified, before admission to the facility that the patient is likely to require less than 30 days of nursing facility services for the condition for which the individual received care in the hospital. Time frame to request the Level II evaluation for Hospital Discharge Exemption: If the individual's stay is anticipated to exceed 30 days, the NF must notify the Level 1 screener by the 25th day of the stay and the Level II evaluation must be completed no later than the 40th day of admission. On 02/03/25, a review of the Electronic Health Record (EHR) was done and a Level 1 PASARR was located. The Level 1 PASARR was done at a hospital on 11/15/22 prior to the resident's admission to this facility on 11/16/22. Resident #50 was admitted to the facility with diagnoses that included Paralytic Syndrome, Bipolar Disorder, Current Episode Depressed, and Peripheral Vascular Disease. A Brief Interview for Mental Status (BIMS) score was 14 on the annual Minimum Data Set (MDS) with an assessment reference date of 11/23/24. This indicated the resident was cognitively intact. A review of the PASARR Level 1 revealed the resident was admitted with a hospital discharge exemption which indicated the resident was likely to require less than 30 days of nursing facility services for the condition for which the individual received care in the hospital. A Level 2 PASARR was not found in the resident's EHR. On 02/05/25 at 11:31 AM, during a side-by-side review and interview, the Social Service Director (SSD) was asked to locate and provide the Level 2 PASARR assessment for Resident #50. He was unable to locate it. The SSD agreed that a Level 2 should have been done based on review of the Level 1 PASARR. He stated that he will do a resident review and submit to Acentra Health with the latest Minimum Data Set assessment and the original PASARR as long as the resident gives consent.

Based on observation, interviews and record review, the facility failed to ensure disposal of garbage and refuse in a sanitary manner. The findings included: A review of the facility's policy titled, Dispose of Garbage and Refuse, dated 8/2017, showed the following: all garbage and refuse will be collected and disposed of in a safe and efficient manner. The Dining Service Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. In an observation conducted on 02/03/25 at 8:42 AM, in the outside area, a large blue metal construction dumpster was noted. The opened dumpster showed garbage bags and multiple food boxes inside the dumpster. Closer observation revealed a foul smell and insects flying around the construction dumpster. In this observation, the facility's maintenance director stated that he has told the kitchen staff multiple times that this construction dumpster is only used for construction garbage and not to throw any other garbage that is coming from the main kitchen. He further stated garbage that is coming from the main kitchen can attract rodents and insects and then said, I am not here 24/7. In an interview conducted on 02/06/25 at 4:00 PM with the facility's Administrator, she was informed of the findings.

Based on observations, interviews and record reviews, the facility failed to provide assistance during dining for 1 of 2 residents reviewed for activities of daily living (ADLs), for Resident #71 and Resident #52. The findings included: 1. A record review showed that Resident #71 was admitted on [DATE] with diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Neuromuscular Dysfunction of Bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 10, which indicated moderately impaired. Section GG of the MDS showed that Resident #71 needs Supervision or touching assistance during dining. In an Observation conducted on 02/03/2025 at 1:25 PM this Surveyor observed Resident #71 in her room staring at the lunch tray and not attempting to eat. This Surveyor further noticed that Resident #71 was in the room without staff. About 40 minutes later, Resident #71 was still unattended with her lunch tray. In an Observation conducted on 02/04/2025 at 9:10 AM this Surveyor observed Resident #71 in her room perplex staring at the breakfast tray and not attempting to eat. This Surveyor further noticed that Resident #71 was in the room without staff. About 30 minutes later, Resident #71 was still unattended with her breakfast tray. In an interview conducted on 02/05/2025 at 1:55 PM with Staff E, Certified Nurse Assistant (CNA), she stated that sometimes Resident #71 eats alone and some other times she needs to be fed. Staff E further stated the Resident needs to be encouraged and directed to feed herself. In an interview conducted on 02/05/2025 at 2:00 PM with Staff F, Registered Nurse (RN), she stated Resident #71 can eat without staff member presents in the room. Staff F further stated that Resident doesn't need assistance during dining. In an interview conducted on 02/05/2025 at 2:10 PM with Staff G, Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse (LPN) and Staff H, MDS Coordinator, Registered Nurse (RN), Staff H stated that Supervision or touching assistance during dining means the Resident needs help setting up the tray. Staff H further stated that it also means that the Resident needs to be encouraged, cleaned and assisted as needed. Staff G stated that the Certified Nurse Assistants (CNA) are the one responsible for assisting with dining. Staff G further said that it wouldn't be expected for the CNA to be constantly present in the residents' room but in and out of the room.

Based on interviews and record review, the facility failed to appoint a guardian in a timely manner for 1 of 1 resident sampled for guardianship (Resident #56). The findings included: Resident #56 was admitted to the facility on [DATE] from another nursing facility. Diagnoses included Other Specified Disorders of Brain, Rhabdomyolysis and Alzheimer's Disease. A Brief Interview for Mental Status (BIMS) score was 2 on the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/25/24. This indicated the resident had severe cognitive impairment. In an interview conducted on 02/06/2025 at 12:05 PM with the Primary Physician, she stated that she is familiar with Resident #56. The family hasn't been involved in years. The resident doesn't have a guardian to make the decisions. A telephone call was placed to the resident's cousin on 02/06/25 at 12:24 PM with no answer and no ability to leave a voice mail. The cousin was the only representative listed on the facesheet. An interview was conducted with the Social Service Director (SSD) on 02/06/25 at 12:30 PM. The SSD stated that the resident has a cousin that he had spoken to in the past who doesn't want anything to do with her. She has been on his list for a guardian since April 2024. The hold up is finding an attorney that does it. She is indigenous status. If there is an emergency with the resident, we will send her to the hospital and they can assign her a proxy and this can be done quickly. On 02/06/25 at 1:30 PM , the SSD gave this surveyor a copy of a progress note written by a previous social worker. He stated he was wrong, the facility has been working on this longer that he thought. The progress note, dated 01/25/24, revealed writer and staff conducted a care plan meeting called cousin, he stated he no longer wants to be contacted to please remove him off her contact list. Facility will move forward with guardianship process due to the fact that resident doesn't have a legal representative. The SSD stated that the facility has been working on this at the corporate level but he could not find any paperwork regarding this. An interview was conducted with the Administrator on 02/06/25 at 2:00 PM. The Administrator stated it usually takes between 6 to 9 months to obtain guardianship. It depends on the court system. They have to assess mental capability, have a court hearing and the judge makes a ruling. She signed for 2 residents about 2 weeks ago for a lawyer but was not aware of this particular resident. She became aware of this resident's need for guardianship today. The Administrator was asked for a policy on guardianship and she stated there was none.

Based on observations, interviews and record reviews, facility failed to provide food that meets residents' preferences, allergies and intolerances for 4 o 4 residents observed during dining observation (Resident #56, Resident #15, Resident #118, Resident #368). Findings included: 1. A record review showed that Resident #56 was admitted on [DATE] with diagnosis of other specified disorders of brains and rhabdomyolysis. The Minimum Data Set (MDS) quarterly dated 10/25/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 2, which indicates severe cognitive impairment. During an observation conducted on 02/03/2025 at 1:30 PM this surveyor observed that Resident #56 meal ticket consisted of: 1 Cup of Chicken Pot Pie with 1 biscuit, 1/2 cup of green peas, 1/2 cup of deluxe fruit salad, 1/2 cup of fortified mashed potatoes, 6oz of tea of choice and 4oz of apple juice. Resident #56's tray did not have mashed potatoes nor fortified mashed potatoes. 2. A record review showed that Resident #15 was admitted on [DATE] and readmitted on [DATE] with diagnosis of Cerebral Infarction and Atherosclerotic Heart Disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 14, which indicates no cognitive impairment. In an observation conducted on 02/03/25 at 1:35 PM this surveyor saw that Resident #15's meal ticket consisted of: 8 ounces (oz) of Ground Chicken Pot Pie with bread, 1/2 cup of broccoli florets chop, 1 assorted ice cream, 8oz of whole milk, 6 oz of hot tea, and 1 can of diet Gingerale soda. The meal tray did not have ice cream on it. 3. A record review showed that Resident #118 was admitted on [DATE] with diagnosis of Intracranial Abscess and Granuloma and Encounter for Surgical Aftercare following Surgery of the Nervous System. The admission Minimum Data Set (MDS) dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairment. In an observation conducted on 02/03/2025 at 1:20 PM this surveyor observed Resident #118 frustrated and taking out the green peas from the chicken pot pie and putting them on the plate. Resident #118 explained that he explicitly told multiple staff that he does not like peas or greens but unfortunately, they always put some sort of green on his plates. The Resident's plate consisted of 1 Cup of chicken pot pie with 1 biscuit, 1/2 cup of broccoli florets, 1/2 cup of deluxe fruit salad, and 8oz of lemonade. 4. A record review showed that Resident #368 was admitted on [DATE] with diagnosis of Chronic Inflammatory Demyelinating Polyneuritis and Type 2 Diabetes Mellitus without complications. The Minimum Data Set (MDS) is not yet available due to Resident being newly admitted . In an interview conducted on 02/03/2025 at 10:00 AM Resident #368 stated that food is inedible, they don't put any condiments like salt, pepper, ketchup, or seasonings. Resident #368 further stated that her preferences are not taken into consideration. For example, she doesn't drink milk or juice, she doesn't eat pancakes or white bread but always gets these things on her tray. Resident continued by explaining how the food is always served cold. 5. In an observation conducted on 02/05/25 at 11:45 AM in the kitchen, the surveyor was given the menu of the day that consisted of: Open-Faced Roast Pork Sandwich (2oz sliced Pork) alternative 3oz of Salisbury Steak, 1/2 cup of Herbed [NAME] Beans or 1/2 cup of Brussels Sprouts, 1/2 cup of Mashed Potatoes or 1/2 cup of Buttered Noodles, 1 Dinner roll or 1 Bread and 1 square of Lemon Cake with Lemon Icing. The surveyor further asked to weigh the Roasted Pork and the Salisbury Steak which weighed respectively 2 ounces and 3 ounces. In an interview conducted on 02/06/25 at 2:00PM, the District Manager stated that they have three checkpoints to make sure that the meal ticket always matches the meal tray. The three checkpoints are: the first one is the aide that puts the tray together, the second one is another aide in the kitchen, and the third one is the nurses on the floor who take the lids off to checkwhat was on the tray matches what is on the meal ticket. The District Manager further stated that she and her assistant are also always in the kitchen double checking. In another interview conducted on 02/06/25 at 3:15 PM, the District Manager stated that the pork on the Open-Faced Roast Pork Sandwich was 2oz and that Salisbury Steak 3oz on the alternative menu was different portion because as the pork cooks the weight is reduced. The District Manager further stated that another reason could be because the pork is served on bread which would make up for the ounce missing. The District Manager continues saying that a resident ordering the Open-Faced Roast Pork Sandwich would get 2oz and a resident ordering the Salisbury Steak would get 3oz. 49060 6. In an observation conducted on 02/03/25 at 12:40 PM, the tray cart arrived at the 400 unit with lunch meals. Staff A, Licensed Practical Nurse (LPN) was observed at the tray cart to distribute the lunch trays to the residents. Further observation revealed Staff A was checking the meal ticket, however, he did not uncover the plate to assure the food consistency matched the meal ticket. Then, at 12:47 PM the tray cart was moved to the 500 unit to be distribute by another nurse, Staff D, LPN; and again observed food plates were not uncovered to check for consistency by Staff D. 7. On 02/05/25 at 11:47 AM, another observation of the lunch trays was conducted. Staff A was observed distributing the lunch trays at 700 unit. Staff A checked the residents' meal tickets on the trays; however, he did not uncover the plates to check for correct consistency. At 12:13 PM the meal cart was observed at the 500 unit and the lunch trays were being distribute by Staff B, LPN. Further observation revealed Staff B checking the meal tickets and not uncovering the plate to check for correct consistency. 8. During an interview conducted with Staff B, who stated she has worked at the facility for 11 1/2 years. She stated that when distributing the meal trays, she checks the name, room number, fluids and correct diet/consistency on the meal ticket. Then she was asked if she uncovers the plate to check for the correct food consistency, Staff B stated oh, yes, of course! 9. During an interview conducted on 02/05/25 at 1:50 PM with Staff A, LPN, who stated he has worked at the facility for over a year. He stated the responsibility of the nurse during meal tray distribution is to check the meal ticket for the resident's name, room number, and confirm the right diet is correct on the meal trays. Staff A stated he knows which type of diet each resident is on because he knows most of the residents. He also stated he does uncover the food plate to check the consistency. Staff A was told that during a couple of observations the surveyor noticed that he did not uncover the plate to check the food consistency. He acknowledged that he did not uncover the plates to check the food consistency. Then he stated the Certified Nursing Assistants (CNAs) will let him know if the meal does not look like the consistency for the resident; in addition, Staff A stated if he is not too busy he sometimes assist feeding the residents and in that case he checks the food consistency.

Based on observations, interviews and record review, the facility failed to maintain laundry equipment in a clean manner, store linens, and dispose of Personal Protective Equipment (PPE) in a manner to ensure infection control; and the facility failed to provide appropriate infection control surveillance related to scabies outbreak; the facility failed to practice hand hygiene during catheter care observation for 1 sampled resident for catheter care (Resident #67); the facility failed to maintain a sterile environment during trach care for 1 resident sampled for respiratory care (Resident #401). The findings included: 1.) Review of the facility's policy titled, Surveillance -Infections with an effective date of 04/01/22 that included: The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infection (HAI), to guide appropriate interventions and to prevent future infections. Under Section General Guidelines included: The criteria for such infections are based on the current standard definitions of infection. Infections that should be included in routine surveillance included those with: Pathogens associated with serious outbreaks (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies , and influenza). If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist should collect data to help determine the effectiveness of such measures. When transmission of Healthcare-Associated Infections continues despite documented efforts to implement infection control and prevention measures, the appropriate state agency and/or a specialist in infection control and epidemiology should be consulted for further recommendations. In the section Gathering Surveillance Data included: The infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI Committee may be involved interpretation of the data. The surveillance should include a review of any or all of the following information to help identify possible indicators of infection: Laboratory records Skin care sheets Infection control rounds or interviews Verbal reports from staff Infection documentation records Temperature logs Pharmacy records Antibiotic review and Transfer log/summaries. Daily (as indicated): record detailed information about the resident and infection on an individual infection report form. 2.) Review of the facility's policy titled, Hand Hygiene with a revised date of 02/05/23 included: To prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. All staff should perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Referenced in the table for conditions and indication where hand hygiene is required listed under indication, before applying and after removing personal protective equipment (PPE), including gloves, use either soap and water or alcohol-based hand rub (ABHR) 60% or higher (ABHR is preferred). 3.) Review of the facility's Rash Investigation Report revealed the facility contacted the Department of Health (DOH) on 04/28/23 and there were no recommendations provided. The facility contacted DOH on 09/25/23, and recommendations were given. On 09/12/23 the pest control vendor did a room assessment for bed bugs that was negative (no indication which room(s) or units. In the Facility Intervention Log listed deep clean 05/16/23-05/17/23 with no notes, deep clean was also mentioned on 09/05/23 with a note that said deep clean to room of diagnosed patient, patient belongings and mattress bagged, mattress replaced. There was no indication which resident this was or what room they resided in. Again, a deep clean had a date of 09/18/23 with a note of deep cleaning to all carpeted room started on 09/18/23, all carpeted room are scheduled for deep cleaning of room and carpet. This did not identify which room numbers or when and/or if the deep cleaning was completed. There was a chart audit with a date of 05/25/23 with a note that documented last PRN (as needed) medication for itching used on 05/22/23 after deep cleaning, 64% of the affected patients have not had to use a PRN medication for itch/rash. There is no mention of which resident or their rooms. In the Patient Chart Audit list various resident with room number, date of intervention and date of intervention. For 12 out of the 16 residents listed had a comment about a diagnoses but with each time a resident was treated with a medication there was no comment. This indicated that the facility did not keep a comprehensive all-inclusive list in their Rash Investigation Report. Review of the line listing of residents who had been diagnosed with scabies included 4 residents. The first was listed as an onset date of 09/10/23, the second resident had an onset date of 09/19/23, the third resident had an onset date of 09/21/23, and the fourth resident had an onset date of 09/26/23. Review of a document provided by the Infection Preventionist (IP), revealed the outbreak of scabies was not reported in a timely manner to DOH (Department of Health). It was reported after the facility had a fourth resident with scabies, on 09/26/23. Review of the recommendations revealed the facility did not follow recommendations provided by DOH that included: Institute a system for conducting active daily surveillance of all patients, staff members, and visitors. Maintain a roster of suspected cases which includes names, location in the nursing home, date of onset of rash, treatment, current status and association with other cases prior to infestation. Clip the nails of the patients and clean carefully under the nails. During an interview conducted on 10/17/23 at 4:15 PM with the contact person from the Department of Health, she stated she was informed by Staff H IP by email on 09/25/23 of an outbreak of scabies with 3 confirmed cases of residents residing in the facility. The contact from the Department of Health sent a form of recommendations for a scabies outbreak that included it is better for laundry not to be sent home for family members to do, all linens and personal clothing need to washed and dried using high heat, and any non-washable items should be kept in a plastic bag for a minimum of 72 hours. When asked when she last had contact with the facility in any way, she stated she had not heard any additional information from the facility. During an interview conducted on 10/18/23 at 8:20 AM with the in-house Dermatologist who was asked if he knows how to treat linens and personal clothing for resident with positive diagnosis of scabies, he said hot water but did not know how hot the water would be. He stated resident may be treated for scabies or suspect of scabies for a very long time. When asked if he could elaborate, he stated a post scabies rash may last 1-2 weeks and should start to subside after about 4 weeks. When asked if he placed any of the residents on contact isolation for having a positive diagnosis of scabies or residents suspected of having scabies, he said he does not, that would be up to the facility to follow their standard protocol for contact isolation. When asked if a resident is diagnosed as have scabies should they be placed on contact isolation, he said yes. When asked if residents being treated prophylactically for scabies should be on contact isolation, he said that is up to the facility's standard protocol, I am sure they have one. When asked if he knew how many residents were treated prophylactically for scabies or diagnosed as having scabies, he said he does not keep track of that, all documentation should be in each resident's medical record. When asked if he had given the facility or the IP, or DON any recommendation for treating or preventing scabies he said no. When asked if he checked all resident in the affected wings with scabies outbreak or suspected scabies, he said he is not sure, all documentation would be for each resident in their individual medical record. During an interview conducted on 10/18/23 at 2:00 PM with Staff H, Infection Preventionist (IP) PRN (as needed) who stated she works remotely now, and she was the IP full time on site for 9 months before she went PRN on 09/30/23. Also present during the interview was Staff G, Director of Nursing/Infection Preventionist (DON/IP). Staff H said she was doing all monitoring/reporting for any infections such as covid or scabies only until she went PRN, she continues to do the reporting but no longer does the monitoring since she went PRN on 09/30/23. When Staff G and Staff H were asked about the outbreak of scabies, Staff H stated around March they received complaints from some of the patients they were itching and having a rash. All of the patients with the itching and rash were on the long-term care side of the building. Staff H stated she in April she had contacted the Department of Health (DOH) for any suggestions or recommendations but did not get any suggestions or recommendations at that time. Staff H stated they consulted the in-house Dermatologist who diagnosed the affected residents as having Contact Dermatitis. Staff H stated the in-house Dermatologist performed scraping for about 80% of the affected residents or who he thought might have scabies. Staff H stated that some of the family members took some of those affected residents to an outside dermatologist due to the unresolved itching/rash. The DON/IP stated the facility helped the families to arrange for the appointments and the transportation to the outside dermatologist for a second opinion. Staff H and the DON/IP stated in April they had also had their pest control vendor come into the facility to do an inspection of the facility for any pest and were unable to find any bedbugs. The pest control vendor recommended to do a deep cleaning of carpet and furniture. At this time, they also had the maintenance department look into the air filters and they verified with the housekeeping department there had been no change in the detergents used. For the residents affected with the itching/rash that were having their laundry washed by family, they checked with the family members about any change in detergent and most families stated they had not changed laundry detergent and or used sensitive type detergent. They stated they would notify the in-house Dermatologist with a list of residents who were complaining of itching or had a rash, and the in-house dermatologist did a biopsy on some of those residents. When asked since the residents continued with itching/rash and more residents were complaining of itching/rash, did they check all residents on the long-term care side of the building for itching/rash, the DON/IP stated she thinks every resident gets a weekly skin check. When Staff G and Staff H were asked if they were keeping any sort of surveillance on the residents on the long-term care side building, they stated they started a timeline. Staff G stated she updated the timeline monthly but may not include follow ups by dermatology, or all biopsies, treatment for rash/itching and if conditions improve worsen or resolved. When asked when the first resident was diagnosed with scabies, Staff H said it was on 09/10/23. She stated they an additional resident test positive for scabies on 09/19/23, again on 09/21/23 and again on 09/26/23. She said each resident who was positive for scabies was placed on contact isolation and treated prophylactically and if any of the residents who tested positive for scabies had a roommate the roommate would have been treated prophylactically and also placed on contact isolation. When asked when they placed residents on contact isolation, Staff G stated immediately when the biopsy came back positive, and they were on contact isolation until after 24 hours after treatment. She also stated any resident who was being treated prophylactically, all linens and clothing were cleaned in house and all of the family members of positive residents were made aware that the resident was positive for scabies or being treated prophylactically. Staff H stated on 09/26/23 she contacted DOH to report an outbreak of scabies and received recommendations for an outbreak of scabies. When asked if they followed the recommendations from the DOH for a scabies outbreak, Staff G said yes, they did. When Staff G was asked if that included instituting a system for conducting active daily surveillance of residents, staff members, and visitors, she said no. The DON/IP stated we do weekly skin checks for residents. When asked if they maintain a roster of suspected cases which includes names, location in the nursing home, date of onset of rash, treatment, current status and association with other cases prior to infestation, they said they just have the line listing that they sent to DOH with the 4 residents who were positive for scabies. 4.) During a tour of the laundry room conducted on 10/16/23 at 2:00 PM with the Director of Housekeeping (DOH) and the Director of Maintenance (DOM) the following observations were made: a) In the washer/dryer laundry room the handwashing sink was dirty, had a kitchen utensil in the basin, basin surface was crumbling (Photographic evidence obtained). b) In the washer/dryer laundry room the trash container was overflowing with garbage and used personal protective equipment (Photographic evidence obtained). c) In the washer/dryer laundry room the personal use washing machine inside tub was rusted (Photographic evidence obtained). d) In the washer/dryer laundry room the wheeled red transport bin had personal clothing and a used disposable glove all uncovered (Photographic evidence obtained). e) In the washer/dryer laundry room the wheeled wire cart had personal items in a mesh bag, privacy curtains, and a mechanical lift sling all uncovered (Photographic evidence obtained). f) In the laundry folding room the wheeled red transport bin contained uncovered hospital gowns and linens (Photographic evidence obtained). g) In the laundry folding room the table had uncovered folded laundry (Photographic evidence obtained). During an interview conducted on 10/16/23 at 2:30 PM with the Department of Housekeeping, who when asked if the laundry items (linens and personal items) should be left out uncovered, he said it is ok. When asked if laundry items should be left in bins or carts uncovered, he said he will take the items out, they are to be washed or folded. He stated the personal washing machine is not used, and 1 of the 3 commercial washers has been broken and is no longer used. When asked about the trash bin overflowing with used PPE, he said it just needs to be emptied. 5.) Record review for Resident #67 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy. Review of the Minimum Data Set (MDS) for Resident #67 dated 10/04/23 revealed in Section C the resident had a Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. Review of the Physician's orders for Resident #67 revealed an order dated 09/29/23 for foley catheter 16FR/10cc normal saline, diagnoses Obstructive Uropathy, drain and record output. Review of the Physician's orders for Resident #67 revealed an order dated 09/29/23 for foley catheter care with soap and water every shift and as needed. Review of the Care Plan for Resident #67 dated 09/30/23 with a focus on resident has indwelling catheter related to diagnosis of Obstructive Uropathy. The goal was for the resident to show no signs/symptoms of urinary infection through review date and for the resident to be/remain free from catheter related trauma through review date. The interventions included: Provide catheter care as ordered. On 10/16/23 at 11:44 AM an observation was made of Resident # 67 lying in bed and indwelling catheter drainage bag with privacy cover hanging from bed frame. On 10/18/23 at 11:05 AM an observation was made of indwelling catheter care for Resident #67 performed by Staff E Certified Nursing Assistant (CNA). The CNA gathered supplies, washed hands, applied gloves, cleaned the resident's penis, scrotum, and catheter, and removed her gloves 6 times and applied new gloves. For 3 out of the 6 times the CNA changed her gloves she did not perform hand hygiene (either washing with soap and water or using alcohol-based hand rub). During an interview conducted on 10/18/23 at 11:35 AM with Staff E CNA who stated she has worked at the facility for 9 years. When asked about hand hygiene between gloves being changed, she stated she knew she forgot to use hand sanitizer a couple of times. She stated she is supposed to either wash her hands or use hand sanitizer when she removes her gloves before she puts new gloves on. 49060 6.) Review of the facility's policy titled, Nursing-Tracheostomy Care, dated 04/01/22, included the following: The purpose of this procedure is to guide tracheostomy care and cleaning of reusable tracheostomy cannulas. Equipment and Supplies: Gloves (clean and sterile). General Guidelines: Aseptic technique must be used: During tracheostomy tube changes, either reusable or disposable. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be always available at the bedside. Clean the Removable Inner Cannula: Open tracheostomy cleaning kit. Set up supplies on sterile field. Maintaining sterile field. Put on sterile gloves. Secure the outer neck plate with non-dominate gloved hand. Unlock the inner cannula with gloved dominate hand. Gentle remove the inner cannula. A tracheostomy care observation was conducted on 10/18/23 at 4:52 PM with Staff N, Licensed Practical Nurse (LPN) for Resident #401. Staff N introduced herself to Resident #401 and advised that she was going to perform tracheostomy care. Staff N closed the room door for privacy. She washed her hands, donned clean gloves, and cleaned the bedside tabletop. She removed the gloves, discarded, used hand sanitizer, and donned clean gloves. She then gathered the following supplies: one tracheostomy cleaning kit, normal saline tubes (4), disposable inner cannula (1), hand sanitizer, extra gauze dressing and a suction catheter kit (the suction machine was already present in the room). Staff N opened the tracheostomy care kit and set up the sterile field on the cleaned bedside table. She carefully opened a paper/plastic container and poured the four normal saline tubes into it. She then carefully opened the disposable inner cannula package and dropped the inner cannula onto the sterile field. She then removed her gloves, discarded, used hand sanitizer, and donned clean gloves. She moved the supplemental oxygen mask to the side of the tracheostomy prior to removing the inner cannula. She mentioned that since it is a disposable cannula, it does not need to be cleaned and it will be thrown away. She then removed the old tracheostomy dressing. She removed her gloves, discarded, used hand sanitizer, and donned clean gloves. She placed 2 sterile cotton-tipped applicators in the container of normal saline. She then used one cotton-tipped applicator and cleaned the left-side of the tracheostomy outer neck plate and discarded; she then used the other cotton-tipped applicator and cleaned the right-side of the tracheostomy outer neck plate and discarded. She removed her gloves and discarded, used hand sanitizer, and donned clean gloves, placed 4 gauze pads in the saline solution. Then, she picked up 2 gauze pads and cleaned the outer right area of the tracheostomy tube, discarded, then picked up the other 2 gauze pads and cleaned outer left area of the tracheostomy tube and discarded. She removed her gloves, discarded, used hand sanitizer, donned clean gloves, and inserted the new disposable inner cannula into the tracheostomy. She soaked 4 gauze pads in the normal saline container; used 2 gauze pads to clean each side of the stoma, using a single sweep for each side. She then wiped the stoma with dry gauze, using a single sweep for each side. She removed her gloves, discarded, used hand sanitizer, and donned clean gloves. She then applied the fenestrated gauze pad around the tracheostomy insertion site and replaced the supplemental oxygen mask over the tracheostomy site. She then removed her gloves, discarded, and washed her hands. An interview was conducted with Staff N following the procedure. The surveyor asked, if there are sterile gloves included in the tracheostomy kit, when would you use the sterile gloves during the care? Staff N responded that she would use it during suctioning. She then stated that she was not sure when she would use the sterile gloves. On 10/19/23, the areas of concern regarding the tracheostomy care for Resident #401 were discussed with the Director of Nursing and the unit manager.

Based on observation, interview and record review, it was determined the facility failed to provide a Quality Assessment and Assurance (QAA) practice that demonstrates identification, monitoring and implementation of an effective Action Plan to the residents medical and emotional needs affecting 6 (Resident #254, #111, #131, #275, #286 and #264) of 77 of the resident census, as evidenced by failure to promote dignity, pain management, sufficient staffing, call light response in a timely manner, and meal being delivered with appropriate hot temperatures. The finding includes: The Quality Assessment & Assurance (QAA) review on 1/17/14 at 10:16 AM and interview conducted with the Administrator who is the QAA Chairperson. This interview included a review of the past 6 months QAA committee ' s documentation. A review of the following was conducted: #1) Dignity, #2) Pain management, and #3) Sufficient staffing, a) Call light response time in a timely manner, b) Meal trays / Food items served at appropriate temperatures. The facility did not show evidence of resolving or improving facility wide concerns with the following: #1) Dignity: The offsite preparation of the survey included a telephone contact with the local Long Term Care Ombudsman on 1/13/14. This telephone interview revealed an investigation was conducted at the facility on 10/20/13. At that time the Ombudsman found the allegations concerning dignity were substantiated. Upon interview and record review, the QAA Chairperson was not aware of the Ombudsman's investigation on 10/20/13 and resolution of the dignity allegation. During this interview concerning the QAA action plan to ensure dignity is provided to the residents, the QAA Chairperson stated and displayed to the surveyor several white plastic "Knock before entering room" door hangers, and stated the facility provides these for the residents and they hang on the inside of the door when not being used; and on the outside of the doors facing the hallway when privacy and knocking is required and requested by the residents. The QAA Chairperson further stated this is the Standard of Practice of the facility and it's staff to ensure dignity is provided to the residents. During the stage one survey Residents ID #254 and #111 stated dignity was not provided as the staff does enter their room without knocking. Observations tours that included staff interviews on the Acute Care and Progressive Care Units were conducted starting on 1/17/14 at 1:05 PM revealed a census of 40 residents on the Acute Care Unit. During this tour 12 occupied rooms were observed without a "knock before entering room" privacy door knob hanger nether inside or outside the door handles. The Progressive Acute Care unit has a resident census of 43 residents. During tour of the Progressive care unit, observation revealed 17 occupied resident rooms without a "Knock before entering room" privacy door knob hanger nether inside or outside the door handles. Additionally, the Acute Care Unit and Progressive Care three shower rooms do not have "Knock before entering room" door hangers in these rooms. Upon interview with Resident #264, the resident stated a male staff did enter the shower room while she was taking a shower without knocking or asking for entrance. During the observation of wound care on 1/16/14 at 9:38 AM revealed the Wound Nurse assigned to Residents # 63 did not place a "Knock before entering room "door hanger on the door knob during this procedure. The facility QAA committee Chair Person / Administrator stated in the QA review interview that a "Knock before entering room" door hanger is available and placed on the exterior resident door knob when procedures are conducted. The QAA Chairperson acknowledged that dignity is currently a concern with the facility residents, and the action plan is currently in progress. #2) Pain Management: During the Stage 1 survey two residents expressed that insufficient pain management is provided. During the subsequent investigation during stage two the resident observation and records reviews substantiated Residents # 157, #264 and #100 complaints. Subsequently disclosing the facility investigation and action plan to implement pain relief on these residents with pain levels of 4 or greater for more than 7 days would be referred to the pain control management physician. In interviews with the assigned nurse to Residents # 157, #264 and #100 disclosed that this action plan was no implemented, and their pain management goals was not met. #3) Sufficient Staffing: During the Stage 1 survey seven residents expressed that facility staffing was not at an appropriate level to provide for their health care needs, call light answering in a timely manner and meals to be served at appropriate temperatures. During the subsequent investigation during stage two the resident observation and records reviews substantiated Residents #254, #111, #131, #275, #286 and #264's complaints. Subsequently disclosing the facility investigation and action plan to implement staffing and the application of care provided for these residents had not met the resident's care needs as evidenced by the following: a) Call Light responses: The Stage two survey investigation that included observation, interviews and records reviews revealed Resident #254, #111, and #131 had not received the care needs required for call light responses in a timely manner specifically during the morning hours when toileting and hygiene and delivery of morning care is required. During these periods of waiting for call light responses for toileting care incontinence accidents have occurred and dignity concerns were felt by the residents. The QAA Chairperson/Administrator stated during the QAA review on 1/17/14 at 10:16 AM that during the morning care when the residents concerns for call light responses are at their highest the QAA Residents Action Plan is to have the Supervisors assist with call light responses and all staff are to answer the call lights when observed in a timely manner. She acknowledged that this Action Plan was at times "not effective" in the delivery of the morning call light response delivered of hygiene, toileting and general assistance for direct resident care needs. b) Food served at appropriate temperatures: The Stage two survey investigations that included observation, interviews and records reviews revealed Residents #275, #286, and #264 had not received the care needs required for receiving meals during the breakfast meals at appropriate warm temperatures; these foods included coffee, and eggs. The QAA Chairperson/Administrator stated during the QAA review on 1/17/14 at 10:16 AM that during the morning meal delivery that the QAA Residents Action Plan is to have the supervisors assist with meal tray delivery to facilitate this tray delivery in a timely manner. She acknowledged that this Action Plan was at times "not effective" in the delivery of the morning meal trays being delivered with warms food warm to meet the resident's needs. During the Quality Assessment & Assurance (QAA) review on 1/17/14 at 10:16 AM an interview and record review was conducted. This review included the last 6 months QA meeting resident care interventions and Action Plans for the above mentioned concerns: Dignity, Pain Management, and Sufficient Staffing. The QAA Chair Person/Administrator acknowledged that the facility QAA is an ongoing effort and the aforementioned have not been reached.

Based on observation, interview and record review, the facility compromised the residents function and the ability to reach the highest practicable as a result of the failure to recognize significant episode of pain and failure to implement adequate pain management interventions for 3 out of 3 sampled residents observed for pain out of a total of 27 sampled residents (Resident #264, #157 and # 100). The findings include: 1. Resident #264 was admitted to the facility on [DATE] from the hospital after sustaining a [MEDICAL CONDITION] (L3) after a fall. The resident's medical [DIAGNOSES REDACTED]. The resident was admitted for rehabilitation, IV antibiotic therapy and pain management. Review of the hospital records reveals the resident was diagnosed with [REDACTED]. A spinal and orthopedic evaluation was completed. The resident was receiving large doses of [MEDICATION NAME] on a daily basis and started on [MEDICATION NAME], every 4 hours as needed. A spinal CT scan revealed [MEDICAL CONDITION] Joint Disease of C3-C7 and acute fracture at superior L3 with several disk herniations of L2-L3, L3-L4, and L4 -L5. The resident was discharged with a PICC IV line for Antibiotic administration of [MEDICATION NAME] 2 Gm, every 4 hours for [MEDICAL CONDITION]-Sensitive Staphylococcus Aureus (MSSA) . An interview and observation of Resident #264 on 01/14/2014 at 09:00 AM revealed the resident was in bed, she was restless, adjusting her legs on the elevated bed and grimacing. The resident sat up very slowly and cautiously, she placed a hard structured back brace around her back and transferred to her wheelchair. She stated she had severe pain with movement due to "bone rubbing against bone"' in her spine. She stated her pain level was a score of 8 out of 10. She stated that the medication " took the edge off her pain but never takes it away " . She stated that she regularly takes [MEDICATION NAME] around the clock and " her body knows when the pain will intensify " She stated that there have been 3 times when the [MEDICATION NAME] was not available immediately when she needed it. She stated that on Monday she went to the desk at 7 AM to ask for her [MEDICATION NAME], the staff nurse informed her they " didn't have her meds". She stated that the staff provided her pain medication at 7:45 AM. She stated that her pain intensifies when she does not receive the medication on time. She stated that the pain becomes a score of 10 out of 10. She started to cry and stated that she was in severe pain most of the day but is " just living with the pain " . She stated that she had been on [MEDICATION NAME] at the hospital but had requested to be on [MEDICATION NAME], out of fear of becoming addicted. She stated that she had been visited by a pain management physician in December and he adjusted her [MEDICATION NAME] dosage, prescribed a [MEDICATION NAME] and [MEDICATION NAME] muscle relaxant. She stated that the patch has helped but she does not take the [MEDICATION NAME] because it makes her sleepy. She stated that since the IV antibiotic therapy had finished, the pain has become worse and the pain medication is not effective. Review of the care plan for pain (related to back pain, lumbar fracture and muscle spasms) reveals treatment interventions to include: report GI (gastrointestinal) distress secondary to [MEDICATION NAME] use nausea and vomiting; administer pain medications as ordered by physician, and notify physician if pain frequency/ intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective. No documentation of non- therapeutic interventions to treat pain symptoms was noted. The resident is assessed to be independent with ADL care but requires assistance with bathing. The resident is mobile via wheelchair and is able to ambulate limited distances with a walker. Review of the Physician order [REDACTED]. Review of Admission Pain assessment dated [DATE] reveals the resident has a lumbar spinal fracture and pain is described as constant, aching and score at 4/10. The pain is exacerbated by walking, bending, and position changes with relieving factors of medication only. The pain negatively affects the resident's ADLs, walking, sitting and activities. Medications are documented as effective, no non pharmacological interventions are documented. Review of the MDS dated 1/27/2013 documents the resident as receiving as needed pain medications. No non- medication interventions are currently being implemented, pain assessment is conducted with documentation the pain is almost constant, very severe, horrible hard to sleep at night, and limits day to day activity. Review of the Nurses notes and Medication Administration Record ( MAR) reveal the resident was assessed every day shift ranging from 3 to a 10 pain score for her lower back pain. The MAR reveals the resident was on [MEDICATION NAME] 5/325 mg 2 tablets every 4 hours as needed for severe pain until 12/6/2013 when the order was changed to [MEDICATION NAME] 10/325 mg every 4 hours as needed for severe pain. The resident was also administered a [MEDICATION NAME] 100 patch 72 hour every 3 days. The MAR reveals the resident was administered the "as needed" [MEDICATION NAME] regularly 5 times each day and was assessed 16 times at a pain level of 7/10 or above. Further review reveals the resident had pain at a level of 4 or higher, at least 2 times a day , for 11 days. Review of the January 2014 MAR reveals the resident was administered [MEDICATION NAME] 10/325 mg, 11 times for a pain level for 8 or above,and 11 times in 14 days for a pain at a level of 4 or higher. The MAR reveals the daily pain assessment on the day shift was documented from 2 to 8 out of 10 score. Review of the record reveals on 11/25/2013, a pain management consult was ordered. The Pain Management Note dated 12/6/2013 reveals the resident is feeling better with the [MEDICATION NAME]. The note documents the resident is requesting an increase in the pain medication to [MEDICATION NAME] 10/325 mg 1 tablet every 4 hours instead of [MEDICATION NAME] 5/325 mg 1-2 tablets every four hours. Also [MEDICATION NAME] 10 mg was ordered for muscle cramping. The note documents the resident as having chronic lower back pain, MSSA Bacteremia with psoas abscess and substance abuse. Review of the 12/10/2013 Note reveals the resident denies pain, feeling good. Sleeping 7 hours thru the night, and making progress with pain control. Review of the 12/13/2013 note reveals the resident has a complaint of lower back pain, stating medications are not controlling the pain. She is requested additional medication and appears to be drug seeking. The note documents no additional medication was ordered, but to continue on Duragestic patch and [MEDICATION NAME] as needed. The note further documents consideration of spinal injection. On 1/16/2014 at approximately 10:00 AM an interview was conducted with a Licensed Practical Nurse (LPN), she stated the resident has a care plan for pain which states that if the resident was not finding relief, the nurse would notify the physician. She stated that if the resident required a pain consultation, the nurse would document the complaint of pain and arrange for the consultation. When questioned if the resident was finding pain relief, based on her regular request for [MEDICATION NAME], the nurse stated that the care plan should be updated and pain re-evaluated. She stated that she was not aware of any non-pharmalogical interventions being implemented to relieve pain for the resident. On 1/14/2014 at approximately 2 PM during an interview with an LPN she stated the resident has chronic lower back pain and takes [MEDICATION NAME] regularly every 4 hours. She stated the resident describes her pain a score of 7 out of 10 after medication administration. She stated the resident is independent for ADL care, and uses a wheelchair for mobility. She stated resident has no medications for breakthrough pain between the [MEDICATION NAME] administration. On 1/14/2014 at approximately 2:45 PM during an interview with the Registered Nurse (RN) Unit Manager, she stated the resident's [MEDICATION NAME] prescription is written for a certain amount of pills per physician order. She stated that the resident regularly requests the medication 4-5 times daily. She stated that the floor nurse placed the refill order to pharmacy during the evening shift on 1/13/2014. She stated the pharmacy did not deliver the medication because the prescription had run out. She stated that the nurse called the medical director to obtain a new prescription at 5:45 AM that morning. She stated that the pharmacy was called to obtain an authorization to dispense a [MEDICATION NAME] tablet from the emergency kit as required by law. She stated that the pharmacy did not inform the facility that the prescription had run out and therefore there was a delay in administering the medication for 45 minutes when the resident requested her pain medication. On 1/16/2014 at 10:15 AM during an interview with the Consultant Pharmacist, he stated that the nurse should notify the pharmacy prior to administering the last dose, of the need for a refill order. He stated that the resident received the [MEDICATION NAME] tablet at 7:45 AM, after proper authorization had been approved. He agreed that the incident was a result of poor human decision making and poor timing on the part of the nurse, by waiting too long to refill the pain medication. He agreed the resident was documented to have severe chronic pain and waiting for pain medication could have been prevented, with better communication. On 1/14/2014 at approximately 3:15 PM a phone interview was conducted with the Pain Management Physician. He stated that he had visited the resident several times during December 2013 for complaint of chronic lower back pain. He stated that he had modified the residents pain medication but would not recommend increasing the oral medications based on her history. He stated that he would recommend an increase strength in the pain patch and injections. He stated that he thought the resident was making functionally progress in Physical therapy (PT) and had been discharged . Review of Pain Management note 1/16/2014 reveals resident expressed that her back pain had increased after her IV antibiotic therapy had been completed. The note documents that the physician will still consider steroid injections but unable to complete at this time due to the MSSA infection. A spinal injection of 5 cc [MEDICATION NAME] 1% was administered into left buttock/lumbar paraspine and the resident tolerated the procedure well. On 1/16/2014 at 5:00 PM during an interview with the Pain Management Physician, he stated that he had visited the resident last month several times and thought she was making progress in PT. He stated that the resident had a history of [REDACTED]. He stated that due to the residents spinal infection, he would not inject steroids. He stated that he had administered Xylociane 1% spinal injection for relief and had increased the [MEDICATION NAME] strength. He stated that he relies on the nursing staff to inform him of any concerns/ issues with the effectiveness of medication regimen, since he is not at the facility daily. He stated that he had not seen the resident since December 2013 and had completed a new assessment today, 1/16/2014. He stated that he was not aware the resident had been transferred within the facility and as a result, he had not followed her. He stated that he does not recommend steroid injections at this time due to the MSSA infection. He stated that he will be following the resident for pain management, does not want the resident to be in pain while she waits for an infectious disease consultation and repeat MRI next week. Record review dated 1/2/2014 reveals the resident was seen by an orthopedic surgeon. The resident has finished 8 weeks IV antibiotic therapy with [MEDICATION NAME] 2 GM every 4 hours for diskitis at L2-L3 with L3 fracture and bilateral psoas abscesses and [MEDICAL CONDITION]-sensitive Staphylococcus Aureus Bacteremia. The physician orders [REDACTED]. On 1/16/2014 at approximately 11:30 AM during an interview with the Director of Nursing (DON) she provided weekly physician progress notes [REDACTED]. The DON stated that the resident is assessed and treated for [REDACTED]. Review of facility policy dated 11/2011 reveals under "Pain Prevention and Reduction "section that residents with pain should be re-evaluated regularly on a daily basis and documented on the Medication Administration Record (MAR) after each observation. Residents with a score of 4 to 7 twice in a 7 day period or who had a score of 8,9, or 10 are reported to the physician for possible treatment adjustment, noted on the 24 hour report, reviewed during the Eagle Room process and monitored. Pain may fluctuate over time so appropriate pain evaluation is essential. Pain status and interventions are re-evaluated if the staff believe inadequate pain control may be affecting the patient ' s ability to perform ADL care, sleep, attain personal goals, mood, cognition and behavior, participation in usual activities and appetite. Non-pharmacological approaches can minimizes the need for medications, permit use of the lowest dose or result in discontinuation of medication. 2. Resident #157 was observed on 1/14/2014 at 3:50 PM in her room, sitting in her wheelchair. The resident did not respond to her name, yet made mumbling sounds. She was observed with her legs elevated and bilateral heel protective booties in place. Record review revealed the resident was admitted to the facility on [DATE] from the hospital. The resident previously resided in an Assisted Living Facility Memory Care unit. Her diagnoses' included Advanced Dementia, [MEDICAL CONDITION], Ulcerative Colititis, and Shortness of Breath. The resident complained of pain in both legs along with swelling. A doppler study revealed [MEDICAL CONDITION] in the popliteal vein and she was started on started on [MEDICATION NAME]. Upon admission to the facility, the resident was admitted to the facility with bilateral blistering on both heels. On admission, the Skin Assessment, dated 11/24/2013 documents a Braden score of 15, low risk. The resident is documented as having no sensory impairment, occasionally incontinent, very limited mobility and requiring maximum assistance in moving. and requiring complete lifting and frequent repositioning. The MDS dated [DATE] documents the resident as severely impaired for cognitive function. The resident is documented as having no pain, not receiving pain medication and having no non-pharmalogical pain reducing interventions. The Pain Assessment, completed 11/5/2013 documents pain in lower legs, described as aching. The relieving factors include repositioning and medication effectiveness, is documented as effective. The Pain assessment dated [DATE] documents generalized pain, aching with exacerbated factors to include position changes. Relieving factors include repositioning, medications,and change activity. Medications listed as over the counter are effective. Review of the Medication Administration Record (MAR) from December 2013 and January 2014 revealed the resident is ordered Tylenol 325 mg 2 tablets by mouth every 6 hours for pain as needed, the resident is assessed daily, on the day shift, to have no pain. The record documents no pain medications were given until 1/15/2014 at 8:32 AM prior to wound care observation. Review of the Care Plan for Pain related to disease process and complaint of pain in legs documents interventions to include adjust times of ADL care and treatment activities (ie therapy, wound dressing changes), so that they occur after [MEDICATION NAME] benefits have been achieved, to administer pain medications as ordered, and notify MD if pain frequency / intensity worsening, or if current [MEDICATION NAME] regimen has become ineffective. On 1/15/2014 at 9:15 AM during an interview with the aide, she stated that the resident requires total ADL care and is unable to turn and position herself. The aide stated that the resident is confused but does speak a few words occasionally. She states she feeds the resident her meals and checks the resident for incontinence every 2 hours, along with turning and repositioning every 2 hours. She stated that the resident does not complain of pain but she will call out when positioned. On 1/14/2014 at approximately 5 PM during an interview with the RN unit manager, she stated that the resident has developed a hard Deep Tissue Injury ( DTI) on the sacrum. She stated that the resident is unable to turn and position herself. She stated that the Wound Care physician has been following the resident for the heel wounds since admission. Review of the Nurses Notes from 1/10/2014 reveals skin alteration of left buttocks, 3 x 3 cm purple area noted on left buttocks. The area is round, firm, surrounding tissue redness physician/ARNP is informed. physician's orders [REDACTED]. Monitor alteration of left buttocks if redness, heat, and/or pus notify physician. Review of the Wound Care Physician note dated 1/14/2014 reveals sacral DTI measuring 3 x 2 cm, intact blood blister with no exudate. Treatment orders to include skin prep around area and apply foam dressing. The resident to be turned and positioned, with air mattress in place. The note documents the wound is unavoidable due to risk factors of cognitive impaired,decreased mobility, weight loss, and incontinence of bladder and bowel. The left heel wound measurements are 3 x 3 x 0.1 cm with 30% granulation and 70% eschar. The right heel measurements are 3 x 4 cm, 20% granulation with 80% eschar tissue. The note documents a call was placed to residents daughter to update condition. An observation of wound care was conducted on 1/15/2014 at 9:25 AM with an LPN and the RN Unit Manager. The facility wound care nurse was not working that day. The RN stated that Resident #157 has 2 unstageable heel wounds and has developed DTI wound on the left buttocks which was seen by the wound care doctor yesterday. The LPN stated that the resident had been premedicated with Tylenol prior to the wound care treatment. She stated that she had assessed the resident for pain and the resident denies pain. The nurse stated that she observes the residents facial expression because resident has dementia with confusion and does not answer when questioned for pain. The RN stated that the resident had never been assessed to have pain or vocalized any pain. Upon observation, it was noted that the resident was positioned by the nurses and as the RN reached to touch the resident's right leg, the resident pulled her leg up and started to breathing heavily. As the LPN removed the soiled dressings from both heels, she pulled the adhesive dressings which were adhered to the wounds. The resident continued to pant and breathing heavily. As the LPN cleansed and dressed the bilateral heel wounds, the resident's lower extremities were observed tensed and stiff. As the RN and LPN were turning the resident on her left side in preparation of wound care to her left buttocks, the resident cried out "no, no, stop, pain". The RN stated that the behavior was because the resident was afraid of falling. An additional open wound was observed on the right buttocks measuring approximately 1 x 1 cm and pinkish in color. On 1/16/2014 at approximately 11:00 AM during an interview with the facility wound care nurse, she stated that the resident has dementia and does not always communicate verbally. She stated that she has not witnessed any signs or symptoms of pain from the resident. She stated that the resident has not shown, facial grimacing or withdrawing her legs up during wound care. She stated that she does not administer pain medications but would inform the nurse if the resident required medication. When ask by the surveyors what non-pharmalogical interventions are provided for the resident to address pain, the nurse stated that she does not provide any. She stated that she was unsure what the term non-pharmalogical interventions meant. She stated that the resident has very stiff lower extremities due to mild contractures but the resident can move legs when she wishes. When questioned if the resident had previously received pain medication prior to wound care, she stated the resident has not been requiring pain medications. On 1/17/2014 at 7:30 AM during an interview with the RN Unit Manager she stated she spoke with Resident #157's daughter last evening, informed her of changes in the residents skin condition and pain management. She stated the daughter insisted that the resident seemed "ok to her". The RN stated that new medication orders were obtained, [MEDICATION NAME] HCL 50 mg by mouth every day 30 minutes prior to wound care. She stated that the wound care physician had assessed the resident and had ordered TriadHydrophillic wound dressing paste to the right buttocks and sacrum every day for excoriation and redness. The RN was questioned what additional pain relieving non-pharamlogical interventions were in place for the resident, she stated each aide provides their own interventions. On 1/17/2014 at approximately 12:30 PM during an interview with the Wound Care Physician he stated that the new open area on the right buttocks is excoriation not a new DTI. He stated that he has not observed the resident to be in pain. He stated that the resident has dementia and can be fearful. He stated that his "routine" is to hold the residents hand, and play music that she likes, while he performs his weekly observation of the wounds. He stated that he does not believe strong pain medications are appropriate for older residents. On 1/17/2014 at 12:00 PM during an interview with the resident's daughter, she stated that she visits her mother daily. When asked if she felt her mother could express pain, she stated that her mother could not verbalize specific pain but she had observed her mother call out " No, no, stop" when she was being positioned. She stated that she often wondered if her mother was experiencing pain with the multiple wounds. Review of the facility "Skin Practice Policy" dated 1/2013 reveals " patients can experience pain associated with dressing changes or at rest. Pain during dressing changes can be associated with dried dressings that have exudate adhering to the tissue or strong adhesives that pull at sensitive peri-wound skin. Strategies to minimize wound pain include evaluate pain prior to initiating wound treatment, premedicate if indicated. Discuss effectiveness of [MEDICATION NAME] with patient, consult MD if needed. Care plan interventions may include pain management,and palliative care. The policy reveals pain is difficult to assess in a resident with cognitive impairment. Pain that interferes with movement and or affects mood may contribute to immobility and contribute to the development of pressure ulcers. Pain is an individual perception and response and report of the pain is generally a valid indicator of pain. 3. An observation of Resident #100's wound care treatment on 1/16/2013 at 9:38 AM revealed Resident #100 denied pain at that time and was lying on her left side. Resident #100 was offered pain medication prior to this procedure, but refused it. Resident #100 has a Pressure Ulcer wound on the mid sacrum/coccyx area. During the procedure while irrigating the wound, Resident #100 stated she had pain but upon inquiry refused pain medication. During the measuring and packing of the wound she expressed discomfort again and was asked if she desired a pain medication and she stated " No." A review of Resident #100 medical records reveals that she has a pressure wound on her sacrum/coccyx that is 1 centimeter in length, 1 centimeter in width, and 2 centimeter in depth. A pain assessment was completed on 11/26/2013 and there was no pain present. Resident # 100 has a care plan dated 11/27/2013 for pain related to disease process. The care plan states to administer pain medication per physician orders [REDACTED]. The care plan did not address any non- pharmacological interventions since her date of admission. A review of Resident #100's physician orders [REDACTED]. A review of The Minimum Data Set (MDS) dated for 12/3/2013 for pain revealed Resident #100 expressed no pain within the last 5 days prior to 12/3/2013, has no scheduled pain regimen, was not offered or declined any pain medication as needed. An interview with the Wound Care Nurse was conducted on 1/16/2014 at 10:38 am. She stated Resident #100 receives wound care treatment 3 times a week and as needed. She stated each time she does wound care she asks Resident #100 if she has pain and she responds stating "No". She stated when Resident #100 exhibits signs of pain she will offer to call the physician or offer pain medication and Resident #100 will refuse it. The Wound Care nurse stated she has no documentation of when Resident #100 refuses pain medication. She stated she ensures that Resident #100 has pillows for comfort measures. She stated she is unaware of any non- pharmacological interventions for Resident #100. An interview was conducted with the Minimum Data Set Coordinator (MDS) on 1/16/2014 at 11:31 am. She stated and verified that the care plan for pain was completed on 11/27/2013 and the MDS was completed on 12/3/2013. She agreed that the care plan is inconsistent with the MDS. A review of the facility's Pain Practice Guide reveals discussions with the physician includes current situation, background, assessment and recommendations for pain management strategies. There are also non- pharmacologic considerations that may be utilized within the initial plan of care. It also reveals that the MDS identifies triggers of pain including staff assessment of pain. Further review of Resident #100's medical record revealed the pain assessment completed on 11/26/2013 is not conducive with the care plan for pain dated 11/27/2013.