Every finding on record at Boca Raton Rehabilitation Center

Based on observation, interview and record review, the facility failed to clarify and confirm an order for leg wraps with the ordering physician, and failed to document the physician order for the leg wraps for 1 of 3 sampled residents (Resident #2). Findings included:A review of the facility's policy titled, Physician Orders, with an effective date of 02/2026, documented under procedure to:Clarify unclear written orders by reviewing with the physician and documenting clarification on the physician's telephone order form, or in the electronic medical record as clarification order.Notify the resident/resident representative.Confirm the accuracy of orders. Review orders daily in the clinical meeting to confirm accuracy in transcription and identify errors of omission.Records review documented Resident #2 was admitted to the facility on [DATE] with diagnoses which included Chronic Venous Hypertension (Idiopathic) without Complications of Bilateral Lower Extremities, and Chronic Embolism and Thrombosis of Unspecified Veins of the Right Lower Extremity.A record review of the latest Minimum Data Set (MDS) assessment, dated 12/26/25, revealed under Section C of the Brief Interview for Mental Status (BIMS), a score of 15, indicating Resident #2 had good cognitive function.It was documented under physician order dated 03/03/26 that Resident #2's doctor appointment with a vascular surgeon was on 03/04/26.There was no physician order documented after the vascular surgeon visit. In an interview conducted with Staff D, a Registered Nurse (RN) and a Unit Manager on 03/12/26 at approximately 10:45 AM, she was asked about an order after the vascular surgeon's visit on 03/04/26, she responded the resident had a leg wrap paper order. When she was asked why the order was not documented in PCC, she did not respond. When asked what kind of leg wrap is ordered for Resident #2 by a vascular surgeon she responded, she would check. She then provided this surveyor with the document. The paper documented wrap. When she was asked if the order was clear, she responded, yes. When she was asked if there is a written order for the exact wrap size appropriate for the swelling legs, the type of compression required, the time the wrap must be applied, and time it must be removed from Resident #2's legs, she did not respond. When she was asked if there was an updated written physician order about the wrap from the 03/04/26 visit in PCC, she did not respond.When she was asked if she called the physician about clarifying the leg wrap order, she responded, no. When she was asked how they applied the leg wrap without clear physician order, she responded, the resident refused them. When she was asked whose responsibility it is to clarify unclear orders, she responded, we, as Nurses. She was asked why the order was not written under the nursing progress notes, and under the electronic physician orders, she did not respond. In an interview conducted with Resident #2 on 03/12/26 at approximately 11:00 AM, he stated that staff do not wrap his leg with compression materials. When he was asked when he received information about wrapping his legs with compression materials, he responded on his last visit with a vascular surgeon, on 03/04/26. He added that staff keep wrapping his swelling legs with the same kerlix ordered by a facility physician since last year. He saw another physician on 03/04/26. but staff do not follow his order. He was concerned about his swelling legs, but staff do not pay attention. When he was asked if he talked with staff regarding the leg wrap order, he responded, staff do not listen to him and keep on putting the same leg wrap. He decided to refuse the kerlix wrap because that was not the specific compression wrap the vascular surgeon ordered during his visit on 03/04/26. The next documented order was on 03/12/26. This order is for a follow up appointment with an Outpatient Rehab Center on 03/16/26 at 11:30 AM.

Based on record reviews, and interviews, the facility failed to follow State Law and the professional standards of practice for Intravenous (IV) therapy, for 1 of 4 sampled residents (Resident #1). The findings included: In the State of Florida, for an LPN to administer IV Therapy, they must meet the requirements of the Florida Board of Nursing (FBON) and Rule 64B9-12 Florida Administration Code (Administration of Intravenous Therapy by Licensed Practical Nurses). The required course to become IV Certified is no less than 30-hours, and administered by a FBON approved provider. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Infection and Inflammatory Reaction due to Internal Right Knee Prosthesis, subsequent encounter; Muscle Wasting and Atrophy; Methicillin Resistant Staphylococcus Aureus (MRSA) Infection of the Unspecified Site; and Encounter for Other Orthopedic Care. A review of Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 15 indicating Resident #1 had no cognitive impairment. A review of orders dated 07/19/25 revealed Daptomycin intravenous solution, use 650 milligram (mg) IV for infection, one time a day for wound until 08/27/25. During an entrance conference on 12/02/25 at 9:30 AM with the Director of Nursing (DON) and Staff A, Licensed Practical Nurse (LPN), they were asked to provide certification, education and training for IV therapy of all LPNs working in the facility. They were also asked for the sign-in sheet of all staff who attended training and in services for infection control, and the medication administration policy. The DON responded, we will provide them. A review of Resident #1's August 2025 Medication Administration Record (MAR) revealed that Daptomycin 650 mg IV was administered by Licensed Practical Nurses (LPNs) based on the initials documented in Medication Administration Record (MAR). The LPNs' initials were confirmed by DON and Staff A, LPN on 12/2/25 at 1:00 PM. When the DON was asked if this surveyor can interview any of the LPN staff on the list, she responded they are not working today. When she was asked if this surveyor may interview them over the telephone, she responded, sure, we will find their numbers and will give them to you. No telephone numbers were provided for this surveyor. During an interview conducted on 12/02/25 at 11:30 AM with Staff B, Registered Nurse (RN), when she was asked if the LPNs in the facility administer IV medications for residents, she responded, yes. When she was asked if she accompanied the LPNS during IV administration, she responded, they go by themselves because they give IV therapy to their assigned residents, and I have my own assigned residents. On 12/02/25 at 12:50 PM the DON was asked again for the certification, education and training of all LPNs, and the sign in sheet of training and in-services for all staff, she responded that she is still gathering the paperwork. She was reminded to provide the other requested paperwork during the entrance conference. She was informed that the electronic access to this surveyor had stopped. An interview was conducted on 12/02/25 at 1:30 PM with DON and Staff A, LPN, who confirmed that the initials on the MAR for Resident #1 belong to some LPNs. They were both asked for the education, training and certification of all LPNs on the list and they told this surveyor that they will bring them later. On 12/02/25 at 3:00 PM, two RNs were asked if one of them can direct this surveyor to a resident with an IV therapy, they both responded, the resident was asleep, but the next shift Nurse might accompany the surveyor. When this surveyor approached the next shift nurse, Staff A, LPN, stated that the LPN was preparing for the change of shift, but she will call the surveyor when she is done. Staff A, LPN was asked by this Surveyor to print the MAR of the resident who is receiving IV therapy and she responded, sure. She was reminded that this surveyor has no access to residents' record. She was again asked for electronic access. On 12/02/25 at 5:00 PM, the DON was asked again for the education, training and certification of all the LPNs in the facility, she responded, I am still gathering the documents. She was reminded about the infection control training sign in sheet for all staff, and electronic access for residents' record. On 12/02/25 at 5:30 PM, when the DON was asked for the certification, education and training for IV therapy of all LPNs in the facility, she responded that only Registered Nurses give IV therapy, so there are no certifications required for all the LPNs. She was asked to provide the medication policy of the facility and the sign-in sheet for all the recent infection control training provided for all staff, she responded, yes, we will provide them. She was also asked for electronic access to residents' record. On 12/02/25 at 5:45 PM, Staff A, LPN, was asked for the IV therapy observation with an LPN, she responded, the resident does not get the IV therapy until 8 PM, and the staff are helping residents for dinner. She was asked to provide this surveyor with the MAR of the resident with IV therapy. She was also asked additional information like the name of the resident, and the order for IV therapy. This surveyor waited until 6:20 PM, but no paperwork was provided. There was no electronic access provided to this surveyor after 12:50 PM on 12/02/25. This surveyor kept asking Staff A, LPN, for access to residents' EHR (Electronic Health Record), she stated, yes, but no access was provided since 12:50 PM on 12/02/25. On 12/03/25 at 10:00 AM, the DON was asked again for the education, training and certification for IV therapy of all LPNs, she responded, we told you yesterday that LPNs do not administer IV therapy, so they do not have education training and certification. During an interview conducted with Staff A, LPN on 12/03/25 at 11:15 AM, when she was asked how she would know a medication was administered to a resident, she responded that the nurse's initials are documented parallel to the name of the medication, the date and the time the medication was administered. When she was asked again for facility's medication policy, she responded, the DON will give it to you. When she was asked if nurses are allowed to document their initials on MAR for the medications they did not administer to a resident, she responded, no. During an interview conducted with Staff C, RN on 12/03/25 at 12:30 PM, when she was asked how she would know a medication was administered to a resident, she responded, the initials of the one who administered the medication are documented on the MAR parallel to the name of the medication, date and time it was administered. On 12/03/25 at 3:00 PM, the DON was asked for the certification of all LPNs and she responded, LPNs do not administer IV medications here, so they do not have IV certifications. They were informed that there are Medication Administration Records which demonstrated the IV medication was administered by a LPN.

Based on observations, record reviews, and interviews, the facility failed to follow the professional standards of practice for ensuring medications and treatments were administered according to doctor's orders for 2 of 2 sampled residents (Residents #4 and #6). The findings included: During an entrance conference with the Director of Nursing (DON), and Staff A, Licensed Practical Nurse, on 12/02/25 at 9:30 AM, they were asked to provide the medication administration policy.1) Resident #4 was admitted to the facility on [DATE] with diagnoses that included Muscle Wasting and Atrophy, Essential Primary Hypertension, and Unspecified Disorders of the Muscle.A review of recent Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #4 had good cognitive function. A review of physician order dated 07/14/24 documented Lyrica, 150 milligrams (mg), give one tablet every 6 hours for nerve pain. A review of the Medication Administration Record (MAR) for November 2025 documented on 11/30/25 that Lyrica was administered at 6:00 PM and at 7:00 PM by 2 different Nurses based on initials in the Controlled Drug Declining Inventory Sheet and according to interviews with Staff A, Licensed Practical Nurse (LPN), and Staff C, Registered Nurse (RN). During an interview conducted with Staff A, LPN, on 12/03/25 at 11:20 AM, she stated that the Nurse administered the medication at 6:00 PM on 11/30/25, and another Nurse administered the above medication at 7:00 PM indicating the physician order was not followed. During an interview conducted with Staff C, RN on 12/03/25 at 1:00 PM, she stated that based on the Medication Administration Record (MAR) for Resident #4, it documented that the medication was administered to him at 6:00 PM on 11/30/25 by a Nurse with different initials from the Nurse who administered the same medication on 11/30/25 at 7:00 PM. She added that the physician order was not followed. 2) Resident # 6 was admitted to the facility on [DATE] with diagnoses that included Respiratory Failure, Malignant Neoplasm of Supra glottis, Dysphagia, Oropharyngeal Phase, and Tracheostomy Status. A review of Medication Administration Record (MAR) sent electronically by the DON on 12/05/25 documented Resident #6 had orders for tracheostomy care daily as follows: Cleanse site with normal saline, pat dry and cover with drain sponge daily and as needed. Additional review of MAR documented that from 12/01/25 until 12/03/25, the order was not followed due to absence of check marks and nurse's initials parallel to the order. In an interview conducted with Staff C, RN on 12/03/25 at 1:08 PM, when she was asked if they stored solutions, and biologicals at resident's bedside, she responded, no. When she was asked if a tracheostomy care physician order must be followed by staff she responded yes. When she was asked how would staff know that a tracheostomy care order was followed and done by staff, she responded that parallel to the order are Nurse's initials and check marks.

Based on observations, record reviews and interviews, the facility failed to provide maintenance services necessary to maintain a sanitary, safe, clean, and homelike environment for residents. The findings included: During entrance to the facility on [DATE] at 9:10 AM, it was observed that the back area visible to residents who smoke, had old furniture, metal filing cabinets, tarp covered boxes of paraphernalia, and some uncovered boxes of gadgets. During another observation on 12/03/25 at 9: 21 AM, the same collections of furniture, boxes and gadgets were present. In an interview with the Maintenance Director, he stated he is trying to organize all these gadgets, furniture and supplies that came from a storage box. When he was asked when he would think it would be organized, he did not respond. In an interview conducted with a resident, she stated that the view is not good for relaxation because it seemed like trash is everywhere. An additional tour of one of the resident's rooms revealed that the bathroom had no trash bin, with 1 (one) defective light above the bathroom sink, 2 defective lights, and a missing mirror above the sink inside the main room. There was a rusted uncovered screw at bottom part of the toilet seat. The other rooms in that section all have trash bins in the bathrooms, working lights above the bathroom sink, and the main room with mirrors above the main room sink. A tour of the room on the opposite side revealed defective bathroom sink lights and above the sink lights in the main room. In an interview conducted with the Maintenance Director on 12/02/25 at 3:30 PM, he stated he started working 3 weeks ago and he is still trying to get inventories of all necessary repairs inside the facility. In interviews conducted with the nurses and Certified Nursing Assistants (CNA) on that section of the facility on 12/02/25 at 11:30 AM, they stated that they tried to work with minimum lights and use the other trash bins inside the residents' rooms if there are no trash bins in the residents' bathrooms. They added they learned to live with these lacks. They added that they noticed the holes inside the residents' rooms too, but stated the management is aware. During a continuing tour of the facility on 12/02/25 at 3:45 PM, and 12/03/25 at 10:30 AM, it was observed that some areas have holes like in the bathroom doors, and behind the residents' beds. When the residents were asked, they stated that they told staff about the holes, and they never received responses on when they will be fixed. In interviews conducted with other residents on 12/02/25 at 11:30 AM, they stated that the main dining room ceiling had been leaking for months, staff were aware, but nothing had been done. They added that there is also a ceiling leak in the short hall area that staff had been aware, but still nothing had been done. They wanted to know when these areas would be repaired. In interviews conducted with the NHA and the DON on 12/02/25 at 4:05 PM, when they were asked about the leaks in the main dining room and the short hall, they responded that no residents have been using the main dining room in 10 months. They provided no reason for the Main Dining Room to be closed. In an interview with the DON on 12/02/25 at 11:45 AM, she was asked to provide the work order for the leaks in both the short hall and the main dining room, she responded that she would ask the Maintenance Director. Nothing had been submitted to the Surveyor.

Based on interview and record review, the facility failed to meet 24 hour staffing requirements on weekends for the period of 10/1/24 to 12/31/24. The findings included: The CMS Payroll Based Journal (PBJ) report for the facility for the First Quarter of 2025 for the period from October 1, 2024 to December 31, 2024, indicated the facility had excessively low staffing on the weekends for the quarter. This report was run on 05/27/25. On 06/02/25 at 12:13 PM, an interview was conducted with Resident #63. Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates she was cognitively intact. Resident #63 had her most recent MDS assessment dated [DATE]. This was the resident's Annual Assessment. Resident #63 stated that there were not enough staff, especially on weekends. Resident #63 stated that it could take hours for anyone to come to the room (respond to the call light) on weekends and overnight. Resident #63 indicated that her roommate, Resident #55, who is also her spouse, was more impacted because he required more assistance than she did. On 06/12/25 at 12:13 PM an interview was conducted with Resident #55, roommate and spouse of Resident #63. Resident #55 was re-admitted to the facility and had his 5-day MDS assessment dated [DATE]. Resident #55 had a BIMS of 13, which indicated he was cognitively intact. Resident #55 expressed agreement with Resident #63. Resident #55 stated he needed to be moved out of bed by using a lift, which requires 2 people to operate. Resident #55 stated that on weekends it takes longer for staff to get him out of bed to his wheelchair because the staff often needs to wait until there are two of them available. On 06/03/25 at 11:54 AM an interview was conducted with Resident #9, who had a BIMS of 15. Resident #9 had her Quarterly MDS assessment dated [DATE]. Resident #9 stated that there could be better service on the weekend. Resident #9 clarified that she did not believe there was enough staff on the weekend. Resident #9 did not wish to elaborate further. On 06/04/25 at 11:43 AM, an interview was conducted with the Business Office Assistant (BOA). The BOA stated he is responsible for documenting and reporting Payroll Based Journal data. The BOA explained that the PBJ data is loaded directly to the CMS system from the computerized payroll system. The BOA stated that hours worked are calculated based upon when the employee punches in punches out. The BOA acknowlodged that there have been times that the facility has been understaffed in the past. On 06/05/25, calculations were performed for weekend staffing from October 2024 through December 2024. The calculations were performed for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). The calculations involved totaling reported hours for nurses (RNs and LPNs) and dividing by the number of residents reported for the day. The results revealed 12 weekends with a ratio of nursing hours per resident to be less than 1.0. This included the following dates: 10/26, 10/27, 11/2, 11/3, 11/10, 11/30, 12/01, 12/07, 12/14, 12/15, 12/28, and 12/29.

Based on review of policy and procedure, observation and interview, the facility failed to maintain infection control standards, as per protocol, in the Laundry Room and Soiled Utility areas. The findings included: Review of the facility policy titled Laundry Services provided by the Director of Nursing (DON) effective October 2021 documented in the Policy Statement: The facility will strive to protect residents and employees from facility-acquired infections and communicable diseases and to reduce the risk of cross-infection by utilizing hygienic practices for the handling and processing of soiled linens appropriate procedures will be followed to minimize potential healthcare associated and occupational risks associated with soiled linen handling .Standard Precautions will be followed when handling soiled linens. Procedure: 1. Clean washer and dryer .surfaces daily with a disinfectant. 2. Clean lint traps after each load .12. Clean and disinfect all laundry areas routinely. Review of the facility policy titled Description of Steps in the Laundry Process provided by the Administrator revised 09/05/17 documented in the Policy Statement: There are six steps in the laundry process: 1) Pick-up or collection of soiled linen A. Collection of Soiled Linen: Soiled linen containers or barrels should be on each Nursing unit stored in a soiled area so that nursing can deposit soiled linen. These containers should be checked at regular intervals to keep the soiled linen from over-flowing, which may cause odor and infection control problems Soiled linen must be removed from the units for two (2) reasons: 1. Keep the area infection free .B. It is very important to properly transport and store soiled linens to prevent the spread of infection. To do so, all soiled linen and clean linen must be covered during transportation and while being stored on unit or floors .At designated times, laundry workers are to collect soiled linens from each Soiled Linen Room using a large bin with lid, marked For Soiled Linen Use Only 2. Sorting Soiled Linen Soild linens brought down manually must .be placed into the soiled linen bins C. Lint Screens: a lint screen is installed in the bottom compartment of all commercial dryers. Lint that falls from the linen as it dries is caught by the lint screen, preventing lint from moving directly through the vent and blowing all over the outside of the building. These lint screens must be brushed and cleaned after every load or every hour. If not, the screen will be become packed with lint. When this occurs, warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation; i.e., where one spark on lint can cause fire. Torn or improperly fitted screens must be reported to facility maintenance personnel via a work order for immediate repair. Lint may also: a) Build-up between the drum and the sides of the dryer is the root cause of many dryer fires. This may cause a problem because in many dryers there is a heat sensor there. This sensor reads the heat of the basket and is programmed to shut the dryer down if the temperature gets too hot. If this sensor is covered with lint, the lint acts as insulation and fools the sensor into thinking the basket is not as hot as it really may be. So, instead of shutting the dryer down, it allows heat to continue to pour in. It is extremely important that you remove the entire front of the dryer and vacuum the entire interior. b) Build-up on the top compartment of the dryer. This is dangerous because the heat source is here. The top panel must be opened and the area must be cleaned daily. During an observational tour of the Laundry Room on 06/03/25 at 9:54 AM, it was observed that for one (1) of two (2) commercial dryers: the Speed Queen, this dryer's inner drum was noted to have multiple surface areas covered with some type of thick caked on rust-colored and whitish gunky substance areas (which contained a heavy/caked on/crusted/peeling amount of potentially- contaminated, melted dark matter/debris, along the inner drums of both dryers, all touching and coming into direct contact with the resident's clean clothing. And, it was also noted in 1 of 2 commercial dryers that the Fagor dryer's lint trap filter basket was full with ripped and torn areas, and caked with hanging lint noted in pieces and piles and the lint trap itself was loosened with the rust colored metal bar noted to be broken hanging down and not attached to the dryer itself; all creating a potential, fire hazard. Photographic Evidence Obtained. On 06/03/25 at 9:54 AM a consecutive interview was conducted with two (2) laundry aides Staff E, and Staff F, in which they were asked if they were aware of when the Speed Queen's dryer drum was last cleaned by Maintenance Department and they both responded that they did not know. On 06/03/25 at 10:15 AM during an interview, the Housekeeping Director stated that she recalled that the Maintenance Director told her that he had spoken to a vendor regarding cleaning the dryer drum and the lint traps. However, the Housekeeping Director indicated that she was unable to recall exactly when or with whom. She added that she was not sure how often the outside company comes in to clean the dryer drums and she acknowledged that she did not have any documentation regarding the cleaning schedule for the dryer drums and the lint traps. The Housekeeping Director stated that she would have to check with Maintenance regarding this. The Housekeeping Director further acknowledged that the Speed Queen dryer's drum did have multiple surface areas covered with some type of thick rust-colored and whitish gunky substance areas. The Housekeeping Director stated that she had not been made aware of this, but she reiterated the fact that she had spoken with the Maintenance Department about it, and she was told that they did not want to order any new machines, and she was also unable to recall how long ago this was. The Housekeeping Director ended by saying that she did not document any of the above conversation with the Maintenance Director. As the laundry room tour progressed on 06/03/25 at 10:25 AM, it was noted that one (1) of two (2) commercial washing machines, Speed Queen, was observed to be non-functional and non-operational with multiple chipped off rust covered areas on the side base and to the rear of the washing machine, to include the very rust-colored door; which was left hanging open. According to the Housekeeping Director, she said that this washing machine has been down and not usable for about thirty (30) days and she said that she told Maintenance about it at the time. She said that the Maintenance Director had spoken with the vendor, to her knowledge, yesterday and she does not know what the outcome was. She acknowledged that this facility (with a current capacity of 111, as of 06/02/25) has been operating on only one (1) washing machine, for the past thirty (30) days, she added that she did not document this conversation with the Maintenance Director, anywhere either. During a subsequent interview conducted on 06/03/25 at 10:35 AM again with the two (2) laundry aides Staff E and Staff F, in which they were asked, how long has the Speed Queen, commercial washing machine not been working, to their knowledge, and both responded, that it has been at least for four (4) weeks, or so. On 06/03/25 at 11:05 AM during a tour of 100 hallway Soiled Utility Room, it was noted that there was a clear, smaller plastic bag sitting atop the sink and outside of the main clear, soiled laundry bag; both of which contained residents soiled linen, the smaller, clear resident linen bag was not properly bagged and covered, which clearly exposed the soiled linen. Photographic evidence obtained. On 06/03/25 at 11:07 AM, a consecutive interview was conducted in which all of the above was acknowledged by both the Housekeeping Director, and by the Assistant District Manager of Health Care Services. And, the Assistant District Manager of Health Care Services acknowledged that the dryer drums should have been cleaned on a regular monthly basis. Interview on 06/03/25 at 1:52 PM with the Maintenance Director, he stated that the Speed Queen washing machine has been out of service for at least the past two (2) weeks. The Maintenance Director indicated that he had obtained a quote in order to either fix the washing machine motor, or for a new washing machine replacement. He said to this Surveyor that he had just been made aware of both the inner Speed Queen dryer drum with the built up melted materials, as well as of the Fagor dryer's lint trap filter having ripped and torn areas, which were loosened with caked on lint; the the rust colored metal bar was noted to be hanging down and not attached to the dryer itself. The Maintenance Director said that the laundry personnel were responsible for shaking out the linen, prior to putting it in the machines. According to the Maintenance Director, the dryer drums are cleaned out, only on an as needed basis, by the Maintenance department. However, he was unable to provide any current paperwork to show the last time that this had been done. The Maintenance Director acknowledged that both the dryer drum and lint trap basket needed to be done now. Resident #57 was admitted to the facility on [DATE]. She had a Brief Interview Mental Status (BIM) score of 12, indicative of moderate impairment. During an interview conducted on 06/04/25 at 11:10 AM with Resident #57 regarding the broken washing machine, she was asked the following three (3) questions, with a response: 1) Are your clothes being laundered on a regular basis? Yes, at least once a week, on a day she chooses, she places her dirty laundry in a bag for the facility to wash. About how long does it take to get your clean laundry back? She stated that it will take more than a week to get her clean clothing back. She said that a CNA will come to her room and gather the bag of dirty clothing and take it to the laundry; then it will come back over a week later. She also said that she had asked the CNA why does it take so long to get her clean clothing back and she said that she was told by the CNA that the washing machine was broken. 2) Does this bother you? Absolutely, yes, it does, according to the resident. 3) How long has this been happening? She said ever since that she has been residing in this facility starting shortly after her admission date of 01/06/25. Record review was conducted of the 04/25/25 quote, provided by the Administrator, labeled Re-build the motor with the sheave/removed to re-build and install and test for proper operation at a quoted cost of $1,1840, work labor quoted at a cost of $920, for a grand total of $2,760. Both the Administrator, and the Maintenance Director were interviewed, in which both were asked, since they had been aware of the Speed Queen washing machine's mal-function, since this quote, what was the hold-up, with getting this washing machine repaired or replaced, in a timely manner, for the residents in the facility? The Maintenance Director responded first by saying that he verbally told the Administrator about the receipt of the quote to repair the washing machine which had been exhibiting issues, at that time. Then, the Administrator stated that, when the machine finally broke down, he said that he then contacted the vendor, two (2) weeks ago via phone, and he was sent a quote for repair of the current washing machine motor. The Administrator and the Maintenance Director both acknowledged that the facility had been operating with only one (1) machine for their capacity of well-over one-hundred (100) residents; for a period of at least two (2) weeks, or more. Both the dryer drum and dryer lint trap were not cleaned, until after surveyor intervention. The Administrator further recognized and acknowledged on 06/03/25 at 3:45 PM regarding all of the above. He acknowledged that the washer had not been working, since at least the past two (2) weeks. And, the Administrator also indicated that he had just been made aware of the above dryer issues, during this survey, and he added that the dryer drum and dryer lint trap should have been kept cleaned regularly and properly.

Based on observation interviews and record review, the facility failed to ensure that a call light was within reach and working for 1 of 30 sampled residents (Resident #76). The findings included: A chart review revealed Resident #76 was admitted on [DATE] with diagnoses of Muscle Weakness and Hypertension. The Annually Minimum Data Set (MDS) dated [DATE] showed that Resident #76 has a Brief Interview Mental Status Score of 13, which indicated the resident is cognitively intact. In an observation conducted on 06/02/25 at 10:17 AM, Resident #76 was noted on bed with the call light noted on the floor and away from Resident #76's reach. In an observation conducted on 06/02/25 at 11:11 AM, Resident #76 was noted in bed with the call light noted on the floor and away from Resident #76's reach. In an observation conducted on 06/02/25 at 11:52 AM, Resident #76 was noted in bed with the call light noted on the floor and away from Resident #76's reach. In an observation conducted on 06/02/25 at 12:30 PM, Resident #76 was noted in bed with the call light noted on the floor and away from Resident #76's reach. In an observation conducted on 6/04/25 at 1:37 PM, Resident #76's call light was noted on the bed within reach. Resident #76 was observed pressing the call light, but no light or noise was illuminated outside Resident #76's room or at the nurses' station, indicating that the call light was being used in Resident #76's room. In an interview conducted on 6/4/25 at 2:45 PM with Staff B, the Certified Nursing Assistant (CNA), she stated call lights need to be working and within reach of residents when needed. She further noted that when a resident uses the call light, a light outside the resident's room will turn on, indicating that the call light has been pressed. In this interview, this Surveyor asked Staff B to try and press the call light for Resident #76. Staff B pressed Resident #76's call light and said that it needed to be looked at since only one side of the call light was working. Staff B stated that she had pressed Resident #76's call light earlier and noticed that it was not functioning properly.

Based on observations, interviews, and record reviews, the facility failed to monitor and reassess the nutritional needs of 1 of 1 residents reviewed for tube feeding (Resident #19). The findings included: A review of the facility's policy titled Weight Management dated January 2021 showed the following: The dietitian and/or authorized designees will assist the team with identifying significant weight changes and pertinent trends as needed based on the facility process. 1 week 2%, 1 month 5%, 3 months 7.5% and 6 months 10%. The dietitian will reassess the nutritional needs and intake of the Resident with a weight change. Appropriate recommendations will be documented in the medical record via a dietitian recommendation form. Resident #19 was readmitted on [DATE] with diagnoses of Muscle Weakness and Severe Protein-Calorie Malnutrition. The Minimum Data Set, dated [DATE] showed a Brief Interview Mental Status score of 15, which is cognitively intact. A review of the weight logs showed the following weight history for Resident #19: 1/7/2025, a weight of 126.2 pounds. 5/7/25, a weight of 98.4 pounds. 05/14/25, a weight of 98.7 pounds. This showed a 22% weight loss from 1/7/2025 to 5/7/2025. Resident #19's Initial admission to the facility was on 4/28/23, and he was discharged from the facility on 3/26/25 and readmitted again on 4/8/25. The Nutrition Evaluation Comprehensive, dated April 9, 2025, showed the following: Resident #19 has been refusing to be weighed since January, which makes monitoring changes in nutritional status difficult. The Registered Dietitian (RD) used 126.2 pounds from 1/7/2025 to assess Resident #19's needs. The estimated energy needs were calculated at 1710-1995 calories, 71-85 grams of protein, and 1425-1710 milliliters (ml) of fluids. A tube feeding Glucerna 1.5 (tube feeding formulary) at 65 ml an hour for a total of 1300ml. Resident #19's Basal Metabolic Index (BMI) was noted at 16.2, which indicated an underweight status. A follow-up nutritional note dated 05/09/25 showed the following: Resident #19 has been pulling his tube feeding out, and it was recommended to switch to bolus feeding to ensure the Resident's intake of feeding meets his estimated needs. It was recommended to change the tube feeding to Jevity 1.5 (tube feeding formulary), with five cans per day, for a total of 1,185 mL. In this note, the RD did not address the weight loss from 126.2 pounds to 98.4 pounds. A Progress note dated 5/19/2025 showed Resident #19 refused his bolus feeding at 9:00 AM and 1:00 PM. A follow-up nutrition note dated 5/30/25 showed Resident's weight was documented at 100 pounds with a favorable gain of 2 pounds from the last weight. In this note, the RD did not reassess Resident #19's nutritional needs related to the weight loss of 27.8 pounds identified on 05/07/25. In an interview conducted on June 4, 2025, at 9:00 AM with Staff C, the Registered Nurse (RN) stated that Resident #19 is receiving a bolus feeding tube with Glucerna 5 times a day. She is responsible for the feeding times at 9:00 AM and 1:00 PM, which is on her shift. Staff C further stated that Resident #19 was tolerating his tube feeding well. On June 4, 2025, at 1:45 PM, Staff C was preparing to administer the bolus tube feeding to Resident #19. Resident #19 said, I am full of poop, and told Staff C that he did not want the bolus tube feeding at this time. An interview conducted on 6/4/25 at 1:39 PM with the facility's clinical RD stated that she completes a monthly nutritional assessment for residents on tube feeding. She will also address any significant weight loss of 5% in one month, 7.5% in 3 months, and 10% in 6 months. For any residents with unknown weights, she will use the prior weights until she gets a more current weight. When asked if she reassessed Resident #19's needs after the new weight was identified on 5/7/2025, she said no. The RD acknowledged that Resident #19 had a significant weight loss, and she did not complete the monthly nutritional assessments. In an interview conducted on 6/04/2025 at 3:00 PM with Resident #19, he stated that he did not understand why he could not eat by mouth and asked this Surveyor why he had to be on a feeding tube. The Care plan dated 5/13/25 showed that Resident #19 was at high nutritional risk and required maintaining nutritional intake without significant changes.

Based on observations, interviews, and record review, the facility failed to follow the Pureed diet consistency for 1 of 2 visits to the main kitchen. This has the potential to affect 9 residents on a Pureed diet out of 103 current census residents. The findings included: A review of the facility ' s policy titled Pureed Diet, dated 11/2017, showed the following: Pureed means that all food has been grounded, pressed, and/or strained to a soft, smooth consistency like pudding. An observation conducted on June 4, 2025, at 11:45 AM during the lunch tray line revealed a container of pureed turkey on the tray line. Closer observation revealed pieces of green particles in the pureed turkey. Staff A, Cook, said that she made the pureed turkey and added sweet relish for flavor. In an interview conducted on June 4, 2025, at 11:55 AM with the Food Service Director, he acknowledged the green particles in the pureed turkey. In an interview with Staff D, the speech-language pathologist, on June 4, 2025, at 12:00 PM, it was stated that a pureed diet should have a mashed potato-like consistency with a uniform texture and no lumps or pieces.

Based on observations, interviews, and record review, the facility failed to provide food choices and preferences for 2 of 4 residents reviewed for nutrition (Resident #88 and Resident #95). The findings included: 1. A chart review revealed that Resident #88 was admitted on [DATE] with diagnoses of Hypertension and Hyperlipemia. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating cognitive intact. On 06/02/25 at 12:35 PM, an observation was conducted, and Resident #88 was found in her room eating her lunch tray. The meal ticket noted the following: large portion, 5 ounces pulled pork, plantains, yellow rice, mango mouse, mighty shake, and a peanut butter and jelly sandwich. The lunch meal plate was noted with the magic cup, but it did not contain a large portion of the 5 ounces of pulled pork, plantains, or yellow rice, as indicated on the meal ticket. The Care Plan for Resident #88 showed nutritional problems and to provide diet and supplements as ordered. 2. A chart review revealed Resident #95 was admitted to the facility on [DATE] with diagnoses of Chronic Anemia and Adult Failure to Thrive. The admission MDS dated [DATE] revealed a BIMS score of 13, which indicated the resident is cognitively intact. On 06/03/25 at 8:41 AM, an observation was conducted, and Resident #95 was eating his breakfast tray. The meal ticket was noted as follows: a large portion of ham and cheese Frittata, cereal of choice, wheat toast, juice of choice, 2% milk, and a fresh fruit cup. The breakfast meal plate was missing the fresh fruit cup and the 8 ounces of milk. Closer observation revealed that Resident #95 did not receive a large portion of his breakfast meal either. In this observation, Resident #95 said he did not get his milk or fresh fruits this morning. The Care plan dated 2/27/2025 showed that weight gain would be favorable for this Resident and to provide large portions as ordered. In an interview conducted on June 3, 2025, at 3:00 PM with the Food Service Director, he stated that the meal tray is checked for food accuracy and that the correct diet order is provided. Two staff members on the tray line check for the accuracy of the trays and any orders of large portions.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses during two of the two visits to the main kitchen. The findings included: 1. A tour of the main kitchen was conducted on 6/2/25 at 9:39 AM with the following issues noted: A bottle of 46 ounces of Thickened Orange Juice from the walk-in refrigerator with a used date of April 30, 2025. The facility's internal thermometer in the walk-in refrigerator indicated 50 degrees Fahrenheit rather than the necessary 41 degrees Fahrenheit or below. A yellow cleaning bucket containing dark-colored water was noted in the food production area. A cup of strawberries near the food tray line showed 59.0 degrees Fahrenheit, not the necessary 41 degrees Fahrenheit or below. A cup of grapes near the food tray line showed 59.4 degrees Fahrenheit, not the necessary 41 degrees Fahrenheit or below. A cup of canned pears near the food tray line showed 58.1 degrees Fahrenheit, not the necessary 41 degrees Fahrenheit or below. The floor in the dry storage room was filled with debris and food wraps all around. 2. A second visit to the main kitchen on 06/4/2025 at 11:30 AM during the lunch tray line showed the following: A cold container of pureed turkey meat with a temperature of 44.5 degrees Fahrenheit and not the necessary 41 degrees and below. A metal container of lettuce with a temperature of 58.8 degrees Fahrenheit and not the necessary 41 degrees and below. A metal container of sliced tomatoes with a temperature of 58.9 degrees Fahrenheit and not the necessary 41 degrees and below. In this observation, the Food Service Director stated that he would return the sliced tomatoes and lettuce to the refrigerator to ensure they cooled to the appropriate temperature. In an interview conducted on 06/05/25 at 3:00 PM with the administrator, he was informed of the findings.

Based on observations, interviews and record review, the facility failed to provide foods in accordance with professional standards for food safety. The findings included: 1). During the initial kitchen tour, on 03/04/24 at 7:38 AM, accompanied by the Food Service Manager, the following was noted: a. There was an accumulation of ice on the cooling unit in the walk in freezer. b. The wall under and behind the steamer was damaged. c. There was an accumulation of dust and debris inside of the vents of the air conditioning unit. At the conclusion of the initial tour, the Food Service Manager acknowledged understanding of the concerns. 2). During the follow up tour, on 03/06/24 at 11:23 AM, the following was noted: a. Staff L, Cook dropped a ladle on the floor. The Cook picked up the ladle and went to the three compartment sink and began to wash the utensil in the wash basin. The Cook then rinsed the ladle and then swished the ladle in the sanitizer, without completely submerging in the sanitizer and then placed the utensil on the drying rack with other cleaned and sanitized utensils. The cook then removed the ladle to use for food service. This surveyor instructed Staff L to properly wash, rinse and sanitize the ladle before being used. During the observation, the Cook did not perform hand hygiene. b. Staff L was observed handling soiled utensils with gloved hands the Cook proceeded to dry the gloves on her hands with paper towel and began handling cleaned and sanitized utensils and clean and sanitized pans. The Cook was instructed by this surveyor to stop and remove the gloves and perform hand hygiene. c. Staff M, Cook was observed as she dropped serving utensils on the floor. The Cook picked up the utensils with gloved hands and then placed on the cutting board attached to the hot holding unit. The cook then removed the gloves and placed them in direct contact with the food contact surface of a clean and sanitized set of tongs that were intended to be used to plate the meal. As the Cook was beginning to use the set of tongs that had been in contact with the contaminated gloves, this surveyor informed her of the observation and the Cook was instructed to replace it with a clean and sanitized utensil. d. The handle of a spatula had been melted in a manner that created an uncleanable surface. At the conclusion of the follow up kitchen tour, the Food Service Manager, Staff L and Staff M acknowledged their understanding of the concerns.

Based on observations and interview, the facility failed to honor residents' choices for 2 of 2 residents with preferences for eating in the dining room, Residents #80, and 88. The findings included: The facility's Mealtimes and Delivery Schedule documented: Main Dining Room Seating Schedule Breakfast: 7:10 AM to 7:20 AM 1). Resident #80 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), dated [DATE], Resident #80 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #80's diagnoses at the time of the MDS. During an interview with Resident #80, on 03/04/24 at 8:09 AM, in the Main Dining Room, it was noted that the resident had his breakfast on the table in front of him and that there was no staff in the dining room. During an observation of breakfast being served to the residents in their rooms, on 03/05/24 at 8:03 AM, Resident #80 was noted to be in the Main Dining Room with his breakfast on the table in front of him. During an observation of breakfast being served to the 100 unit, on 03/06/24 at 7:44 AM, Resident #80 was observed in the Main Dining Room and did not have a breakfast as he had the previous two observations. During an interview with Resident #80, on 03/06/24 at 08:09 AM, when asked about not having his breakfast, Resident #80 stated that he takes all meals in the Dining Room. Resident #80 further stated they will only allow residents to eat in the Dining Room during lunch because there is no CNA (Certified Nurse's Assistant) or nurse in the dining room. We have to have breakfast and dinner in our rooms because there is no staff to watch us in case we choke. I don't understand why it would matter that I eat in the Dining Room or my room because there is no one in my room if I choke. On 03/06/24 at 8:16 AM, Resident #80 returned to the unit and confronted the Social Services Director about eating in the dining room. Resident #80 was upset about not being able to have his breakfast in the Dining Room. During an interview, on 03/06/24 at 8:25 AM, with Staff K, UM/LPN, when asked about Resident #80 eating breakfast in the Dining Room, Staff K replied, There is no supervision in the Dining Room, and we don't leave the resident unsupervised in the dining room. I wasn't aware that he was there for breakfast. On 03/06/24 at 8:35 AM, Resident #80 was observed in the dining room after confronting the Social Services Director. Resident #80 stated that he had refused breakfast and ordered a meal to be delivered from Door Dash (a food delivery company) that was on the table in front of him. It was noted that there were no staff members in the Dining Room at the time of the interview and observation. During an interview, on 03/06/24 at 10:04 AM, with the Social Services Director, when asked about Resident #80 not being served breakfast in the Dining Room, the Social Services Director replied, I went to the nurse, because I didn't know why either. During the observations and interviews with Resident #80, it was noted that Resident #80 was eating the meals independently. 2). Resident #88 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly MDS, dated [DATE], Resident #88 had a BIMS score of 15. Resident #88's diagnoses at the time of the assessment included: Hypertension, Diabetes, Anxiety Disorder, Muscle Wasting and Atrophy, Lack of Coordination, Morbid Obesity, Polyneuropathy, Insomnia. During an observation of the lunch meal, on 03/06/24 at approximately 1:00 PM in the main dining room, Resident #88 was sitting at a table with Resident #80. When asked about having breakfast in the Dining Room, the resident stated that she would have breakfast in the Dining Room but did not due to concerns that the breakfast meal would be served later than it already is. During the interview, Resident #88 was noted to be eating the meal independently. During an interview with the Registered Dietitian, on 03/07/24 at 11:52 AM, when asked about residents' preferences for having breakfast in the Main Dining Room, the Registered Dietitian replied, During food committee, I ask, and no one has ever said nothing. They are always telling us that they want to, and I tell them that it is open for Breakfast, Lunch and Dinner, we just need somebody to be there in the dining room. During an interview with the Director of Nursing (DON), on 03/07/24 at 3:00 PM, when asked about residents eating breakfast in the Dining Room, the DON replied, they can, that needs to be in-serviced. I brought it up with the administrator before and then nobody wanted to eat in the Dining Room. The nurses are assigned for lunch and dinner. They said that they wanted to open the Dining Room for lunch and dinner.

Based on record review, observations and interviews, the facility failed to provide care and services in a dignified manner to 1 of 1 resident (Resident #21) reviewed for Dignity. The findings included: Review of Resident #21's clinical record documented an admission on 11/02/22 with no readmissions. The resident diagnoses included Alzheimer's Disease, Persistent Mood [Affective] Disorder, Cognitive Communication Deficit, Type 2 Diabetes Mellitus, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Metabolic Encephalopathy (a problem in the brain), Abnormalities of Gait and Mobility and Muscle Weakness. Review of Resident #21's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0 indicating that the resident had severe cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on staff for toileting and needed substantial to maximum assistance with most of the activities of daily living. Review of Resident #21's care plan titled (Activities of Daily Living) ADL: The Resident has an ADL self-care performance deficit as evidence by: weakness, difficulty walking, gait imbalance initiated on 11/04/2022 and revised on 11/04/2022. The care plan interventions included: .resident is total dependent upon staff for ADLs .transfer: assist of 2 staff participation with transfers with mechanical lift .toilet use: assist of 2 . Review of Resident #21's care plan titled INCONTINENCE: The resident is incontinent of bladder/bowel and is not a candidate for a toileting program related to: immobility, involuntary or unpredictable bladder and bowel elimination initiated on 05/28/2022. The care plan interventions included: .check for incontinence with routine care, upon arising, before and after mealtime .Provide incontinence care as indicated .Observe for foul smelling . On 03/06/24 at 10:15 AM, during an interview, the Director of Nursing (DON) and the Regional Nurse were asked to submit the facility's policy related to Activities of Daily Living (ADLs). The Regional Nurse stated the facility did not have one. On 03/06/24 at 2:18 PM, observation revealed Resident # 21 sitting in a wheelchair in her room and rubbing her hands together. The resident was non-verbal, did not answer to questions asked. Further observation revealed a strong offensive odor like stool while standing in front of the resident. Staff C, Registered Nurse was in the room attending the resident's roommate. On 03/06/24 at 2:23 PM, observation revealed the Assistant Director of Nursing (ADON) entered Resident #21's room and confirmed a strong foul smell in the room. Observations revealed Resident #21 continue rubbing her hands vigorously and had brown matter on her hands. Subsequently, the ADON was informed of the resident having brown matter on her hands. The ADON acknowledged and called in Staff A, Certified Nursing Assistant assigned to the resident. On 03/06/24 at 2:41 PM, observation revealed Staff A, Certified Nursing Assistant (CNA) entered resident #21's room, searched the resident closet and pulled blue pads and was observed cleaning the resident's hands with a blue pad. At 2:49 PM, Staff A left the room and left the resident in the room sitting in a wheelchair. On 03/06/24 at 3:06 PM, Further observation revealed the strong foul smell was stronger in the room and near Resident #21. The resident continued rubbing her hands vigorously. At 3:09 PM, observation revealed the resident wheeling herself in the room up and down with her unbutton pants. Furthermore, observation revealed a blue color pad under the pants. Consequently, the ADON was asked to have Resident #21's brief checked due to the strong offensive odor, stool like smell. On 03/06/24 at 3:13 PM, observed the ADON was not able to reposition Resident #21's bed down. On 03/06/24 at 3:23 PM, observation revealed Staff I, CNA came in to change the resident and stated the bed needed to be fixed and left the room. Continuing observation revealed Resident #21 moving around the room in wheelchair, shuffling her feet, appeared to be uncomfortable. On 03/06/24 at 3:26 PM, observations revealed Resident #21 wheeling herself out of her room into the hallway and with unbutton pants. The resident wheeled herself about 15 feet away from her room. Subsequently, observation revealed the ADON looking for Resident #21's assigned CNA, Staff I. On 03/06/24 at 3:31 PM, observations revealed Staff I, CNA and Staff J, CNA entered Resident #21's room . Staff I and Staff J placed the resident in bed without using a mechanical lift as per care plan. The resident's wheelchair had brown matter on the wheelchair arm rest. Further observation revealed the resident was attempting to pull her brief off. Staff J told the resident relax, we are to change it. During an interview, Staff J acknowledged the resident was uncomfortable. Staff I pulled the resident's pants down and stated, what a mess. Observation revealed the resident's pants had brown matter on the back of the pants. The resident had a brief and a blue pad tucked in the front area. The brief had a large amount of paste brown stool with a strong offensive odor. Staff I was not aware that the resident needed to be changed. On 03/07/24 at 9:38 AM, an interview was conducted with the ADON who stated that Staff A, CNA should had cleaned and changed Resident # 21's brief before she left the facility. On 03/07/24 at 9:42 AM, a joint interview was conducted with the DON and Staff A, CNA. Staff A was asked why she did not change Resident # 21's brief before she left her in room. Staff A stated she could not put the resident back in bed by herself. Staff A was asked why you did not ask for help and replied, I couldn't find nobody. On 03/07/24 at 1:34 PM, during an interview, the Director of Nursing (DON) was asked to submit the facility's policy related to Incontinence Care and stated the facility did not have one.

Based on observations, interviews and record reviews, the facility failed to resolve grievances regarding the timing of meal deliveries voiced by residents and members of the Resident Council. The findings included: The meal delivery schedule documented the following schedule for the breakfast and lunch meals: Breakfast Wing 1 Short Hall, Rooms 101 to 112 at 7:20 AM to 7:35 AM Wing 2 Short Hall, Rooms 201 to 212 at 7:35 AM to 7:45 AM Wing 1 Long Hall, Rooms 113 to 126 at 7:45 AM to 7:55 AM Wing 2 Long Hall, Rooms 213 to 226 at 7:55 AM to 8:10 AM Lunch Wing 1 Short Hall, Rooms 101 to 112 at 11:30 AM to 11:40 AM Wing 2 Short Hall, Rooms 201 to 212 at 11:40 AM to 11:50 AM Wing 1 Long Hall, Rooms 113 to 126 at 11:50 AM to 12:00 PM Wing 2 Long Hall, Rooms 213 to 226 at 12:00 PM to 12:10 PM On 03/04/24 at 7:38 AM, during the initial kitchen tour, Staff were in the process of preparing the food to be served for the breakfast meal for that day and no meals had left the kitchen to be served to the residents. Staff did not begin plating the meal until approximately 8:00 AM. On 03/04/24 at approximately 12:30 PM, lunch arrived to the Wing 1 Short Hall - one hour after the scheduled time. On 03/05/24 at 8:03 AM, Breakfast arrived on the Wing 1 Short Hall, Rooms 100-112 - more than 30 minutes after the scheduled time. On 03/05/24 at 8:23 AM, Breakfast arrived on the Wing 1 Short Long Hall, Rooms 113-126 - more than one half hour after the scheduled time. During a meeting with member of the Resident Council, on 03/05/24 at 2:15 PM, when asked about grievances, Resident #58 replied, The grievances are supposed to be written by the Activities Director and then he goes to Social Services and they don't do anything, it is just paperwork. Resident #94 stated, Last week it was 9:30 for Breakfast and 7:30 PM for Dinner. The Food Service Manager meets with us once a month and we have told him that the meals are late. During an interview, on 03/06/24 at 9:53 AM with the Social Services Director, when asked about grievances from the Resident Council, the Social Services Director replied, It is a different person (referring to the Activities Director). If there is a grievance that comes up, she would write it up as a grievance for the individual resident and for the group, she would do one as a group. When asked about the grievances voiced regarding the meals being served late, the Social Services Director replied, I can't' say that I am familiar with that. 03/06/24 at 11:05 AM, this Surveyor returned to the kitchen for the follow up tour. Upon entering the kitchen, the Food Services Manager(FSM) stated that the kitchen would not be ready to take temperatures and assemble the food on the plates for another 15-20 minutes. On 03/06/24 at 11:23 AM, this Surveyor returned to the kitchen for the follow up tour. Upon entering the kitchen, the kitchen staff were observed taking the temperature of the commercially processed meatballs in a six inch deep full-sized hotel pan that were part of the meal being served for lunch. The temperature of the meatballs was 111 degrees Fahrenheit, and the meatballs were placed back into the convection oven for further heating. At the conclusion of the tour and observations, the Food Service Manager was asked about the grievances voiced by the residents regarding meals being served late, the Food Service Manager replied, Each day, we deliver to a different unit first, we like to mix things up a little. Today, we are going to the unit 2 short hall first and tomorrow we will serve a different unit first. On 03/06/24 at 12:43 PM, the first cart arrived on the Wing 2 Short Hall for the lunch meal - nearly one hour after the scheduled time. During an interview with the Registered Dietitian, on 03/07/24 at 11:52 AM, when asked about the delivery of the meals from the kitchen to the unit the Registered Dietitian replied, I just got here in the end of November, I wasn't aware of the changing of the meal schedule. When asked about the grievances voiced by residents and the Resident Council, the Registered Dietitian replied, I do audits in the kitchen for sanitation, we do audits, I haven't documented them. We are watching the temperatures of the storerooms, look at the cleanliness of the floors, physical environment, emergency food, reach in logs and temperatures, cleanliness, food temperature logs. I observe tray line once a month or so - the compliance with the meal ticket, condiments, supplements, thickened liquids, fluid restrictions, following diet consistencies. Review of the Grievance Log revealed no grievances by or on behalf of the Resident Council related to the meals being served late.

Based on observation, interviews and record review, the facility failed to provide fingernails grooming for 2 of 2 sampled residents, Residents #11 and #44, observed for nail grooming. The findings included: Review of the facility's Job Description for Certified Nursing Assistants provided by the Director of Nursing documented direct care responsibilities .provides nail and hair care . 1) Review of Resident #11's clinical record documented an admission on 06/29/23 and no readmissions. The resident diagnoses included Tremors Secondary Parkinsonism, Encephalopathy (a problem in the brain), Lack of Coordination, Muscle Weakness, Glaucoma, and Major Depressive Disorder. Review of Resident #11 Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident needed partial to moderate assistance from the staff to complete most activities of daily living (ADLs). Review of Resident #11's care plan titled ADL: The resident has an ADL self-care performance deficit-Disease Process Parkinson's initiated on 06/29/23 and revised on 02/13/24. The care plan interventions included: anticipate needs, assist with personal hygiene . On 03/04/24 at 8:34 AM, initial tour to the facility's wing 1 was conducted. Observation revealed Resident #11 siting up in a wheelchair in his room and having involuntary fast movements (tremors) to his right hand. An interview was conducted with the resident who stated he had been in the facility for 6 months. Observation revealed the resident had elongated fingernails approximately 1/2 inch with black matter underneath the nails. The resident stated he had asked many times to get his nails cut and no one had done it. The resident added he had a nail clipper and pointed out to the nail clipper on top of the night stand. On 03/06/24 at 7:59 AM, observation revealed Resident #11 continues to have long fingernails with black matter underneath. Subsequently, a side by side review of the resident's fingernails was conducted with Staff C, Registered Nurse (RN) who stated the resident had not asked her to do his nails. Staff C was apprised of observation since 03/04/24 revealed his fingernails long and with black matter. Staff C stated it will be done today. On 03/06/24 at 8:01 AM, a side-by-side review of Resident #11 fingernails was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B stated she offered the resident fingernails care on 03/05/24 and he refused. On 03/06/24 at 8:08 AM, an interview was conducted with Staff F, CNA who stated the CNAs were responsible to do the resident's fingernails, clean and trim them. On 03/06/24 at 8:49 AM, an interview was conducted with Staff E, CNA who stated that on every Tuesday she goes around the units and check on the residents to see if they need to be shaved, checks the fingernails and cut and clean those that needed to be done. Staff E stated she had informed the Director of Nursing (DON) of those residents that refuse fingernails care. Staff E was asked if she did check on resident's fingernails on 03/05/24 and stated she did not because she had to help on the floor. Staff E added that Resident #11 refused fingernails care the prior week. On 03/06/24 at 9:24 AM, an interview was conducted with the DON who was apprised of Resident #11 elongated fingernails with black matter underneath observed since the beginning of the survey on 03/04/24. The DON stated it was the CNA job duties to do the residents fingernail care. The DON added if the resident refuses care, the CNA was supposed to go to the nurse who can reinforce with the resident and nurse then document in the clinical record. The DON stated that a couple of days a week Staff E CNA gets a census list from her and she had asked her to do an audit, to see who needed fingernail care and offer it. The DON added this was a backup plan separate to the CNA plan of care under the task report. The DON was apprised of no refusal of fingernails care was documented in the resident's clinical record. The DON confirmed Staff E did not do resident's fingernails care on 03/05/24. Subsequently, a side-by-side review of Resident #11's nail care CNAs task report from 02/06/24 to 03/05/24 was conducted with the DON. The task report did not document Resident #11 refusal of nail care. Furthermore, review revealed Staff A, CNA documented that she provided nail care on 02/29/24, 03/02/24 and 03/03/24. The DON stated Resident #11's nurses progress notes documented that the resident refused care but not specific to fingernail care. On 03/07/24 at 10:15 AM, an interview was conducted with Staff C, RN who stated she was not aware that Resident #11 refused fingernails nail care. Staff C added she will reinforced the care with the resident if she was informed. 2) Review of Resident #44's clinical record documented an admission on 04/10/23 and no readmissions. Review of Resident #44's MDS quarterly assessment dated [DATE] documented a BIMS score of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident needed supervision and touching assistance from the staff to complete the activities of daily living. Review of Resident #44's medical diagnoses included Muscle Wasting and Atrophy, Glaucoma, and Cellulitis of Left Lower Limb. Review of Resident #44's care plan titled ADL: The resident has an ADL self-care performance deficit initiated on 04/10/23. The care plan interventions included: assist with personal hygiene . On 03/04/24 at 8:00 AM, observation revealed Resident #44 up sitting by the edge of the bed wearing a pair of dark black sunglasses. An interview was conducted with the resident who stated that the staff needs to be educated about the safety of the blind. Observation revealed Resident #44 fingernails elongated approximately 1/2 inch and jagged. The resident was asked if he had his fingernails done and replied that was in his priority list for today and added that he asked for his fingernails to be cut many times. The resident pointed out to his left hand index finger, jagged nail. The resident added that at one time he made an outside appointment to have his nails done in a timely matter. The resident stated that he asked and the staff tells him, later 2-3 days later, not done. The resident added that the 3-11:00 PM shift aide told him that they won't do it to wait for day shift. On 03/06/24 at 7:51 AM, observation revealed Resident #44 sitting in a wheelchair. An interview was conducted with the resident who stated they cut his fingernails but still having a problem with two of them. Observation revealed two fingernails were jagged. On 03/06/24 at 8:01 AM, an interview was conducted with the Regional Nurse who stated the CNAs were responsible to do the resident's fingernails cleaning and trimming. On 03/06/24 at 8:02 AM, an interview was conducted with Staff A, CNA, assigned CNA, who stated she had not done Resident #44 fingernails and added that sometimes he refuses. Staff A was apprised of the resident fingernails were noted long on Monday (03/04/24) and that he had requested to be cut. Staff A stated that long time ago when she was the activities aide, she did the resident's fingernails and added the CNAs were responsible to do it. On 03/06/24 at 8:39 AM, a side by side review of Resident #44 fingernails was conducted with Staff A, CNA. Subsequently, an interview was conducted with the resident who stated and pointed out to two fingernails that were cut but were not filed and were jagged. During the review, Staff A stated that the resident had not asked her to do his fingernails. Staff A was asked why she did not offer to do his nails and stated she will do it today. On 03/06/24 at 8:49 AM, an interview was conducted with Staff E, CNA who stated that on Tuesday 03/05/24, she did not check on resident's fingernails as done every Tuesday because she had to help on the floor. Staff E was asked if she checked on Resident #44's fingernails on Tuesday 02/27/24 and replied she did not. Staff E stated Resident #44 had not refused fingernails care for her before. On 03/06/24 at 9:20 AM, an interview was conducted with Staff G, RN who stated the residents fingernails were done by the activities lady, but the CNA can do them too, if they see it needs to be done. On 03/06/24 at 9:21 AM, an interview was conducted with Staff H, CNA who stated the activities CNA will do the resident's fingernails or she can do it to. On 03/06/24 at 9:50 AM, an interview was conducted with the DON who was apprised of Resident #44's elongated, jagged fingernails. A side-by-side review of the resident's nail care CNAs task report from 02/06/24 to 03/05/24 was conducted with the DON. The task report did not document Resident #44 refusal of nail care. Furthermore, review revealed Staff A, CNA documented that she provided nail care to Resident #44 on 02/29/24 and 03/03/24. The report documented that Staff B, CNA provided nail care to resident #44 on 02/26/24, 02/27/24 and on 03/02/24. On 03/06/24 at 10:15 AM, during a joint interview with the Regional Nurse and the DON were asked to submit the facility's policy related to Activities of Daily Living (ADLs), fingernail grooming. The Regional Nurse stated they did not have a policy on ADLs or nail care. On 03/06/24 1:38 PM, an interview was conducted with the MDS Coordinator who stated Resident #44 had severe vision impairment, was blind and needed the staff to do his fingernails. The MDS Coordinator stated she was not aware of the resident refusal of nail care and that the resident was not care planned for refusal of it.

Based on observations, interviews, and record review, the facility failed to follow the Physician's orders for wound treatment and to provide wound care in a timely manner for 1 out of 1 resident reviewed for wound care (Resident #95). The findings included: On 01/15/24, Resident #95 was admitted to the facility with a medical history of Polyneuropathy, Type 2 Diabetes Mellitus, Hypertension, Anxiety Disorder, and Protein-Calorie Malnutrition. On 01/30/24, Resident #95 was hospitalized due to possible infection related to the wound on the right foot. On 02/05/24, she returned from the hospital with the following diagnosis, right great toe amputation, leukocytosis, and osteomyelitis. An Admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #95 had a Brief Interview of Mental Status (BIMs) score of 02, which indicated that she had severe cognitive impairment. Review of Section GG revealed that Resident #95 required assistance for most of her Activities of Daily Living (ADLs). Section M revealed that Resident #95 was at risk of developing Pressure ulcers or injuries and had an infection of the foot. Review of the Care Plan dated 01/26/24 documented that Resident #95 had Skin integrity risk. Goals were to have no complications and have minimize causative factors of discoloration areas through the next review. Interventions included follow facility protocols for treatment and monitor and document location, size, and treatment of skin. Review of the physician's orders revealed: Apply to right great toe topically every day shift, every 2 days for wound healing s/p (status post) R (right) great toe amputation cleanse affected area with n/s (normal saline), pat dry, apply Betadine, cover with Adaptic, 4 x 4 gauze, wrap with kerlix, secure with ace wrap AND apply to R great toe topically as needed for wound healing s/p R great toe amputation dated 02/06/24 (which was discontinued and revised on 03/06/24). Further review of the Physician's orders dated 03/06/24, cleanse right great toe with n/s, apply Betadine-soaked gauzed cover with dry dressing, wrap with rolling gauze, every day shift every 2 day(s) for wound care and as needed for wound care. In an observation conducted on 03/04/24 at 09:56 AM, Resident #95 was observed in bed, under the covers with her right foot dangling out of the bed. Upon closer observation of the foot revealed that the right foot was wrapped with a soiled gauze dressing dated 03/02/24 and signed by 7-3 Shift (Photographic evidence obtained). On 03/05/24 at 09:20 AM, an observation of Resident #95's right foot revealed the same soiled gauze dressing observed on 03/04/24 (Photographic evidence obtained). Review of the March 2024 Treatment Administration Record (TAR) for Resident #95 revealed the scheduled treatment for the right great toe amputation was for every two days and as needed (PRN). Further review revealed that treatment was done on 03/01/24, and the 03/03/24 treatment was left blank with no further documentation. In addition, the PRN order revealed that no treatment was done on 03/02/24. On 03/05/24 at 12:18 PM, an interview was conducted with Staff G, Registered Nurse (RN). She stated that she is usually the day shift nurse and has done the wound care for Resident #95's foot. She stated that Resident #95 tends to rub her feet together and the bandages move. She didn't change it on Monday (03/04/24) because the treatment was not scheduled to be done that day. In addition, she stated that she was not aware that Resident #95's bandage was dirty. On 03/06/24 at 12:40 PM, an interview was conducted with the Director of Nursing (DON). She stated that on Tuesdays she assesses and performs the treatments for all the residents with wounds in the facility. She stated that yesterday she noticed the bandages had not been changed for Resident #95, and that the treatment was about a day late.

Based on record review, observations and interviews, the facility failed to perform appropriate hand hygiene during room dining observation in wing 2 as evidenced by not performed hand hygiene between residents meal tray delivery; and failed to prevent potential of cross contamination during Trach Care and Tube Feeding pump re-setting as evidenced of reaching to a uniform pocket with a gloved hand. The findings included: Review of the facility's policy titled, Hand Hygiene effective 10/2021 provided by the Regional Nurse documented .employees must wash their hands .under the following conditions: .before and after entering isolation precautions .before and after assisting a resident with meals .after contact with a resident with infectious diarrhea including .Clostridium (infection) Difficile (hand washing with soap and water) . 1) On 03/04/24 at 8:55 AM, dining observation was conducted of the facility's wing 2 residents room dining service. On 03/04/24 at 9:03 AM, Observation revealed Staff B, CNA entered Resident #26's room to deliver his meal tray. Staff B placed the tray on top of the table, repositioned the resident's bed using the bed control, then proceeded to pour sugar on the hot cereal. Staff B came out of Resident #26's room and without performing hand hygiene, Staff B opened the trays cart and retrieved Resident #41's meal tray. Staff B entered the resident's room, placed the tray on the table, and then repositioned the bed using the bed control. Staff B then came out of Resident #41's room without performing hand hygiene and walked to the coffee cart and retrieved a cup of coffee for Resident #41 and delivered it. Staff B continued to open the meal cart without hand hygiene and pulled Resident #11's meal tray and delivered the tray. Staff B then left the area without performing hand hygiene and pushed the coffee cart away from the area. On 03/04/24 at 9:15 AM, observation revealed Staff A, CNA, setting up Resident #70's tray. Staff A stated the resident was blind and ate by himself after he was set up. At 9:16 AM, Staff A opened the meal cart and pulled Resident #66's meal tray. Resident #66 was on Contact Precautions due to Clostridium Difficile infection. Staff A entered the resident's room, did not don a gown or gloves. Staff A placed Resident #66's tray on top of the table, and without wearing gloves, retrieved the bed control and repositioned the bed. Staff A then went to the room sink placed the tip of her fingers without soap under the running water, then dry her hands. Continue observation revealed Staff A, without hand hygiene, opened the meal cart, pulled Resident #60's meal tray, delivered his tray, then peeled his banana, opened the mighty shake container and opened the room blinds. At 9:22 AM, observations revealed Staff A came out of Resident #60's room, roommate of Resident #66, without performing hand hygiene, opened the meal cart, retrieved a carton of milk from a tray, and delivered the milk to Resident #60. Dining observation revealed Staff A on 03/04/24 at 9:23 AM, performed hand hygiene with hand sanitizer, opened the meal cart and retrieved Resident #4's meal tray, delivered the tray and repositioned the resident's bed using the bed control. Staff A came out of the resident's room without performing hand hygiene. Staff A then entered Resident #21's room and removed a gown the resident had over her clothes. Staff A left the room without performing hand hygiene, then opened the meal cart and retrieved Resident #36's meal tray. At 9:30 AM, Staff A entered Resident #36's room, the resident requested to be moved up in bed to eat. Staff A left the room to get help and returned to the room. Staff A and the Staffing Coordinator entered the room and without hand hygiene they both donned gloves and move the resident up in the bed. Observation revealed Staff A removed her gloves, walked towards the exit door of Resident #36's room and without soap, placed the tips of her fingers under running water for approximately 3 seconds. Observation revealed no soap canister by the sink. Staff A then placed sugar on the resident's hot cereal, opened the carton of milk by sticking her finger into the carton. At 9:36 AM, Staff A left the resident's room without performing hand hygiene. Observation revealed a hand sanitizer canister outside Resident #36's room. Staff A stated she was going to get a cup of coffee for Resident #36. At 9:42 AM, Staff A returned to Resident #36's room and without performing hand hygiene, proceeded to feed the resident. On 03/04/24 at 9:51 AM, Staff A, CNA left Resident #36's room with the meal tray, placed the tray in the cart and did not performed hand hygiene. On 03/06/24 at 8:20 AM, observation revealed Staff B, CNA leaving room [ROOM NUMBER] after delivering a tray and stated, I need hand sanitizer and walked to the nurses station. Subsequently, an interview was conducted with Staff B who stated she had to do hand sanitizer after delivering a tray. Staff B was asked why she did not do hand hygiene after delivering trays on 03/04/24 and replied, I forgot. On 03/06/24 at 9:01 AM, an interview was conducted with Staff A, CNA who stated she used the hand sanitizer down the hall during meal delivery. Staff A was apprised that on Monday (03/04/24) while she was passing meal trays, she did not do hand sanitation between residents. Staff A stated she did. Staff A was apprised that she rinsed her hand with water only because there is not soap container by the sink in Resident #36's room. Staff A replied her hands were not dirty. On 03/06/24 at 9:33 AM, during an interview the DON was asked to submit the facility's Hand Hygiene policy. The DON and ADON were apprised of the lack of hand hygiene during dining observation on 03/04/24. Consequently, a side-by-side review of Resident 336's room was conducted with the DON. The DON stated the sink in the resident's room was the eye emergency station. The DON confirmed there was no soap by the sink. 2) Review of Resident #72, clinical record documented an admission on 09/19/22 and no readmissions. The resident diagnoses included Gastrostomy Status, Hepatic Failure, Chronic Respiratory Failure With Hypoxia, Protein-Calorie Malnutrition, Dysphagia, Cognitive Communication Deficit, and Encephalopathy. Review of Resident #72's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of the Mental Status the resident was not unable to complete the interview, had severe cognition impairment. Review of Resident #72 physician order dated 10/20/22 documented every shift Enteral Feed: Jevity 1.5 Cal Continuous via tube to infuse at a rate of 65millimeters per hour . Start at 2 PM . On 03/06/24 at 2:14 PM, observation revealed Resident # 72 feeding formula off with 900 ml left in the bottle. The bag was labeled 03/06/24 at 7:28 AM. On 03/06/24 at 2:16 PM, observation revealed Staff C, RN with gloved hands, restarted Resident #72's feeding formula. During an interview, Staff C reached into the uniform pocket with her right gloved hand. Staff C was apprised regarding reaching her pocket with a gloved hand after restarting the machine and stated she was distracted. 3) Review of Resident #160's clinical record documented an admission on 02/29/24 and no readmissions. The resident diagnoses included Tracheostomy Status, Gastrostomy Status, Aphasia following a Cerebrovascular Disease. Review of Resident #160's physician order dated 03/01/24 documented Tracheostomy care daily and as needed . On 03/06/24 at 2:23 PM, observation of Resident # 160 tracheostomy care performed by Staff C, RN assisted by the Assistant Director of Nursing (ADON) was conducted. Staff C performed hand hygiene, donned gloves, and proceeded to performed the resident's tracheostomy care. Staff C cleaned the tracheostomy surroundings area, changed the cannula and the mask, then with gloved left hand reached into her uniform pocket to get a pen, changed the tracheostomy collar, and reached her uniform pocket again with her right gloved hand and retrieved a marker. On 03/06/24 at 3:06 PM, observation concluded and subsequently a joint interview was conducted with Staff C and the ADON. Staff C was apprised of entering her pocket with a gloved hand twice. Staff C opened her eyes wide and stated she had a clean hand and a dirty hand. Staff C was apprised she entered her unform pocket with both hands. The ADON acknowledged the findings. The ADON stated she was not supposed to entered the pocket with a glove on.

Based upon interview and observation the facility failed to provide a safe, clean, and homelike environment. The findings included: During routine observations of rooms conducted by surveyors on 10/31/22 and 11/01/22, and a subsequent facility observation tour conducted on 11/03/2022 at 12:30 PM with the Administrator, the Maintenance Director, and the Regional Nurse Consultant, the following environmental concerns were noted: 100 Unit: (a) Room 104: The foot board for bed104-A was cracked and pitted. (b) Room 107: the paint on the ceiling was peeling above the headboard for 107-C. 200 Unit: (c) The hallways in the entire 200 Unit had an odor best described as old, musty urine. (d) Room 204: The footboard for bed 204-A was missing from the resident's bed and there was a loose screw observed on the floor. In the bathroom of room 204 there was no pull cord for the emergency call signal. (e) Room 219: For 219-A the night stand laminate and baseboard behind the bed were in disrepair. The door for room 219 had wood chipped off. (f) Room 220: For 220-A the baseboard behind the bed was in disrepair and peeling away from the wall. (g) Room 221: For 221-A the resident bed rail is rusted. For the rest of the room: the baseboard for the wall by the closets was peeling away and held with a blue piece of tape. The closet wood was in disrepair. There was sawdust like matter observed underneath the room sink. (h) Room 222: For 222-B observations revealed room closet drawer paint, wall paint, and the baseboard behind the bed in disrepair. (i) Room 223: For 223-C the over bed table had rust colored staining on the leg and the table was difficult to wheel about. The baseboard behind the bed was in disrepair. For the room in general the clock appeared to be stopped. In the bathroom for 223 there was a hole in the wall next to the electrical outlet. The ceiling vent had a large amount of black debris. The closet furthest from the entrance had sawdust like matter and black debris on the floor around it. The door was in disrepair with black mold type debris next to it. Note - Photographic evidence obtained all all environment concerns in resident rooms. Interviews were conducted with staff at the time of the observations, and they acknowledged the findings.

Based on records review and interviews, it was noted that the facility did not involve a Certified Nursing Assistant (CNA) in the developement of the care planning process of 2 of 22 sampled residents (Resident #33 & Resident #73). The findings included: 1.) Review of the Care Plan (CP) signing sheet for Resident #33 revealed that it was signed on June 28, 2022. The CP record showed that the participants who acknowledged their presence by their signature were: Resident #33, the Food Service Manager (FSM), the Clinical Reimbursement Director (CRD), RN, and the Social Service Director (SSD). Review of a second care plan meeting held on 10/6/2022 revealed that only Resident #33, the SSD, and the Registered Dietitian (RD), signed the CP. There was no CNA signature on the CP signing sheet. On 11/01/22 at 10:54 AM Resident #33 stated she had filed multiple complaints about her call bell not being answered on time. She reported that it can at times take more than 1 hour to receive assistance. Resident #33 is diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She scored 15 on the brief interview for mental status (BIMS). She is cognitively alert and able to make her needs known. 2.) Review of the care plan signing sheet of Resident #73 revealed that it was signed on June 16, 2022. The individuals who signed the document and who were present were Resident #73, the Resident's son via telephone, the SSD, and the CRD/ RN. During another care plan meeting held on 9/20/2022, the individuals who signed the CP were Resident #73, the CRD, and the RD. There was no CNA signature on the CP signingt sheet. Review of the electronic clinical record revealed that Resident #73'ss diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/01/22 at 11:06 AM Resident #73 reported that she had filed a few complaints regarding her call light not being answered timely to the Administration. She reported that her call light was at times not within reach or not being answered on time. In an interview with the staff responsible for the minimum data set (MDS) management or the MDS Coordinator on 11/03/22 at 2:23 PM, she reported that she has been trying to have CNAs attend the Care plan meeting with no success. She said she understands that it is important to have the CNAs attend the CP meetings so that they can provide their feedback and report any concerns in implementing the residents' plan of care. At the exit meeting on 11/03/2022, the findings were reported to the Administration and no additional information was provided.