Every finding on record at Edward J Healey Rehabilitation and Nursing Center

Based on observation, interview and record review, the facility failed to provide care and services to prevent the development of new pressure ulcers, as evidenced by, failure to implement the physician's order for soft boots and to properly document the resident's refusal of them for 1 of 2 sampled residents reviewed for pressure ulcers (Resident #6). The findings included:Review of the facility's policy and procedure titled, Prevention of Pressure Injury, revised on 04/2020 documented, 1. Interventions will be implemented in accordance with practitioner's orders, including the type of devices to be used, and the frequency of performing the tasks. 2. Interventions will be documented in the Care Plan and EMAR, Electronic Medication Administration Record, and will be communicated to all relevant staff, including the Certified Nursing Assistant (CNA) via the Road Map.Review of the record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, Muscle Weakness and Stage 4 Ulcer of the Sacral region. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0-15 scale, indicating the resident had moderate cognitive impairment. This MDS also documented the resident was on Hospice services; the resident's lower extremities were impaired and was dependent on staff for dressing, shower, and personal hygiene. Review of the physician's orders dated 07/11/23 instructed Resident #6 to always wear Soft Boots every shift while in bed.Review of the current care plan dated 04/14/26 indicated Resident #6 was at risk for new skin breakdown due to impaired mobility and a history of deep tissue injury to both heels with an intervention for soft boots to be always worn in bed. This care plan lacked documentation that the resident refused to wear the boots.Review of the progress notes dated from 05/05/26 to 05/19/26 lacked documentation of the resident's refusal of the soft boots.During an observation on 05/18/26 at 10:01 AM, 05/18/26 at 1:01 PM, 5/19/26 at 8:46 AM, 05/19/26 at 10:30AM and on 05/20/26 at 8:58 AM, Resident #6 did not have soft boots on while in bed.During an interview and side by side record review with Staff G, Registered Nurse (RN) on 05/20/26 at 10:25 AM Staff G was asked the interventions in place to prevent further skin breakdown for Resident #6. According to Staff G, soft boots were prescribed for the resident; however, she had refused to wear them. Staff G reviewed the orders and verified they were to be worn always when in bed. She was then asked to provide documentation that Resident #6 had been refusing the soft boots. Staff G reviewed the resident's record from 05/18/26 to 05/20/26, up to the time of the interview, and confirmed there had been no documentation of the resident's refusal. She further provided information that she did not find any documentation of refusal of soft boots since 02/09/26. When asked if each time the resident refused it would be documented, she said, yes.During an interview with Staff F, Dolphin Unit Manager (UM) on 05/20/26 at 11:50 AM, she stated the resident's order should be connected to the task list to ensure the staff documented the intervention; but it was not linked, so it was not done. Staff F was then asked if each time the resident refused, should it be documented elsewhere, she confirmed, yes, it should have been documented.

Based on observation, interview, policy review and record review, the facility failed to provide care and services to maintain range of motion for 2 of 4 sampled residents, as evidenced by failure to follow a physician's order for use of self-feeding adaptive equipment for Resident #84, and failure to provide bilateral boots for contracture prevention for Resident #76. The findings included:1) Review of the policy titled, Use of Assistive Devices-Procedure effective date 05/15/20, documented, in part, 1. Assistive devices include: f. Orthotic or prosthetic equipment, g. Eating utensils 3. The facility will provide assistive devise for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as ordering and/or replacement. 5. Direct care staff will be trained in the use of the devices as needed to carry out their roles and responsibilities regarding the devices. Training will also include when to refer to other departments for changes in condition or problems with the device. 6. A nurse with responsibility for the resident will monitor the consistent use of the device and safely in the use of the device. Refusals of use, or problems with the device, will be documented in the electronic medical record. Modifications to the plan of care will be made as needed. Review of the record revealed that Resident #84 was admitted to the facility on [DATE]. Review of the EJH Transfer to Restorative Nursing form revealed that Resident #84 had a primary diagnosis of Hemiplegia and Hemiparesis affecting right dominant side, and Muscle Weakness, and was being transferred to the Restorative Nursing Program (RNP) on 04/17/26 as Resident #84 completed his therapy program and required restorative staff to maintain present Activities of Daily Living (ADL) functional status. This form also documented that Resident #84 would be in the Restorative Nursing dining program 5 times per week for 1 meal per day for 3 months and the adaptive equipment included in part, bent utensils with left wrist splint with utensil holder with all meals. Further review of the record revealed that the Care Plan with a start date of 04/17/26 for RNP problem: Resident #84 requires training and skill practice in eating/swallowing related to diagnosis of muscle weakness with an approach: Adaptive Equipment-Bent utensils with left wrist splint with utensil holder with all meals. The record also revealed a Physicians order dated 04/14/26 for Adaptive Equipment- bent utensils with left wrist splint with utensil holder with all meals. An initial interview was conducted on 05/18/26 at 9:57 AM with Resident #84 who was positioned in bed and stated that he felt like some of the things he used to be able to do have gotten worse like feeding himself. The resident moved his left arm in the motion from down at his side to imitating the movement of bringing his hand to his mouth. Resident #84 stated that he used to use a hand splint to feed himself with the therapist, but he does not get therapy anymore. An observation on 05/18/26 at 12:10 AM was made in the dining room where Resident #84 was positioned in his wheelchair and Staff B, Certified Nursing Assistant (CNA) was sitting next to him and feeding him with a curved spoon. Resident #84 was not participating in self-feeding and was not wearing a hand splint. On 05/20/26 at 12:15 PM, observations revealed Resident #84 was being fed by Staff B, and his left hand was under his clothing protector. Staff B was asked what type of skill Resident #84 was working on as part of the RNP. Staff B stated, mostly drinking from the Kennedy cup. She assisted Resident #84 with placement of his left hand around the handle of the cup, assisted with bringing it to his mouth and then he was able to hold it and drink from the cup himself. Staff B was asked if there was any other adaptive equipment that Resident #84 used during meals and she stated, yes, the bent spoon. Staff B agreed that she was feeding the resident with the bent spoon and he was not working on that skill. Staff B was then asked if Resident #84 had a left wrist splint for use during meals. She stated that they did use the left wrist splint with him during Occupational Therapy (OT) but when Resident #84 started on the RNP he was refusing to use the splint and was getting upset and refused to use it. Staff B was asked if the Occupational Therapist (OT) knew that Resident #84 had refused to use the left wrist splint and she stated, yes, the OT knows. An interview was conducted on 05/21/2026 at 9:57AM with Staff C, Occupational Therapist who has worked at the facility for 7.5 years. Staff C was asked what type of adaptive equipment Resident #84 uses for self-feeding during the RNP. She stated that he uses a universal splint on his left hand that you can put a utensil in and he can assist with feeding himself. The OT went on to say that Resident #84 has orders to use a bent spoon but can use any utensil he likes with the left wrist splint. Staff C was asked if she has received any update from the RNP regarding Resident #84 and she stated, no, not that I remember. Staff C was then asked if a resident refused to use an adaptive device that was ordered, would the RNP document that refusal. She stated yes, it would be in a progress note written by a Restorative Nurse or if they told the OT department they would have written a progress note. Review of the progress notes under the discipline heading of Restorative Nursing revealed an initial note dated 04/17/26 about Resident #84 beginning in the RNP with the focused area of eating and dining and that staff will assist him in using adaptive equipment including bent utensils, a left wrist splint with a utensil holder, a Kennedy cup with a lid for liquids, and a scoop plate for meals to promote safer and more effective self-feeding. Further review of the progress notes revealed that on 05/12/26 Resident #84 required extensive assistance with the use of adaptive equipment including the left wrist splint with utensil holder. The progress notes did not state that Resident #84 had refused to use the left wrist splint. A second interview was conducted on 05/21/26 at 11:34 AM with Staff C, OT who was asked if she was aware that Resident #84 had refused to use the left wrist splint with utensil holder and she stated she was not aware of that and that when she worked with Resident #84 he liked to use the left wrist splint with utensil holder. The OT was also unable to find any documentation about Resident #84 refusing to use the left wrist splint. Staff C agreed to observe Resident #84 during lunch with the surveyor. An observation was conducted on 05/21/26 at 12:00 PM when Resident #84 was brought into the dining room by Staff B, CNA, and he was not wearing and did not have his left wrist splint with him. Staff C also observed Resident #84 sitting at the table in the dining room without his left wrist splint. She then went to his room and located the left wrist splint in his drawer. The OT brought the left wrist splint out to the dining room and asked Resident #84 if he would like to use it during lunch with the Restorative Nurse. Resident #84 told the OT that he liked the other white splint better and the OT reminded him that the white splint is a palm protector with a finger spreader and is not the splint that is used for meals. Resident #84 appeared to understand and agreed to use the left wrist splint with utensil holder. Staff B, CNA came to the table and the OT showed her the splint and asked the CNA if Resident #84 has been using it. Staff B, CNA, stated that they used to use it with him but that he told the therapist he refused to use it and the OT stated she was not told that Resident #84 refused to the left wrist splint. The CNA was asked who she told or if she documented that Resident #84 had refused to use the left wrist splint and she stated, why would I need to tell anyone if Resident #84 had already told the therapist. The CNA walked away and started to assist another resident with their meal. The OT then assisted Resident #84 with donning the left wrist splint and using a smaller bent spoon. Resident #84 needed hand over hand assistance to scoop food on the spoon but then was able to bring the spoon to his mouth and eat without physical assistance at least 5 times during the observation. The OT asked the surveyor if she could leave and the surveyor asked the OT if she thought she should show the CNA how she assisted Resident #84 with use of the left wrist splint to make sure the CNA could recreate the same assistance. The OT then went over to the CNA and they came back to the table and the OT demonstrated the technique and the CNA was then able to assist Resident #84 with his self-feeding goal. 2) Review of the record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses to include Spinal Cord Injury and Paraplegia. Review of the current Quarterly MDS documented the resident had a BIMS score of 3, on a 0 to 15 scale, indicating severe cognitive impairment. This MDS also documented impairment to bilateral lower extremities and that he was dependent upon staff for lower body dressing. Review of the current orders documented as of 06/15/22 the resident was to wear bilateral ankle boots for contracture management. A contracture is defined as a permanent tightening or shortening of muscles, tendons, skin, or other soft tissue that causes joints to become stiff. Review of the care plan initiated on 06/17/16 documented that the resident was dependent upon staff for most of his ADLs (activities of daily living). An added intervention dated 06/15/22 documented the use of the bilateral ankle boots for contracture management. Review of the documentation by the Certified Nursing Assistants (CNAs) lacked any evidence of the provision of the ankle boots. Review of progress notes from 03/01/26 to the date of survey lacked any documentation related to the ankle boots. Observations on 05/18/26 at 12:43 PM and on 05/20/26 at 12:45 PM revealed Resident #76 in the main dining room for lunch in the company of his private aide. On both occasions the resident was sitting in his wheelchair with his feet resting in a blue foot wedge attached to the wheelchair, with the resident wearing regular shoes. During an interview on 05/20/26 at 12:50 PM, when asked about the care of Resident #76, Staff G, Registered Nurse (RN), stated the resident had recently transferred from a different unit and had a history of aggressive behavior towards other residents, therefore a private aid was required every day. When asked about the use of bilateral boots, the RN first questioned, boots? and then confirmed the order in the electronic medical record. The RN stated that application of the bilateral boots was the responsibility of the CNAs. She continued to explain that if the resident refused them, the CNAs would report the refusal to the nurse for documentation in the progress notes. During an interview on 05/20/26 at 12:55 PM, when asked if she applied the ankle boots for Resident #76 that morning, Staff H, Certified Nursing Assistant (CNA) did not answer. When asked if she was aware of the order for the bilateral ankle boots, CNA would not answer yes or no. The CNA was then asked how she would know what care was needed for each resident. The CNA stated she would look at the road map. When asked how she was provided with the road map, the CAN stated it was a paper document that she could get each day. The CNA did not confirm if she had the road map for the day or not. During an interview on 05/20/26 at 1:00 PM, when asked about the physician order for the bilateral ankle boots for Resident #76, Staff I, Physical Therapist (PT), confirmed she placed the order in the record in 2022, but it was still active, and should be carried out by the nursing staff, specifically the CNAs. The PT explained that a resident with paralysis lacks the ability to flex their ankles to a normal position, and the ankle boots keep the feet from contracting to a downward (foot drop) position. When asked about the blue foot wedge noted on the resident's wheelchair, the PT explained the boots were for contracture maintenance and the stop drop leg rest was to keep the resident's feet from dropping off the wheelchair and keeps the feet in an upright position. During an observation and interview on 05/20/26 at 1:34 PM, when asked to observe the ankle boots for Resident #76, the private aide obtained them from the bottom of the resident's closet, under some clothing and other items. When asked if the resident was refusing the boots, the private aide stated she was not sure as the resident was usually up in his wheelchair before she arrived at 11:00 AM each day. During an interview on 05/21/26 at 11:33 AM, Staff E, Starfish Unit Manager/ADON (Assistant Director of Nursing) confirmed the CNAs have never been able to document the provision of the ankle boots, as the order was put into the computer incorrectly in 2022, and had no explanation as to how it did not get corrected.

Based on observations, record review and interviews, the facility failed to properly complete quarterly assessments for bed rails/assist bars for 3 of 4 sampled residents reviewed for accidents (Resident #20, Resident #57 and Resident #81). The findings included:Review of the State Operations Manual (SOM) revealed the definition of Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to: Side rails, bed side rails, safety rails; Grab bars and assist bars. Resident Assessment: The facility must assess the resident for the risks of entrapment and review possible risks and benefits of bed rails prior to installation or use.A review of the facility's policy titled, Bed Rails, dated 08/22/23 documents that part of the bed rail comprehensive assessment, the following components will be considered when determining the resident's needs. The medical diagnosis, conditions, symptoms and or behavioral symptoms, size and weight, sleep habits, medications, acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, cognition, communication, mobility in and out of bed and risks of falling. Monitoring and supervision of ongoing assessments to ensure that the bed rail is used to meet the residents' needs. A nurse assigned to the resident will complete reassessments not less than quarterly, upon a significant change in status or a change in the type of bed/mattress/rail.A review of the User-Service Manual for the Deluxe Assist Handle documents that the assist device is intended for use as an aid in entering or exiting the bed sleep area, as well as a stable handhold during self-positioning within the bed sleep area.1. Observation on 05/19/26 at 8:58 AM revealed that Resident #20's had an assist handle in place, on the upper left side of his bed.A review of Resident #20's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses to include Cerebral Infarction, Hemiplegia affecting Right Dominant Side, Aphasia, Dysphagia, Essential Hypertension, Muscle Spasm, Peripheral Vascular Disease, Obstructive and Reflux Uropathy, Neuromuscular Dysfunction of Bladder, and Muscle Weakness.A review of the residents quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed that his BIMS (Brief Interview for Mental Status) did not have a number score, which means the resident refused to answer the questions. A physician's order dated 08/22/25 documented a left side upper transfer assist bar. An Occupational Assessment that is done quarterly, dated 01/21/26 and 04/20/26 documented N/A (not applicable) under bed rails with no assessment being completed. It does document the resident uses a left side upper transfer assist bar for mobility. Resident #20 care plan for ADLs (Activities of Daily Living) documented that he is set-up, to dependent with his ADLs. One of the interventions is that the resident had a left side upper transfer bar for mobility.2. Observations on 05/21/26 at 8:30 AM revealed that Resident #57 had an assist handle in place, on the right side of his bed.A review of Resident #57's medical records revealed that Resident #57 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following Cerebral Infarction, affecting Left non-Dominant Side; Essential Hypertension, Spinal Stenosis, Vascular Leukoencephalopathy, Muscle Weakness, Chronic Kidney Disease, Anxiety Disorder, Unspecified Psychosis, Vascular Dementia Severe with Behavioral Disturbances, Peripheral Vascular Disease, Benign Prostatic Hyperplasia, Acute Kidney Failure, Cognitive Communication Deficit, Hallucinations, Auditory Hallucinations, and Depression. A review of the quarterly MDS dated [DATE] documented his BIMS score as a 4, which indicates his cognition is severely impaired. A physician's order dated 01/19/23 documented a right-side upper transfer assist bar. Resident #57's ADL care plan documented he needs assistance with most ADLs and is dependent on staff for some of his ADLs. One of the interventions documented that he has a right-side upper transfer assist bar for mobility. A review of the Occupational Assessment documented the last two assessments were completed on 01/22/26 and 04/20/26, showing N/A next to bed rails; and No assessment completed. There is a comment documented that he has an upper right assist bar for mobility. 3. Observations were made on 05/19/26 at 10:58 AM of Resident #81 having an assist handle in place attached to the upper right side of his bed.Review of Resident #81's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Heart Failure, Vascular Dementia with Mood Disturbances, Dysphagia, Depression, Hemiplegia Left non-dominate, Hypertension, Chronic Kidney Disease, Muscle Weakness, and Reduced Mobility. Resident #81's quarterly MDS dated [DATE] documented he has a BIMS score of a 6, which indicates his cognition is severely impaired. A physician's order dated 12/19/25 documented a right side of bed upper transfer assist bar. Resident #81's care plan for ADLs documented that Resident #81 is dependent on staff for most of his ADLs and mobility. One of the interventions included right-side upper transfer assist bar for mobility. A review of an assessment dated [DATE] documented bed rails are not necessary at this time. The Occupational assessment dated [DATE] and 05/21/26 documented N/A next to bed rails, but has a statement that the resident has a right upper transfer assist bar.During an interview on 05/21/26 at 10:23 AM with Staff J, RN (Registered Nurse), she was asked who completes the bed rail assessments. She stated PT (Physical Therapy) does them, we just follow the orders.During an interview on 05/21/26 at 10:35 AM with the Rehab Director, he was asked who completes the bed rail assessments. He stated we do, the physical therapy department completes them quarterly. He looked up Resident #20's electronic medical chart and stated, Oh he doesn't have a bed rail, he has an assist bar; those are not considered bed rails. We do quarterly assessments on everyone, but we don't classify the assist bars as bed rails. He stated that the assessment falls under the Occupational Therapy Assessments.During an interview on 05/21/26 at 10:45 AM with the Administrator, she stated that the assist bars are not considered bed rails although when asked for a policy for assist bars, she stated we only have a policy on bed rails. When the surveyor went back into her office and showed her the definition of bed rails from the State Operations Manual (SOM), she acknowledged that the devices do fall under bed rails.During a secondary interview on 05/21/26 at 12:30 PM, with the Administrator, she stated the assist bars are actually called assist handles and are not considered a bed rail, cannot cause entrapment, and that is one of the reasons why they went with those. She said the physician put assist bars instead of assist handles in the orders. The surveyor requested a copy of the user manual for the assist handles.During an interview on 05/21/26 at 12:50 PM with the Maintenance Director, he stated, We do weekly checks of the bed rails. We do one unit a week.

Based on policy review, observation, interview and record review, the facility failed to ensure staff maintained sterile technique during tracheostomy care and suctioning as evidenced by improper handling of sterile supplies, failure to prevent contamination of the sterile field, failure to change gloves after contact with potentially contaminated surfaces and equipment. This deficient practice had the potential for increased risk for infection for 1 of 1 sampled resident (Resident #52); and failed to change gloves during wound care for 1 of 1 sampled resident (Resident #28).The findings included:The facility policy titled Tracheostomy Care and Suction Policy and Procedure, dated 05/04/26, indicated the purpose of the policy was to establish standardized, evidence based best practices for the care and maintenance of tracheostomy tubes in the skilled nursing center setting. The policy stated proper tracheostomy care and suctioning minimizes the risk of infection, maintains airway patency, and promotes resident safety and comfort. The procedure for respiratory therapy trach care #3 directed staff to maintain sterile technique throughout the procedure. Clinical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Quadriplegia, and Respiratory Failure. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment and was rarely understood. The assessment further revealed the resident received oxygen therapy, suctioning, and tracheostomy care. The care plan dated 03/26/26 revealed Resident #52 had altered respirations related to respiratory failure evidenced by the presence of a tracheostomy. Review of physician orders revealed: 09/06/23 – Suction three times daily for secretions. 09/11/25 – Change trach collar daily and as needed. 09/23/25 – Trach #4 Shiley cuffless for respiratory failure. On 05/20/26 at 8:48 AM, tracheostomy care was observed with Staff A, Registered Nurse. Staff A donned clean gloves and disinfected the bedside table. She then removed the gloves, washed her hands, opened the treatment cart, and gathered sterile utility drapes. Staff A opened the sterile drapes and placed two sterile drapes on the bedside table using bare hands without gloves, which had the potential to contaminate the sterile field prior to use. Staff A then sanitized her hands and donned a gown, mask, face shield, and clean gloves. She returned to the treatment cart and obtained supplies including a suction kit, trach care kit, trach mask, split sponge, hydrogen peroxide, and normal saline (NS). She touched all items with clean gloves and placed them next to the sterile drapes. Staff A increased the oxygen to 10 liters and placed a pulse oximeter on the resident's finger with oxygen saturation noted at 99 percent. She then removed the gloves, sanitized her hands, and donned new clean gloves. Staff A retrieved suction tubing attached to the wall above the bed and placed the tubing directly on the resident's bed next to Resident #52, creating a contamination risk. While wearing the same pair of clean gloves, Staff A used the bed remote to raise the bed, closed the privacy curtain, repositioned the trash can, and immediately proceeded to remove the tubing/mask from the resident's neck and tracheostomy area without changing gloves after touching environmental surfaces and equipment. Staff A then lowered the oxygen to 5 liters. She removed the gloves, sanitized her hands, and donned a new pair of clean gloves. Using clean gloves, Staff A opened supplies and placed the trach mask, size 4 inner cannula, NS, split sponge, and gauze onto the sterile utility drapes after touching the items with clean gloves, potentially contaminating supplies intended for the sterile field. The only item not touched prior to placement on the sterile drape was the size 4 inner cannula, which was allowed to drop onto the field. Staff A opened the NS and poured it into a container, removed the clean gloves, sanitized her hands, and donned sterile gloves. She attached sterile suction tubing to the suction tubing previously placed on the resident's bed and suctioned the tracheostomy twice. These practices failed to maintain a sterile field throughout the tracheostomy care and suctioning procedure. On 05/20/26 at 12:52 PM, an interview was conducted with the [NAME] Unit Manager. After reviewing the observation findings with her, she acknowledged concerns related to tracheostomy care and infection control and stated Staff A would review the tracheostomy care policy. On 05/20/26 at 1:00 PM, an interview was conducted with Staff A. She agreed with the findings. On 05/20/26 at 1:07 PM, a subsequent interview with the [NAME] Unit Manager revealed the sterile drapes should not have been touched with bare hands and Staff A should have changed gloves before removing the oxygen tubing/mask from the resident. On 05/21/26 at 10:28 AM, an interview with the Nursing Home Administrator revealed Staff A was provided competency training and an instructor observed her performing tracheostomy care on a resident following the surveyor's observation. During the competency review, the instructor identified concerns with Staff A's tracheostomy care technique and had to stop and re-educate her during the procedure. 2) Review of the policy Wound Care (EJH-NUR-074A) reviewed 04/27/21, documented in part, Procedure: . 5. Perform hand hygiene, don gloves and any PPE needed. 6. Set up area for supplies. 7. Place resident in a comfortable position. 8. Remove old dressing, pull glove over old dressing and discard in red bag. 9. Perform hand hygiene and don gloves. This policy then instructed staff to provide the wound care. Review of the record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses to include Paraplegia. Review of the current Annual MDS assessment documented that the resident had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Further review of this MDS documented the resident did not have a current pressure injury. Review of the wound assessments for Resident #28 revealed a new pressure injury to the resident's coccyx as of 03/18/26. Review of the physician orders documented the current wound care as of 04/27/26 was to cleanse the wound with normal saline, apply a dampened Hydrofera Blue dressing (an antibacterial foam dressing), and cover with gauze and a border dressing. During an observation on 05/20/26 at approximately 10:00 AM, Staff A, Registered Nurse (RN)/Wound Care Nurse, obtained the wound care supplies for Resident #28 and placed them on a clean barrier. The RN donned PPE to include gloves and gown, repositioned the resident, then removed the gloves and donned sterile gloves. The RN removed the old dressing with the sterile gloves, dropped the dressing into the red bag trash, and continued the wound care with the now contaminated gloves from the old dressing. During an interview on 05/21/26 at 11:16 AM, the Infection Preventionist was made aware of the observation made on 05/20/26 with the Wound Care Nurse. When told of the failure to change gloves, the Infection Preventionist stated she should have taken the dressing off with the non-sterile gloves and then provide the care with the sterile gloves.

Based on observations, interviews and record review, the facility failed to provide adaptive equipment for a resident when consuming liquids for 1 out of 2 sampled residents reviewed for adaptive equipment, affecting Resident #6. The findings included: Review of the facility's policy titled, Adaptive Feeding Equipment Policy and Procedure, with an effective date of 09/25/24, included in part, the following: To provide adaptive equipment to obtain and/or maintain a resident highest practicable level. Residents requiring assistance in feeding are potential candidates for a restorative dining program or adaptive utensil use, as determined by the occupational therapist. The dietary department should be notified of residents needing adaptive feeding equipment; the equipment is stored and maintained in the dietary department. Appropriate utensils should be placed on the resident's food tray, at each meal, and returned to the dietary department, on the food tray, for sanitization. Record review for Resident #6 revealed the resident was originally admitted to the facility on [DATE], with readmission on 03/19/21, with diagnoses that included, in part, the following: Anoxic Brain Damage, Dysphagia, Other Speech Disturbances, and Electrocution. Review of the Minimum Data Set assessment for Resident #6 dated 11/07/24 documented in Section C that a Brief Interview of Mental Status was not completed, due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #6 revealed an order dated 05/31/17 for NAS (No Added Salt), Pureed, and No straw. Review of the Physician's Orders for Resident #6 revealed an order dated 03/11/22 for aspiration precautions: 90 degrees all meals, no straws, and small bites/sips. Review of the Physician's Orders for Resident #6 revealed an order dated 07/17/23 for adaptive equipment - nosey cup with liquids, to enhance feeding. Review of the Care Plan for Resident #6 dated 11/19/24 with a problem of resident is at risk for alteration in nutrition/hydration and weight fluctuations related to impaired cognition secondary to anoxic brain damage, other abnormal involuntary movements, and vary PO (oral) intake. He is at increased risk for aspiration related to diagnosis of dysphagia and needed mechanically altered diet. The goal was for the resident to maintain weight within the healthy BMI (Body Mass Index) range (18.5-24.9) via monitor of weight report. He will continue to consume >50% of meal provided and nutritional supplement acceptance via daily PO intake observation. No noted s/s (signs/symptoms) of aspiration via daily observation. The approaches included, in part, the following: Adaptive equipment: Nosey cup with liquids to enhance feeding. And NAS/Puree texture/thin liquids diet, no straw. He is fed by staff. On 12/09/24 at 10:15 AM, observations revealed Resident #6 in his room, sitting up in a chair with a rolled washcloth in each hand wearing hand splints. Further observations revealed a Styrofoam cup containing water, sitting on the nightstand. There was no nosey cup at the bedside. On 12/09/24 at 12:10 PM, a second observation was made of Resident #6 in his room, with a Styrofoam cup containing water, at bedside. No nosey cup was observed. On 12/09/24 at 12:30 PM, observation was made of Resident #6 with a lunch tray brought into his room, containing apple juice and one nosey cup. Staff A, Certified Nursing Assistant (CNA) was assisting Resident #6 with eating. An interview was conducted on 12/09/24 at 12:32 PM with Staff A, who stated she has worked at the facility for [AGE] years. When asked about the nosey cup on the Resident #6's lunch tray, she said the resident needs the nosey cup to drink all liquids. On 12/12/24 at 9:56 AM, a side-by-side observation was made with Staff B, Nursing Manager, in the room of Resident #6, who acknowledged the resident had a Styrofoam cup with a straw, full of water at the bedside. There was no nosey cup observed. An interview was conducted on 12/10/24 at 9:50 AM with Staff C, Registered Nurse (RN), who stated she has worked at the facility since 2017. She was asked if a resident has adaptive equipment for a special cup, would the resident need the special cup for water at the bedside. She stated, when the resident has an order for adaptive equipment, it comes with the meals from the kitchen. When asked would the resident need the adaptive equipment for any liquids at the bedside, she said it would have to come from the kitchen.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 11.11 percent. Three medication errors were identified while observing a total of 27 opportunities, affecting 2 of 6 sampled residents observed (Residents #45 and #58). The findings included: 1) A medication pass observation for Resident #45 was made on 06/02/22 beginning at 8:28 AM with Staff A, a Registered Nurse (RN). The RN obtained eleven medications, to include nine pills, a patch, and an eye drop. The RN also poured a nutritional supplement. The medication prepared by the RN was as follows: a) [MEDICATION(S)] 10 mg (milligrams) - one tablet b) Calcium 600 mg - one tablet c) Vitamin B12, 250 mcg (micrograms) - one tablet d) [MEDICATION(S)] 5 mg - two tablet e) [MEDICATION(S)] Sulfate 325 mg - one tablet f) [MEDICATION(S)] Patch 5% g) [MEDICATION(S)] 17 gm (grams) - powder mixed in water h) [MEDICATION(S)] Sulfate ER (extended release) 60 mg - one tablet i) [MEDICATION(S)] - one tablet j) [MEDICATION(S)] Lubricant eye drops k) Vitamin D3, 50 mcg/2000 IU (international units) - one tablet l) ProHeal 30 ml (milliliters) - liquid nutritional supplement When asked if that was all that was due for this medication pass for Resident #45, the RN stated it was. The RN was asked to count the number of pills she had obtained for administration to Resident #45, as a way to verify the surveyor's documentation . The RN counted out nine pills, informing the surveyor she had poured out two of the [MEDICATION(S)] for administration. Staff A, the RN, administered the above medications and supplement to Resident #45. During reconciliation of the medications with the physician orders, the record documented the order for [MEDICATION(S)] ER 10 mg daily. Review of the corresponding Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/02/22 at 11:34 AM, when asked about the [MEDICATION(S)] that was ordered for daily administration, the RN stated, It was in there. The surveyor reviewed with Staff A the medications pulled from the medication cart for Resident #45, confirming the nine pills. The RN again stated she thought the [MEDICATION(S)] was in the medications that she had obtained from the cart, but agreed it could not have been. Staff A agreed with the medication error. 2) On 06/01/22 at 9:25 AM, an observation of medication administration was conducted with staff B on Resident # 58. Staff B administered 1 tablet of Multivitamin with mineral without a physician order, and Staff B omitted the Vitamin D3 1000 unit that was ordered to be administered at 9 AM. Staff B had administered the following medications to Resident #58: Multivitamin with Mineral 1 tablet by mouth; [MEDICATION(S)] 10 mg 1 tablet by mouth; and Aspirin 81 mg 1 tablet by mouth, for a total of 3 pills which was confirmed with Staff B before the administration. After the medication administration, the medications were reconciled and compared against the orders and the scheduled medications. It was revealed that there was no order for Multivitamin with Mineral that Staff B had administered, and the Vitamin D3 1000 unit, that was scheduled to be administered, was omitted. Once the surveyor questioned Staff B about these meds, Staff B, acknowledged the errors, she removed the Vitamin D3 1000 unit out of the medication cart and administered it to Resident #58. Record review revealed Resident #58 was admitted to the facility on [DATE], the quarterly Minimum Data Set (MDS) assessment reference date 03/23/22 documented a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. On 06/02/22 at 3:01 PM, an interview was held with the Director of Nursing (DON), she voiced she was made aware of the medication error by the attending nurse and the nurse was in-serviced.

Based on observation, interview, and record review, the facility failed to allow a resident to utilize a motorized wheelchair, who was otherwise immobile, for 1 of 3 sampled residents reviewed for neglect (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive assessment dated [DATE] documented the resident was independent, decisions consistent and reasonable, exhibited no moods, had behaviors verbal and other directed toward others, was a total two-person assist for bed mobility, transfers did not occur, had no locomotion on or off the unit, and no mobility devices. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, had no moods, no behaviors, no wandering, was a total two-person assist with bed mobility, transfer occurred 1-2 times with two-person assist, and mobility device was a wheel chair (manual or electric). Resident #1 was care planned, dated 06/16/15, for being dependent on staff for activities of daily living (ADL) needs. He is independent with locomotion in a motorized wheelchair (at this time resident is choosing to stay in bed). He gets agitated at times and it is his preference not to receive care from certain staff members and he frequently refuses care. An intervention, dated 06/01/21, documented out of bed to motorized wheelchair (manual wheelchair if motorized chair not available) to promote mobility as resident chooses, (at this time he is choosing to stay in bed). The care plan was last reviewed/revised on 01/03/22. An interview was conducted with Resident #1 on 02/03/22 at 10:30 AM. The resident was dressed, clean, and odor free. The resident stated he wanted to leave this facility, they won't let me leave. The resident further stated they refuse to let him get in his motorized wheelchair. The resident stated the facility said he threatened to run some over with his motorized wheelchair. The resident stated, they lied. Resident #1 stated he refused to get in his high back wheelchair, as he has no mobility, and dependent on staff. The resident stated if he cannot get into his motorized wheelchair, he will not get out of bed. An observation of Resident #1's room revealed a high back wheelchair and a motorized wheelchair in the corner of the room. An interview was conducted with Staff A, a Certified Nurse Aid, on 02/03/22 at 10:45 AM. Staff A stated Resident #1 refuses care. Staff A further stated the resident wanted to get out of bed to his motorized wheelchair, but administration said no. An interview was conducted with Staff B, a Licensed Practical Nurse, on 02/03/22 at 11:00 AM. Staff B stated Resident #1 always refuses care. Staff B further stated the resident was not allowed up to his motorized wheelchair per administration. An interview was conducted with the Director of Rehabilitation on 02/03/21 at 11:15 AM. The Director stated Resident #1 was not receiving services at the time. The resident was last screened 01/20/22 by Physical Therapy (PT) and Occupational Therapy (OT). Per PT, Resident #1 required total assistance, and was non-ambulatory. The Director further stated Resident #1 was not assesses as unsafe for motorized wheelchair use. Record review revealed two Psychiatry Progress Notes dated 09/10/21 and 12/03/21. Neither note deemed Resident #1 as incapacitated, or unsafe for use of a motorized wheelchair. A review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's record, did not reveal any documentation of the use of the resident's motorized wheelchair taken away, or any notification to the resident that he could no longer use his motorized wheelchair. An interview was conducted with the Director of Nursing (DON) on 02/03/22 at 4:30 PM. The DON stated Resident #1 had threatened to run over a staff member with his motorized wheelchair once. The DON further stated Resident #1 was a flight risk/elopement risk. The DON acknowledged Resident #1 was cognitively intact and able to make his own decisions. The resident had not been deemed incapacitated, and there was no assessment or documentation of the resident being unsafe for use of a motorized wheelchair. The Nursing Home Administrator was not available during survey.

Based on observation and interview, it was determined that the facility failed to ensure the resident environment remained free of accidents hazards that included failure to secure insulin syringes and lancets on 1 ([NAME] Wing) of 5 residential wings. The findings included: During the observation of the lunch meal on he [NAME] Wing on 05/17/21 at 12:35 PM, it was noted that one of the medication carts was located in the main hallway, just outside of the entrance to Room #220. Further observation noted that a box of Insulin Syringes (100 count) and a case of Lancets were stored in view on top of the cart. Further observation noted that no staff (nurses, CNA's) were in the area. After waiting 5 minutes no nurse was noted to come to the medication cart . The surveyor then took the box of syringes and lancets off the cart and brought them to the nurses station. The boxes were given to the Charge Nurse who stated to the surveyor that sharps should not be left unattended on medication carts and that sharps must be properly securely stored at all times. The Charge Nurse stated that she would investigate and get back to the surveyor as to why this occurred. On 05/17/21 at 12:55 PM, the Charge Nurse approached the surveyor and stated that the Central Supply (Staff A ) left the boxes of sharps on the medication cart and failed to inform the nurse that the sharps were left unattended on the medication cart. Interview with Staff A on 05/17/21 at 1 PM, it was reported that he was trained to not leave sharps unattended and did so without thinking. During an interview conducted with the [NAME] Wing Charge Nurse on 05/17/21 at 2 PM revealed that the [NAME] Wing hallway (Room's #211-228) houses 10 residents who ambulate independently without staff supervision who could come into contact with the unsecured syringes and lancets. It was also noted on 05/17/21 documentation submitted by the Administrator that staff were in-serviced on the required policy of sharps delivery and storage.

Based on observation, record review, and interview, it was determined that the approved menu for pureed diets was not being followed for 8 facility residents which included 2 sampled resident's (Resident's #46 and #69) who were reviewed for Nutrition. The findings included: During the review of the approved menu for the lunch meal of 05/19/21 it was noted that the residents who were on the pureed diets were to receive : Pureed Baked Fish Pureed Caramelized Onions Pureed Yellow Rice Purred Stewed Tomatoes Pureed Frosted Yellow Cake During observation of the lunch meal meal tray assembly line on 05/19/21 at 11:30 AM, it was noted that the staff failed to puree caramelized onions, yellow rice, stewed tomatoes, and frosted yellow cake. Interview with the Facility Cook (Staff B) at the time of observation, was noted to state that he failed to review the approved pureed menu for the lunch meal of 05/19/20 and further stated that he failed to prepare the pureed caramelized onions. He further stated that he failed to prepare the pureed stewed tomatoes and prepared cream of Rice Cereal in place of pureed Yellow Rice. The cake was pureed but failed to have frosting included in the cake mixture. Further interview with Staff B noted a lack of training and skill in the preparation of pureed foods to include following menus, pureed food restrictions for Dysphagia diets, and pureed food palability and appearance. During the review of the facility's diet census for 05/20/21, it was noted that there were currently 8 residents which included Resident #46 and Resident #69 with physician ordered pureed diets. Of the 8 facility residents all were noted to have a diagnoses of Dysphagia. During the observation of the lunch meal conducted on 05/19/21 at 11:30 AM, it was noted that green beans were prepared and ready to be served to pureed diets. Further observation noted that large pieces could be seen within the green bean mixture. The green bean pureed mixture was taste tested by the surveyor and the facility's Consultant Dietitian . The testing confirmed that the green bean pureed mixture was not smooth in consistency and contained large pieces of the vegetable. It was further discussed that residents with a diagnoses of Dysphagia and swallowing issues requires a smooth purred mixture to ensure that choking and aspiration does not occur. Further interview with the facility's Consultant Dietitian on 05/19/21 noted that the facility's Speech Pathologist (SLP) gave an in-service to the dietary staff concerning pureed diets. It was noted the SLP to state that the facility was not pureeing foods to the required consistency and that many foods that are currently on the approved menu should be deleted because they cannot be properly pureed to meet the needs of dysphagia residents. Review of the Diet Census for 05/19/21 noted 8 residents with physician ordered pureed diets which included sampled Resident #46 and # 69. It was further noted that all 8 residents including Resident's #46 and #69 had a current diagnoses of Dysphagia.

Based on observation, interview, and record review, it was determine that the facility failed to prepare pureed food in a form to meet the needs of 8 facility residents that included 2 of 2 sampled resident (Resident #46 and #69). The findings included: During the observation of the lunch meal in the main kitchen conducted on 05/19/21 at 11:30 AM, it was noted that green beans had been prepared and ready to be served to residents who were prescribed pureed diets. Further observation noted that large pieces could be seen within the green bean mixture. The green bean pureed mixture was taste tested by the surveyor and the facility's Consultant Dietitian . The testing confirmed that the green bean pureed mixture was not smooth in consistency and contained large pieces of the vegetable. It was further discussed that residents with a diagnoses of Dysphagia and swallowing issues require a smooth pureed mixture to ensure that potential choking and aspiration does not occur. Interview with the facility's Consultant Dietitian on 05/19/21 revealed that the facility's Speech Pathologist (SLP) in-serviced dietary staff concerning preparation of pureed foods. It was revealed that SLP confirmed that staff did not have current knowledge of preparing pureed foods to required thin consistency and that pureed foods being served were not the proper thin consistency required for Dysphagia residents. During a review of the facility's diet census for 05/19/21, it was noted that there were currently 8 residents which included Resident #46 and #69 with physician ordered pureed diets. Of the 8 facility residents, all were noted to have a diagnoses of Dysphagia.

Based on interview, observation, and record review the facility failed to follow doctor's orders for fluid restriction for 1 of 5 sampled residents reviewed for nutrition, Resident #32. The findings included: Resident #32 was admitted to the facility on [DATE] with admission diagnosis of End Stage [CONDITION(S)] and dependence on renal [CONDITION(S)]. Other significant diagnoses include but not limited to the following: a Left Leg Above the Knee amputation, Paranoid [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] of left non-dominate side related to [CONDITION(S)] disease and Type 2 Diabetes Mellitus with diabetic chronic kidney disease. The last complete Minimum Data Set (MDS) assessment was the Quarterly MDS dated [DATE]. The following findings were documented in the assessment: C- Cognitive Brief Interview of Mental Status (BIMS) 13 mild impairment G- Functional Status Bed mobility - extensive assistance, one person assist. Transfer - total dependence, two + person assist Walk in room did not occur Locomotion on unit extensive assist, one person assist Locomotion off unit extensive assist one person assist Eating independent, set-up only Toilet use - total dependence, two + assist Personal hygiene - independent, set-up only H - Bowel and Bladder - frequently incontinent of urine always incontinent of bowel. J- Health conditions (Pain)- has occasional pain 6/10 over the last 5 days (prior to 2/15/21) K- Swallowing/Nutritional Status - no issues. M-Skin Conditions - potential for ulcers, negative for skin conditions, preventative equipment employed. N Medications - Antipsychotic for past 7 days (prior to 2/15/21), Insulin for past 7 days (prior to 2/15/21). O Special Treatments - [CONDITION(S)] while a resident. Resident #32 had orders for Hemodialysis three times a week on Monday (M), Wednesday (W) and Friday (F) with a 10:45 AM chair time. There was an order for snacks to go with the resident for hemodialysis. Resident #32 had a fluid restriction order, placed on 01/13/2020, of 1000 milliliters (ml) a day. This fluid restriction was documented as follows: Per [CONDITION(S)] restrict fluid intake to 1 Liter daily. Special Instructions: 400 ml nursing (200ml 7-3, 120 ml 3-11 and 80 ml 11-7) 600 ml dietary (200 ml at each meal). Every shift; Day, Evening, Night. This order is considered open ended (no end date). During an interview with the facility's Regional Dietary Consultant on 05/20/21 at 9:34 AM, a disclosure was made that Resident #32 preferred to have snacks at [CONDITION(S)] instead of meals, however, the planned selections to be prepared for Friday 05/21/21 included a package of [NAME] Doones shortbread cookies, a turkey sandwich and 4 ounces (oz) of juice. (4 oz of liquid is equivalent to 240 ml). Resident #32 also had a dietary supplement of Nepro- 1 8 fluid (fl) ounce carton twice a day. Resident #32 had an order for monthly weights as weights could vary with [CONDITION(S)] and monthly weights helped the dietician evaluate needed changes in response to overall weight changes month to month and over a 6-month period. There was an order to monitor [MEDICATION(S)] levels monthly as phosphates affect kidney function. On 05/20/21 at 9:34 AM, during an interview with the Regional Dietician for the facility, a review of the menu selections for 5/19/21 revealed the following beverage selection: For breakfast 6 oz of coffee which is equivalent to 180 ml, for lunch 8 oz of apple juice which is equivalent to 240 ml and for dinner 8 oz of apple juice (240 ml) and 6 oz of coffee (180 ml). The total fluid intake totaled to 840 ml for dietary for the day. This exceeded the ordered amount for dietary of 600 ml by 240 ml. The order for 8 oz of Nepro twice a day added 172 ml of water per serving based upon the label on the Nepro, which identifies water as an ingredient for calculating intake. Water on the label is identified as 172 grams (g). 1 g of water is equal to 1 ml of water. This added 344 ml to the daily intake which brought the dietary total up to 1,184 ml. This alone was 184 ml more than the ordered 1000 ml not counting the 400 ml allotted for nursing. On 05/20/21 at 09:38 AM, an interview was conducted with Staff C, a Registered Nurse (RN), who was assigned to care for Resident #32. Staff C explained that she provided Resident #32 with 60 ml of water for each of the medication administrations for Resident #32. When asked to explain how she knew how much water she was providing, Staff C stated she was using a medicine cup, which was delineated for volume, to measure the 60 ml. The medicine cup had a full capacity of 30 ml, which would require two fillings to make 60 ml. The 60 ml was pouring into a plastic drinking cup. Staff C stated that she administered medication twice a day to resident #32. This meant that Staff C was providing Resident #32 with 120 ml of water for the first shift. An observation of Resident #32's room revealed that the resident had a left-over cup of coffee from breakfast in his room with no other beverages observed. On 05/20/21 at 10:02 AM, an interview was conducted with the food services Production Supervisor who explained how to interpret the meal tickets for the residents. The Production Supervisor explained that dietary personnel enter the menu selections for each resident into a tablet that is connected to the dietary network. The orders for the residents are then printed to be used on the line for the plating of the meals. The Production Supervisor explained that the meal ticket daily shows the actual selections served to the resident in green when printed. A review of the food orders for Resident #32 for 5/16/21 to 05/19/21 showed that the beverage selection for these dates were consistent with the initial review done for the day 05/19/21 as follows: For breakfast 6 oz of coffee which is equivalent to 180 ml, for lunch 8 oz of apple juice which is equivalent to 240 ml and for dinner 8 oz of apple juice (240 ml) and 6 oz of coffee (180 ml). The total fluid intake totaled to 840 ml for dietary for each day. Adding the 344 ml for the Nepro daily as well as the 400 ml allotment for nursing brings the total volume to 1, 584 ml a day, which is more that 50% additional volume. This puts additional strain on the kidneys, which are already failing. The care plan for Nutritional Status, with a start date of 01/05/2018, states the problem as follows: 3/8 Weight gain is showing a significant gain for 90 days, which is a reversal of weight loss from hospitalization at that time. Increased nutritional needs related to ESRF (End Stage Renal Failure) with hemodialysis. Anticipated wt (weight ) fluctuations R/T (related to) [CONDITION(S)] (End Stage [CONDITION(S)]), [CONDITION(S)] disease and inconsistent PO (by mouth) intake. The goal for Nutritional status states: Weight stable at 155 # (pounds) +/- 5% through monitoring of weight. No S & S (signs and symptoms) of hyper/[CONDITION(S)] (high or low blood sugar levels) will be experienced through daily monitoring. The approach that addresses the fluid restriction states: CCHO (controlled carbohydrates), NAS (no added sodium) avoid high potassium foods diet. 1000 ml fluid restriction. This approach was started on 02/24/20.

Based on observation and interview, it was determined that the facility failed to treat 19 residents including 3 of 3 sampled residents (Resident #61, #81, and #101) with respect and dignity that included to serve beverages in proper drinking cups and not require residents to drink beverages from cartons. The findings included: During an observation of the breakfast meal on the Manatee Unit on 09/11/19 at 7:45 AM, it was noted that 5 residents were seated in the dining room area. Further observation noted that all five residents which included Resident #61 were served a breakfast tray that included a carton milk. It was noted that during the serving of the meal the milk was not poured into a drinking cup and the residents were required to drink directly from the carton. It was also noted that the issue was the same for the 14 resident breakfast trays served to the rooms on the Manatee unit which included Resident # 81 and # 101. Continued observation noted that a tray of drinking cups was located on top of the food delivery cart, however staff failed to utilize any of the cups for drinking purposes. At the request of the surveyor, the issue was brought to the attention of the Director of Nursing and the Certified Dietary Manager (CDM). Both were unaware that residents should not be drinking out of beverage cartons and that a drinking cup should be provided for all beverages. The CDM further stated that the tray of drinking cups provided on top of the food transportation cart were for resident water and not for milk.

Based on observation, interview, and record review the facility failed to provide tube feeding to meet the nutritional needs for 1 of 3 sampled residents, Resident #79, receiving nutrition by [DEVICE]. The findings included: On 09/09/19 at 2:54 PM, during the Initial Pool process, a notation was made regarding changes in weight for Resident #79. Investigation revealed that Resident #79 was readmitted to the facility after hospitalization on [DATE]. At that time the resident's weight was documented as being 168 pounds. Prior to the hospitalization the resident had been ordered [MEDICATION NAME] 1.5 Kcal (Kilocalories) via PEG tube. A PEG tube, Percutaneous Endoscopic Gastrostomy, is a tube placed through the skin of the abdomen into the stomach to allow for alternative feedings and medication administration. [MEDICATION NAME] is a type of formula used for feeding by PEG. The orders for the PEG read [MEDICATION NAME] 1.5 Kcal at 65 ml / hr (milliliters per hour) for 20 hours. This provided 1950 Kcal total. According to the dietary note dated 08/05/19 the resident also received a protein supplement (ProMod), which brought his total intake to 2050 Kcal with 93 grams (g) of protein and 2788 ml of fluid. This was documented as meeting the nutritional needs of Resident #79 as evidenced by no significant weight changes from 30/90/180 days out to present. Upon return to the hospital on [DATE] the resident's feeding was changed, per hospital order, to a flow rate of 55 ml/hr. This reduced his caloric intake to 1650 Kcals with 70 grams of protein. On 09/10/19, during an interview with the Unit Manager of the Pelican Unit, where Resident #79 resides, the Unit Manager disclosed that the nurses had noticed a discrepancy in reported weights for those residents who are weighed by Hoyer lift. A change in procedure and a recalibration of the lift were performed. This recalibration was done internally using a 10-pound weight. Further record review provided the following information: 1. On 08/29/19 the resident weighed 168.2 pounds 2. On 08/30/19 the resident weighed 167.4 pounds 3. On 08/31/19 the resident weighed 165.4 pounds 4. On 09/03/19 the resident weighed 159.5 pounds 5. On 09/04/19 the resident weighed 157.9 pounds 6. on 09/05/19 the resident weighed 156 pounds 7. On 09/09/19 the resident weighed 158.4 pounds 8. On 09/11/19 the resident weighed 152.6 The weight on 09/11/19 was observed by the surveyor. On 08/29/2019, the resident weighed 168 pounds. On 09/11/2019, the resident weighed 152 pounds which is a -9.52 % Loss. This loss took place over 13 days. During an interview, on 09/11/19 at 1:53 PM, with the Dietetic Technician, she stated that she missed the change in the feedings where the flow rate was reduced from 65 ml/hr to 55ml/hr. The Dietetic Technician stated that the resident, who was known to be receiving nutrition by PEG, should have been re-evaluated within the first three days after re-admission. She also stated that she would have made the recommendation at that time to return the resident to his prior feeding regimen. The new evaluation was made on 9/11/19 and the recommended feeding adjustment was documented.

Based on observation, interview, and record review , it was determined that the facility failed to follow physician orderd therapeutic diets (Low fat/Cholesterol) for 1 (Resident #101) of 6 sampled residents. The findings included: During the observation of the breakfast meal in the Manatee Unit on 09/11/19 at 8 AM, it was noted that the meal ticket provided on the tray of Resident #101 documented Low Fat/Cholesterol, CCHO, No Straws. Observation of the resident's breakfast tray noted that a serving of regular sausage and cheese grits was provided on the Low Fat/Cholesterol diet. An interview conducted with the Diet Technician (DT) at the time of the observation noted to state that the approved menu does not have a spread sheet for the diet of Low Fat/Cholesterol and that the Carbohydrate Controlled (CCHO) diet is used in its place. The DT agreed that the sausage and grits should not have been served on the Low Fat/Cholesterol diet . During a review of the clinical record of Resident #101 on 09/11/19, it was noted an original admission date of [DATE] and current physician orders [REDACTED]. A second interview conducted with the DT on 09/11/19 revealed that the facility's Consultant Dietitian group was called and stated that the facility currently does not have a Low Fat/Cholesterol and that one would be crated and implemented on 09/11/19. Also revealed during ther interview that the facility currently has 18 residentsincluding Resident #101 with physician ordered Low Fat/Cholesterol Diet. A second interview conducted with the CDM on 09/11/19 revealed that the failed to purchase and serve low fat sausage and low fat cheese grits to residents receiving Low fat/Cholesterol diets. During the observation of the lunch meal of 09/11/19 and interview with the Certified Dietary Manager (CDM)it was again noted that the lunch main entree of Egg Salad Sandwich was not made utilizing fat free mayonnaise in place of regular mayonnaise. The CDM stated that staff forgot to prepare the low fat Egg Salad Sandwich.

Based on observation, interview, and record review, it was determined that the facility failed to provide physician ordered special eating equipment (Dysphagia cup) for 1 (Resident #61) of 6 sampled residents. The findings included: During the observation of the breakfast meal in the Manatee Unit on 09/11/19 at 7:45 AM, it was noted that tray was served to Resident #61 in the dining room. Further observation noted that a Dysphagia drinking cup was only provided for coffee and no Dysphagia cup was provided for the serving of orange juice and milk. A review of the meal tray provided documented tan dysphagia cup. Further observation of the breakfast meal noted that Resident #61 drank all of the beverage in the served in the Dysphagia cup and drank 0% of the beverages provided in the regular drinking glass. During review of the clinical record of Resident #61 on 09/11/19, noted an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of current physician's orders [REDACTED]. During an interview with the Director of Skilled Therapy and review of Occupational Therapy screening it was noted that Resident #61 was assessed by the Occupational Therapist on 09/12/17. The screening documented that the resident suffered from right hand tremors and that weighted cups were needed for all meals. A review of the resident's current care plans noted the problem of Nutritional Risk for fluid imbalance with the intervention dated 07/31/19 for a Dysphagia cup to enhance self feeding skills.

Based on observation, record review and interview, the facility failed to assess 2 of 2 sampled residents with devices used as restraints, for the need and use of the restraint (Resident #29 and #76). The findings included: 1) On 02/25/19 at 9:31 AM Resident #29 was noted in bed. A specialty chair with a seat belt was observed in the room. A review of the record lacked any documentation related to a restraint. An observation on 02/25/19 at 3:05 PM revealed Resident #29 in the TV room. The resident was in a Broda Pedal Rocker (the specialty chair) with a seat belt noted. On 02/26/19 at 12:23 PM Resident #29 was being fed by Staff A, a Certified Nursing Assistant (CNA). The resident and the CNA were in the TV room during the meal, while the surveyor at the nurse's station was able to observe the entire meal. At no time did the resident attempt to take off the seat belt. When asked about the seat belt, the CNA volunteered they also had a chair alarm on because he the resident was known to unhook the seatbelt and had tried to get up. The CNA stated, We don't want him to fall. Review of the record revealed Resident #29 was admitted to the facility on [DATE]. The current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #29 needed extensive to total assistance for all Activities of Daily Living (ADLs). This MDS lacked any falls since the previous assessment, and lacked any documented restraints. During an interview on 02/27/19 at 9:51 AM, the Director of Therapy and Staff B, an Occupational Therapist (OT) both stated that Resident #29 could self release the seat belt. The Director of Therapy stated that most of the time Resident #29 would open the seat belt when he wanted, not when asked specifically to do so. The therapy staff were asked if Resident #29 was assessed for the use of the potential restraint, and the Director of Therapy stated they never considered the device as a restraint, or the need to assess the device as a restraint. During an observation on 02/27/19 at 12:43 PM, Resident #29 was asked in Spanish to unbuckle the seat belt by both the Manatee Unit Manager, and then a few minutes later by the Activity Director. Resident #29 did not follow the request and further stated, No. When asked if a less restrictive belt like a Velcro belt had been attempted, the Unit Manager stated he didn't think so. The Unit Manager stated the reason for the seat belt was for a reminder not to get up out of the chair, as the resident had gotten up in the past and fallen. Resident #29 was observed multiple times during the four day survey in or about the TV room, and at no time did the surveyor observe the resident attempting to remove the seat belt. Further record review revealed the original order dated 06/07/16 for the seat belt for safety. A current order dated 12/21/17 documented, Self release seat belt alarm for poor safety awareness related to needs assistance with transfer. Review of the current fall care plan documented the approach dated 12/22/17 for a self release seat belt alarm to the wheel chair related to poor safety awareness. 2) On 02/25/19 at 3:08 PM, Resident #76 was observed sitting up in wheel chair with a full lap tray noted in place. Review of the record revealed Resident #76 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented Resident #76 needed extensive to total assistance for all ADLs, had not had a fall, and no documentation related to a restraint. A current order dated 02/13/19 documented, Lap tray for the wheelchair for upper extremity positioning and improving posture. During the continued interview on 02/27/19 beginning at 12:43 PM, the Unit Manager stated Resident #76 could push the tray away from himself, but could not remove it. The Unit Manager and Director of Therapy were asked to locate and provide the assessment for the lap tray as a possible restraint, and again the Director of Therapy stated they did not think of the lap tray as a restraint.

Based on observation, record review, and interview, the facility failed to provide needed fingernail care for 1 of 24 sampled residents (Resident #88). The findings included: An observation on 02/24/19 at 10:00 AM revealed long thick fingernails to the right hand of Resident #88. Review of the record revealed Resident #88 was admitted to the facility on [DATE], with no discharge or hospitalization . Review of the current Minimum Data Set ((MDS) dated [DATE] documented Resident #88 needed the extensive assist of one person for personal hygiene. Resident #88 was not a diabetic. Review of the current care plan dated 07/26/18 with a revision on 02/16/19 documented Resident #88 needed extensive/total assistance with most of his ADLs (Activities of Daily Living). An intervention was that staff were to provide needed assistance. During an interview on 02/26/19 at 10:52 AM, Staff A, a Certified Nursing Assistant (CNA) confirmed they clip and clean fingernails of the residents. Staff A stated Resident #88 was cooperative with his care. Upon observation of the resident's nails with the CNA in the common area, Resident #88 stated he does not mind having his nails trimmed. The Manatee Unit Manager joined the conversation to explain the resident's fingernails grow very quickly, and that he personally trims the resident's nails weekly. This closer observation revealed the resident's fingernails on his left hand were very thick and broken off at different levels of the nail bed. The fingernails on his right hand were thick and elongated beyond the finger, and wider than the normal fingernails. The Unit Manager was asked to locate and provide evidence that the resident's fingernails had been addressed by a physician or dermatologist. During an interview on 02/26/19 at 11:30 AM, the Manatee Unit Manager stated Resident #88 had not been seen by dermatology for his fingernails. When asked if his attending physician or the Advanced Registered Nurse Practitioner (ARNP) had addressed his fingernails, the Unit Manager stated that he verbally spoke with the ARNP about the resident's fingernails, but he does not think she documented anything. During an interview on 02/26/19 at 12:23 PM, the Assistant Director of Nursing (ADON) was asked if she had any knowledge about the fingernails of Resident #88. The ADON stated she did not, and was told of the observation of thick jagged nails to the left hand and thick fingernails to the right hand. The ADON visualized the fingernails, and placed a call to the ARNP who stated she had not addressed the fingernails. The ADON stated she was going to have the ARNP take a look at them as she agreed with the observation. Review of the ARNP Progress Note dated 02/26/19 at 12:59 PM, after surveyor intervention, documented the plan was to start Resident #88 on Terbinafine (an antifungal medication) daily for 12 weeks, and to consult dermatology.

Based on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents observed for pressure ulcers was provided with preventative care and services to prevent a pressure ulcer. Resident #76 was observed on a non-functioning specialty air mattress, and the Certified Nursing Assistant (CNA) failed to notify the nurse of a new open area. The findings included: An observation on 02/24/19 at 10:28 AM revealed Resident #76 lying in bed. A specialty air mattress machine was noted at the end of the bed, but it was not turned on at present time. A second observation on 02/25/19 at 9:42 AM revealed Resident #76 lying in bed. The specialty air mattress power was not on. The electronic screen to the machine was dark. There was no sound of a functioning air mattress. An observation of Resident #76 was made on 02/26/19 at 10:12 AM with Staff C, a CNA, who stated she had just recently completed morning care to include a full bath. She reported the specialty air mattress was functioning, as it was heard and the electronic screen was illuminated. Resident #76 was clean and dressed, lying in bed on his back, with the head of the bed elevated. The CNA stated there were no skin issues. The CNA was asked to do a skin check, in order to have the surveyor observe the resident's bottom. An observation of the buttock revealed a protective ointment on each buttock. Upon observation of the skin, a small (approximately 1 cm x 0.25 cm) open area was noted at the top crease of the buttock. The CNA stated she did not notice the open area. Staff D, the Registered Nurse (RN) caring for Resident #76 was called into the room and agreed with the observation. The RN stated it was a new area and would be treated with the barrier cream, and an event report would be completed. On 02/26/19 at 12:16 PM, the Assistant Director of Nurse (ADON) agreed with the observed open area of Resident #76, stating that she was called up to look at it. The ADON was informed the CNA provided care that morning, verbalized there were no skin issues or concerns, that upon observation with the CNA the surveyor identified the open area, and then the RN was notified. The ADON agreed and stated the open area was 1.0 cm x 0.3 cm. Review of the record revealed Resident #76 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented Resident #76 needed extensive to total assist for all Activities of Daily Living (ADLs). This MDS documented the resident was at risk for developing a pressure ulcer, did not have a current pressure ulcer, and had a pressure reducing device for the bed. Review of the current care plan dated 04/04/18 with a revision date of 02/03/19 documented Resident #76 was at risk for skin breakdown, with interventions to include an air mattress and Clinitron pad.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that 1 of 3 sampled residents, Resident #18, with limited hand mobility received appropriate services, equipment, and assistance to maintain and or improve mobility. The facility also failed to ensure restorative nursing services related to mobility and range of motion services were provided for 1 of 1 random sampled residents, Resident #76, as per therapy recommendation. The findings included: 1) During the initial tour of the facility on 02/24/19 at 10 AM, it was noted that Resident #18 was in bed, unable to communicate, and had severe contractures of the left and right hands without any splint or contracture devices. Continued observations conducted hourly of Resident #18 on 02/24/19 (10 AM through 2 PM, and 02/25/19 (8 AM through 2 PM) again revealed no hand splints or contracture relieving devices. During the review of the open clinical record of Resident #18 on 02/25/19 it was noted an original admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the record and current physician's orders [REDACTED]. Interview and observation of R #18 on 02/26/19 with the Nurse Manager of the Sandollar Wing on 02/26/19 at 9 AM revealed that the resident only had a hand roll to the left hand. The manager confirmed that the order is for the hand rolls at all times and further stated that the night shift had not applied the rolls on 02/24/19, 02/25/19, and 02/26/19. Interview with the Director of Skilled stated that the order for the hand rolls was much earlier than the date because of a computer upgrade. The Director submitted an Occupational Therapy Screening Form dated 02/11/19 that documented the resident presented flexion contractures of bilateral wrist, hand, elbow, and limited range of motion to bilateral shoulders. The form further documented the resident is unable to tolerate palm protectors secondary to not wanting to wear them. The Director stated that the resident was further assessed to benefit from bilateral hand with rolled wash cloths for the contractures although this was not documented in the screening. On 02/27/19 the Director of Skilled Therapy submitted a Occupational Therapy Screening Form dated 02/26/19 that documented recommendation to continue with rolled washcloths on bilateral palms for contracture management. Additional record review on 02/27/19 noted a current care plan for the problem of ADL Function of which the approach was to provide a rolled wash cloth to bilateral hands as per physician order. 2) During an interview on 02/24/19 at 10:51 AM, an adult family member of Resident #76 stated the resident used to be up and about all the time. The family member voiced concerns that he had not seen Resident #76 up in the last 3 to 4 months. The family member stated he visits every week or every other week at minimum. Review of the record revealed Resident #76 was admitted to the facility on [DATE]. Review of the physician order [REDACTED].#76 was to be out of bed to his high back wheel chair daily. Review of the current care plan dated 07/17/18, with a revision on 01/27/19 documented the resident was dependent on staff for his Activities of Daily Living, and that he was to be out of bed daily. An interview was conducted on 02/26/19 at 1:12 PM with Staff C, a Certified Nursing Assistant (CNA). Staff C explained the normal routine for Resident #76 was to get him up between 12:00 PM and 1:00 PM so that he could go to restorative therapy. Review of the restorative nursing for active range of motion services from 1/26/19 through 02/26/19, documented the services were provided only 1 to 3 times weekly, with a total of only nine restorative sessions documented. The record lacked any refusals from the resident during that same time period. Review of the restorative services from 01/10/19 through 01/26/19 documented only 6 sessions were completed. During an interview on 02/26/19 at 12:43 PM, the Restorative Nurse explained Resident #76 goes to the gym Monday through Friday for restorative services related to range of motion. When asked for the documented order, the Restorative Nurse provided the Transfer to Restorative Nursing assessment completed on 01/10/19 that documented Resident #76 was to receive restorative nursing services 5 times weekly for 3 months. The Restorative Nurse stated that the resident goes to the gym unless he is not feeling well or is out on leave, and the aides working on her team should chart the interventions or lack of interventions daily. Review of the Restorative Nursing Report with the Restorative Nurse for the past 30 days lacked any documented reason for not providing the restorative services. The Restorative Nurse agreed the restorative services were not documented as completed. The Assistant Director of Nursing (ADON), who was present during the interview, agreed there should be documentation of the restorative services, or the refusal or lack of services.

Based on interview and record review, the facility failed to follow the post elopement plan of care for 1 of 1 sampled residents, Resident #31, reviewed for elopement by not ensuring that the resident's picture and important information was added to the Roam Alert Binders/elopement books. The findings included: Resident #31 was admitted to the facility with a history of Diabetes Mellitus 2 with diabetic [MEDICAL CONDITION], Cerebral infarction, [MEDICAL CONDITION]. Review of the Minimum Data Set (MDS) assessment on 12/4/18 noted Brief Interview for Mental Status (BIMS) 8, with some cognitive impairment. On 01/26/18 the resident left the facility unaccompanied by staff or family. On 02/24/19 at 01:45 PM, Resident #31 was observed lying on his bed and stated that he wears an ankle alarm and lifted his trousers to show the surveyor. The resident stated that he did not get permission to go out on the road to the corner gas station. On 02/26/19 at 12:55 PM, the Registered Nurse (RN) Manager on the 2nd floor Pelican Unit conducted a side by side review of the Roam Alert/elopement book and agreed that there was no information or picture of Resident #31. On 02/26/19 at 3:30 PM, the Risk Manager discussed the elopement of Resident #31 and stated the resident had not been assessed as an elopement risk with admission, but on 01/26/18 the resident left the facility without permission, pass or an order. After investigation, an elopement Adverse Day 1 and Day 15 Report was filed on 02/09/18. The Risk Manager stated that Roam Alert Binders/elopement books were just updated on 02/26/19 to include Resident #31 after the surveyor asked why Resident #31's picture was not in the Alert Binders/elopement books as noted in his plan of care. On 02/27/19 at 12:10 PM elopement books on 1st, 2nd, 3rd floors were all reviewed and now featured a picture and information on Resident #31 with added date of 2/26/19. Review of the Policy and Procedure for Missing Resident or Departing Resident noted Elopement occurs when a resident leaves the premises or safe area without authorization to do so . The Risk Manager/designee will ensure that the resident's picture and appropriate information is added to the Roam Alert Binders Roam Alerts will be checked by the nursing staff at least daily for functioning. The plan of care for Resident #31 listed: Elopement Risk related to altered mental status - start date 11/01/18 revised 12/12/18. Goal: Resident will not leave facility without supervision of an escort. All staff is aware and new staff informed of elopement risk. His picture is to be placed in elopement books located in the facility. Roam alert on right ankle Roam alert to be checked daily to ensure it is functional. On 02/27/19, the Risk Manager responded to a request for documentation that Resident #31 was being monitored and the Roam Alert is checked. The Risk Manager stated that the Roam Alert check off books for elopement residents are on all the units but on the Pelican Unit (where resident resides) the book could not be located and that a call had been placed to the night staff for information on location of the said book. Adequate supervision could not be verified.