Every finding on record at Brookwood Gardens Rehabilitation and Nursing Cente

Based on observation, interview, and record review, it was determined that the facility failed to ensure procedures and safety measures were in place for the temperature and serving of hot beverages for one (Resident #1) of three residents reviewed. Staff served hot coffee without checking the temperature to Resident #1, an individual with upper extremity weakness who was left unsupervised. Subsequently, the coffee was spilled, resulting in Resident #1 sustaining third-degree (full thickness) burns on the abdomen, left hip, and right lower back. This incident led to a notable level of harm. The findings included: Observation on 05/14/2026 at 7:08 AM Resident #1 was noted in bed with eyes closed no distress noted.Review of the facility's policy titled: Accident and Incident Prevention, Reporting, and Response. Dated 07/2025 and Reviewed 05/05/2026 included:PurposeTo ensure a safe environment for all residents by minimizing accident hazards, providing adequate supervision and assistive devices, and implementing a proactive and systematic approach to preventing, investigating, and mitigating accidents and incidents in accordance with federal regulations (F689), facility policies, and resident-centered care principles.Policy StatementThe facility is committed to: Maintaining a resident environment that is as free as possible from accident hazards while meeting individual resident needs. Ensuring adequate supervision and appropriate use of assistive devices to reduce the risk of accidents and incidents. Promptly identifying, reporting, documenting, investigating, and mitigating all incidents or accidents involving residents.Definitions Accident: An unexpected, unintended event that results in or has the potential to result in injury, harm, or adverse change in a resident's condition. Incident: Any event, occurrence, or situation that is not consistent with the routine operation of the facility or the routine care of a resident, regardless of whether it results in injury. Record review of the facility's policy titled Hot Beverage Safety dated 5/2026 included:PolicyThis center's policy outlines procedures for the safe preparation, distribution, and consumption of hot beverages to help ensure the safety of residents and staff by minimizing the risk of burns or scalding from hot beverages, such as coffee, soups, and teas.Background:The mouth has protective mechanisms that can reduce the risk of injury from hot beverages. Saliva's mechanism is to cool a hot beverage during consumption. The very rapid blood flow in the mucosa in the mouth carries away some heat. The lips and tongue are sensitive and help take in hot beverages only as fast as the mouth can cool the beverages. Skin on the arms and legs is less sensitive than the skin on the mouth and can be burned before the danger is realized. Clothes may hold a hot beverage spill against the skin, increasing the risk of injury in a shorter amount of time.Procedure: A. Beverage Temperature Standards - When NOT coming directly from the kitchen: 1. All hot beverages served to residents must be at or below 120 F (48.9 C). 2. Staff (nurse or CNA) must use a calibrated food thermometer to verify beverage temperatures prior to serving when the beverage is not coming from the kitchen. 3. Any beverages exceeding 120 F must be allowed to cool before service. 4. Reheating liquids/soups in a microwave a., when possible, reheat at 70% power instead of 100%. c. At the end of the heating, let the food/beverage stand for one minute. e. Do not serve the resident until the internal temperature is 120 degrees or less. f. Staff (nurse or CNA) must take the temperature of the beverage/soup prior to delivering to the resident. The temperature cannot exceed 120 degrees Fahrenheit prior to delivery. On 06/10/2026 the coffee temperatures checked with a digital thermometer revealed:South dining area coffee temperature for lunch: 132.1 degrees Fahrenheit.North Side coffee temperature for lunch: 140.3 degrees Fahrenheit.East Side coffee temperature for lunch: 128.2 degrees Fahrenheit.South dining area coffee temperature for dinner: 124.6 degrees Fahrenheit. Record review of the incident description documented: At approximately 2:30 AM, the resident requested a CNA (Certified Nursing Assistant) to prepare instant coffee. The CNA heated approximately 16 oz (ounces) of water in a foam cup in the microwave for about 2 minutes. Instant coffee was mixed, covered with a lid, and placed on the resident's bedside table, which was positioned over his abdomen. The resident then requested privacy, and the CNA exited the room. Shortly afterward, around one minute, the resident activated the call light. Upon returning, the CNA observed that the resident had spilled hot coffee onto his abdomen. The CNA immediately notified the assigned nurse. Resident was noted to be wearing a t-shirt and covered with a blanket (per CNA report); gown was grabbed by CNA to clean the coffee, which was promptly removed. Skin assessment revealed erythema extending from the mid-abdomen to the right flank, with some areas of blistering. The physician was notified, and treatment was initiated with Silvadene (silver sulfadiazine).Review of the facility's incident Summary indicated: The resident sustained a thermal burn to the abdomen/right flank after spilling hot coffee. Immediate nursing intervention and physician notification were completed, and appropriate treatment was initiated. Contributing factors may include the high temperature of the liquid, resident behavior, and positioning of the beverage. Incident reviewed for adverse - not considered adverse as the patient did not go to a higher level of care and the plan of care was being followed as resident was set up only for meals. No abuse/neglect suspected.Review of Health Status Note Effective Date: 04/22/2026 time stamped 02:37 (2:37 AM) completed by Staff D, Registered Nurse (RN) noted: At approximately 2:30 AM, resident requested a hot coffee beverage, which was provided by CNA (Certified Nursing Assistant) as requested. Resident was positioned in high Fowler's position, and the coffee cup was placed on the bedside table within reach. Resident was alert and oriented x (times) 4 and stated he would manage the drink independently, beginning to sip coffee and requesting CNA to leave the room. While exiting, CNA was called back by the resident. Upon re-entry, CNA observed that the resident had spilled hot coffee on himself. At the time, the resident was wearing a hospital gown and was covered with a blanket. CNA immediately notified this nurse. Gown and blanket were removed promptly, and assessment revealed a superficial blister with surrounding erythema to the right lower back area. Cold water compresses were applied to the affected site, followed by Silvadene cream and coverage with a non-adherent dressing. PRN (as needed) Acetaminophen was administered for pain as ordered, with noted relief. When questioned, resident reported that the coffee cup slipped from his hands while drinking. Staff J, ARNP [Advanced Registered Nurse Practitioner] was notified, and new wound care orders were received and implemented as directed. Vital signs were obtained following the incident and were stable within normal limits. No abnormal behaviors noted. Resident's emergency contact was also notified of the incident. Will continue to monitor closely. The patient was evaluated by the wound care team today following a request from the floor nurse and supervisor. During a head-to-toe assessment erythema (redness) was observed on the abdomen, measuring 34.4 x 14.7 x nm, with a small fluid-filled blister noted. Treatment: Apply Silver Sulfadiazine cream daily and as needed, leaving the area open to air. The patient received education on skin and wound care each day. Patient demonstrated understanding asked for Social Services. and [Staff H] Social Services agent was notified. Staff J, APRN (Advanced Practice Registered Nurse) was notified.Review of the Skin/Wound note dated 04/22/2026 at 13:20 (1:20 PM), completed by Staff L, RN, documented that the resident's family member was contacted by telephone and provided with care plan information and updates regarding the Resident #1's newly identified skin condition.Review of the Risk Manager Comments dated 04/29/2026 documented: Around 2:30 AM, resident requested a hot coffee beverage, which was provided by CNA. Resident was positioned in high Fowler's position, and the coffee cup was placed on the bedside table within reach. Resident alert and oriented x4. Then resident called CNA to report that he spilled the coffee on top of his abdomen. CNA immediately reported to nurse and assessment was completed, resident noted with redness are to abdomen. Treatment initiated. W/C (Wound Care) evaluation and treatment in place. Plan of care reviewed. OT (Occupational Therapy) order for special cup (spill proof). All belongings arranged to right side to promote easy accesses due to left side hemiplegia. W/C Doctor evaluation. MD (Medical Doctor) and responsible party notified. Upon investigation resident stated he was trying to put the coffee back to the table and the cup slides from table. Table was within easy reach. Call light next to resident bed in good working condition, HOB (Head of Bed) elevated . Review of Resident #1's clinical records revealed the resident was admitted to the facility on [DATE] with diagnoses, including but not limited to unspecified cerebral infarction, non-traumatic intracerebral hemorrhage in the hemispheres, cortical hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, difficulty walking, muscle weakness, oral phase dysphasia, and unspecified insomnia. Resident #1 was discharged to home on [DATE]. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] Cognitive Section indicated the resident is cognitively intact. Functional and Activities of Daily Living (ADLs) Sections documented that the resident has impairment affecting one side of both upper and lower extremities. Partial to moderate assistance is required for oral hygiene, supervision and minimal physical support are needed for eating, and substantial to maximal assistance is necessary for toileting hygiene, bathing, upper body dressing, and personal hygiene. Resident #1 is dependent on staff for footwear management and lower body dressing. Bowel and bladder records show occasional incontinence, and the resident is not enrolled in a bowel or urinary training program. Health Conditions Section noted the resident receives both scheduled and as-needed pain medication, occasionally experiencing pain levels up to 7 out of 10, and has sustained one fall without major injury since admission. The Skin Conditions section notes risk for pressure ulcers, though none are present, with preventative measures including a turning schedule. The Special Treatments section confirms receipt of physical, occupational, speech-language, and respiratory therapies, in addition to oxygen therapy. A review of Resident #1's care plans initiated on 04/04/2026 indicated the resident is at risk for impaired skin integrity due to fragile skin and incontinence. The goals specify that the resident will maintain or achieve clean and intact skin by next review date. Interventions included ensuring skin remains clean and dry; applying lotion to areas of dryness; exercising caution during transfers and bed mobility to prevent contact with sharp or hard surfaces; educating the resident, family, and caregivers regarding contributing factors and preventative measures; and adhering to facility protocols for injury treatment. During an interview on 05/14/2026 at 6:55 AM, Staff A, RN, stated that following the incident involving Resident #1, thermometers were placed in the pantry to check the temperature of hot liquids after microwaving. Liquids should not exceed 120 degrees before being served to residents. Observation on 5/14/2026 starting at 7:01 AM revealed thermometers with instructions were in all three pantries. During an interview on 05/14/2026 at 8:05 AM, the Director of Nursing (DON)revealed she was on vacation at the time of the incident and upon her return she was informed that on 04/22/2026 at around 2:00 AM Resident #1 asked for coffee the CNA brought the coffee and placed it on the overbed side table on top of his abdomen he asked for privacy and she stepped out of the room and as soon as she stepped out he put the light on and then she went back to the room she noticed he had spilled the coffee on himself. The DON stated that the investigation revealed he had tried to put back the coffee on the table and it spilled. He has instant coffee in in his room so the staff would get the hot water and prepare it. After the incident a thermometer was placed in all the pantries, and the CNAs now know how to check the temperature before. The Director of Nursing was asked if this incident could have been avoided and reported. The DON revealed the incident was not reported and was the decision made by the previous Administrator/Risk Manager. On 05/14/2026 at 11:12 AM the Assistant Director of Nursing (ADON)/East Supervisor revealed that upon her arrival in the facility on 4/22/2026 at around 7:30 AM: The supervisor told me she received report from the night supervisor that the patient [Resident #1] requested hot water to make coffee and the CNA prepared everything and left the room and few minutes after the resident called on the light and when they went to the room the resident had spilled coffee on his stomach, abdomen and it went to his back, the supervisor called the doctor called the family and the next day when I came, we reviewed and discussed the incident with the Administrator/Risk Manager. When asked if this type of incident could it be avoided the ADON stated: Maybe yes maybe no because the patient is alert and oriented and he requested coffee and we provided the coffee. When asked what system the facility had in place regarding the temperature of hot liquids, it was revealed that there was no system in place until the incident occurred and the pantries were not equipped with a thermometer to check heated food/liquids temperatures before serving. During an interview on 05/14/2026 at 11:25 AM, Resident #1 recalled the incident that occurred on 04/22/2026. The resident stated: I asked for coffee and she set it on the table. I requested a few minutes of privacy, and she pulled the curtain and left. I mixed the coffee and tried to cool it, then took a sip. It burned me so badly the cup fell from my hand, burning me all over my belly all the way to my back. I cried like a baby. The resident explained that he usually requested hot coffee or hot water for his coffee during the night and had experienced coffee that was heated too much and had burned his tongue before. This time, it was way too hot.On 05/14/2026 at 11:30 AM Resident #1 voluntarily showed the sections of his body that had been burnt from the spilled coffee. The injured areas displayed pink and unpigmented skin measuring approximately 3 inches long and 11 inches wide on the upper abdomen, and on the lower right abdomen measuring approximately 5 by 5 inches. The front of the left hip had pink and unpigmented skin that measured 4 by 7 inches, and the right lower back area measured approximately 3 inches. Resident #1 reported that the right lower abdomen area remained tender.Observation 0n 05/142026 at 11:40 AM revealed the brewed coffee was poured into urns/ air pots temperature checked noted 140 degrees Fahrenheit. Staff poured coffee and served to residents individually during meal service but did not check coffee temperatures during meal service. On 05/14/2026 at 11:43 AM observation and review of the coffee temperatures during lunch service on the 600 wing the coffee being poured from the urn was noted at 138 degrees Fahrenheit was poured individually by staff and then taken to the resident's rooms and temperature check for the tested cup of coffee from the kitchen to the floor to a resident's room was noted at 131 degrees.Observation on 05/14/2026 at 12:06 PM Resident # 1 was served lunch; the Certified Nursing Assistant (Staff O) did the set up for the resident and added sugar to the coffee as requested by the resident The coffee was served in a dark non spillproof colored plastic type cup with a handle. The coffee temperature was not checked by the staff before serving.Interview on 05/14/2026 at 12:31 PM Staff O, CNA was asked about the facility's protocol for serving hot liquids. Staff O, CNA did not respond. During an interview conducted on 05/14/2026 at 1:07 PM, Staff E, Registered Nurse explained, When heating liquids or food, I typically use a thermometer in the kitchen to check the temperature. If a thermometer is unavailable, I previously tested the temperature on my hand. The Director of Nursing has provided guidance and conducted in-service training on proper temperature checks, and now thermometers are available in the pantry, which must be used to verify temperatures before serving residents hot beverages or food. During an interview on 05/14/2026 at 2:51 PM Staff G, Certified Nursing Assistant stated: On 04/22/2026, [Resident #1] asked me for coffee around 2:00 AM. [Resident #1] requested for the coffee to be heated for 2 minutes and that is what I did. I offered to prepare the coffee for him, but he refused. I adjusted the head of the bed and placed the bedside table close to him so he could place the coffee there and then exited his room. Approximately 2 seconds later, [Resident #1] called me via the call light for assistance because the coffee had spilled on his abdomen. I then informed the nurse immediately and removed his shirt and sheet right away. This incident should not have happened. I believe it could have been prevented because he should not be permitted to drink coffee at night. I do not feel like it was my fault. I learned my lesson because from now on, I will be calling the nurse when a resident requests coffee or anything hot or cold during the night. It was wrong for me to have heated the coffee for the 2 minutes. Staff G, CNA stated that after the incident training for hot beverage was received and the facility's protocol for heating up any drinks, including coffee is to heat up to no more than 120 degrees Fahrenheit.On 05/14/2026 at 3:35 PM, an interview with the Chief Nursing Officer and Director of Nursing revealed that, following the incident, corrective measures were taken to prevent recurrence. These actions included risk assessments, placement of thermometers in every microwave area, staff training to check for proper temperatures, and the development and implementation of a hot beverage/liquid policy and trainings are ongoing.During an interview on 05/14/2026 at 3:55 PM Staff D, Registered Nurse 11:00 PM to 7:00 PM shift stated: When heating coffee or drinks, the staff needs to check the liquid with the thermometer that is now located in the pantry. The temperature should not exceed 120 degrees Fahrenheit. I recalled when the CNA informed me that the coffee had spilled on [Resident #1] and when I entered the room, I saw redness and a small blister on his abdomen. I immediately called the doctor and informed the family. The CNA informed me that she had provided hot water and instant coffee at his bedside because [Resident # 1 wanted to mix it on his own. I believe this incident could have been prevented. The CNA Should have asked me first or she could have assisted him. On 06/10/2026 at 12:10 PM during a telephone interview the previous Administrator revealed the incident was not reported at the time of the nursing assessment because they determined it was caused by the resident. My primary concern was ensuring that we had a policy regarding any hot items after certain hours of the day. Communication from the ADON (Assistant Director of Nursing) and regional team indicated that the incident did not require immediate action, as it was caused by the resident and the burn was not severe or high risk enough to send the resident to the hospital. For an incident to be classified as adverse, there must be evidence of intentional harm. In this case, the wound did not appear excessive or caused by another party; therefore, I believed reporting was unnecessary. The resident requested coffee, which is part of his routine. When I was there, we had a few residents who would get late night coffee. When asked if the incident could have been avoided the previous Administrator stated that from a professional perspective, he would have to say no, as there was no existing policy at the time that could have prevented the situation or provided additional supervision. However, it is possible that the incident might have been avoided if such a policy had been in place.On 06/10/2026 at 12:15 PM Staff N, RN stated: If a resident asks for coffee to heated or reheated, we need to make sure to check the temperature before serving it. The temperature should be no more than 120 degrees Fahrenheit. We have a thermometer in each pantry of the facility.During an interview on 06/10/2026 at 12:58 PM, the Dietary Manager explained that the dietary staff played a role in providing hot liquids, such as coffee, tea, and hot water. When coffee and hot water came out of the pot in the kitchen, staff poured them into the urns and kept the top or cover off until the temperature reached 140 degrees. Once the urns reached the proper temperature, they left the kitchen, and the staff on the floor took responsibility for serving the coffee at a temperature no higher than 120 degrees. The kitchen provided hot coffee during the daytime three times a day with every meal cart and the kitchen does not leave hot coffee nor water after the kitchen is closed overnight for residents. During an interview on 06/10/2026 at 1:46 PM the Social Services Director stated: I did not know about the incident until after I returned to work. I regularly visited the resident and always asked about any issues or concerns at that time, the resident did not mention any issues or concerns related to the incident. I only learned about the injury after a clinical review. I believed the incident happened over the weekend when I was not present. As the Social Services Director, I believed I should have received notification ahead of time or at the point when the incident occurred and I should have received immediate notification about any issue involving abuse, neglect. In this case, the resident requested coffee, which staff brought to him. He said that the coffee was not hot enough and asked for it to be reheated, and staff fulfilled his request. Some of the coffee spilled on him and caused burns. When asked if the incident could have been avoided, the Social Services Director stated: I believe if a policy had existed, perhaps the incident could have been prevented, especially considering his cognition. Both cognition and policy play roles. Given that abuse and neglect weren't observed or experienced, and since the resident didn't express any concerns, based on definitions, I would not report it. Reporting goes to the Administrator first, who then reports to [State agency].During an interview on 06/10/2026 at 5:37 PM, Staff I, RN, who worked the 7:00 AM to 3:00 PM shift, stated: I received a report from the night shift nurse and supervisor. They explained that the patient (Resident #1) had sustained burns from hot coffee during the early morning hours. After I heard this information, I conducted my rounds and checked in with the patient in his room. He told me he felt fine and denied having any complaints of pain at that time. I consulted the supervisor for additional details, and shortly after, the wound care nurse arrived, having already been notified of the incident. Together, we assessed the patient. I observed some redness, and the wound care nurse completed the dressing. I followed established procedures as required. During our assessment, we mostly examined the chest area and upper stomach, though I did not fully recall if there was redness on both legs. I noticed redness on the mid-chest area, the patient's side, the top of his hip, and lower back. When asked about expectations if a resident requested hot coffee from the CNA, Staff I, RN, stated: As a licensed nurse, safety is very important.Even if the patient requested it, staff had to ensure the coffee was at an appropriate temperature and monitor for any signs such as visible shaking.On 6/10/2026 at 5:49 PM Staff K, Wound Care Registered Nurse stated: When I came in the morning at 8:00 AM, I went to the patient's room with the nurse (Staff I, RN) and my assistant to examine the patient's skin. I saw some erythema (redness) in the abdomen and in the left lower back he denied pain I cleaned the area and explain to him that I needed to put Silvadene Cream and leave it open air to alleviate the erythema area and I documented everything. The next week the wound doctor [wound care provider] came in to evaluate him. Every day during the week I did wound care and he got medication for pain 30 minutes before wound care, and he did not complain of pain and there was no sign or symptom of infection at any time. When asked what degree of burns the resident sustained the wound care nurse indicated it was not documented as burn and the doctor saw the lesion and put erythema. I don't classify the burn it's the doctor and the doctor didn't say anything. I explained what happened and the doctor documented it. The wound care doctor assessed the skin, and she kept the treatment with Silvadene Cream 1% (silver sulfadiazine), and she told me to cover after applying the Silvadene Cream daily and PRN (as needed). No decision was made really about the degree of the burns. If I would be the one to identify the burn, I would say they were second-degree burns. When asked if the incident could have been avoided, Staff K, Wound Care RN stated: I believe the incident could have been avoided because the resident's safety was compromised. Review of Staff J, APRN (Advanced Practice Registered Nurse) Notes dated 04/25/2026 indicated: Chief complaint burning episode to abdominal and low back. Review of Abdomen erythema was noted measuring 34.4 x 14.7 x nm (nanometer) with small fill filled blister Right Lower Abdominal Quadrant full filled blister was noted measuring 1.0 x 1.3 x nm; Left Iliac crest (front) full filled blister was noted measuring 5.3 x 2.2 x nm. Right Lower Back open blister was noted measuring 7.4 x 4.8 x 0.1 cm (centimeters).left side weakness, decreased range of motion. Burn of unspecified body region, unspecified degree. Burn of unspecified degree of lower back, initial encounter. Burn of unspecified degree of abdominal wall, initial encounter. Changes in skin texture.During an interview on 06/10/2026 at 6:17 PM Staff J, APRN stated: I was working the day after the incident but was notified the day before (the night it occurred) by one of the nurses. After I arrived, I went to evaluate the resident. I had already ordered the Silvadene cream via telephone when I was called on the day of incident. After the exam, we decided to continue with the initial treatment. Upon examining the abdomen, I observed a small blister and some redness to back. It was a second degree burn according to my evaluation. I also requested the wound care nurse's opinion, but she stated it was a full thickness burn which is a third-degree burn. I did document the diagnosis, but it was undetermined. We were not sure if it was a partial or full thickness burn. I diagnosed it as an unspecified degree because I was waiting for a second opinion.Record review of the Wound Specialty Physician's Summarized Wound Care Assessment and Individualized Treatment Plan for the visit dated 04/30/2026 indicated:Site 1 - Abdomen, Non-Pressure Full Thickness Wound: Improvement shown by reduced surface area. Surgical debridement and fluorescence imaging performed today. The wound was cleaned and numbed with a topical anesthetic. Using a sterile blade, unhealthy tissue removed from the wound. After the procedure, only healthy tissue remained, and bleeding was controlled and clean dressing applied. Primary Dressing: Silver Sulfadiazine 1% applied three times weekly and as needed for 28 days. Secondary Dressing: Gauze Island with Border used three times weekly and as needed for 28 days.Site 2 - Right Lower Back, Non-Pressure Full Thickness Wound. Surface area decreased; autolytic debridement ongoing. Fluorescence imaging performed today. Continue same dressing protocol as Site 1 for 28 days. Target: 8% wound surface area reduction. Review of the Wound Specialty Physician's evaluation signed by the Wound Care MD on 05/05/2026 at 10:31 AM shows: Abdomen non-pressure wound (Site 1), full thickness, cause undetermined, resolved as of 05/05/2026 after more than 8 days. The wound is now epithelialized and requires follow-up only if needed. Focused Wound Exam (Site 2): Right lower back non-pressure wound-full thickness, etiology unknown. Duration: over 8 days. Status: resolved as of 5/5/2026; area is now epithelialized. Follow-up only if needed. During an interview on 06/10/2026 at 6:52 PM the Wound Specialty Doctor stated: When I assessed the resident, I documented as undetermined etiology. The wound was on the abdomen and right lower back. I did not assess the resident right away. it was a couple of days later. He did not need any other interventions at the time of my assessment. I documented it was unknown etiology because I did not know how it happened.

Based on observations, records reviewed and interviews the facility's staff did not properly label and securely store medications and biologicals on two of five medication carts (South Cart 300 and East Cart 500). Specifically, medications and supplies were left unsecured on the unattended South Medication Cart 300. This deficiency elevated the risk to resident safety. Additionally, no open date was recorded on the vial of glucometer test strips located inside East Cart 500. The findings included: Observation on 05/14/2026 at 6:25 AM, Staff A, RN, left the South Cart 300 medication cart unlocked and unattended at the nurses' station while administering medications to a resident in their room. On top of the unattended cart were two cups containing medications—one cup with a single Lyrica capsule, and another cup containing one white tablet identified as Oxycodone and one Lyrica capsule—as well as lancets and test strips. Staff A returned to the cart at 6:38 AM. During this interval, several individuals passed through the hallway. Photo evidence Review of the facility's Medication Storage Policy with reviewed date 02/16/2026 indicated: Drugs and biologicals should be stored in a safe, secure, and orderly manner. Policy Interpretation and Implementation ,6. Compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) 7. Drugs are stored in an orderly manner in cabinets, drawers, or carts. These compartments are of sufficient size to prevent crowding. Each resident is assigned a cubicle or drawer to prevent the possibility of a drug for one resident being given to another resident. 9.All controlled drugs are stored under double-lock and key. During an interview on 05/14/2026 at 6:46 AM Staff A, RN stated that she should have locked the cart and put the medications away the supervisor was present during this conversation with the nurse and stated that medication should never be left unattended and the cart should never be left unlocked for resident safety because anyone could have taken the medications. On 05/14/2025 at 6:58 AM, during a medication storage check with staff A, Licensed Practical Nurse (LPN) on the East side (Cart #500), a glucometer test trip vial was located inside the cart drawer with no open date written on vial (photo evidence). When Staff A, LPN, was asked about the expiration date, he stated: I was not the one who opened the glucose test strips vial, so I do not know when it was opened. Interview with Staff A, Licensed Practical Nurse (LPN) on 05/14/2026 timestamped 6:58 AM revealed when asked regarding the expiration for the glucose test strips, he stated: I received the medication cart in the morning but only checked the glucose test strip manufacturer's expiration date. I did not realize the opened date was not written on the vial. The facility's policy is to date the glucose test strip vial once it is opened because it can only be used for up to one month after someone opens it.

Based on observations, interviews and record review the facility failed to store food under sanitary condition by ensuring the proper temperatures in the 1) walk-in refrigerator and walk-in freezer and ensure the walk-in refrigerator and walk-in freezer were working properly and 2) ensure that staff wore hair nets when in the kitchen. The food items in the walk-in refrigerator had condensation on them, the food items in the walk-in freezer were soft to the touch and the ice creams were melted. This has the potential to affect 156 out of 167 residents who eat orally residing in the facility at the time of the survey.The findings included:Record review of the Food Storage Policy and Procedure (no written dated documented); Policy-Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination; Procedures-16) Refrigerator temperatures: a) Temperature for refrigerators should be 41 degrees F (Fahrenheit), b) Every refrigerator must be equipped with an internal thermometer and 17) Freezer temperatures: a) Temperatures for freezer should be 0 degrees or below and must be recorded daily and d) Every freezer must be equipped with an internal thermometer, even if equipped with an external thermometer.1) Observation during the initial kitchen tour on 8/25/2025 at 8:27 AM with the Food Service Director revealed the walk-in refrigerator exterior temperature was 50 degrees Fahrenheit (F) and the interior temperature was 55 degrees F. Items noted in the walk-in refrigerator were: Produce, Pasteurized eggs in the shell and liquid, Juices and Thawed meats on the lower shelf. Condensation was noted on the items in the walk-in refrigerator. Photographic evidence submitted.Observation during the initial kitchen tour on 8/25/2025 at 8:31 AM with the Food Service Director revealed the walk-in freezer exterior temperature was 38 degrees F and the interior temperature was 40 degrees F. Items noted in the walk-in freezer were: Breakfast foods, Vegetables, Meats and Ice Cream. The foods were not frozen and soft to the touch. The Chocolate Ice Cream was soft to the touch and melted. Photographic evidence submitted.Interview with the Food Service Director on 8/10/2025 at 8:33 AM revealed that Maintenance was aware for a while that the temperatures were not working properly but the walk-in refrigerator and walk-in freezer have not been fixed. He confirmed that the temperatures in the walk-in refrigerator and walk-in freezer were not acceptable temperatures.Review of the Walk-in Refrigerator Temperature Log for August 2025 documented the following: On 8/25/2025 A.M. Temperature was 39 degrees F and P.M. Temperature was 38 degrees F. The Walk-in Freezer Temperature Log for August 2025 documented the following: On 8/25/2025 A.M. Temperature was 20 degrees F and P.M. Temperature was -1 degrees F.Interview with the Regional Director of Operations on 8/25/2025 at 2:47 PM. He stated, They threw everything out of the walk-in freezer. They are getting two refrigerators from Walmart to put the food items in from the walk-in refrigerator. In the entrance to the kitchen, we will put the juices in the milk box. They are trying to fix the walk-in refrigerator and freezer.Interview with the Regional Director of Operations on 8/26/2025 at 8:32 AM. He stated, The tech came out yesterday evening and it was determined that the compressor was bad in the walk-in refrigerator. The walk-in freezer was determined to be good. He is at the warehouse trying to find the parts now.Second observation of the kitchen walk-in refrigerator and walk-in freezer on 8/26/2025 at 9:03 AM with the Dietary Director and Regional Director of Operations revealed they were both empty and the temperatures were in range. Two stand-alone refrigerators were noted in the kitchen with food items from the walk-in refrigerator and walk-in freezer. The Dietary Director revealed the walk-in freezer interior temperature was 0 degrees F and that the food was hard and frozen to the touch. Photographic evidence submitted.Interview with the Regional Director of Operations on 8/27/2025 at 9:11 AM revealed that the air conditioner repair technician came on 8/26/25 and replaced the outdoor condenser system and added freon to the walk-in refrigerator.Record review of the walk-in refrigerator invoice from the Air Conditioner company dated 8/26/25 documented the following: Replaced the outdoor condenser system, added freon and system cooling at this time. 2) Record review of the Hairnets Policy and Procedure (written date December 2025); Policy: Per Food Code requirements, all associates who work in the dietary department with unpackaged food, clean equipment or utensils or food contact surfaces will wear proper hair restraints to prevent hair from contacting exposed food, clean equipment, linen and unwrapped single service and single use articles; Policy Interpretation and Implementation: 1) Hairnets, bouffant caps and beard covers shall always be readily available near the entryway to the food service department; 2) All food service department associates must don appropriate hair restraints upon reporting to work in the food services department and 3) All visitors and guests entering the food services department must do appropriate hair restraint when entering the food services department.Observation of a staff member in the kitchen on 8/26/2025 at 9:00 AM revealed she was putting ice into a personal cup from the ice machine and not wearing a hairnet.Interview with the Food Service Director on 8/26/2025 at 9:01AM. He revealed that the staff was just getting ice from the machine.Interview with the Regional Director of Operations on 8/26/2025 at 9:02 AM. He revealed that all staff must wear a hairnet or covering when entering the kitchen. He would have maintenance immediately install a container on the wall to hold the hairnets right outside of the kitchen.Record review of the In-Service Sign-in sheets on Hair Nets Inside the Kitchen Area was conducted on 8/26/25 to all staff. The staff are to stay outside of the kitchen area unless it is necessary.

Based on observations, interviews and record review the facility failed to ensure the walk-in refrigerator and walk-in freezer were working properly. This has the potential to affect 156 out of 167 residents who eat orally residing in the facility at the time of the survey.The findings included:Record review of the Food Storage Policy and Procedure (no written dated documented); Policy-Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination; Procedures-16) Refrigerator temperatures: a) Temperature for refrigerators should be 41 degrees F (Fahrenheit), b) Every refrigerator must be equipped with an internal thermometer and 17) Freezer temperatures: a) Temperatures for freezer should be 0 degrees or below and must be recorded daily and d) Every freezer must be equipped with an internal thermometer, even if equipped with an external thermometer.Observation during the initial kitchen tour on 8/25/2025 at 8:27 AM with the Food Service Director revealed the walk-in refrigerator exterior temperature was 50 degrees Fahrenheit (F) and the interior temperature was 55 degrees F. Items noted in the walk-in refrigerator were: Produce, Pasteurized eggs in the shell and liquid, Juices and Thawed meats on the lower shelf. Condensation was noted on the items in the walk-in refrigerator. Photographic evidence submitted.Observation during the initial kitchen tour on 8/25/2025 at 8:31 AM with the Food Service Director revealed the walk-in freezer exterior temperature was 38 degrees F and the interior temperature was 40 degrees F. Items noted in the walk-in freezer were: Breakfast foods, Vegetables, Meats and Ice Cream. The foods were not frozen and soft to the touch. The Chocolate Ice Cream was soft to the touch and melted. Photographic evidence submitted.Interview with the Food Service Director on 8/10/2025 at 8:33 AM revealed that Maintenance was aware for a while that the temperatures were not working properly but the walk-in refrigerator and walk-in freezer have not been fixed. He confirmed that the temperatures in the walk-in refrigerator and walk-in freezer were not acceptable temperatures.Review of the Walk-in Refrigerator Temperature Log for August 2025 documented the following: On 8/25/2025 A.M. Temperature was 39 degrees F and P.M. Temperature was 38 degrees F. The Walk-in Freezer Temperature Log for August 2025 documented the following: On 8/25/2025 A.M. Temperature was 20 degrees F and P.M. Temperature was -1 degrees F.Interview with the Regional Director of Operations on 8/25/2025 at 2:47 PM. He stated, They threw everything out of the walk-in freezer. They are getting two refrigerators from Walmart to put the food items in from the walk-in refrigerator. In the entrance to the kitchen, we will put the juices in the milk box. They are trying to fix the walk-in refrigerator and freezer.Interview with the Regional Director of Operations on 8/26/2025 at 8:32 AM. He stated, The tech came out yesterday evening and it was determined that the compressor was bad in the walk-in refrigerator. The walk-in freezer was determined to be good. He is at the warehouse trying to find the parts now.Second observation of the kitchen walk-in refrigerator and walk-in freezer on 8/26/2025 at 9:03 AM with the Dietary Director and Regional Director of Operations revealed they were both empty and the temperatures were in range. Two stand-alone refrigerators were noted in the kitchen with food items from the walk-in refrigerator and walk-in freezer. The Dietary Director revealed the walk-in freezer interior temperature was 0 degrees F and that the food was hard and frozen to the touch. Photographic evidence submitted.Interview with the Regional Director of Operations on 8/27/2025 at 9:11 AM revealed that the air conditioner repair technician came on 8/26/25 and replaced the outdoor condenser system and added freon to the walk-in refrigerator.Record review of the walk-in refrigerator invoice from the Air Conditioner company dated 8/26/25 documented the following: Replaced the outdoor condenser system, added freon and system cooling at this time.

Based on record review, interviews, and record reviews the facility failed to ensure the Quality Assurance Performance Improvements plans are effectively implemented and sustained as evidenced repeated deficient practices identified for F867-QAPI/Quality Assessment and Assurance (QAA) Improvement Activities. The findings included.Review of the facility's survey history revealed during the Recertification Survey with exit dated 04/25/2024 the facility was cited F867 (QAPI/Quality Assessment and Assurance (QAA) Improvement Activities) for repeated deficient practices that included F812-Food Procurement, Storage, Preparation, and Sanitary Practices; During this Recertification Survey with exit dated 08/28/2025 the facility was cited F867 (QAPI/Quality Assessment and Assurance (QAA) Improvement Activities) for repeated deficient practices related to F550 Resident Rights related to dignity during dining and F812 Food Procurement, Storage, Preparation, and Sanitary Practices.During the Quality Assurance and Performance Improvement (QAPI) review on 08/28/2025 at 5:38 PM with the Administrator (NHA), Director of Nursing and Corporate staff; the NHA revealed the members of the QAPI committee team members includes NHA, Director of Nursing, Assistant Director of Nursing Medical Director, Pharmacy Representative and all department heads. The last meeting was held on 08/15/2025. The QAPI committee activities related to effectiveness and goals related to previously cited deficiencies were reviewed and discussed. Review of the facility's document titled Quality Assessment & Assurance (QAA) Committee-Policy & Procedure - Skilled Nursing Facility (Florida) Reviewed/Revised dated 08/2025 indicate:1) PurposeTo establish and maintain a QAA Committee that oversees the facility's Quality Assurance and Performance Improvement (QAPI) program, ensuring a data-driven, systematic approach to resident safety, quality of care? quality of life, and regulatory compliance_.2) ScopeApplies to all departments, services, and contracted providers functioning within the facility, including clinical and operational domains (e.g., nursing, medical staff, therapy, pharmacy, dietary, social services, environmental services, admissions/business office).3) Definitions QAPI: Coordinated application of Quality Assurance (QA) and Performance Improvement (Pl) across the facility. Performance Improvement Project (PIP): A focused, data-driven initiative addressing identified priorities; at least one high-risk/problem-prone PIP annually.

Based on observations, interviews and record review, the facility failed to be demonstrated effective plans of actions were implemented to correct identified quality deficiencies in the problem areas, as evidence by repeated deficient practices identified for F550-related to dignity during dining, F812-Food Procurement Store/Prepare/Serve/Sanitary and F908-Essential Equipment, Safe Operating Condition The findings included.Review of the facility's survey history revealed during the Recertification Survey with exit dated 04/25/2024 the facility was cited F550 Resident Rights related to dignity during dining F812-Food Procurement, Storage, Preparation, and Sanitary Practices. During this Recertification Survey with exit dated 08/28/2025 the facility was cited F550 Resident Rights related to dignity during dining and F812 Food Procurement, Storage, Preparation, and Sanitary Practices and F908-Essential Equipment, Safe Operating Condition.During the Quality Assurance and Performance Improvement (QAPI) review on 08/28/2025 at 5:38 PM with the Administrator (NHA), Director of Nursing and Corporate staff; the NHA revealed the members of the QAPI committee team members includes NHA, Director of Nursing, Assistant Director of Nursing Medical Director, Pharmacy Representative and all department heads. The last meeting was held on 08/15/2025. The QAPI committee activities related to effectiveness and goals related to previously cited deficiencies were reviewed and discussed. Review of the facility's document titled Quality Assessment & Assurance (QAA) Committee-Policy & Procedure - Skilled Nursing Facility (Florida) Reviewed/Revised dated 08/2025 indicate:1) PurposeTo establish and maintain a QAA Committee that oversees the facility's Quality Assurance and Performance Improvement (QAPI) program, ensuring a data-driven, systematic approach to resident safety, quality of care? quality of life, and regulatory compliance_.2) ScopeApplies to all departments, services, and contracted providers functioning within the facility, including clinical and operational domains (e.g., nursing, medical staff, therapy, pharmacy, dietary, social services, environmental services, admissions/business office).

Based on observation, interview and record review the facility failed to ensure residents had a dignified dining experience as evidenced by failure to deliver lunch trays on the 300 South Cart 1 in a timely manner for 15 out of 22 residents who dine in their rooms for lunch.The findings included: Record review of the Resident Rights Policy and Procedure (no written dated documented); Policy-All residents in this facility have rights guaranteed to them under Federal and State law and by this facility's personnel; Guidelines: 1) The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility.Observation of 300 South Cart 1 dining on 08/25/2025 at 12:29 PM revealed the food cart was delivered and the trays were not delivered to the residents. The Certified Nursing Assistants (cnas) were standing around the cart waiting for the nurses to give them the food trays.Interview with Staff A, Certified Nursing Assistant on 08/25/2025 at 12:41 PM. She stated, I cannot take the trays to the resident until the nurse puts the tray in my hand.Observation of 300 South Cart 1 dining on 08/25/2025 at 12:44 PM revealed the nurses placed the food trays in the cnas hands and the food was delivered to the residents in their rooms. The lunch cart arrived 15 minutes before and sat there. The cnas would not deliver the trays until the nurse came to give them the tray.Interview with the DON on 08/28/2025 10:11 AM. She stated, They have five minutes to deliver the food trays to the resident once the trays arrive on the floor. The nurse is checking the consistency of the food with the meal ticket on the plate and then they give the cna the food tray. The cnas cannot give the food trays without nursing checking the trays.Interview with Staff B, Registered Nurse on 08/28/2025 at 12:32 PM. She stated, The nurse checks the tray and the diet with each patient. The nurse gives the tray to the cna. The trays should be passed less than 15 minutes after they arrive. Only the nurse can take the tray out of the food cart.

Based on observations, interviews, and record reviews, the facility failed to ensure residents group meetings are organized and well structured, as evidenced by lack of assistance in the organizing of Resident Council meeting and addressing concerns effectively and in a timely manner in order to boost resident attendance. The findings include:Observation of the Resident's Council meeting held on 08/27/2025 at 10:30 AM, revealed six residents in attendance Resident #6, a council member for approximately eight months has participated consistently; and five first time attendees: Resident #111, Resident #151, Resident # 148 and Resident #53 who began running for council president two weeks prior. Review of resident council meeting minutes from January through May 2025 documented ongoing, unresolved issues, including missing clothing, delayed call light responses, inadequate snack availability, and dissatisfaction with food quality. A meeting was not held in June 2025, and there was no documentation of follow-up or resolution for issues raised in previous meetings. During interviews, residents expressed continued dissatisfaction with food quality, small portion sizes, and the repetitive nature of meals. Concerns extended beyond food. Multiple residents reported missing clothing and unresolved grievances. Interview on 08/28/2025 at 2:20 PM, the Food Service Director revealed the menus are developed corporately and adjusted only slightly based on resident input. He stated that resident preferences are collected within two days of admission, but there is no always available menu. Alternative meal options depend on leftover or available items. For residents who dine in-room, they must request alternatives in order to be informed of them. Certified Nursing Assistants (CNAs) are expected to offer these alternatives and report unmet needs, but no verification of this process was provided. Portion increases are only made following reported weight loss or formal resident requests to the dietitian.On 08/28/2025 at 7:25 PM the Administrator was informed of the identified concerns. Review of the policy titled Resident Right - Resident/Family Group and Response. It is the policy of the facility to encourage and assist the resident to organize and participate in resident groups within the facility in such a manner to acknowledge and respect resident rights indicates:Procedure:The resident has a right to organize and participate in resident groups in the facility.The facility will provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.The facility will provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.The facility will consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.a) The facility will be able to demonstrate their response and rationale for such response

Based on observations, records reviewed and interviews, the facility failed to ensure privacy of confidential information on one (East Station) out of three Nursing Stations in the facility as evidenced by a census left unattended with health insurance information visible. There were 167 residents residing in the facility at the time of the survey. The findings included: The findings included:On 08/27/25 at 9:20 AM, an observation at the East Nursing Station revealed anunattended census with resident health insurance information visible on top of a medication cart (Photographic evidence). Surveyor waited on staff to return to cart. On 08/27/25 at 9:49 AM A Staff C, Registered Nurse (RN) was observed exiting a resident's room and was notified by surveyor of the identified concern. Staff, RN was asked about the facility's protocol for protecting resident information and stated, We are supposed to keep resident information covered so no one can see it at all times. I did not do that because I was helping a resident and forgot.Interview on 08/27/2025 at 10:55 AM The Director of Nursing stated: The nurses should keep any resident information covered. Record review of a Policy titled, Health Insurance Portability and Accounting Act of 1996 (HIPAA) not dated revealed Policy: Facility will keep information regarding a resident's health private and confidential.

Based on record review and interview facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was accurately completed for two residents (#4, #6) out of two residents sampled as evidenced by Level I PASRR dated 5/22/25 for Resident#4 omitted diagnosis of Psychotic Disorder and Level I PASRR dated 4/9/25 for Resident#6 omitted diagnosis of Psychotic Disorder. There were 167 residents residing in the facility at the time of survey. The Findings Included:Record review of a Policy titled, Preadmission Screening (PASRR) reviewed 1/17/25 and updated 6/25 revealed Policy: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. (1) Resident#6 was initially admitted on [DATE] and readmitted [DATE] with diagnosis that included: Unspecified Psychosis not due to a substance or known physiological condition. Record review of a Significant Change - None PPS / (Modification) Minimum Data Set (MDS) reference dated 7/14/25 revealed Resident#6 had a Brief Interview for Mental Status score of 10, indicated moderate cognitive impairment, not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, Depression (other than bipolar) , Psychotic disorder (other than schizophrenia) , Unspecified Mood Disorder and Primary Insomnia, was taking Antidepressant, Antipsychotic and received no Psychological Therapy. Record review of a Care Plan initiated on: 05/06/24 and revised on: 07/24/25 revealed Resident#6 had a mood problem related to depression, insomnia, anxiety; mood disorder and; Psychosis with a goal to have improved sleep pattern by reporting adequate rest or fewer documented episodes of insomnia through the review date and improved mood state: happier, calmer appearance, no signs of depression, anxiety or sadness through the review date with interventions that included: Administer medications as ordered and monitor/document for side effects and effectiveness, and behavioral health consults as needed. Record review of a Preadmission Screening and Resident Review (PASRR) LEVEL I Screen for Resident#6 completed on 4/9/25 revealed Section I:PASRR Screen Decision-Making, A. MI or suspected MI (check all that apply): Psychosis was not checked. Record review of a physician's order sheet revealed an order dated 7/17/25 for Risperidone Oral Tablet two Milligram (MG) directions: Give one tablet by mouth two times a day related to Unspecified Psychosis not due to a substance or known physiological condition. Record review of a Psychiatry Progress Note dated 7/22/25 revealed diagnosis included: Unspecified Psychosis. (2)Resident#4 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Unspecified Psychosis not due to a substance or known physiological condition, Major Depressive Disorder, Primary Insomnia, Unspecified Mood Disorder, and Anxiety Disorder. Record review of a Annual Minimum Data Set (MDS) reference dated 10/14/24 revealed Resident#4 had a Brief Interview for Mental Status score of undetermined, was not considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition, had Depression (other than bipolar), and Psychotic disorder (other than schizophrenia) , was taking Antidepressant, Antipsychotic, Antianxiety and received no Psychological Therapy. Record review of a Care Plan initiated on: 10/21/24 and revised on: 05/07/25 revealed Resident#4 had a mood problem related to Psychosis with a goal to have improved mood state: happier, calmer appearance, no signs of depression, anxiety or sadness through the review date with interventions that included: Administer medications as ordered and monitor/document for side effects and effectiveness, and behavioral health consults as needed. Record review of a Preadmission Screening and Resident Review (PASRR) LEVEL I Screen for Resident#4 completed on 5/22/25 revealed Section I:PASRR Screen Decision-Making, A. MI or suspected MI (check all that apply): Psychosis was not checked. Record review of a physician's order sheet revealed Resident#4 had an order dated 8/09/25 for Quetiapine Fumarate Tablet 100 Milligram (MG) directions Give one tablet by mouth at bedtime for Unspecified Psychosis related to Unspecified Psychosis not due to a substance or known physiological condition Record review of a Psychiatry Progress Note dated 7/08/25 revealed diagnosis included: Unspecified Psychosis. On 8/27/2025 at 10:42 AM The MDS Lead Registered Nurse was interviewed and stated, Resident#4 and Resident#6 are coded on the MDS for Psychotic disorder. On 08/27/25 at 9:58 AM The Social Services Director was interviewed about The PASSR process and stated, When a resident is admitted within 24 hours we have clinical meeting where the information is reviewed including the PASSR to determine if it is correct or incorrect. The Psychiatrist completes an assessment for new residents. If there is a difference in diagnosis I create a new PASSR. On 08/27/25 at 10:52 AM The Director of Nursing was interviewed about the PASRR process stated, We update the diagnosis and changes during the Risk Meeting and then the PASSR is updated. Psychotic disorder is listed on the last psychiatric eval and should be included on the PASSR. The Resident#4 and Resident#6 have Psychotic disorder.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the environment remained free of pests (roaches), as evidenced by roach sightings in the facility. There were 167 residents residing in the facility during the survey.The findings included: During observation and interview on 08/25/2025 at 09:49 AM, Resident #162 was in her room on the bed, a roach was seen crawling on the wall behind the resident. The resident stated, “I haven’t seen any roaches before but please take care of that.” On 08/28/2025 at 08:35 AM, the Administrator revealed pest control services are provided weekly and acknowledged recent sightings of pests, including lizards and baby lizards, both outside and inside the facility. Observation outside of resident’s rooms on the 300 South Wing on 8/25/2025 at 10:26 AM, revealed a roach crawling outside of the room. Photographic evidence submitted. Observation and interview conducted with resident #61’s wife on 8/25/2025 at 10:28 AM, she revealed that there are bugs in the room. While interviewing the resident's wife, an observation revealed a roach crawling up the wall in the 300 South Wing. Photographic evidence submitted. Review of the facility’s policy titled “Pest Control” (undated) indicated: The facility shall maintain an ongoing pest control program to ensure the building is free of insects and rodents. Pest control services are provided by []. Maintenance staff assist in pest control services as needed. Only FDA- and EPA-approved insecticides are permitted.

Based on observation, interview and record review the facility failed to ensure 1) food items in the walk-in refrigerator that were opened were labeled and dated, 2) to store food under sanitary conditions and maintain the food safely using a method to determine the temperatures in the milk box and 3) failure to ensure the proper cleaning and maintenance of exhaust hoods and vents to prevent food contamination. This has the potential to affect one-hundred and thirty-two out of one-hundred and forty-two residents who eat orally residing in the facility. The findings included: 1) Record review of the Food from Home and Outside Sources Policy and Procedure (written date November 2017); Policy Statement-Food and Beverage not procured by the Food and Nutrition Services department shall adhere to the same uniform handling procedures established by the center to ensure that the food or beverage is wholesome and safe to consume; Policy Interpretation and Implementation-2) If the food or beverage items require refrigeration or freezer storage, the item must be stored in an appropriate area and bear the following information: Open date and 4) Any and all stored food and beverages found to be left unattended or without proper labeling, dating and storage requirements will be discarded. Observation of the initial kitchen tour with the Accounts Manager/Food Service Director on 4/22/2024 at 6:33 am revealed opened and undated mozzarella cheese and egg salad. (Photographic evidence submitted) Interview with the Accounts Manager/Food Service Director on 4/22/2024 at 6:34 AM. She stated, The items should be dated when opened. If they are not dated, they should not be in here. 2) Record review of the Food Storage Policy and Procedure (written date November 2017); Policy Statement-Food storage areas shall be maintained in a clean, safe and sanitary manner; Policy Interpretation and Implementation-3) Cold foods shall be maintained at temperatures of 41 degrees or below; 4) There is an accurate thermometer in each refrigerator and freezers used for perishable foods and 8) The Dietary Manager or designee will check refrigerators and freezers daily for proper temperatures. Observation of the milk box with the Accounts Manager/Food Service Director on 4/22/2024 at 6:37 am showed no thermometer on the inside of the milk box. The Milk box contained cartons of milk. Interview with the Accounts Manager/Food Service Director on 4/22/2024 at 6:38 am. She stated, There should be a thermometer in here. I will put another one in here. Record review of the Milk Box Refrigerator Temperature Log for the month of April 2024 documented on April 22, 2024 the temperature was 34 degrees F (Fahrenheit) for the AM (morning). 3) Observation of the dish machine hood ventilation system with the Accounts Manager/Food Service Director on 4/23/2024 at 9:42 AM was rust laden. (Photographic evidence submitted). Interview with the Accounts Manager/Food Service Director on 4/23/2024 at 9:43 AM. She stated, The vent should be cleaned every day. We were cited last year for this. Observation with the Corporate Regional Nurse Consultant on 4/23/2024 at 10:45 AM of the dish machine hood ventilation system was cleaned but still contained rust. (Photographic evidence submitted).

Based on record review and interview, the facility failed to provide advance directives documentation for seven out of seven sampled residents (Resident #102, Resident # 137, Resident # 305, Resident # 307, Resident # 65, Resident # 76 and Resident # 77). The findings included: Record review of Resident #102's demographic face sheet noted an admitted [DATE]. Review of Resident # 102's clinical records showed no written documentation related to advance directives. Record review of Resident #137's demographic face sheet noted an admitted [DATE]. Review of Resident # 137 clinical records showed no written documentation related to advance directives. Record review of Resident # 305's demographic face sheet noted an admitted [DATE]. Review of Resident # 305's clinical records showed no written documentation related to advance directives. Record review of Resident # 307's demographic face sheet noted an admitted [DATE]. Review of Resident # 307's clinical records showed no written documentation related to advance directives. During an interview on 04/24/2024 at 8:10 AM. The Administrator reported; Resident # 102, Resident # 137, Resident # 305, Resident # 307 do not have Advance Directives on file. Interview with Social Services Director on 04/24/24 at 10:01 AM. She reported, the Advance Directives was part of the Admission Package. as soon as a resident is admitted . The Admission Director oversees offering the Advance Directives to residents at time of Admission. Interview with Admission Director on 04/24/24 at 10:46 AM. She reported that when a resident is admitted , she explain to the resident or resident's representatives about the Advance Directives. The resident or the resident's representative then decides whether to execute or not; the resident or the resident's representative is informed that if they already have any form of Advance Directives at home such as Living Will, Power of Attorney, Health Care Surrogate, etc. They must bring these documents to the facility as soon as possible. The facility does not have any document signed by the residents or the residents' representative informing them they are being offered the Advance Directives by the facility and decided not to execute. Record review of Policies and Procedures for Advance Directives dated November 2017 revealed the Policy: A resident's choice about Advance directives will be respected. Policy Interpretation and Implementation: 1-Prior to, or upon admission the Care Plan Team will ask residents/their family members, about the existence of Any Advance Directives. 2-Should the resident indicate that he or she has issued Advance Directives about his or her care and treatment, the Center will require that a copy of such directives be included in the medical record. 31581 Record review of Resident #65's demographic face sheet noted admitted was 4/10/2023. Review of Resident #65's clinical record showed no written documentation related to advance directives. On 4/25/2024 at 12:27 PM, interview with the Social Services Director revealed, she does not have an Advance Directives on file. Record review of Resident #77's demographic sheet noted admitted was 10/30/2023. Review of Resident #77's clinical record showed no written documentation related to advance directives. On 4/25/2024 at 1:08 PM, during an interview the Social Services Director reported she does not have an Advance Directives on file. 34007 Review of Resident #76's medical records, revealed the resident was admitted to the facility on [DATE]. The records reviewed for the resident or family's receipt of advance directive information was not found in the resident's records. On 04/24/24 at 07:15 AM the Administrator stated: For some residents we do not have documentation. On 04/24/24 at 10:00 AM Social Services reported that upon admission the advance directive is offered together with the admission package, if the residents do not want executed, the facility does not keep any record.

Based on record review and interview, the facility failed to ensure an effective Quality Assessment and Assurance (QAA) committee/ Quality Assurance/Performance Improvement (QAPI) as evidenced by not implementing corrective plans of action for correcting repeated deficiencies related to labelling and storage of drugs and biologicals, sanitary food handling and infection control and sanitary food handling. Cross reference F761 Label/Store Drugs & Biologicals; Cross reference of F880 for Infection Prevention and Control and F812 for Sanitary Food Handling and Cross reference of F880 for Infection Prevention and Control and F867 QAPI/QAA. These repeated deficient practices have the potential to increase the risk of negative resident outcomes. There were 142 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during the last recertification survey with exit dated 12/15/2022, F761 Label/Store Drugs & Biologicals, F812- Food Procurement, store/ prepare/serve-Sanitary, F880-Infection Prevention and Control and F867 QAPI/QAA were cited. During an interview on 04/24/2024 at 1:11 PM, the Administrator reported the committee meets monthly and consist of the Director of nursing (DON), Medical Director, Assistant Director of Nursing (ADON), Infection Preventionist/Staff Developer, Director of Social Services, Admission Coordinator, Food Service Manager, MDS coordinator, Medical Records, Human Resources Director, Activities Director, Plant Ops Director, Environmental Supervisor, Central Supply, Staffing and Pharmacy Consultant. The Administrator stated: We have Performance Improvement Plans (PIPs) for Fall. Decreasing the falls, implementing fall decrease. Make sure that there is one-on-one staff for residents who hare on a high-risk fall. This started in March and is on-going. The falls have decreased, but we will be working at least for the next three months. Review of the facility's Policies and Procedures dated March 1, 2024: Policy Statement: our center's written QAPI plan provides needed guidance for our overall quality improvement program which coincides with our vision and mission statements. Our QAPI plan includes the policies and procedures used to: Identify and use date to monitor our performance. Establish goals and thresholds for our performance measurement. Utilize resident, staff, and family input. Identify and prioritize problems and opportunities for improvement. Systematically analyzed underlying causes of systematic problems and adverse events. Develop corrective action of performance improvement activities. Current Quality Assessment and Assurance Activities. The QAA committee will review data from areas the Center believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality. How our center will conduct performance improvement projects (PIPs). Our Center will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or service in areas that we identify as needing attention. We will conduct PIPs that will lead to changes and guide corrective action in our systems, which cross multiple departments, and have an impact on the quality of life and quality of care for residents living in our community. We will conduct PIPs that will improve care and service delivery, increase efficiency, lead to improve staff and resident outcomes, and lead to greater staff, resident, and family satisfaction. An important aspect of our PIPs is a plan to determine the effectiveness of our performance improvement activities and whenever the improvement is sustained.

Based on observation and interview facility failed to properly dispose biohazard material for one resident (Resident#74) out of seven sampled residents as evidenced by an observation of staff placing biohazard bag in bin with white lid, after a wound care observation for R#74. There were 142 residents residing in the facility at the time of the survey. The Findings Included: On 4/24/2024 at 10:57 AM After a wound care observation of R#74, Staff D, Certified Nursing Assistant, (CNA) entered The Soiled Utility room and disposed of the biohazard trash bag into a bin with a white lid. (see photo evidence) On 4/24/2023 at 10:58 AM Staff D, CNA When asked where biohazard bag was placed, stated I placed the biohazard bag into the bin with the white lid bin. Stated I am supposed to put in into the bin labeled biohazard box. Stated I placed into the other bin because I didn't see the biohazard bin because I am nervous. On 4/24/2024 at 11:00 AM Staff D, CNA removed biohazard bag from bin with white lid and plaed into carton labeled Biohazard. On 4/25/2024 at 12:01 PM The Director of Nursing (DON) stated any materials that contain blood or body fluids are to be placed inside a biohazard bag for disposal. Stated the biohazard bag is to be then placed into the box labeled Biohazard, located inside The Soiled Utility room in. Stated I have provided staff with education regarding proper disposal of biohazard materials. Stated the purpose of this practice is to protect staff and residents from infection because if the biohazard bag is placed into the incorrect bin it can potentially cause cross contamination. Policy and Procedure entitled, Waste Disposal dated 10/2019. Policy All infectious and regulated waste shall be handled in a safe and appropiate manner. Policy Interpretation ad Implementation. 1. All infectious and regulated waste awaiting disposal shall be placedd in a closable leak- proof containers or bags that are color-coded or labeled as described. It shall be the responsibility of the Infection Preventionist in conjunction with the environmental services director to ensure that waste is properly disposed of and the following rules are observed: Disposal of all infectious and regulated waste shall be in accordance with applicable federal, state, and local regulations.

Based on observations, interviews and record review, the facility failed to ensure the high temperature dish machine for the wash cycle and the final rinse cycle was working properly. This has the potential to affect one-hundred and thirty-two out of one-hundred and forty-two residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Dish Machine Temperatures Policy and Procedure (written date November 2017); Policy Statement-Temperatures will be recorded daily in all Dish machine units that are utilized in the dietary department; Policy Interpretation and Implementation-1) A log will be maintained for all Dish machine equipment daily. Temperatures for wash cycle, rinse cycle will be recorded daily as assigned by the dietary department supervisor; 3) If wash temperatures are noted to be outside the safe zone of 160 degrees Fahrenheit (High Temperature Machine), the dietary supervisor must be immediately notified and 5) Rinse Cycle must reach 180 degrees Fahrenheit for (High Temperature Machine). Notify Dietary Supervisor if temperatures do not meet threshold. Observation of the high temperature dish machine on 4/23/2024 at 9:37 AM with Staff A, Dietary Aide and the Accounts Manager/Food Service Director revealed wash dial was at 150 degrees F and the final rinse dial was at 174 degrees F. Staff A, Dietary Aide placed several more trays with cups and dishes to be washed through the dish machine and the wash dial and the final rinse dial did not move, it stayed at 150 degrees F for the wash and the final rinse dial was at 174 degrees F. Several more cycles were conducted and the wash dial stayed at 150 degrees F and the final rinse dial was at 174 degrees F. (Photographic evidence submitted) Interview with the Accounts Manager/Food Service Director on 04/23/2024 09:38 AM. She stated, The dish machine was ran earlier at 9:00 AM and the dish machine log says for breakfast the wash was 155 and the rinse was 191. She revealed the wash temperature should be at 150 and the final rinse at 180. The Accounts Manager/Food Service Director immediately stopped the dish machine and called the service tech company to come to the facility and service the dish machine. Record review of the Dish Machine Log for the month of April 2024 documented on April 23, 2024 the wash temperature was 155 degrees F and the final rinse was 191 degrees F for breakfast. Interview with Staff A, Dietary Aide on 4/23/2024 at 9:39 AM. He stated, The dish machines final rinse temperature should be 180 and the wash should be 155-160. Observation of the high temperature dish machine on 4/23/2024 at 11:37 AM revealed the dish machine technician servicing the dish machine. Interview with the Regional Maintenance Director on 4/23/2024 at 11:38 AM. He stated, There was a knife stuck in the dish machine drain and now it is working. The dish machine is now at the proper temperature. Review of the Dish machine Repair Company Invoice dated 4/23/2024 documented the following: After troubleshooting, I found fork clogged inside drain pipe causing water to leak and temperature to be low. The fork was removed and a new temperature gauge was installed. New vacuum break has also been installed. At this moment machine is reaching proper temperature and functioning 100% properly.

Based on observations, interview, and record review the facility failed to provide dignity while dining for one resident (Resident #27) out of seven residents sampled, as evidenced by staff standing while assisting Resident #27 to eat breakfast. There were 142 residents residing in the facility at the time of the survey. The findings included: Observation on 04/24/2024 at 8:46 AM, revealed Staff E, a Certified Nursing Assistant (CNA) was standing while assisting Resident #27 to eat breakfast. Record review of Resident #27's demographic sheet revealed an admitted [DATE] and readmission on 3/30/2024 with diagnosis that included Morbid obesity. Record review of Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] section C for cognitive status revealed a Brief Mental Status (BIMS) score of undetermined. Section GG for functional status revealed set up clean up assistance for eating. Section K for swallowing status revealed no or unknown. Record review revealed a care plan initiated on 3/1/2023 and started on 4/19/2023 for potential nutritional problem. The interventions included assisting with meals. On 4/24/2024 at 8:50 AM Staff E, CNA stated: I am aware of the facility's protocol for assisting resident with meals. I am to be seated while assisting residents with meals. I was not seated next to {Resident #27] while assisting her to eat because the bed is too high; next time I can lower the bed to adjust to my height so I can be seated while assisting [Resident#27] to eat. On 4/25/2024 at 12:19 PM The Director of Nursing (DON) stated: Staff are to be seated next to residents while assisting with meals and the reason for this is to provide dignity for the resident. Record review of the facility's policy entitled Dignity dated 12/2017 revealed Policy-The Center must treat each Resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Procedure-Treat each resident with respect and dignity with regards to the following: Assisting with eating and other activities of daily living.

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident #149) out of five residents reviewed for discharges. As evidenced Resident #149 was discharged to home; but the MDS indicated the resident was discharged to hospital. The finding included: Record review of Resident #149's admission record revealed the resident was admitted to the facility on [DATE] and discharged home on 04/04/2024. Record review of Medical Diagnosis revealed the resident's diagnosis included, but were not limited to, Malnutrition and chronic obstructive pulmonary disease with (acute) exacerbation, Record review of Resident #149's Care Plan initiated on 04/12/2024 revealed Focus: The resident wishes to return/be discharged to home with sister-in-law. Record review of progress notes dated 4/4/2024 at 18:33 revealed Discharge Summary Resident is going home discharge in stable condition . discharge instructions signed by patient. Record review of Discharge Return Not Anticipated Minimum Data Set (MDS) Section C dated 04/24/2024 revealed the Brief Interview for Mental Status Summary score was 09 out of 15. Review of section A2105 for Discharge Status documentation indicated a coding of 01 meaning the resident was discharged to Home/Community. Interview on 04/24/2024 at 10:34 AM, the MDS Coordinator stated: I believe it was an oversite while coding it and I will correct it immediately. Review of the facility's Policy and Procedure; Subject: Resident Assess Instrument (RAI), dated 1/12/2024. Intent: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frame stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for each care plan development.

Based on observation, record review and interview, the facility failed to ensure that a splint device was in place/worn to prevent worsening of left hand and left elbow contractures for one (Resident #12) out of one resident reviewed for positioning and mobility out of twelve residents with contractures. The findings included: An initial observation of Resident #12 was conducted on 4/22/2024 at 8:47 AM. The resident was sitting up in bed, watching television, the resident had contractures on the right elbow, right hand, left elbow and left hand. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Second observation of Resident #12 was conducted on 4/23/2024 at 8:40 AM. The resident was sitting up in bed eating breakfast, television. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Third observation of Resident #12 was conducted on 4/24/2024 at 10:03 AM. The resident was sitting up in bed asleep, television was o. No hand rolls were noted on the right- or left-hand contractures and no splints were noted on the contractures for the right or left elbows. Fourth observation of Resident #12 was conducted on 4/24/2024 at 12:56 PM. The resident was sitting up in bed asleep, television on. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Record review of the Demographic Face Sheet for Resident #12 documented the resident was admitted on initially 4/19/2016. The resident was discharged to the hospital on 3/29/2024 and returned the same day (3/29/2024) to the facility, with diagnoses that include but not limited to multiple sclerosis, diabetes mellitus, functional quadriplegia, anxiety disorder, contractures on right elbow and right hand, left elbow and left hand. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #12 dated 2/20/2024 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 09 out of 15 indicating mild cognitive impairment and required total dependence assistance for ADLs (Activities of Daily Living) and had impairment on both sides for the upper and lower extremities. Review of Resident #12 Physician's Order Sheet (POS) for April 2024 documented the resident was to wear left grip hand splint and left elbow contracture management splint to be worn daily on in AM and off in PM as tolerated during therapy one time only for contracture management of the left hand and elbow for 30 days. The start date was 4/23/2024 and the end date 5/23/2024. The order was written on 4/23/2024. Review of Resident #12's Contracture care plan written 9/12/2023 and revised 2/27/2024 documented the resident has an alteration in musculoskeletal status related to contracture, right elbow, functional quadriplegia, contracture left elbow, contracture right hand, muscle spasm, contracture left hand; Goals: 1) Resident will remain free of injuries or complications related to review date, 2) Resident will remain free from pain or at a level of discomfort acceptable to the resident through the review date; Interventions: Anticipate and meet needs, Resident needs to change position; No interventions noted with splints. On 4/25/2024 at 10:07 AM, interview with Staff B, Registered Nurse. She stated, She is total care, but eats by herself. She started wearing splint on left arm on Tuesday, 4/23/2024. She wears it for 3-4 hours. Therapy comes into her room to give her therapy. On 4/25/2024 at 11:26 AM, interview with the Director of Rehab. She stated: She was just evaluated. She has left hand and left elbow contractures. She has a splint on the left hand. The order was written on 4/23/2024 by the therapist and signed off by the doctor. She only tolerates it a couple of hours per day. She receives OT (occupational therapy) and SLP (speech therapy). She had OT on 10/19/2023 and was discharged from OT on 11/22/23. She was tolerating it for two hours. She was again evaluated for OT on 4/23/2024 and determined to wear the grip left hand splint and left elbow contracture management splint. Fifth observation of Resident #12 was conducted on 4/25/2024 at 11:31 AM. The resident was sitting up in bed watching television and had contractures on the right elbow, right hand, left elbow and left hand. No hand rolls were noted on the right or left hand and no splints were noted on the right or left elbows. Interview with the resident she revealed that before this week she did not wear a splint on her left hand or arm. The facility only put on the left hand splint this week. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment for Resident #12 documented the resident was certified to received OT services for 4/23/2024 to 5/22/2024; Diagnoses: Contracture left elbow; Contracture left hand with a frequency of 16 times for 30 days. Short term Goals: Patient will tolerate left hand orthosis (brace) for 4 hours daily or as tolerated; PT (patient)will tolerate left elbow flexion contracture orthosis for 4 hours daily; Reason for therapy: Referred to skilled OT services by nursing for left UE (upper extremities) contracture management and to assess appropriateness of the previously recommended orthotic devices for contracture management. Patient was found with increased left elbow flexion rigidity; however, patient was receptive to work on wearing the orthosis to try preventing further joint contracture of the left elbow and hand. Left slim grip hand orthosis was applied and appeared to fit well however the left elbow contracture management orthosis was not able to fit at this time due to increased rigidity. On 4/25/2024 at 1:56 PM, the Director of Nursing (DON) stated: When the resident went to the hospital, the splint was discontinued. She went to the hospital on 3/29/24. The doctor wrote the order on 4/23/24 for her to wear the splint. Record review of the Assistive Devices and Equipment Policy and Procedure (Revised 12/12/2023) documented: Policy-All resident who are observed to need rehabilitation equipment (such as splint/brace/prosthetic devices) will be screened and/or evaluated by a licensed therapist to determine medical necessity and the most appropriate device for that situation; Procedure: 1) Upon admission, transfer or return, all residents will be screened/evaluated for appropriate rehab equipment; 2) Whenever indicated, nursing will send a consultation request form to the Rehab department identifying a perceived need for Rehab equipment; 3) A licensed therapist will screen/evaluate the resident to determine medical necessity and the most appropriate type of device and 4) The therapist will provide off the shelf, customize equipment or contact a vendor to order an appropriate device.

Based on observation, record review and interview facility failed to keep drug records in an order that an account of all controlled drugs is maintained and periodically reconciled for one resident (Resident #74) out of seven residents sampled as evidenced by total number of pills in bingo card labeled Clonazepam Tab 0.5 mg (milligrams), less than the amount recorded on Controlled Drug Receipt/Proof of use/Disposition form. There were 142 residents residing in the facility at the time of the survey. The findings included: On 04/24/24 at 3:37 PM a narcotic count was completed with Staff C, a Licensed Practical Nurse (LPN) for South cart in nursing section 300. Resident #74's Clonazepam 0.5 mg (milligrams) tablet blister pack count was 33 tablets and the Controlled Drug Receipt/Proof of use/Disposition form for Resident #74's Clonazepam 0.5 mg tablet was 34, last signed on 4/23/2024. (photo evidence) Record review of electronic medication administration record revealed Staff C, LPN signed that Clonazepam 0.5 mg tablet was administered to Resident #74 on 4/24/2024 at 1:16 PM. Staff C, LPN stated she forgot to sign after administration of medication. Staff C stated: I am supposed to sign after administering to the resident, but I got distracted. On 4/25/2024 at 12:22 PM The Director of Nursing DON stated that nurses are to sign out the controlled medications on The Controlled Drug Receipt/Proof of use/Disposition form at the time it is removed from the from the bingo card. Record review of the facility's policy and procedure entitled, Control Drugs dated 10/2017 revealed Policy Drugs listed in Schedule II, III, IV, shall be subject to special handling, storage, disposal, and record keeping. Policy Interpretation and Implementation. 3. If the count is correct, a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain d. Number on hand. i. Time of administration. K. Signature of nurse administering drug.

Based on record review and interviews, the facility failed to ensure one (Resident #2) out of three sampled residents was free from abuse and neglect and is determined to be at a level of harm, as evidenced by: the facility's staff failure to implement interventions for constipation and prevention of fecal impaction that resulted in the fecal impaction of Resident # 2 who subsequently expired after being transferred to the hospital. There were 155 residents residing in the facility at the time of the survey. The findings included: Review of Resident #2's medical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]; and discharged to the hospital on [DATE]. Resident # 2's clinical diagnoses included but not limited to: Cachexia, Anorexia, Nutritional anemia, type 2 diabetes mellitus (DM) and Disease of esophagus and Dementia. Review of the Physician's Orders Sheet for October to [DATE] revealed Resident #2 had orders that included but not limited to: Docusate sodium oral tablet 100 mg- give 1 capsule orally two times a day related to constipation,. Elder tonic liquid, give 15 ml orally two times a day related to eating disorder, unspecified. Diet-Regular diet, Regular texture, Regular/Thin consistency. Record review of Resident # 2's Discharge Return anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented a Brief Interview of Mental status Score (BIMS) of 11, on a ,d+[DATE] scale indicating the resident is cognitively moderately impaired. Section GG for Functional Status documented the resident required supervision for transfer, walking, toilet use, personal hygiene, and limited assistance for dressing. Section H for Bowel and Bladder Documented the resident is continent of bowel and bladder. Section K for Nutritional Status documented the resident was 67 inches tall, weighed 80 pounds and had no unknown weight loss/gain. Review of Resident #2 's Care Plans Reference Date [DATE]. revision date [DATE] documented Resident is at risk for bowel/ bladder incontinence related to impaired mobility. Interventions include- Ensure the resident has had unobstructed path to the bathroom. Monitor and document intake and output as per facility policy. Monitor/document for signs and symptoms of Urinary Tract Infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Monitor/ document/ report as needed any possible causes of incontinence: bladder, infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Review of Resident #2 's Care Plans Reference Date [DATE] documented Resident has a potential risk for constipation, Interventions include: Encourage by mouth fluids as tolerated, follow facility bowel protocol for bowel management., Monitor medications for side effects of constipation. Keep physician informed of any problems, Monitor/document/report as needed signs and symptoms of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Bradycardia (slow, low pulse), Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Diaphoresis, Abdomen: tenderness, guarding, rigidity, fecal compaction. Record bowel movement pattern each day, every shift. Describe amount, color, and consistency. Review of Resident #2 's Care Plans Reference Date [DATE] documented Resident is at risk for falls. Interventions include Anticipate and meet the resident's need. Follow facility fall protocol. Physical Therapy to evaluate and treat patient as ordered. Review of the progress notes dated [DATE] timestamped at 10:44 AM documented: At 10:38 AM Resident was sitting in wheelchair outside patio and fell out of wheelchair on floor as per report by bystanders. Observed in right side lying position upon arrival to scene by assigned nurse. Management on scene. Resident was alert and oriented x 2, verbally responsive, no sign and symptoms of injuries. At 10:39 AM Fire rescue called by assigned staff while other staff nurse and management assisted patient to room. Head to toe assessment was completed with no visual injuries observed. Family notified spoke with resident's emergency contact after 3 attempts to contact resident's son by the phone number on record. Nurse Practitioner notified, Fire rescue arrived and assessed resident and left the facility at 11:10 AM to [local hospital] with the resident. Review of Resident #2's hospital records revealed on [DATE] upon arrival to the hospital's emergency department (ED) the patient was hypotensive (low blood pressure) BP (Blood Pressure) of ,d+[DATE],, Hypothermic (low body temperature) with temperature of 33 degrees Celsius/91.4 degrees Fahrenheit. The resident's final diagnoses included Septic shock, Fecal Impaction of Colon, Metabolic Acidosis, and Closed Traumatic Brain Injury. Interview on [DATE] at 1:19 PM with the Director of Nursing (DON). The DON stated: On [DATE] the resident was on the smoking patio sitting having a conversation with another resident, the other resident was waving to the staff because [Resident # 2] was pale and started sliding from the wheelchair, staff responded, took the resident to her room, evaluated the resident, took her vital signs, documented the vitals in the situation, background, assessment and resolution (SBAR), the resident was alert, her blood pressure was low and she looked confused, normally she is alert and oriented, while she was in the room with the staff the resident had a bowel movement and was stating that she needed her purse. We called the resident's physician and was told to transfer the resident to the hospital for evaluation. 911 arrived shortly, they checked on the resident, she was responding to all their questions, the only thing that they found was she had low blood pressure, Rescue initially, did not want to take the resident to the hospital, but we insisted because we notice a change in the resident. The day the resident fell she had a bowel movement in the room during the time the staff was assessing her. The Certified Nursing Assistants (CNAs) are responsible for recording the residents' bowel movement every shift. Regarding this resident, she is very independent, and she used to go to the bathroom by herself but sometimes she needed help. The CNAs ask the resident if she have a bowel movement to notify them about it and we educated the resident about making sure she let nursing staff know when she wants to use the bathroom and when she has a bowel movement, also about safety regarding using the call light for help when she goes to the bathroom. The resident was also educated to leave the toilet unflushed after being used for bowel movement and notify the staff so they could see the amount and type of bowel movement. According to the documentation on the task list on [DATE] was the last documented bowel movement for this resident. I know for sure the resident had a bowel movement on [DATE] after the fall when she was in her room being assessed by the nurse. My follow up was trying to contact the resident's son, on [DATE] there was no answer on the phone; the hospital then called later in the day for family contact information for the resident. On [DATE] the resident's son called the facility, and stated he changed his number, I let the resident's son know we needed his new information to update the records. The resident's son notified me that he was coming to the facility the following week. He came to the facility a few days later, me, NHA (Nursing Home Administrator) and business office staff met with him about his mother's purse-he wanted to retrieve the purse, he was given his mother's purse. At that time the resident's son did not request any medical records or voiced any concerns about his mother's care in the facility and apologized for the incident we had with other family members coming to the facility and going through the resident's belongings in her room looking for documents on [DATE]. We did not know that the resident incurred any injuries after the fall, she was alert, was able to move all her extremities. On [DATE] we called the facility liaison at the hospital; the resident was still in the emergency room , and she did not have any update for us at that time. When we followed up with the liaison afterwards, we found out the resident passed away, but we were not given any diagnosis or results. When the admission department contacted the hospital, they received a report that the resident had constipation complications. We are still waiting for the resident's records from the hospital. Interview on [DATE] at 2:02 PM Licensed Practical Nurse (Staff A) stated: on [DATE] I was called to the patio to check on the resident, I was the resident's assigned nurse that day, I went to the patio, the resident was on the floor in front of her wheelchair, management and other staff was already there. I did a quick assessment of the resident, I asked the resident was she ok, the resident responded yes, The resident was on the floor, and I was not sure how she got there, my immediate response after assessing her was to call 911, I called 911 and other nurses on the scene were assisting the resident back to her wheelchair. We took her to her room, I did another assessment on the resident, vital signs, her blood pressure was on the low side. I do not recall if the resident had a bowel movement, it was a long time ago. While we were in the room with the resident rescue arrived, they did not want to take her to the hospital at first, we let them know she had fallen, and her blood pressure was low. Rescue decided to take the resident to the hospital. The family and the resident's physician were notified. This resident usually went to the bathroom by herself, the Certified Nursing Assistants (CNAs) would communicate with the resident about her bowel movements, she was very alert, she did not complain about any pain to me before the fall. Interview on [DATE] at 2:06 PM Certified Nursing assistant (CNA) (Staff B) stated: I have been employed in the facility for 8 years. After I assist a resident with incontinence care I record the bowel movement daily using the tablet on the electronic system. If I notice a resident does not have a bowel movement for a few days I report it to the nurse. Interview on [DATE] at 2:10 PM. Certified Nursing assistant (CNA) (Staff C) stated: I have residents on my assignment who are continent of bowel and bladder. I keep a record of their bowel movements by asking them throughout the day and updating it in the electronic system. If there is a resident who has not had any bowel movements in a couple days, I report it to the nurse. Interview on [DATE] at 2:13 PM CNA (Staff D) stated: I have been employed in this facility since 2019. I have residents who are incontinent. I record their bowel movements by looking in the incontinent brief and recording in the point of care electronic system what type, size, and color I see. If a resident does not have a bowel movement in a couple days I report it to the nurse. Review of the Bowel and Bladder Task list revealed the last bowel movement was documented on [DATE] at 23:29 bowel movement/large/formed/normal. Last toileting use documented was on [DATE] at 23:30. Review of the Transfer Details Report documented on [DATE] at 10:45 AM. Reason for transfer post status fall. Clinical events/presentation which led to this transfer: lethargic. Transfer Date/Time: [DATE], 10:48 am transfer to: [local hospital]. Vitals signs: temperature: 97.7, pulse: 57, respiration:16, blood pressure: ,d+[DATE], oxygen saturation: 95%, blood sugar 90. Continent status: continent of bowel and bladder. Date of last Bowel movement: [DATE]. Review of the Situation Background Assessment Transfer Report (SBAR) documented on [DATE] at 10:44 AM post status fall, Vitals: blood pressure ,d+[DATE], pulse- 66, respiration 16, temperature 97.9 blood glucose 90, oxygen saturation 97%. At 10:38 AM Resident was sitting in wheelchair outside patio and fell out of wheelchair on floor as per report by bystanders. Observed in right side lying position upon arrival to scene by assigned nurse. Management on scene. Resident was alert and oriented x 2, verbally responsive, no sign and symptoms of injuries. At 10:39 AM Fire rescue called by assigned staff while other staff nurse and management assisted patient to room. Head to toe assessment was completed with no visual injuries observed. Family notified spoke with resident's emergency contact after 3 attempts to contact resident's son by the phone number on record. Nurse Practitioner notified, Fire rescue arrived and assessed resident and left the facility at 11:10 AM to [local hospital] with the resident. Reviewed Training on Abuse, Neglect, Exploitation and Restraints, most recently completed for all facility staff on [DATE] to [DATE]. Review of the facility's policy and procedure titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property dated [DATE] states: It is the policy of this Center that each resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind, exploitation, and misappropriation of property. In addition, each resident will also be protected from those practices and omissions, which if left unchecked, could lead to abuse. Further, each resident will be treated with respect and dignity at all times. The Center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care. Residents will not be subjected to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, contract staff, family members, friends, or others. Neglect: Neglect means the failure of the center, its associates or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on record review and interviews, the facility failed to ensure one (Resident #2) out of three sampled residents received care and treatment in accordance with professional standards of practice related to consistency in the resident's bowel management; that include but not limited to interventions for constipation and prevention of fecal impaction. Resident # 2 expired in the hospital and was diagnosed with fecal impaction. This deficient practice was determined to be at the level of harm. There were 155 residents residing in the facility at the time of the survey. The findings included: Review of the undated facility policy and procedures titled, Quality of Care Attain and Maintain Each resident must receive, and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Guidelines: 1. This facility will monitor the resident to prevent unavoidable deterioration by identification, interventions, and analysis. 3. The facility will ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment and within the limits of recognized pathology and normal aging process. Review of Resident #2's medical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]; and discharged to the hospital on [DATE]. Resident # 2's clinical diagnoses included but not limited to: Cachexia, Anorexia, Nutritional anemia, type 2 diabetes mellitus (DM) and Disease of esophagus. Review of the Physician's Orders Sheet for October -[DATE] revealed Resident #2 had orders that included but not limited to: Docusate sodium oral tablet 100 mg- give 1 capsule orally two times a day related to constipation, unspecified. Ferrous sulfate tab 325 Milligram (mg)- give 1 tablet orally one time a day related to anemia. Calcium tablet 600 mg-give 1 tablet orally one time a day for vitamin deficiency, unspecified. Elder tonic liquid, give 15 ml orally two times a day related to eating disorder, unspecified. Diet-Regular diet, Regular texture, Regular/Thin consistency. Review of Resident # 2's Discharge Return anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented a Brief Interview of Mental status Score (BIMS) of 11, on a ,d+[DATE] scale indicating the resident is cognitively moderately impaired. Section GG for Functional Status documented the resident required supervision for transfer, walking, toilet use, personal hygiene, and limited assistance for dressing. Section H for Bowel and Bladder Documented the resident is continent of bowel and bladder. Section K for Nutritional Status documented the resident was 67 inches tall, weighed 80 pounds and had no unknown weight loss/gain. Review of Resident #2 's Care Plans Reference Date [DATE]. revision date [DATE] documented Resident is at risk for bowel/ bladder incontinence related to impaired mobility. Interventions include- Ensure the resident has had unobstructed path to the bathroom. Monitor and document intake and output as per facility policy. Monitor/document for signs and symptoms of Urinary Tract Infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Monitor/ document/ report as needed any possible causes of incontinence: bladder, infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Review of Resident #2 's Care Plans Reference Date [DATE] documented Resident has a potential risk for constipation, Interventions include: Encourage by mouth fluids as tolerated, follow facility bowel protocol for bowel management., Monitor medications for side effects of constipation. Keep physician informed of any problems, Monitor/document/report as needed signs and symptoms of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Bradycardia (slow, low pulse), Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Diaphoresis, Abdomen: tenderness, guarding, rigidity, fecal compaction. Record bowel movement pattern each day, every shift. Describe amount, color, and consistency. Review of Resident #2 's Care Plans Reference Date [DATE] documented Resident is at risk for falls. Interventions include Anticipate and meet the resident's need. Follow facility fall protocol. Physical Therapy to evaluate and treat patient as ordered. Review of the progress notes dated [DATE] timestamped at 10:44 AM documented: At 10:38 AM Resident was sitting in wheelchair outside patio and fell out of wheelchair on floor as per report by bystanders. Observed in right side lying position upon arrival to scene by assigned nurse. Management on scene. Resident was alert and oriented x 2, verbally responsive, no sign and symptoms of injuries. At 10:39 AM Fire rescue called by assigned staff while other staff nurse and management assisted patient to room. Head to toe assessment was completed with no visual injuries observed. Family notified spoke with resident's emergency contact after 3 attempts to contact resident's son by the phone number on record. Nurse Practitioner notified, Fire rescue arrived and assessed resident and left the facility at 11:10 AM to [local hospital] with the resident. Review of Resident #2's hospital records revealed on [DATE] upon arrival to the hospital's emergency department (ED) the patient was hypotensive (low blood pressure), Hypothermic (extremely low body temperature). The resident was diagnosed with Septic shock, Fecal Impaction of Colon, Metabolic Acidosis, and Closed Traumatic Brain Injury. Interview on [DATE] at 1:19 PM with the Director of Nursing (DON). The DON stated: On [DATE] the resident was on the smoking patio sitting having a conversation with another resident, the other resident was waving to the staff because [Resident # 2] was pale and started sliding from the wheelchair, staff responded, took the resident to her room, evaluated the resident, took her vital signs, documented the vitals in the situation, background, assessment and resolution (SBAR), the resident was alert, her blood pressure was low and she looked confused, normally she is alert and oriented, while she was in the room with the staff the resident had a bowel movement and was stating that she needed her purse. We called the resident's physician and was told to transfer the resident to the hospital for evaluation. 911 arrived shortly, they checked on the resident, she was responding to all their questions, the only thing that they found was she had low blood pressure, Rescue initially, did not want to take the resident to the hospital, but we insisted because we notice a change in the resident. The day the resident fell she had a bowel movement in the room during the time the staff was assessing her. The Certified Nursing Assistants (CNAs) are responsible for recording the residents' bowel movement every shift. Regarding this resident, she is very independent, and she used to go to the bathroom by herself but sometimes she needed help. The CNAs ask the resident if she have a bowel movement to notify them about it and we educated the resident about making sure she let nursing staff know when she wants to use the bathroom and when she has a bowel movement, also about safety regarding using the call light for help when she goes to the bathroom. The resident was also educated to leave the toilet unflushed after being used for bowel movement and notify the staff so they could see the amount and type of bowel movement. According to the documentation on the task list on [DATE] was the last documented bowel movement for this resident. I know for sure the resident had a bowel movement on [DATE] after the fall when she was in her room being assessed by the nurse. My follow up was trying to contact the resident's son, on [DATE] there was no answer on the phone; the hospital then called later in the day for family contact information for the resident. On [DATE] the resident's son called the facility, and stated he changed his number, I let the resident's son know we needed his new information to update the records. The resident's son notified me that he was coming to the facility the following week. He came to the facility a few days later, me, NHA (Nursing Home Administrator) and business office staff met with him about his mother's purse-he wanted to retrieve the purse, he was given his mother's purse. At that time the resident's son did not request any medical records or voiced any concerns about his mother's care in the facility and apologized for the incident we had with other family members coming to the facility and going through the resident's belongings in her room looking for documents on [DATE]. We did not know that the resident incurred any injuries after the fall, she was alert, was able to move all her extremities. On [DATE] we called the facility liaison at the hospital; the resident was still in the emergency room , and she did not have any update for us at that time. When we followed up with the liaison afterwards, we found out the resident passed away, but we were not given any diagnosis or results. When the admission department contacted the hospital, they received a report that the resident had constipation complications. We are still waiting for the resident's records from the hospital. Interview on [DATE] at 2:02 PM. Licensed Practical Nurse (Staff A) stated: on [DATE] I was called to the patio to check on the resident, I was the resident's assigned nurse that day, I went to the patio, the resident was on the floor in front of her wheelchair, management and other staff was already there. I did a quick assessment of the resident, I asked the resident was she ok, the resident responded yes, The resident was on the floor, and I was not sure how she got there, my immediate response after assessing her was to call 911, I called 911 and other nurses on the scene were assisting the resident back to her wheelchair. We took her to her room, I did another assessment on the resident, vital signs, her blood pressure was on the low side. I do not recall if the resident had a bowel movement, it was a long time ago. While we were in the room with the resident rescue arrived, they did not want to take her to the hospital at first, we let them know she had fallen, and her blood pressure was low. Rescue decided to take the resident to the hospital. The family and the resident's physician were notified. This resident usually went to the bathroom by herself, the Certified Nursing Assistants (CNAs) would communicate with the resident about her bowel movements, she was very alert, she did not complain about any pain to me before the fall. Interview on [DATE] at 2:06 PM. Certified Nursing assistant (CNA) (Staff B) stated: I have been employed in the facility for 8 years. After I assist a resident with incontinence care I record the bowel movement daily using the tablet on the electronic system. If I notice a resident does not have a bowel movement for a few days I report it to the nurse. Interview on [DATE] at 2:10 PM. Certified Nursing assistant (CNA) (Staff C) stated: I have residents on my assignment who are continent of bowel and bladder. I keep a record of their bowel movements by asking them throughout the day and updating it in the electronic system. If there is a resident who has not had any bowel movements in a couple days, I report it to the nurse. Interview on [DATE] at 2:13 PM CNA (Staff D) stated: I have been employed in this facility since 2019. I have residents who are incontinent. I record their bowel movements by looking in the incontinent brief and recording in the point of care electronic system what type, size, and color I see. If a resident does not have a bowel movement in a couple days I report it to the nurse. Review of the Bowel and Bladder Task list revealed the last bowel movement was documented on [DATE] at 23:29 bowel movement/large/formed/normal. Last toileting use documented was on [DATE] at 23:30. Review of the Transfer Details Report documented on [DATE] at 10:45 AM. Reason for transfer post status fall. Clinical events/presentation which led to this transfer: lethargic. Transfer Date/Time: [DATE], 10:48 am transfer to: [local hospital]. Vitals signs: temperature: 97.7, pulse: 57, respiration:16, blood pressure: ,d+[DATE], oxygen saturation: 95%, blood sugar 90. Continent status: continent of bowel and bladder. Date of last Bowel movement: [DATE]. Review of the Situation Background Assessment Transfer Report (SBAR) documented on [DATE] at 10:44 AM post status fall, Vitals: blood pressure ,d+[DATE], pulse- 66, respiration 16, temperature 97.9 blood glucose 90, oxygen saturation 97%. At 10:38 AM Resident was sitting in wheelchair outside patio and fell out of wheelchair on floor as per report by bystanders. Observed in right side lying position upon arrival to scene by assigned nurse. Management on scene. Resident was alert and oriented x 2, verbally responsive, no sign and symptoms of injuries. At 10:39 AM Fire rescue called by assigned staff while other staff nurse and management assisted patient to room. Head to toe assessment was completed with no visual injuries observed. Family notified spoke with resident's emergency contact after 3 attempts to contact resident's son by the phone number on record. Nurse Practitioner notified, Fire rescue arrived and assessed resident and left the facility at 11:10 AM to [local hospital] with the resident. Review of the undated facility policy and procedures titled Bowel Protocol documents: Bowel Protocol-To promote elimination via non-medical interventions when able to prevent constipation. 1. Residents who have not had a bowel movement for 3 days are identified and considered to be at risk for constipation. 2. Nursing staff will encourage the resident to increase ingestion of fluids. 3. Nursing Staff will encourage daily mobility as capable of helping increase peristalsis and help keep bowels moving. 4. Residents will continue to be monitored by nursing staff for bowel movements following each step of the protocol and document results as appropriate. 5. An alert will be generated in electronic health record notifying nursing staff when a resident has not had a bowel movement for three consecutive days. Day 1 bowel protocol-Milk of Magnesia, Day 2 bowel protocol-Suppository, Day 3 bowel protocol-Enema.

Based on observation, interview, and record review the facility failed 1). to ensure adequate supervision and appropriate shaving supplies was available for 1 (Resident #76) of 2 out of 46 residents triggered for Assistance with Daily Living (ADL) care and 2) to maintain 1 out of 34 residents room reviewed on stage-1 in safe hazardous-free manner by not ensuring the electrical socket in room 410 was in good condition. This has the potential to affect all residents residing in the facility at the time of this survey. This was found to be actual harm at scope and severity of G, for actual harm to resident #76 left unsupervised with a razor, resulting in facial cuts. The findings include: 1). Observation on 03/21/2017 at 12:09 PM revealed that resident (R) #76 was in bed wearing his hospital gown. The resident was bleeding from nicks and cuts to his cheek, chin and around his lip. There was a paper napkin around his neck and chest, and another napkin on his right hand that he used to dry the blood and apply pressure. A blue razor was on the bedside table. Interview with R#76 on 03/21/2017 at 12:09 PM revealed that he finished shaving his face with a razor. The resident stated that the Certified Nursing Assistant (CNA) helped him shave sometimes but other times he shaved himself with no supervision. The resident confirmed that today he was unsupervised while he shaved. He stated that he was ok and that he got it. Record review of the face sheet revealed that R#76 was admitted to the facility on [DATE] His [DIAGNOSES REDACTED]. Record review of the residents comprehensive Minimum Data Set (MDS) revealed that R#76 had a Nursing Home Comprehensive (NC) Item Set completed on 02/24/2017. MDS' Section G; Functional Status on personal hygiene, was coded 03 for self-performance and 02 for support, indicating that the resident required the extensive assistance of one person for maintaining personal hygiene, including shaving. Record review of R#76's Care Plan dated 03/14/2016, updated and revised on 3/1/17, goal dated 6/1/2017, revealed {the resident}has Self-Care Deficit & is at risk for complications related to physical deficits. He requires varying levels of assistance due to decreased mobility, poor balance and decreased strength. Goal: Resident will not develop any complications related to decrease ADL self-care performance through next review date. Approaches included, (3) Staff to provide the amount of assistance / supervision to meet Resident's needs for all ADLs. (10) Provide adaptive/safety equipment as needed. Further review of the Care Plan revealed that R#76 is at risk for abnormal bleeding or hemorrhage related to use of antiplatelet ASA (acetylsalicylic acid). Approaches included; Staff to use and instruct resident to shave using an electric razor due to risk for bleeding. Interview on 3/22/2017 at 12:07 PM, with staff A, CNA revealed she was familiar with R#76's daily care. Staff A reported that the resident required extensive assistance with all of his ADLs. She was in charge of setting up and assisting the resident with his shaving needs. The setting up included retrieving disposable razors and other supplies from the utility room. Staff A reported that she never used electrical razors to shave the residents; it was not a facility practice. The CNA also reported that at times R#76 preferred to shave himself, when he did, she provided him with the razor and any other supplies. Interview on 03/22/2017 at 12:41 PM, with R#76 revealed that he shaved on average three times a week. He again reported that sometimes staff helped and supervised, other times he did it himself. Observations made at this time revealed four small scars on the residents face, around the lip, chin and cheeks. The resident confirmed the scars were a result from him shaving himself. Interview on 3/22/2017 at 3:27 PM, with Staff D, LPN, revealed The LPN was not aware of R#76's after-shave injuries. The LPN reported that staff should have remained with the resident and observed for any bleeding. The LPN revealed the resident is on anticoagulant therapy; therefore, he should have used an electric shaver. In addition, staff should have immediately reported any injuries or bleeding. During the interview, Staff C admitted that the facility only had razors and that she had never seen an electric shaver used on R#76 or any other resident. The LPN agreed that the use of razors could be a danger for resident #76. Interview on 3/22/2017 at 3:56 PM with the Staff D, Charge Nurse, agreed that the use of razors could be a dangerous for some residents, including R#76, and said that would immediately start working on a plan of correction. On 03/22/2017 at 3:39 PM, verified with CNA that there were no electrical razors used in the facility. 2). Record review of the facility's policy titled Maintenance Service dated January 2005 noted Maintenance service shall be provided to all areas of the building, grounds, and equipment. The Procedures: 1. The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2. The following functions are performed by maintenance, but are not limited to a-maintaining the building in compliance with current federal. state, and local laws, regulations, and guidelines. b-maintaining the building in good repair and free from hazards f-establishing priorities in providing repair service. i-providing routinely scheduled maintenance service to all areas. j-others that may become necessary or appropriate. Observation on 3/20/17 at 11:56AM of room 410 revealed there was an electrical socket on the left side of bed-B. The electrical socket had two items; an oxygen concentrator and nebulizer machine. The plate surrounding the socket was missing and there was an open space surrounding the plugs. Observation on 03/21/17 at 8:08AM revealed the electrical socket remained in disrepair. Observation on 03/21/17 at 4:50PM revealed the electrical socket remained in disrepair. Observation 03/22/17 at 8:50AM revealed the electrical socket remained in disrepair. Observation on 03/22/17 at 9:50AM revealed the maintenance door had a clip board hanging on it. There were forms attached to the clip board that are used to make request for items to be repaired in the building. Record review of the form titled Building Services Work Order Request had sections to be completed which include the date, description of the work to be done, area, room number and type of service needed. The forms clipped to the door did not include a request for room 410 relating to the electrical socket. Interview on 03/22/17 at 9:50AM revealed he has three clipboards in the facility. Two at the nurses station and attached to the door of the Maintenance room. He stated staff are to use the forms to report any repairs needed in the building. He makes continuous repairs as they are reported but if staff does not report to him he would not be aware. He stated the facility recently hired an assistant and this would allow him to conduct more routine rounds to the residents rooms and surrounding grounds of the facility to make note of anything in disrepair. Observation on 03/22/17 at 9:55AM with the Maintenance Director and facility Administrator confirmed the electrical socket needed to be repaired.

Based on observation, interview, and record review, the facility failed to follow care plans for: 1) two (resident #70 and resident #115) out six residents sampled for unnecessary medications, 2) one (resident #255) out two residents sampled for pressure ulcers, and 3) one (resident #56) out two residents sampled for nutrition out of 26 sampled residents whose care plans were reviewed. There was a total of 141 residents in the facility at the time of this survey. This represents actual harm for resident #56 related to the severe unplanned weight loss in a resident who already experienced impaired nutrition and resident #255 related to the development of an unstageable pressure ulcer related to suspected deep tissue injury. Refer to F314, F325 and F329. Findings included: 1.) Record review revealed resident #56 (R#56) was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review revealed a care plan for R#56 dated 7/3/14: Resident is at risk for unintended weight loss/decline in parameters of nutrition. Risk factors include Depression, Dementia, Body Mass Index (BMI)<19.0, Dysphagia, Mechanically altered diet, and dependence for eating. Approaches include, but are not limited to: Provide diet as ordered. Pureed NAS (No Added Salt), provide supplements as ordered 9/4/14 QID (four timeS daily), 9/22/14 Frozen Treat twice daily, 11/6/14 liberalize NAS restriction to Pureed with Thin Liquids, small frequent meals, and snack at PM. Review of R#56's physicians orders revealed a diet order or upon admission: Pureed No Added Salt (NAS) with Thin Liquids, allergies [REDACTED]. Small frequent meals daily. Snack at bedtime. Review of a nursing progress note for R#56 dated 11/6/14 revealed: received new dietary order: Liberalize NAS restriction to Regular diet. Continue with nutritional supplements BID (twice daily), Small frequent meals, snack at bedtime. Review of the clinical record for R#56 including the November physician's orders [REDACTED]. The order to liberalize the diet to Regular was not carried out. The resident remained on an NAS restriction through 11/19/14. Review of the tray ticket does not reflect small portions at meals. The tray ticket did not indicate a change to provide small portions with meals and small frequent meals were not provided. Review of the clinical record to include physicians orders and the Medication Administration Record [REDACTED]. The resident continued to receive the supplement only twice daily through the present. The order to increase the supplement to four times daily was not received until 11/19/14. This was more than two months after the recommendation was made. Weights: (recorded in pounds) Admission 7/25/14 83.2, 8/1/14 79.2, 8/8/14 Isolation, 8/15/14 Isolation (no weights obtained due to resident isolation), 9/14 (no date specified) 76.0 (-8.14% <90 days) which represents a severe weight loss, 9/8/14 71.8 (-5.5% <30 days) which represents a severe weight loss, 9/15/14, 77; 9/22/14, 62.6 (-24.7% <90 days since admission) which represents a severe weight loss, 9/25/14, 70.0; 10/1/14, 70; 11/4/14, 73; 11/20/14, 71.6 (-13.9% in <180 days since admission). These were severe weight losses. Review of the clinical record revealed no documentation of the actual severe weight loss which occured through 9/22/14 with a weight recorded at 62.6 lbs. There were no nutritional assessment or progress updates on file in the clinical record from 9/4/14 through 11/6/14 to address continued weight loss. Observation on 11/19/14 at 8:46 am revealed, resident #56 in her room in bed with her breakfast tray. Her tray ticket revealed her diet order was for Pureed NAS Low Fat/Low Cholesterol. Allergy - Dairy and eggs. No Milk/Dairy Products. No Eggs. Observation on 11/19/14 at 12:55 pm revealed resident #56 in bed eating lunch. The tray ticket reflected a Pureed NAS diet. The tray ticket listed Frozen Treat as a special request, but it was not provided on the tray. 2) a.) Record review of the medical face sheet for resident #70 revealed that the resident was originally admitted on [DATE], and readmitted on [DATE]. In an observation on 11/19/2014 at 9:09 am revealed resident #70 in her room; the resident was finishing up the last remnants of her breakfast. The resident was not in any pain or distress and said that her breakfast was good. She thanked the surveyor for coming to visit her. Record review of the physician's orders [REDACTED].#70 was prescribed 0.5 milligrams (mg) of [MEDICATION NAME], an antipsychotic, to be given twice daily for [MEDICAL CONDITION]. Record review of the [MEDICAL CONDITION] Medications care plan dated 10/17/2014 for resident #70 revealed that the resident was care planned for the risk of signs and symptoms of [MEDICAL CONDITION] medication use. Some of the approaches included, but not limited to, "observe for any signs and symptoms of drug related: ....Cognitive Impairment, Behavioral Impairment, ADL decline, Decline in appetite." Record review of the Behavior Monitoring Record for the month of November 2014 revealed resident #70 was monitored for behaviors of hallucinations. However, on 11/08/2014 during the morning and evening shift, and 11/17/2014 during the night shift, there was no notation to indicate that the resident was monitored for hallucinations or side effects related to the [MEDICATION NAME] medication. Also, there was no Behavior Monitoring Record for the month of October 2014. In an interview with Staff T on 11/19/2014 at 1:10 pm on the North Unit revealed, she documented on the behavior monitoring form when resident #70 has an episode, but since her [MEDICATION NAME] has been increased, the resident has not had many episodes. Staff T could not confirm if she worked on the days in question on the Behavior Monitoring Record for the month of November 2014. In an interview with the Director of Nursing (DON) on 11/19/2014 at 1:30 pm confirmed, the days on the Behavior Monitoring record for the month of November 2014 should have been notated. When the surveyor inquired about the Behavior Monitoring record for the month of October 2014, the DON said, it had not been filed in the medical record yet. b.) Record review of the medical face sheet for resident #115 revealed that the resident was originally admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. During an observation on 11/19/2014 at 8:56 am revealed, resident #115 in her room in bed. The resident's bed was in the low position with air loss mattress and the side rails were in the upright position. The resident had just finished her breakfast and she said that it was good. The resident was not in any pain or distress, and was free from the presence of odors. The resident did not appear to be heavily sedated. Record review of the physician's orders [REDACTED].#115 was prescribed 25 milligrams (mg) of Quetiapine [MEDICATION NAME], an antipsychotic, to be given once daily for [MEDICAL CONDITION], and 50 mg to be given at bedtime. The resident was also prescribed two benzodiazepine medications: [REDACTED]. Record review of the Behavioral Problems care plan dated 09/12/2014 for resident #115 revealed that the resident was care planned for the risk of behavior problems, involving the resident being resistive to care and being disruptive and yelling. Some of the approaches included, but not limited to, administer and monitoring the effectiveness and side effects of medications as ordered. Record review of resident #115's medical chart did not reveal a behavior monitoring form for the month of October 2014 for the Quetiapine [MEDICATION NAME], and [MEDICATION NAME] medications that the resident was receiving. For the month of November 2014 there was no behavior monitoring form for the Quetiapine [MEDICATION NAME] medication for [MEDICAL CONDITION], but there was a form for the [MEDICATION NAME] for anxiety and [MEDICATION NAME] for [MEDICAL CONDITION]. However, on the behavior monitoring form for the month of November 2014, it was revealed that on 11/02/2014, 11/03/2014, 11/06/2014, 11/07/2014, 11/09/2014, 11/10/2014, 11/13/2014, and 11/18/2014 there was no notations to indicate that the resident was monitored for behaviors of calling out, resisting care, and difficulty sleeping and whether interventions were needed for the resident, or if there were any side effects of the medications. In an interview with Staff A on 11/19/2014 at 9:58 am on the North Unit revealed that she provided care to resident #115, and that she documented on the behavior monitoring form when she is monitoring the resident's behaviors. The nurse confirmed that there was no behavior monitoring form for the resident's Quetiapine [MEDICATION NAME] medication, and that at the end of each shift they are supposed to document on the form that the resident was evaluated for any behaviors. Staff A could not remember if she worked on the days in question on the behavior monitoring form for the month of November 2014. In an interview with the Assistant Director of Nursing (ADON/Staff H) on 11/19/2014 at 10:38 am, she confirmed that there was no notation on the Behavior Monitoring form for the month of November 2014 for the days in question and that staff would be in-serviced. In an interview with the Director of Nursing (DON) on 11/19/2014 at 11:00 am, she confirmed that there were no Behavior Monitoring forms for the Quetiapine [MEDICATION NAME] medication for [MEDICAL CONDITION] that resident #115 was receiving, and instructed Staff A to start creating one. Record review of the Facility's Policy on [MEDICAL CONDITION] Drug Use dated 12/2010 revealed that with regards to antipsychotic, antianxiety, and hypnotic medications, the facility would use behavior monitoring as a documentation tool in the "Quarterly Reduction of Medication Usage Review Process." 3.) An observation on 11/17/14 at 3:00 PM of Resident # 255 revealed the resident awake and alert in bed. The resident is not wearing heel protectors. Her feet were not elevated and were lying flat on the bed. An observation on 11/18/14 at 9:00 AM of Resident # 255 revealed the resident in bed with her eyes closed. She was not wearing heel protectors. Her feet were not elevated. An observation on 11/19/14 at 9:32 AM of Resident # 255 revealed the resident awake in bed. Staff O, the resident's nurse, was present during the observation. The resident was not wearing heel protectors and her feet were not elevated. Staff O removed the resident's sock to expose the left heel. Observed on the resident's heel were several closed areas of red, brown, and black discoloration. There was no drainage or odor noted. The surrounding tissue was intact. In an interview on 11/19/14 at 10:50 AM Staff O stated that the resident had physician's orders [REDACTED]. She confirmed that the resident's heels were not off-loaded, the resident was not wearing heel protectors, and the resident's left heel was covered with a sock. She stated that the resident's heel protectors were being laundered. In an interview on 11/19/14 at 10:53 AM, Resident # 255 and her husband reported that the resident has never worn heel protectors while at the facility. The resident stated that sometimes pillows are placed under her left heel, but rarely under both. The resident added that she is not currently in pain, but when she walks, she has pain in her left heel. In an interview on 11/19/14 at 11:00 AM with Staff H revealed that according to the physician's orders [REDACTED]. Review of Resident # 255's demographic face sheet showed that the resident was admitted to the facility 10/24/14. Medical [DIAGNOSES REDACTED]. A review of Resident # 255's medical record showed physician's telephone orders dated 11/04/2014 stating that 1) The resident left heel is to be cleaned with skin prep and left open to air until resolved and 2) The resident is to wear heel protectors on both heels while she is in bed. Physician's telephone orders dated 10/25/14 to off-load the resident's heels on pillows while in bed. A review of Resident # 255's Care Plans showed 1) A care plan dated 11/07/2014 indicating that the resident was at risk for developing pressure ulcers. The interventions for this care plan included floating (off-loading) the resident's heels when in bed and 2) A care plan dated 11/07/2014 indicating that the resident had a pressure ulcer; left heel deep tissue injury (DTI). The interventions for this care plan included positioning the resident with pillows to maintain proper body alignment. Cross Reference to F314, F325 and F329.

Based on observation and record review the facility failed to follow care plans for one (resident #56) out of three residents sampled for review of therapeutic diets out of three sampled residents whose care plans were reviewed. There was a total of 141 residents in the facility at the time of this survey. Findings included: Record review revealed resident #56 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review revealed a care plan dated 7/3/14: Resident is at risk for unintended weight loss/decline in parameters of nutrition. Risk factors include Depression, Dementia, BMI<19.0, Dysphagia, Mechanically altered diet, and dependence for eating. Approaches include, but are not limited to: Provide diet as ordered. Pureed NAS (No Added Salt), provide supplements as ordered 9/4/14 QID (four time daily), 9/22/14 Frozen Treat twice daily, 11/6/14 liberalize NAS restriction to Pureed with Thin Liquids, small frequent meals, and snack at PM. Review of the physicians orders revealed diet order or upon admission: Pureed NAS with Thin Liquids, allergies [REDACTED]. Small frequent meals daily. Snack at bedtime. Review of a nursing progress noted dated 11/6/14 revealed: received new dietary order: Liberalize NAS restriction to Regular diet. Continue with nutritional supplements BID (twice daily), Small frequent meals, snack at bedtime. Review of the clinical record including the November physician's orders [REDACTED]. The order to liberalize the diet to Regular was not carried out. The resident remained on an NAS restriction through 11/19/14. Review of the tray ticket does not reflect small portions at meals. The tray ticket did not indicate a change to provide small portions with meals and small frequent meals were not provided. Review of the clinical record to include physicians orders and the Medication Administration Record [REDACTED]. The resident continued to receive the supplement only twice daily through present. The order to increase the supplement to QID was not received until 11/19/14. Observation on 11/19/14 at 8:46 am revealed resident in her room in bed with her breakfast tray. Her tray ticket revealed her diet order was for Pureed NAS Low Fat/Low Cholesterol. Allergy - Dairy and eggs. No Milk/Dairy Products. No Eggs. Observation of the tray revealed an 8 oz carton of whole milk, three whole slices of bacon, grits, orange juice, a slice of toast, and a whole Danish. The resident was not eating the food provided. Observation on 11/19/14 at 12:55 pm revealed resident in bed eating lunch. The tray ticket reflected Pureed NAS diet. The tray ticket listed Frozen Treat as a special request, but it was not provided on the tray. During interview with the FSD (Food Service Director - Staff D) on 11/20/14 at 11:21 am revealed when a resident has an order for [REDACTED].

Based on observation, interview, and record review, the facility failed to provide the care and services necessary to prevent the development of a pressure ulcer for 1 out 2 (Resident # 255) residents reviewed for pressure ulcers of six residents in the facility with pressure ulcers. Failure to implement interventions to relieve pressure resulted in actual harm due to the development of a pressure ulcer related to suspected deep tissue injury. Findings include: An observation on 11/17/14 at 3:00 PM of Resident # 255 revealed the resident awake and alert in bed. The resident is not wearing heel protectors. Her feet are not elevated and are lying flat on the bed. An observation on 11/18/14 at 9:00 AM of Resident # 255 revealed the resident in bed with her eyes closed. She is not wearing heel protectors. Her feet are not elevated. An observation on 11/19/14 at 9:32 AM of Resident # 255 revealed the resident awake in bed. Staff O, the resident's nurse was present during the observation. The resident was not wearing heel protectors and her feet were not elevated. Staff O removed the resident's sock to expose the left heel. Observed on the resident's heel were several closed areas of red, brown, and black discoloration. There was no drainage or odor noted. The surrounding tissue was intact. An observation on 11/19/14 at 10:26 AM of wound care for Resident # 255 being provided by Staff O revealed that at the start of care the resident's left heel was elevated on a pillow, the right heel was not. The resident's left foot was covered with a sock. At the completion of care, Staff O only placed a pillow under the resident's left heel. She then replaced the sock to the resident's left foot. In an interview on 11/19/14 at 10:50 AM Staff O stated that the resident had a physician's orders [REDACTED]. She confirmed that the resident's heels were not off-loaded, the resident was not wearing heel protectors, and the resident's left heel was covered with a sock. She stated that the resident's heel protectors were being laundered. In an interview on 11/19/14 at 10:53 AM Resident # 255 and her husband reported that the resident has never worn heel protectors while at the facility. The resident stated that sometimes pillows are placed under her left heel, but rarely under both. The resident added that she is not currently in pain but when she walks, she has pain in her left heel. In an interview on 11/19/14 at 11:00 AM with Staff H revealed that according to the physician's orders [REDACTED]. In an interview on 11/20/14 at 12:00 PM with Staff M (the nurse for the resident this shift) confirmed that he was the nurse who first identified the pressure ulcer on Resident # 255's left heel. He reported that physician's orders [REDACTED]. He confirmed that he had not seen the resident wearing heel protectors on this day. He stated that he would check in the resident's nightstand for the heel protectors. In an interview on 11/21/14 at 12:35 PM, the facility's Director of Nursing (DON) reported that staff are expected to follow physician's orders [REDACTED].# 255's heels and placing heel protectors while the resident was in bed. The DON added that orders for heel protectors and off-loading aid in the prevention of pressure ulcers. Although this resident was not a "high risk" for pressure ulcers, she was at risk due to the lack of mobility. Review of Resident # 255's demographic face sheet showed that the resident was admitted to the facility 10/24/2014. Medical [DIAGNOSES REDACTED]. A review of the Nursing Admission Assessment completed on 10/24/2014 showed that the resident's heels were intact without signs of redness or skin breakdown. A review of Braden Skin Assessment for Predicting Skin Breakdown completed on 10/24/2014 showed that the resident was at risk for developing pressure ulcers. A review of Resident # 255's Admission Minimum Data Set with the assessment reference date of 10/31/14 showed the following: Section M Skin Conditions: At the time of the assessment, the resident had no pressure ulcers. The resident was classified as being at risk for the development of pressure ulcers. Section G Functional Status: The resident required extensive assistance for bed mobility (how the resident moves to and from the lying potion, turns side to side, and positions the body while in bed). A review of Resident # 255's progress notes dated 11/04/2014 at 10:30 AM revealed, during the morning assessment a pressure ulcer classified as a deep tissue injury was found on the resident's left heel with surrounding tissue redness. The cause of the ulcer was identified at that time as being caused from the pressure from the heel being in direct contact with the bed. The resident reported that this occurred because of her heels rubbing the bed. Nursing interventions implemented included the use of heel protectors and off- loading the heels on pillows. A review of Resident # 255's Pressure Ulcer Record revealed that this ulcer was facility acquired and identified on 11/04/14. Interventions include leaving the area open to air and bilateral heel protectors while in bed. A review of Resident # 255's physician's telephone orders dated 11/04/2014 documented: 1) The resident left heel is to be cleaned with skin prep and left open to air until resolved and 2) The resident is to wear heel protectors on both heels while she is in bed. Physician's telephone orders dated 10/25/14 documented, to off-load the resident's heels on pillows while in bed. A review of Resident # 255's Medication Administration Record [REDACTED].

Based on observation, interview and record review, the facility failed to properly assess residents nutritional status and provide a therapeutic nutritional regimen to ensure maintenance of weight for one (R#56) of two residents reviewed for Nutrition of eleven sampled residents with unplanned significant weight loss. This is evidenced by resident #56 showing a severe unplanned weight loss following admission. This represents actual harm for resident #56 related to the severe unplanned weight loss in a resident who already experienced impaired nutrition. Cross reference to F282. Findings included: Record review revealed resident #56 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of physicians orders revealed a diet order for: Pureed NAS (No Added Salt) with Thin Liquids, allergies [REDACTED]. Small frequent meals daily. Snack at bedtime. Review of a nursing progress noted dated [DATE] revealed: received new dietary order: Liberalize NAS restriction to Regular diet. Continue with nutritional supplements BID (twice daily), Small frequent meals, snack at bedtime. Review of the clinical record including the November physician's orders [REDACTED]. The order to liberalize the diet to Regular was not carried out. The resident remained on an NAS restriction through [DATE]. Review of the Nutritional Assessments and Progress Updates revealed the following: Initial Data Collection/Evaluation Nutritional Form completed [DATE]. Height 60 inches, weight 83.2 pounds. UBW (Usual Body Weight -unknown). IBW (Ideal Body Weight) Range 100 +/-10%. BMI (Body Mass Index) 16.0. Food allergies [REDACTED]. Food preferences include no Applesauce. Diet - Pureed NAS. Swallowing problem due [MEDICAL CONDITION](Cerebro Vascular Accident). Ability to self food: Assistance needed. Labs [DATE] [MEDICATION NAME] 4.0g/dl, Total Protein 7.4g/dl, Hemoglobin/Hematacrit (H/H) 10.8g/dl/33.0% (low), Calcium 8.24mg/dl, Glucose 83mg/dl, Sodium 137meq/l, Potassium 4.1meq/l, BUN (blood urea nitrogen) 12mg/dl, Creatinine 0.45mg/dl. Section IV: Evaluation of Nutritional Needs. Section Blank. Calorie/Protein/ and Fluid needs for this resident were not calculated or documented on the Initial Assessment. Nutrition Diagnosis: [REDACTED]. Problem: Decreased appetite and intake at meals. Etiology : Swallowing difficulty, Dementia and Depression. Signs and symptoms: BMI (body mass index) <19.0, Resident is at 83% of IBW (ideal body weight). Plan: Continue Pureed NAS diet due to hypertension to provide 1800 Kcal (kilocalorie) and 80 gm (grams) protein. Nutritional Intervention: House supplement 120 ml PO BID for an additional 400 kcal and 20 gm protein. Multivitamin/Mineral PO daily due to low H/H. Monitoring: Proceed to care plan because resident is at risk for alteration in nutrition. Resident will be encouraged to consume food and fluids provided. The assessment is signed by the Registered Dietitian (RD) on [DATE] Review of the above initial assessment reflects section IV - Evaluation of Nutritional Needs was never completed. The next Nutritional Progress Note was dated [DATE] which was noted as a follow-up and RD Consult. The note revealed the resident continues with low PO intake. Currently provided House supplement 120 ml BID (twice daily) for extra 480 kcal/20 gm protein. Diet Puree NAS with thin liquids. New [DIAGNOSES REDACTED]. Will recommend to increase house supplements to 120 mg QID (four times daily) for 960 kcal and 40 gm protein. Resident also receives ProMod 30 ml daily for an extra 10 gm protein. New labs noted [MEDICATION NAME] 3.5g/dl (deceased ) and total protein 5.6 g/dl(low). H/H 12.2g/dl/,[DATE]%. Glucose 133mg/dl (high). BUN 16mg/dl, Creatinine 0.48 mg/dl(low), sodium 138meq/l, potassium 3.9meq/l. Calcium 8.82mg/dl. Estimated calorie needs BEE 887 x 1.2 X 1.0 + 500 = 1600 kcal/day. Resident consumed 75% of dinner today and informed to be tolerating house supplement/ Will recommend to take weekly weights times four weeks to monitor for changes and keep monitoring po intake. No skin breakdown issues notes. Will continue to monitor and follow up as needed. Addendum: Residents protein needs at 1XXX,[DATE].3 gm/kg. IBW 48 kg. Protein needs ,[DATE] gm/day. Continue with ProMod 30 ml for 10 gm protein. In addition of 40 gm from house supplement. Review of the clinical record to include physicians orders and the Medication Administration Record [REDACTED]. The resident continued to receive the supplement only twice daily through present. The order to increase the supplement to QID was not received until [DATE]. The next and last documented Nutritional Review in the clinical record was dated [DATE] which revealed : Current weight 73 lbs. Up 4% in 30 days, down 7% in 90 days. Diet Pureed NAS Thin Liquids. % Intake: Food 50%, Fluid 25%, Supplements 100%. Ability to Feed Self - Requires Assistance. Comments: Med Plus 2 supplements 120 ml QID. ProMod 30 ml TID. Frozen Treat twice daily. Comments: Visited resident for follow up and poor PO intake.. Resident stated having poor appetite eating <50% of most meals; however, stated great compliance with supplements. Resident is willing to continue with supplements and addition of one PM snack. Noted change BMI 14.0 which puts resident in underweight category. Intervention: Liberalize NAS restriction to improve PO intake. Continue with supplements daily. Snack PM. Small portions with meals. Honor food preferences. Completed and signed by the RD [DATE]. Review of the clinical record including the November physician's orders [REDACTED]. The order to liberalize the diet to Regular was not carried out. The resident remained on an NAS restriction through [DATE]. Review of the tray ticket does not reflect small portions at meals. The tray ticket did not indicate a change to provide small portions with meals and small frequent meals were not provided. Weights: (recorded in pounds) Admission [DATE] 83.2, [DATE], 79.2; [DATE] Isolation, [DATE] Isolation, ,[DATE] (no day specified) 76.0 (-8.14% <90 days), [DATE], 71.8 (-5.5% <30 days), [DATE], 77; [DATE], 62.6 (-24.7% <90 days since admission), [DATE], 70.0; [DATE], 70; [DATE], 73; [DATE], 71.6 (-13.9% in <180 days since admission). Review of the clinical record revealed no documentation of the actual significant weight loss which occurred through [DATE] with a weight recorded at 62.6 lbs. There were no nutritional assessment or progress updates on file in the clinical record from [DATE] through [DATE] to address the continued weight loss. During interview with the Registered Dietitian (RD - Staff E) on [DATE] at 2:30 pm revealed there may be some discrepancy in the weights in September because she went from 76.0 lbs to 62.6 lbs and then back up to 70 lbs in a three week time period. Usually the Food Service Director (FSD) gets the weights and puts them in the computer system and it will generate a report for calculating the significant change. If a resident has a significant weight change, the dietitian is notified and then the change is charted by the Dietitian. When asked about the progress update written [DATE] with the recommendation to increase the supplements from BID to QID she stated, I am not the RD that made that recommendation but after checking the chart she confirmed the order was never received. She confirmed, the resident was receiving ProMod TID, Frozen Treats twice a day, and the House Supplement 120 ml BID. I know the ProMod and the Frozen Treat was added after admission, but the supplement was not increased. The RD stated, she receives a report of significant weight changes. Review of the computerized weight report does not reflect that the September or October weights were ever entered into the system to alert her of the significant weight loss. The RD confirmed, the residents nutritional requirement were not calculated at the time of admission, she stated she had no explanation for not completing this section. She stated, the nutritional requirements were calculated when the progress note was written by another RD on [DATE]. She confirmed there were no assessments or progress updated after [DATE]. Review of the weight report printed [DATE] reflects no September weights entered into the system; therefore, the significant weight change was not triggered on the report. There were no additional nutritional assessments completed for this resident from [DATE] through [DATE]. Weights (recorded in pounds) [DATE], 83.2; [DATE], 79.2; [DATE] Isolation, [DATE] Isolation, ,[DATE] (no date specified)76.0; [DATE], 71.8; [DATE], 77; [DATE], 62.6; [DATE], 70.0; [DATE], 70; [DATE], 73; [DATE], 71.6. During interview with the ADON (Assistant Director of Nursing - Staff H) on [DATE] at 2:06 pm confirmed, these were all of the residents weight from the chart and the weight books. During interview with the Restorative Certified Nursing Assistant (CNA - Staff F) on [DATE] at 2:13 pm revealed, if a resident is on isolation we first check with the nurse to see if the resident can be weighed. If we obtain the weight we have to clean the scale before and after we obtain the weight and then we have to bag the sling. During follow up interview with the ADON (Assistant Director of Nursing - Staff H) on [DATE] at 2:15 pm revealed, a resident on isolation can still be weighed, the staff just has to gown up and use PPE (personal protective equipment) and then we clean the equipment with MicroKill and place the sling in a biohazard waste bag. She stated resident #56 was on isolation in August, but she could have been weighed weekly. During interview with the ADON (Staff H) on [DATE] at 10:39 pm, she reported, when the Dietitian makes a recommendation and she gives the form to the nurse. If there is a weight loss this is included on the form. The nurse contacts the physician to report the weight loss and the recommendation by the Dietitian. If an order is received, the nurse writes a telephone order. We make a copy of the order and the recommendation which is sent to the FSD. During interview with the Food Service Director (FSD - Staff D) on [DATE] at 2:55 pm revealed, nursing takes the weights and gives them to dietary to enter into the computer to give the weight report to the Dietitian. The Dietitians check the report to see if there is weight loss. I enter whatever weights they provide to me. I get the weights from nursing by the 12th of the month at the latest. I enter the weights into the computer. If I am missing weights, I would go back to nursing to request the weights. If they do not give me a weight, I cannot enter anything. During interview with the Restorative CNA (Staff F) on [DATE] at 3:11 pm revealed, the Restorative CNA's do all of the weights. The monthly weights are done between the 1st and the 10th of the month. There are three Restorative aids and we are each responsible for one unit. I am responsible for the South Wing. If the weight change is 5 lbs over or under we re-weigh the resident right away. We report any weight changes +/- 5 lbs to the nurse and the DON. We also provide the weights to Dietary. From there Dietary determines if there is a significant weight change. The CNA stated R#56 has not been eating well. She used to eat in the dining room, but she was not feeling well, so she is now eating in her room. She takes her time but she feeds herself. Review of the Policy and Procedure titled, "Weight Monitoring Program" dated ,[DATE] revealed: Each resident will be weighed at least monthly. New admissions and readmissions will be weighed weekly x 4, then converted to monthly once weights determined stable by the RD. All monthly weights will be completed and recorded on the weight log by the 5th of the month. A re-weight will be obtained that is +/-5 lbs in one or +/- pounds in a week using the same scale within 24 hours. Recommendations and interventions of the committee will be implemented as appropriate including physician, therapy and dietary recommendations. The committee will monitor weekly for 4 weeks or until stable as determined by the RD. During interview with the Director of Nursing on [DATE] at 9:44 am, she said the facility is in the process of setting up a formal nutrition at risk program where she will meet with one of the ADON's, Care Plan Coordinator and the Dietitian to discuss nutrition concerns including weight loss, hydration concerns, abnormal labs, wounds, residents with feeding tubes, etc. Observation on [DATE] at 10:10 am revealed, resident #56 in her room in bed. She appeared thin and frail, but did not appear dehydrated. During interview with resident #56 via a surveyor translator on [DATE] 9:59 am, she said the food is not bad here, but she does not have an appetite. She said, she receives fluids with meal, but not between meals. She states she is not offered fluids between meals. I do not ask for water. I prefer to buy the water in the bottles. She states, "if I get thirsty I can get my bottle". Also noted on her meal tray was a carton of whole milk. The carton was unopened. She states she used to have [MEDICATION NAME] Milk because she is allergic to milk. She said, she she has told them several times she cannot drink milk, but they continue to send the milk and I cannot drink it. This was a breakfast tray that was sitting on a table in the room at 10:12AM. The resident had accepted all of the food, but none of the milk, and 50% of the apple juice. She states, at one time her doctor had prescribed [MEDICATION NAME] milk for her, but she only received this once and never again. Review of her tray ticket revealed the diet order: Pureed NAS (No Added Salt) Low Cholesterol/Low Fat. Allergy - Dairy. No milk Products. Observation on [DATE] at 8:46 am revealed, the resident in her room in bed with her breakfast tray. Her tray ticket revealed her diet order was for Pureed NAS Low Fat/Low Cholesterol. Allergy - Dairy and eggs. No Milk/Dairy Products. No Eggs. Beverages listed on the ticket that should be provided included Apple Juice, Coffee, and Whole Milk. Observation of the tray revealed an 8 oz carton of whole milk, three whole slices of bacon, grits, orange juice, a slice of toast, and a whole Danish. The resident was not eating the food provided. Staff entered the room and the resident spoke Spanish to the Certified Nursing Assistant (CNA) saying this is not her breakfast. Review of the tray card revealed her name listed on the ticket. The CNA stated, she would speak to the nurse and ask her to check the tray. During interview with the CNA (Staff B) on [DATE] at 9:01 am, she said she spoke to the Nurse (Staff C) and asked her to call the kitchen to change the breakfast for this resident. During interview with the Licensed Practical Nurse (LPN -Staff C) on [DATE] at 9:10 am, she said the CNA only told her the resident did not like the food, she did not tell me the resident was not eating and needed another tray. She then stated she had not requested another tray, but would call the kitchen and request another tray. Observation on [DATE] at 9:12 am revealed the same breakfast tray remained in the room untouched. When asked if she was okay, she stated "No" and pointed to the food and then to her throat and stated "no swallow". She had not accepted any of the food/fluid provided. During interview with the LPN (Staff C) [DATE] at 9:15 am, she said she had contacted the kitchen to request another tray. She said the staff is supposed to check the trays when they are delivered to make sure the tray was served to the correct resident by checking the name on the ticket and also make sure the food on the tray was the correct diet. She confirmed through review of the physicians orders that the resident was currently on a Pureed diet texture and was allergic to Milk and Eggs. Observation on [DATE] at 9:25 am, revealed resident in bed with a new breakfast tray. The tray contained pureed food items and cranberry juice. She was able to feed herself after tray set up. She was observed placing syrup and sugar on her food, stating it is good now. The food items appeared to be grits, scrambled eggs, and pureed bread. The resident did not eat the scrambled eggs provided. During interview with the Food Service Director (Staff D) on [DATE] at 9:30 am, she confirmed the food items provided to the resident on the second tray included pureed eggs, grits, and pureed bread. She stated the resident likes her food sweet so she puts sugar on the food. The cook who prepared the tray confirmed the tray contained pureed scrambled eggs. Observation of the tray with the FSD at 9:35 am confirmed there were scrambled eggs on the tray. The FSD confirmed the resident was allergic to eggs. Observation on [DATE] at 12:55 pm revealed resident in bed eating lunch. The tray ticket reflected Pureed NAS diet. Beverages listed include coffee and cranberry juice. Special request included Frozen Treat. The tray contained pureed food with applesauce for dessert. The condiments included sweet and low. There was no Frozen Treat on the tray. The resident accepted approximately 50% of the hot food, drank the coffee, ,[DATE] (120 cc (cubic centimeters) juice) and she was observed drink bottled water. She stated she was finished. The food was better today, but she is done. She revealed she does not like the dessert "apple". Her roommates daughter was present and stated she likes her food with sugar, but they did not put the sugar on the tray. During interview with the FSD (Staff D) on [DATE] at 11:21 am revealed, when a resident has an order for [REDACTED]. Review of the Initial Data Collection/Evaluation Nutritional Form completed [DATE] revealed, Food allergies [REDACTED]. Food preferences include no Applesauce. Observation on [DATE] at 5:20 pm revealed, resident in bed with her dinner tray served. She received a Pureed diet with [MEDICATION NAME] Milk and Juice. This was the first observation during the survey that she was provided with the [MEDICATION NAME] Milk.

Based on observation, interview and record review the facility failed to properly assess residents nutritional status and provide a therapeutic nutritional regimen to ensure maintenance of weight and acceptable nutritional parameters for one (R#56) of two residents reviewed for Nutrition of eleven resident with unplanned significant weight loss. This is evidenced by resident #56 showing a significant unplanned weight loss and decline in nutritional parameters (laboratory results) following admission. Findings included: Record review revealed resident #56 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of physicians orders revealed diet order: Pureed NAS (No Added Salt) with Thin Liquids, allergies [REDACTED]. Small frequent meals daily. Snack at bedtime. Review of a nursing progress noted dated [DATE] revealed: received new dietary order: Liberalize NAS restriction to Regular diet. Continue with nutritional supplements BID (twice daily), Small frequent meals, snack at bedtime. Review of the clinical record including the November physician's orders [REDACTED]. The order to liberalize the diet to Regular was not carried out. The resident remained on an NAS restriction through [DATE]. Review of Nutritional Assessments and Progress Updates revealed the following: Initial Data Collection/Evaluation Nutritional Form completed [DATE]. Height 60 inches, weight 83.2 pounds. UBW (Usual Body Weight -unknown). IBW (Ideal Body Weight) Range 100 +/-10%. BMI (Body Mass Index) 16.0. Food allergies [REDACTED]. Food preferences include no Applesauce. Diet - Pureed NAS. Swallowing problem due [MEDICAL CONDITION](Cerebro Vascular Accident). Ability to self food: Assistance needed. Labs [DATE] [MEDICATION NAME] 4.0, Total Protein 7.4, Hemoglobin/Hematacrit (H/H) 10XXX,[DATE].0 (low), Calcium 8.24,Glucose 83, Sodium 137, Potassium 4.1, BUN (blood urea nitrogen) 12, Creatinine 0.45. Section IV: Evaluation of Nutritional Needs. Section Blank. Calorie/Protein/ and Fluid needs for this resident were not calculated or documented on the Initial Assessment. Nutrition Diagnosis: [REDACTED]. Problem: Decreased appetite and intake at meals. Etiology : Swallowing difficulty, Dementia and Depression. Signs and symptoms: BMI (body mass index) <19.0, Resident is at 83% of IBW (ideal body weight). Plan: Continue Pureed NAS diet due to hypertension to provide 1800 Kcal (kilocalorie) and 80 gm (grams) protein. Nutritional Intervention: House supplement 120 ml PO BID for an additional 400 kcal and 20 gm protein. Multivitamin/Mineral PO daily due to low H/H. Monitoring: Proceed to care plan because resident is at risk for alteration in nutrition. Resident will be encouraged to consume food and fluids provided. The assessment is signed by the Registered Dietitian (RD) on [DATE] Review of the above initial assessment reflects section IV - Evaluation of Nutritional Needs was never completed. The next Nutritional Progress Note was dated [DATE] which was noted as a follow-up and RD Consult. The note revealed the resident continues with low PO intake. Currently provided House supplement 120 ml BID (twice daily) for extra 480 kcal/20 gm protein. Diet Puree NAS with thin liquids. New [DIAGNOSES REDACTED]. Will recommend to increase house supplements to 120 mg QID (four times daily) for 960 kcal and 40 gm protein. Resident also receives ProMod 30 ml daily for an extra 10 gm protein. New labs noted [MEDICATION NAME] 3.5 (deceased ) and total protein 5.6 (low). H/H 12XXX[DATE]. Glucose 133 (high). BUN 16, Creatinine 0.48 (low), sodium 138, potassium 3.9. Calcium 8.82. Estimated calorie needs BEE 887 x 1.2 X 1.0 + 500 = 1600 kcal/day. Resident consumed 75% of dinner today and informed to be tolerating house supplement/ Will recommend to take weekly weights times four weeks to monitor for changes and keep monitoring po intake. No skin breakdown issues notes. Will continue to monitor and follow up as needed. Addendum: Residents protein needs at 1XXX,[DATE].3 gm/kg. IBW 48 kg. Protein needs ,[DATE] gm/day. Continue with ProMod 30 ml for 10 gm protein. In addition of 40 gm from house supplement. Review of the clinical record to include physicians orders and the MAR, the recommendation by the RD to increase the supplement to QID was not followed. The resident continued to receive the supplement only twice daily through present. The order to increase the supplement to QID was not received until [DATE]. The next and last documented Nutritional Review in the clinical record was dated [DATE] which revealed : Current weight 73 lbs. Up 4% in 30 days, down 7% in 90 days. Diet Pureed NAS Thin Liquids. % Intake: Food 50%, Fluid 25%, Supplements 100%. Ability to Feed Self - Requires Assistance. Comments: Med Plus 2 supplements 120 ml QID. ProMod 30 ml TID. Frozen Treat twice daily. Comments: Visited resident for follow up and poor PO intake.. Resident stated having poor appetite eating <50% of most meals; however, stated great compliance with supplements. Resident is willing to continue with supplements and addition of one PM snack. Noted change BMI 14.0 which puts resident in underweight category. Intervention: Liberalize NAS restriction to improve PO intake. Continue with supplements daily. Snack PM. Small portions with meals. Honor food preferences. Completed and signed by the RD [DATE]. Review of the clinical record including the November physician's orders [REDACTED]. The order to liberalize the diet to Regular was not carried out. The resident remained on an NAS restriction through [DATE]. Review of the tray ticket does not reflect small portions at meals. The tray ticket did not indicate a change to provide small portions with meals and small frequent meals were not provided. Weights: (recorded in pounds) Admission [DATE] 83.2, [DATE] 79.2, [DATE] Isolation, [DATE] Isolation, ,[DATE] (no date specified) 76.0 (-8.14% <90 days), [DATE] 71.8 (-5.5% <30 days), [DATE] 77, [DATE] 62.6 (-24.7% <90 days since admission), [DATE] 70.0, [DATE] 70, [DATE] 73, [DATE] 71.6 (-13.9% in <180 days since admission). Review of the clinical record revealed no documentation of the actual significant weight loss which occurs through [DATE] with a weight recorded at 62.6 lbs. There were no nutritional assessment or progress updates on file in the clinical record from [DATE] through [DATE] to address continued weight loss. During interview with the Registered Dietitian (RD - Staff E) on [DATE] at 2:30 pm revealed there may be some discrepancy in the weights in September because she went from 76.0 lbs to 62.6 lbs and then back up to 70 lbs in a three week time period. Usually the FSD gets the weights and puts them in the computer system and it will generate a report for calculating the significant change. If a resident has a significant weight change, the dietitian is notified and then the change is charted by the Dietitian. When asked about the progress update written [DATE] with the recommendation to increase the supplements from BID to QID she stated I am not the RD that made that recommendation but after checking the chart she confirmed the order was never received. She confirmed the resident was receiving ProMod TID, Frozen Treat twice a day, and the House Supplement 120 ml BID. I know the ProMod and the Frozen Treat was added after admission, but the supplement was not increased. The RD stated she receives a report of significant weight changes. Review of the computerized weight report does not reflect that the September or Octobers weights were ever entered into to system to alert her of the significant weight loss. The RD confirmed that the residents nutritional requirement were not calculated at the time of admission, she stated she had no explanation for not completing this section. She stated the nutritional requirements were calculated when the progress note was written by another RD on [DATE]. She confirmed there were no assessments or progress updated after [DATE]. Review of the weight report printed [DATE] reflects no September weights entered into the system; therefore, the significant weight change was not triggered on the report. There were no additional nutritional assessments completed for this resident from [DATE] through [DATE]. Weights (recorded in pounds) [DATE] 83.2, [DATE] 79.2, [DATE] Isolation, [DATE] Isolation, ,[DATE] (no date specified)76.0, [DATE] 71.8, [DATE] 77, [DATE] 62.6, [DATE] 70.0, [DATE] 70, [DATE] 73, [DATE] 71.6. During interview with the ADON (Assistant Director of Nursing - Staff H) on [DATE] at 2:06 pm confirmed these were all of the residents weight from the chart and the weight books. During interview the Restorative Certified Nursing Assistant (C N A - Staff F) on [DATE] at 2:13 pm revealed if a resident is on isolation we first check with the nurse to see if the resident can be weighed. If we obtain the weight we have to clean the scale before and after we obtain the weight and then we have to bag the sling. During follow up interview with the ADON (Assistant Director of Nursing - Staff H) on [DATE] at 2:15 pm revealed a resident on isolation can still be weighed, the staff just has to gown up and use PPE (personal protective equipment) and then we clean the equipment with MicroKill and place the sling in a biohazard waste bag. She stated resident #56 was on isolation in August, but she could have been weighed weekly. Review of Labs: [DATE] Total Protein 5.6 (low), [MEDICATION NAME] 3.5, [MEDICATION NAME] 15.2 [DATE] Total Protein 5.0 (low), [MEDICATION NAME] 3.1. [DATE] [MEDICATION NAME] 3.1, [MEDICATION NAME] 13.9 (noted progress decrease in visceral protein status from initial labs [DATE]). Reference ranges: [MEDICATION NAME] 3XXX,[DATE].0, Total Protein 6XXX,[DATE].9, Pre-[MEDICATION NAME] 17XXX,[DATE].0 During interview with the ADON (Staff H) on [DATE] at 10:39 pm, she said when the Dietitian makes a recommendation and she gives the form to the nurse. If there is a weight loss this is included on the form. The nurse contacts the physician to report the weight loss and the recommendation by the Dietitian. If an order is received, the nurse writes a telephone order. We make a copy of the order and the recommendation which is sent to the FSD. During interview with the Food Service Director (FSD - Staff D) on [DATE] at 2:55 pm revealed nursing takes the weights and gives them to dietary to enter into the computer to give the weight report to the Dietitian. The Dietitians check the report to see if there is weight loss. I enter whatever weights they provide to me. I get the weights from nursing by the 12th of the month at the latest. I enter the weights into the computer. If I am missing weights I would go back to nursing to request the weights. If they do not give me a weight I cannot enter anything. During interview with the Restorative CNA (Staff F) on [DATE] at 3:11 pm revealed the Restorative CNA do all of the weights. The monthly weights are done between the 1st and the 10th of the month. There are three Restorative aids and we are each responsible for one unit. I am responsible for the South Wing. If the weight change is 5 lbs over or under we re-weigh the resident right away. We report any weight changes +/- 5 lbs to the nurse and the DON. We also provide the weights to Dietary. From there Dietary determines if there is a significant weight change. The CN A stated R#56 has not been eating well. She used to eat in the dining room, but she was not feeling well so she is now eating in her room. She takes her time but she feeds herself. Review of the Policy and Procedure titled "Weight Monitoring Program" dated ,[DATE] revealed: Each resident will be weighed at least monthly. New admissions and readmissions will be weighed weekly x 4, then converted to monthly once weights determined stable by the RD. All monthly weights will be completed and recorded on the weight log by the 5th of the month. A re-weight will be obtained that is +/-5 lbs in one or +/- pounds in a week using the same scale within 24 hours. Recommendations and interventions of the committee will be implemented as appropriate including physician, therapy and dietary recommendations. The committee will monitor weekly for 4 weeks or until stable as determined by the RD. During interview with the Director of Nursing on [DATE] at 9:44 am, she said the facility is in the process of setting up a formal nutrition at risk program where she will meet with one of the ADON's, Care Plan Coordinator and the Dietitian to discuss nutrition concerns including weight loss, hydration concerns, abnormal labs, wounds, residents with feeding tubes, etc. Observation on [DATE] 10:10 am revealed resident #56 in her room in bed. She appeared thin and frail, but did not appear dehydrated. During interview with resident #56 via Spanish speaking surveyor as interpreter on [DATE] 9:59 am, she said the food is not bad here, but she does not have an appetite. She said she receives fluids with meal, but not between meals. She states she is not offered fluids between meals. I do not ask for water. I prefer to buy the water in the bottles. She states, "if I get thirsty I can get my bottle". Also noted on her meal tray was a carton of whole milk. The carton was unopened. She states she used to have [MEDICATION NAME] Milk because she is allergic to milk. She said she she has told them several times she cannot drink milk, but they continue to send the milk and I cannot drink it. This was a breakfast tray that was sitting on a table. The resident had accepted all of the food, but none of the milk, and 50% of the apple juice. She states at one time her doctor had prescribed [MEDICATION NAME] milk for her, but she only received this once and never again. Review of her tray ticket revealed the diet order: Pureed NAS (No Added Salt) Low Cholesterol/Low Fat. Allergy - Dairy. No milk Products. Resident states she has told them several times she cannot drink milk, but they continue to send the milk and I cannot drink it. This was a breakfast tray that was sitting on a table in the room at 10:12 am. The resident had accepted all of the food, no milk, and 50% of the apple juice. She states at one time her doctor had prescribed [MEDICATION NAME] milk for her, but she only received this once and never again. Observation on [DATE] at 8:46 am revealed resident in her room in bed with her breakfast tray. Her tray ticket revealed her diet order was for Pureed NAS Low Fat/Low Cholesterol. Allergy - Dairy and eggs. No Milk/Dairy Products. No Eggs. Beverages listed on the ticket that should be provided included Apple Juice, Coffee, and Whole Milk. Observation of the tray revealed an 8 oz carton of whole milk, three whole slices of bacon, grits, orange juice, a slice of toast, and a whole Danish. The resident was not eating the food provided. Staff entered the room and the resident spoke Spanish to the Certified Nursing Assistant (CNA) saying this is not her breakfast. Review of the tray card revealed her name listed on the ticket. The CNA stated she would speak to the nurse and ask her to check the tray. During interview with the CNA (Staff B) on [DATE] at 9:01 am, she said she spoke to the Nurse (Staff C) and asked her to call the kitchen to change the breakfast for this resident. During interview with the Licensed Practical Nurse (LPN -Staff C) on [DATE] at 9:10 am, she said the CNA only told her the resident did not like the food, she did not tell me the resident was not eating and needed another tray. She then stated she had not requested another tray, but would call the kitchen and request another tray. Observation on [DATE] at 9:12 am revealed the same breakfast tray remained in the room untouched. When asked if she was okay, she stated "No" and pointed to the food and then to her throat and stated "no swallow". She had not accepted any of the food/fluid provided. During interview with the LPN (Staff C) [DATE] at 9:15 am, she said she had contacted the kitchen to request another tray. She said the staff is supposed to check the trays when they are delivered to make sure the tray was served to the correct resident by checking the name on the ticket and also make sure the food on the tray was the correct diet. She confirmed through review of the physicians orders that the resident was currently on a Pureed diet texture and was allergic to Milk and Eggs. Observation on [DATE] at 9:25 am revealed resident in bed with a new breakfast tray. The tray contained pureed food items and cranberry juice. She was able to feed herself after tray set up. She was observed placing syrup and sugar on her food, stating it is good now. The food items appeared to be grits, scrambled eggs, and pureed bread. The resident did not eat the scrambled eggs provided. During interview with the Food Service Director (Staff D) on [DATE] at 9:30 am, she confirmed the food items provided to the resident on the second tray included pureed eggs, grits, and pureed bread. She stated the resident likes her food sweet so she puts sugar on the food. The cook who prepared the tray confirmed the tray contained pureed scrambled eggs. Observation of the tray with the FSD at 9:35 am confirmed there were scrambled eggs on the tray. The FSD confirmed the resident was allergic to eggs. Observation on [DATE] at 12:55 pm revealed resident in bed eating lunch. The tray ticket reflected Pureed NAS diet. Beverages listed include coffee and cranberry juice. Special request included Frozen Treat. The tray contained pureed food with applesauce for dessert. The condiments included sweet and low. There was no Frozen Treat on the tray. The resident accepted approximately 50% of the hot food, drank the coffee, ,[DATE] (120 cc (cubic centimeters) juice) and she was observed drink bottled water. She stated she was finished. The food was better today, but she is done. She revealed she does not like the dessert "apple". Her roommates daughter was present and stated she likes her food with sugar, but they did not put the sugar on the tray. During interview with the FSD (Staff D) on [DATE] at 11:21 am revealed when a resident has an order for [REDACTED]. Review of the Initial Data Collection/Evaluation Nutritional Form completed [DATE] revealed Food allergies [REDACTED]. Food preferences include no Applesauce. Observation on [DATE] at 5:20 pm revealed resident in bed with her dinner tray served. She received a Pureed diet with [MEDICATION NAME] Milk and Juice. This was the first observation during the survey that she was provided with the [MEDICATION NAME] Milk.