Every finding on record at Covenant Village Care Center

Based on observations, interviews and record reviews, the facility failed to initiate a care plan for monitoring behaviors and side effects for 2 of 5 sampled residents on psychotropic medications (Resident #268 and Resident #33). Facility also failed to initiate a care plan for monitoring pain for 1 of 5 sampled residents on narcotic medications (Resident #268). The findings included: 1. A record review showed that Resident #268 was admitted on [DATE] with diagnosis of Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side and Epilepsy, not intractable, without status epilepticus. The Minimum Data Set (MDS) comprehensive dated 05/04/2025 revealed that the Brief Interview of Mental Status (BIMS) score is 14, which indicated intact cognition. A review of the orders revealed the following: 04/30/25: Divalproex 125 mg tablet, delayed release Every 12 Hours. 04/30/25: Tramadol 50 mg tablet as needed Every 4 Hours. 05/01/25: Enoxaparin 40 mg/0.4 mL subcutaneous syringe 1 Time Daily for 30 Days. 05/01/25: Pain Assessment 05/01/25: Behavior Monitoring 05/01/25: Side Effect Monitoring A review of Resident #268 medication administration record (MAR) indicated that the behaviors and side effects were being monitored. The pain assessment was also completed. A review of the comprehensive care plan dated 05/13/25 stated that Resident #268 is at risk for potential bleeding related to Anticoagulant Therapy. And monitoring of bruising and bleeding to put in place. A review of the comprehensive care plan dated 05/13/25 indicated that no care plan was put in place for monitoring behaviors or side effects related to the use of psychotropic medications or pain assessment related to the use of narcotics. 2. A record review showed that Resident #33 was admitted on [DATE] with diagnosis of Urinary tract infection and Parkinsonism. The Minimum Data Set (MDS) 5 days dated 04/28/2025 revealed that the Brief Interview of Mental Status (BIMS) score is 10, which indicated moderate cognitive impairment. A review of the orders revealed the following: 04/23/25: Eliquis 5 mg tablet Every 12 Hours for 30 Days. 04/23/25: Gabapentin 100 mg capsule Every 12 Hours. 04/28/25: Escitalopram 10 mg tablet Hour of Sleep. 04/23/25: Side Effect Monitoring every Shift . 04/23/25: Behavior Monitoring every Shift. 04/23/25: Pain Assessment every Shift. A review of Resident #33 medication administration record (MAR) indicated that the behaviors and side effects were being monitored. The pain assessment was also completed. A review of the comprehensive care plan dated 05/06/25 stated that Resident #33 is at risk for potential bleeding related to Anticoagulant Therapy. And monitoring of bruising and bleeding to put in place. A review of the comprehensive care plan dated 05/06/25 stated that Resident #33 is receiving antidepressant drugs on a regular basis. And monitoring for side effects and mood and behaviors to put in place. A review of the comprehensive care plan dated 05/13/25 indicated that no care plan was put in place for monitoring behaviors or side effects related to the use of psychotropic medications. In an interview conducted on 05/14/25 at 10:55 AM, the minimum data set (MDS) coordinator stated that Resident #268 is on psychotropic medications for seizures not for psychiatric problems and on narcotics for pain. She further explained that when psychotropics are not given for psychiatric disorders it's not necessary to monitor the resident for side effects nor for behaviors and mood. The MDS coordinator acknowledges the missing care plan for narcotics use.

Based on observation, interviews, record review and policy review, the facility failed to remove narcotics from 2 of 3 medication carts for residents who have no current orders for the narcotics. The findings included: The facility's policy titled Discarding and Destroying Medications revised 10/2014 revealed Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. On 05/15/25 at 12:05 PM, medication cart east was reviewed with Staff C, Registered Nurse (RN). Upon review of the as needed (prn) narcotics, Resident #4's medication card for Alprazolam 0.25 milligrams (mg) was in the narcotic locked box with no current order and last given on 03/11/25. The order was discontinued on 11/26/24. On 05/15/25 at 12:15 PM, medication cart middle was reviewed with Staff A, RN. Resident #17's medication card for Hydrocodone 5 mg-acetaminophen 325 mg was in the narcotic locked box with no current order and last given on 04/21/25. The order was discontinued on 02/21/25. This was discussed with the Administrator on 05/15/25 at 12:30 PM.

Based on observations, interview, and record review, the facility failed to implement interventions to monitor side effects and behaviors related to antidepressant medication for 1 out of 5 residents reviewed for Unnecessary Medications (Resident # 13). The findings included: Record review for Resident # 13 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Dementia, a condition characterized by a progressive decline in affecting memory, thinking, language, and behavior and Major Depressive Disorder. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident # 13 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated that she was moderately cognitively impaired. Review of Section GG of the MDS dated [DATE] revealed that the resident needed supervision and assistance for activities of daily living. Review of the Physician's Orders showed that Resident # 13 had an order dated 02/25/25 for Fluoxetine 10 mg capsule every morning for depression. Review of the Care Plan dated 03/01/25 documented that Resident #13 had an active order for medication to treat depression. Goals were to observe Resident #13 for changes in mood/behavior (sleep patterns, fatigue, appetite, ability to concentration, participation in activities, crying) and to record behaviors on the Behavior Tracking form. Review of the Treatment Plan for Resident # 13, date 02/25/25, lacked documentation of side effects monitoring or behavior observations. During a side-by-side review of the record and interview on 05/14/25 at 9:28 AM with Staff Nurse C, Registered Nurse (RN), she confirmed the lack of a physician order for behavioral monitoring for the medication Fluoxetine. She stated that the resident refuses her medications on most days. The last recorded administration date and time of Fluoxetine 10 mg was on 05/10/25 at 9:00 AM. The electronic record revealed that there was no behavioral monitoring for Resident #13 and the Staff Nurse agreed that the resident should be monitored.

Based on observation, interview, record and policy review, it was determined that the medication error rate was 7.14 percent, 2 medication errors were identified while observing a total of 28 opportunities, affecting Resident #323. The findings included: The facility's policy titled Medication Administration implemented 01/2001 and revised 04/2019 revealed Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. On 05/15/25 at 10:04 AM, Staff B, Registered Nurse (RN) was observed preparing medication for Resident #323. Resident #323's blood pressure was 105/82, and heart rate was 55. Staff B prepared Amoxicillin 500 milligrams (mg) 1 tablet po (by mouth), Carvedilol 6.25mg 1 tablet po. The parameters for Carvedilol were to hold for SBP<110 DBP <60 HR <60. (Hold for systolic blood pressure under 110 and diastolic blood pressure under 50 and heart rate under 60). She also prepared 6 other medications. The Surveyor intervened after Staff B walked into the resident's room to give the medication and asked her to review the orders for Amoxicillin and Carvedilol. Staff B reviewed the orders and stated she should have prepared 2 pills for Amoxicillin and should not have prepared Carvedilol because the resident's blood pressure was under 110/60 and heart rate was under 60. This was discussed with the Administrator on 05/15/25 at 11:00 AM.

Based on observation, interview and policy review, the facility staff failed to lock the medication cart during medication administration for 1 of 9 residents observed for medication administration and failed to properly dispose a wasted drug during medication administration. The findings included: The facility's policy titled Medication Labeling and Storage revised 02/2023, revealed Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transfer such items are not left unattended if open or otherwise potentially available to others. On 05/14/25 at 9:20 AM, Staff B, Registered Nurse (RN) was observed leaving her medication cart unlocked while going into the room to give medication to Resident # 219. This cart continued to be unlocked during the time the cart was pushed to room [ROOM NUMBER] to give medications to Resident #121. Staff B took Resident #121's vitals at 9:25 AM. Then washed her hands in the bathroom with the cart parked outside of the door of the room unlocked. At this time a Certified Nursing Assistant (CNA) was walking in and out of the resident's room and other residents were being pushed in their wheelchairs to physical therapy with the physical therapists. At 9:36 AM the resident was given medication with the cart still unlocked in front of the door. Observation continued with Staff B during medication administration. Staff B pushed the medication cart to room [ROOM NUMBER] at 9:47 AM. The cart was now parked in front of room [ROOM NUMBER] unlocked. Resident #24 was given medications then Staff B returned to her medication cart at 9:56 AM and locked it. Staff B then prepared medications for Resident #323 at 10:04 AM in the same room. The cart was unlocked to prepare the medications. Staff B prepared 6 medications and put them in the medication cup then spilled the 7th medication. The medication (Glipizide ER (extended release) 5 milligrams was picked up by Staff B and put into the trash receptacle. The Surveyor asked Staff B if that is where the discarded medication goes and she said it should go into the pill buster and stated she was sorry about that. Staff B prepared 3 more medications then locked the cart and went into the resident's room to administer the medications. This was discussed with the Administrator on 05/14/25 at 11:00 AM.

Based on record review, observation and interviews, the facility failed to practice appropriate infection prevention and control and failed to follow wound care physician orders during wound care observation for 1 of 1 resident sampled for wound care review (Resident #45). The findings included: Review of the facility's policy provided by the administrator titled, Hand Hygiene with no revision date and without the facility's name listed documented .additional considerations: the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Review of Resident #45's clinical record documented an admission on 01/09/24. The resident diagnoses included a fracture to the Right Femur, Muscle Weakness and Retention of Urine. Review of Resident #45's Minimum Data Set (MDS) 5 days admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 12, indicating that the resident had moderate cognition impairment. The assessment documented under Functional Abilities and Goals that the resident needed substantial/maximum assistance for most of his Activities of Daily Living (ADL's). Review of Resident #45's care plan titled, At risk for skin breakdown related to incontinence, impaired mobility . initiated on 01/10/24 and revised on 01/18/24. The care plan documented that on 02/09/24 the resident was observed with a right heel open area and a non-blanchable redness to the left heel as per nurses observation. Review of Resident #45's physician order dated 02/20/24 documented Clean right heel with Dakin's solution, pat dry, skin prep to the peri wound, apply Santyl, alginate calcium, cover with bordered island dressing daily and when soiled. On 02/27/24 at 2:43 PM, observation revealed Resident # 45 in a bed with an air mattress lying flat on his back. An interview was conducted with the resident in Spanish who stated he was cold and did not want to get out of bed. Observation revealed the resident was wearing bilateral heel booties. On 02/27/24 at 3:30 PM, a telephone interview was conducted with the MDS Coordinator who stated that as per Resident #45's initial assessment done 01/15/24, the resident did not have pressure wounds reported on admission. The MDS Coordinator stated that on 02/09/24 the nurse observed right heel open area and a non-blanchable redness to the left heel and treatment was started. The Coordinator stated the resident was receiving daily Physical therapy. On 02/28/24 at 8:04 AM, an interview was conducted with Staff D, Registered Nurse (RN). Staff D stated Resident #45 had a wound to his right heel and she will do his wound care sometime this shift. On 02/28/24 at 11:27 AM, wound care observation for Resident #45 performed by Staff D, RN started. Observation revealed Staff D reviewed the physician orders and gather the following supplies: a Derma Wound Cleanser bottle, a red bag, one bordered island gauze, three gauze packages, a package of calcium alginate, two skin prep pads, resident labeled Santyl ointment tube and a pair of scissors. At 11:36 AM, Staff D entered Resident #45's room, placed the supplies on top of the resident's dresser, donned gloves and cleaned his over the bed table with two dry paper towel, then placed three paper towels as a barrier on the table. Staff D then removed her gloves, performed hand hygiene and donned gloves. Observation revealed Staff D retrieved the scissors and without disinfecting the scissors, cut up a piece of the whole calcium alginate dressing and placed the scissors on top of the dresser. Staff D then poured a small amount of Santyl ointment into a medication cup and placed all supplies including the cut up piece of calcium alginate on top of the barrier. Staff D removed the resident's non-skid socks and the right heel dressing, removed her gloves, performed hand hygiene and donned gloves. Staff D retrieved the wound cleanser bottle and proceeded to spray the wound, dried up the wound and spray it with wound cleanser again and pat dry the wound. Observation revealed Staff D continues to wear the pair of gloves she used to clean the wound. Staff D proceeded to applied skin prep to the peri wound, then inserted her gloved index finger into the medication cup to retrieve the Santyl ointment and pasted into Resident #45's open right heel wound and covered with the bordered island dressing. Observation revealed Staff D removed her gloves and without hand hygiene, donned gloves and reached to her uniform pocket and retrieved an ink pen to date the dressing. Continued observation at 11:48 AM, revealed the wound cleanser fell to the floor and Staff D picked the bottle from the floor and placed it back on the table. Staff D put the resident non-skid socks back on and the bootie. Staff D then applied skin prep to Resident #45's left heel scab, removed her gloves and without hand hygiene donned gloves and put on the resident's non-skid sock and the bootie. Observation revealed Staff D removed her gloves, performed hand hygiene, returned to the treatment cart and placed the opened cut up calcium alginate dressing in the top drawer, and without disinfecting, Staff D placed the wound cleanse bottle that fell on the floor and the scissors back in the treatment cart. On 02/28/24 at 11:56 AM, an interview was conducted with Staff D, RN who stated she cleans her hand before and after working with the residents. Staff D was asked if she washes her hands between gloves changes, and replied if she touches something contaminated or dirty. Staff D confirmed she put the opened calcium alginate package, the wound cleanser bottle and the scissors back in the cart. Staff D stated she was supposed to clean the scissors and the wound cleanser bottle that was contaminated before putting those back in the treatment cart and did not. Staff D was apprised that she did not change gloves before applying Santyl ointment to the open wound with her finger. On 02/28/24 at 1:22 PM, an interview was conducted with the Director of Nursing (DON) who was apprised of Resident #45's wound care observations findings. The DON stated the nurses have applicators in the treatment cart to apply Santyl ointment to the wound. On 02/29/24 at 11:02 AM, a side by side review of Resident #45's wound care order was conducted with the DON. The DON was apprised Staff D did not use Dakin's solution, as per physician order, rather used Derma Wound Cleanser spray to clean the resident's wound. Subsequently, a side by side review of the wound cleanser ingredients was conducted with the DON. The DON acknowledged the Derma Wound Cleanser and Dakin's solution did not have the same ingredients.

Based on observations, interviews and record review, the facility failed to provide assistance during dining (Resident #30) and failed to provide fingernails grooming (Resident #1) for 2 of 3 residents reviewed for Activities of Daily Living (ADLs). The findings included: Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting revised on 03/2018 documented .appropriate care and services will be provided for residents who are unable to carry out ADLs independently including appropriate support and assistance with: hygiene ( grooming .) .dining (meals ) . 1) Review of Resident #30's clinical record documented an admission on 08/02/22 with a discharge to a local hospital on 12/19/23 and a readmission to the facility on [DATE]. The resident diagnoses included Acute Respiratory Failure with Hypoxia (lack of oxygen) Myocardial Infarction, Pulmonary Embolism, Malignant Neoplasm of the Mouth, Dysphagia and Cognitive Communication Deficit. Review of Resident #30's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 6, indicating that the resident had severe cognition impairment. The assessment documented under functional abilities and goals the resident needed partial/moderate assistance with eating and needed substantial/maximal assistance with most ADLs. Review of Resident #30's active care plan titled Self-care Deficit- Resident requires extensive assistance for completion of most ADL related to decrease mobility and cognitive status .Feed and Supervised with each meal. Review of Resident #30's active care plan titled, Nutrition- The resident is at risk for inadequate (by mouth) po/fluid intake . with interventions that included provide cues, encouragement and assistance .open containers and wrapping as needed . Review of Resident #30's physician order dated 01/06/24 documented Feed and Supervised with each meal. On 02/27/24 at 3:15 PM, a telephone interview was conducted with the MDS Coordinator who stated that Resident #30's assessment was not coded as a set up for meals nor for supervision during meals. The MDS Coordinator added the resident needed more than that, needed a staff member to be with her during meals. The MDS Coordinator stated that Resident # 30 requires substantial assistance due to her cognitive status and requires to be fed and supervise at times with each meal. The MDS Coordinator stated the resident's care plan was revised on 01/24/24. On 02/26/24 at 9:32 AM, observation revealed Resident #30 sitting up in bed with her breakfast tray set up in front of her. Further observation revealed the resident was dozing off, her eyes were closed. Attempted to interview the resident but she was not answering questions. The resident stared at the surveyor while attempting to interview her. The resident was asked if she wanted to be fed and nodded her head up and down (positive sign). The resident had her arms flexed up to her chest and in a cross position. Further observation revealed Staff F, Certified Nursing Assistant (CNA) in the resident's room feeding the roommate. Subsequently, an interview was conducted with Staff F who stated Resident #30 was able to feed herself. On 02/26/24 from 9:32 AM to 9:46 AM, observation revealed Resident #30 continues to have her breakfast tray in front of her, food was untouched. On 02/26/24 at 9:46 AM, observation revealed Staff E, Activities Aide, entered Resident #30's room and Staff F, CNA was in the room feeding the roommate. Further observation revealed no assistance or encouragement was provided by Staff E nor Staff F from 9:32 AM to 9:46 AM. On 02/26/24 at 1:00 PM, observation revealed lunch tray cart was parked by Resident #30's room. At 1:23 PM, observation revealed Resident #30's tray delivered by Staff F, CNA. Subsequently, an interview was conducted with Staff F who stated that she was helping a resident in another room. Staff F stated Resident #30 fed herself and added the resident did not eat anything for breakfast and wanted lunch. Observation revealed Staff F setting up Resident #30's lunch tray. The resident was asked if she wanted to eat and nodded her head up and down (meaning yes). On 02/26/24 at 1:30 PM, observation revealed Resident #30 feeding herself using her right hand with difficulty, unable to grab puree food on the fork. Observation revealed the resident kept moving her fork side to side on the plate and the plate edges to grab some of the pureed food with very little amount noted on the fork. The resident kept her left arm under the cover. The resident's napkin was soaked wet with food dropped into the napkin. Observation revealed no staff assisting, or providing cues nor encouraging Resident #30 during her meal. On 02/28/24 at 9:01 AM, observation revealed Staff F, CNA delivered Resident #30's tray. Staff F asked the resident if she was ready to eat and she nodded her head up and down. Staff F added I will set you up to eat. On 02/28/24 at 9:18 AM, observation revealed Resident #30 feeding herself, putting the fork into the cup of juice and bringing it to her mouth. The resident had a napkin over her chest that was soaked wet. Staff F, CNA was feeding her roommate and acknowledged Resident #30 was trying to drink her juice with a fork. Staff F from the across the room asked Resident #30 to use the straw. Observation revealed the resident was able to put the straw into the cup but removed it immediately, did not use it. Further observation revealed the resident again tried to drink the juice with a fork. The resident was observed attempting to get her pureed food on the fork and was able to get very little amount. The resident did not touch her (enhanced) oatmeal. The tray contains thin liquid, pureed food, a carton of whole milk, a cup of coffee, a glass of cranberry juice and a glass of water. By 9:21 AM, observation revealed Resident #30 had taken approximately 10% of the pureed food, and 25 % of the cranberry juice. On 02/28/24 at 9:21 AM, during an interview, Staff F, CNA stated again that Resident #30 fed herself all meals and eats everything. Observation revealed a thick red liquid dripping out of the resident's mouth. The resident was able to retrieve a very small amount of the pureed food on the fork and into her mouth. Observation revealed the resident had a chunk of white piece of food in her mouth. Continued observation at 9:27 AM, revealed Resident #30 grabbed a small unopened butter container with her right hand attempting to open it with one hand and was not able to. The resident left arm was under the cover. At 9:30 AM, observation revealed the resident putting the fork inside the cup of cranberry juice multiple times and bringing it to her mouth. During the observation, Staff F, CNA continues to feed Resident # 30's roommate without providing encouragement, nor supervision to Resident #30, who had a physician order to be fed and supervised. Furthermore, Staff E, Activity Aide entered Resident #30's room to deliver an I-Pad and did not encouraged the resident to eat nor offer assistance. At 9:35 AM, observation revealed Resident #30 attempted to get food from the plate and was not able to. The resident's napkin over her chest was noted soaked wet with a reddish color. Continued observation revealed the resident was moving her straw from the table to the tray back and forth, the spilled half of the cup of cranberry juice over her tray and pushed her tray away from her. On 02/28/24 at 9:44 AM, observation revealed Staff F, CNA came to Resident #30's bedside and asked her if she wanted help, the resident shook her head from side to side (meaning no). At the time, Staff F smashed the resident's pureed biscuit that was 75% untouched. The resident then got a spoon full of pureed meat and biscuit smashed by Staff F. The resident was not swallowing and Staff F had to remind her to chew and swallow. At 9:50 AM, Staff F asked Resident #30 if she would like another juice and the resident nodded her head up and down (meaning yes). The resident continues to attempt to get more of the smashed pureed biscuit and meat into her mouth without swallowing. The resident kept putting spoonfuls of food into her mouth. At 9:51 AM, Staff F returned to Resident #30 with a second container of cranberry juice. The resident was pushing the tray away. Surveyor asked the resident if she would like Staff F to help her and nodded her head up and down. Staff F asked the resident if she wanted help and the resident nodded her head up and down. Observation revealed the resident open her mouth multiple times to be fed by Staff F. Further observation revealed Staff F had to repeatedly tell the resident to chew and swallow. At 9:56 AM, Staff F was feeding the resident and stated, I can't give it to you unless you swallow. At 9:58 AM, Staff F stated the resident was pocketing her food and stated the resident had never taken so long to eat. At 10:01 AM, continued observation revealed Resident #30 pouring milk over her pureed biscuit. At 10:04 AM, the resident decline more food. The resident ate 75% of her food after assistance was provided. On 02/28/24 at 10:24 AM, an interview was conducted with the Speech Pathologist, (SP) who stated that Resident #30 received therapy until 01/31/24 because of Dysphagia (difficulty swallowing). The ST stated the resident needs supervision with meals. The ST was apprised that Resident #30 did not eat breakfast on 02/26/24, and with the 02/28/24 breakfast meal, the resident spilled her food and juice all over her napkin, was attempting to drink juice with a fork and was pocketing her food in her mouth. The ST was apprised there was no staff close to the resident to assist and supervise her, the staff across the room was not assisting nor supervising Resident #30. On 02/28/24 at 1:38 PM, observation revealed Resident #30 sitting up in bed and Staff G, CNA next to the resident. An interview was conducted with Staff G who stated the resident needed to be fed. 50370 2) A record record review revealed that Resident #1 was admitted on [DATE] with diagnoses of major depression, dysphagia, and heart failure. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 99, which indicated the resident is cognitively impaired. An observation was conducted on 02/26/24 at 12:10 PM. Resident #1 was noted in her room. Closer observation showed that Resident #1 had long, unkept fingernails on both hands, with a brown, unidentified matter underneath the pointer finger of her right hand. Photographic evidence obtained. In an observation conducted on 02/28/24 at 12:50 PM, Resident #1 was noted eating her lunch in the assisted dining hall. Closer observation showed that Resident #1 had long, unkept fingernails on both hands with a brown, unidentified matter underneath the pointer finger of her right hand. The care plan for Resident #1 under the Activities of Daily Livings (ADLs) section revealed that Resident #1 has a self-care deficit and requires assistance with self-care and her ADLs. Intervention included clean and manicured fingernails as needed. An interview was conducted on 02/28/24 at 4:00 PM with Staff B, Certified Nursing Assistant (CNA), who said she usually cleans and trims residents' fingernails before dinner. She was then asked to accompany Surveyors into Resident #1's room. She said yes when asked if Resident #1's fingernails needed trimming and cleaning. Staff B stated that it was not her Resident and that Staff E, Activity Aid, usually cuts and trims the Resident's fingernails. In an interview conducted on 02/28/24 at 4:10 PM, the facility's Director of Nursing (DON) stated that fingernail grooming is part of the overall grooming and that the Certified Nursing Assistants do not have a specific place in the electronic system that is just for fingernail grooming. The DON said that Resident #1 likes her fingernails long and that when staff tries to cut or trim her fingernails, she refuses. The DON stated that the Activity Director would know more about Resident #1 since she usually cuts and trims her fingernails during activities. An interview conducted on 02/28/24 at 4:17 PM with Staff C, Certified Nursing Assistant, stated that after dinner, they dress the residents, brush their teeth, and put them to prepare the resident for bed. Nail grooming is done when the showers are done, which is usually twice a week. When she looks at the fingernails, she makes the judgment of whether to trim the fingernails or cut the fingernails. They do it; and sometimes, the activity staff members trim and cut the fingernails. Staff C said that sometimes she works with Resident #1 and has her today and yesterday. In this interview, the Surveyors asked Staff C to accompany them to Resident #1's room. When asked if Resident #1's fingernails needed cutting and trimming, she said, It needs to be trimmed down. An interview conducted on 02/28/24 at 4:56 PM with the Activity Director, she stated that she trims and cuts Resident #1's fingernails during Monday activities that are dedicated to pampering hands and nail polish. She further noted that Resident #1 usually likes it and that it is unusual for Resident #1 to refuse or not want staff to cut or trim her fingernails. When asked by the Surveyors how long they keep the fingernails, she said just enough to be able to put nail polish but not too long. In this interview, the Activity Director was asked by Surveyors to accompany them to Resident #1's room. When asked to look at Resident #1's fingernails, she confirmed that some of the fingernails needed to be trimmed, shaped, and cleaned underneath, especially the thumb on the right hand.

Based on interviews and record review, the facility failed to ensure that a Gradual Dose Reduction (GDR) for Psychotropic medication was being followed as per the Physician's orders for 1 of 5 residents reviewed for unnecessary medications (Resident #32). The findings included: A review of the facility's policy titled, Psychotropic Medication Use, dated 2001, revealed that the use of psychotropic medications is not increased when efforts to decrease antipsychotic medicines are being implemented. The medication management process will include an indication of use, dose, and duration. A record review revealed that Resident #32 was admitted on [DATE] with diagnoses of Anxiety Disorder and Major Depressive Disorder. The care plan, which was initiated on 11/14/23, revealed the following: Resident #32 is on routine antianxiety medication and administers medication as indicated. A review of the Physician's orders in the paper chart revealed an order to discontinue Ativan (Lorazepam) 0.5 milligrams (mg)once a day and start Ativan 0.25 mg once a day, which was dated 12/21/23. A review of the Physician's orders in the electronic system revealed the following: Lorazepam 0.5 mg, 0.25 mg oral one time a day for anxiety and agitation. The February 2024 Medications report revealed an order for Lorazepam 0.5 mg (0.25 mg) once a day starting on 12/21/23, which was discontinued on 02/28/24. In an interview conducted on 02/27/24 at 2:27 PM with Staff A, a Registered Nurse, she was asked to clarify the Physician's order for Lorazepam. She stated that Resident #32 receives 0.5 milligrams of Lorazepam daily at 5:00 PM. Staff A proceeded to show the Surveyors the printed order in the electronic system. When asked by Surveyors how she would interpret the above electronic order, she said, I see what you are saying, and then said, It needs to be looked at. Staff A further stated that when she was looking at the order, what stood out was the 0.5 mg of Lorazepam and not the 0.25 mg. An observation of Resident #32's Bingo Medication Dispenser card revealed that he was receiving a Lorazepam 0.5 mg tablet, which was provided by Staff A, taken from the locked medication cart. Photographic evidence obtained. An interview was conducted on 2/28/24 at 5:17 PM with Staff D, a Registered Nurse, who stated that she was supposed to give Resident #32 his order for Lorazepam 0.25 mg, but she did not because they did not have any in-house and that she contacted the Unit Manager to let her know. A review of the Psychiatry Subsequent Note dated 01/03/24 revealed the following: Resident #32 mood has been stable and has no behavioral concerns. Stable symptoms of depression and anxiety, and the staff reported that the behavior has been appropriate. In this note, the Psychiatrist documented that Resident #32 receives Lorazepam 0.25 mg once a day. A review of the care plan note dated 01/17/24 revealed the following: Resident #32 is receiving Lorazepam 0.25 mg once a day, and no medications that have failed GDR at this time. An interview conducted on 02/28/24 at 6:00 PM with the facility's Director of Nursing stated that the Psychiatrist decided to change the order back to Lorazepam 0.5 mg and called the Pharmacy to ask for the higher dosage. The surveyor requested documentation regarding the above dosage change, which was not provided. An interview conducted on 02/29/24 at 1:20 PM with the Psychiatrist Nurse Practitioner stated that he wanted Resident #32's Lorazepam decreased to 0.25 mg as he prescribed on 12/21/23. He was not aware that Resident #32 was receiving 0.5 mg of Lorazepam and not the Gradual Dose Reduction of 0.25 mg.

Based on observation, interview, and record review, the facility failed to provide the appropriate diet consistency per the Physician ' s orders for 1 of 5 sampled residents reviewed for nutrition (Resident #308). The findings included: A record review revealed that Resident #308 was admitted on [DATE] with diagnoses of Dementia and Hypertension. The Comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #308 had a Brief Interview of Mental Status (BIMS) score of 11, which was mild cognitive impairment. Record review showed a Diet Order and Communication yellow slip noted with a regular/pureed diet, which was dated 02/24/24. The Physician's order revealed an order for a pureed diet, which was dated 02/24/24. The care plan initiated on 02/24/24 revealed the following: allow time to eat and provide encouragement and assistance. Monitor dietary tolerance and symptoms of coughing or choking when eating or taking fluids. The nutrition progress note dated 02/26/24 revealed that Resident #308 was admitted under hospice to the facility for a short respite stay. History of dementia and dysphagia and is on a pureed diet consistent with thin liquids. In an observation conducted on 02/26/24 at 9:30 AM, Resident #308 was noted in her bed with a breakfast tray in front of her. Closer observation revealed a meal choice ticket: orange/apple/cranberry juice, scrambled eggs, sliced bacon, corn beef hash, mini croissant, oatmeal, milk, and coffee. The bottom of the meal choice ticket revealed Resident #308 diet crossed out, and underneath was written regular diet with the Resident's last name and room number. In this observation, Resident #308 said, this does not look like my tray; it seems like someone was eating from my breakfast meal. Resident #308 then picked up her tablespoon and ate from the breakfast tray. The meal tray was noted with scrambled eggs, milk, oatmeal, and coffee. Photographic evidence obtained. An observation conducted on 02/26/24 at 12:43 PM revealed Resident #308 in her bed. Closer observation showed a menu food selection sheet for the next day with meal choices for breakfast, lunch, and dinner dated 02/27/24. The menu food selection sheet had Resident #308's name and room number written on the bottom. The menu food selection sheet showed a regular diet meal choice and not the appropriate puree meal choices. Photographic evidence obtained. An interview conducted on 02/28/24 at 12:17 PM with the facility's Registered Dietitian stated that the daily menu is printed on paper with the food menu choice and placed on the breakfast trays for all residents. Residents can pick their food choices for the next day, and nurses will pick up the menus and give them to the dietary department. This is done daily and taken to the main kitchen for the dietary aides to review. The menu food choices forms have the diet listed with the name of the resident and the room number for each Resident. The meal trays should have a white diet slip attached to the menu food choices paper on each meal tray. The dietary service aides oversee placing the menu selection paper on the meal trays every morning and making sure that it has the correct Resident name and diet order and that the menu will match the right food choices. The Certified Nursing Assistants are also responsible for ensuring that the diet orders are accurate for the specific residents. The surveyor showed the Registered Dietitian the picture of the breakfast meal for regular consistency that was taken on 02/26/24, and she said, I do not know how that happened.

Based on interview, review of policy and procedure, and record review, the facility failed to promptly notify the resident's responsible party of the resident's fall in the facility for 1 of 2 sampled residents (Resident #1). The findings included: Review of the facility policy and procedure, titled Change in a Resident's Condition or Status, revised February 2021, was provided by the Director of Nursing (DON) and it documented in the Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . Resident #1 was initially admitted to the facility on [DATE] with diagnoses which included Fusion of Spine, Lumbar Region, Basal Cell Carcinoma of Skin, Hypertension, Chronic Obstructive Pulmonary Disease, Unsteadiness on Feet, Difficulty with Walking, Need assistance with Personal Care, and Urinary Tract Infection (UTI). Resident #1 had a Brief Interview Mental Status (BIM) score of 13 (cognitively intact), and required one person assist with transfers and daily ADLs (activities of daily living). During a telephone interview conducted on 01/05/24 at 9:17 AM,with Resident #1's daughter and second emergency contact, she reported neither she nor the resident's first emergency contact, her sister, was ever notified of Resident #1 having had a fall in the facility on Tuesday 11/14/23. The resident's daughter stated that the resident was the one who called her to let her know that she had fallen in her room while getting up from her wheelchair. Resident #1's daughter went on to say that she didn't understand why the facility did not notify her nor her sister about the resident's fall, and why it was that she had to hear about this from her Mother, who was residing in the facility, for care. The resident's Fall care plan documented that on 11/14/23 Resident observed on floor, no injuries noted; 11/15/23 transfer to hospital and back after a few hours status post fall; no new orders. An interview was conducted with the Social Services Director on 01/05/24 at 3:11 PM, in which she acknowledged that Resident #1 was found sitting on the floor in her room on Tuesday 11/14/23 sometime well after lunch and she said that she reported this to Resident #1's assigned nurse, Staff A, a Registered Nurse (RN). A side-by-side computerized record review was conducted with the DON of the nurses' note effective date 11/14/23 at 4:45 PM by Staff A, in which it was documented Staff A was notified by the Social Services Director that Resident #1 was on the floor. It was also documented that Staff A went into the room to find the resident sitting on the floor in front of the bed with both legs facing the window, with the wheelchair facing the T.V. An assessment was done, vital signs taken, no obvious injuries, or complaints of pain, denied hitting head, resident was able to move all extremities without pain. It was further documented that Resident #1 indicated to Staff A that she was trying to get to her bed and her legs gave out and she sat on the floor. During an interview conducted on 01/05/24 at 3:50 PM with Staff A, Resident #1's assigned day nurse, she acknowledged that Resident #1 was found sitting on the floor in her room on Tuesday 11/14/23, and she also acknowledged that it was not documented in the medical record that Resident #1's fall had been reported to the resident's responsible party/representative. A telephone interview was conducted on 01/05/24 at 5:17 PM with Staff B, Licensed Practical Nurse (LPN), the day nurse assigned to Resident #1 on 11/15/23 after the resident's fall in the facility, in which she indicated that Resident #1's daughter was updated when she visited the facility, and not beforehand, regarding Resident #1's fall in the facility. Staff B went on to say that the resident was transferred out non-emergency to the hospital to be evaluated after Resident #1's daughter had arrived to the facility. Further computerized record review of the nurses' note dated 11/15/23 by Staff B, only described the action of Resident #1 being transferred to the hospital for further evaluation; with no official physician's order on file authorizing the hospital transfer. This note did not document that the resident's physician had been contacted and notified of the resident's fall in the facility. On 01/05/24 at 4:22 PM, an interview was conducted with Staff C, the assigned RN Evening Supervisor on the evening of the fall Tuesday 11/14/23. Staff C also acknowledged that she made no documentation in Resident #1's record with regards to her fall. Staff C went on to state that she vaguely remembered the resident and her care that evening and was unable to recall any other information pertaining to this resident. There was no notation in the nurses' note, nor anywhere in the resident's medical record to indicate that Resident #1's representatives had been contacted and made aware of her fall in the facility, at the time. The DON further recognized and acknowledged during her interview on 01/05/24 at 5:30 PM that it was not documented in the computerized medical record that Resident #1's responsible party was not notified or made aware of the resident's fall in the facility.

Based on review of policy and procedure, record review, and interview, it was determined that the facility failed to ensure that it maintained sufficient nursing staff, on a 24-hour basis to provide nursing and related services to residents, in order to maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The findings included: Review of the facility policy and procedure, titled Staffing, revised October 2017, provided by the Administrator, documented in the Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: 1. Licensed nurses and certified Nursing Assistants (CNAs) are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care 4. Direct care staffing information per day (including agency and contract staff) is submitted to the Centers for Medicaid and Medicare Services (CMS) payroll-based journal (PBJ) system on the schedule specified by CMS, but no less than a quarter . On the Staffing Calculations Form for the three (3) months of April, May and June 2022, it was documented that the licensed nursing staff hours reflected less than 1.0 hour on the following nine (9) days: Sunday 04/17/22, Monday 04/18/22, Thursday 04/28/22, Sunday 05/01/22, Monday 05/02/22, Friday 05/06/22, Friday 05/13/22, Wednesday 05/18/22 and Wednesday 06/01/22. Further record review revealed that, it was also documented the average combined hours (licensed nursing staffing and certified nursing assistant), were less than 3.6 hours on the following twenty-two (22) days: Sunday 04/03/22, Tuesday 04/05/22, Sunday 04/10/22, Sunday 04/17/22, Tuesday 04/19/22, Thursday 04/28/22, Sunday 05/01/22, Saturday 05/07/22, Tuesday 05/10/22, Friday 05/13/22, Saturday 05/14/22, Tuesday 05/17/22, Thursday 05/26/22, Friday 05/27/22, Sunday 05/29/22, Friday 06/03/22, Monday 06/06/22, Thursday 06/09/22, Friday 06/10/22, Saturday 06/11/22, Saturday 06/18/22 and Saturday 06/25/22. A side-by-side record review was conducted with the Administrator in which it was revealed for the three (3) months of April, May and June 2022 the licensed nursing staff hours were less than 1.0 hour on nine (9) days, and the average combined hours (licensed nursing staffing and certified nursing assistant) were less than 3.6 hours on twenty-two (22) days. An interview was conducted with Resident #7 on 11/07/22 at 12:17 PM, in which she indicated that it does bother her that on the weekends, the facility is sometimes short staffed affecting her overall care needs. Resident #7 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). An interview was conducted with Staff A, a CNA, on 11/16/22 at 10:29 AM, in which she verbalized that sometimes the facility is short-staffed with only six (6) CNAs on the floor, when the facility would usually have had seven (7) CNAs on the floor. During an interview conducted on 11/16/22 at 1:10 PM with Staff E, a Registered Nurse (RN), in which she was questioned as to how often that she is asked to stay late or come in early to provide additional nurse staffing coverage, and she replied, at least on an almost bi-weekly basis. On 11/16/22 at 10:40 AM, according to the Administrator, the staffing information provided during this survey by their current Staffing Coordinator, was not the same information that was previously submitted to the PBJ for the months of April, May, and June of 2022 by the facility's former Staffing Coordinator. During an interview conducted on 11/16/22 at 10:49 AM with the Staffing Coordinator, she indicated that she was aware of the Federal and State regulations for sufficient nurse staffing. She acknowledged the licensed nursing staff hours were less than 1.0 hour on the following nine (9) days: Sunday 04/17/22, Monday 04/18/22, Thursday 04/28/22, Sunday 05/01/22, Monday 05/02/22, Friday 05/06/22, Friday 05/13/22, Wednesday 05/18/22 and Wednesday 06/01/22. She also acknowledged that the average combined hours (licensed nursing and certified nursing assistant) were less than 3.6 hours on the twenty-two (22) days noted above. An interview was conducted with the Director of Nursing (DON), on 11/16/22 at 11:47 AM regarding the licensed nursing staff hours less than 1.0 hour, and the average combined hours less than 3.6 hours, and she acknowledged that staffing is to be provided per the resident needs. In fact, there were eleven (11) weekend days identified during this time frame, that were identified as having either low licensed nursing staff hours or low combined hours (certified nursing assistant and licensed nursing). The Administrator further recognized and acknowledged on 11/16/22 at 12:15 PM that sufficient nursing staff should have been maintained, on a 24-hour basis.

Based on observation, interview, record review, and policy review, it was determined the facility failed to ensure accurate accountability and reconciliation of controlled medications for 1 of 6 sampled residents (Resident #204). The findings included: Review of the facility policy titled Administering Medications dated 2001 documents, The individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered. During an observation of the West-end Medication Cart on 11/08/22 at 2:22 PM, a review of the [MEDICATION(S)] (a controlled medication) was completed for Resident #204 with Staff B, a Licensed Practical Nurse (LPN). Review of the number of [MEDICATION(S)] taken from the medication cart as recorded on the Controlled Drug Declining Inventory Sheet dated 11/01/22 through 11/08/22, compared to the number of [MEDICATION(S)] administered to Resident #204 as per the corresponding MAR, revealed the following discrepancies: On 11/01/22 at 10:30 AM, 11/01/22 at 6:00 PM, 11/02/22 at 3:37 PM, 11/02/22 at 7:29 PM, 11/02/22 at 11:40 PM, and 11/05/22 at 9:00 PM, one [MEDICATION(S)] was taken from the medication cart with no corresponding documentation of administration to Resident #204 on the Medication Administration Record (MAR). This revealed the record lacked documented administration of the medication 6 of 16 times between 11/01/22 at 10:30 AM and 11/08/22 at 9:42 AM. On 11/16/22 at 7:30 AM a side-by-side review was done comparing the Controlled Drug Declining Inventory Sheet and the MAR with the DON. The DON verified 6 doses of [MEDICATION(S)] given between 11/01/22 at 10:30 AM and 11/08/22 at 9:42 AM, were not charted or incorrectly charted on the MAR for Resident #204. On 11/16/22 at 8:10 AM Staff D stated she was aware she documented incorrectly the doses of [MEDICATION(S)] for Resident #204 on 11/02/22. The doses were documented under another medication on the electronic MAR and she did not know how to correct it.

Based on records review and interviews, the facility failed to ensure that an interdisciplinary hospice comprehensive care plan reflected the facility's responsibility for 1 of 2 sample residents (Resident #5). The findings included: Resident #5 was originally admitted to the facility in 2019, and recently readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospice Interdisciplinary Comprehensive Assessment and plan of care dated 2/29/2020, documented additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospice Interdisciplinary Care Plans (ICP) dated 5/26/21 and 4/8/22 did not outline the facility's role in the delivery of service. There was no indication of the starting date of services and no end date. It was unclear whether the Facility staff was involved in the plan development. There was no facility staff signature in the plan. The Integration tool dated 4/8/22 revealed that the resident terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Those who signed the Plan were all hospice representatives and their responsibilities (Nursing, Social Worker, Certified Nursing Aides and Chaplain), but there was no indication as to what the nursing home facility's responsibilities entailed. The Facility's Plan of Care updated 10/21/2022 showed the goal for Resident #5 was to keep her comfortable daily, throughout her end-of-life process, until the next review date. As interventions, the facility would conduct 1:1 visit; observe any changes in Resident #5's mood and behavior. During an interview with the Director of Nursing (DON) on 11/16/22 at 10:29 AM, she reported the facility's DON, Social Worker, or the Minimum Data Set (MDS) Coordinator of the facility were responsible for reviewing the Interdisciplinary Care Plan (ICP). However, they failed to recognize that their role was not outlined in the ICP. During an interview with the Hospice Case Manager on 11/16/22 at 10:59 AM, she said during the plan development, they communicate with the facility's representatives and the facility knows what they are responsible for. She ensued that they do not write down facility's responsibility on the ICP. The Administrator provided no additional information during the Exit meeting held on 11/16/2022.

Based on observations, interviews and record review the facility failed to provide tube feeding regimen as prescribed by the attending physician for 2 of 3 residents reviewed for tube feeding (Resident #103 and Resident #49). The findings included: Review of the facility's policy titled Enteral Feeding Via Continuous Pump revised in November 2018 showed to check the enteral nutrition label against the order before administration. It further showed to include the prescribed enteral formula and the date and time the formula was administered. 1. Record review showed that Resident #103 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order noted for Pureed with thin liquids diet for breakfast and lunch dated 09/02/21. The care plan dated 08/28/21 showed that Resident #103 is dependent on nutrition and hydration through tube feeding. In an observation conducted on 09/07/21 at 9:45 AM, Resident #103 was observed in bed. Closer observation of the feeding tube (Osmolite1.5) showed that the tube feeding bag was not running. It further showed 700 ml of formula left in the bag, out of a total volume of 1000 ml. The bag was dated 09/06/21 and start time showed 6:00 PM the day before. Tube feeding running at 60 ml an hour for 12 hours will provide a volume of 720 ml of tube feeding formula, with 280 ml left in bag. In another observation conducted on 09/09/21, at 10:00 AM, Resident #103 was observed in bed. Closer observation of the tube feeding showed that it was not running. It further showed 450 ml of formula left in the bag, out of a total volume of 1000 ml. The bag was dated 09/08/21 and started at 6:00 PM. Review of the Nutrition assessment dated [DATE] showed that Resident #103 is dependent on tube feeding for nutrition and hydration needs. Follow up note dated 09/02/21 showed the Resident #103 is with poor intake and that an increase daily of tube feeding to 80 ml is recommended. In an interview conducted on 09/09/21 at 1:50 PM, with Staff A, Certified Nursing Assistant, she stated that she did not see how much Resident #103 ate of her lunch meal, and that Staff B, knows how much she ate for lunch. In an interview conducted on 09/09/21 at 2:45 PM, Staff B, Registered Nurse, stated Resident #103 did not eat much of her lunch meal today. At 3:00 PM, Staff B further stated that Resident #103 did not eat her lunch tray and that it was her breakfast tray that she ate only 25 percent. Staff B also reported that Resident #103's tube feeding is running from 6:00 PM to 6:00 AM, and that it is well tolerated. In an interview conducted on 09/09/21 at 2:52 PM, with the Clinical Dietitian, she stated that the tube feeding running at 60 ml for 12 hours would have provided 720 ml of formula out of a 1000 ml bag. When showed the photographic evidence of the tube feeding bag on 09/07/21 and on 09/09/21 she acknowledged all findings. 2. In an observation conducted on 09/07/21 at 9:30 AM, Resident #49 was observed in her room. Closer observation showed a tube feeding on hold with [MEDICATION(S)] 1.2 (tube feeding formula) at 60 milliliters (ml) an hour which started on 09/06/21 the day before. The tube feeding showed that 300 ml was left in the bottle from a total volume of a 1000 ml. Record review showed that Resident #49 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 08/25/21, showed that the tube feeding will be administered as ordered and that Resident #49 is receiving tube feeding as sole nutritional provision. Review of the Tube Feeding Nutritional Reassessment dated [DATE], showed that Resident #49, remains dependent on tube feeding, and any decrease in caloric intake may increase her risk for nutrient deficits. This may lead to breakdown and malnutrition. In an interview conducted on 09/09/21 at 2:54 PM, with the facility's Clinical Dietitian, she reported that if the tube feeding is running at 60 ml an hour for 18 hours it would have provided a total of 1070 ml. When asked what should have been left in the tube feeding bag, she said nothing. In an interview conducted on 09/09/21 at 3:15 PM, with Staff D, Licensed Practical Nurse, she reported that Resident #49 is tolerating her tube feeding with no issues. She further stated that the tube feeding starts the day before and that she stops it at 10:00 AM the next day. Staff D stated that when the tube feeding is stopped only a small amount of tube feeding is left in the bottle. In an interview conducted on 09/10/21 at 10:20 AM, with the Administrator and the Director of Nursing they acknowledged all findings.

Based on record review and interviews, the facility failed to assure that [CONDITION(S)] drugs, as needed (PRN) were limited to 14 days, and that the attending physician documented a rationale for the PRN order to be extended beyond 14 days, for 1 of 5 residents reviewed for unnecessary medication (Resident #33). The findings included: Review of the facility's policy titled Psychoactive Medication Use revised on December 2016, showed the following: PRN orders for Psychoactive medication will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of the medication. It further showed that the staff will observe, document and report to the Attending Physicians information regarding the effectiveness of any interventions including psychoactive medications. Review of the clinical record showed that Resident #33 was admitted on [DATE] with diagnoses of Dysphagia, Major Depressive Disorder and Agitation. Further review showed that Resident #33 was placed on hospice on 05/06/21. Review of the Physicians' Order Sheet showed an order for: Lorazepam (for anxiety/agitation) 0.5 milligrams as needed every four hours dated 05/06/21. Review of the Pharmacy recommendation dated 05/26/21 showed that the Pharmacist recommended to review the PRN medication for Lorazepam, to assure that it did not exceed 14 days with the exception that the prescriber document their rationale in the resident's record. Further review of the Physician's portion of the recommendations showed that the Physician agreed with the Pharmacist recommendations and wrote to have Psych review with hospice team which was dated 09/07/21. This was 3 months after the recommendation that was written on 05/26/21. In an interview conducted on 09/09/21 at 4:40 PM, with the Director of Nursing, she stated that when she started working in May of this year, she noticed that the recommendations for the month of May 2021 were not addressed, she then had the Pharmacist resend her the recommendations. When asked as to why Resident #33 did not have a Psych consultation, she reported that they did not have the Pharmacy meeting this month. Further review of the hospice binder's notes from 05/06/21 to current, did not show the hospice's Physician addressing the use of the PRN medication. Review of Resident #33's chart did not show a psych consultation or visit from 05/06/21 to current. Review of the care plan initiated on 05/25/21 showed that Resident #33 is receiving psychoactive drugs on a regular basis. It further showed to record behaviors on tracking forms and monitored pattern of behaviors. Review of the Medication Administration Record showed that Resident #33 was given Lorazepam on: 08/23/21, 08/26/21, 08/30/21, 09/01/21, 09/02/21, 09/03/21, 09/07/21, 09/08/21, 07/12/21 and 07/29/21. In an interview conducted on 09/09/21 at 5:25 PM, with the Director of Nursing; the findings were discussed, and she was informed the practitioner needs to write the rationale for the PRN medication and indicate the duration of the PRN medication. In a phone interview conducted on 09/10/21 at 10:40 AM, with the Pharmacist, he stated that review of medications is done monthly. For any orders that are PRN [CONDITION(S)] medications, he will contact the Prescribing Physician regarding the order. He further stated that he will check on the recommendation the following month to see if it was addressed. If it was not, he will let the facility know that it was not addressed and will resubmit the recommendation again. The Pharmacist reported that on 07/23/21, he readdresses the recommendation of PRN medication for Resident #33. He did not get a response from the Attending Physician and is still listed as pending.

Based on observations, interviews and record review the facility failed to follow the Therapeutic diet for Mechanical Soft Diets, as prescribed by the Attending Physicians (Resident #33, Resident #8, Resident #6, and Resident #15). This has the potential to effect 12 residents out of 45 residents that are on Mechanical Soft Diet. The findings included: Review of the International Dysphagia Diet Standardization Initiative (IDDSI), provided by the facility's Speech Therapist showed the following 7 transitional foods: thin, slightly thick, mildly thick, moderately thick, extremely thick, minced/moist, soft/bite size, easy to chew and regular. Adapted from the National Dysphagia Diet: Standardization for Optimal Care. American Dietetic Association dated 2002, Showed that a Level 2 Dysphagia Mechanically Altered Diet, is a diet consists of foods that are moist, soft-textured, and easily formed into a bolus. All foods on Level 1 are allowed. Meats and other select foods may be ground or minced into small pieces no larger than ¼. All food items should be easy to chew. All soft, well-cooked vegetables should be less than 1/2 inch and should be easily mashed with a fork (https://www.dysphagia-diet.com/Images/Level%202%20Dysphagia%20Mechanically%20Altered%20Diet.pdf) 1. Record review showed that Resident #33 was admitted on [DATE] with diagnoses of: Dementia, Alzheimer's, and Dysphagia. Review of the care plan initiated on 05/25/21 showed that she has chewing, and swallowing difficulties related to Dementia and Dysphagia. It further showed to continue with No Added Salt Mechanical Soft Diet. Resident #33 is with impaired vision as well. Review of Physicians Orders Sheet showed an order for Regular No Added Salt Mechanical Soft Diet dated 04/24/21. Review of the Speech Therapist Note dated 06/01/21 showed that Resident #33 is with an upgraded diet to Mechanical Soft with Ground Meats, for pleasures with small portions and the Dietitian was advised. Review of record showed Resident #8 was admitted on [DATE] with diagnoses of: Type 2 Diabetes, [CONDITION(S)] and Dementia. Review of the Physician's Order Sheet showed an order for a Mechanical Soft Diet dated 09/05/21. Review of the Minimum Data Set (MDS) dated [DATE] showed that Resident #8 is with a Brief Interview of Mental Status (BIMS) score of 04 which is cognitively impaired. Review of record showed that Resident #6 was admitted on [DATE] with diagnoses of: Dementia and Depressive Disorder. Review of the MDS dated [DATE] showed that Resident #6 is with BIMS score of 99 which is cognitively impaired. In an observation conducted on 09/07/21 at 12:25 PM in the Restorative Dining Room, Resident #33 was observed eating her lunch. Closer observation showed a lunch plate with cooked carrots, pasta and chopped meat. In this observation, Resident #33 was attempting to cut the carrots with a knife but was not able too. Resident #8 was also in the dining room, with a lunch tray that had cooked carrots, pasta and chopped meat. Closer observation of the meal ticket showed the following: Level 2, Mechanical Altered Diet (photographic evidence). Resident #6 was in the dining room, with a lunch tray that had cooked carrots, pasta and chopped meat. Closer observation of the meal ticket showed Level 2, Mechanical Altered Diet (photographic evidence). Staff C, Activity Assistant, was observed helping Resident #6 with her lunch meal. She was attempting to cut the cooked carrots with a knife using force. In an interview conducted on 09/07/21 at 12:35 PM, with Staff C, when asked by the surveyor if the cooked carrots are easy to cut, she stated some are softer than others. In an observation conducted on 09/07/21 at 12:45 PM, surveyor, attempted to cut the cooked carrots using a table knife. Slight force was used to cut some of the carrots on the plate. Surveyor used the facility's ruler to calculate the length of the carrots on the plate. It showed that each carrot on the plate was around 2 inches in length and not the recommended ½ an inch or less (photographic evidence). In this observation the facility's Clinical Dietitian, was attempting to cut the carrots on the plate with a knife. She then stated, that is not okay, they need to be softer. In an interview conducted on 09/10/21 at 8:11 AM, with the facility's Speech Therapist, she reported following the IDDSI guidelines for some time now. She further stated that she has been doing her assessments according to this system but has not been fully enforced by the facility. She then stated, the facility is not ready for the full change and are in the process of changing. When asked as to what it means to be on a Mechanical Soft Diet, level two, she reported that it is any food which can easily be mashed with a fork. If a person has dementia, they need bite size foods to be able to chew more easily. Therefore, she likes the IDDSI system for her assessments. The Speech Therapist stated that she was told yesterday that she needed to use a new guidelines system of food textures because they are not ready to convert to the IDDSI system. This is because there has been confusion with the diet consistencies and the interpretation of the different consistencies. 2) During an observational resident room lunch meal tour conducted on 09/07/21 at 11:08 AM, it was noted that Resident #15 had some fresh raw onions and a fresh raw tomato slice on his lunch tray. The resident was observed feeding himself, after set-up by staff, some of the raw purple onions and some of the raw tomato. Resident #15 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus Type II, [CONDITION(S)], Chronic Kidney Disease, Gastroesophageal Reflux (GERD) and Dysphagia. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). (Photographic evidence obtained of fresh raw onions and a fresh raw tomato slice). On 09/07/21 at 11:10 AM, a record review was conducted of Resident #15's meal ticket located near the resident which clearly indicated that he was ordered an altered oral diet order that was Mechanical soft. During a brief interview on 09/07/21 at 11:15 AM, Resident #15 stated he is served this all of the time. Record review indicated that Resident #15's diet order dated 08/21/21 indicates for mechanical soft chopped. Offer soft easy to chew foods. Bite sized meats. The mechanical diet indicates that the consistency, of these food items, should be cooked for the resident prior to serving/eating.

Based on observations, interviews and record reviews, the facility failed to ensure that nutritional reassessments and interventions were done in a timely manner, and the facility failed to address severe weight loss in a timely manner, for 2 of 3 residents (Resident #1 and Resident #2) reviewed for nutrition. The findings included: 1. Record review of the facility's policy titled Resident Weight and Weight Changes, revised date on 10/17, stated the following: (a) Each resident is weighed and measured upon admission. The height and weight are recorded in the medical record by nursing. (b) The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. (c) Monthly weights will be done within the first week of the month. (d) A reweigh must be obtained within 48 hours if a weight change that meets the following criteria is noted: 3 percent (%) of body weight change in 1 week, 5% of body weight change in 1 month, 7.5% of body weight change in 3 months, or 10% of body weight change in 6 months. (e) The dietitian will reassess the nutritional needs and intake of the resident with a weight change. Appropriate recommendations will be documented in the medical record. (f) The dietitian and/or designee will track resident weights over a 180-day period to ensure that all significant weight changes are recognized. 2. Resident #2 was admitted to the facility on [DATE]. Resident #2 was diagnosed with [REDACTED]. Review of the Nutritional Assessment completed on 9/2/19 showed that Resident #2 had an admission weight of 160 lbs. Review of the weight history showed that Resident #2 weighed 145.3 lbs. on 12/11/19, 139.1 lbs. on 1/2/20, 138.9 lbs. on 2/4/20, 136.3 lbs. on 3/17/20, 132.9 lbs. on 4/7/20, 129 lbs. on 5/6/20, 124.5 lbs. on 6/15/20, 126 lbs. on 6/23/20, and 118.4 lbs. on 9/15/20. This showed a 11.2% weight loss from 12/11/19 - 5/6/20. Review of the RD Re-Assessment Note dated 12/18/19 showed that Resident #2 had a weight of 145.3# and was on Med Pass 2.0 (nutritional supplement) three times daily. In this assessment, the RD reported significant weight loss over the past month which was related to resolved [MEDICAL CONDITION]/diuretics. The RD also reported that Resident #2 had an oral intake of 50-100% of her meals. Review of the physician's orders [REDACTED].#2 was on [MEDICATION NAME] (diuretic) 20 milligrams, however, the order was discontinued on 9/13/19 (12 days after her admission). This showed that the weight loss that occurred after 9/13/19 was not attributed to the use of diuretics. Review of Section C of the Annual MDS dated [DATE] showed that Resident #2 had a BIMS of 03 which showed that she was severely cognitively impaired. Section G of the MDS dated [DATE] showed that Resident #2 was coded with extensive assistance with one person assist for meals. Review of the RD Quarterly assessment dated [DATE] noted significant weight loss for Resident #2. In this assessment, the RD reported that Resident #2's weight was 138.9 lbs. and her oral intake of meals was between 50-75%. RD further stated that the weight loss was related to diuretic medication and medical diagnoses. She further reported a significant weight loss of 13.2% in 150 days. According to the RD Assessment, Resident #2 had an inadequate energy intake due to varied oral intake of meals. RD further suggested to decrease the Med Pass 2.0 from three times a day to two times a day. Review of the weight history showed that Resident #2's weight dropped from 138.9 lbs. on 2/29/20 to 129 lbs. on 5/6/20. This showed a 7.13% weight loss which was not addressed until 5/30/20. Review of the RD Quarterly assessment dated [DATE] noted that Resident #2 was continuing to experience significant weight loss. RD further reported a weight loss of 7.2% in 90 days. This assessment showed that Resident #2 was below ideal body weight, had skin redness on the sacral and bilateral heel, and had a decreased oral intake of meals. Review of the physician's orders [REDACTED].#2 had an order for [REDACTED].#2 was documented with significant weight loss on 2/29/20, 5/30/20, 6/18/20, and 6/19/20, no changes were made to her nutritional supplement orders until 8/25/20. Order for Med Pass 2.0 Fortified Nutritional Shakes two times a day and Ensure Clear once a day were dated 8/25/20. During an interview on 10/28/20 at 12:34 PM, RD stated that in December 2019, Resident #2 was on Med Pass and [MEDICATION NAME] (diuretic). For that reason, RD attributed Resident #2's weight loss to fluid loss and was not overly concerned with the significant weight loss. Surveyor reported that the physician's orders [REDACTED].#2's admission. When asked by the surveyor as to why she contributed the weight loss to the use of discontinued diuretics, RD did not have an answer. When asked about weights for Resident #2 from admission to 6/15/20, RD stated that she has had continuous weight loss and acknowledged that this was a severe weight loss. In this interview, surveyor reviewed Resident #2's weight history with RD and asked why she did not address the trending weight loss sooner. RD stated that prior to the COVID-19 pandemic, Resident #2 used to go out to a bistro with her husband twice a week. RD further stated that her oral intake was between 50-100% and that she was not in need of nutritional supplements. According to the RD, she did not address the significant weight loss until Resident #2 was triggered on 6/15/20 for weight loss. RD stated that this is when she put her interventions in place. RD stated, I should have addressed Resident #2's continuous weight loss sooner. When asked why she did not reassess the efficacy of the nutritional supplements or the need for additional supplements, RD did not have an answer. During an observation on 10/28/20 at 1:17 PM, Staff A was observed at Resident #2's bedside feeding her the lunch meal. Staff A stated that Resident #2 requires assistance with all of her meals. She further stated that she usually works with Resident #2 and that her oral intake of meals varies from 25% to 50%. 3. Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 was admitted with a right femur fracture. Further review showed [DIAGNOSES REDACTED]. Review of Section C the Minimum Data Set ((MDS) dated [DATE], showed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which showed he was cognitively intact. Review of the weight history documented by the facility showed that Resident #1 weighed 188.6 pounds (lbs.) on 5/15/20, 183.6 lbs. on 5/20/20, and 175.2 lbs. on 5/26/20. This showed an overall severe weight loss of 7.10% within 11 days, from 5/15/20 - 5/26/20. Review of the Registered Dietitian (RD) Initial assessment dated [DATE] showed that Resident #1 had a height of 75 inches, a weight of 188.6 lbs., and a body mass index of 23.6 (normal). RD documented that weight maintenance was desired, and no significant weight changes were reported by Resident #1. In this assessment, the RD placed Resident #1 at an overall nutritional risk category of 6, which showed that Resident #1 was at moderate risk. RD interventions were to proceed with current diet order, provide nutrition education as needed, obtain weekly weights for 4 weeks, and encourage adequate fluid intake daily to meet calculated needs. Review of the Clinical Notes Report dated 05/14/20 to 06/01/20 did not show any progress notes or interventions that were done by the RD for Resident #1. Further review of the clinical notes did not show any nutritional interventions after Resident #1's weight loss of 7.10% on 5/26/20. Review of the Certified Nursing Assistant (CNA) Intake Sheet of the daily 3 meals from 05/14/20 to 05/31/20 showed that Resident #1's intake of meals varied between 50%-100%. Review of the Physician order [REDACTED].#1 was not on any nutritional supplements during his stay. Further review of the Care Plan dated 05/22/20 did not show any nutritional problems or interventions in place. During an interview on 10/28/20 at 10:30 AM, the Director of Nursing (DON) stated that any RD follow-up assessments or RD progress notes would be in the notes tab or assessment tab in their electronic charting system. Surveyors were unable to locate RD follow-up assessments and RD progress notes and asked the DON to locate them. DON reviewed the electronic charting system and stated that Resident #1 did not have any RD follow-up assessments or RD progress notes. During an interview on 10/28/20 at 10:38 AM, the RD stated that she tries to see newly admitted resident within 3-5 days of admission for their initial assessment. RD further stated that she likes to wait a few days before conducting an initial assessment because she finds that the first 2 days of admission, residents don't always have a good appetite. RD stated that she enters her initial assessments under the assessment tab and her follow-up assessments in the notes tab in their electronic charting system. When asked about weights, RD stated that the Restorative Aide from nursing oversees weighing residents. RD stated that they take weights within 24 hours of admission, then on a weekly basis for the first month, and then if stable, they take weights on a monthly basis. The Restorative Aide is responsible for bringing the weights to the RD. Once she receives the weights, RD stated that she is responsible for entering the weights into the system, assessing for significant changes, and writing progress notes. RD stated that a significant weight loss would be for those who lose 5% or more in 30 days, 7.5% or more in 3 months, or 10% or more in 180 days. When asked about residents with significant weight loss, RD stated that she would find out how the weight loss occurred, offer nutritional supplements or high calorie cereal, and have the resident order menu items they want. When asked about Resident #1, RD confirmed that Resident #1 was admitted on [DATE] and discharged on [DATE]. She further stated that the initial assessment was done on 5/19/20. When asked about her initial assessment for Resident #1, RD stated that he was a diabetic and did not follow a strict diet at home. Resident #1 consumed 75% of his meals, had [MEDICAL CONDITION] to his right foot, and had blood glucose levels of 156-260mg/dl. According to the RD, she identified percentage of meals consumed by looking at the CNA Intake Sheet to identify how Resident #1 was eating. When asked as to why a follow-up assessment or progress note was not completed for Resident #1, RD stated that she does not follow a resident unless there was a trend in the weights. Surveyor reviewed Resident #1's weight history with RD. RD acknowledged that Resident #1 experienced a severe weight loss of 4.58% between 5/20/20 - 5/26/20 and a severe weight loss of 7.10% from 5/15 - 5/26/20. RD stated, I should have done an assessment. I entered the weights. I should have gone back to visit him to see if there were any changes to his intake and to see if he needed any supplements or a re-weight.

Based on observation, interview, and record review, it was determined that the residents' environment was not free from hazards involving high hot water temperature in resident rooms, and failure to secure the entry gate to the community pool area. The findings included: A review of the facility's policy and procedures for Safety of Water Temperatures noted that water heaters that service resident rooms, bathrooms, and common tub/shower areas shall be set to temperature of no more than 105-115 F, or the maximum allowed temperature per state regulation. It was also noted the policy to state, if at any time the water temperature feels excessive to the touch, staff will report this finding to the immediate supervisor. 1) During the initial resident observation tour conducted on 02/08/20 at 10 AM, the water temperature in the bathroom of room [ROOM NUMBER] felt very hot to the touch. The surveyor requested the maintenance department to test the hot water temperature. Prior to the test the surveyor requested the maintenance staff (Staff A) to calibrate the thermometer to determine the accuracy of the test. Staff A stated he did not know how to calibrate a the digital thermometer using the ice/cold method of testing. The surveyor was required to demonstrate to the Maintenance Director the correct method to test the digital thermometer utilizing ice water. The test recorded the facility's digital thermometer at 33 degrees F. At the request of the surveyor the temperature of resident bathroom rooms were taken and revealed the following : room [ROOM NUMBER] = 121 F Room # 103 = 119 F Room # 105 = 119 F Room # 109 = 119 F Room # 112 = 120 F Room # 115 = 119 F It was further noted that the hot water temperatures were cooler in rooms (5) located on the East wing and were recorded at 113 to 115 F. A subsequent tour conducted on 02/10/20 at 11 AM with the Maintenance Supervisor revealed that the commercial hot water heater was located in the boiler room just down the hall from rooms #101 through # 116. Observation of the 2 hot water pipes leading from the hot water heater were noted to have thermometers. An observation of both thermometers revealed that the hot water exiting the heater to the residents rooms was between 120 - 122 degrees F. The surveyor requested that the temperature of the hot water be reduced immediately to a safe level to prevent potential scalding of residents. The surveyor also requested hourly updates of the hot water temperatures flowing into resident rooms #101 through #116. At the request of the surveyor the hot water temperature log for the last 3 months were reviewed. The review noted excessive hot water temperatures on a daily basis in resident rooms #101 through #116. The hot water documentation in these rooms was 115 - 122 degrees F. Interview with the Administrator on 02/10/20 revealed that the policy failed to be followed for months and that she was never made aware of the potentially excessive hot water temperature danger. Review of the Resident Grievance Log and Accident Incident Logs for the last 6 months did not reveal any documentation of accident/incidents concerning hot water temperatures. A review of daily hot water temperature logs from 02/10/20 through 02/13/20 noted documentation that hot water temperatures in resident rooms remained at safe level since the 02/10/20 onset. A meeting was requested by the facility's administration team to have the contracted plumbing service meet with the surveyor. The boiler services representative stated that the hot water issue at the facility was assessed and that a quote was given to the facility for removing and replacing existing water boilers and replace with high efficiency propane gas tank type heaters. Also, to install a new thermostatic mixing valve. The representative stated that the repair parts would have to ordered and work installation would begin in approximately 7 days. 2) On 2/10/20 at approximately 12:30 PM, while waiting for lunch tray delivery in the west hallway, an exit door was observed just beyond the dining room. Further investigation revealed that the door was an automatic sliding door, that led out to a walkway and by a swimming pool. The swimming pool was surrounded by a pool fence that had a child safety gate, as would be found around a residential, non-public pool. The pool gate could be easily opened by any person who could stand or reach to the top of the gate. The gate opened inward toward the pool. According to the Florida Department of Health guidelines and the Florida Building Code guidelines a pool gate is supposed to open outward, away from the pool. The pool was unattended. This situation provided a potential safety risk of drowning. These findings were witnessed by the Team Coordinator as well. When these findings were brought to the attention of the Nursing Home Administrator (NHA) and the Director of Nursing the surveyors were informed that the back door was protected by a Wanderguard system. A demonstration of the Wanderguard system was performed by the NHA and DON. On the first trial the system failed to lock the sliding door as it was being accessed at the same time the NHA was approaching the door with a transmitter in her hand. All other tests locked the door successfully. The Maintenance Director was made aware of the situation and the NHA determined that the pool gate in question would have a lock installed. Photographic evidence was obtained.

Based on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods by methods that conserve nutritive value, flavor, and appearance for 11 facility residents that included Residents #6, #20, #29, #32, #56, and 58. The findings included: During the observation of the lunch meal in the Assisted Dining Room on 02/10/20 at 12:30 PM, it was noted that all 11 resident's in attendance for the meal have some degree of cognitive impairment and require extensive to total assistance with eating. During the meal observation it was noted that 5 of the residents received a pureed diet meal tray which included Residents #6, #20, #29, #32, #56, and #58. During the observation it was noted that the pureed foods (entree, vegetable, and starch) on the main plate appeared to be large puddles. The food puddles were so thin that the pureed food ran together in the main plate. It was noted that while staff were feeding that the pureed foods ran together to make a single mixture of pureed food. It was also noted that a orange sauce type mixture had been ladled across all the pureed foods. Following the meal an interview was conducted with the facility Dietitian and Cook and it was revealed that kitchen preparation staff were unaware of proper pureed food preparation to ensure that too much fluids added during preparation would result in loss of nutritive value. It was also unknown though the interview if staff was aware of the pureed foods appearance, attractiveness, and palability. The staff stated that staff would be trained on pureed food preparation and the issue would be corrected prior to the next meal. On 02/12/20 at 12:30 PM a second lunch meal observation was conducted in the Assisted Dining Room. The observation of the 5 residents (#6, #20, #29, #32, #56, and #58) again revealed pureed foods served in large puddles, and running together on the main plate. Following the observation the pureed foods were observed on the steam table located in the satellite kitchen. The observation noted that the pans of pureed food were liquid and thin and poured out of the serving utensils. Dietary staff stated that there was an equipment issues during the preparation of pureed foods. Review of the diet census on 02/12/20 noted that there were currently 11 residents, which included Residents #6, #20, #29, #32, #56, and #58, who were receiving a physician ordered pureed diet.

Based on interview and record review, the facility failed to provide Intravenous (IV) medications by properly trained and supervised Licensed Practical Nurses, for 2 of 4 residents receiving IV medications (Residents #2 and #4). Findings included: 1. At 11:00 AM on 02/13/20, during a review of the Medication Administration Record [REDACTED]. When questioned the LPN admitted she was not IV certified. The LPN stated that she did not administer the IV medication, but her RN supervisor had administered for her. There was no documented evidence found to support this claim. The Director of Nursing (DON) was apprised of this information and was shown that there was no documentation that showed an RN had administered the medication. At approximately 11:30 AM an interview was conducted with Staff D, a Registered Nurse (RN) The RN stated that he administered the antibiotic, but he could not provide supporting documentation for this claim. At 12:10 PM, documentation was added by the RN that indicated the IV medication had been administered, however, the documentation did not state that the RN himself had administered the medication. 2. A record review for Resident #4, one of four residents who has IV antibiotics and a PICC line, revealed that on 2/10/20 the resident received an IV antibiotic from Staff E, an LPN. The antibiotic was [MEDICATION NAME] 2 Gm and was administered at 6:00 AM. The DON was informed that under Florida Administrative Code Rule 64B9-12.004, an LPN who has not successfully completed a 30-hour IV therapy course may only administer hydrating fluids under the supervision of an RN. IV antibiotics are not hydrating fluids. Additionally, even with completion of a 30-hour IV therapy course, the LPN must be supervised by an RN. By 2:00 PM on 02/13/20 the DON was only able to provide evidence that two LPNs, Staff F and Staff G, had completed a 30-hour IV therapy course. Photograhic evidence obtained.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition as evidenced by significant weight loss for 1 of 3 sampled residents (Resident #8). The findings include: Resident #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation on 8/6/12 at 12:00 PM of resident #8 in the assisted dining room during lunch at 12:45 PM the resident was observed at the table and had not been assisted with her meal. At 1:25 PM the resident was removed from the dining room, had not been assisted with her meal and did not consume any of her food. The resident drank some of the juice that was in front of her. At 2:10 PM, resident #8 was observed sitting in a wheelchair in the doorway of her room. The resident was asked if she was hungry and nodded her head yes. A facility Certified Nursing Assistant (CNA) overheard and saw the resident nod her head. The CNA offered the resident a can of Ensure and notified the surveyor that the resident consumed 100%. Observation on 8/7/12 at 8:55 AM of the breakfast meal in the assisted dining room, Resident #8 was observed sitting at the table with a bowl of oatmeal in front of her and no breakfast tray. Thirteen residents and 4 staff members were noted. At 9:15 AM, the resident was removed from the dining room. The resident was never given a breakfast tray, and the bowl oatmeal was still full. The resident had not been assisted with her meal, and the tray was observed in the food cart. A review of the resident's breakfast meal intake on 8/7 documents the resident refused the meal. A review of the nursing notes dated 6/30/12 and 7/31/12 identifies the resident's need for total assistance with eating. A review of the resident's weights identifies a significant weight loss of 5% from 5/7/12 through 6/4/12. On 5/7 the resident's weight was 133 lbs and on 6/4 127 lbs. A significant weight loss of 5% was also noted from 6/11-through 7/16. On 6/11 the resident's weight was 125 lbs. and on 7/16 119 lbs. During an interview on 8/7/12 at 2:00 PM, with the director of nursing (DON) regarding weight loss, the DON stated the facility would ask the physician for an order for [REDACTED]. The care plans were reviewed and the DON stated we should see a CNA with the resident during meals encouraging and assisting her with meals. During an interview on 8/8/12 at 11:45 AM, with the therapy director regarding a resident with significant weight loss, he stated nurses should pick up on the decline and notify dietary who should have documentation and make a referral for a therapy evaluation. The director stated a 5% weight loss should trigger therapy and the therapy department should be doing diet upgrades and downgrades after an assessment to see what resident is capable of not dietary. Therapy has not been watching resident #8 because dietary never made a referral. During an interview on 8/8/12 at 2:35 PM, with the facility and corporate dieticians regarding significant weight loss, the facility dietician stated she would assess the resident's dietary needs and food preferences. The facility dietician also stated she assessed resident #8 after a significant weight loss in June, realizing the resident had a loose tooth so she downgraded the diet from mechanical soft to pureed and contacted the resident's physician thinking it was an appetite issue. The resident was put on appetite stimulants. There was no evidence of documentation in the resident's record regarding a dietary assessment for food preferences or a referral for therapy to evaluate the resident's eating/chewing/swallowing capabilities prior to adding appetite stimulants to the resident's medication regimen and downgrading the diet. A review of the quarterly minimum data set ((MDS) dated [DATE] section G for activities of daily living documents the resident is independent with set up only for eating. Weight loss triggered in section k300 noting the resident is not on a planned weight loss program and the dental section notes the resident has broken or loose teeth with mouth or facial pain, discomfort or difficulty with chewing. The MDS does not accurately reflect the residents need for assistance with activities of daily living. During an interview on 8/8/12 at 3:15 PM with the MDS coordinator and corporate dietician to review the accuracy of resident # 8's record, he stated he gets the information from the CNAs and nursing staff when doing the MDS. He stated if he was going to reassess the information and do a significant change MDS on the resident to reflect her current needs. The MDS coordinator stated today he would code the resident's needs as extensive or total assist with eating. Due to the facility's failure to reassess and assist resident #8 with eating their meals in the assisted dining room, this resulted in a negative outcome compromising her physical well-being resulting in a monthly significant weight loss for 2 consecutive months.