Every finding on record at Dade Health and Rehab

Based on observations, record review, interviews with the resident, family, and staff, and review of the facility's policy titled Comprehensive Care Plan, the facility failed to ensure that care plan interventions related to activities of daily living (ADL), specifically showers, were implemented for one of two sampled residents (R) (R33) reviewed for care plans. This deficient practice resulted in the resident's bathing needs and preferences not being consistently met, placing the resident at risk for decreased quality of life.Findings include:Review of the facility's policy titled Comprehensive Care Plan, revised 01/15/2026, documented in the Policy section, It is the policy of this facility to develop and implement a comprehensive, person-centered care plan for each resident to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Documented in the Definitions section, Person-centered care means focusing on the resident as the locus of control and supporting the resident in making his or her own choices and having control over their daily lives.Review of the Electronic medical records (EMR) revealed R33 was admitted to the facility on [DATE]. R33 had a complex medical history that included impaired coordination; abnormal gait; difficulty walking; generalized muscle weakness; muscle spasms and morbid obesity.Review of the Quarterly MDS dated [DATE] revealed that in Section C, the resident had a Basic Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. Section GG, Functional Abilities, revealed impairment in both upper and lower extremities. The resident required substantial to maximal assistance with eating and is dependent on staff for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. Section H revealed that the resident is always incontinent of both bowel and bladder.Review of the care plan dated 03/16/2026 documented that R33 had self-care deficits related to activities of daily living. The goal is for R33's needs will be met through the efforts of staff and family, with the resident remaining neat, clean, odor-free, and with dignity maintained through the next review date. Interventions included the use of a Hoyer lift for transfers with assistance from two staff members, with additional assistance provided as needed. Bathing and showering are to be completed per facility policy and as needed, including regular shampooing and monitoring of nail length, with trimming and cleaning as necessary, and reporting any changes to the nurse.Review of the Tasks in the electronic medical record (EMR) revealed a task description: ADL-Bathing: TUESDAY, THURSDAY, SATURDAY AND PRN.An observation and interview of R33 on 03/17/2026 at 9:08 AM revealed the resident was in her room, in bed. She stated she is [AGE] years old, is unable to care for herself, and requires significant assistance from staff. She stated she would have a shower later that day, as Tuesday is her scheduled shower day. She stated her other scheduled shower days are Thursday and Saturday.In an interview with R33's Power of Attorney (POA) on 03/17/2026 at 1:45 PM revealed his expressed dissatisfaction with care, stating that insufficient staffing results in the resident not being bathed regularly.In an observation and interview with R33 on 03/18/2026 at 7:55 AM, the surveyor asked whether she had received her shower the previous day. R33 stated she did not receive her scheduled shower. She reported that although she is scheduled for showers on Tuesday, Thursday, and Saturday, she frequently misses them and had reported her concerns along with her family. She stated, I can't do it myself. I need their help-even to get me out of bed they use a lift.On 03/18/2026 at 8:00 AM, in an interview with the shower team Certified Nursing Assistant (CNA) AA she stated that she did not have enough time to provide showers to all scheduled residents and that showers are completed between 6:00 AM and 2:00 PM. She stated that she documents showers on the Shower Sheets, in a binder that is kept at the nurses' station, and that if she is unable to complete all scheduled residents, other CNAs are expected to complete the remaining showers. She further stated that staff are aware of which residents have not received showers, as they assist with getting residents out of bed and can identify who has already been bathed.In an interview on 03/18/2026 at 8:05 AM, CNA BB stated she was not assigned to R33 and was unsure whether the resident had received a shower the previous day. She stated that if the shower team CNA is unable to complete all scheduled showers, other staff are expected to complete them, and the showers are then documented on the shower sheet.In a joint interview on 03/18/2026 at 8:07 AM with the Director of Nursing (DON) and Medical Records Personnel CC, the DON stated that if CNA AA, who is part of the shower team, is unable to complete all scheduled showers, the CNA assigned to the resident is responsible for providing the shower. The assigned CNA was not working on 03/18/2026 and was unavailable for interview. The DON further stated that if a shower is missed, the resident should be prioritized for the next scheduled shower. Medical Records Personnel CC stated that shower sheet audits were implemented to assist CNAs in tracking which residents have received showers.Facility provided shower sheets were reviewed with the DON and Medical Record Personnel CC for the last two months. They were unable to locate all shower sheets; however, available paper documentation and EMR records indicated that R33 received five showers in February (02/11/2026, 02/17/2026, 02/19/2026, 02/21/2026, and 02/26/2026) and three showers in March from 03/01/2026 through 03/17/2026 (03/05/2026, 03/10/2026, and 03/12/2026).The DON stated that the facility strives to provide showers three times per week but is sometimes unable to meet this schedule. He was unable to explain why R33 received fewer showers than expected, specifically five in February instead of 12, and three in March through 03/17/2026 instead of six based on the established schedule.In an interview on 03/19/2026 at 11:30 AM, the Director of Nursing (DON) stated that the MDS Coordinator was out at that time and he was filling in. When asked how the facility ensures that care plans are implemented, including ensuring that showers are provided in accordance with the care plan, he stated that the facility conducts shower audits to ensure these preferences are followed. He further emphasized that care plans are individualized based on each resident's needs and preferences, including shower preferences. The DON confirmed that R33's care plan related to shower preferences was not implemented as written.

Based on observations, record review, interviews with the resident, family, and staff, and review of the facility's policy titled Activities of Daily Living, the facility failed to ensure that one resident (R) (R1) of nineteen sampled residents who required assistance with activities of daily living was provided necessary assistance required for showers as scheduled and requested. This deficient practice resulted in the resident's bathing needs and preferences not being consistently met, placing the resident at risk for poor hygiene and a decreased quality of life. Findings include:Review of the facility's policy titled Activities of Daily Living revised 01/01/2025 documented the following: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable Care and services will be provided for the following activities of daily living: 1. Bathing .2.The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .4.The facility will maintain individual objectives of the care plan and periodic review and evaluation.Review of the Electronic medical records revealed R33 was admitted to the facility on [DATE]. R33 has a complex medical history that includes impaired coordination; abnormal gait; difficulty walking; generalized muscle weakness; muscle spasms and morbid obesity.Review of the Quarterly MDS dated [DATE] revealed that in Section C, the resident had a Basic Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. Section GG, Functional Abilities, revealed impairment in both upper and lower extremities. The resident required substantial to maximal assistance with eating and is dependent on staff for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. Section H revealed that the resident is always incontinent of both bowel and bladder.Review of the care plan dated 03/16/2026 documented that R33 had self-care deficits related to activities of daily living. The goal is for R33's needs will be met through the efforts of staff and family, with the resident remaining neat, clean, odor-free, and with dignity maintained through the next review date. Interventions included the use of a Hoyer lift for transfers with assistance from two staff members, with additional assistance provided as needed. Bathing and showering are to be completed per facility policy and as needed, including regular shampooing and monitoring of nail length, with trimming and cleaning as necessary, and reporting any changes to the nurse.Review of the Tasks in the electronic medical record (EMR) revealed a task description: ADL-Bathing: TUESDAY, THURSDAY, SATURDAY AND PRN.An observation and interview of R33 on 03/17/2026 at 9:08 AM revealed the resident was in her room, in bed. She stated she is [AGE] years old, is unable to care for herself, and requires significant assistance from staff. She stated she would have a shower later that day, as Tuesday is her scheduled shower day. Her other scheduled shower days are Thursday and Saturday.In an interview with R33's Power of Attorney (POA) on 03/17/2026 at 1:45 PM revealed his expressed dissatisfaction with care, stating that insufficient staffing results in the resident not being bathed regularly.In an observation and interview with R33 on 03/18/2026 at 7:55 AM, the surveyor asked whether she had received her shower the previous day. R33 stated she did not receive her scheduled shower. She reported that although she is scheduled for showers on Tuesday, Thursday, and Saturday, she frequently misses them and had reported her concerns along with her family. She stated, I can't do it myself. I need their help-even to get me out of bed they use a lift.On 03/18/2026 at 8:00 AM, in an interview with the shower team Certified Nursing Assistant (CNA) AA she stated that she did not have enough time to provide showers to all scheduled residents and that showers are completed between 6:00 AM and 2:00 PM. She stated that she documents showers on the Shower Sheets, in a binder that is kept at the nurses' station, and that if she is unable to complete all scheduled residents, other CNAs are expected to complete the remaining showers. She further stated that staff are aware of which residents have not received showers, as they assist with getting residents out of bed and can identify who has already been bathed.In an interview on 03/18/2026 at 8:05 AM, CNA BB stated she was not assigned to R33 and was unsure whether the resident had received a shower the previous day. She stated that if the shower team CNA is unable to complete all scheduled showers, other staff are expected to complete them, and the showers are then documented on the shower sheet.In a joint interview on 03/18/2026 at 8:07 AM with the Director of Nursing (DON) and Medical Records Personnel CC, the DON stated that if CNA AA, who is part of the shower team, is unable to complete all scheduled showers, the CNA assigned to the resident is responsible for providing the shower. The assigned CNA was not working on 03/18/2026 and was unavailable for interview. The DON further stated that if a shower is missed, the resident should be prioritized for the next scheduled shower. Medical Records Personnel CC stated that shower sheet audits were implemented to assist CNAs in tracking which residents have received showers.Facility provided shower sheets were reviewed with the DON and Medical Record Personnel CC for the last two months. They were unable to locate all shower sheets; however, available paper documentation and EMR records indicated that R33 received five showers in February (02/11/2026, 02/17/2026, 02/19/2026, 02/21/2026, and 02/26/2026) and three showers in March from 03/01/2026 through 03/17/2026 (03/05/2026, 03/10/2026, and 03/12/2026).The DON stated that the facility strives to provide showers three times per week but is sometimes unable to meet this schedule. He was unable to explain why R33 received fewer showers than expected, specifically five in February instead of 12, and three in March through 03/17/2026 instead of six based on the established schedule.

Based on observations, staff interviews, and review of the facility's policy titled, Medication Storage in the Facility, the facility failed to ensure that all drugs and biologicals were discarded prior to the expiration date. Specifically, there were nine medications found to be past the expiration date. The deficient practice had the potential to put residents at risk for medical complications related to potential changes in their chemical composition, failing to treat the intended condition properly, and in some cases, causing harm due to unexpected side effects. The facility census was 28. Findings include: Review of the facility's policy titled Medication Storage in the Facility dated June 1, 2018, revealed on page 1. Under Procedures: . L. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedure for medication disposal .Page 3. G. All expired medications will be removed from the active supply and destroy in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. Observation on 3/5/2025 at 10:14 am of the medication storage room/supply room, with the Director of Nursing (DON) revealed medications neatly arranged on multiple shelves. Observation of random bottles of medication revealed a box of three milliliter (ml) syringes with an expiration date of 2/1/2025, moisture balancing hydrogel dressing adhesives (four boxes) with an expiration date of 12/31/2024, and Povidone - iodine 10% solution with an expiration date of January 2025. Observation on 3/5/2025 at 10:14 am of the medication refrigerator located behind the nurse's station revealed two unopened boxes of influenza vaccine located in the medication refrigerator with an expiration date of 5/31/2024. Interview on 3/5/2025 at 10:30 am with the DON revealed that the stock person was to check for expired items and remove them from the stock room. The DON stated, this is old, when handed the two boxes of flu vaccine. The DON removed all expired medications from the storage rooms immediately. Interview on 3/5/2025 at 3:10 pm with the Infection Preventionist (IP) and the DON revealed that no resident nor staff had received the expired medications nor flu vaccine and they were unaware where the unopened vials of flu vaccines came from. The IP stated that, someone must have been cleaning up and found the vials and placed them in the refrigerator. The IP then revealed that the Wound Care Nurse (WCN) used a different vial that was not expired to administer flu shots for this season and had records of the lot number and expiration date to prove it. Interview with the WCN on 3/5/2025 at 3:30 pm revealed a list of residents and staff who had received the flu vaccine this season along with the lot number and expiration dates documented on paper. The WCN stated that this information could also be found in each resident's electronic medical record (EMR) under Immunization along with the date of administration.

Based on observations, staff interviews, and review of the facility policies titled, Medication Administration-General Guidelines and Cleaning and Disinfecting Non-Critical Resident Care Items, the facility failed to practice acceptable infection control practices to prevent possible cross-contamination by not practicing proper hand hygiene during medication pass observation for five of 19 sampled residents (R) (R6, R8, R16, R17, and R23). The facility also failed to bag and label wash basins, urinals and bed pans in three Rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The facility census was 28. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines dated April 1, 2016, under Procedures: A. 2) Handwashing and Hand Sanitation: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations, and before and after administration of medications- via enteral tubes. a. Examination gloves are to be worn when necessary. b. Hand sanitization is done with an appropriate sanitizer-between handwashing's, when returning to the medication cart or preparation area . at regular intervals during the medication pass such as after each room . Review of the facility's policy titled, Cleaning and Disinfecting Non-Critical Resident-Care Items last reviewed January 2025 documented the following under Procedures: 1. Single resident use items are for single resident use only. [NAME] with the resident's name and/or room number and discard upon transfer or discharge. 2. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals). 3. Staff must return urinals and bedpans to the residents' bedside cabinet once the items have been thoroughly cleaned. 1. Observation on 3/5/2025 at 08:10 am of medication pass with Licensed Practical Nurse (LPN) CC revealed her administering medications to R16, R17 and R8. No handwashing nor hand sanitizing was performed before or after medication preparation. Hand hygiene was also not performed in-between residents, even after LPN CC was noted touching R8's straw to assist with drinking, and the bedrails of R17. Interview on 3/5/2025 at 8:42 am with LPN CC confirmed not performing hand hygiene at any time during the medication pass until after the task was completed and stated that she should have performed it when going in and out of all rooms. LPN CC also stated that she had been a nurse for a little over a year and was not sure when to perform soap and water washing or at what times in-between or after how many residents to sanitize her hands, but that she would find out. Observation on 3/5/2025 at 8:50 am of medication pass with LPN AA revealed medication administered to R6 and R23. No hand hygiene was performed before or after medication preparation. LPN AA was observed putting on gloves on three separate occasions during the medication preparation process when she accidentally dropped pills onto a tissue and picked them up again. She removed the gloves after using them and no hand hygiene was performed either time. LPN AA was observed crushing medications and placing them in apple sauce and administering them without performing hand hygiene before or after the administration. Interview on 3/5/2025 at 9:13 am with LPN AA confirmed that she did not perform hand hygiene at any time during the medication preparation process and stated that she was aware she was supposed to perform hand hygiene before putting on and after removing gloves. LPN AA stated she didn't realize that she had not performed hand hygiene in-between each resident. Interview with the Director of Nursing (DON) revealed that it was his expectation that the nurses performed hand hygiene before and after using gloves, in between residents, and when entering and exiting rooms. He stated that the Infection Preventionist (IP) had in-services in January 2025 and medication pass was evaluated. He also stated that the nurses should be washing with soap and water after using sanitizer three times. 50943 2. Initial screening observation on 3/4/2025 at 10:02 am revealed a wash basin and urinal were nested together on the bathroom floor near the garbage can in room [ROOM NUMBER]. The wash basin and urinal were unlabeled and unbagged. Observation on 3/4/2025 at 11:27 am revealed a wash basin and urinal were nested together on the bathroom floor underneath the sink in room [ROOM NUMBER]. The wash basin and urinal were unlabeled and unbagged. Observation on 3/5/2025 at 9:52 am revealed a wash basin and urinal were nested together on the bathroom floor near the garbage can in room [ROOM NUMBER]. The wash basin and urinal were unlabeled and unbagged. During a facilty tour on 3/6/2025 between 11:06 am to 11:13 am with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) AA and LPN BB, the following was confirmed: A wash basin and urinal were nested together on the bathroom floor underneath the sink in room [ROOM NUMBER]. The wash basin and urinal were unlabeled and unbagged. A wash basin and urinal were nested together on the bathroom floor near the garbage can in room [ROOM NUMBER]. The wash basin and urinal were unlabeled and unbagged. Three wash basins were stacked together on top of the bathroom sink in room [ROOM NUMBER]. The wash basins were unbagged and unlabeled. Interview on 3/6/2025 at 11:15 am with the DON, LPN AA and LPN BB revealed the wash basins and urinals were supposed to be bagged and labeled. The DON, LPN AA and LPN BB confirmed the nature of the wash basins and urinals were incorrect and unacceptable. It was also indicated that the wash basins and urinals should not be stored on the floor nor bathroom sink. The DON and LPN AA and BB were unsure of who was responsible for cleaning and managing the wash basins.

Based on observations, staff interviews, and review of the facility policy titled, Maintenance Service, the facility failed to provide a safe, clean, comfortable, homelike environment for five rooms (room [ROOM NUMBER], 122, 119, 117, 111) on two of three halls. Specifically, these rooms contained broken tiles in toilet areas, dirty ceiling HVAC (heat, ventilation, air conditioning) vents in bathrooms, dirty bathroom exhaust vent fans, and a dirty, damaged Packaged Terminal Air Conditioner (PTAC) unit. Review of the facility policy titled Maintenance Service revealed in the Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. Observations during the initial tour of the facility on 3/ 4/2025 at 11:16 am revealed dirty bathroom ceiling exhaust vent fans and HVAC vents. The PTAC filter was also dirty with particles falling out. The filters were pulled from the unit in room [ROOM NUMBER]. Observation on 3/5/2025 at 11:25 am revealed the PTAC filter was dirty with particles falling out as the filters were pulled from the unit in room [ROOM NUMBER]. Observation on 3/6/2024 at 11:40 am revealed dirty bathroom ceiling exhaust vent fan in room [ROOM NUMBER]. 50943 2. Initial screening observations on 3/4/2025 at 9:59 am revealed the ceiling return vent was filled with a thick, gray, fuzzy substance in the bathroom of room [ROOM NUMBER]. Further observation of room [ROOM NUMBER] revealed damaged paint on the bathroom floor around the toilet area. The floor was dark brown in front of and behind the toilet. Initial screening observation on 3/4/2025 at 10:02 am revealed the ceiling return vent was filled with a thick, gray, fuzzy substance in room [ROOM NUMBER]. Observation on 3/5/2025 at 8:54 am revealed the ceiling return vent was filled with a thick, gray, fuzzy substance in room [ROOM NUMBER]. Observation on 3/5/2025 at 8:57 am revealed the ceiling return vent was filled with a thick, gray, fuzzy substance in room [ROOM NUMBER]. The paint on the bathroom floor was damaged with brown discoloration in front of and behind the toilet. Interview and observation on 3/6/2025 at 10:09 am with the Maintenance Director (MD) confirmed the bathroom ceiling vents were filled with a thick, gray, fuzzy substance in rooms [ROOM NUMBER]. The MD stated he initially painted the bathroom floor in room [ROOM NUMBER], but someone destroyed the paint near the toilet area before it could completely dry. MD also confirmed the PTAC unit in room [ROOM NUMBER] was filled with dust and food crumbs. The MD confirmed the conditions of the ceiling return air vents, flooring, and PTAC unit were unacceptable and needed to be addressed immediately. The MD stated, Housekeeping is responsible for cleaning the ceiling return vents, but the facility has been experiencing issues with keeping up due to us no longer having a housekeeping supervisor and I have been given the responsibility to oversee both departments and it has caused us to get behind, but honestly, there is no excuse for the conditions of the ceiling vents, flooring, and PTAC units, and I will rectify the concerns as soon as possible.

Based on observations, resident and interviews, record review, and review of the facility's policy titled, Oxygen Concentrator, the facility failed to ensure that two of six residents (R) (R20 and R9) receiving oxygen (O2) therapy had an O2 concentrator that was clean, sanitary and free of sediment build up, that O2 supplies were bagged when not in use, that humidifier bottles be supplied with water, and that O2 was set on the prescribed setting. The deficient practice had the potential to put R20, and R9 at risk for medical complications such as hypoxia, respiratory depression, and infection. Findings include: Review of the facility's policy titled Oxygen Concentrator last revised 3/5/2024 documented under Policy Explanation and Compliance Guidelines: . 2. Oxygen is administered under orders of the attending physician. 5. Care of the Concentrator: a. Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device, external filters will be cleaned weekly. b. Only trained individuals, such as the Maintenance Director or supplier shall service the device. c. The Housekeeping Department Responsibilities: i. Clean the outside casing of the concentrator and nebulizer units during routine room cleaning with an EPA- registered disinfectant in accordance with label instructions. d. Nursing Responsibilities: . ii. Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer when in use. 1. Review of the clinical electronic record revealed R20 was admitted with diagnoses that include but not limited to chronic obstructive pulmonary disease (COPD), emphysema, congestive heart failure (CHF), and anxiety disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] for R20 revealed in Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of 14, indicating minimal cognitive decline. Section GG (Functional Abilities), Impairment to left lower extremity, uses walker and wheelchair, eating- set up, oral- independent. Toileting- independent, shower- partial/ moderate assist, independent with upper and lower body. Section J (MDS): Received as needed medication, short of breath (SOB) with exertion, sitting and lying flat. Resident has a condition or chronic disease that may result in a life expectancy of less than six months. Section O (Special Treatments, Procedures, and Programs), On oxygen (O2) therapy. Hospice care. Review of care plan for R20 dated 12/30/2024 revealed focused area of (CHF) (congestive heart failure) with goal: Signs and symptoms of exacerbation of CHF will be identified early and appropriate interventions. Interventions: Administer furosemide as ordered per doctor (MD). Administer potassium as ordered per MD. Monitor intake and output. Monitor lab work per physician order. Notify MD if indicated. Monitor/report PRN (as needed) any s/sx signs/symptoms) of CHF dependent edema of legs and feet, periorbital edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation (listening with stethoscope) of the lungs, orthopnea (shortness of breath when lying flat), weakness and/or fatigue, increased heart rate (Tachycardia) lethargy and disorientation. Monitor/report PRN any s/sx of hypokalemia (low potassium) receiving diuretic therapy: fatigue, muscle, weakness, diminished appetite, nausea and vomiting and dysrhythmias abnormal heart rhythm), monitor potassium levels. No salt packet on tray unless requested. Oxygen settings: O2 via nasal canula (NC) at 3 liters per minute (LPM). Review of the Physician orders dated 4/14/2024 revealed clean oxygen concentrator filter weekly every night shift every Friday for when oxygen is in use, change O2 tubing weekly every night shift every Friday for when oxygen is in use, change humidifier bottle on oxygen concentrator PRN for when oxygen is in use, and administer oxygen at 3 liters/minute per nasal cannula PRN. Observation on 3/4/2025 at 10:04 am revealed R20 lying in bed with O2 tubing on. The O2 concentrator was noted to be on and running with fluffy, brown/gray/white substance covering the filter area and the entire machine. The O2 tubing was on the floor. No water was in humidifier bottle and the humidifier straw was noted to be crusted over. Observation on 3/5/2025 at 8:04 am revealed R20 lying in bed with the O2 concentrator running with fluffy brown/gray/white substance covering machine and filter area. No water was in humidifier bottle and the humidifier straw was noted to be crusted over. R20 was currently using O2 via NC. Observation on 3/5/2025 at 2:05 pm revealed R20 lying in bad using the O2 concentrator, tubing remained on the floor with the O2 concentrator filter covered with fluffy, light-brown and white substance. Humidifier water bottle remained empty with crusting straw. Interview and observation on 3/4/2025 at 10:05 am of R20 revealed R20 lying in bed with O2 on with NC in place. The O2 tubing was found on the floor with the O2 concentrator covered with white, fluffy substance, no water noted in the humidifier bottle with a thick white substance covering the humidifier straw. R20 stated that she needed the O2 all the time and that the staff came in her room at night to tend to the O2 when she was asleep. Interview and observation on 3/06/2025 at 10:56 am with Director of Nursing (DON) and Licensed Practical Nurse (LPN) AA confirmed that R20's O2 setting being at 2 LPM. LPN AA stated R20's O2 saturation was 95%. The DON stated, The filters and concentrators are changed and cleaned on Fridays and the night shift nurse is responsible. The DON confirmed and stated the machine doesn't look clean but that the tubing was changed. The DON confirmed that the physician orders and care plan indicated the O2 concentrator was to be set at 3 LPM PRN. The DON stated that he was supposed to be auditing every Monday morning to make sure the machines were cleaned but admitted he had not been checking behind the responsible nurse to ensure it was done. 50943 2. Review of the electronic medical record (EMR) revealed R9 was admitted to the facility with diagnoses including but not limited to pneumonia and history of COVID-19. Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R9 had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident's cognition was severely impaired. Further review revealed R9's upper and lower extremities were impaired on both sides. Section J0100-Pain Management revealed R9 is also receiving pain management and Section O-Special Treatments, Procedures, and Programs revealed oxygen therapy. Review of the care plan for R9 dated 2/11/2025 documented: Administer oxygen via NC PRN @ 2 LPM, monitor for effectiveness. Review of the physician orders for R9 revealed staff must change oxygen tubing weekly every Friday night shift for when the oxygen is in use and as needed. Staff must clean oxygen concentrator weekly every Friday night shift. Staff must also obtain and document oxygen saturation with use of pulse oxygen meter as needed for shortness of breath, notify MD if results less than 90%, and administer oxygen at two liters/minute per nasal cannula as needed. Initial screening observation on 3/4/2025 at 10:48 am revealed R9's O2 concentrator set at 1 LPM. The O2 tubing was on the floor, and the filter in the back of the O2 concentrator was dirty with a gray, fuzzy substance. Observation on 3/5/2025 at 8:50 am revealed R9 lying in bed. Further observation of R9's O2 revealed an O2 concentrator set at 1.5 LPM. The tubing was on the floor, and the filter in the back of the O2 concentrator was dirty with a gray, fuzzy substance. Observation and interview on 3/6/2025 at 11:04 am with the DON and LPN AA confirmed R9's O2 concentrator was unclean with thick, gray fuzzy substance.

Based on interviews and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (Form CMS- ) and failed to completely fill out the Notice of Medicare Non-coverage (NOMNC), (CMS Form ) with the Quality Improvement Organization (QIO) name and the toll-free number of the QIO, for two residents (R) (R#6 and #17) out of three residents who were reviewed after being discharged from Medicare Part A Services and remained in the facility. Findings include: 1. A review of R#6's SNF Beneficiary Protection Notification Review provided by the facility revealed Medicare Part A Skilled Services Episode Start Date was 10/30/2020 with last day of covered Part A Service was 1/12/2021. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Facility indicated a SNFABN was provided to the resident as well as a NOMNC. There is no evidence of the CMS- form being provided to the resident. Review of the NOMNC lacked the QIO and toll-free number of the QIO. 2. A review of R#17's SNF Beneficiary Protection Notification Review provided by the facility revealed Medicare Part A Skilled Services Episode Start Date was 10/29/2020 with last day of covered Part A Service was 1/12/2021. Facility indicated a SNFABN was provided to the resident as well as a NOMNC. Facility indicated a SNFABN was provided to the resident as well as a NOMNC. There is no evidence of the CMS- form being provided to the resident. Review of the NOMNC lacked the QIO and toll-free number of the QIO. Interview on 7/13/2021 at 4:15 p.m. with the Social Services Director revealed the facility discusses discharges from skilled services in their morning meeting. She reported she provides notification to family/residents when a resident is being discharged from skilled services based on information provided from their meeting. She indicated she was not aware of any policy or guidance related to this process. Interview on 7/13/2021 at 5:00 p.m. with the Corporate Financial Controller confirmed that the facility is providing the Form CMS R-131 and not the SNFABN. Interview on 7/14/2021 at 2:22 p.m. with Social Services Director (SSD) revealed the Administrator in 2018 trained her how to complete the notices and which ones to give out. An interview on 7/14/2021 at 2:35 p.m. with the Administrator revealed she was not aware of the different forms for the ending of different benefits.

Based on observations, record review, interviews and review of facility menus and meal tickets, the facility failed to ensure that foods served accommodated the food preferences of green beans and carrots for one resident (R) R#22. The census was 46. Findings include: Review of the clinical record for R#22 revealed she was admitted to the facility on [DATE] with diagnosis of hypertension (HTN), [CONDITION(S)], muscle weakness, [CONDITION(S)], [CONDITION(S)], hypo-osmolality, diverticulitis, [CONDITION(S)], and protein calorie malnutrition. The resident's Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, indicating no cognitive impairment. Section G revealed resident required limited assistance with eating. Section GG revealed resident required maximum assistance with meal setup. Review of the care plan for R#22 dated 6/1/2021 revealed resident is at risk for decreased nutrition related to poor intake. Interventions to care include discuss food preferences with resident and incorporate in diet and offer replacement items for uneaten foods. Review of the 7/12/2021 posted daily menu revealed lunch as salmon patty, baked potato, marinated carrots, choice of bread, pineapple upside down cake, sour cream, margarine, and coffee/tea. Review of the 7/13/2021 posted daily menu revealed lunch as pot roast and potatoes, key west vegetable blend, choice of roll, cherry pie, margarine, and coffee/tea. Observation on 7/12/2021 and 7/13/2021 during lunch meal service, R#22 lunch meal tickets revealed dislikes to barbeque, baked beans, slaw, fish, green beans, and carrots. R#22 was served green beans and carrots on 7/12/2021 and 7/13/2021. Interview on 7/14/2021 at 9:15 a.m. with the Dietary Manager (DM) revealed on 7/12/2021 lunch meal vegetables were green beans and carrots and on 7/13/2021 the lunch meal key west vegetables blend is a combination of green beans, carrots, and squash. Interview on 7/14/2021 at 5:00 p.m. with the DM revealed she is sent a request form for diet changes and for food dislikes. She revealed they try to honor resident's food preferences and dislikes, but stated they get overlooked sometimes. During further interview, she stated they are listed on the meal slip that is sent down the line when the meal is plated. An interview on 7/15/2021 9:30 a.m. with the Administrator revealed she was unaware green beans and carrots were served on consecutive days.

Based on observation, record review and staff interview the facility failed to follow the physician's order to obtain and document oxygen (O2) saturation with use of pulse ox meter as needed (PRN) for shortness of breath (SOB) for one (1) resident (R#44) who receives O2 therapy of 22 sampled residents. Findings Include: Record review for R#44 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the physician's order for R#44 revealed an order to obtain and document oxygen saturation with use of pulse ox meter PRN for SOB and notify MD if less than (<) 90% and an order to administer oxygen at 3 liters/minute per nasal cannula PRN for SOB. Record review of the May, June, July and August 2017 medication administration record (MAR) for R#44 revealed no documentation of O2 saturation for the days of which O2 was administered. Observation of R#44 on 8/9/17 at 10:38 a.m. revealed resident in bed wearing a nasal cannula with O2 at 3 liters per minute (lpm) from oxygen concentrator. Observation of R#44 on 8/9/17 at 12:31 p.m. revealed resident sitting in wheelchair outside on the patio wearing nasal cannula with O2 at 3 lpm from E (type of O2 cannister) cylinder tank. Observation of R#44 on 8/10/17 at 11:00 a.m. revealed resident sitting in wheelchair in lobby visiting with her daughter. The resident was wearing a nasal cannula with O2 at 3 lpm from E cylinder tank. During an interview with the Administrator on 8/10/17 at 10:00 a.m. she revealed the facility does not have a policy related to oxygen administration or for following physician's orders. During an interview with License Practical Nurse (LPN) DD on 8/10/17 at 11:29 a.m. she stated she places the resident on oxygen when the resident becomes SOB. She also stated today the resident is on oxygen because she became short of breath after taking a shower. The LPN DD stated she documents on the MAR the reason for the PRN oxygen but she does not document the residents' O2 saturation on the MAR. During an interview with the Director of Nursing (DON) on 8/10/17 at 12:24 p.m. she stated she expects the nurse to administer oxygen to this resident per physician order as needed for SOB or difficulty breathing. The DON also stated she expects the nurse to document the reason for administering the oxygen in the nurses' notes, obtain O2 saturations when resident is SOB and document to O2 saturation on the MAR. The DON confirmed the O2 saturations have not been documented on the MARs for the months of May, June, July and August 2017 when oxygen was administered.

Based on review of resident trust fund accounts, Reliable Health Care resident trust fund policy, resident and staff interviews, the facility failed to ensure that acceptable accounting principles were maintained for twelve (12) residents (#1142, # 3, #1239, #32, #59, # , # 3, #1224 # , #1393, # 3 and A) from fifty (50) fund accounts managed by the facility. Findings Include: During review of resident trust funds on 9/21/2015 at 1:30 PM and 3:30 PM with Business Office Manager AA it was revealed the facility manages fifty (50) trust fund accounts. AA further revealed that she started managing trust fund accounts in December 2014 after the discrepancies were identified. AA acknowledged the Med Easy system used for resident trust funds crashed in May 2015 and no trust records were available for transactions before May 2015. Review of the individual trust fund accounts revealed the following: Resident #1239 - miscellaneous item withdrawal check #2290 for $100.00. Receipts total $90.87. AA revealed that she believed that amount was rounded up. Patient liability for this resident was $1272.00 from 1/1/2015 through 4/30/2015. On 1/1/2015, 2/11/2015, 3/12/2015 and 4/6/2012 $1366.00 was withdrawn for patient liability. AA was unsure why excess liability was charge and was unable to determine if a refund was made or the resident notified. Resident #32 - Check #4276 for $299.97 dated 10/1/2014 with no receipt. Resident #59 - patient liability was $1495.00. Patient liability was debited on 9/12/2014 for $1412.00. Liability was debited on 10/28/2014 for $1462.00 and 11/14/2014 for $1462.00. AA was not aware of why the correct liability was not removed. Resident #4668 - 13 Patient liability removed check # 4506 on 8/13/2015 for $440.80 and same check number for $1205.00. AA remembered there may have been an insurance issue that resident owed. AA did not know if the resident was notified that extra monies were removed. This resident trust account reflected a negative balance of -$20.00 on 6/1/2015 and remained negative through 7/28/2015. Disbursements from this account were made without verification of balances. This resident ' s balance on 5/2/2015 before Med Easy crash was recorded as $10.00 and on 6/1/2015 after recreation of accounts was -$20.00. Resident #1455 - Patient liability check #4519 for $716.00 on 8/26/2015. The resident ' s liability was $636.00. The resident is owed $80.00 according to AA . Resident #1142 - Liability was removed on 6/2/2015 in the amount of $111.08, the resident ' s liability owed was $1203.00. This resident's balance on 5/8/2015 before Med Easy crash was recorded as $1502.43 and on 6/1/2015 after recreation of accounts was $1502.52. Resident # 1224 - Check # 4516 for $90.00 reference lawn service. AA was not certain whose lawn this service was for she believed for the home the resident used to live in. This resident's balance on 5/8/2015 before Med Easy crash was recorded as $908.30 and on 6/1/2015 after recreation of accounts was $908.27. Resident # 3 - 7/27/2015 check # 4492 in the amount of $32.25 from residents account. Cashed check # 4492 was for petty cash in the amount of $43.61 and withdrawn from the residents account in error. Check # 4495 on 7/27/2015 the same amount of $32.25 was removed without a receipt of purchases. This resident's balance on 5/8/2015 before Med Easy crash was recorded as $198.19 and on 6/1/2015 after recreation of accounts was $197.46. Resident # 1393 - had no patient liability removed in April 2015. The following month's liability were charged. This resident's balance on 4/30/2015 before Med Easy crash was recorded as $82.62 and on 6/1/2015 after recreation of accounts was $72.63. Resident #1374 - withdrawal reference velour outfit x 2 check # 4481 for $116.50 without a receipt or name on canceled check. This resident's balance on 5/5/2015 before Med Easy crash was recorded as $849.00 and on 6/1/2015 after recreation of accounts was $661.98. Resident #417 1- 13 Checks #4282 for $56.24, #4303 for $24.55, #4347 for $41.88, #4454 for $52.00, #4479 for $37.23, and #4507 for $37.88 were written to names other than the responsible party with no supporting documentation these purchases were used for this resident. Resident A trust account maintained a negative balance from 12/2/2014 -$1.75 through 1/19/2015 -$203.75. No trust records were available from 1/20/2015 thru 6/1/2015. During interview with AA while reviewing residents account she revealed that this resident did not want to have his money sent directly to the facility. She indicated he was very upset and had his debit card account closed because he did not want her to have his money without his permission first. In June 2015 AA called Social Security for him and made him have his check sent to the facility. When asked if the residents have to have their funds managed by the facility she indicated if they cannot pay they cannot stay. On 6/3/2015 check# 4459 for $2500.00 and $754.00 was debited from this account for liability owed. An interview was conducted with this resident on 9/22/2015 at 9:15 am where A revealed he did not want his money taken by the facility at first. He is okay with it now and it is probably better since he does not have money anyway. He was told that he would get an extra cable channel on his television if the facility paid the bill for him. Interview conducted with AA on 9/23/2015 at 12:40 PM in reference to the resident trust balances at the end of April and the resident trust balances beginning May AA further revealed there is no way to know the exact transactions for May 2015. And she does not know why six (6) resident balances are not have discrepancies from April and May balances. Review of Reliable Health Care resident trust fund policy revealed the facility must maintain a separate, accurate and complete accounting of the resident trust fund. The facility has no authority to automatically deduct funds for outstanding room and board charges unless special written consent has been received from the resident and/or his/her responsible party. Under no circumstances will a negative balance be authorized or allowed. Negative balances are not allowed. Resident account balances must be verified prior to making any disbursements transactions should be posted to the resident accounts daily so that the balance is up to date at all times.

Based on Review of the Residents ' Trust Fund Accounts, other pertinent facility documents and staff interviews the facility failed to ensure the Quality Assurance committee was involved in the development and implementation of plans of action to address misappropriation of funds which had been identified in December 2014. The facility further failed to assess and re-address the interventions to ensure the problems were corrected. The facility was responsible for the management of fifty (50) resident trust fund accounts and twelve (12) continued to have accounting errors. Findings include: Review of the resident trust fund accounts revealed twelve (12) resident accounts were found to have errors in the management of the funds. Review of the facility self-report to the State Agency GA 704 revealed that during a December audit of the resident trust fund accounts it was discovered that a former employee was possibly taking money from the accounts. A formal investigation and audit was initiated and the employee was fired. A new Business manager was hired and another employee was trained to oversee the resident trust funds to ensure there was separation of money and finances. Interview conducted on 9/22/15 at 9:00 am with the Business Office Manager AA and the Administrator and both confirmed that in December 2014 there had been questions of misappropriation of funds and a report was filed with the State. The employee was terminated and the problem was addressed in the December Quality Assurance (QA) meeting. Both also revealed that the Med Easy system used to manage resident accounts crashed in May 2015 and no resident trust fund accounts can be produced for review before May 2015. During interview with the Administrator and review of the QA sign in sheets conducted on 9/22/15 at 10:40 am revealed that on the QA meeting conducted on 12/22/15 they discussed the issue with the funds and the committee was informed that Corporate was finishing an audit concerning the misappropriation of funds. She further confirmed the issue was not discussed during the January, February, March or April QA meetings. In addition the Administrator did not discuss resident trust in any later meetings after the Med Easy program crashed on 5/26/15. Final interview conducted on 9/24/15 at 11:13 am with the Administrator regarding the facility QA committee revealed when a problem is identified then she fills out a QA form where the problem is identified and a date of resolution is determined. That problem is then discussed at the Quarterly QA meeting. The problem is assigned to a department head. Upon completion the department head returns information to the administrator and it is reviewed in the next quarterly meeting. Depending on the problem, determines if the problem continues to be monitored or it is resolved. The facility had monthly QA meetings in the past however beginning January 2015 they went back to holding quarterly meetings again. The Administrator further confirmed when she believe that funds were not being managed correctly she brought the problem to the December QA meeting. She assigned the investigation to herself and was completed within a week. She did not see any reason to bring her findings back to subsequent QA meetings because it did not concern any of the department heads. When the Med Easy computer system crashed in May 2015, this was also not considered a problem that needed to be discussed in the QA meeting.

Based on record review, review of facility policy, staff and physician interviews, the facility failed to ensure that two (2) residents (#52, #24)were free of significant medication errors related to the administration of [MEDICATION NAME]/[MEDICATION NAME] according to physician's orders [REDACTED]. Findings Include: 1. Record review revealed that resident #52 was admitted to the facility on [DATE] and has numerous [DIAGNOSES REDACTED]. Further record review revealed that on 5/14/14 the physician ordered a change in the resident [MEDICATION NAME]/[MEDICATION NAME] dose to six(6) milligrams (mg) daily at eight (8) PM. On 6/3/14 the physician was notified of the results of the [MEDICATION NAME] Time (PT) of 35.9 and International Normalized Ratio (INR) of 3.75 drawn on 6/3/14. The physician ordered to hold the [MEDICATION NAME]/[MEDICATION NAME] for two (2) doses and repeat the PT/INR on Thursday. Review of the June 2014 Medication Administration Record [REDACTED]. There was no evidence in the medical record of a physician's orders [REDACTED]. The PT/INR was repeated on 6/5/14 and [MEDICATION NAME]/[MEDICATION NAME] 6mg was restarted. On 6/17/14 resident #52 was receiving [MEDICATION NAME]/[MEDICATION NAME] 6mg daily at 8:00 PM. The Physician was notified of PT/INR drawn on 6/17/14 with the results of PT of 31.6 and the INR of 3.17. The physician ordered to hold [MEDICATION NAME]/[MEDICATION NAME] 6mg for two doses then repeat PT/INR on 6/19/14. Review of the June 2014 MAR indicated [REDACTED]. The 6/19/14 PT/INR results revealed an increase PT to 40.2 and an INR of 4.34. The physician ordered Vitamin K to be given Now and repeat the PT/INR on 6/20/14. The 6/20/14 PT/INR results revealed an increase in the PT of 47.8 and an INR of 5.43. The physician again ordered Vitamin K to be administered Now and repeat PT/INR on Monday. Review of the June 2014 MAR indicated [REDACTED]. An PT/INR drawn on 6/25/14 revealed a PT of 14.1 and INR of 1.11 and the physician ordered to start [MEDICATION NAME]/[MEDICATION NAME] 6mg tonight and recheck next Tuesday. Review of the Policy and Procedure [MEDICATION NAME]/[MEDICATION NAME] Therapy reveals the nurse entering the order for [MEDICATION NAME]/[MEDICATION NAME] will be responsible for initiating the [MEDICATION NAME]/[MEDICATION NAME] Flow record, and completing the top of the form including the resident's therapeutic goal range. The facility designated nurse manager will review all PT/INR results on the day that they are obtained, if this is a weekend or after hours the RN Supervisor, or the charge nurse if the supervisor is unavailable will review the results and the following guidelines will be utilized: All INR results will be reported to the physician; notification of the physician will be documented on the lab result, in the nursing progress note, and on the [MEDICATION NAME]/[MEDICATION NAME] Flow Record and will include the order received. During interview with the Director of Nursing (DON) on 9/4/13 at 4:37 PM, she acknowledged the [MEDICATION NAME]/[MEDICATION NAME] 6mg was held for three days on 6/3/14, 6/4/14 and 6/5/14 in error and the 6mg was given on 6/17/14 and 6/18/14 in error. 2. Resident #24 was admitted to the facility on [DATE] with numerous [DIAGNOSES REDACTED]. On 7/22/14 resident #24 was receiving [MEDICATION NAME]/[MEDICATION NAME] 5.5mg daily at 9:00 PM. On 7/22/14 the physician was notified of PT/INR results, PT of 17.7 and a INR of 1.49. The physician ordered to increase the [MEDICATION NAME]/[MEDICATION NAME] to 6mg daily. Review of the July 2014 MAR indicated [REDACTED]. The first administration of [MEDICATION NAME] 6mg was on 7/28/14. Interview with the Assistant Director of Nursing (ADON) on 9/4/14 at 2:05PM revealed that the physician order [REDACTED]. She said the process is for the DON to call the results to the physician, document on the lab results that the Physician had been notified and document dosage changes on the lab report. The results, current dose, and dosage change is then recorded on the [MEDICATION NAME]/[MEDICATION NAME] Flow Record. The new order is then entered into the computer by the DON at that time and she believed it had never been entered. Interview by phone conducted on 9/10/14 at 3:45pm with the physician revealed he was unaware of the medication errors until after the facility was made aware of them by the surveyor and they notified him. Also resident usually have toxic level when there is something going on or she is taking antibiotics. That is why he will order more frequent monitoring of the PT/INR levels. If the resident's INR is high he will sometimes order Vitamin K to be given and the resident will usually respond well to it. Further, his goal is to have the INR level between 1.8 - 2.8. Interview conducted with the Administrator on 9/11/14 at 11:00 am revealed the facility was unaware of the medication errors until they were identified by the surveyor and the errors were made by one (1) nurse.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to check tube placement prior to administration of medication for one (1) resident (#89) from a sample of twenty-nine (29) residents. Findings include: Review of the clinical record for resident #89 revealed the resident was admitted to the facility on [DATE] with an enteral feeding tube. Observation of medication administration for resident #89 conducted on 9/3/2014 at 10:15 a.m. revealed the Medication Nurse "AA" pause the feeding pump, using a syringe flushed the tube using undetermined amount of water pour from resident drinking cup, and proceeded to administer each medications diluted with water. Following administering the medications "AA" flushed the tube again with undetermined amount of water. "AA" failed to check placement of tube prior to administering medication. Interview with "AA" following the procedure, revealed that she check for tube placement at 8:00 a.m. ` Interview with Director of Nurses (DON) conducted on 9/4/2014 at 2:10 p.m. revealed that all nurses are to check for enteral tube placement right before administering the medication and should be documented on MAR by placing their initial at the appropriate time. A physician's orders [REDACTED]. Further medical record review revealed a physician's orders [REDACTED]. Review of facility policy indicated to verify tube placement by use either of the following procedures: (a). Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope or gurgling sound or (b) Aspirate stomach contents with syringe. Check placement of tube prior to hanging new formula container, prior to any type of bolus including medications and routinely every four hours.

Based on record and policy review, the facility failed to complete Neurological Assessments on one (1) resident (#14) involved in an un-witnessed fall out of a sample of thirty-two (32) residents. Findings include: Resident #14 was admitted to the facility [DIAGNOSES REDACTED]. Review of nurses' note dated 8/1/14 revealed nursing staff was called to the room by the Certified Nurse Assistant (CNA). The resident was found sitting on the floor with her legs outstretched. The resident stated she had not hit her head. Neurological checks began. The physician notified. Review of the Neurological Assessment Flow Sheet revealed neurological assessments were conducted on 8/1/14 at 6:55 AM through 8/2/14 at 8:40 AM for a total of twenty five (25) hours. Review of the Policy and Procedure for Accidents and Incidents Investigating and Reporting revealed that neurological assessment to include vital signs will be initiated on all residents with an un-witnessed fall or other incident with a blow to the head (with or without apparent injury), and/or suspected head injury. Neurological Assessments will be performed by the licensed nurse every fifteen (15) minutes times four (4), every hour times four, every two (2) hours times four, every four hours times four, then every eight (8) hours times four, totaling seventy two (72) hours. This frequency may not be reduced.

Based on review of resident's plan of care, review of Registered Dietician (RD) recommendations, and staff interviews the facility failed to follow a resident's plan of care for an RD recommendation to increase a supplement for one (1) resident (#75) from a sample of thirty-six (36) residents. Findings include: Observation of resident #75 on 1/9/13 at 8:05am revealed the resident sitting at bedside eating breakfast. Resident consumed a 100% of her meal which included pancakes,eggs,sausage, oatmeal and beverages, coffee, chocolate milk, and orange juice. On 1/9/13 at 1:00pm, staff indicated that resident the resident consumed 70% of her lunch. She ate all of her spaghetti, salad, and desert, but left the garlic bread. Review of RD notes revealed a note dated 12/18/12 that indicated the resident's weight was down to 141 pounds, a six (6) pound loss in one (1) month. The RD recommended an increase in the supplement Boost (VHC) from 90cc tid to 120cc tid. There was no evidence that this recommendation was addressed. Review of the resident's plan of care revealed the resident had significant weight loss and that the approaches included to report RD recommendations to the physician for review and possible implementation. Interview with the Administrator on 1/8/13 at 2:00pm revealed that RD recommendations are presented to the Dietary manager or Director of Nursing (DON). The DON gives the recommendations to the assistant director of nursing (ADON), who obtains phone orders from the resident's physician. . Review of the Physician Communications/Recommendations sheet for 12/18/12 indicated a recommendation for resident #75 to increase VHC to 120cc tid due to another six (6) pounds lost in past month. Interview with the RD "CC" on 1/8/13 at 2:20pm via phone revealed he fills out the top portion of the physician recommendation sheets as well as the complete list of resident recommendations for the month. Both are given to the DON or placed in her mailbox. "CC" was not aware that the December 2012 recommendation for resident #75 had not been addressed.

Based on observation, review of physician's orders, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s orders for one (1) resident ('Z') from a sample of thirty-six (36) residents Findings include: The following observations revealed that resident "Z" was not observe wearing TED hose: 1/8/13 at 1:40pm the resident was walking to an activity with staff with no TED hose on. 1/9/13 at 8:45am the resident was up in her room and at 10:00am walking with staff with no TED hose on 1/9/13 at 2:00pm resident observed not wearing TED hose. Interview with resident 'Z' on 1/8/13 at 9:30am revealed that she did not wear Ted hose every day. She can take them off, but can not put them on. Her daughter came yesterday and put them on for her. The staff always put them on when the she asked but sometimes she forgot. 'Z' further revealed her cardiologist instructed her to wear them every day. The resident's medical doctor visited yesterday, agreed with the cardiologist, and was going to write the order. Review of physician's orders revealed an order dated 1/7/13 for resident 'Z' to wear support hose daily, on every morning, off every bedtime. Review of the MAR for January 2013 revealed no TED hose were listed. Further review of the Activity of Daily Living (ADL) sheets indicated TED hose were to be applied daily in the morning and removed every bedtime. Interview with the charge nurse "TT" on 1/8/13 at 9:45am revealed that the Certified Nursing Assistants (CNAs) were responsible for any application of hose or protective devices, and the instructions were on the ADL sheets. Interview with another charge nurse "AA" on 1/10/13 at 8:20am revealed that she was aware of the daily TED hose as of Sunday 1/6/13, when she was told by the resident's daughter. "AA" added this to the treatment book but was already on the ADL sheet for the CNAs. She counts on the treatment nurse to make sure that the order is followed. Interview with the treatment nurse "BB" on 1/10/13 at 8:25am revealed she checks for special treatments like TED hose on Mondays thru Fridays, but is off on week-ends. On week-ends the supervisor or charge nurse should check to make sure hose were on, and if the resident refused it should be documented. Follow up interview with 'Z' on 1/10/13 at 8:30am revealed she has never refused to wear TED hose, but understands that sometimes staff might forget even when she asked for them.

Based on review of facility letter sent to resident families, family and staff interviews the facility failed to ensure that charges do not occur for services covered under Medicare or Medicaid for two (2) residents ("X" and "Y") from thirty-six (36) sampled residents. The facility identified forty-four (44) resident occasionally or frequently incontinent of bladder and thirty- four (34) occasionally or frequently incontinent of bowel. The facility has a census of fifty-seven (57) residents with fifty-one (51) residents being Medicare or Medicaid. Findings include: Interview with a family member of resident "X" on 1/7/13 at 3:00pm revealed that the family had received a letter which stated something about cutting down on wasting of diapers and that the family could be charged if the resident continues to need a large amount. Interview with family member of resident "Y" on 1/7/13 at 3:15pm revealed that she had not received the letter regarding paying for briefs but her sister had. Review of a facility letter dated August 7, 2012 revealed that Family Member and/or Responsible Party were notified that the facility was planning to charge for incontinent briefs if a resident used over the number allowed per day. The letter indicated that the facility had not been abiding by it's policy; however, due to economical reasons and the increase in the cost of the briefs, the policy now must be strictly enforced. The letter assured that residents would not go without briefs but if the facility found that an excessive number were being used, then the facility would ask the families for assistance in covering the charge. Interview with the Administrator on 1/10/13 at 7:55am revealed the facility did send a letter out to the families of residents regarding the number of briefs being used and potential wastage. The facility wanted to clarify that either pull ups or briefs would be used and if an excessive number was used then the families would be asked to cover/pay for the excessive number. The administrator indicated that clinical conditions such as diarrhea were considered. The Administrator further revealed that it has been the facility's policy to limit the number of briefs used per day to eight (8). As of today they have not had to ask anyone to contribute toward the cost of briefs, or pull ups. A second interview on 1/10/13 at 8:55am with the Administrator revealed that, after she had talked with the Corporate Nurse Manager, the facility does not have a policy with a specific number of briefs allowed. The eight (8) briefs per day is based on national average.

Based on review of the medical record and care plan, and review of the facility's reports, the facility failed to follow the care plan related the appropriate application of a seat belt while up in a wheelchair and shower chair for one (1) resident (#19) from a sample of twenty-eight (28) residents. Review of the annual Minimum Data Set ((MDS) dated [DATE] assessed resident # 19 as being totally dependant for bathing with one person assist, and extensive assistance with 2+persons for physical assistance with transfers and wheelchair for mobility. Review of the Fall Risk assessment dated [DATE] indicated the resident is high risk for falls. Review of the care plan for resident # 19 revealed the resident was care plan for potential injury related to falls and that interventions included; a seatbelt to wheel chair when out of bed, Safety belt to shower chair during showers, and bed alarm on when in bed. Review of the Incident/Accident Report and nurse's note revealed the following: On 6/21/11 at 4:25pm Resident was found in lobby of the dining room on the floor. The resident received a laceration to the head. Investigation revealed that the seatbelt to wheelchair had not been fastened properly and resident fell out of wheelchair. On 8/2/11 at 11:15am revealed that a Certified Nursing Assistant (CNA) left the resident unattended in shower without a seat belt and the resident fell out of the shower chair. Cross-refer to F323, example 1

Based on record review, staff and family interviews, review of the facility's reports, and facility' s policies, the facility failed to provide supervision to prevent falls for one (1) resident (#19) and to ensure wheelchair seatbelt and lift pad were appropriately applied for two (2) residents (#19 and " X ") from a sample of twenty-eight (28) residents. These failures resulted in harm for two (2) residents. Findings include: 1. Review of the medical record for resident # 19 revealed the resident had been admitted on [DATE] with numerous [DIAGNOSES REDACTED]. Review of the Resident Occurrences History Log dated 9/1/10 through 8/10/11 and corresponding nurse's notes revealed the following multiple falls with injuries: 09/09/10 at 8:50am the resident was found lying in floor in front of wheel chair (w/c). Seatbelt on w/c was broken. Interventions implemented were: medication review with increase noted to Robaxin, new stronger seatbelt attached and neuro-exam per facility protocol. 1/1/11 at 12:45am the resident rolled out of bed with no injury. The physician was notified for possible medication change. No medication changes were noted and neuro checks where done per facility protocol. The resident's bed was in the low position and bed bolsters were in place. 3/26/11 at 3:00am the resident was found on floor beside her bed with no injury, neuro-checks per facility protocol, and physician was notified. 5/29/11 at 7:30am the resident was again found on floor in the room, neuro-checks were done per facility protocol, and would continue to use bolsters to bed, and keep the bed in lowest position. No injury was noted 6/21/11 at 4:25pm Resident was found in lobby of the dining room on the floor. The resident received a laceration to the head. Investigation revealed that the seatbelt to w/c had not been fastened properly and resident fell out of w/c. Neuro-checks per facility protocol,and added to the Falls PAR. Review of the Incident/Accident Report and nurse's note for this fall revealed the resident's wheel chair (w/c) was located two (2) feet away with the seatbelt unfastened. The summary of the incident report indicates upon investigation, that resident fell out of w/c, seat belt was not fastened completely when resident was gotten up with the lift and placed in w/c. The resident has muscle spasms/[DIAGNOSES REDACTED], and was able to thrust herself forward. 7/5/11 at 7:00pm the resident was found on floor in room. Neuro-checks per facility protocol, medication review with changes noted. Ativan was ordered as needed (PRN) for anxiety. No injury was noted. 8/2/11 at 11:15am the resident was left unattended in shower chair without a seatbelt on and fell out of shower chair. No injury occurred. Interventions include one on one in-service with shower team and the staff member that left resident unattended was suspended for 3 days. Review on the nurse's notes included a fall not listed on the Occurrences History Log for 5/2/11 at 5:00pm which indicated resident # 19 was found sitting in floor between A and B beds. Her legs were under bed B and she had two (2) small indentations noted on the right shin. Interview on 8/11/11 at 8:00am with Certified Nursing Assistant (CNA) "BB", who was responsible for providing care for resident # 19 on 6/21/11, revealed he/she was not conscious of whether the seat belt clicked when it was applied. "BB" further revealed he/she was in-serviced immediately after the in-service however, had never received any training before the incident on how to apply the seat belt. Interview with the DON on 8/12/11 at 12:45pm revealed that when the CNAs transferred the resident to the w/c the seat belt did not completely fasten and the resident was found on the floor with a laceration to the forehead. On 6/22/11 all CNAs were in-serviced on checking restraints, proper positioning and making sure the seat belts are secured before leaving the residents. Review of the Incident/Accident Report and nurse's note dated 8/2/11 revealed the nurse was notified by CNA "CC" that the resident was left unattended in shower without a seat belt on by another CNA ("DD") and that the resident had fallen out of the shower chair. Both staff were in-serviced in leaving residents unattended and disciplinary action was taken. Review of the facility's Shower Protocol indicates the following should be followed: a) If assistance is required during the resident's shower Do Not leave the resident, but to pull the emergency cord and wait for assistance. b) Residents are Never to be left unattended in bathing area even if they have not been transferred to a shower chair. c) There should never be more residents than staff in the shower room at any time. d) Seat belts are to be used to prevent falls, ask nurse if unsure about seat belt use. . Interview on 8/8/11 at 11:59am with Registered Nurse "EE" indicated that resident # 19 had a fall on 8/2/11 in the shower room. "EE" further revealed a CNA left the resident in shower chair, there was another CNA in the shower assisting another resident but CNA was unable to prevent the resident from falling. There were no injuries noted with this fall. Interview with the DON on 8/9/11 at 8:00am revealed that the CNA involved with the incident on 8/2/11 was suspended for 3 days. All staff were in-serviced on leaving a resident unattended in a shower chair. Resident #19 is on the Fall Patient At Risk (PAR) and followed by the Interdisciplinary Team. Interview on 8/10/11 at 1:05pm with CNA "DD" revealed he/she had left resident # 19 in the shower room to get a bobbie pin for the resident's hair. "DD" further revealed that the safety belt was not fastened on the chair because there was lotion on the belt and did not want to get the lotion on the resident's clothes. "DD" acknowledged that the resident should not have been left alone. Interview on 8/11/11 at 9:45am with CNA "CC" revealed that he/she was in the shower room bathing a resident when another CNA "DD" left resident #19 unattended in a shower chair without the safety belt fastened. "CC" further revealed that he/she tried to keep the resident from falling but due to having wet, soapy hands she was only able to keep the resident from hitting the floor hard. "CC" further revealed that residents should not be left unattended in the shower room. Review of the current August 2011 Activity of Daily Living (ADL) Flow Record revealed the resident is a risk for falls, restraint use is for a seat belt to a standard wheelchair when out of bed, the minimum number of staff required to assist when transferring is two (2), bolsters to bed for support and repositioning. Review of the resident's care plan revealed the resident has the potential for injury related to falls, and interventions include: to wear seatbelt when up in wheelchair, a safety belt to shower chair during showers, and bed alarm on when in bed. Further review of the care plan revealed these intervention are addressed other care plan areas. 2. Review of the medical record for resident "X" revealed the resident was admitted to the facility with numerous [DIAGNOSES REDACTED]. Interview conducted on 8/9/2011 at 11:00a.m. with resident "X" responsible party revealed that she observed several bruises on the resident's left arm and swelling of the elbow. She indicated that she is very upset and wants to know what caused the bruises and how could the facility allow this injury to occur. The responsible party indicated that she was contacted by facility nurse on 8/8/2011 and was told that they had found some black marks on the resident. She was further informed that the marks were caused by a lift during a transfer due to the pad used for the transfer was too small. Observation of resident "X" conducted on 8/9/2011 at 11:30 a.m. revealed black and yellow discoloration was noted along the posterior and lateral aspect of resident's left arm extending from above the wrist to the deltoid. Record review revealed that on 8/8/2011 at 3 a.m. while CNAs were turning resident, they discovered a discoloration to the posterior left upper arm measuring 4 inches x 1 in, and to the right arm a circular discoloration measuring 1 in. x 1 in. where the top of mechanical lift pad meets the top of arms. Resident able to move bilateral arms without pain or difficulty and no signs or symptoms of pain/discomfort. Interview with Director of Nursing (DON) conducted on 8/10/2011 at 10:00 a.m. revealed that the bruises occurred during a transfer with a lift in which a large lift pad used was too small for resident's size. She indicated that the resident needed an extra-large pad to be used during lift transfers and that all direct care staff are trained to determine the size of the pad needed for each resident to ensure a safe transfer. DON indicated that since the incident staff were properly re-trained and an extra-large pad was placed in the resident room. A second interview conducted with resident's "X" responsible party on 8/10/2011 at 12:15p.m. revealed that she had met with DON and was informed that the bruises were caused by the pad used to transfer the resident was too small for the resident's size and resident's arm was bruised in the process. DON informed her that a larger pad will be used for transfer so this incident should not happen again. Review of facility's investigation revealed that on 8/7/11 first shift CNAs got resident up using a smaller lift pad and that when second shift CNAs put her back to bed, the lift pad got caught and caused friction pinching the resident's skin on arms and back and the bar of the lift hit the left elbow. This caused bruising later that evening.