Every finding on record at Emerald Nursing and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure sufficient qualified nursing staff were always available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. The findings include: On Sunday 06/08/25 at 9:15 AM an initial tour of the facility was conducted. During the entrance, the surveyors were informed that the Director of Nursing (DON) was in the building, however, after further investigation, the receptionist stated that the DON was on her way. During the tour, nursing staff were interviewed, and no specific person was designated as in charge. Staff DD, Registered Nurse (RN), who stated she has worked at the facility for 2 years in the [NAME] wing. She was asked who she contacts if something goes wrong, she stated a name but could not recall the last name (the name was not on the staff board as one of the unit managers or supervisors) and stated that this person is usually the unit supervisor when she comes in at 7:00 AM; however she believes she left for the day. Then, Staff DD stated she was not sure who is in charge right now. Review of the units listed unit supervisors' names on the staff board, however at 9:23 AM no supervisor was seen on the units. At 9:48 AM while touring the South wing noted the Assistant Director of Nursing (ADON), one of the unit managers and the DON. An interview was conducted on 06/10/25 at 8:45 AM with Staff X, CNA, who stated she has worked at the facility for 1 year as a floater. She stated that on Sundays some staff members have called out and the residents are divided among the CNAs that are in the facility. She stated this can add an additional 2 to 3 residents to her schedule. On 06/10/25 at 9:19 AM an interview was conducted with Staff M, Licensed Practical Nurse (LPN), who stated she has worked at the facility for over a year part time and usually in the Central wing. She stated that she does not often work on the weekends and sometimes just Saturdays. She has noticed that on occasion they are short staff during the Saturday. She stated currently her assignment is 30 residents. During an interview conducted on 06/10/25 at 2:17 PM with Staff BB, CNA, who stated she has worked at the facility for over 10 years. She stated she has noticed that on some weekends she has had 12 plus residents scheduled to provide care due to staff members calling out. Staff AA said she currently cares for 10 residents which is her usual. On 06/10/25 at 3:20 PM an interview was conducted with the Director of Nursing (DON), who stated she started about a week and a half ago. She was made aware that the facility was flagged low weekend staffing. She stated that it will not happen again, she was aware that the staff was not happy with previous management. During an interview conducted on 06/10/25 at 4:32 PM with Staff Z, CNA, who stated she has worked at the facility for 10 years. She stated that she is often scheduled to care for 10 residents, however, there have been days that she has to provide care for 13 plus residents due to not having enough staff, especially on the weekends. On 06/10/25 at 4:41 PM an interview was conducted with Staff Y, CNA. She stated she has worked at the facility for 16 years and scheduled to the [NAME] wing. Staff Y stated she currently cares for 9 to 10 residents, however on some weekends she can be scheduled to provide care to 11 to 12 residents and often she feels rushed to provide the care and finish on time.

). During an observation of the mechanical ware washing machine, as part of the initial kitchen tour, it was noted that the water temperature of the rinse cycle did not reach the 160 degrees necessary for hot water sanitizing, and that there was an accumulation of residue on the spray arms and nozzles inside of the ware washing machine. At the time of the observation, the Food Service Director acknowledged the concerns and stated that the machine will default automatically to chemical sanitizer when hot water sanitizing was not working appropriately. 4). During an observation of lunch being served to the residents in the Dining Room, on 06/08/25 at 1:04 PM, the following were noted a. Saff K, Restorative Aide, was observed pouring coffee into the basin of the only hand washing sink in the Dining Room. Moments after pouring the coffee into the sink, Staff L, Restorative Aide, approached the sink and began washing her hands, without having the sink cleaned and disinfected sine pouring the coffee into the basin. b. Single serve condiments, coffee cups, single use and disposable utensils were stored on a counter directly under a pest control device with a glue board. At the conclusion of the meal, the Food Service Director acknowledged understanding of the concerns. Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses during two of the two visits to the main kitchen. The findings included: 1. In a tour of the main kitchen on 6/08/2025 at 9:15 AM with the Food Service Director, the following issues were noted: Five out of eight air conditioning air filters were noted to be clogged and soiled, accumulated with a grease-like substance and other contaminants typical of a kitchen environment. The Delfield reach-in refrigerator had a thermometer located in the back with a reading of 59.0 Degrees Fahrenheit (F), rather than the necessary 41 degrees F or below. The Delfield reach-in refrigerator had an expired 8 ounces of soy milk with an expiration date of March 8, 2025. The Delfield reach-in refrigerator had two expired 46 ounces of nectar honey thickened lemon water with an expiration date of June 3, 2025, and May 9, 2025. The walk-in refrigerator was noted to have 4 rolls of 10 pounds each of raw ground beef sitting on a flat, open tray with red liquid all over it. Closer observation did not show the date that the ground beef was placed in the walk-in refrigerator or an expiration date. A large tray of roast beef with a date of 06/04/25 indicating when the roast beef was placed in the walk-in refrigerator. A large bag of shredded red cabbage showing it was placed in the walk-in refrigerator on 5/02/2025, but no expiration date was noted on the bag. Two large cooking pots were noted to be coated with a black-like residue on both their interior and exterior surfaces. This black substance is typically composed of carbon-like deposits, which result from the overheating of oils and fats during cooking. The Hood area was noted to have 3 out of 7 light bulbs not working. The dry storage area was noted with 7 expired boxes of honey thickened liquids (46 ounces each) all expired last month. The Food Service Director noted a hairnet that was only half covering her hair, with the bottom portion of her hair exposed. In this tour, the Food Service Director was asked to calibrate a facility's thermometer to take the temperatures of food items pulled from the Delfield reach-in refrigerator. She was observed taking a cup of ice and overflowing it with water before placing the thermometer inside the cup. The temperature of the iced water did not go down to the necessary ranges of 32 degrees F. The Food Service Director did not make sure that the ice in the cup was mostly ice with just enough water to fill the gaps too much water will raise the temperature above 32°F (0°C). This Surveyor intervened to ensure that the correct method of calibration was used. 2. During a second tour of the main kitchen conducted on June 10, 2025, at 11:45 AM, the following was observed: Staff C, the Dietary Aid, was observed without a facial hairnet. During the tour Staff CC, Cook, was noted in the food production area, preparing Chicken Fajita. He removed his gloves, touched the oven door, and then a dirty rag on the food counter. He then placed a new pair of gloves on without washing his hands first and continued to prepare the Chicken Fajita. Staff D, [NAME] was noted in the tray line plating the lunch plates. Closer observation showed that she was wearing loop earrings about 2 inches in length. In an interview conducted on 06/11/25 at 2:30 PM with the Administrator, he was informed of the findings.

Based on review of policy and procedure, observation and interview, the facility failed to provide liners for sharps containers for 2 out of 4 wings in the facility. The findings included: Review of the facility policy titled, Regulated (Biohazard) Medical Waste provided by the Director of Nursing (DON), implemented 03/2021 documented in the Policy Statement: It is the policy of this facility to ensure that regulated medical waste is managed, handled, stored and transported as per Federal, State and local guidance and regulations. Definition: Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. Compliance Guidelines: 1. Examples of regulated medical waste include: .f. Sharp items (e.g. needles, scalpels) contaminated with blood .3. The facility will adhere to Federal, State, and local guidelines and regulations in regard to what categories of regulated medical waste are subject to regulation and requirement for treatment and disposal .9. Contaminated sharps will be placed in appropriate sharps containers located at the point of use. Items to be considered into placement within sharps containers include discarded laboratory tubes with small amounts of blood, scalpel blades, needles and syringes, and unused sterile sharps. 10. Sharps containers must be the following: a. Closable; b. Puncture resistant; c. Leak proof on sides and bottom; d. Labeled with the appropriate biohazard labels as per OSHA standards. 11. Sharps containers must be maintained replaced routinely. Do not overfill the container. 12. Sharps containers will be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage or transport . During an observational resident room tour on both 06/08/25 and on 06/09/25, the following were noted (Photographic Evidence Obtained of all below): #1) On 06/08/25 at 12:37 PM observation of resident room [ROOM NUMBER] east wing revealed that there was a wall mounted needle box container with used sharps and connector tubing, and other discarded items noted in the bottom, with no red container receptable liner, nor box inside to store them in. #2) On 06/08/25 at 1:25 PM observation of resident room [ROOM NUMBER] east wing revealed that there was a wall mounted needle box container with several old, used, contaminated sharps and connector tubing and some trash/garbage/discarded items noted in the bottom; with no red container receptable liner, nor box inside to store them in. #3) On 06/09/25 at 12:28 PM observation of resident room [ROOM NUMBER] south wing revealed that there was a wall mounted needle box container, with several used, sharps and connector tubing, and other discarded items, noted in the bottom of the container with no red container receptable liner, nor box inside to catch and house them in. #4) On 06/09/25 at 12:48 PM observation of resident room [ROOM NUMBER] south wing revealed that there was an unlocked and open wall mounted needle box container, with several used, sharps and connector tubing, and other discarded items, noted in the bottom, with no red container receptable liner, nor box inside to store them in. #5) On 06/09/25 at 12:42 PM further observation of multiple resident rooms on the newer section of the 400 South wing hallways, revealed that there were wall mounted needle box containers, with several used, sharps, connector tubing and other discarded items, noted in the bottom, with no red container receptable liners, nor boxes inside to store them in. # of needle sharps boxes in the facility was On 06/09/25 at 3:15 PM, 06/09/25 at 3:20 PM and 06/09/25 at 3:25 PM three (3) separate interviews were conducted with Staff O, Registered Nurse , Staff A, RN, Staff P, Licensed Practical Nurse/Unit Manager (LPN/UM), all three (3) nurses acknowledged that the needle sharps containers in the resident rooms had no liner, nor box container inside to catch and house the used, sharps, connector tubing, nor the laboratory paraphernalia inside along with other discarded items inside. On 06/09/25 at 3:38 PM, on 06/09/25 at 3:44 PM, and on 06/09/25 at 3:50 PM again, three (3) consecutive, separate interviews were conducted with Staff Q, LPN Staff R, RN/UM, and the DON, in which all three (3) were asked about the un-lined and non-boxed sharps needle boxes mounted in the resident's rooms. Staff Q, and Staff R acknowledged that the, used, needle sharps containers in the resident's rooms had no liner, nor box container inside to state the sharps, connector tubing, laboratory paraphernalia inside with other garbage, and other discarded items. The resident room needles sharp box containers were not emptied, cleaned, lined and properly maintained, until after surveyor intervention.

Based on policy review, observation, interview and record review, the facility failed to ensure the call light was in reach for 1 of 33 sampled residents (Resident #463). The findings included: Review of the policy titled, Call-Light System, issued 09/2020, documented in part, 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring the resident access to the call light. 2. With every interaction in the resident's room, staff will ensure the call light is within reach of the resident and secured. Review of the record revealed that Resident #463 was admitted to the facility on [DATE] with a readmission on [DATE]. Review of the current minimum data set (MDS) assessment dated [DATE] documented Resident #463 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0-15 scale, indicating the resident was cognitively intact and that he required physical assistance for self-care needs. During an initial interview on 06/08/25 at 11:25 AM, when Resident #463 was asked how do you get help when you need it, he responded that he uses the call light but that he usually could not find it. The call light cord was observed to be wedged between the bedrail and the bottom of the mattress with the bulb of the call light hanging down close to the floor out of reach of Resident #463. (Photographic evidence obtained). During an observation on 06/09/25 at 12:38 PM, it was noted that the call light was out of reach for Resident #463. (Photographic evidence obtained). During interview on 06/10/25 at 8:05 AM, Resident #463 reported that he needed help to get changed, but he could not reach the call light. (Photographic evidence obtained). Staff H, Licensed Practical Nurse (LPN) was asked to come to Resident #463's room. The resident told Staff H, LPN that he could not reach his call light. Staff H went over to the left side of the bed and had to lower the head of the bed to release the call bell cord that had been stuck between the bottom of the mattress and the bedrail.

Based on policy review, interviews, observation and record review, the facility failed to follow treatment and services for heel pressure ulcers for 1 of 2 sampled residents (Resident #463) reviewed for not offloading heels as a preventative pressure ulcer measure. The findings included: Review of the policy titled, .Wound Care issued 04/2020, documented, in part, 1. It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. 2. Preventative measures, such as utilization of pressure-relieving surfaces, floating heels, protective boots and use of positioning devices can be employed. Review of the summary of a nursing in-service dated 05/21/25 titled, Prevention of skin impairment (Certified Nursing Assistant), did not include staff training on the facilities policy to utilize pressure-relieving surfaces and floating heels as preventative measures. Review of the record revealed that Resident #463 was admitted to the facility on [DATE] with a readmission on [DATE]. Review of the current minimum data set (MDS) assessment dated [DATE] documented Resident #463 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0-15 scale, indicating the resident was cognitively intact and that he required physical assistance for self-care needs. Review of progress notes dated 06/06/25 documented in part, Resident #463 skin integrity assessment reveals left heel with flattened blister tissue measures 8 x 5.6 x 0. Plan of care with intervention in place including offloading heels while in bed. Review of the Treatment Administration Record (TAR) revealed orders dated 05/20/25, Offload heels with pillow while in bed every 12 hours as needed for prevention. During an observation on 06/09/25 at 12:38 PM, Resident #463 reported that his left foot was hurting. His left foot (heel) was observed positioned on the mattress and the right foot (heel) was positioned on top of a pillow (not offloaded but resting on the pillow). (Photographic evidence obtained). On 06/10/25 at 8:05 AM, observations revealed Resident #463's heels were both positioned on top of pillows and not offloaded. During observation on 06/10/25 at 10:52 AM, it was noted that Resident #463 had been assisted with morning care and was dressed and waiting to go to Physical Therapy (PT) and both of his feet were on top of two pillows (one pillow positioned vertically under each foot) not offloaded. During an interview on 06/10/25 at 11:04 AM, Staff E, Certified Nursing Assistant (CNA), who assisted Resident #463 with dressing that morning, was asked what does offloading of heels with pillows mean. Staff E replied, sometimes the heel should not touch the pillow. At that time, she was asked to look at Resident #463 to see if his heels were offloaded. R#463's heels were on top of the pillows. When Staff E was asked if that is offloading, Staff E replied, No, the pillow needs to be higher on Resident #463's calf, so his heel is off the edge of the pillow. During an observation on 06/11/25 at 7:35 AM, Resident # 463 was in bed eating breakfast with his right heel on top of a pillow (not offloaded) and his left heel on top of the mattress (no pillow and not offloaded). (Photographic Evidence obtained).

Based on review of policy and procedure, observation, interview and record review, the facility failed to properly secure catheter for 1 of 1 sampled resident observed during Foley Catheter care, Resident #82. The findings included: Review of the facility policy titled Foley Catheter Care Policy provided by the Director of Nursing (DON) implemented 03/2020 documented in the Policy Statement: It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Policy Explanation and Compliance Guidelines: 1. Catheter care will be performed every shift and as needed by the nursing assistant .21. Assist resident to a comfortable, appropriate position .25. Document care and report any concerns noted to the nurse on duty. Resident #82 was re-admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Chronic Kidney Disease stage 3, Diabetes Mellitus Type II, Osteomyelitis, Hypertension and Adult Failure to Thrive. She had a Brief Interview Mental Status (BIM) score of 00, indicative of severe impairment. During a Peri and Foley catheter care observation of Resident #82 on 06/11/25 10:06 AM, the resident was observed lying down in bed resting. Peri-care was observed being performed by Staff K, Certified Nursing Assistant (CNA), after having washed her hands for 35-40 seconds. Staff K was assisted by Staff S, CNA, who also washed her hands for 35-40 seconds prior to the procedure. Both Staff K and Staff S retrieved a gown from the container located just outside of Resident 82's room, in order to perform this procedure. Resident #82 provided permission for this surveyor to observe her peri Foley catheter care. However, it was observed during the care that the Foley catheter strap with anchor was not properly secured in place, as per the Medical Doctor (MD) written order. Further observation revealed that the Foley catheter strap was old, frayed, discolored and fading and the leg strap was triple wrapped around Resident #82's right leg. This Foley catheter strap was also observed to be slipping off, moving and sliding slowly down Resident #82's leg and not properly secured and anchored in place to prevent movement. Photographic Evidence Obtained. On 06/11/25 at 10:22 AM two (2) consecutive, but separate interviews were conducted with both Staff K and Staff S regarding the above and both indicated that they did not know when the Foley catheter strap was last changed, and neither did they know often this was supposed to be done. But both staff members acknowledged that the strap needed to be changed to a new one because it was not supposed to be fitting on the resident, as observed. On 06/11/25 at 10:32 AM Interview was conducted with Staff T Licensed Practical Nurse (LPN), also regarding the above and she initially had a difficult time trying to identify exactly what the item was when asked, then Staff T indicated that it looked like a Foley catheter strap. Next, Staff T stated that she had not changed one of those. Staff T immediately stated that the Foley catheter strap was not properly placed on the resident. Finally, Staff T ended by saying that the Foley catheter straps were changed every three to four (3-4) days by the night shift nurse. During a demonstration conducted on 06/11/25 at 10:37 AM by Staff U, Registered Nurse (RN), he showed the proper positional placement for the Foley catheter strap with anchor on the resident, as provided by Staff R, RN/Unit Manager (RN/UM) East wing. Photographic Evidence Obtained. A brief interview was conducted on 06/11/25 at 10:41 AM with Staff U, in which he acknowledged that the Foley catheter strap, that was previously placed, had been done so improperly, for Resident #82. On 06/11/25 at 10:44 AM an interview was conducted with Staff R regarding the improperly placed Foley catheter strap, and he said that he was not aware of when the last time this strap had been changed. Staff R went on to say that every time the Foley catheter is changed every 15 days and as needed (PRN), it must be monitored every shift, by the nurse. He ended by acknowledging that the previously placed Foley catheter strap had been improperly placed on this resident. On 05/26/25 the physician's order documented, to Monitor and keep leg strap on and ensure catheter bag is always strapped to the side to prevent trauma/dislodgement. Record review of Resident 82's Care plan revised 04/28/25 indicated Focus: Resident has an indwelling catheter and is at risk for Urinary Tract Infection (UTI) and other catheter related problems . Interventions: Provide indwelling catheter care as per facility protocol. Goal: Resident #82 will be able to function normally with catheter and signs and symptoms of UTI or other urinary problems will be identified early for prompt intervention through the next review date. A side-by-side record review was conducted with Staff R, of the Treatment Administration Record (TAR) for June 2025, in which it had been documented that the nursing staff had been initialing in the boxes that this was being done, per the physician's ordered dated 05/26/25 which indicated to, Monitor and keep leg strap on and ensure catheter bag is always strapped to the side to prevent trauma/dislodgement. However, direct observation clearly revealed that this was not being done by nursing staff. Resident # 82's Foley catheter strap was not changed and properly placed on the resident, until after surveyor intervention. The DON further recognized and acknowledged on 06/11/25 at 1:45 PM that the resident's Foley catheter strap should be routinely monitored, positioned and changed, as per protocol.

Based on interviews, and record review, the facility failed to monitor the dialysis (Central Venous Catheter) CVC access site for 1 of 1 sampled resident reviewed for dialysis (Resident #35). The findings included: A chart review revealed Resident #35 was readmitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and Anemia and Depended on Renal Dialysis. The admission Minimum Data Set (MDS) showed a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitive integrity. A review of the physician's order showed the following: an order for hemodialysis on Tuesday, Thursday, and Saturday, with a right upper chest catheter, dated 05/20/20/2025. Further review of the orders did not show an order to monitor the CVC dialysis site for any bleeding, bruising, or signs of infection. The Care plan dated 06/02/25 documented to check the access site for signs and symptoms of infection, pain, or bleeding daily. In an interview conducted on 06/10/25, at 9:01 AM, the Director of Nursing (DON) stated that when a resident is on dialysis with a CVC access site, they will follow up on labs and monitor the access site for signs of infection, including redness, color changes, temperature fluctuations, and bleeding. The orders to monitor dialysis access sites are the facility ' s protocols and are part of batch orders attached on admission. It is then documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). In an interview conducted on 06/10/25 at 9:10 AM with Staff A, Registered Nurse (RN), she stated that the CVC access site is monitored daily for signs and symptoms of swelling, redness, pain, or bleeding. When asked where it is documented, she said it is on the progress note in the electronic system. A chart review revealed that an order was placed in the system for Hemodialysis - Assess site for bruising, bleeding, or symptoms of infection, which was entered into the electronic system at 9:12 AM on 06/10/25.

Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliation was accurate for 4 of 9 sampled residents (Resident #70, #115, #147 and #47) and failed to obtain a physician order for a controlled medication for 1 of 9 sampled residents (Resident #70) reviewed during the controlled drugs record review. The findings included: Review of the facility's policy titled, 4.0 Schedule II Controlled Substance Medication, undated, included the following: This policy is to ensure adherence to state and federal laws relating to the dispensing of Scheduled II controlled substance medications. In a non-emergency situation, Schedule II controlled medications will NOT be dispensed without a written or electronic prescription. Procedure: H. Dispensing of Controlled Dangerous Substances (CDS) 5.When a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. 1) Record review for Resident #70 revealed that the resident was admitted to the facility on [DATE] with a readmission on [DATE] and with diagnoses that included: Dementia, Schizoaffective Disorder and Major Depressive Disorder. Review of the Physician's Orders showed that Resident #70 had an order dated 04/25/25 for Lorazepam 0.5 mg tablet to give every 8 hours as needed for Anxiety for 14 days, with an end date of 05/09/25. Further review revealed no current physician's order for Lorazepam 0.5 mg. Review of Resident #70's Medication Monitoring/Control Record or the declining inventory sheet (DIS) for Lorazepam 0.5 mg revealed the medication was removed from the locked box for administration on the following dates: 05/03/25 at 9:00 AM 05/05/25 at 9:00 AM 05/10/25 1330 (1:30 PM) 05/15/25 12:15 PM 05/20/25 0600 (6:00 AM) 06/01/25 2108 (9:08 PM) Review of the May and June Medication Administration Record (MAR) documented Resident #70 was administered Lorazepam 0.5 mg on 05/03/25 at 8:08 AM and 05/05/25 at 11:35 AM. No other administration entry for Lorazepam 0.5 mg was documented in the MAR. Furthermore, the May MAR revealed the Lorazepam 0.5 mg order was completed on 05/09/25. 2) Record review for Resident #115 revealed that the resident was admitted to the facility on [DATE] with no readmissions and with diagnoses that included: Fracture of Nasal Bones and Pedestrian injured in traffic accident. Review of the Physician's Orders showed that Resident #115 had an order dated 09/09/24 for Percocet (Oxycodone w/Acetaminophen) 5-325 mg tablet give every 6 hours as needed for non-acute pain scale of 6 to 10. Review of Resident #115's DIS for Percocet 5-325 mg revealed the medication was removed from the locked box for administration on the following dates: 06/08/25 at 2300 (11:00 PM) 06/09/25 at 8:58 AM 06/09/25 at 1732 (5:32 PM) 06/09/25 at 2300 Review of the June MAR documented Resident #115 administered Percocet 5-325 mg on the following dates: 06/08/25 at 9:30 AM with a pain level of 0 out of 10. 06/09/25 at 8:57 AM with a pain level of 6 out of 10. 06/09/25 at 2300 with a pain level of 5 out of 10. 3) Record review for Resident #147 revealed that the resident was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included: Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. Review of the Physician's Orders showed that Resident #147 had an order dated 05/04/25 for Oxycodone HCl 5 mg tablet give every 6 hours as needed for non-acute pain. Review of Resident #147's DIS for Oxycodone HCl 5 mg revealed the medication was removed from the locked box for administration on the following dates: 06/09/25 at 0001 (12:01 AM) 06/09/25 at 1300 (1:00 PM) 06/09/25 at 2100 (9:00 PM) 06/10/25 at 1300 Review of the June MAR documented Resident #147 was administered Oxycodone HCl 5 mg on the following dates: 06/09/25 at 0138 (1:38 AM) with pain level of 6 out of 10. 06/09/25 at 2058 (8:58 PM) with pain level of 5 out of 10. 06/10/25 at 2128 (9:28 PM) with pain level of 7 out of 10. An interview was conducted on 06/11/25 at 10:15 AM with Staff G, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 3 years. She stated for administration of controlled substance medication, she would first check the physician's orders on the computer, compare the order to the declining inventory sheet (DIS), dispense the medication and sign the DIS. Once administered, Staff G stated she would then document in the MAR that the medication was given. She agreed that both the IDS and the MAR should correlate the date and time when the controlled substance was given. On 06/11/25 at 10:28 AM, a side-by-side review of Resident #70's DIS and May MAR for Lorazepam 0.5 mg tablet to give every 8 hours as needed for Anxiety for 14 days, was conducted with Staff H, LPN and the Director of Nursing (DON). The review revealed no physician's order in Resident #70's chart for Lorazepam 0.5 mg and no documentation for administration on the above dates. Staff H stated that after 14 days the order is completed, the nurse or supervisor would contact the doctor for a new order for the medication. In addition, Staff H stated if she is to administer a controlled substance medication, she first checks if there's a physician's order, then compares the order with the DIS, dispenses the medication, administers the medication to the resident and then documents in the computer and the DIS almost at the same time. Both DON and Staff H acknowledged there's discrepancy between the DIS and the MAR for controlled substance medications. 4) Resident #47 was admitted to the facility on [DATE] with the diagnoses that included Cerebral Infarction due to Occlusion or Stenosis of a Small Artery, Osseus and Subluxation Stenosis of Intervertebral Foramina of the Lumbar Region, and Malignant Neoplasm of the Colon. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 15, indicating Resident #47 had intact mental cognition. A review of orders revealed Oxycodone Hydrochloride, 5 mg (milligram), 1 tablet every 6 hours as needed for pain. During a medication storage review with Staff G, Licensed Practical Nurse (LPN) on 06/10/25 at 10:35 AM, the Narcotic sheet revealed the Bingo medication dispenser for Oxycodone was received on 04/23/25 with 25 pills. Staff G, LPN verified the Narcotic sheet and the Bingo medication dispenser both had 21 remaining pills, and the administrations on these dates, 06/07/25 at 11:20 AM, 06/08/25 at 10:55 PM, and 06/10/25 at 10 PM were also documented in the MAR. A further review revealed the 06/07/25 at 11:47 AM recorded administration on the Narcotic sheet was not documented on Resident # 47's Medication Administration Record (MAR). In an interview with Staff G, an LPN on 06/11/25 at 10:54 AM, she verified that a Nurse with the written initials on the Narcotic sheet had removed 1 pill on 06/07/25 at 11:47 AM, but she does not know why it was not documented on Resident # 47's MAR. She added that every time a controlled substance is taken from the medication Bingo dispenser, it must be initialed by a nurse with a date and a time on the Narcotic sheet. This documentation must correspond with the MAR documentation, indicating the exact date, time and with the same Nurse's initials.

Based on observations, interviews, and record review, the facility failed to monitor the behaviors of residents on psychotropic medication for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #134 and Resident #173). The findings included: A review of the facility's policy titled Using Psychotropic Medications, revised on 10/2024, showed the following: the facility will manage and monitor the residents' medication regimen to promote and maintain the resident's practicable mental, physical, and psychosocial well-being. This includes tracking behavior and monitoring progress. A chart review showed Resident #134 was admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Anxiety. The Quarterly Minimum Data Set (MDS) assessmentdated 5/20/25 revealed Resident #134 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. A review of the physician's order documented the following orders: Risperidone (an antipsychotic medication), 0.5 milligrams twice a day. It further documented to monitor Behaviors with the following code: 0) No 1) Fear 2) Anger 3) Scream 4) Danger/Self/Others 5) [NAME]/Hall 6) Sad 7) Other(desc) dated 11/14/2024. An order for Risperidone (antipsychotic medication), 0.25 milligrams two times a day. It further documented to monitor Behaviors with the following code: 0) No 1) Fear 2) Anger 3) Scream 4) Danger/Self/Others 5) [NAME]/Hall 6) Sad 7) Other(desc) dated 11/14/2024. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that no behaviors were documented, if any, or '0' documented for no behaviors if none were observed. The Care plan dated 5/14/25 revealed the following: Resident #134 is on antipsychotic therapy related to Schizophrenia and Bipolar. Administer Antipsychotic medications as ordered by physicians. Monitor behavioral symptoms and side effects. In an interview with Staff F, a Registered Nurse, on June 11, 2025, at 10:10 AM, she stated that the behaviors of Resident #134 are monitored daily and documented on the MAR and TAR. If there are no behaviors, she puts 0 in the electronic system. She then proceeded to show this Surveyor the documentation in the MAR and TAR. Staff F stated that she did not know why there is no section to document behaviors and said that it only gives her an option for Yes or No. In an interview conducted on 6/11/2025 at 10:20 AM with the Director of Nursing (DON), she stated that she started working in the facility a week ago and was not aware that documentation for behaviors was not done according to the specific order and that the nursing staff were filling in only a checkmark instead of the particular codes as above. she further acknowledged that this needs to be corrected. 2) Resident #173 was admitted on [DATE] with diagnoses that included Cerebral Infarction, Unspecified Dementia, unspecified severity, without Behavioral Disturbance, Psychotic Disturbance and Anxiety, Acute Kidney Failure, and Presence of Prosthetic Heart Valve. A review of the recent Minimum Data Set (MDS) assessment under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 4 indicating Resident #173 had severely impaired cognition. A review of orders revealed the following:1). Lorazepam 0.5 milligram (mg), give 1 tablet by mouth, 2 times a day for Anxiety; 2). Citalopram Hydrobromide 20 mg, give 1 tablet by mouth one time a day for depression. Use the following behavior codes :0=No, 1=Fear, 2=Anger, 3=Scream,4=Danger to self and others,5=Delirium, 6=Sad, 7=Other. The following were the codes for Interventions: 1= Music, 2=reminisce, 3=Ex, 5= Quiet, 6=PRN (as needed). Additional orders revealed the following: 3). Seroquel 100mg tablet, give 1 tablet by mouth at bedtime for psychosis:4). Depakote sprinkles, delayed release 125 mg, give 2 capsules by mouth, 2 times a day for mood disorder: 5). Donepezil Hcl 5 mg, give 1 tablet by mouth at bedtime for dementia: 6). Lorazepam 0.5 mg, give 1 tablet by mouth, 2 times a day for anxiety; Use the following behavior codes: 0=No, 1=Fear, 2=Anger, 3=Scream, 4=Danger to self and others, 5=[NAME]/hall, 6=Sad, 7=Other (describe). The following were the intervention codes:1=Music, 2=Reminisce, 3=Ex, 4=1:1, 5=Quiet, 6= PRN. The following were the codes for the outcome: 1=improve, 2=same, 3=worse. The following were the side effects codes: 0=none,1=eps, 2=tardive dyskinesia, 3= hypotension, 4= behavior, 5= drowsy, 6=dizzy. A further review of June 2025 MAR revealed on 06/07/25 and 06/08/25 during day shifts, there were yes responses, with check marks and nurses' initials, but no behavior codes were documented for Citalopram, Depakote, Lorazepam, Seroquel, and Zoloft. On 06/08/25 at 6:00 AM, an intervention code 8 for Lorazepam 0.5 mg was documented for a 0 behavior code, with a check mark and nurse's initials. There was no code 8 per physician order. An additional review of the same MAR for the box corresponding to the monitoring of the outcome of intervention (12 hours), revealed only check marks and nurses' initials from 06/01/25 until 06/10/25 during the day and night shifts. The supposedly used codes were U for unchanged, W for worsened, and the above corresponding codes. In an interview with Staff G, Licensed Practical Nurse (LPN) on 06/11/25 at 10:45 AM, when she was asked about behavior monitoring, she responded, Yes, I monitor the resident's behavior, and I document them in the MAR. She added that she observed resident's behavior before and after administrations of psychotropic medications. She added that she uses the behavior and intervention codes as ordered by physicians, and she documents these codes in MAR. In an interview with the Medical Director on 06/11/25 at 2:30 PM, when he was asked why behavior, and side effects monitoring is important for the resident, he responded, he ( Resident # 173) is receiving 2 antidepressants and one anxiety, which were the medications he used to take at home. He added, During my previous record reviews, these medications were necessary, but now I think I have to stop 1 antidepressant (I do not know which one yet), and I will try to start weaning him from the Benzodiazepine.

Based on observations, interviews, and record reviews, the facility failed to ensure it was free of significant medication errors for 1 of 5 sampled residents reviewed for medications (Resident #69). The findings included: A review of the facility's policy titled, Medication Preparation and Dispensing, undated, revealed to verify the medication is the right drug, at the right dose, the right route, at the right rate, at the right time for the right customer (G-1). Resident # 69 was admitted on [DATE] with diagnoses that included Parkinson's Disease without Dyskinesia (a condition characterized by abnormal involuntary movements), Encounter for Palliative Care, Unspecified Osteoarthritis, Unspecified Dementia, Anxiety, and Major Depressive Disorder. A review of quarterly Minimum Data Set (MDS) assessment dated [DATE] under Section C of the Brief Interview for Mental Status (BIMS) revealed a score of 2, indicating Resident # 69 had severely impaired cognition. A review of orders revealed the following: Tramadol Hydrochloride tablet, 25 milligram (mg), give 1 tablet, 2 times a day for pain; Carbidopa-Levodopa 25-100mg , give 1 tablet by mouth , three times a day for Parkinson's ; on 05/09/25, no routine laboratory, and weights to be performed, resident is under hospice care, decline expected due to terminal condition; Divalproex oral capsule delayed release, 125 mg, give 2 capsules every 12 hours related to Major Depressive Disorder. During a medication administration observation on 06/10/25 at 10:45 AM using Medication cart 2 on the East section, with Staff G, a Licensed Practical Nurse, (LPN) who stated, she was preparing the 9:00 AM medication for Resident #69. When she opened her computer screen, it revealed pink color on all the 9:00 AM scheduled medications. When she was asked what the screen tells her, she responded, I am administering the medications later than the scheduled time. The acceptable time is one hour before and one hour after the scheduled time. She started preparing the following medications: Divalproex Sodium 12.5 mg (milligram), two (2) capsules by mouth, Carbidopa Levodopa 25-100 mg, one (1) tablet, 2 times a day, with an expiration date of 05/29/26; and Tramadol 25 mg, 1 tablet, 2 times a day, Staff G, LPN went inside Resident #69's room at 10:50 AM. A record review of the Medication Administration Audit Report, revealed the following: Divalproex Sodium oral capsule 125 mg, 2 capsules, every 12 hours; Carbidopa-Levodopa 25-100 mg, 1 tablet , 3 times a day; and Tramadol 25 mg,1 tablet, 2 times a day, were all administered at 11:05 AM. In an interview with the Director of Nursing on 06/10/25 at 12:00 PM, when she was asked what is considered timely medication administration, responded, One hour before and one hour after the scheduled time is considered timely. In an interview with The [NAME] President of Clinical Practice on 06/11/25 at 11:25 AM, she stated that One hour before and one hour after the scheduled time is considered timely medication administration. When she was asked to verify the administration time stamp of the above medications, she responded, It was 11:00 AM.

Based on review of policy the facility's and procedures, observation and interview, the facility failed to 1) ensure that it secured the Wound Care treatment cart for 1 of 5 sampled Wound Care carts observed, East wing Wound Care cart; 2) ensure that it secured the Medication Administration Cart for 1 of 9 sampled Medication Administration carts observed, Medication cart A East wing; 3) secure medication in 1 of 8 medication carts observed, medication cart A, on the Center wing; and 4) failed to properly label medication for general population use for 1 of 9 medication carts, during a Medication Storage Observation (medication cart 2 of the East wing. The findings included: Review of the facility policy titled Labeling of Medications Storage of Drugs and Biologicals provided by the Director of Nursing (DON) issued 03/2020 documented in the Policy Statement: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Purpose: The purpose of this procedure is to ensure the accurate labeling of all medications and biologicals to facilitate consideration of precautions and safe administration of medications Storage of Drugs Safe and secure storage of all medication. Policy Explanation and Compliance Guidelines: 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices 1) During an observational tour of the East wing on 06/08/25 at 10:02 AM, it was revealed that there was an unlocked Wound Care cart on the East wing containing several different resident topical prescriptions and over the counter (OTC) wound dressing ointments (e.g. B & C ointment dressing, muscle rub, Ciclopirx Olamine cream 0.77%, Nystatin powder), along with wound care supplies. The cart was unsecured, unattended and accessible to residents, visitors and other employees. (Photographic Evidence Obtained). On 06/08/25 at 10:06 AM an interview was conducted with Staff V, Registered Nurse (RN) in which she stated that she was the last nurse to use the East wing Wound Care cart, and she acknowledged that she had left the Wound Care cart unlocked, when she should have locked it. 2) On 06/09/25 at 04:10 PM during a random hallway tour, it was revealed that there was an unlocked Medication cart (A) on the East wing, containing twenty-four (24) active resident prescription and OTC medications, all unsecured, unattended and accessible to residents, visitors and other employees. (Photographic Evidence Obtained). On 06/09/25 at 4:20 PM separate consecutive interviews were conducted with Staff Q, Licensed Practical Nurse (LPN) and with Staff R, RN, Unit Manager (UM), who both acknowledged that the medication cart should not have been unattended and should have been kept locked. 3) On 06/10/25 at 2:59 PM during a Medication Storage Observation conducted with Staff F, RN, and Staff W, RN/UM for Medication cart A Center wing, it was observed that there was one (1) white, unidentified loose pill, in the bottom of the second drawer in the Medication cart. An interview was conducted on 06/10/25 at 3:11 PM with Staff F, and with Staff W, RN/UM, in which they both acknowledged that the medication pill should not have been found at the bottom of the medication drawer and should have been secured. The Wound Care Cart, the Medication Cart and the loose, unidentified pill were not secured and discarded, until after surveyor inquisition. The DON further acknowledged on 06/08/25 at 10:16 AM and on 06/09/25 at 04:25 PM, that both the Wound Care Cart and the Medication Carts and all medications should be secured, at all times. The findings included: Review of the facility policy titled Labeling of Medications Storage of Drugs and Biologicals provided by the Director of Nursing (DON) issued 03/2020 documented in the Policy Statement: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Purpose: The purpose of this procedure is to ensure the accurate labeling of all medications and biologicals to facilitate consideration of precautions and safe administration of medications Storage of Drugs Safe and secure storage of all medication. Policy Explanation and Compliance Guidelines: 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices 1) During an observational tour of the East wing on 06/08/25 at 10:02 AM, it was revealed that there was an unlocked Wound Care cart on the East wing containing several different resident topical prescription and over-the-counter (OTC) wound dressing ointments (e.g. B & C ointment dressing, muscle rub, Ciclopirx Olamine cream 0.77%, Nystatin powder), along with wound care supplies. The cart was unsecured, unattended and accessible to residents, visitors and other employees. (Photographic Evidence Obtained). On 06/08/25 at 10:06 AM an interview was conducted with Staff V, Registered Nurse (RN) in which she stated that she was the last nurse to use the East wing Wound Care cart, and she acknowledged that she had left the Wound Care cart unlocked, when she should have locked it. 2) On 06/09/25 at 04:10 PM during a random hallway tour, it was revealed that there was an unlocked Medication cart (A) on the East wing, containing twenty-four (24) active resident prescription and OTC medications, all unsecured, unattended and accessible to residents, visitors and other employees. (Photographic Evidence Obtained). On 06/09/25 at 4:20 PM separate consecutive interviews were conducted with Staff Q, Licensed Practical Nurse (LPN) and with Staff R, RN, Unit Manager (UM), who both acknowledged that the medication cart should not have been unattended and should have been kept locked. 3) On 06/10/25 at 2:59 PM during a Medication Storage Observation conducted with Staff F, RN, and Staff W, RN/UM for Medication cart A Center wing, it was observed that there was one (1) white, unidentified loose pill, in the bottom of the second drawer in the Medication cart. An interview was conducted on 06/10/25 at 3:11 PM with Staff F, and with Staff W, RN/UM, in which they both acknowledged that the medication pill should not have been found at the bottom of the medication drawer and should have been secured. The Wound Care cart, the Medication Cart and the loose, unidentified pill were not secured and discarded, until after surveyor inquisition. The DON further acknowledged on 06/08/25 at 10:16 AM and on 06/09/25 at 04:25 PM, that both the Wound Care cart and the Medication Carts and all medications should be secured, at all times. 4) During a medication storage observation of medication cart 2 on the East wing, with Staff G, Licensed Practical Nurse, on 06/10/25 at 10:35 AM, the fourth (4th) drawer revealed a bottle of Elder Tonic, without an opened date label, and an unreadable expiration date. When Staff G, LPN was asked why the bottle of medication was inside the cart, she responded, some residents are using the medication. When asked if Nurses verify the expiration dates and the opening dates of the medication before administration, she responded, Nurses always check the expiration dates, and the date a medication bottle was opened before storing them back inside the Medication cart. When she was asked to provide the opening date and the expiration date of the Elder Tonic bottle, she stated, There was no label for opening date, and I cannot read the expiration date. When she was asked how often Nurses check the Medication cart assigned to them, she responded, During every shift change, a Nurse must check his/her own Medication cart to verify if there are expired medications, loose pills from the Bingo dispenser, unlabeled medications, available supplies, and the cleanliness of the entire cart specially the bottom areas where all fluids are stored. She added that she also checks if there is a bottle of drug buster to discard expired or unused medications. She added that We do not keep bottles of medications with opening dates of more than a year. In an interview with the Director of Nursing (DON) on 06/10/25 at 11:55 AM, when she was asked about the facility's policy when storing medications inside the Medication Cart, she responded, Nurses must put the opening date of any bottle of medications for general use, and Nurses must check the expiration dates. She added, Nurses also check the Medication cart during their shifts.

2). Resident #13 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly MDS, with a reference date of 05/08/25, Resident #13 had a BIMS score of 06, indicating a severe cognitive impairment. The assessment documented that the resident required partial/moderate assistance for eating. Resident #13's diagnoses at the time of the assessment included: Anemia, Hypertension, Renal insufficiency, Alzheimer's disease, Non-Alzheimer's dementia, Malnutrition, Depression, Chronic lung disease, Respiratory failure, Muscle wasting and atrophy, Immunodeficiency, Osteoarthritis, SOB, (Shortness of Breath), Dysphagia, Cognitive communication deficit. Resident #13's care plan for nutrition documented: Care plan for nutrition: Resident is at risk for a decline in nutritional parameters due to dependence on a mechanically altered diet with thickened liquids, multiple diagnoses, multiple medications, underweight, History of significant weight loss, abnormal labs, and inadequate oral intake. Date Initiated: 02/13/2025 Revision on: 02/13/2025. The goal of the care plan was documented as: Resident will maintain adequate nutritional status as evidenced by gaining 0.5-1.0# per month, no signs and symptoms of malnutrition, and consuming meals daily through the next review date. Date Initiated: 02/13/2025 Revision on: 02/13/2025 Target Date: 07/31/2025 Interventions of the care plan included, provide and serve diet as ordered. Monitor intake and record meals. Date Initiated: 02/13/2025 Record review revealed Resident #13's diet orders included: Regular diet, Pureed (PU4) texture, Nectar/Mildly Thick consistency - 03/24/25. On 06/09/25 at 8:36 AM, Resident #13 was observed in bed sleeping with breakfast and pre-packaged and commercially processed snacks on an over bed table that were not consistent with the resident's diet orders. During an interview, on 06/11/25 at 10:20 AM, with the Speech Language Pathologist (SLP), and the SLP were shown a photo of the meal with the snacks. When asked about the snacks being appropriate for a resident with orders for pureed diet, the SLP confirmed that the snacks were not appropriate. When asked about the risk of not following the pureed diet order, the SLP replied, in general, the risk is aspiration, choking and decreased PO (oral) intake 3). Resident #89 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an Annual MDS, with a reference date of 05/19/25, Resident #89 had a BIMS score of 15, indicating the resident was cognitively intact. The assessment documented that the resident required partial/moderate assistance for eating. Resident #89's diagnoses at the time of the assessment included: Anemia, Atrial fibrillation, Hypertension, Hyperlipidemia, Alzheimer's disease, Malnutrition, Anxiety disorder, Depression, Chronic lung disease, Vitamin D deficiency, Tinea Unguium, Muscle weakness, Dysphagia, Irritable Bowel Syndrome and the need for assistance with personal care Resident #89's care plan for nutrition documented: Residents have potential nutritional problems related to Hypertension, Chronic Obstructive Pulmonary Disease, Atrial fibrillation, anemia hyperlipidemia, dysphagia, overweight, Irritable Bowel Syndrome, assistance by staff for meals, mechanically pureed, nectar thickened liquid diet. History of edema, with fluid shifts anticipated. Renal diet provided. Significant weight loss - 05/18/22 with a revision date of 02/15/24. The goal of the care plan was documented as: Residents will maintain adequate nutritional status as evidenced by absence of unplanned significant weight changes, no (signs / symptoms) of malnutrition, and consuming adequate food/fluids through review date. Date Initiated: 12/10/2024 Revision on: 06/09/2025 Target Date: 08/10/2025 Interventions of the care plan included: o Provide, serve diet/supplement as ordered. Monitor intake and record (every) meal. Date Initiated: 05/18/2022 o RD to evaluate and make diet change recommendations PRN. Date Initiated: 05/18/2022 Record Review revealed Resident #89's diet orders included. Renal diet, Pureed (PU4) texture, Nectar /Mildly Thick consistency - large entree portions - 03/24/25. On 06/09/25 at 8:35 AM, Resident #89 was observed in bed with breakfast on an overbed table. The oatmeal that was served to the resident in an insulated cup did not appear to be smooth and had lumps of oatmeal in the cup. An interview was attempted with the resident; however, the resident fell asleep during the meal and observation. During an interview, on 06/11/25 at 10:20 AM, with the Speech Language Pathologist (SLP), SLP was shown a photo of the oatmeal being appropriate for a resident with orders for pureed diet, the SLP confirmed that the oatmeal was not appropriate. When asked about the risk of not following the pureed diet order, the SLP replied, in general, the risk is aspiration, choking and decreased PO (oral) intake. Based on observations, interviews, and record review, the facility failed to provide the correct Pureed diet consistency for 1 of two observations in the main kitchen. This has the potential to affect 22 residents out of 209 residents, according to the facility ' s census, including Resident #89 and Resident #13. The findings included: A review of the facility policy titled Policy on IDDSI (International Dysphagia Diet Standardization Initiative) Implementation, not dated, showed the following: On the Pureed diet, foods are smooth, pureed, and require no chewing. This level is designed for individuals with severe difficulties in chewing and swallowing. 1. In an observation conducted on 06/08/2025 at 1:27 PM in the main kitchen during the lunch tray line, the following was noted: A metal container of Pureed seasoned spinach was noted with a texture that was not fully smooth and contained irregularities such as small lumps and fibrous strands. A metal container of Pureed Chorizo and Cheddar Quiche with lumps and stringy pieces and did not have a smooth texture. In this observation, the Surveyor explained that the above textures do not meet the standard definition of an actual pureed texture as recognized by the clinical guidelines of IDDSI. The Food Service Director acknowledged the findings and stated that she would correct the problem. In an interview conducted on 06/09/25 at 11:45 AM with Staff B, the Language Pathologist stated for the Pureed diet consistency, the food needs to be smooth and pureed with no lumps or pieces.

Based on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for infection control standards on residents for Enhanced Barrier Precautions (EBP) for 1 of 37 residents for EBP (Resident #37) and failed to properly clean the nebulizing equipment after a resident's treatment (Resident #132). The facility also failed to properly dispose of glucose strip containers used on an EBP resident and failed to follow their own policy for blood glucose monitoring for 1 of 37 sampled residents (Resident #37). The findings included: According to the Center for Disease Control and Prevention (CDC) Enhanced Barrier Precautions, it revealed the following: Everyone must clean their hands, including when both entering and leaving the room: Providers and Staff must also wear gloves and a gown for the following; high-contact care resident care activities, dressing, bathing-showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting: Device care or use; central line, urinary catheter, feeding tube, tracheostomy: Wound care with any skin opening requiring a dressing. https://www.cdc.gov/long-term-care facilities/media/pdfs/ A review of a policy titled, Blood Glucose Monitoring, with an implementation date of 03/20 revealed the following procedure: clean the intended site with an alcohol pad and allow to dry completely (7), f required by the facility, wipe away the first drop of blood using a gauze pad (10). An additional review of a policy titled, Medication Preparation for Dispensing, undated, page 6-2, revealed to discard any unused medication supplies (e.g. alcohol swabs, syringes, etc.). A further review of policy titled, Nebulizer Therapy, with a revision date of 02/21 revealed the following: clean the equipment after each use, disassemble parts after each treatment, and rinse the nebulizer cup and mouthpiece with sterile or distilled water, shake off excess water, air dry on absorbent towel, once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 1) Resident # 132 was admitted on [DATE] with diagnoses that included Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebro Vascular Accident affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus, and Pleural Effusion. A review of Minimum Data Set (MDS) assessment dated [DATE] under Section C of the Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #132 had intact cognition. A review of orders dated 04/27/25 revealed Pulmicort Inhalation Suspension 0.25 milligram (mg)/2 milliliter (mg), I unit, inhaled orally every 12 hours. During a medication observation on 06/10/25 at 9:36 AM with Staff G, Licensed Practical Nurse (LPN) who stated she would give nebulizing treatment to Resident #132. Staff G, LPN applied the nebulizing mask after instilling the medication to resident's face on 06/10/25 at 9:51 AM. On 06/10/25 at 10:00 AM, she removed the resident's nebulizing mask and stated I am done with the treatment. She removed the mask from the resident's face and put it back inside a plastic bag. She did not clean the nebulizing equipment she used for the resident before storing it inside the bag. When asked what the proper procedure is after providing nebulizing treatment to the resident, she responded, 'I will check him again to see if he is having respiratory distress. The Surveyor stayed with Staff G, LPN until 11:05 AM, but she did not disinfect or clean Resident #132's nebulizing face mask. 2) Resident #37 was admitted on [DATE] with diagnoses that included Partial Arterial Traumatic Amputation of the Right Foot, Type 2 Diabetes Mellitus with Hyperglycemia, Peripheral Vascular Disease, Immunodeficiency, and Local Infection of the Skin and Subcutaneous tissues. A review of Minimum Data Set (MDS) dated [DATE] under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 15 indicating Resident #37 had intact cognition. A review of orders dated 04/29/25 revealed Humalog Kwik pen subcutaneous solution pen injector 100 unit/ml, inject subcutaneously before meals and at bedtime for Type 2 Diabetes Mellitus. Inject per sliding scale: if 70 - 150 = 0u; (units) 151 - 200 = 2u; 201 - 250 = 4u; 251 - 300 = 6u; 301 - 350 = 8u; 351 - 400 = 10u; 401+ = 12u Administer. Call MD, During a medication observation with Staff H, an LPN (Licensed Practical Nurse) on 06/10/25 at 11:13 AM, she stated she needed to perform blood glucose test for Resident # 37. Staff H gathered supplies including 2 lancets with no expiration dates. She stated when Staff opened the lancet box, they checked the expiration dates, but there is no way for them to put the expiration date inside the medication cart. She also gathered 2 Assure needles, a whole plastic container of glucose strips, a glucometer wrapped in a plastic bag, alcohol wipes, tissue paper, and Resident #37's Lispro Kwik pen insulin. She placed them all inside a small Styrofoam tray. On 06/10/25 at 11:17 AM, Staff H, an LPN entered Resident #37's room without performing hand hygiene and immediately put her Styrofoam tray with all prepared supplies for blood glucose testing on top of the resident's meal table, without asking for the resident's permission and without cleaning and disinfecting the table. Staff H went to the bathroom and performed hand washing. She went back to the resident's side with the table and told the resident what she was going to do. She then put on gloves. Staff H wiped the resident's finger using an alcohol wipe and immediately pricked it with the lancet. She did not wait for the alcohol to dry. She wiped the area with tissue paper and started squeezing the resident's finger. With the same right-gloved hand, Staff H, LPN opened the glucose strip container to get a glucose strip. She put the strip inside the top of the glucometer and continued to squeeze Resident #37's finger. Once the reading was obtained, she removed her gloves, put on new ones, and manipulated the Insulin Kwik pen. She alcohol wiped the resident's right upper arm and immediately touched it with her gloved hands. The surveyor had to remind her that she had just sanitized the area. Staff H, LPN changed her gloves and used another alcohol wipe to sanitize resident's right upper arm. This time she let the area dry before injecting the insulin. She removed her gloves and discarded the used supplies. Staff H, LPN performed hand washing, put on gloves and put the supplies including the Insulin pen, directly on top of resident's table. Then she gathered all her supplies including the glucometer, and a plastic container of glucose strips from the top of the resident's table and left the room. She did not return the table to the resident and did not disinfect the table. In front of the medication cart, she disinfected the glucometer using the purple top Sani-cloth wipes, but did not disinfect the plastic container of the glucose strip which she put in the first drawer of medication cart 2 south section. During an observation on 05/10/25 at 11:37 AM, the Assistant Director of Nursing (ADON) entered Resident #37's room without performing hand hygiene. There was a blue post with a picture of a nurse above the resident's name outside . During a medication admisnitration, on 06/10/25 at 11:17 AM, this surveyor observed a CDC post for EBP was observed above the head part of the resident's bed.The resident had dressing on the foot and an IV access line. After talking with the resident for 6 minutes, he (ADON) left the room and did not perform hand hygiene. On 06/10/25 at approximately 11:42 AM, the Director of Nursing (DON) was informed of where Staff H, LPN put the glucose strip container, but the DON did not ask Staff H to remove the glucose strip container from the medication cart. The surveyor stayed for 10 minutes, but the whole plastic container of the glucose strip used on an EBP resident stayed in the medication cart. In an interview with the Assistant Director of Nursing (ADON) on 06/10/25 at 2:39 PM, when asked if the facility follows the CDC guidelines and recommendations for EBP, he responded, Yes'. When asked why he did not follow the CDC guidelines regarding performing hand hygiene before entering and after leaving the room of a resident with an EBP post, he responded, I entered the room to translate for a few minutes, and I did not touch anything inside the resident's room. When the ADON was asked if he knew the resident had an EBP post, he responded, Yes, a Staff could easily identify before entering that a resident was under EBP protocol because of a blue nurse post outside the resident's room. Upon entering the resident's room, a CDC poster for EBP was on top of resident's bed, indicating EBP guidelines must be followed for that resident. The ADON admitted that he did not perform hand hygiene before entering and after leaving the resident's room because he just answered the resident's questions. In an interview with the Infection Preventionist on 06/10/25 at 4:10 PM, she stated that medical equipment and resident's area are disinfected with Sani cloth purple top wipes, when performing blood glucose test. These wipes have a contact time of 2 minutes and a drying time of 2 minutes indicating Staff must disinfect the area for 2 minutes, let it completely dry for another 2 minutes before storage or reuse for another resident. When she was asked if Staff must bring the whole glucose strip container inside a resident's room when performing blood glucose test, she responded, No, due to infection control practices, we do not let Staff bring any medication supplies that would be reused for another resident. Any glucose strips, lancets and syringes must be discarded once they entered a resident's room even if they were unused. When she was informed regarding a Staff LPN who brought the whole glucose strip container inside the resident's room, who also did not perform disinfection of the glucose container after bringing it inside the resident's room, then put it back inside medication cart 2 on the south section, she responded, The Staff should not have done all those things. She should have thrown away the glucose strip container. In an interview with Staff G, LPN on 06/11/25 at 11:00 AM, when asked to explain the process of a blood glucose test, she responded, We wipe the area with alcohol and let it dry before puncturing with a lancet. We do not use the first drop of blood and wipe it off with a gauze pad or tissue paper. We disinfect the glucometer after use, but discard all other supplies brought inside the resident's room. When she was asked if she ever brought the whole plastic container of glucose strip, she responded, No, due to infection control practices, it is not allowed, but if I forgot, then I must discard the whole container. I will not use the strips for another resident, and I will not put them back inside my medication cart.

Based on review of policy and procedure, observation, interview and record review, the facility failed to follow physician's orders to administer Insulin medications to a Diabetic resident; and failed to check and document a Diabetic resident's Blood Sugar Level (BSL). This affected 1 of 2 sampled residents reviewed, Resident #1. The findings included: Record review of the facility's Policy and Procedure titled, Medication Dispensing System (not dated) documented, All medications will be prepared and administered in a manner consistent with .general requirements .G. Prior to Medication Administration: 2. Verify that the Medication Administration Record (MAR) reflects the most recent medication order Record review of the facility's Policy and Procedure titled, Blood Glucose Monitoring, revised 05/2023 documented, It is the policy of this facility to perform blood glucose monitoring to Diabetic residents as per physician's orders. Policy Explanation and Compliance Guidelines: 1. The facility will perform blood glucose monitoring as per physician's orders Record review of the facility's Policy and Procedure titled, Policy & Procedure: Changes in Condition revised 03/22/24 documented, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician .Procedure: The facility must inform the resident, consult with the resident's physician .when there is a change requiring such notification .2. A significant change in the resident's physical, mental or psychological status, that is a deterioration in health, mental, or psychological status in either life-threatening conditions or clinical complications Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Fracture of Neck of Left Femur, Spastic Paraplegia, Type II Diabetes Mellitus without Complications and Hypertension. He had a Brief Interview Mental Status (BIMS) score of 13, indicating intact cognition. Record review revealed on 09/09/24 at 12:05 PM, a nursing progress note by Staff A, a Licensed Practical Nurse (LPN) documented, Therapist notified that patient was sweating profusely and that he was acting off exhibiting altered mental status in his room. Patient was quickly assessed, vital signs within normal limits. Blood sugar was 499. Provider was contacted and Novolog 12 units administered. Patient's family was at bedside and they insisted that patient be evaluated at the hospital. Record review revealed on 09/09/24 at 8:02 PM, the facility's Medical Director documented, was notified by nursing that Blood Glucose 499, patient somnolent. Concerns for Diabetic Ketoacidosis (DKA) Upon review, there appears to have been an error in Insulin administration. Recommend emergent transfer to hospital for further evaluation and management of suspected DKA. Diagnosis. An interview was conducted with Staff A, on 10/02/24 at 2:51 PM, regarding Resident #1's elevated BSL and she stated that she did contact Resident #1's doctor on Sunday 09/08/24 at 11:19 AM for a BSL of 403 and obtained the following new order, Insulin Glargine (Long-acting) Solution 100 unit/ml Inject 10 unit subcutaneously in the morning for Diabetes Mellitus (DM) - Start Date Sunday 09/09/24 for 0600 AM. Staff A also stated that she does recall verbally reporting this new order to the on-coming Nurse Staff B, Licensed Practical Nurse (LPN). However, there was no documentation to indicate that this was done. Record review of the nursing progress notes by Staff A dated 09/08/24 documented, Provider gave new orders for high lunch Insulin. 15 units of short acting Insulin now, as scheduled + 10 units of long acting. New order to add long-acting insulin in the AM - 10 Units. Further record review revealed that on Monday 09/09/24 at 11:46 AM, Staff A, documented that she had checked Resident #1's BSL; it was now at 499. The resident's physician was contacted, and he was sent out on Monday 09/09/24 at 12:02 PM to the hospital per family request. Review of the two facility's nursing progress notes computer entry for the dates of Sunday 09/08/24 at 6:26 AM were only noted as documenting the Orders - Administration Note of the physician's orders for: 1) Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) (Fast acting). Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 2 units; 207-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-300 = 10 units; >400 call MD; which did indicate that the resident's Insulin medication had been administered by the nurse at that time, on that day. The facility's nursing progress notes computer entry for the dates of Monday 09/09/24 at 5:55 AM were only noted as documenting the Orders - Administration Note of the physician's orders for: Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) (Fast acting). It is usually used in combination with a medium- or long-acting Insulin product). Inject 15 unit subcutaneously before meals related to Diabetes Mellitus Type II without complications. Further review revealed the two nurses' facility record entries reflected the doctor's orders, but not whether or not the resident's Insulin had actually been administered by the nurse on those two days. There was no evidence to reveal that the new order for 10 units of the morning Insulin had been given; only that the sliding scale of four (4) units had been administered. Staff B, an LPN who could not be reached, was unavailable and did not respond back to this surveyor, for interview, during this survey. An interview was conducted with Staff C, Registered Nurse (RN)/Unit Manager (UM) South wing, on 10/03/24 at 12:54 PM regarding Resident #1's elevated BSL and he stated that on the morning of Monday 09/09/24, he was called by the nurse on duty, into Resident #1's room and once entering the room, with the nurse, he said that he noted that Resident #1 was sleepy, hard to arouse and he was sweating; no pain at that time. Staff C said that both he and the nurse repositioned the resident, took his vital signs and placed Oxygen on the resident. He stated that Resident #1's vitals were all stable, except for the BSL, which was high. The resident was ultimately sent out to the hospital with a BSL of 499. During this interview, a side-by-side record review was also conducted with Staff C, Staff C indicated that he had acknowledged all of the following as having been reviewed: there were two BSLs not recorded in Resident#1's record on Sunday 09/08/24 before breakfast and Sunday 09/08/24 at bedtime; there were two Insulin medications that were not initialed as having been administered on Sunday 09/08/24, Insulin Glargine Solution, to inject 22 units subcutaneously at bedtime, nor was the Insulin Glargine Solution, to inject 10 units subcutaneously at 6 AM on Monday 09/09/24. Staff C further acknowledged that on Sunday 09/08/24 there was no BSL recorded on the Medication Administration Record (MAR) and no indication as to whether or not the Novolog Flexpen subcutaneous solution pen injector (Insulin Aspart) per sliding scale had been administered that day. The Unit Manager revealed that the only Insulin that had been documented as having been administered to the resident on Monday 09/09/24 at 6:30 AM, was for Novolog Flexpen subcutaneous solution pen injector (Insulin Aspart) per sliding scale for four units of Insulin coverage; with Resident #1's BSL recorded as 250 mg/dl. Staff C concluded by saying that the nurse only covered the sliding scale orders, but not the routine standing orders. A side-by-side record review was also conducted with the DON of both Resident #1's Physician's orders, MAR as well as of the nursing progress notes, in which it was noted/indicated that Resident #1 was ultimately ordered the following four Insulin type medications: On Friday 08/30/24 at 9:06 PM the physician's order was written for: Insulin Glargine Solution 100 unit/ml (Long-acting man-made insulin) Inject 22 unit subcutaneously at bedtime for diabetes related to Diabetes Mellitus (DM) Type II without complications. On Friday 08/30/24 at 8:57 AM the physician's order was written for: Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) (Fast acting). It is usually used in combination with a medium- or long-acting Insulin product). Inject 15 unit subcutaneously before meals related to Diabetes Mellitus Type II without complications. There was no indication that this Insulin had been administered to this resident, at that time. On Friday 08/30/24 at 10:40 PM the physician's order was written for: Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) (Fast acting). Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 2 units; 207-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-300 = 10 units; >400 call MD. Four units of this sliding scale Insulin for BSL of 250 was initialed as being given on the MAR on Monday 09/09/24 at 6:30 AM; subcutaneously Abdomen - Left Upper Quadrant (LUQ). On Monday 09/09/24 at 0600 AM, the physician's order was written for Insulin Glargine Solution 100 unit/ml. Inject 10 unit subcutaneously in the morning for DM. Record review of the MAR revealed that there was no BSL result recorded for this resident on Sunday 09/08/24 at 6:30 AM; only an X recorded in the spot, nor on Sunday 09/08/24 at 8 PM; only an X recorded in the spot. However, further record review of the MAR indicated that there is a blank/empty space for the morning date of: Monday 09/09/24 at 0600 AM and not initialed as being given on the MAR. There was no BSL result recorded for this resident on Monday 09/09/24 at 0600 AM. Record review of Resident #1's BSLs checked during his ten short facility stay from 08/30/24 at 11:39 PM thru 09/09/24 at 11:46 AM, showed that his BSLs ranged from: 70 to 499 mg/dL. During an interview conducted on 10/02/24 at 4:45 PM with the DON, she revealed that she was in the facility on Monday 09/09/24, at the time, when the Medical Director had been called by the morning shift nurse re: the BSL 499. She said that he gave an order for Resident #1 to be transferred out of the facility to the hospital; around the same time that same day, the DON said that she was also contacted specifically by telephone by the Medical Director on 09/09/24 after the resident had been transferred out of the facility because he was concerned, after reviewing the resident's electronic record in Point-Click-Care (PCC) and noted that Resident #1's long-acting Insulin had not been administered by the facility, and he wanted to ensure that the night nurse was educated on appropriate Insulin administration. The DON added that the night nurse did not contact the Doctor, the Supervisor nor her regarding Resident #1's elevated BSL, nor did she document any notes, to that effect. Record review of the Resident #1's Care plan initiated and revised 09/02/24 indicated Focus: Resident #1 is at risk for complications of abnormal blood sugar related to Diagnosis: Diabetes Mellitus. Interventions: Give medication (s) as ordered. Monitor blood sugar as ordered. Notify MD if result is above or below specified parameters. Monitor compliance with diet. Monitor for signs/symptoms of hyperglycemia such as weakness, stupor, headache, diaphoresis, lethargy, blurred vision, tingling sensations, confusion and test blood glucose and give sliding scale as ordered. Monitor for signs/symptoms of hypoglycemia such as nausea, vomiting, extreme thirst, dizziness, excessive urination, flushed dry skin, fruity breath, suddenly becomes drowsy or confused and notify MD as indicated. Monitor skin daily during care and report any changes in skin condition. Nourishing snacks as allowed within dietary limitations. Podiatry consult as needed and ordered. Goal: will not develop signs and symptoms of Hypo/Hyperglycemia daily thru next review date. There was no evidence in the resident's record to show that the new physician's Insulin order dated for Monday 09/09/24 at 0600 AM---Insulin Glargine Solution 100 unit/ml Inject 10 unit subcutaneously in the morning for DM - Start Date 09/09/2024 at 0600, nor that two previous physician Insulin orders dated Sunday 09/08/24 at 8 PM Insulin Glargine Solution 100 unit/ml Inject 22 unit subcutaneously at bedtime for diabetes related to Type 2 Diabetes Mellitus without Complications - Start Date 09/08/2024 2000, nor that Monday 09/09/24 at 6:30 AM---Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) Inject 15 unit subcutaneously before meals related to Type II Diabetes Mellitus without Complications - Start Date 08/31/2024 at 0630 AM, had been carried out/followed up or administered by the facility, prior to Resident #1's transfer to the hospital on 09/09/24 at 12:05 PM. The DON further recognized and acknowledged that on 10/02/24 at 4:45 PM, the physician's Insulin order should have been followed and carried out; this was not done.

Based on record review, observation and interview, the facility failed to provide ADL (activities of daily living) care and services for showers for 1 of 2 sampled residents reviewed for ADL's (Resident #47), and fingernail grooming for 1 of 2 sampled residents reviewed for ADL's (Resident #116) . The findings included: 1. Record review revealed Resident #47 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assist with ADL's. An interview was conducted with Resident #47 on 03/05/24 at 3:30 PM. The resident stated he had not had a shower in over 2 weeks and he really wanted a shower. The resident stated he has had sponge/bed baths, but no shower. Resident #47 stated the shower drain was clogged/backed up, and flooded the floor. The resident did not know if the shower drain was repaired. An interview was conducted with Resident #47 on 03/06/24 at 8:42 AM. The resident stated he received a sponge bath, but no shower. The resident stated he was taken to a smaller shower room on the unit, but he could not fit in the shower. An interview was conducted with Staff Z, a Certified Nurse Assistant (CNA) on 03/06/24 at 3:10 PM. Staff Z stated last week the main shower started flooding, and is still not functioning. The other shower room was too small and will check another unit/wing tomorrow to see if Resident #47 can shower in that location. An interview was conducted with the Maintenance Director on 03/06/24 at 3:15 PM. The Director stated the main shower room has an issue with the drain. The drain was clogged and it was fixed over a week ago. The Director stated he was not aware the main shower was not working. The Director stated he would take care of it right away. An interview was conducted with Resident #47 on 03/07/24 at 12:00 PM. The resident stated he had a shower this morning and the shower was fixed. 38349 2) Review of the facility's policy and procedure for Nail Care, dated 11/2019 and provided by the Director of Nursing (DON), indicated Policy: The policy of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during Activities of Daily Living (ADL) care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift.) Nail care will be provided between scheduled occasions as the need arises .6. Principles of nail care: a. Nails should be kept smooth to avoid skin injury 7. Procedure: Document completion of task, any complications, or if resident refuses. Record review revealed Resident #116 was readmitted to the facility on [DATE] with diagnoses which included Gastrostomy Tube, Hydrocephalus, Muscle Wasting and Atrophy, Sepsis, Seizures, Anemia, Hypertension, Respiratory Failure and Major Depressive Disorder. She had a Brief Interview Mental Status (BIM) score of 99 (severely impaired). During an initial observational tour conducted on 03/04/24 at 10:39 AM, Resident #116 was observed with long, dirty, sharp, jagged, unkempt fingernails on both hands. During a second observational tour conducted on 03/04/24 at 4:22 PM, Resident #116 was observed with long, dirty, sharp, jagged, unkempt fingernails on both hands. During a third observational tour conducted on 03/05/24 at 9:56 AM, Resident #116 was observed with long, dirty, sharp, jagged, unkempt fingernails on both hands. During a fourth observational tour conducted on 03/05/24 at 3:29 PM, Resident #116 was observed with long, dirty, sharp, jagged, unkempt fingernails on both hands. During a fifth observational tour conducted on 03/06/24 at 10:05 AM, Resident #116 was still observed with long, dirty, sharp, jagged, unkempt fingernails on both hands. Record review of Resident #116's Monthly CNA ADL (Activities of Daily Living) Task Flowsheet Record dated 02/22/24 thru 03/06/24 revealed that the resident required total dependence and full staff performance with personal hygiene. Record review of Resident #116's Care plan initiated on 08/17/21 and revised 08/17/21 indicated, Focus: Activities of Daily Living (ADL). Resident #116 has an ADL self-care performance deficit related to Hydrocephalus, Encephalopathy, Respiratory Failure, Anemia; impaired cognition, communication and mobility. Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse .She is dependent on staff for proper nail care. Goal: Resident #116 will receive appropriate staff support through the review date. However, Resident #116's fingernail care had not been done, on the dates from 03/04/24 thru 03/06/24. Further review of the Minimum Data Set (MDS) assessment of sections A, C and GG dated 02/08/24 for Resident #116 indicated that she is totally dependent for all ADLs. During a telephone interview, conducted with Resident #116's husband on 03/06/24 at 10:43 AM, regarding his wife's care and services in the facility. He revealed that sometimes the facility does not take proper care of his wife's fingernails which does concern him. He said that he remembers telling a staff member about this some time ago, but nothing happened. He reiterated that he would like his wife's fingernails to be cleaned and trimmed and kept that way. An interview was conducted with Staff L, a certified nursing assistant (CNA), on 03/06/24 at 11 AM, in which she revealed that they had not provided fingernail care to Resident #116. She said that it is the responsibility of the CNA's to clean and trim the resident's fingernails. She further acknowledged that Resident #116's fingernails were long, dirty, sharp, untrimmed, and unkempt. An interview was conducted with Staff M, a Licensed Practical Nurse (LPN) on 03/06/24 at 11:05 AM, regarding Resident #116's nails and she also agreed that Resident #116's fingernails were long, dirty, sharp, untrimmed and unkempt. On 03/06/24 at 11:10 AM, an interview was conducted with Staff N, an (LPN) Unit Manager (UM), for the [NAME] wing, regarding Resident #116's fingernails. She confirmed that it is the responsibility of the CNA's to clean and trim the resident's nails. Staff N further acknowledged that Resident #116's fingernails were long, dirty and that they should have been cleaned, trimmed and cut. An interview was conducted with the Activities Director on 03/06/24 at 10:17 AM in which he stated that his department has been doing Pretty Nails on specified weekends for any resident that request it. Which involves basic clipping, removing and new fingernail polish of their choice and filing for the residents, by either one (1) of his two (2) activities assistants. However, he added that the department is not allowed to cut any of the resident's fingernails. He added that if his staff were to see a resident with long, dirty fingernails that he or his staff would alert either the Nurse or the CNA of the wing or unit involved and let them know to follow-up with the resident. The Activities Director said that his department had not provided any nail care services to Resident #116, during her facility stay. The Director also acknowledged that Resident # 116's fingernails were all long, dirty, untrimmed and unkempt. There was no documented evidence in any of the records reviewed, indicating that Resident #116 had refused any personal (ADL) care nor exhibited any type of behaviors. On 03/06/24 at 11:58 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #116's fingernails being long, dirty, sharp and untrimmed. She also acknowledged that it is the responsibility of the CNA's to clean and trim the resident's nails and she further acknowledged that the resident's fingernails were long and that they should have been cleaned, trimmed and cut. Photographic Evidence Obtained.

Based on observation, interview, and record review, the facility failed to provide an ongoing activities program for 1 of 2 sampled residents reviewed for activities (Resident #140). The findings included: Record review revealed Resident 140 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and was dependent on staff for activities of daily living. Further record review revealed Resident #140 was care planned as dependent on staff for activities. It was documented the resident would be provided with daily individualized, group or self-centered activity programs for cognitive stimulation and for social interaction. The resident was informed of the daily activity events and encouraged to participate in the daily individualized activities of her interests/choice while social distancing and wearing a mask at all times. Activity calendar of events explained to the resident and provided. Interventions included: Invite to scheduled activities; Introduce resident to residents with similar background, interests and encourage/facilitate interaction; and resident needs assistance/escort to Community Life functions. An interview was conducted with Resident #140 on 03/05/24 at 8:45 AM. The resident stated she wanted to get out of bed in the wheelchair. The resident further stated she sees other residents in the hallway in their wheelchairs. The resident stated she was bored just lying in bed watching television. The resident further stated she used to get out of bed when she was receiving physical therapy (PT), but had not been out of bed since PT stopped. Resident #140 was observed in bed all day on 03/06/24, watching TV and sleeping. An interview was conducted with the Unit Manager (UM) on 03/07/24 at 11:00 AM. The UM stated Resident #140 gets out of bed with therapy, and would sit in the hallway in a wheelchair. An interview was conducted with the Director of Rehabilitation on 03/07/24 at 11:15 AM. The Director stated Resident #140 ended physical therapy and occupational therapy on 02/02/24. An interview was conducted with the Activity Director on 03/07/24 at 3:00 PM. The Activity Director stated Resident #140 would be able to attend activities if the resident was out of bed in a wheelchair. A review of the Certified Nurse Assistant (CNA) tasks revealed the last documented time the resident was out of bed was on 02/15/24 and 02/22/24.

Based on observation, interview and record review, the facility failed to obtain urine specimen as ordered for 1 of 12 sampled residents with indwelling urinary catheters (Resident #321). The findings included: Record review revealed Resident #321 was readmitted to the facility on [DATE]. Her diagnoses included Type 2 Diabetes, Congestive Heart Failure and Acute Kidney Failure. Her Brief Interview of Mental Status (BIMS) score was 14 on the 5-day Minimum Data Set (MDS) with an assessment reference date of 02/29/24. This indicated the resident was cognitively intact. On 03/07/24 at 10:15 AM an interview was conducted with Resident #321. She stated she was not feeling well today and she had burning where her Foley catheter was located. Record review revealed a physician's order dated 03/04/24 for a urinalysis and a urine culture. The medical record did not reveal any results from that order. On 03/07/24 at 10:35 AM, an interview was conducted with Staff P, Unit Manager, regarding where the results of the urinalysis and urine culture were. Staff P viewed the lab book and next to the urinalysis and urine culture it read not collected. Staff P stated the technician wrote in that book. Staff P stated he did not know why the urine was not collected for Resident #321, since there were no progress notes indicating why. An interview was conducted with the Director of Nursing (DON) on 03/07/24 at 11:31 AM who stated Resident #321's urine was not collected as ordered and she asked the nurse to collect it today. The Surveyor informed the DON that the resident was complaining of burning and discomfort in the peri area and she (DON) stated she will inform the Nurse Practitioner.

Based on interview and record review the facility failed to ensure physician visits were performed as required for 2 of 2 sampled residents reviewed for physician visits (Resident #29 and #81). The findings included: 1) Record review for Resident #29 revealed the resident was originally admitted to the facility on [DATE] with a readmission on 12/27/23. The diagnoses included: Other Toxic Encephalopathy, Chronic Obstructive Pulmonary Disease, Post Traumatic Stress Disorder, and Epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 02/09/24 revealed in Section C a Brief Interview of Mental Status score of 15, indicating intact cognitive response. Review of the Physician Progress Notes for Resident #29 from 11/02/23 to 03/04/24 revealed the resident was seen by Staff J, Physician Assistant, on 11/27/23, 11/30/23, 12/19/23, 12/21/23, 01/04/24, 01/08/24 and the resident had not been seen by the primary physician. An interview was conducted on 03/06/24 at 9:00 AM with the Assistant Director of Nursing (ADON) who stated she has worked at the facility since 11/13/23. When asked when does the primary physician comes to see a resident, she said the primary physician visits a resident within 72 hours of admission or readmission and then monthly. The primary physician also visits the resident annually to complete a history and physical (H&P). The ADON stated the nurse practitioners and physician assistants are often in the building and are usually in the facility at least weekly. When asked where the primary physician, the nurse practitioner, and physician assistant's document, she stated they are in the residents' chart under miscellaneous. When asked who monitors the primary physician visits to ensure they are completed for the residents, she stated that would be medical records. During an interview conducted on 03/07/24 at 10:00 AM with Resident #29, who was asked if she has been visited in the facility by Staff B, Primary Physician, she said she does not recall seeing that doctor, but she sees a lot of doctors and does not know all of their names. During an interview conducted on 03/07/24 at 12:05 PM with Staff B, Primary Physician, who stated he typically rounds on Wednesdays and sometimes on Fridays. On Wednesdays he will typically see the newly admitted residents. He said he works with his physician assistant who does visits as well. When asked how often he sees a resident, he said he will see the resident for episodic care and the required visits. When asked how often the required visits are, he said he thinks he is supposed to see the resident every 120 days, new admissions are within 72 hours. He alternates routine visits with his physician assistant every 60 days but stated he does not always get to see all of the residents every 60 days. When asked how the documentation of visits is entered into the residents' chart, he said he does not enter documentation directly into the facility's system, his documentation is sent to the facility either by fax or email, and the facility uploads it to the resident's chart. 2). Review of the record for Resident #81 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Major Depressive Disorder Recurrent, Morbid (Severe) Obesity, and Chronic Pain Syndrome. Review of the Minimum Data Set assessment for Resident #81 dated 12/20/23 revealed in Section C, a Brief Interview of Mental Status Score of 15 indicating a cognitive response. Review of the Primary Physician's Progress Notes for Resident #81 from 06/21/22 to 03/04/24 revealed the resident was seen by the Staff K Primary Physician on 06/29/22 and the resident was seen by Staff J, Physician Assistant (PA) on 06/23/22, 08/01/22, 08/04/22, 08/09/22, 10/12/22, 11/28/22, 02/15/23, 05/01/23, 07/28/23, 08/01/23, 09/29/23, 12/07/23. This indicated the resident was not seen by the primary physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter or every 120 days alternating with the PA. During an interview conducted on 03/06/24 at 2:30 PM, Medical Records Coordinator revealed she just started at the facility 2 weeks ago and she is the only person who works in the department. Part of her duties are monitoring primary physician visits. She stated the primary physician needs to visit each resident monthly. The Nurse Practitioner or physician assistants (PA) can visit the residents in place of the primary physician. The primary physician needs to see the resident at least every 60 days and the nurse practitioner or the PA can see the resident on the alternating months with the primary physician. The PA or nurse practitioner may see the resident more often if needed. The primary physician and nurse practitioner or PA document on their own paperwork and these documents are sent directly to medical records via email and the medical record coordinator will then upload the document into the specific residents' chart and it will show up in miscellaneous and is labeled progress notes. She stated all documents sent to her prior to yesterday have been uploaded to the residents' charts. When asked how she knows which residents have been seen by the primary physician for the month or which residents are due to be seen by the primary physician, she stated they have a program on the dashboard (behind the seen), and they are able to tell which residents are due to be seen by a physician. If residents need to be seen she will contact the physician either by phone or by email to inform them. The Medical Records Coordinator acknowledged there were no primary physician progress notes (documentation) for Resident #29 or Resident #81. During an interview conducted on 03/07/24 at 10:10 AM with Resident #81 who was asked how often he is seen by Staff B Primary Physician, the resident stated he has never seen that doctor. The resident said he has seen the doctor assistant several times but never the actual doctor.

Based on observations, interviews, and record review, the facility failed to follow their own menu planning national guidelines, which has the potential to affect 41 residents on a regular diet, and failed to provide food that accommodates resident allergies, intolerances, and preferences: for 3 of 48 residents on East Unit during in-room dining observations (Resident #115, Resident #95, and Resident #370). The findings included: 1). A review of the nutritional menu planning guidelines provided by the facility titled: Healthy U.S.-Style Dietary Pattern at the 2,000-Calorie Level, With Daily or Weekly Amounts From Food Groups, Subgroups, and Component revealed to provide 2 to 2.5 cups of fruits per day. A review of the regular diet week one menu cycle revealed the following servings for fruits: Sunday provides 1.5 cups of fruits and not the recommended servings of 2 cups of fruits, Monday provides 1.5 cups of fruits and not the recommended 2 cups of fruits, Tuesday provides 2 cups of fruits, Wednesday provides 1.5 cups of fruits and not the recommended 2 cups of fruits, Thursday provides 1.0 cup of fruits and not the recommended 2 cups of fruits, Friday provides 1.0 cup of fruits and not the recommended 2 cups of fruits, and Saturday provides 1.0 cups of fruits and not the recommended 2 cups of fruits. A review of the regular week three menu cycle (menu cycle during recertification survey) revealed the following servings for fruits: Sunday provided 1.5 cups of fruits and not the recommended 2 cups of fruits, Monday provided 1.0 cups of fruits and not the recommended 2 cups of fruits. Tuesday provides 1.0 cups of fruit and not the recommended 2 cups of fruit, Wednesday provides 1.0 cups of fruit and not the recommended 2 cups of fruits, Thursday provides 1.0 cups of fruits and not the recommended 2 cups of fruits, Friday provides 1.0 cup of fruits and not the recommended 2 cups of fruits and Saturday provides 1.0 cup of fruits and not the recommended 2 cups of fruits. In an interview conducted on 03/07/24 at 10:11 AM with Staff F, the Registered Dietitian stated the menus are changing quarterly and are still in the winter menu cycle, and the next one coming up is the spring menu cycle. She explained the Corporate Dietitians go over the menu to ensure that it follows the national guidelines that the facility uses. She acknowledged that the facility's menus do not follow the national guidelines for the servings of fruits. 2). Record review revealed that Resident #370 was readmitted to the facility on [DATE] with diagnoses of Type 2 Diabetes and Chronic obstructive pulmonary disease. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. In an interview conducted on 03/05/24 at 8:43 AM, Resident #370 stated that he never gets the correct food items on his meal trays. Resident #370 said that he did not receive bananas, cold cereal, or eggs on his breakfast tray this morning. Closer observation revealed a meal ticket with the following: Concentrated Carbohydrate Diet (CCD), No Added Salt (NAS), no eggs, 8 ounces of milk, one slice of toast, 6 ounces of cold cereal, 4 ounces of juice, 6 ounces of coffee/tea, and one medium banana. The breakfast tray consisted of 4 ounces of orange juice, one toast, 8 ounces of milk, and 6 ounces of oatmeal. The breakfast tray did not have any eggs, bananas, or cold cereal. Resident #370 stated that he is not allergic to eggs and did not know why it said no eggs on the meal ticket. He further reported that he usually gets eggs only once a week with his breakfast meals. (photographic evidence obtained). 3). Record review revealed Resident #95 was admitted to the facility on [DATE] with a diagnosis of cognitive communication deficit. The annual MDS dated [DATE] revealed that Resident #95 has a BIMS score of 10, which is low cognitively impaired. In an observation conducted on 03/06/24 at 10:00 AM, Resident #95 was in his room eating breakfast. The meal ticket showed the following: regular dysphagia advance, lactose intolerance, and allergies to dairy. Closer observation showed a breakfast meal tray consisting of biscuits, sausage gravy, hashbrowns, hot cereal, orange juice, and 8 ounces of whole dairy milk. Resident #95 stated in this observation that he sometimes gets regular milk cartons on his breakfast trays. When asked if he was allergic to milk products, he said he did not know. 4). Resident #115 was admitted to the facility on [DATE] with diagnoses of major depression and anxiety disorder. The Quarterly MDS dated [DATE] showed a BIMS score of 15. In an observation conducted on 03/06/24 at 8:12 AM, Resident #115 was noted eating his breakfast tray in his room. In this observation, Resident #115 stated that he was looking forward to receiving a banana on his tray this morning but did not get it. Resident #115 spoke to the facility Dietitian and asked her to exchange his eggs for a banana this morning. Resident #115's breakfast meal ticket revealed a regular diet with a banana when available. In an interview conducted on 03/06/24 at 8:20 AM with Licensed Practical Nurse Staff H, she was asked if a resident asks for a banana that is not on the tray, will she go into the kitchen and get it. She said we usually do. She then proceeded to walk towards the main kitchen and, five minutes later, stated that the kitchen did not have any bananas. In an interview conducted on 03/07/24 at 10:40 AM with Staff F, the Registered Dietitian stated that the last person on the tray line checks to ensure that the correct food is placed on the meal tray.

Based on observations, interviews, and record review, the facility failed to maintain the appropriate food temperatures in the reach-in refrigerators and walk-in freezer and ensure kitchen equipment was in proper working order during 1 of 3 observations/visits in the main kitchen. The findings included: During the first visit to the kitchen conducted on 03/04/24 at 8:35 AM, the following were noted: The reach-in Delfield refrigerator had an internal thermometer in the back that showed 55 degrees Fahrenheit and not the recommended 40 degrees Fahrenheit or below. The reach-in Avantco refrigerator had an internal thermometer in the back that showed 50 degrees and not the recommended 40 degrees Fahrenheit or below. The hood had one light bulb not working out of 4 light bulbs. The walk-in Freezer was noted with an internal thermometer located at the back of the Freezer, which showed a temperature of 20 degrees Fahrenheit rather than the recommended 0 degrees Fahrenheit or below. Continued observation revealed eight tubs (3 gallons each) of ice cream soft to the touch and 1.5 boxes of 48 (4 ounces) individual servings of ice cream soft to the touch. The plate warmer's left side was warm to the touch. The Surveyor could place a full hand face down on the warmer without pulling the hand away. The right side of the plate warmer was at room temperature to the touch. In this observation, the Regional Dietary Manager stated that the plate warmer needed to be restarted and then turned off and on again, waiting 10 minutes. The Surveyor then touched the left side of the plate warmer, which was still warm to the touch, and the right plate warmer, which was still at room temperature to the touch.

Based on interview and record review, the facility failed to ensure emergency procedures were followed for Resident #1 who was choking for 1 of 1 sampled resident reviewed for choking. The facility staff also failed to ensure a resident had a clear airway prior to starting resuscitation after the resident became unresponsive. Additionally, the staff could not locate Resident #1's Do Not Resuscitate Order (DNRO) after the resident became unresponsive. Resident 31 was resuscitated, transferred to the hospital and later died . On [DATE], it was determined that the findings of the survey posed Immediate Jeopardy to the health and safety of the residents residing in the facility. The facility's Executive Director was informed of the Immediate Jeopardy on [DATE] at 4:50 PM. The Immediate Jeopardy was ongoing as of the exit on [DATE]. The findings included: Record review revealed, Resident #1 was admitted to this facility on [DATE]. The resident's diagnoses included: Dementia, Hypertension, Diabetes, Depression, Cerebral Infarction (Stroke). She was admitted to hospice on [DATE] with a terminal prognosis of Degenerative Disease of the Nervous System. A record review conducted for Resident #1 revealed the resident had a Florida Department of Health Do Not Resuscitate (DNR) Order Form 1896 on yellow paper, which was in the middle of the medical record. This order was signed by proxy, on [DATE], and signed and dated on [DATE] by a physician. A review of the Quarterly MDS (Minimum Data Set) Assessment with an Assessment Reference Date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated mild cognitive impairment. Section G of the assessment indicated extensive assistance with eating, one-person physical assist. Further review of the medical record revealed Resident #1 had speech therapy [DATE]-[DATE] for pocketing food. She was discharged from speech with a diet of dysphagia mechanical soft with no signs or symptoms of difficulty swallowing noted. Further review revealed Resident #1 was on a Regular, no added salt diet, Dysphagia Mechanical Soft texture, Nectar thickened fluids consistency, fortified cereal at breakfast, fortified mashed potatoes. In an interview with the facility's Dietitian on [DATE] at 4:44 PM, she stated the resident had days where she was more alert and less alert. She needed verbal cues to eat some days. Interview with Staff A, a Certified Nursing Assistant (CNA) on [DATE] at 11:45 AM revealed on [DATE] she was feeding the roommate of Resident #1 lunch and Resident #1 was feeding herself. Staff A reported, she left the room to bring the roommate's tray to the cart and in less than a minute when she returned to the room, Resident #1's eyes went back, and she called the nurse. Staff F, a Registered Nurse (RN) went into the room. Staff C, RN, also responded to the room and someone called a Code Blue (code response for cardiac arrest). Staff F, RN, stated in an interview on [DATE] at 2:45 PM, on [DATE] she saw the resident sitting up terrified, then she turned her to the right and she slapped her back and did a finger sweep and she said no food came out. Staff C, RN, came, and someone yelled Code Blue, and someone said she [Resident #1] was full code [desired to be resuscitated and all life saving measures when the heart stops beating or if the person stops breathing]. Resident #1 was making a noise like gag/cough and the aide had the tray. After the resident did the gag sound she passed out. She then started CPR. Staff C, RN, stated in a telephone interview on [DATE] at 1:05 PM, that Resident #1 was unresponsive, and she was not breathing when she entered the room. The resident's extremities were blue and her face was pale. Staff F, RN, told Staff A, CNA, to lower the head of the bed. Staff F, RN, performed back slaps, then initiated CPR. Staff C went to the door and yelled help, Code Blue, and checked Resident #1's pulse. Staff B, LPN (Licensed Practical Nurse), the West Wing unit manager, instructed her to initiate CPR. At that point the room started to fill up with other employees and nurses and she started to perform CPR and then the DON (Director of Nursing) started to perform CPR. They pulled out food from resident's face and they continued CPR. Then the paramedics came and started CPR and they got a pulse, and they wheeled her out of the facility. At one point during CPR, the DON asked if the code status was checked and verified and Staff F said, yes, and she said Staff B, LPN, the unit manager verified it. They did CPR about 10 minutes before the paramedics came. After the paramedics left, the resident's nephew returned the phone call and Staff C told him that his loved one was sent to the hospital. He said that his aunt was a DNR and wanted to know what happened and where she had gone. He was told that he could get an update from the hospital. As far as she knew the paramedics did not ask the code status, and she found out later from Staff E, the unit manager on the East Wing, that a DNR was signed. In an additional interview with the DON on [DATE] at 11:45 AM she stated, Staff B, LPN, waved her down saying we have a Code Blue, and she sees Staff F, RN, doing compressions with a board under the resident. She stated that she asked what the code status was, and Staff B, LPN, said, full code. She asked who confirmed and Staff F, RN, said Staff B, LPN, and she thought they confirmed it. An interview by phone was conducted with Staff B, LPN, on [DATE] at 12:45 PM. She stated, there was a Code[Blue] prior to that one, and she was sitting at the desk doing paperwork. She said, she heard Staff C, RN, call out saying the resident is unresponsive, but she did not go in the room. She called Staff E, the unit manager on the East wing, to get help with the code. She called 911. Nobody said look at the DNR and she did not open the chart. The computer was acting up and she was doing the paperwork, she did not do CPR. The DNR was not in the front of the chart. They printed the paperwork off the computer, the transfer to hospital form, bed hold policy, medication sheet, face sheet, and advance directive. Everything went so fast, and the resident was already gone before all of the paperwork was done. An additional interview with Staff B, LPN on [DATE] at 6:00 PM regarding Resident #1, revealed she did not know the code status, she did not tell anyone the code status, she did not tell anyone to start CPR. She became unit manager in [DATE]. The DNR should have been in the front of the chart, but it was in the middle and was not noticed until the resident left the building. Interview was conducted with Staff E, LPN, the Unit Manager on East Wing, on [DATE] at 2:07 PM. She stated, on [DATE], around 1:40 PM, she was in the hallway on the East wing when she heard the Code Blue West Wing. She rushed there, and she went straight into the room. When she got there, CPR was initiated, the nurse assigned to the resident was in the room, and the other nurse was using the Ambu Bag (a manual breathing unit that forces air into the lungs of the patients who have ceased breathing or struggling to breathe) and she switched with her with the CPR until paramedics arrived. They took over and asked them to leave the room. Most of the people left the unit. She did not ask what the code status was and since CPR was already being done, she believed they knew the code status. Interview with the Medical Director via telephone on [DATE] at 11:18 AM revealed he was notified of the incident regarding Resident #1. There was a Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] and he was involved via telephone. He reports, the facility is doing CPR training as well as everyone is being re-educated on the CPR policy. Staff H, RN, Minimum Data Set (MDS) coordinator, was interviewed on [DATE] at 5:36 PM regarding the MDS coding. She stated certified nursing assistants (CNAs) were charting limited assistance with meals in the look back period of [DATE] to [DATE] for Resident #1. It varies from total dependence to independent with most of the charting as limited assistance. During entrance conference on [DATE] at 11:15 AM, an interview with the Director of Nurses (DON) and Administrator was conducted. The DON stated that when a resident is discharged to the hospital, the Physician orders, Medication orders, order summary, lab work, face sheet, recent order changes, code status or advance directives, go with the resident to the hospital. The DON further revealed that when the resident was in the ambulance, she learned from Staff B, a licensed practical nurse who was the unit manager, that the resident was a DNR. Staff B was not able to complete the transfer paperwork while the resident was still in the building and did not realize the resident was a DNR. They did not notify the emergency room . The family member was reached by phone and was told to call the hospital. This surveyor called hospice to clarify the status of the resident and was told that she passed away on [DATE]. A report from Fire Rescue who responded to this event on [DATE] was reviewed on [DATE]. The report stated, the rescue received a [AGE] year old supine woman .CPR was in progress from the staff .the airway was inspected; secretions were present along with food particles. Oropharynx [part of the throat located in the very back of the mouth] was suctioned of the secretions and the forceps were used to remove several large food particles. Patient was in respiratory distress/arrest .Forceps were used again to remove more food particles. Choking/Heimlich Maneuver . In the event of an adult choking, the American Heart Association offer the below guidelines. Conscious Adult In the event of choking, rescuers should take action if they see signs of severe airway obstructions (including poor air exchange and increased breathing difficulty, a silent cough, cyanosis or if the person is unable to speak or breathe). To differentiate between mild airway obstruction and severe airway obstruction, the rescuer should ask, Are you choking? If the victim nods yes, assistance is needed. Choking also often is indicated by the Universal Distress Signal (hands clutching the throat). If the person can speak, cough or breathe, do not interfere. If the person cannot speak, cough or breathe, give abdominal thrusts known as the Heimlich Maneuver. To employ the Heimlich Maneuver, reach around the person's waist. Position one clenched fist above the navel and below the rib cage. Grasp your fist with your other hand. Pull the clenched fist sharply and directly backward and upward under the rib cage six to 10 times quickly. In case of obesity or late pregnancy, give chest thrusts. Continue uninterrupted until the obstruction is relieved or advanced life support is available. In either case, the person should be examined by a physician as soon as possible. Unconscious Adult Position the person on his or her back, arms by side. Shout for help. Call 911 or the local emergency number. Perform a finger sweep to try to remove any foreign body from the mouth. Only remove an object you can see and easily extricate. Listen for breathing and watch for the chest to rise and fall. If the person is not breathing, perform rescue breathing. If unsuccessful, give six to 10 abdominal thrusts (the Heimlich Maneuver). To perform abdominal thrusts on an unconscious person, kneel over the person and place the heel of one hand on the person's abdomen, slightly above the navel. Next, place your other hand on top of the first. Press into the abdomen with quick, upward thrusts. Repeat sequence: Perform finger sweep, attempt rescue breathing, perform abdominal thrusts, until successful. Continue uninterrupted until the obstruction is removed or advanced life support is available. When successful, have the person examined by a physician as soon as possible. After the obstruction is removed, begin CPR, if necessary . American College of Emergency Physicians website, www.emergencyphysicians.org, accessed on [DATE]. Step for Giving CPR 1. CHECK the scene for safety, form an initial impression and use personal protective equipment (PPE) 2. If the person appears unresponsive, CHECK for responsiveness, breathing, life-threatening bleeding or other life-threatening conditions using shout-tap-shout 3. If the person does not respond and is not breathing or only gasping, CALL [DATE] and get equipment, or tell someone to do so 4. Place the person on their back on a firm, flat surface 5. Give 30 chest compressions Hand position: Two hands centered on the chest Body position: Shoulders directly over hands; elbows locked Depth: At least 2 inches Rate: 100 to 120 per minute Allow chest to return to normal position after each compression 6. Give 2 breaths Open the airway to a past-neutral position using the head-tilt/chin-lift technique Ensure each breath lasts about 1 second and makes the chest rise; allow air to exit before giving the next breath Note: If the 1st breath does not cause the chest to rise, retilt the head and ensure a proper seal before giving the 2nd breath If the 2nd breath does not make the chest rise, an object may be blocking the airway 7. Continue giving sets of 30 chest compressions and 2 breaths. Use an AED as soon as one is available! Source: The American Red Cross website, www.redcross.org, accessed on [DATE]. The Facility's policy titled, Emergency Intervention - Heimlich Maneuver, dated [DATE] includes the Heimlich Maneuver will be used to expel food or a foreign body lodged in a person's throat, creating a blockage of the airway. The procedure for an Adult Lying Down includes: 1. If the victim is lying on his back, face him and kneel astride his hips. 2. With one hand on top of the other, place the heel of the bottom hand on the abdomen slightly above the umbilicus and below the rib cage. 3. Press into the victim's abdomen with a quick upward thrust. 4. Repeat several times if necessary until food or foreign body has been removed. Review of the Facility's policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE] revealed: 1. In the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: - Resident Identity -Current physician order for code status 3. Use the paging system and call Code Blue to room number _, three times (or location of event). 4. In the absence of a physician's order for DNR the facility will immediately begin CPR. 5. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if the resident responds. 6. Notify the physician and resident representative/legal representative. 7. Document in the medical record.

Based on interview and record review, the facility failed to obtain physician orders [REDACTED]. This was evidenced by the failure to implement a plan of care for preventative efforts to reduce falls and injury for 1 of 3 sampled residents (Resident #2), who was a newly admitted resident who had been assessed to be at risk for falls and suffered a fall with head injury within two days of admission. The findings include: The facility's policy and procedure N-1259 titled Fall Risk, effective [DATE] documented, to identify risk factors which place the resident at risk for falls and to facilitate the development of interventions to minimize or prevent falls to the extent possible requires: Residents identified at risk for falls will have individualized prevention interventions added to the resident's plan of care. Initiate interventions to reduce risk. Document identified risk and interventions in the resident's plan of care. Clinical record review revealed, Resident #2 was admitted to the skilled nursing facility on [DATE] from an acute care hospital. An admission fall risk evaluation on [DATE] noted a score of 15, which deems the resident at risk for falls due to intermittent confusion, history of ,[DATE] falls in the past 3 months, chair bound, balance problem while standing, walking and antihypertensive medications. Review of an Admission plan of care for Resident #2 revealed, the Care Plan failed to identify fall safety risks as a problem and care approaches to reduce the falls and injuries. A nursing progress note revealed on [DATE] at 6:00 AM, a CNA (certified nursing assistant) informed a nurse that the resident was laying on the floor. The Nurse found the resident on the floor on the right side of the bed. The assessment noted, laceration to his right eyebrow area bleeding. The resident stated, I was going to the bathroom and fell . The Neurological Assessment Flow sheet documented every 15 minute, neurological assessments between 6:00 AM and 7:00 AM, with no change noted and then hourly neurological assessments at 8:00 AM. At 9:00 AM on [DATE] revealed, a significant decline in the resident ' s neurological function. Vomiting was noted and there was an increased blood pressure readings. Emergency Medical Services transported the resident to a hospital emergency room as a trauma alert at approximately 9:20 AM on [DATE]. The hospital record review revealed, the resident died on [DATE] from fall injuries. An interview was conducted with the Registered Nurse Unit Manager at 3:00 pm on [DATE] regarding, the plan of care for newly admitted residents. The Nurse Manager stated, an admission care plan is completed with interventions for problems identified during the admission nursing assessment. The Nurse Manager reviewed the admission care plan for Resident #2 and verified, the care plan did not document a plan of care for fall/safety risk. An interview conducted with the Director of Nursing (DON) on [DATE] at 3:50 PM, provided no additional information, she stated, they were still investigating the incident.

Based on clinical record review and staff interview the facility's licensed nurses failed to provide timely monitoring and implementation of interventions to meet the resident's needs during a significant decline in neurological functions requiring immediate emergency medical services after a fall resulting in head injuries for 1 of 3 sampled residents (Resident #2). Nurse Practice Act, Florida Statues, CHAPTER 464, PART I: 464.003, (19) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, or a licensed osteopathic physician. (20) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others The findings include: Clinical record review revealed Resident #2 was admitted to the skilled nursing facility on [DATE] from an acute care hospital. The resident's medical history includes Severe [MEDICAL CONDITIONS], Diabetes Mellitus, Hypertension, [MEDICAL CONDITIONS], and Carotid Endarterectomy. End Stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], Abdominal aortic aneurysm, [MEDICAL CONDITION] and Cerebral Vascular Disease. The facility's incident and accident record revealed Resident #2 was found lying on the floor on [DATE] with an injury to his forehead. Resident #2's nursing progress notes and neurological assessment flow sheet documented the following concerns on [DATE]: a. The 6:00 AM nurse's note documented: CNA (Certified Nursing Assistant) informed a nurse the resident is lying on the floor. The Nurse found the resident on the floor on the right side of bed. The assessment noted a laceration to the right eyebrow area bleeding. The resident stated, I was going to the bathroom and fell . The vital signs included a blood pressure (B/P) of ,[DATE], Respiration 22, Pulse 78, Temp 98.1 F (Fahrenheit). Tylenol 2 tablets was given. Neuro checks were initiated. A call was placed to next of kin and MD (Medical Doctor). Awaiting a call from the MD. b. The 6:00 - 7:00 AM neurological assessment flow sheet documented every 15 minutes neuro checks as, resident is alert, pupils are equal and reaction to light, motor functions are intact, B/P ,[DATE]-,[DATE]. The right eye laceration/swelling. c. The 6:55 AM nurse ' s note documented: a second call was placed to MD awaiting call back. d. The 7:20 AM nurse ' s note documented: the writer made rounds with the ,[DATE] nurse, the resident was lying in bed, with a laceration to the right eye. The resident was asked how he was feeling resident and said, Ok . The tab alarm was noted to the bed. The resident was in stable condition. e. The 8:00 AM, neurological assessment flow sheet documented: resident is drowsy, pupils are non-reactive, unable to hand grasp and unable to follow command, and the pain response is absent. The blood pressure had increased to B/P ,[DATE], Pulse 90, Respiration 20. The Right eye was swollen, and bruising. f. The 8:00 AM nurse ' s note documented: resident is breathing; right eye is swollen and bruising noted. Tab alarm noted. The resident was able to follow verbal command. (This statement conflicts with the neurological assessment flow sheet). The MD was called again. g. The 9:00 AM, neurological assessment flow sheet documented, resident is drowsy, pupils are nonreactive, unable to hand grasp and unable to follow command. There was no response to pain. The B/P was ,[DATE], Pulse 100, Respiration 22. The left eye was swollen, and bruising. The resident had vomited. h. The 9:05 AM nurse ' s note documented: the writer went to do neuro checks on the resident, the resident was seen breathing and the right eye was swollen and bruising. Vomit was noted on the right side of the residents gown. The writer applied a sternal rub, the resident responded, 911 called, the MD was called again. At 9:20 AM, the resident out of the building to the ER (emergency room ) for treatment. Upon record review, it was noted that the [DATE], 9:45AM, Fire Rescue Ambulance Record disclosed, emergency medical personnel was initially dispatched to a call at the nursing home for chest pain. While assessing the chest pain patient, a nurse ran to us and explained there was a sick patient who was lethargic and was vomiting in another room. Upon arrival to the other room (Resident #2) was found lying supine in the bed. Glasgow score 6. Dispatch was notified of an adult trauma alert. Patient was only slightly responsive to pain, no verbal or eye opening response. No obvious sign of injury noted on the secondary assessment. Assessment upon arrival at the hospital at 10:04 AM level of consciousness was documented as - Unconscious. Right pupils dilated and B/P ,[DATE]. Interview with a Registered Nurse (RN) was conducted on [DATE] at 3:05 PM, the nurse stated she was the charge nurse on the South unit during the 7A-3PM shift on [DATE]. At approximately 8:00 AM she called 911 for Resident #4 who had chest pain. While Emergency Medical Services (EMS) was assessing the resident with chest pain, a Licensed Practical Nurse (LPN) came to the room and informed the RN, Resident #2 was not responding. The RN and the EMS personnel assessed the resident and found the resident in critical condition and EMS immediately transported the patient to emergency room as trauma alert. EMS called for another ambulance to take Resident #4 to the emergency room . Upon inquiry, the RN reviewed the neurological assessment record and stated the nurse should have called 911 at 8:00 AM, when the nurse observed a change in the resident neurological functions. The RN stated, the physician called back at 9:45 AM and was informed of the resident ' s fall and change in condition. Review of the hospital records revealed a Physician Discharge Summary dated [DATE] which documented Resident #2 was admitted to the hospital on [DATE] with an admission [DIAGNOSES REDACTED]. Further review revealed a CT Brain Scan was performed on [DATE] with a clinical indication of Trauma. The notes from the CT Brain Scan documented, Extensive Acute Subdural Hemorrhage (bleeding between the covering and surface of the brain resulting from serious head injury). Review of the hospital discharge summary revealed Resident #2 expired at the hospital on [DATE]. An interview was conducted at 2:00 PM on [DATE] with the day shift Licensed Practical Nurse (LPN) who was assigned to Resident #2 on [DATE]. The LPN stated, during the neuro checks at 8:00 AM on [DATE], Resident #2 responded slowly to verbal commands, both pupils had A sluggish reaction to light and his blood pressure was high. She informed the RN/charge nurse and Unit manager and also called the physician again, but the physician did not call back. Upon inquiry, the nurse stated she did not increase the frequency of the neurological assessment. When she returned to the resident's room at 9:00 AM, his blood pressure had further increased and was still high. The resident was not responding to verbal stimuli and vomit was noted. The resident responded to sternal rub by opening both eyes. The LPN acknowledged, she did not call 911 for Resident #2, as documented in the nurse ' s notes. The charge nurse had called 911earlier for Resident #4, who had complained of chest pain and they took Resident #2 to the ER because this resident's (#2's) condition was critical. An interview conducted with the Director of Nursing (DON) on [DATE] at 3:50 PM, provided no additional information, she stated they were still investigating the incident.

Based on clinical record review, staff interview and policy and procedure review, the facility failed to implement their Fall Risk policy to ensure a care plan was developed and implemented to reduce falls and injury for 1 of 3 sampled residents (Resident #2), who was a newly admitted resident who had been assessed to be at risk for falls and suffered a fall with head injury within two days of admission. The findings include: The facility's policy and procedure N-1259 titled Fall Risk, effective [DATE] documented, to identify risk factors which place the resident at risk for falls and to facilitate the development of interventions to minimize or prevent falls to the extent possible requires: Residents identified at risk for falls will have individualized prevention interventions added to the resident's plan of care. Initiate interventions to reduce risk. Document identified risk and interventions in the resident's plan of care. Clinical record review revealed, Resident #2 was admitted to the skilled nursing facility on [DATE] from an acute care hospital. The admission nursing assessment on [DATE] disclosed, the resident is alert, oriented to person and place. Short and long term memory is okay, moderately impaired for decision making, usually understands and vision is adequate. Bowel status was usually continent. Bladder occasionally incontinent. There was no pain, and the resident was able to express pain. There was no advanced directive. An admission fall risk evaluation on [DATE] noted, a score of 15, which deems the resident at risk for falls due to intermittent confusion, history of ,[DATE] falls in the past 3 months, chair bound, balance problem while standing, walking and antihypertensive medications. Review of an Admission plan of care for Resident #2 revealed, the Care Plan failed to identify fall safety risks as a problem and care approaches to reduce the falls and injuries. A nursing progress note revealed on [DATE] at 6:00 AM, a CNA (certified nursing assistant) informed a nurse that the resident was laying on the floor. The Nurse found the resident on the floor on the right side of the bed. The assessment noted, laceration to his right eyebrow area bleeding. The resident stated, I was going to the bathroom and fell . Upon examining the resident's room, no sharp items were noted, to cause a laceration to the resident's head or items in the way to cause the resident to have an unsteady gait. Vital signs were documented as (B/P) blood pressure ,[DATE], Respiration. 22, Pulse 78, and Temp 98.1 F. Tylenol 2 tablets was given. Neuro checks were initiated. A call was placed to the next of kin and MD (Medical Doctor). Awaiting call from MD. The Neurological Assessment Flow sheet documented every 15 minute, neurological assessments between 6:00 AM and 7:00 AM, with no change noted and then hourly neurological assessments at 8:00 AM. At 9:00 AM on [DATE] revealed, a significant decline in the resident ' s neurological function. The right and left pupils are nonreactive to light, unable to hand grasp, unable to follow commands and no response to pain. Vomiting was noted and there was an increased blood pressure readings. Emergency Medical Services transported the resident to a hospital emergency room as a trauma alert at approximately 9:20 AM on [DATE]. The hospital record review revealed, the resident died on [DATE] from fall injuries. An interview was conducted with the Registered Nurse Unit Manager at 3:00 pm on [DATE] regarding, the plan of care for newly admitted residents. The Nurse Manager stated, an admission care plan is completed with interventions for problems identified during the admission nursing assessment. The Nurse Manager reviewed the admission care plan for Resident #2 and verified, the care plan did not document a plan of care for fall/safety risk. An interview conducted with the Director of Nursing (DON) on [DATE] at 3:50 PM, provided no additional information, she stated, they were still investigating the incident.