Every finding on record at Encore at Boca Raton Rehabilitation and Nursing Ce

Based on observation, interview, and record review the facility failed to maintain a Resident's privacy for 1 of 1 sampled resident (Resident #190), reviewed for privacy. The findings included: Review of the record revealed Resident #190 was initially admitted to the facility 04/23/26 with the primary diagnosis of Unspecified Atrial Fibrillation Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #190 had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the Resident was cognitively intact. An interview was conducted on 05/04/26 at 8:30 AM, when asked how her care was, Resident #190 stated this morning a lady she had never seen before searched through her drawers without asking for her permission first. When Resident #190 asked her what she was doing, she stated she was looking for drugs and medications. Resident #190 stated she should have explained what she was doing. On 05/04/26 at 8:47 AM the Admissions Director walked into Resident's 190's room to remove her breakfast tray and Resident #190 told the surveyor this is the lady. During a follow up interview on 05/6/26 at 10:15 AM Resident #190 was in her room with her family member at the bedside. Resident #190 restated to the surveyor that they should have asked her for permission before going through her drawers and belongings. During an interview on 05/06/26 at 10:32 AM, the Admissions Director stated she had been working at the facility for a year. When asked what she does on the unit, she stated she was the Guardian Angel for the unit and was there every day from Monday-Friday. When asked what tasks she took care of, the Admissions Director stated she took care of resident concerns, she makes sure the room is clean and tidy and she tries to fix issues right away with whatever department it involved. When asked if she had been involved in any resident room checks this week, she stated yes and they were checking for Over The Counter (OTC) and outside medications. When asked for the process of performing these checks, the Admissions Director stated she asks for permission before she performs the checks and if there is anything found she would educate the resident that it had to be turned into the nurse for administration and storage. She stated all residents had these checks and the family was also educated about the policy relating to outside medication. When Resident #190's concerns were brought up to the Admission's Director, she stated she had asked the resident for permission to check her drawers and told her the medicine she had would have to get turned into the doctor so she could get an order from the doctor. On 05/06/26 at 10:35 AM, Resident #190 and her family member were asked for permission to have an open conversation with the surveyor and Admissions Director in which the resident agreed. On 05/06/26 at 10:36 AM, the Admissions Director asked Resident #190 if she remembered her coming in everyday to check on her, Resident #190 stated I remember you coming in but not every day. The Admissions Director asked if she remembered her coming in and asking for permission to search her drawers to look for medication, Resident #190 stated no you did not ask for permission you just went through my drawers and I remember asking you, what are you doing, and you said you were looking for drugs and medications. Resident #190 stated to the Admissions Director she did not want to argue with her and since this happened early morning, she might not remember all the details, but she did remember her going through her drawers without permission. Resident #190's family member stated to the Admissions Director It may not be what you said but it's how you said it. The Admissions Director apologized to the resident and listened to the resident's further concerns about her care. On 05/06/26 at 10:45 AM, the Admissions Director stated in the future she would try not have conversations with resident's too early in the morning that they can't remember afterwards and would try to better explain what she is doing before she does it.

Based on observation, interview and record review, the facility failed to provide breakfast meals for 1 of 25 sampled residents on the Windsor Unit (Resident #87).The findings included:Record review showed that Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Dementia and Non-Rheumatic Aortic (valve) Stenosis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 12, which indicates mild cognitive impairment.In an observation conducted on 05/04/26 at 9:50 AM, Resident #87 was seen lying in bed looking at his roommate eating his breakfast. At that time, Resident #87 roommate's breakfast tray was 50% empty.In an interview conducted on 05/04/26 at 9:55 AM, Resident #87 stated that he is hungry and is unsure why his roommate got his breakfast and not him. Resident #87 looked very concerned.In an observation conducted on 05/04/26 at 10:00 AM in the Windsor Unit Hallway, the Surveyor opened the food cart and realized that it was empty. At 10:10 AM, staff members started putting the empty/dirty trays in the cart. Resident #87 did not get his breakfast tray.In an interview conducted on 05/04/26 at 10:05 AM with Unit Manager, Staff B stated that they were done passing the trays and opened the food cart to show the surveyor that all the residents had received their trays. The Surveyor went to Resident #87's room with Staff B to show her that Resident #87 did not get his breakfast tray. Staff B explained that she would go personally to the kitchen to get his breakfast tray. In an observation conducted on 05/04/26 at 10:30 AM, Resident #87 was seen in bed, happily eating his breakfast. Resident #87 stated that he is eating what they gave him. Per surveyors' observation Resident #87 did not get a meal ticket. Per surveyors' question, Resident answered that he did not choose what he wanted but would have loved to have bacon instead of just eggs and a biscuit, as observed.In an interview conducted on 05/07/26 at 12:40 PM with Licensed Practical Nurse (LPN), Staff C, she stated that she has been working for the facility for about 3 months. She further stated that she helps with passing the trays and usually works the 3:00 PM to 11:00 PM shift. She explained that the first thing they do in the before passing the trays is to look at the meal ticket to make sure that the name of the resident on the meal ticket and the tray matches. After passing the trays, the LPN rounds the room to make sure every resident receives a tray.In an interview conducted on 05/07/26 at 12:45 PM with CNA, Staff D, she stated that she has been working for the facility for almost a month now. She further stated that she helps with passing the trays. And once they are done passing the trays they go to each room to make sure every resident receives a tray. Then they move to assisting residents with eating. They conduct a last check in the food cart to make sure all the trays are distributed before starting to put the dirty trays in.In an interview conducted on 05/07/26 at 12:50 PM, the Certified Dietary Manager (CDM) stated that he has been working for the facility for almost 6 months now. He further stated that all the meal tickets and the census are printed every morning. He explained that he goes through the meal tickets before starting the tray line to make sure they are accurate. He was made aware of the findings and told the surveyor that he finds it strange because there is a designated staff (checker) in the kitchen that always checks the cart before it leaves to the floor.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was observed during 3 of 4 visits conducted in the Main Kitchen and Pantries. The findings included: 1. A tour of the Main Kitchen was conducted on 05/04/26 at 6:20 AM. The Certified Dietary Manager (CDM) arrived during the tour, and all findings were shared with him. The following items were observed: a. At the handwashing sink near the main kitchen entrance, a small black garbage can was observed with a broken lid. The foot pedal did not open the lid thus a person who washed their hands would have to manually open the lid creating an unsanitary environment. b. In a reach-in refrigerator, a 46-ounce (oz) bottle of Hormel Honey Thick Apple Juice was observed with a date written in black with a permanent marker of 03/24/26. A 46 oz bottle of [NAME], Thick and Easy, Nectar Thick, Orange Juice was observed with a white sticker with a date of 04/21/26. The labels on the bottles stated, Discard if not used within 10 days of opening. A 32 oz bottle of [NAME] Thick and Easy, Nectar Thick, Dairy Beverage was observed with a white sticker that had a date of 04/28/26. The label read, Discard if not used within 4 days of opening. The CDM stated those were the dates received. He did not know the dates they were opened. c. In the walk-in refrigerator, 14- 8 oz cartons of [NAME] Whole Milk had an expiration date of 05/01/26. A Quarter Sized Hotel Pan was labeled Cake Puree with a date of 04/25/26. According to USDA storage guidelines, chocolate cake may be stored for up to 7 days in a refrigerator. d. In the walk-in freezer a frozen water pillar was noted on an ice cube blanket below the freezer cooling unit, indicating there was a leak which had the potential to cause cross contamination or contaminate items stored below it. e. The plate warmer tension spring was dysfunctional thus about one third to half of the plates were not inside the warmer and were not hot. Crumbs and food debris were observed on the top of the plate warmer. f. The ingredient bins with rice, flour, sugar, and thickener were observed with unidentifiable debris and residue. g. In the dishwasher area, the dish tables, lower part of walls, and equipment were observed with drippings and residues of unidentified substances and long-term use without cleaning. Under and around the equipment was a dried liquid residue and there were areas where the paint was missing, exposing uncleanable surfaces. There was water standing in puddles on the floor. The largest puddle was about 2 feet by 1.5 feet. The puddles were observed prior to the breakfast meal service thus it had been hours since the dishwasher was run. h. In the food prep area behind the ovens and steamer there appeared to be corrosion (rust) on the pipes, and the floors were observed with an unidentifiable dried liquid residue. Between the ovens there was accumulation of what appeared to be black grease spillage on the floor, and the pipes appeared to be corroding. The sides of the equipment/ovens had food drippings. i. In front of a reach-in refrigerator there was an irregular shaped puddle of fluid that appeared to be water leaking from under it. Photographic evidence was obtained. 2. On 05/06/26 at 11:17 AM, an observation of the tray line was conducted. Staff E, Dietary Aide, who had facial hair was observed in the food preparation area without a beard guard. Once he was advised to put one on, he had to be instructed on how to properly wear it to cover the hair on his upper lip. On the tray line, ground carrots were 127 degrees Fahrenheit and pureed vegetables were 130 degrees Fahrenheit which were below the required minimal temperature of 135 degrees. Fruit cups on the tray line were 50 degrees Fahrenheit which were above the maximum temperature of 41 degrees. 3. On 05/07/26 at 10:03 AM, an observation of the Pantry in the [NAME] Unit was conducted with Staff A, Unit Manager. The drawers were observed with an unidentifiable debris and residue. One of the drawers had dried up fluid stains and a black colored substance on the side rails. The organizer trays which held condiment packets inside the drawers were also observed with unidentified debris. The CDM was alerted of the findings and photographic evidence was obtained.

Based on observation, interview, and record review, the facility failed to follow their facility assessment regarding their staffing plan for Certified Nursing Assistants (CNAs).The findings included: Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for Excessively Low Weekend Staffing for Quarter (October 1 -December 31, 2025) which documented Metric: .Excessively Low Weekend Staffing.Triggered. Definition: Triggered=Submitted weekend staffing data is excessively low. Review of the facility assessment dated [DATE] was completed on 05/07/26 at 10:00AM. This tool documented, Approach: .This input included identification and adequacy of resources both during normal operations and emergencies such as a hurricane. On page 11 of the facility assessment, it documented, Staffing Plan. Direct Care Staff. CNA: Plan: 7A - 3P (20 CNAs);3P- 11P (20 CNAs); 11P-7A (9 CNAs) . Review of the 2 weeks Minimum Staffing Calculations sheets for Quarter (October 1 -December 31, 2025) revealed 3 days of low staffing ratios for CNAs on the following days: November 23, 2025; November 30, 2025; January 02, 2026. These same sheets revealed that 20 CNAs were scheduled only 3 times in this same quarter (10/02/2025 -first shift; 10/16/2025-first shift ;10/23/2025-first shift.) An interview was conducted on 05/07/26 at 11:40 AM with the Staffing Coordinator and HR (Human Resources) Director. When asked if they were aware the facility had triggered for low weekend staffing, they stated they were not aware. When asked why the facility assessment staffing plan for CNAs did not match the actual scheduled CNAs, they stated they schedule per the census and per the acuity of the Residents. When they were made aware the days that were triggered for low staffing (11/23/2025;11/30/2025;01/02/2026) they had a higher census of 153;148;151, the Staffing Coordinator mentioned they scheduled by budget and that the budget did allow for 20 CNAs. When asked why they had not been scheduling 20 CNAs, they could not answer. An interview was conducted on 05/07/26 at 11:47 AM with the Nursing Home Administrator (NHA). The NHA was asked if he was aware that many residents expressed frustration that their food was delivered cold many times. The NHA stated that he was aware and had put interventions in place such as involving managers to be present when the food carts are delivered to oversee timely delivery of food trays to the residents. He was then asked if the managers were present on the weekend and he stated they were not. When asked if he knew why the facility assessment for CNAs stated it had a plan for 20 CNAs and were not being scheduled, the NHA stated they scheduled based off what corporate told them was the minimum requirement, 2.15 and their PPD (patients per day.) When asked if he was aware he triggered for low staffing he stated he was not aware. He acknowledged the Residents food concerns could relate to their staffing and agreed that relying on managers to oversee, assist and pass trays when they are not there on the weekends was not effective. The NHA agreed to hire more CNAs and stated they would schedule up to 20 CNAs on the weekend since they have the budget for it.

Based on interview, and record review, the facility failed to follow their own policy for water system management by failing to monitor and control contaminants in a resident room's water source after a Legionella pneumophilia result was found above the acceptable standard measures. The findings included:A review of the facility's policy titled, Legionella Water Management Program, undated, documented the following:The facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella.Specific measures are used to control the introduction and/or spread of Legionella (e.g. temperature, disinfectants) by: A system to monitor control limits and the effectiveness of control measures. A plan for when control limits are not met and or control measures are not effective. During a record review of the Legionella Water Management Program, test report # 69263, titled, Laboratory Certificate of Results, dated 06/06/25, documented several tested areas and rooms where Legionella Pneumophilia were not detected (ND), but room [ROOM NUMBER] resulted values were 23 most probable number (MPN)/100 milliliter (ml). The footnote explained that any numerical result is a cause for concern.An additional record review of report# 85759, titled, Laboratory Certificate of Results, dated 04/29/26, revealed that all tested areas had less than 10 MPN/100ml. A footnote revealed that ND, not detected means the analyte was not detected at the reporting detection limit of 10 MPN/100ml. A further review of this report revealed that no re-testing was done for room [ROOM NUMBER].In an interview with the Nursing Home Administrator (NHA) on 05/06/26 at 9:35 AM, when asked what interventions they performed to ensure the number of Legionella pneumophilia contaminants were reduced, responded, the Maintenance Director has the answer.In an interview with the Maintenance Director on 05/06/26 at 10:35 AM regarding report #69263, he stated that they fixed the water pipes in room [ROOM NUMBER]. When he was asked why they did not re-test the water contaminants in room [ROOM NUMBER] after the water pipes were fixed, he responded they decided to test room [ROOM NUMBER]'s water which is adjacent to room [ROOM NUMBER].He added that the most recent report #5759, dated 04/29/26 was ok. A further review of this report # 5759 revealed Legionella pneumophilia contaminants was less than 10 MPN/100 ml, indicating the analyte were not detected for both hot and cold water in several areas of the facility. The report did not include room [ROOM NUMBER]'s retesting values.When Maintenance Director was asked again why he did not retest room [ROOM NUMBER], he stated the adjacent room [ROOM NUMBER] was retested.In an interview with the Regional Nurse Consultant on 05/06/2026 1:59 PM, when she was asked what interventions were performed for the level of contaminants based on the last year's laboratory report, responded, it was not a dangerous level, they contacted the corporate office and they did interventions. In another interview with the NHA on 05/06/2026 2:01 PM, he stated that interventions were done and the corporate made suggestions on what to do.A written report was submitted by the Maintenance Director on 05/07/26 at 9:10 AM explaining that the intervention for the 23 MPN/100 ml Legionella testing results in room [ROOM NUMBER] was to install a new faucet with new aerator, done on 06/13/25. Additionally, the hot and cold water ran for ten minutes each. When he was asked to submit the repair record for the pipes, and the log for water flushing in room [ROOM NUMBER] after the result from last year, he did not respond.

Based on record reviews and interviews, the facility failed to provide blood pressure monitoring to meet the needs of a resident, and failed to assess the accuracy of medication administration, for 1 of 3 sampled residents (Resident #1). The Findings included: A review of the facility's policy on Medication Administration, dated 01/27/2025, revealed medications are administered in accordance with the prescribers orders, and number 11 revealed vital signs are checked and verified for each resident prior to administering medications. 1) Resident #1 was admitted on [DATE] and was discharged on [DATE]. A review of diagnoses included Atrial Fibrillation, Pneumonia with Shortness of Breath, Coronary Artery Disease, and Heart Failure. A review of the Minimum Data Set (MDS) dated [DATE] under Section C for Brief Interview of Mental Staus (BIMS) revealed a score of 15 indicating good mental cognition. A review of orders dated 11/6/24 at 4:47 PM revealed Spironolactone oral tablet 25 MG, give 0.5 tablet by mouth one time a day for edema, hold if Systolic Blood pressure (SBP) is less than 120. A review of orders dated 11/5/24 at 1:00 PM revealed to obtain and document vital signs every shift for 72 hours, then re-assess for continued monitoring. A review of the Medication Adiministration Record (MAR) dated 11/7/24 at 9:00 AM revealed Spironolactone was given by Staff D, Licensed Practical Nurse (LPN), when she took and recorded Resident #1's blood pressure reading of 86/62 on 11/7/24 at 8:55 AM . A review of Resident #1's docuemnted blood pressire (BP) measurement revealed the following : on 11/7/25 at 8:55 AM, it was 86/62, on 11/7/25 at 10:44 PM, it was 87/68, and on 11/8/25 at 6:54 AM, it was 85/42. A further review of documented BP revealed there was no BP recorded between 8:55 AM and 10:44 PM on 11/7/24, revealing no reassessment for continuing monitoring was done per doctor's order. There was no BP documentation on 11/7/24 between 10:44 PM and 11/8/24 at 6:54 AM revealing no re-assessment for continuing monitoring was done per doctor's order. In an interview with Staff B, LPN, on 04/10/25 at 10:35 AM, when asked how she would manage a resident with a blood pressure of 90/50, she responded, I would know by looking at the resident. The resident would have pale lips or darker blue lips, and the skin feels cold. She added that she would check the vital signs. She would also assess the resident's breathing, skin, bowel movement, and if she thinks something is wrong and the resident does not look ok, she will inform the doctor of resident's low BP. In an interview with Staff D, LPN, on 04/10/25 at 11:32 AM, when asked how she would care for a resident if there was a change in condition, she responded, I would check the resident's vital signs and blood pressure. When asked what would she do if the previous BP was 102/70 and now is 90 /60, she responded, I will call the doctor, and I will check the medications. She would make sure the resident is talking, is safe and responsive to questions in bed, then she will go to the nurses station to call the resident's family and call the doctor.

Based on record reviews and interview, the facility failed to ensure adequate hydration and nutrition for 1 of 3 sampled residents (Resident #1) The findings included: During a record review of the Facility's policy, titled weight assessment and intervention , it was revealed under evaluation that the physician and the multidisciplinary team identify conditions or clinical situations and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss based on the following examples, medication related adverse consequences, fluid and nutrient loss, and inadequate availability of food and fluids. Resident # 1 was admitted on [DATE] and was discharged on [DATE]. A review of diagnoses included Atrial Fibrillation, Pneumonia with Shortness of Breath, Coronary Artery Disease, Heart Failure. A review of the Minimum Data Set (MDS) section C for Brief Interview of Mental Status (BIMS) revealed a score of 15 indicating good mental cognition. Section N revealed Resident # 1 was on anticoagulant, antiplatelet and diuretics. A review of Dietary progress notes dated 11/7/24 at 2:37 PM revealed Staff G, Registered Dietitian, notified Medical Doctor (MD) that Resident #1 was noted with increased reflux. Resident #1's daughter rrevealed resident is lactose intolerant. The MD was requested to change Ensure supplement to trial of Ensure Clear. An order by MD included: Pepcid increased to 2x/day; Recommend discontinuing Ensure plus and give Ensure clear daily. Continue to monitor per orem (oral intake and follow up as needed). A review of Nursing progress notes did not include Staff D, LPN monitored the fluid intake of resident on 11/7/24 at 8:55 AM when the blood pressure (BP) of 86/62 was documented. There was no recoded progress notes done by Staff D regarding monitoring of fluid intake when resident is on 2 diuretics, had a low BP. A review of progress notes from the facility's multidisciplinary team did not indicate any nutritional evaluation related to resident's medications such as BP medications and diuretics. An additional review of nursing care plan did not include a focus on fluid and nutrition maintenance and any interventions on how to maintain the resident's fluid and nutrition status. In an interview with Staff A, a Licensed Practical Nurse (LPN), when asked if she monitored resident # 1's fluid status, she responded, she does not remember. In an interview with Resident #1's physician ,on 04/10/25 at 5:30 PM, when asked why he waited for the order of Intravenous fluids until 11/8/24 at 9: 00 AM, he responded, I saw the resident on 11/6/24 and 11/7/24 and she was ok.

Based on observations and interviews, the facility failed to prepare foods in a manner consistent with standards for food safety. The findings included: 1). During the initial kitchen tour, on 12/02/24 at 9:28 AM, accompanied by the Certified Dietary Manager (CDM), it was noted that there was a leak at the filter from the steamer. The CDM stated that she was aware of the leak and Maintenance would be making repairs. 2). Upon approaching the entrance to the kitchen, on 12/03/24 at 9:35 AM, Staff R, Dietary Aide, answered and opened the door with gloved hand and then proceeded to rinse off her gloved left hand in a food preparation sink before handling ready to eat lettuce. Staff R was instructed to remove the gloves and perform hand hygiene. 3). During the follow up tour, on 12/05/24 at 6:34 AM, accompanied by the CDM, the following were noted: a. Staff R was observed stacking bowls on the food service line with her bare hands and fingers directly in the food contact surface of the bowls. Staff R was instructed to place the bowls in the dishwashing area to be washed and sanitized, perform hand hygiene and don single use and disposable gloves. b. The internal temperatures of pork roasts that were to be used for pulled pork as the dinner meal was 76 degrees Fahrenheit (F) and 66 degrees (F). It was noted that the roasts were in 6-inch deep full sized hotel pans, with a layer of parchment paper and covered with 2 layers of aluminum foil. At the time of the observation, the CDM confirmed that the roasts were cooked the previous day and acknowledged that they were not cooled properly. c. Staff R, Dietary Aide, was observed at the dedicated hand sink rinsing her gloved hands. When asked the purpose of washing the gloves, Staff R stated that she was washing the gloves because there was stuff on it. The CDM instructed Staff R to remove the gloves and perform hand hygiene and to don a pair of new disposable gloves. At the conclusion of the tour, the CDM acknowledged the findings from the tour of the kitchen.

Based on observations, interviews, and record review, the facility failed to follow the Menu Planning, in accordance with established national standards, for one week out of three menu cycles. This had the potential to affect all residents that consume their meals prepared by the facility. The findings included: A review of the facility's policy titled, Menu Planning dated 07/17/24, documented the following: The nutritional needs of individuals will be provided in accordance with the established national standards adjusted for age, gender, activity level, and disability. Through nourishing, well-balanced diets unless contraindicated by medical needs. All current menus will be written to provide an adequate amount for each meal to satisfy recommended daily allowances and written using an acceptable standard meal planning guide. Further review revealed that the menus at the facility were used based on a 2000-calorie/day diet with the following: Dairy/Milk: 2 to 3 cups equivalents per day. Fruits: 2 to 2.5 cups equivalents per day. Vegetables: 2.5 cups equivalents per day. A review of the facility's Spring Summer Menu 2024, Week 1, showed the following fruit exchanges each day: Sunday, 12/1/24, showed no fruit serving for breakfast, no fruit serving for lunch, and 1/2 cups of fruit serving for dinner. This provided only 1/2 of the fruit serving a day, not the needed 2 cups as per the facility's menu guidelines. Monday, 12/2/24, showed was no fruit for breakfast, 1/2 cup of fruit for lunch, and 1/2 cup of fruit for dinner. This provided only 1 cup of fruit a day, not the needed 2 cups as per the facility's menu guidelines. Tuesday, 12/3/24, showed no fruit for breakfast, 1/2 cup fruit serving for lunch, and 1/2 cup fruit serving for dinner. This provided only 1 cup of fruit serving a day and not the needed 2 cups of fruit serving as per the facility's menu guidelines. Wednesday, 12/4/24, showed no fruit serving for breakfast, 1/2 cup of fruit serving for lunch, and no fruit serving for dinner. This provided only 1/2 of the fruit serving a day, not the needed 2 cups as per the facility's menu guidelines. Thursday, 12/5/24, showed no fruit serving for breakfast, no fruit serving for lunch, and 1/2 cups of fruit serving for dinner. This provided only 1/2 of the fruit serving a day, not the needed 2 cups as per the facility's menu guidelines. Friday 12/6/24 showed no fruit serving for breakfast, no fruit serving for lunch, and 1/2 cup of fruit serving for dinner. This provided only 1/2 of fruit serving a day, and not the needed 2 cups of fruit serving as per facility's menu guidelines. Saturday 12/7/24 showed no fruit serving for breakfast, no fruit serving for lunch, and 1/2 cup of fruit serving for dinner. This provided only 1/2 of fruit serving a day, and not the needed 2 cups of fruit serving as per facility's menu guidelines. In an interview, conducted on 12/3/24 at 1:36 PM with Staff C, the Registered Dietitian, it was stated that the facility's menus were created and reviewed by the Corporate Dietitian. In another interview conducted on 12/4/24 at 9:32 AM, Staff C stated that the facility's menus were created to provide a 2000 calories-based diet with the following: 2 to 3 cups per day of dairy, 2 to 2.5 cups of fruit, and 2 to 2.5 cups of vegetables. She further acknowledged that the facility's Spring Summer Menu 2024 did not meet the needed serving of fruits daily as per established national standards. Staff C reported that fruit servings are also provided upon request from residents and that it may show on their meal tickets as a preference.

Based on observations, interviews and record review the facility failed to 1) ensure access to call device for 2 of 32 sampled residents (Residents #46 and #94); 2) ensure function of air mattress for 2 of 31 sampled residents provided with air mattress (Residents #80 and #90); 3) provide access to wall light for 7 out of 26 sampled residents on 1 of 2 hallways on the [NAME] unit (Residents #94, #6, #68, #72, #80, #90, #53); 4) provide unobstructed access to bathroom and provide paper towels to 1 of 34 sampled residents (Resident #27); 5) provide clean linen in timely manner for 1 of 34 sampled residents (Resident #86). The findings included: Review of the facility's policy titled, Accommodation of Needs with a revised date of March 2021, included in part, the following: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. In order to accommodate individual needs and preferences, adaptions may be made to the physical environment, including the residents' bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptions may include a) providing access to assistive devices, e) installing longer cords or providing remote controlled overhead or task lighting so that they are easily accessible, f) moving furniture or large items in rooms and common areas that may obstruct the path of a resident using a walker. 1) Record review for Resident #46 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on 10/18/23 with diagnoses that included in part the following: Paraplegia, and Neuromuscular Dysfunction of Bladder Review of the Minimum Data Set (MDS) assessment for Resident #46 dated 10/13/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 14, indicating a cognitive response. On 12/02/24 at 10:52 AM, an observation was made of Resident # 46 sitting up in bed with the call bell on the floor, a full Styrofoam cup of water and 2 empty two handled sippy cups on the nightstand out of her reach. She said they (staff) moved the water when her breakfast came and never put it back. On 12/03/24 at 8:40 AM, an observation was made of Resident #46 sitting up in bed with her breakfast tray in front of her with one handled cup with no spill lid containing coffee, a two handled cup with a lid that was not secured containing orange juice. During an interview conducted on 12/02/24 at 10:52 AM, Resident # 46, stated she is supposed to be checked to see if she needs her [adult incontinent brief] changed every couple of hours, she has been in the same brief since 10:00 PM last night. They usually change her the same time as the other resident, but they have not. She said she normally has a private aid, but the aid is on vacation this week. When asked if she could call for assistance she said yes, but she cannot reach the call bell, it is on the floor. She said she has been in a [soiled adult incontinent brief] for a very long time today. 2) Record review for Resident #94 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Vascular Dementia and History of Falling. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 11/23/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. On 12/05/24 at 9:50 AM, a side-by-side observation with the Director of Nursing (DON) and the Director of Maintenance (DOM) was made of Resident #94, sitting in a wheelchair next to window with the call bell device on her bed and not accessible. The DON attempted to pull the call bell device closer to the resident, but it did not reach, the DOM moved the resident closer to the call device, so it was accessible to the resident. Also observed was the wall light behind the resident's bed with a pull cord of approximately 6 inches long and not accessible to the resident while sitting in the chair or when she is in her bed. 3) Record review for Resident #80 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Dementia and Delusional Disorders. Review of the MDS assessment for Resident #80 dated 11/10/24 documented in Section C a BIMS score of 6, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #80 revealed an order dated 03/24/23 documented, low air loss mattress in use, check placement and function every shift. Review of the Treatment Administration Record (TAR) for Resident #80 from 12/01/24 to 12/03/24, revealed the status of the low air loss mattress function and settings was documented each shift. Review of the Nursing Progress Notes for Resident #80 from 12/01/24 to 12/03/24 revealed no documentation of issues with the low air loss mattress. 4) Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Acute Chronic Diastolic (Congestive Heart Failure), Chronic Kidney Disease Stage 4, and Glaucoma. Review of the MDS for Resident #90 dated 11/04/24 documented in Section C a BIMS score of 8, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #90 revealed an order dated 10/21/24 for low air loss mattress, check function and settings every shift. Review of the TAR from 12/01/24 to 12/03/24 revealed the status of the low air loss mattress function and settings was documented each shift. Review of Nursing Progress Notes for Resident #90 from 12/01/24 to 12/03/24 revealed no documentation of issues with the air mattress. During an in interview conducted on 12/03/24 at 9:00 AM with Staff I, Licensed Practical Nurse (LPN) who was asked if she took care of Resident #80 and Resident #90 yesterday as well as today, she said yes. When asked about the low air loss mattress, she said they are checked every day. When asked what she checks, she stated she checks to make sure it is on, and the machine is functioning properly. When asked if there were any issues with the low air loss mattress for either resident yesterday or today, she said no, not that she is aware of. Staff I LPN and the surveyor then did a side-by-side observation of the low air loss mattress for Residents #80 and Resident #90. She stated Resident #80 and #90's mattress was not working, then said the air mattress was not plugged in and said I did not notice this until just now. 5) Record review for Resident #6 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on 10/09/24 with diagnoses that included, in part, the following: Infection and Inflammatory Reaction Due to Other Cardiac and Vascular Devices Implants and Grafts, and Chronic Obstructive Pulmonary Disease. Review of the MDS for Resident #6 dated 11/18/24 documented in Section C, a BIMS score of 15, indicating a cognitive response. On 12/02/24 at 9:30 AM, an observation was made in Resident 6's wall light, shared between her and her roommate, with no access to the light to turn it off or on. The privacy curtain was located in the middle of the wall light. 6) Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] with a readmission on 03/31/22. The resident's diagnoses included, in part, the following: Dementia and Anxiety Disorder. Review of the MDS assessment for Resident #68 dated 10/01/24 documented in Section C, a BIMS score of 0, indicting severe cognitive impairment. On 12/05/24 at 11:30 AM, an observation was made of Resident #68 lying in bed with wall light, with no pull cord. Resident #72 (the roommate) to Resident #68 stated they put my light on in the night, if they need any light to help my roommate. When asked if this bothers her, she said I am not saying anything, I don't want to get into trouble. 7) Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Review of the diagnoses for Resident #72 revealed the resident had a diagnosis of Post-Traumatic Stress Disorder, dated 11/14/24. Review of the Minimum Data Set assessment for Resident #72 dated 08/14/24 documented in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response. On 12/02/24 11:25 AM, an observation was made of Resident #72 sitting up in bed with the wall light on located at the head of the bed with an approximately 3-inch pull cord. During an interview conducted on 12/02/24 11:25 AM, Resident #72 who was asked if she can put her light on, she stated only if she lays her bed flat, raises her bed height and reaches up behind her. 8) Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with diagnoses including, in part, the following: Dementia, and Inflammatory Spondylopathy Cervical Region. Review of the MDS assessment for Resident #53 dated 09/17/24 documented in Section C a BIMS score of 8, indicating moderate cognitive impairment. On 12/02/24 at 12:40 PM, an observation was made of Resident #53 sitting up on the side of her bed. The wall light behind the head of her bed was noted having a pull chain of approximately 3 inches long. During an interview conducted on 12/02/24 at 12:40 PM with Resident #53 who was asked if she could put the wall light on behind the head of her bed. She stated no, I can't reach it. 51663 9) Record review showed that Resident #27 was admitted to the facility on [DATE] with diagnosis of Atrial Fibrillation and Malignant Neoplasm. The Minimum Data Set (MDS)quarterly assessment dated [DATE], documented the resident's Brief Interview of Mental Status (BIMS) score as 15, which indicates no cognitive impairment. In an observation conducted on 12/03/2024 at 10:10 AM, Resident #27 was observed unable to wheel herself out of the bathroom, in her wheelchair due to piles of linen/clothing that was located on the floor of her bedroom. Resident #27 had no way of picking up the bag of clothes from the floor without assistance. In a brief interview conducted on 12/03/2024 at 9:30 AM, Resident #27 stated that she has been asking for paper towel for over 3 days and no staff member ever brought it for her. In this interview, no paper towel was observed in the bathroom. 10) Record review revealed that Resident #86 was admitted on [DATE] and readmitted on [DATE] with diagnosis of Dementia, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. The Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident's Brief Interview of Mental Status (BIMS) score as an 8, which indicates moderate cognitive impairment. In an observation conducted on 12/02/2024 at 10:00 AM, Resident #86 was found standing next to his bed with all the linens from the bed piled up on the floor. In this observation Resident #86 stated that he needs the bed to be made with a new set of linen because the ones that he took off were dirty. At this time. the Surveyor advised a staff member that Resident #86 needed his bed linens changed. In another observation conducted on 12/02/2024 at 2:00 PM, Resident #86 was found seated in his wheelchair at the room door. Resident #86 asked the Surveyor to please have someone fix his bed because he needed to lay down. Upon observation, the bed was still unmade from the prior observation at 10:00 AM. In an interview conducted on 12/02/2024 at 2:05 PM with Staff B, Registered Nurse (RN), stated that she had already asked the Certified Nursing Assistant on two occasions to fix the Resident #86's bed, but she would ask again. In an interview conducted on 12/05/2024 at 10:20 AM with Staff F, Certified Nurse Assistant (CNA), stated that the bed linens are changed daily and upon request or when the bed is observed dirty. And if Staff are busy, the task is redirected to an available staff member.

Based on observations, interviews and record reviews, the facility failed to develop a comprehensive care plan for Post-Traumatic Stress Disorder (PTSD), for 2 of 2 sampled residents reviewed for behavior, (Residents #72 and Resident #28); failed to implement care plan interventions for 2 of 5 sampled residents reviewed for unnecessary medications, (Resident #88 and Resident #111); and failed to implement interventions regarding psychotropic medications' side effects for 2 of 2 sampled residents (Resident #111 and Resident #88) reviewed for Psychotropic Medications. The finding included: 1) A review of facility's policy titled, Care Plans Comprehensive, published on 09/25/2024, with document ID # 42867439 revealed the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. It revealed statement #2, under Policy Interpretation and Implementation, explaining the comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (admission, annual or significant change in status), and no more than 21 days after admission Additional review of facility's policy titled, Care Planning IDT, revealed a statement explaining the Interdisciplinary team is responsible for the development of resident care plans. It further explained that resident care plans are developed according to the timeframes and criteria established by S483.21 Resident #28 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Post-Traumatic Stress Disorder (PTSD), Dysphagia Following Cerebral Infarction, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. A review of Minimum Data Set (MDS) assessment Section C revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating good mental cognition. A review of electronic care plans initiated on 09/13/24, 09/16/24 and 12/12/24, revealed no care plan was initiated on these dates regarding Resident #28's PTSD. Interview was conducted with a Social Services Staff member on 12/04/24 at 12:21 PM, who has been working in the facility for one year, when asked about Resident #28's care plan for PTSD, she stated, There is no care plan for PTSD. She added that the reason there was no care plan for PTSD was, First upon admission the resident denied anxiety and depression, and secondly, because the resident was evaluated by the psychiatrist. When asked why she had not created a care plan for Resident #28's PTSD yet, she responded that she planned to keep asking the resident, because she wants to make sure Resident#28 is comfortable with her. She added that she plans to quarterly assess this resident. When this Social Services Staff was asked regarding Resident #28's PTSD diagnosis, she stated it was derived from admission. When asked when is she planning to create a PTSD care plan because three (3) months had passed since resident's admission to the facility, she responded she has not made any evaluation to ask for triggers and insisted that she must make a rapport with the resident first. She added it is a continuous process. In an interview with the MDS Coordinator on 12/04/24 at 4:11 PM, when asked how she demonstrated her knowledge of Resident #28's current behavioral and emotional needs, she stated These are based on care evaluations from Psychiatrist, Psychologist, and Social Services assessments. When asked how often she attends Staff Behavioral in-service training, she stated once a year. When asked about the types of behavioral health training she had completed, she stated it was an annual in-service provided by facility to all Staff. When asked how she demonstrates competent interactions when addressing the resident's behavioral care needs, she responded by providing services based on resident's culture. When asked how she would know if a resident was a trauma survivor, and what would she do differently for that resident, she stated she must create a care plan in the MDS. She added that a section in the MDS has specific space for creating a care plan. She added that baseline care plan for the resident should be done in 2 to 3 days, while the comprehensive care plan should be done in 30 days. When asked regarding PTSD interventions for Resident #28, she stated some examples are approaching resident in a calm manner, assuring resident to prevent him/her from getting anxious. When asked about Resident #28's care plan for PTSD, she responded It must be completed. 41837 2) Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Further review revealed the resident had a diagnosis of Post-Traumatic Stress Disorder (PTSD) Unspecified dated 11/14/24. Review of the Minimum Data Set assessment for Resident #72 dated 08/14/24 documented, in Section C, a Brief Interview of Mental Status score of 15, indicating a cognitive response. Review of the care plan for Resident #72 revealed there was no care plan related to PTSD. During an interview conducted on 12/02/24 at 11:25 AM, Resident #72 stated she has PTSD. The resident stated she is seen by a psychiatrist. During an interview conducted on 12/03/24 at 1:40 PM with the Social Service Director (SSD) she stated she has worked at the facility since December last year. When asked about residents with diagnoses of PTSD the SSD stated upon admission we do a stress for life evaluation, refer to psychology and psychiatry services and do monitoring for behaviors and would create a care plan for the PTSD for the resident. When asked about Resident #72 the SSD stated the resident had a stress for life screening upon admission on 02/07/23 and was not positive she had a stress for life screening every quarter with the most recent on 11/12/24 and was positive. The SSD also acknowledged there was no care plan for PTSD for Resident #72 until she created one today, (12/03/24) just before talking with this surveyor. During an interview conducted on 12/04/24 at 3:20 PM with the MDS Director she stated she has worked at the facility for 6 years. When asked if a resident is admitted with diagnosis PTSD would she be the person to create a care plan for the resident. She said if the resident was admitted with the diagnosis she would. The MDS Director stated if the resident was diagnosed with PTSD after admission, she would want to find out more before creating a care plan such as why the resident was diagnosed , what the triggers were and what to avoid to be able to help the resident. When asked about Resident #72, she said she believes the resident was diagnosed with PTSD after admission. The MDS Director recalled having a conversation with Social Worker and other staff regarding the PTSD diagnosis for Resident #72, but could not recall when she said it. The MDS Director stated she generally does not create care plans if they are related to mood, psychosocial, discharge planning or advance directives. These issues would most likely be created by the Social Worker. 40153 3) A record review revealed that Resident #111 was admitted to the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Heart Failure, and Type 2 Diabetes. The 5-day Minimum Data Set assessment dated [DATE] revealed that Resident #111 had a Brief Interview of Mental Status (BIMS) score of 14, which is cognitively intact. A review of the Order Summary Report documented an order for Alprazolam 0.25 milligrams, 1 tablet at bedtime for Anxiety which was dated 11/21/24. No order was noted to monitor the side effects of Alprazolam. The pharmacy recommendation from 10/1/24 to 10/31/24 revealed that the guidelines requires that a side effect needs to be monitored every shift to support the use of Alprazolam. The care plan initiated on 11/22/24 revealed to observe for signs and symptoms of Anxiety, as needed. It further documented to observe the resident for potential side effects such as confusion, forgetfulness, nausea, vomiting, diarrhea, appetite changes, lightheadedness, and drowsiness. A progress note dated 10/21/24 revealed that Resident #111 was prescribed Xanax (anxiety medication) at bedtime and continue to monitor the side effects of the psychotropic medication. In an interview conducted on 12/04/24 at 3:04 PM with the Director of Minimum Data Set, she stated that antianxiety medication should be initiated with a care plan that included monitoring it's side effects. She further said all residents on psychotropic medications need to be monitored for side effects. 51663 4) Record review revealed Resident #88 was admitted to the facility on [DATE] with diagnosis of non-Hodgkin lymphoma and Myelofibrosis. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairments. A review of the care plan dated 11/12/2024 indicated that Resident #88 is prone to side effects related to the use of antidepressant medications, which needs to be observed for potential side effects such as: hypotension, tachycardia, nausea, vomiting, diarrhea, blurred vision, chest pain, rash, drowsiness, lethargy. A review of the physician's orders dated 08/23/24, documented: Sertraline HCl Oral Tablet 25 MG (Sertraline HCl), give 1 tablet by mouth one time a day for depression, give with 100mg tablet to equal a total of 125mg daily. Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) give 1 tablet by mouth one time a day for depression, give with 25 mg to equal total of 125mg daily. A review of the physician orders, the Medication Administration Report (MAR) and the Treatment Administration Report (TAR) indicated that the facility failed to order and implement intervention to monitor side effects related to the use of antidepressant medications for Resident #88.

Based on observations, interviews and record review, the facility failed to ensure the resident environment remains free of accident hazards including 1 out of 4 emergency carts containing sharps left unlocked and unattended, 1 out of 7 med carts with a broken sharp disposal container, and 2 out of 32 sampled residents with sharps at the bedside (Resident #88 and #108). The findings included: On 12/05/24 from 7:00 AM to 2:30 PM, the Administrator and Director of Nursing were asked several times for a policy regarding sharps or accident/hazards the only policy provided was the facility policy titled, Sharps Disposal undated (printed dated of 12/05/24). Review of the facility's policy titled, Sharps Disposalundated (printed dated of 12/05/24) included in part the following: 3. During use, containers for contaminated sharps will be handled as follows: c) Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. 1) On 12/02/24 at 1:10 PM, an observation was made of med cart located between rooms [ROOM NUMBERS]. The sharp's container attached to the med cart was broken, containing unsecured sharps (Photographic Evidence Obtained). Staff I, Licensed Practical Nurse (LPN) and Customer Success Representative present at the med cart. During an interview conducted on 12/02/24 at 1:10 PM with Staff I, LPN and the Customer Success Representative who were present at the med cart were asked about the broken sharp's container containing unsecured sharps. Staff I, LPN and the Customer Success Representative stated it was broken. Staff I, LPN unlocked the sharps container holder and acknowledged it was broken. The Customer Success Representative stated maintenance should be contacted, Staff I, LPN locked the sharps container holder and left the med cart. The Customer Success Representative also left the med cart. 2) On 12/03/24 at 7:18 AM, an observation was made of unlocked emergency cart across from the [NAME] nursing station with several safety razors, 2 pair of scissors, and box of lancets (200 count). A side-by-side observation conducted on 12/03/24 at 8:08 AM with Staff B, Registered Nurse (RN) of unlocked emergency cart across from [NAME] nursing station. Staff B, RN acknowledged the unlocked and unattended emergency cart contained 11 safety razors, 2 pair of scissors, and a box of lancets (200 count). An interview was conducted on 12/03/24 at 8:011 AM with Staff B, RN who stated she has worked at the facility for 1 month. Staff B, RN stated emergency carts should be locked at all times. When asked about residents having razors or scissors at the bedside, she said residents should not have razors or scissors stored at the bedside 3) Record review for Resident #88 revealed the resident was admitted to the facility on [DATE] with diagnoses including, in part, the following: non-Hodgkin lymphoma, Myelofibrosis, Polycythemia, and Recurrent Depressive Disorders. Review of the Minimum Data Set (MDS) assessment for Resident #88 dated 11/04/24 documented in Section C a Brief Interview of Mentals Status score of 15 indicating a cognitive response. On 12/02/24 at 11:07 AM, an observation was made of Resident #88 sitting in a wheelchair in his room, on nightstand there was a safety razor in a Styrofoam cup. On 12/03/24 at 9:00 AM, a second observation was made of the safety razor in the Styrofoam cup on the nightstand in Resident #88's room. 49060 4) Record review for Resident #108 revealed that the resident was admitted to the facility on [DATE] with a readmission on 11/24/23 with the following diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris; Hyperlipidemia; Tremor; Essential (Primary) Hypertension; Parkinsonism. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #108 had a Brief Interview for Mental Status (BIMS) of 09, which indicated that she had moderate cognitive impairment. Review of Section GG of the same MDS revealed that Resident #108 had functional Range of Motion (ROM) with limitations of the upper and lower extremities. Review of the Physician's Orders showed that Resident #108 had an order dated 11/25/23 for Benztropine Mesylate Oral Tablet 1mg, give 1 tablet by mouth one time a day for Parkinson's disease. Review of the Physician's Orders showed that Resident #108 had an order dated 12/15/23 for Austedo (Deutetrabenazine) Oral Tablet 6 mg, give 1 tablet by mouth two times a day for tardive dyskinesia. Review of the Care Plan dated 10/15/24 documented that Resident #108 has Parkinson's Disease. Goals were to minimize risk of complications though next review date. Interventions were to monitor for risk of falls; Monitor/document/report to doctor as needed sign and symptoms of Parkinsons complications: Poor balance, Constipation, Poor coordination, Insomnia, Dysphagia, Tremors, Gait disturbance, Incontinence, Muscle cramps or rigidity, Decline in ROM, Skin breakdown, Mood changes, Decline in cognitive function. Review of the Care Plan dated 10/15/24 revealed no documentation that Resident #108 was assessed for scissors safety. During the initial tour of the facility conducted on 12/02/24 at 10:10 AM, Resident #108 was observed sitting on her bed using regular size scissors to cut paper towels into squares. When asked if those were her scissors, Resident #108 stated yes and she uses them to cut the paper towels because she does not like waste, so she cuts them into rectangles. An interview was conducted on 12/03/24 at 10:32 AM with the Director of Nursing (DON), in which she stated she was not aware that Resident #108 had scissors in her room. She also stated she will do an assessment of Resident #108 to see whether she is able to safely use the scissors. During an observation conducted on 12/04/24 at 5:24 PM, revealed no scissors in Resident #108's room. During an interview conducted on 12/05/24 at 10:30 AM with Staff M, Certified Nursing Assistant (CNA), she stated she has worked at the facility for 2 years and has cared for Resident #108 before. Staff M stated she has not seen Resident #108 with scissors in the room. She noted that if she finds any sharps in residents' rooms, she is to report it to the nurse manager. During an interview conducted on 12/05/24 at 1:37 PM with Staff K, Activity Aide, she reported she has been working at the facility for 1 1/2 years. Staff K was asked if Resident #108 can safely use scissors on her own, she stated we do not allow residents to use regular scissors or any sharps during activities. She stated she has never seen Resident #108 with scissors in her room and acknowledged that residents are not allowed to have scissors in their rooms. On 12/05/24 at 2:00 PM, an interview was conducted with the DON. She stated Resident #108's scissors were probably brought in by the family. She stated an assessment was conducted on Resident #108 and safety was a concern, therefore, the scissors were removed from Resident #108's room.

Based on observations, interviews and record review, the facility failed to ensure the drainage bag for a resident with an indwelling urinary catheter is maintained in a manner to prevent infection and maintain dignity for 1 of 1sampled resident reviewed for a urinary catheter (Resident #46). The findings included: Review of the facility's policy titled, Catheter Care Urinary with a revised date of August 2022 included in part the following: Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection Control: 2. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility's policy titled, Dignity with a revision date of February 2021 included, in part, the following: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1) Residents are treated with dignity and respect at all times. Record review for Resident #46 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on 10/18/23. The resident's diagnoses included in part the following: Paraplegia, and Neuromuscular Dysfunction of Bladder Review of the Minimum Data Set assessment for Resident #46 dated 10/13/24 documented in Section C a Brief Interview of Mental Status score of 14, indicating a cognitive response. Review of the Physician's Orders for Resident #46 revealed, and order dated 03/08/24 for Foley Catheter (type of indwelling urinary catheter) 16 Fr (size of catheter) DX(Diagnosis): Neurogenic Bladder. Review of the Physician's Orders for Resident #46 revealed an order dated 03/12/24 documented, Maintain Foley Catheter to straight drain, keep foley below the level of the bladder, check placement and function every shift, monitor for any kinks in the tubing, keep the urinary drain bag covered every shift. Review of the Physician's Orders for Resident #46 revealed an order dated 03/12/24 documented, Maintain Foley Catheter to straight drain, keep foley below the level of the bladder, check placement and function every shift, monitor for any kinks in the tubing, and keep the urinary drain bag covered every shift. Review of the Care Plan for Resident #46 dated 10/19/23 with a focus on the resident has a 16 Fr. Foley Catheter for Neurogenic bladder due to paraplegia, potential for infection, catheter related trauma and accidental dislodgement. The goals were for infection to be minimized, risk for accidental dislodgement will be minimized and risk for catheter-related trauma will be minimized through next review date. The interventions included, in part, the following: Catheter care every shift and as needed. Empty drainage bag every shift. Provide dignity cover for drainage bag. On 12/02/24 at 10:52 AM, an observation was made of Resident #46 lying in bed with an indwelling urinary catheter drainage bag lying on the floor (not hanging from bed) with no privacy cover. On 12/02/24 at 1:30 PM, a second observation was made of Resident #46's indwelling urinary catheter drainage bag hanging from the bed with no privacy cover. On 12/03/24 at 7:32 AM, an observation was made of Resident # 46 lying in bed with indwelling urinary catheter drainage bag lying on the floor with no privacy cover in place. During an interview conducted on 12/02/24 at 10:55 AM with Resident # 46, she was asked about her indwelling urinary catheter and she stated they told her originally, they would be changing the catheter every 6 months, but she insisted they change it monthly. During an interview conducted on 12/05/24 at 10:58 AM with Staff E, Certified Nursing Assistant, who stated she has worked at the facility for 1 year. When asked about residents with indwelling urinary catheters, she said the catheter care is done daily and documented in POC (Point of Care) for the resident and the bag needs to be hanging and have a privacy cover.

Based on observations, interviews and record reviews, the facility failed to monitor intake of nutritional supplements for 2 of 3 sampled residents reviewed for Nutrition (Residents #98 and Resident #53). The findings included: The facility's policy titled, Oral Supplements with a reference date of May, 2023, documented: Policy: The Department shall provide nutritional supplements to residents whose nutritional needs cannot be met through three meals per day, as ordered by the physician. Procedures: Nursing staff documents the resident's acceptance/rejection of supplements by amount. Records the amount of nourishment consumed by the resident in EMR (electronic medical record), and notifies the dietitian if the resident refuses the produce consistently. 1). Resident #52 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Medicare 5-day Minimum Data Set (MDS), dated [DATE], Resident #52 had a Brief Interview for Mental Status (BIMS) score of 09, indicating the resident had moderate cognitive impairment. The assessment documented that Resident #52 was dependent upon staff for eating. Resident #52's diagnoses at the time of the assessment included: Heart Failure, Hypertension, Renal Insufficiency, Non-Alzheimer's Dementia, Malnutrition, Chronic Lung Disease, Acute Embolism and Thrombosis, Thryotoxicosis, Atrial Fibrillation, speech and language deficits following cerebrovascular disease, Dysphagia following cerebrovascular disease, Diverticulosis of intestine, Osteoarthritis, and Disorder of Kidney and Ureter. Resident #52's dietary orders dated 11/12/24 included: Regular diet, Puree texture, Nectar Thickened Liquids consistency - 11/08/24 Ensure Plus one time a day - 11/08/24 Weekly weight times one time a day every Tuesday for monitoring. Resident #52's Care plan for nutrition documented, Resident at high nutrition risk diagnoses Urinary Tract Infection (UTI), Chronic Obstructive Pulmonary Disease (COPD), Dementia, Thyrotoxicosis, Deep Venous Thrombosis (DVT), Atrial Fibrillation, Congestive Heart Failure, Hypertension, Chronic Kidney Disease, Diverticulosis. Potential for weight fluctuations, mechanically altered diet. 11/8/24 s/p hospitalization . Impaired skin. + edema to bilateral lower extremities (BLE). Weight gain 11/14/24 Weight loss; - edema BLE 12/2/24 Weight loss r/t (related to) edema Date Initiated: 10/07/2024 The goals of the care plan included: o Resident will exhibit no signs or symptoms of dehydration as evidenced by good skin turgor, moist mucous membranes, moist lips, no complaints of thirst, free from electrolyte imbalance lab values by next review. Date initiated: 10/07/24. Target date: 01/21/25. o Resident edema will subside Date Initiated: 11/08/2024 Target Date: 01/21/2025 o Resident's pressure injury/wound will improve/heal by next review date Date Initiated: 11/08/2024 Target Date: 01/21/2025 Interventions in the care plan included: o Monitor oral intake of food and fluid Date Initiated: 10/07/2024 o Monitor Skin Integrity Date Initiated: 11/08/2024 o Monitor weight monthly/weekly Date Initiated: 10/07/2024 o Provide > 8 cups fluid per day with meals/between meals Date Initiated: 10/07/2024 o Provide diet as prescribed Date Initiated: 10/07/2024 o Provide fortified foods (specify) Date Initiated: 11/08/2024 o Provide necessary assistance at mealtime and between meals Date Initiated: 11/08/2024 o Provide nourishments/snacks/fluids prn Date Initiated: 10/07/2024 o Provide oral supplements as ordered Date Initiated: 10/07/202 A Nutrition Progress note, dated 12/02/24, documented: Note Text: Wt reviewed: 11/21-117lbs; 11/29-107lbs. reweight completed. Noted with 10lbs/8.5% significant weight loss x 1 week. Regular Diet order with pureed altered texture, nectar liquids. During meal rounds, resident dependent with meals; PO intake ~75% of today's lunch. Nursing documents 50-75% of most meals. Receiving Ensure Plus as ordered with ~50% as per nursing. Resident's family informed of weight status via phone. Resident s/p edema upon readmission. As per nursing, resident with decreased edema. Wound care to sacrum noted; see Wound Evaluation 11/27 for details. Wound care including MVI/Minerals with protein supplementation to aide in healing. MD (Medical Doctor) is aware. Continue with fortified cereal at breakfast meal. Increase Magic Cup to 2x daily at lunch and dinner. Continue to follow as warranted. On 11/07/2024, the resident weighed 123 lbs. On 11/29/2024, the resident weighed 107 pounds which is a -13.01 % Loss. An Admission Progress note dated 11/06/24 documented Resident #52's admission weight of 115 pounds. During an interview on 12/05/24 at 11:30 AM, with Staff C, Registered Dietitian (RD), when asked about Resident #52's weight loss, Staff C replied, She came back with edema. She was post status and was on diuretics before. Our weekly weight is due. We got a weight on Tuesday or Wednesday and she was 117 pounds and I requested a re-weigh and today her weight was 115. I requested the re-weight because I was questioning the accuracy. 107 pounds was a re-weight from last week's weights. When she first came back, she had bilateral edema. Reduced edema. I asked for a re-weight on 11/29, and she weighed 107 pounds. Her intake was fine, she was already on supplements, we increased her nourishment. When asked about recommendations for supplements, Staff C replied, When they make a recommendation its placed in order and in the MAR (Medication Administration Record). Magic Cup is in the meal tracker, so it will show in the meal ticket not in the orders. During an interview, on 12/05/24 at 11:51 AM, with Staff Q, RN, when asked about providing the supplements to the residents, Staff Q replied, The supplements come from us (nursing) we document the intake in the progress notes. A side-by-side review of progress notes with Staff Q revealed no documentation of the intake of the supplements in Resident #52's records. During a follow up interview with Staff C, on 12/05/24 at 1:15 PM, when asked about documenting the percentage of intake of meals, Staff C replied, when they do the intake, it includes just the lunch. The supplements are written in the doctors' orders and they give them to the resident and document the percentage consumed in the MAR. Review of the MAR and progress notes revealed no documentation of intake of the supplements. Durine a side-by-side review of Resident #52's electronic health records with Staff C, revealed no documentation of the resident's intake. 51663 2). Record review showed that Resident #98 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Complex Regional Pain Syndrome I and Obstructive and Reflux Uropathy. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score was 8, which indicates moderate cognitive impairment. A thorough review of the weight log for Resident #98 showed the following: 182.2 pounds on 06/13/24 and dropped to 172.0 pounds on 06/27/24. This showed a 5.5% severe weight loss in less than one month. Continued review indicated a weight loss from 172 pounds on 06/27/24 to 161pounds on 07/11/24, which showed an overall severe 12% weight loss in less than 2 months. Resident #98 had an overall trending weight loss of 14% from 06/13/2024 to 11/04/2024 (past 6 months). A review of the Dietary progress note dated 06/28/24 (a day after the 5.5% weight loss was identified) revealed the following: Staff D, Registered Dietitian documented Resident #98 had a non-significant weight loss. Resident #98 received Magic cup (nutritional supplements) once a day and it was recommended to also increase the Ensure Plus (nutritional supplements) from once a day to twice a day. This note revealed that Resident #98 had an intake of meals between 50% to 100% of meals. A review of the Dietary progress note dated 07/12/2024 revealed the following: Staff D, Registered Dietitian documented Resident #98 had significant weight loss. Resident #98 was recommended to increase the Ensure Plus 8 ounces to three times a day (TID) for an additional 1050 calories and 48 grams of protein a day, and the addition of fortified foods at breakfast and lunch meals. A review of Resident #98's Physician's orders showed the following: Ensure Plus 8oz TID was started on 07/13/2024 and discontinued on 09/11/2024. A new order was written for Ensure Plus twice a day and started on 09/11/2024. No orders were noted for fortified meals or Magic Cup. In an observation conducted on 12/04/2024 at 12:35 PM Resident # 98 was observed in the dining room eating. His meal ticket consisted of Mechanically Altered Chopped Orange Glazed Chicken 3oz, Mechanically Altered Chopped Normandy Vegetable blend 4oz, Cream of Rice 4oz, Diced Peaches 1/2Cup, Magic Cup 1/2 Cup and Sugar Free Lemonade 8oz. No fortified foods were noted on the meal ticket or on the actual meal tray. Further observation of the meal tray showed the following: a Magic cup noted on the side table and not on the meal tray, and a regular chocolate ice cream on the side table as well. Resident #98, unassisted, picked the regular ice cream chocolate instead of the Magic cup ice cream. Staff in the room did not ensure that Resident #98 was given the correct nutritional supplements as needed or assisted him with the lunch meal. In an interview conducted on 12/04/2024 at 11:30AM with Staff C, Registered Dietitian stated that when a Magic Cup is recommended it is not added as a physician order but placed directly into the meal tracker to auto populate on the meal ticket. The same process applies for any recommended fortified foods. Staff C said that the percent intake of the Magic Cup is not documented better yet the tray is reviewed as a whole. Unlike for Ensure Plus which is ordered and documented for percentage intake in the Medication Administration Record (MAR). According to Staff C the fortified meal for lunch is Mashed Potatoes which was not provided to Resident #98. In an interview conducted on 12/04/2024 at 4:45 PM with Staff D, she stated that the progress note dated 06/28/2024 said no significant weight loss because she was comparing the weight loss from one week to another instead of seeing the overall weight loss in less than a month. When asked how do you assess the effectiveness of the nutritional supplements not documented in the MAR she did not have an answer. In an interview conducted on 12/05/2024 at 10:20 AM with Staff F, Certified Nurse Assistant (CNA), she reported that she did not know what a Magic Cup was and did not know that it was a nutritional supplement. In another interview conducted on 12/05/2024 at 10:45 AM with Staff G, Certified Nurse Assistant (CNA), she reported that she had no idea what a Magic Cup was, and also asked : Is it a cup?

Based on observations, and record review, the facility failed to ensure a resident receiving oxygen has a physician's order for 1 of 4 sampled residents reviewed for respiratory affecting Resident #111 and failed to ensure respiratory supplies are cared for in a manner to prevent infection for 4 of 4 sampled residents for respiratory affecting Residents #17, # 111, #6 and #8. The findings included: Review of the facility's policy titled, Department (Respirator Therapy) -Prevention of Infection with no date (just a printed date of 12/05/24) included in part the following: Purpose The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among residents and staff. Infection Control Considerations Related to Oxygen Administration: 7. Change the oxygen cannula and tubing every seven (&) days, or as needed. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. 1) Record review for Resident #111 revealed the resident was admitted to the facility on [DATE] with readmission on 03/17/24 with diagnoses that included, in part, the following: Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set assessment for Resident #111 dated 11/19/24 revealed in Section C a Brief Interview of Mental Status score of 14, indicating intact cognition. Review of the Physician's Orders for Resident #111 revealed no evidence of an order for oxygen. On 12/02/24 at 12:04 PM, an observation was made of Resident #111 sitting up in bed wearing oxygen, the oxygen concentrator was set at 2 liters. 2) Record review for Resident #6 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on 10/09/24 with diagnoses of Infection and Inflammatory Reaction Due to Other Cardiac and Vascular Devices, Implants and Grafts, and Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set for Resident #6 dated 11/18/24 revealed in section C a BIMS score of 15, indicating intact cognition. Review of the Physician's Orders for Resident #6 revealed an order dated 11/21/24 documented to change the nebulizer mask and tubing weekly; date and place in dated plastic bag (Fri 7-3). Place in dated bag when not in use every day shift every Friday On 12/02/24 at 9:30 AM, an observation was made of Resident #6's nebulizer mask on top of a personal cart (mask not in a plastic bag). On 12/02/24 at 5:50 PM, an observation was made of Resident #6's nebulizer mask, laying on the nightstand next to a plastic bag. During an interview conducted on 12/02/24 at 5:52 PM with Resident #6, who was asked if she receives breathing treatments, she said oh yes, she needs them. 3) Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] with a diagnoses that included, in part, the following: Acute On Chronic Diastolic (Congestive Heart Failure), Primary Pulmonary Hypertension, Anxiety Disorder, Dementia, and Presence of Cardiac Pacemaker. Review of the MDS for Resident #17 dated 11/13/24 documented in Section C a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #17 revealed an order dated 09/10/24 for oxygen 2 Liters/min per nasal cannula continuously every shift for Shortness of Breath. Review for Nursing Progress Notes for Resident #17 from 11/24/24 to 12/01/24 revealed no documentation of oxygen tubing being changed. On 12/02/24 at 10:35 AM, an observation was made of Resident #17 sitting up in bed wearing oxygen via nasal cannula. The nasal canula had a label with the date of 11/11/24. During an interview conducted on 12/03/24 at 11:31 AM with the Director of Nursing (DON). She stated she has been working at the facility for 2 months. When asked about administering oxygen, she said the resident needs an order. When asked about oxygen tubbing being changed, she said it should be changed weekly and as needed. When asked about storage of nebulizer masks, she said they should be in a plastic bag at the bedside when not in use. 50370 4.) Resident # 8 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a lung condition requiring low level of oxygen administration to allow better lung perfusion), Atrial Fibrillation, and Dependence on Supplemental Oxygen. A review of Minimum Data Set (MDS) Section C revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. A review of physician orders dated 11/21/24, revealed oxygen at 2 Liters by nasal cannulae to keep oxygen saturation equal or greater than 90% every shift. Another order revealed to change nebulizer mask and tubing weekly, place in plastic bag on (Friday between 7:00AM-3:00PM), place in plastic bag when not in use every AM shift, and every Friday. A review of nursing progress notes dated 04/26/24 revealed to administer and monitor the effectiveness of treatments{(see current physicians orders), (such as oxygen -incentive spirometer -nebulizer treatments)}. A review of a nursing care plan revealed Resident #8 has alteration in breathing patterns related to Chronic Obstructive Pulmonary Disease with goals: to prevent acute therapy tasks and equipment including ventilators, among residents and staff, respiratory distress, and complications; with interventions requiring resident to have oxygen through nasal cannula at bedtime, and with staff administering, and monitoring the effectiveness of treatments {(see current physicians orders) (such as oxygen, incentive spirometer, and nebulizer treatments)}. During observation on 12/02/24 at 11:30 AM, Resident #8 was wearing oxygen nasal cannula on both nares at the end of long clear oxygen tubing with a tape tag black marked 11/18. The oxygen flow meter was set at 3 Liters per minute on the portable oxygen box machine. During the following day observation on 12/03/24 at 2:00 PM, Resident #8's oxygen cannulae and tubing were observed with an attached tape tagged and black marked 11/18. Resident was sitting on his bed, and not wearing the oxygen nasal cannula on both nares. Further observation revealed some parts of the oxygen cannula and tubing were under the portable oxygen box machine on the floor. The nasal cannula portion and the tubing were not inside any plastic containment. During another observation on 12/04/24 at 9:21AM, Resident #8 was asleep on his left side in bed, wearing nasal oxygen cannula on both nares of a clear oxygen tubing attached to the portable oxygen box machine. The tubing was tape tagged and black marked 11/18. The oxygen level was at 3 Liters per minute. During an interview with Resident #8 on 12/02/24 at 11:30 AM, he stated he uses oxygen when he sleeps. When asked about the oxygen tubing, he stated the facility provides him with long tubing. When asked about the frequency of oxygen tubing changes, he stated that Sometimes, the facility staff change the oxygen tubing.

Based on observations, interviews and record reviews the facility failed to identify triggers for residents diagnosed with Post-Traumatic Stress Disorder (PTSD), for 2 of 2 residents sampled for mood and behavior, (Resident #72 and Resident #28). The finding include: 1.) Review of the facility's policy titled, Trauma Informed Care Proc with Document ID #98875710, published on 05/19/2023 revealed the following: Purpose: a. To guide Staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice: and b. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. General Guidelines: Triggers are highly individualized. Some common triggers may include: a. experiencing a lack of privacy or confinement in a crowded or small space. b. exposure to loud noises. c. certain sights such as objects; and or d. sounds, smells, and physical touch Resident Screening included the following: 1. Perform universal screening of residents, which include a brief, non-specialized identification of possible exposure to traumatic events, 2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant, and sensitive. 3. Screening may include information such as : 1. Perform universal screening of residents, which include a brief, non-specialized identification of possible exposure to traumatic events, 2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant, and sensitive. 3. Screening may include information such as : a. trauma history, including type, severity and duration. b. depression, trauma-related or dissociative symptoms. c. risk for safety (self or others); d. concerns with sleep or intrusive experiences. e. behavioral, interpersonal or developmental concerns. f. historical mental health diagnosis. g. substance use. h. protective factors and resources available; and i. physical health concerns, 4. Utilize initial screening to identify the need for further assessment and care. Resident Care Planning: 1. Develop individualized care plans that address past trauma in collaboration with the resident ad family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. Review of the facility's documentation, titled, Stressful Life Experiences Evaluation submitted by the MDS Coordinator on 12/04/24 at 3:00 PM, revealed the following: A. Stressful Life Experiences: INSTUMENT: Please indicate how much you have been bothered by each problem in the past month. For these questions, the response options are Not at All, A Little Bit, Moderately, Quite a Bit, or Extremely. An individual is considered to have screened positive if the sum of these items is 14 or greater. There was no question indicating triggers for PTSD. 1) Resident #28 was admitted to the facility on [DATE], with diagnoses including, Diabetes Mellitus without Complications, Post-Traumatic Stress Disorder (PTSD), Dysphagia Following Cerebral Infarction, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. A review of the Minimum Data Set (MDS) Section C revealed a Brief Interview of Mental Status (BIMS)score of 14, indicating intact cognition. A review of progress notes dated 09/14/24 revealed a behavior code number 1 (one) labelled as depressed or withdrawn and to document number of times behavior occurred on each shift. Additional progress notes written by Social Services Staff, dated 09/24/24 revealed Resident #28 will demonstrate adjustment to nursing home placement by/through review date. A review of Physician Progress Notes dated 09/16/24 revealed a doctor tried to complete a psychology assessment, but was unable to locate Resident #28. A review of Psychiatry Referral Progress Notes dated 09/19/24 revealed the chief complaint for the consultation was for Resident #28's history of depression. There was no consultation related to PTSD. During an observation and interview with Resident #28 on 12/12/24 at 12:18 PM, he stated he is not happy. He was observed with a contracted left hand, and left elbow bandage. Resident #28 stated he wants to get out of the facility, because staff do not answer call lights when he needed them the most. In an interview with Staff N, a Certified Nursing Assistant (CNA), on 12/04/24 at 10:11 AM, when asked how he addresses residents who are exhibiting distress, he responded that he observes body shaking, and resident's state of confusion about time, place and events, and resistance to care. When asked about the common signs of resident's distress, he stated agitation, or being scared. When asked how he manages resident's distress, he stated he checks the residents regularly and familiarizes himself with resident's needs. When asked how he knows if a resident was a trauma survivor, and what does he need to do differently for that resident, he stated when a resident is unable to move any body parts, and have dressing on the head, he would know based on his visual observation. This staff added that his eyes can detect if a resident was a trauma survivor. He added that residents might be constipated, and not going to the bathroom, not responding to his questions and always lying down in bed. He added he will read resident's records, calm resident's anxiety, and try to understand them. When asked about the types of behavioral health training he has completed, he responded he had some, but does not remember the date or the name of the training. In an interview with a Social Services Staff on 12/04/24 at 12:21 PM who has been working in the facility for one year, when asked about Resident #28's care plan for PTSD , she stated, There is no care plan that has been created. She added that the reason there was no care plan for PTSD was, first upon admission the resident denied anxiety and depression, and secondly, because the resident was evaluated by the psychiatrist. When asked regarding the resident's triggers, she stated she did not identify triggers on 09/13/24 upon admission, because she wanted to do a continuing process of building rapport with the resident. She added she is quarterly monitoring the resident and maybe next time she will be able to ask for triggers. When asked when is the next time, she did not give a specific date. When asked how she proposes caring for residents with PTSD with no information about his triggers, she stated it was a continuing process, but she is planning to eventually ask about the resident's triggers. When asked why she has not created a care plan for resident #28's PTSD yet, she responded that she plans to keep asking the resident, because she wants to make sure Resident#28 is comfortable with her. She added that she plans to quarterly assess Resident #28. When asked regarding Resident #28's PTSD diagnosis, she stated it was derived from admission. When asked when she is planning to create a PTSD care plan because 3 months had passed since the resident's admission to the facility, she responded she has not made any evaluation to ask for triggers and insisted that she must make a rapport with the resident first. She added it is a continuous process. When asked about a Psychiatry Evaluation of Resident #28 related to PTSD, she stated she will provide the documentation to the Surveyor, but until the end of this survey, no Psychiatry Evaluation was presented. In an interview with the MDS Coordinator on 12/04/24 at 4:11 PM, when asked how she demonstrated her knowledge of Resident #28's current behavioral and emotional needs, she stated these are based on care evaluations from Psychiatrist, Psychologist, and Social Services assessments. When asked how often she attends Staff Behavioral in-service training, she stated once a year. When asked about the types of behavioral health training she had completed, she stated it was an annual in-service provided by facility to all Staff. When asked how she demonstrates competent interactions when addressing the resident's behavioral care needs, she responded by providing services based on resident's culture. When asked how she evaluates resident's anxiety, she responded by checking resident's appearance and verbalization. When asked how she would know if a resident was a trauma survivor, and what would she do differently for that resident, she stated she must create a care plan in the MDS. She added that a section in the MDS has specific space for creating a care plan. She added that baseline care plan for the resident should be done in 2 to 3 days, while the comprehensive care plan in 30 days. When asked regarding PTSD interventions, she stated some examples are approaching the resident in a calm manner, assuring the resident to prevent him/her from getting anxious. When asked who is responsible for completing the Stressful Life Events documentation, she stated a Social Worker, but the MDS Coordinator inputs clinical assessments, plans, goals and interventions with the Social Services Staff, then both establish a care plan meeting based on the completed admission evaluation. When asked regarding a required time frame to complete a resident's care plan meeting , she stated approximately 2 weeks after the admission evaluation. When asked who completes the Stressful Life Events, she stated the MDS Coordinator with data and update information, assessment and intervention from the Social Services Staff. She added that during a care plan meeting, staff discussed the content of the admission evaluation including the Stressful life events form. There is a time frame for completion of Stressful life events form which is approximately 2 weeks after admission. When asked the facility's process for identifying residents with possible Mental Disability (MD), Intellectual Disability (ID), or related condition prior to admission to the facility, this staff responded that she assesses resident, follows admission and nurses' interventions, supervises resident and follows doctor's orders on admission. In an interview with Staff P, a Registered Nurse (RN) on 12/05/24 at 11:30 AM, when asked how the facility identifies residents with newly evident or possible serious MD, ID or related condition after admission, she responded by speaking with the resident and watching the resident's behaviors. This staff added that changes in behaviors are important indicators of new behavioral symptoms and stressing that any complaints of pain must be assessed. 41837 2) Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Review of the diagnoses for Resident #72 revealed the resident had a diagnosis of Post-Traumatic Stress Disorder (PTSD) Unspecified dated 11/14/24. Review of the Minimum Data Set for Resident #72 dated 08/14/24 documented in Section C a Brief Interview of Mental Status score of 15, indicating intact cognition. Review of the Stress for Life Screening for Resident #72 dated 02/07/23 and 11/12/24 revealed no documentation of triggers (related to PTSD) being asked or discussed with the resident. Review of the Social Service Progress Notes for Resident #72 dated from 02/07/23 to 12/01/24 revealed no documentation of triggers (related to PTSD) being asked or discussed with the resident. During an interview conducted on 12/02/24 at 11:25 AM with Resident #72, who stated she has PTSD, but was not able to clearly articulate to the surveyor what her triggers were. She stated she does have triggers, and they are related to others controlling her or taking her items. The resident stated she is seen by a Psychiatrist. An interview was conducted on 12/03/24 at 1:40 PM with the Social Service Director (SSD), who stated she has worked at the facility since December last year. When asked about residents with diagnoses of PTSD the SSD stated upon admission we do a stress for life evaluation, refer to psychology and psychiatry services and do monitoring for behaviors and would create a care plan for the PTSD for the resident. When asked about Resident #72 the SSD stated the resident had a stress for life screening upon admission on 02/07/23 and was not positive. She had a stress for life screening every quarter with the most recent on 11/12/24 and was positive. When asked if the stress for life screening addresses or asks about triggers, she stated it does not. When asked if she asks the resident about triggers, she said they do not ask residents about their triggers, usually the resident would just tell them. The SSD acknowledged there were no triggers documented for Resident #72.

Based on observations, interviews, and review, the facility failed to ensure the controlled substance medication reconciliations were accurate for 6 of 12 sampled residents reviewed during the controlled substance record review (Residents #10, #51, #73, #88, #345, and #346). The findings included: Review of the facility's policy titled, Controlled Substances, dated November 2022, included the following: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances: 1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 1) Record review for Resident #10 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Dementia, Osteoarthritis, Anxiety Disorder, Cognitive Communication Deficit, and Chronic Pain Syndrome. Review of the Physician's Orders showed that Resident #10 had an order dated 11/29/23 for Percocet (oxycodone-Acetaminophen) Tablet 10-325 mg, give 1 tablet by mouth four times a day for moderate to severe pain. On 12/04/24 at 5:15 PM, a review of Resident #10's Controlled Drug Disposition sheet was conducted. The disposition sheet documented Percocet 10-325 mg (24 tablets), to be given four times daily for moderate to severe pain, was received by the facility from the pharmacy on 11/26/24. There were 11 tablets left in the controlled substance box. Further review of the disposition sheet revealed the last Percocet tablet was given on 11/29/24 at 9:30 PM. Review of Resident #10's November Medication Administration Record (MAR) revealed the Percocet 10-325 mg tablet was documented as administered to Resident #10 on 11/30/24 at the scheduled times of 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. 2) Record review for Resident #51 revealed that the resident was admitted to the facility on [DATE] with a readmission on 09/17/24 with the following diagnoses: Fracture of Shaft of Left Fibula, Anxiety Disorder, Psoriatic Arthritis Mutilans, Dementia, and Osteoarthritis. Review of the Physician's Orders showed that Resident #51 had an order dated 09/24/24 for Oxycodone HCl Oral Capsule 5 mg, give 5 mg by mouth every 6 hours as needed for pain. Review of Resident #51's Controlled Drug Disposition sheet revealed Oxycodone HCL 5 mg (28 capsules) was received at the facility from the pharmacy on 10/01/24. Resident #51 was given the medication on 10/01/24, 10/11/24, 10/18/24, 10/22/24, and 10/25/24. Further review of the Disposition sheet revealed that there were 23 Oxycodone HCL 5 mg capsules left in the controlled substance box with the last one administered on 10/25/24 at 3:35 PM. Review of Resident #51's October MAR revealed that Resident #51 was administered Oxycodone HCL 5 mg on all the above dates and on 10/03/24 at 1:25 PM (which was not documented in Resident #51's Controlled Drug Disposition sheet). The resident's controlled substances was not reconciled. 3) Record review for Resident #73 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Sequelae of Cerebral Infarction, Hypertension, Atherosclerosis of Aorta, and Gastro-Esophageal Reflux Disease. Review of the Physician's Orders showed that Resident #73 had an order dated 10/24/24 for Temazepam Oral Capsule 15 mg, give 1 capsule by mouth at bedtime for insomnia. On 12/04/24 at 4:59 PM, a review of Resident #73's Controlled Drug Disposition sheet was conducted. The disposition sheet documented Temazepam15 mg (10 capsules), to be given at bedtime for insomnia, was received by the facility from the pharmacy on 12/01/24. There were 8 capsules left in the controlled substance box with the last capsule administered on 12/02/24 at 8:13 PM. Further review of the Disposition sheet revealed that a signature, date and time was added after the 12/02/24 entry (on 12/03/24 at 10:12 PM). However, the count on the Disposition sheet matched with the amount left in the controlled substance box (8 capsules). Review of Resident #73's December MAR documented that Resident #73 was administered Temazepam on 12/03/24, as scheduled (no exact time was recorded in the MAR). On 12/05/24 at 1:34 PM a side-by-side review of Resident #73's Controlled Drug Disposition sheet was conducted with Staff L, Licensed Practical Nurse (LPN). She acknowledged that there were 7 capsules left of the Temazepam in the controlled substance box and one capsule was administered on 12/04/24. When asked if she received any report from the night nurse regarding the documentation for 12/03/24 (which the amount given was left empty), Staff L stated she did not receive any information and was not sure what happened. However, the amount of the medication was correct in the controlled substance box, and she was not concerned. 4) Record review for Resident #88 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: non-Hodgkin lymphoma, Myelofibrosis, and Polycythemia Vera. Review of the Physician's Orders showed that Resident #88 had an order dated 08/03/24 for Morphine Sulfate Extended Release (ER) 15 mg tablet, give 1 tablet by mouth every 12 hours for pain. Review of Resident #88's Controlled Drug Disposition Sheet revealed Morphine Sulfate ER 15 mg (28 tablets) was received at the facility from the pharmacy on 11/28/24. Resident #88 was given the medication on 11/28/24 at 10:57 PM, 12/03/24 at 10:09 PM, and 12/04/24 at 9:00 AM. Further review revealed that there were 25 Morphine Sulfate ER 15 mg tablets left in the controlled substance box which matched the Disposition sheet count. Review of Resident #88's December MAR documented Resident #88 was administered Morphine Sulfate ER 15 mg from 12/01/24 to 12/03/24 at 9:00 AM and 9:00 PM. The resident's controlled substance was not reconciled. 5) Record review for Resident #345 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Stage 3B, and Urinary Calculus. Review of the Physician's Orders showed that Resident #345 had an order dated 11/07/24 for Tramadol HCl Oral Tablet 50 mg, give 1 tablet by mouth every 6 hours as needed for Pain Control for 7 Days, end date 11/14/24. Review of the Physician's Orders showed that Resident #345 had an order dated 11/22/24 for Tramadol HCl Oral Tablet 50 mg, give 1 tablet by mouth every 6 hours as needed for Back Pain for 3 Days, end date 11/25/24. Review of Resident #345's Controlled Drug Disposition sheet revealed Tramadol HCl 50 mg (24 tablets) was received at the facility from the pharmacy on 11/08/24 and revealed Resident #345 was given the medication on 11/22/24 at 9:59 PM, 11/23/24 at 7:00 PM, 11/24/24 at 8:51 PM, and 11/25/24 at 1:39 PM. Further review of the Disposition sheet revealed that 18 tablets remained, which matched the count in the controlled substance box. Review of Resident #345's November MAR revealed no nurse initialed for the administered Tramadol HCl 50 mg on 11/25/24 at 1:39 PM (which was recorded in Resident #345's Controlled Drug Disposition sheet). The resident's controlled substances were not reconciled. 6) Record review for Resident #346 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Parkinson's Disease Without Dyskinesia, Other Chronic Pain, Dementia, and Anxiety Disorder. Review of the Physician's Orders showed that Resident #346 had an order dated 12/01/24 for Oxycodone HCl Tablet 15 mg, give 1 tablet by mouth three times a day for moderate to severe pain for 3 days, end date 12/04/24. Review of the Physician's Orders showed that Resident #346 had an order dated 12/05/24 for Oxycodone HCl Tablet 15 mg, give 1 tablet by mouth three times a day for moderate to severe pain. Review of Resident #346's Controlled Drug Disposition sheet revealed Oxycodone HCL 15 mg (9 tablets) was received at the facility from the pharmacy on 12/01/24. Resident #346 was given the medication on 12/02/24 at 9:53 AM and 5:44 PM, on 12/03/24 at 11:12 AM, 2:00 PM, and 5:49 PM, and 12/04/24 at 9:00 AM and 12:30 PM. Further review revealed that there were 2 Oxycodone HCL 15 mg tablets left in the controlled substance box which matched the count on the Disposition sheet. Review of Resident #346's December MAR revealed that Resident #346 was administered Oxycodone HCL 15mg on all the above dates, in addition to 12/01/24 and 12/02/24 at 5:00 PM (which were not documented in Resident #346's Controlled Drug Disposition sheet). The resident's controlled substances were not reconciled. During an interview conducted on 12/05/24 at 1:10 PM with Staff J, Registered Nurse (RN), she stated she is one of the weekend supervisors and picks up shifts sometimes during the week. She stated if a resident is scheduled for a controlled medication, such as a pain medication, she is to follow Physician's orders which she can view on the computer (PCC). Staff J stated she would evaluate pain level, dispense and administer the medication. After the resident takes the medication, she stated that's when she signs in PCC and almost at the same time sign the Controlled Drug Disposition sheet with the time from PCC. Staff J acknowledged that reconciliation of controlled substance stored in the medication cart is done by the nurses during the change of shift. An interview was conducted on 12/05/24 at 1:34 PM with Staff L, LPN. She acknowledged after administration of a controlled medication is when she documents in PCC and the Controlled Drug Disposition sheet of the medication. In addition, Staff L stated that the entered times in both places (PCC and Disposition sheet) need to match. During an interview conducted on 12/05/24 at 1:43 PM with the Director of Nursing (DON), she stated she has been working at the facility for 2 months. She stated nurses are to do reconciliation of the controlled medications during the change of shift. In addition, two weeks ago, she and the managers started to perform audits of medication carts and controlled substance reconciliation daily. She stated the audits consisted of checking the medication blister sheets and Disposition sheets count matched and in-service education was provided for discrepancies. The first week she did the audits daily and the managers took over the following week and she was confident that it was done at least several times a week for each medication cart. The DON also stated education was provided to the nurses to report any discrepancies at any time to her. The 6 residents' Disposition sheets (Residents #10, #51, #73, #88, #345, and #346) were reviewed with the DON and she acknowledged the plan in place is not working.

Based on observations, interviews, and record review the facility failed to ensure medication error rate was below 5 percent; a total of 32 opportunities were observed with 4 medication errors identified which yield a medication error rate of 12.50 percent, affecting 2 of 5 sampled residents reviewed for medication administration, Resident #63 and Resident #32. The findings included: Review of the facility's policy titled, Administering Medications, dated April 2019, included the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4.Medications are administered in accordance with prescriber orders, including any required time frame. 1) Record review for Resident #63 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Leukemia of Unspecified Cell Type in Remission, Drug Induced Subacute Dyskinesia, Anxiety Disorder, and Major Depressive Disorder. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that she was cognitively intact. Review of Section N revealed Resident #63 was on antipsychotic, antianxiety, antidepressant and Antipsychotics were received on a routine basis. During a medication administration (med pass) on the [NAME] unit conducted on 09/24/24 at 9:28 AM, with Staff B, Registered Nurse (RN), she was observed preparing the following medications to administer to Resident #63: Buspirone HCl 5 mg tablet, give 1 tablet by mouth two times a day for Anxiety. Lactulose Solution 20 GM/30ml, give 30 ml by mouth two times a day for Constipation. Metoprolol Tartrate 25 mg tablet, give 1 tablet by mouth two times a day for Hypertension. Omeprazole 20 mg capsule delayed release, give 1 capsule by mouth two times a day for Gastroesophageal Reflux Disease (GERD). Sennosides-Docusate Sodium Tablet 8.6-50 mg, give 2 tablets by mouth two times a day for Constipation. Vitamin C (Ascorbic Acid) 500 mg tablet, give 500 mg by mouth two times a day for nutrition supplement. Lorazepam (Zanax) 0.5mg tablet, give 1 tablet by mouth one time a day for Anxiety. Reconciliation of Resident #63's physician's orders and Medication Administration Record (MAR) revealed Resident #63 was scheduled to receive the above medications at 9:00 AM, plus 3 other medications which were not observed as administered during the med pass: Ingrezza (Valbenazine Tosylate) 60 mg capsule, give 1 capsule by mouth one time a day for Tardive Dyskinesia. Polyethylene Glycol 3350 Powder, to give 17 grams by mouth two times a day for Stool Softening. Ferrous Sulfate 325 mg (65 Fe) tablet, give 1 tablet by mouth one time a day for Anemia. Further review of Resident #63's December MAR revealed Staff B initialed as administering all the medications scheduled for 9:00 AM. On 12/03/24 at 9:35 AM (after the med pass observation), Resident #63 was observed in her wheelchair, in the hallway between [NAME] and Windsor units wheeling herself towards the Windsor unit for an activity event. During an interview conducted on 12/03/24 at 10:23 AM with Staff B, she stated she has been working at the facility for 1 month. When asked about the 3 medications that were not observed during med pass observation, she stated she administered the Ingrezza 60 mg and the Polyethylene Glycol 3350 Powder to Resident #63 after med pass observation was done. Staff B stated Resident #63 sometimes complains that she is getting too many medications therefore she administered the medications afterwards. However, Staff B realized the Ferrous Sulfate 325 mg (65 Fe) needed to be ordered and currently the facility has not received it. When asked why she documented the Ferrous Sulfate 325 mg as administered, she stated she forgot that the medication had to be ordered. Review of the Medication Administration Audit Report (time stamp) revealed Staff B documented Resident #63 received the 9:00 AM scheduled medications between 9:32 and 9:40 AM including the Ingrezza 60 mg (9:32 AM), Polyethylene Glycol 3350 Powder (9:34 AM) and Ferrous Sulfate 325 mg (9:33 AM). The last medication observed during the med pass was Lorazepam 0.5 mg, which according to the time stamp, the documentation time was 9:40 AM. An interview was conducted on 12/03/24 at 1:50 PM with the Director of Nursing (DON) and review the time stamp report for Resident #63. She acknowledged that the medications (Ingrezza 60 mg, Polyethylene Glycol 3350 Powder, and Ferrous Sulfate 325 mg) were omitted from the med pass and Staff B documented them as being administered while the med pass was observed. 41837 2) Review of the manufacturer's prescribing information for Fiasp FlexTouch insulin injector pen at https://www.novo-pi.com/fiasp.pdf included in part the following: Priming your FIASP(R) FlexTouch(R) Pen: Step 7: oTurn the dose selector to select 2 units Step 8: oHold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. Step 9: oHold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. oA drop of insulin should be seen at the needle tip (See Figure J). o If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. o If you still do not see a drop of insulin, change the needle and repeat steps 7 to 9. Record review for Resident #32 revealed the resident was originally admitted to the facility on [DATE] most recent readmission on 08/11/19 with diagnoses that included, in part, the following: Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus, Parkinson's Disease, and Dementia. Review of the Minimum Data Set for Resident #32 dated 11/01/24 documented in Section C, a Brief Interview of Mental Status score of 12, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #32 revealed an order dated 04/21/24 for Fiasp FlexTouch 100 UNIT/ML Solution pen-injector, Inject subcutaneously before meals for Diabetes. Inject as per sliding scale: if 60 - 150 = 0; 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 400. On 12/03/24 at 8:30 AM, an observation of a med pass was conducted with Staff B, Registered Nurse (RN) for Resident #32. Staff B, RN prepared the Fiasp FlexTouch 100unit/ml insulin pen to give 6 units subcutaneously to the resident. Staff B, RN primed the insulin pen by holding the pen upside down (needled pointing to the floor). An interview was conducted on 12/03/24 at 8:33 AM with Staff B, RN who stated she has worked at the facility for 1 month. When asked about priming the insulin pen, she said she did, she turned the dial and saw the liquid insulin come out of the tip of the needle. When asked why the needle was facing down instead of up, she said that is how she was shown by another nurse to do so. An interview was conducted on 12/03/24 at 2:15 PM with Consultant Pharmacist who was asked if Fiasp FlexTouch 100 UNIT/ML Solution pen-injector dosage would be accurate if the insulin pen was not properly primed. She stated she could not say the dose would be accurate or not accurate if the insulin pen was not primed according to manufacturer's instructions. She acknowledged the Fiasp FlexTouch 100 UNIT/ML Solution pen-injector should be primed with the needle pointing up.

Based on observations, interviews and record review, the facility failed to secure medications at bedside for 3 out of 34 sampled residents; (Residents #49, # 72, 115 ) and failed to secure 1 of 7 med carts; failed to secure medication left on top of 1 of 7 med carts; and failed to properly dispose of medication(s) during 2 out of 5 medication observations. The findings included: Review of the facility's policy titled, Medication Labeling and Storage with a published date of 05/19/23 included in part the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Review of the facility's policy titled, Self-Administration of Medications with a Published date of 05/19/23 included in part the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 8. Self-administering medications are stored in a safe and secure place, which is not accessible by other residents. Review of the facility's policy titled, Discarding and Destroying Medications with a revised date of November 2022 included in part the following: Medications that cannot e returned to the dispensing pharmacy (e.g., non-unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 6. e)The collector is responsible for managing the collection receptacles, including picking up and properly disposing of medications collected in the receptacles and training facility staff on the procedures associated with collection and storage of controlled substances awaiting disposal. 7.For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: b) Mix medication, either liquid or solid with an undesirable substance. 1) On 12/03/24 at 8:26 AM, during an observation with Staff B, Registered Nurse (RN), left a Fiasp FlexTouch 100unit/ml insulin pen on top of the unlocked and unattended med cart ([NAME] unit) to obtain insulin pen needles. An interview on 12/03/24 at 8:26 AM , Staff B, RN, revealed she has worked at the facility for 1 month. When asked about leaving the insulin on the unlocked and unattended med cart she said she did not know why she did that, but meds and the med cart should always be locked up. 2) Record review for Resident #49 revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, in part, the following: Atrial Fibrillation, and Essential (Primary) Hypertension. Review of the Minimum Data Set (MDS) for Resident #49 dated 11/09/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #49 revealed no order for Tums (calcium carbonate). Record review for Resident #49 revealed no evaluation for self-administration of medication. On 12/02/24 at 10:18 AM, an observation was made of Resident #49 in bed with a bottle of Tums on her nightstand. 3) Record review for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Post Traumatic Stress Disorder. Review of the Minimum Data Set for Resident #72 dated 08/14/24 revealed in Section C a Brief Interview of Mental Status score of 15, indicating intact cognition. Record review for Resident #72 revealed no evaluation for self-administration of medication. Review of the Physician's Orders for Resident #72 revealed an order dated 11/20/23 for Artificial Tears Ophthalmic Solution 0.2-0.2-1 % (Glycerin-Hypromellose-Polyethylene Glycol 400) Instill 2 drop in both eyes every 2 hours as needed for eye drop. Review of the Medication Administration Record for Resident #72 from 11/01/24 to 12/01/24 revealed no documentation of Artificial Tears being administered. On 12/02/24 at 11:25 AM, an observation was made of Resident #72 sitting up in bed with 2 bottles of artificial tears on her overbed table. On 12/03/24 at 9:30 AM, a second observation was made of Resident #72 sitting up in bed with 2 bottles of artificial tears on her overbed table. During an interview conducted on 12/02/24 at 11:25 AM with Resident #72, who was asked about the eye drops at her bedside, she stated one is a backup, and she has dry eye syndrome, so she uses the drops several times a day. She stated her doctor gave orders for her to have them at the bedside and give them to herself. 4) On 12/03/24 at 7:59 AM, a med pass observation was conducted with Staff A, Licensed Practical Nurse (LPN), who was working on Windsor med cart #2 and passing medications to Resident #84. After resident tool all medications orally, Staff A, LPN noticed a small pink pill on the floor next to the resident's bed. Staff A, LPN picked up the pill and disposed of it in the sharp container in the resident's bathroom. An interview was conducted on 12/03/24 at 8:02 AM with Staff A, LPN who stated she has worked at the facility for 10-[AGE] years. When asked about medication disposal, she said she should have disposed of the pill in the drug buster solution, not put it into the sharp's container in the resident's bathroom. An interview was conducted on 12/03/24 at 11:31 AM with the Director of Nursing (DON) who stated she has been at the facility for 2 months. When asked if residents can have medications at the bedside, the DON stated normally not unless the resident specifically has a of plan of care for self-administration. When asked what is needed for the resident to self-administer medication, the DON stated they would need to be evaluated for self-administration and have a care plan for that as well. When asked about med carts, treatment carts and emergency carts being locked, she said they all should be locked at all times unless the nurse is using them. When asked about medication disposal, she stated they should be disposed of per their policy. 49060 5) Record review for Resident #115 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Parkinsonism, Hypertension, Anxiety Disorder, Malignant Neoplasm of Central Portion of Female Breast, Dysphagia, and Insomnia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #115 had a Brief Interview for Mental Status (BIMS) of 12, which indicated that she was moderately cognitively impaired. Review of Section N revealed that Resident #115 was on antipsychotic, antianxiety, and received antipsychotics on a routine basis. During an initial observational tour conducted on 12/02/24 10:22 AM, Resident #115 was noted to have a few over the counter (OTC) medications on top of her nightstand table, visible and easily accessible to other residents, employees and visitors. Further observation revealed the OTC medications were two used bottles of Nasal sprays (one with an expiration date of 06/2022), a Neosporin ointment tube, Preparation H ointment tube and a large bottle of Probiotic chewable supplement. Review of the Physician's Orders showed that Resident #115 had no orders for self-administer medications, and no orders for any of the above OTC medications. An interview conducted on 12/02/24 at 10:24 AM with Resident #115, she revealed that she had been looking for the OTC medications and felt someone moved them to her nightstand. She stated she has used the nasal spray because sometimes she feels congested. During a second initial observational tour conducted on 12/03/24 10:13 AM, Resident #115 was still noted to have the OTC medications on top of her nightstand table, visible and easily accessible to other residents, employees and visitors. During an interview conducted on 12/03/24 at 12:35 PM with the Director of Nursing (DON), she stated she has been working at the facility for 2 months. She stated she has been inspecting all the residents' rooms and educating the nursing staff to make sure no medications are in the residents' rooms. She acknowledged that it has been difficult since residents' families bring in medications for the residents. She stated she was surprised that there were OTC medications in Resident #115's room. The management team had just inspected the units. A follow-up interview was conducted on 12/05/24 at 2:02 PM with the DON. She stated that the OTC medications at the bedside of Resident #115 were brought in by the resident's [family member]. She stated she had a plan in place for medications at the bedside. The first week the plan went in place she audits the second floor and was done with residents' permission. The DON acknowledged that there are still concerns with OTC medication in the residents' rooms. 6) During a medication administration (med pass) observation conducted on 12/03/24 at 9:28 AM in the [NAME] unit with Staff B, Registered Nurse (RN), a Senna Plus bottle was observed not closed and spilled into the drawer and the hallway floor. Staff B picked up the tablets in the drawer with a tissue, while the wound care nurse (WCRN) helped to pick up the tablets that went onto the floor. Staff B was about to discard the tablets in the sharp container (attached to the medication cart), and was stopped by the WCRN which the WCRN noted would discard them in the drug buster located at the medication room. After the med pass, the surveyor pointed out another Senna Plus tablet on the floor which was missed. Staff B picked up the tablet with a glove and discarded it into the sharp container. When Staff B was asked if that is the proper practice to discard medications, she stated if it was a controlled substance, she would need another nurse to sign the waste and the manager would discard the medication in the drug buster. However, for medications like this one, they can be discarded in the sharp container. An interview was conducted on 12/04/24 at 1:50 PM with the DON. She stated as per policy, nurses are to dispose of medications using the drug buster that is in the medication room. She acknowledged discarding the medications in the sharp container is a bad habit by the nurses.

Based on observations, interviews and record reviews, the facility failed to provide food that meets residents' preferences, allergies and intolerances for 6 of 6 sampled residents observed during dining observation (Resident's #122, #54, #39, #69, #44, and #46). The findings include: 1) Record review revealed that Resident #122 was admitted to the facility on [DATE] with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side and Non-traumatic Intracranial Hemorrhage. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score of 11, which indicates slight cognitive impairment. In an interview conducted on 12/02/2024 at 10:45 AM Resident #122 stated that breakfast was okay, but it would be great if only she could really get what is on her meal ticket. For example, this morning she didn't get the grits that were on the meal ticket. In a second interview conducted on 12/02/2024 at 1:30 PM Resident #122 stated that she asked staff for a turkey sandwich instead of what was on the menu today. The staff answered that there were no more turkey sandwiches. Resident #122 did not touch her plate because this food tastes like dog food. 2) Record review revealed that Resident #54 was admitted ot the facility on 10/07/2024 with diagnosis of Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting the left non-dominant side. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 11. In an observation conducted on 12/02/2024 at 1:10 PM Resident #54's meal ticket consisted of a No Added Salt diet with the following: Beef & Vegetable Stir Fry 6oz, Steamed Rice 4ounces (oz), Mandarin Orange 1/2 Cup, Ginger Ale 1Can, Apple Juice 8oz. And the tray consisted of Beef & Vegetable Stir Fry, Steamed Rice, 2 Cups of Mandarin Orange, and 2 Cans of Cola and was missing the Apple Juice and the Can of Ginger Ale as noted on the meal ticket. 3) Record review revealed that Resident #39 was admitted to the facility on [DATE] with diagnosis of Parkinson's Disease without Dyskinesia, without mention of fluctuations and multi-system Degeneration of the Autonomic Nervous System. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score of 13, which indicates intact cognition. In an observation conducted on 12/02/2024 at 1:15 PM, Resident #39's meal ticket consisted of a Regular Diet with the following: Egg Salad Sandwich 3oz, Lettuce/tomato Slice 1 serving (Srv), Tossed [NAME] Salad 1/2 Cup, Dressing 2 Packets (Pkt), Diet Ginger Ale 8oz, Fruit Cup 1/2 Cup. And the tray consisted of Egg Salad Sandwich, Lettuce/tomato Slice, Tossed [NAME] Salad, dressing 1 Pkt, 1 Can of Cola and was missing the Fruit Cup and the Diet Ginger Ale. 4) Record review revealed that Resident #69 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus without complications and unspecified Dementia, unspecified severity without behavioral. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score of 8, which indicates Moderate Cognitive Impairment. In an observation conducted on 12/02/2024 at 1:21 PM, Resident #69's meal ticket consisted of a Regular Diet with the following: Beef & Vegetable Stir Fry 6oz, Fortified Mashed Potatoes 4oz, Ice Cream of Any flavor 4oz, Sugar Free Lemonade 8oz. And the tray consisted of Beef & Vegetable Stir Fry 6oz, Fortified Mashed Potatoes 4oz, Mandarin Orange and was missing the Sugar Free Lemonade and the Ice Cream. In a brief interview conducted on 12/02/2024 at 1:22 PM, Resident #69's Private Aid stated that the meal tickets almost never match the tray and when she asks the staff for missing items on the tray, or about the meal tickets not matching the tray the answers she usually gets are: the meal ticket was printed wrong, or they get it confused. 5) Record review revealed that Resident #44 was admitted to the facility on [DATE] with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left the non-dominant side. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score of 10, which indicates Moderate Cognitive Impairment. In an observation conducted on 12/02/2024 at 1:30 PM, in the second-floor dining room, Resident #44's meal ticket consisted of a No Added Salt Diet with the following Chef Salad 1 Each (Ea.), Crackers 1 Package (Pkg), Mandarin Oranges 1/2 Cup, Diet Ginger Ale 8oz. And the tray consisted of Chef Salad, 1 Can of Cola and was missing the Crackers, Mandarin Oranges and the Diet Ginger Ale. In an interview conducted on 12/04/2024 at 5:00 PM with the facility Food Service Assistant, she stated that she gets the residents' preferences by interviewing them, and she also gives them ideas of what they carry on the facility's menu and asks them what they usually eat at home. She also stated that some residents go with facility's food choices that are on the menu and other ones pick different things. As soon as the food preferences are obtained, she adds them on the meal tracker. If the residents have ingredients/food that they dislike, she adds them in the categorical refusal as part of the electronic system and the program automatically substitutes and gives them their picked preferences. The Food Service Assistant also explained the process of quality control of the tray line and the accuracy of the meal tickets is regulated by a staff member (starter) and another staff member(checker) to monitor the accuracy of the food items on the trays to ensure that the correct food items are placed on the trays. For residents who do not like the food choices on their tray, they will offer sandwiches and then said, there is no such thing as being out of sandwiches. 40153 6) Review revealed that Resident #46 was admitted to the facility on [DATE] with diagnoses of Paraplegia and Chronic Obstructive Pulmonary Disease. The Minimum Data Set assessment dated [DATE] showed a Brief Interview Status (BIMS) score of 14, which is cognitively intact. A review of the list of food items posted outside the main dining room for the Tuesday breakfast meal dated 12/3/24 listed the following: pancakes, turkey sausage, oatmeal, and banana. A review of Resident #46's meal ticket for Tuesday 12/3/24, revealed the following: pancakes, cereal, orange juice, coffee, creamer, whole milk and Splenda. The breakfast meal tray did not have banana on the tray. An interview was conducted on 12/03/24 at 9:36 AM with the Food Service Assistant (FSA), who stated she has been working at the facility for about 3.5 weeks. When asked about food preferences, she said food preferences and likes/dislikes are addressed at the time of admission and are documented in the meal tracker system. When asked about the posted breakfast for 12/03/24 that included a banana, she said they had substituted grapes. When asked about Resident #46, the FSA acknowledged there were no preferences, likes, or dislikes for fruit for the resident in the meal tracker system.

Based on facility staff and family interview, clinical record review and facility policy review on 02/26/20, it was determined facility staff neglected to ensure Resident #1 was provided adequate supervision with eating. Resident #1 with a [DIAGNOSES REDACTED].#1 choking on a whole Brussel sprout requiring immediate intervention by the facility and subsequent emergent transfer to the hospital for treatment. A return to the facility for additional information was conducted on 03/06/20. On 03/06/20 it was determined the findings of the survey posed Immediate Jeopardy to the health and safety of the residents in the facility. The Administrator was informed of the Immediate Jeopardy on 03/06/20 at 2:30 PM. The Immediate Jeopardy was identified on 03/06/20, as beginning on 02/08/20 and removed on 03/06/20. The scope and severity was decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 02/10/20 and verified by interview, observation and record review on 03/06/20. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. Cross Reference - F689 The findings included: Review of the facility Abuse, Neglect and Exploitation of Residents Policy stated, 'Neglect is the failure to provide goods or services which are necessary to maintain physical or mental health, and necessary to avoid physical harm, mental anguish or mental illness. Neglect may be a repeated course of conduct or a single incident. Neglect is also the repeated failure to follow the plan of care, and a failure to follow the plan of care that results in injury of the resident.' Review of the clinical record for Resident #1 revealed he was admitted to the facility on [DATE] for long term care residency. Resident #1 is dependent on facility staff for all ADLs (activities of daily living) and required assistance and supervision with meals. Resident #1 resided in a semiprivate room and on 02/08/20 his roommate was Resident #4. Review of a Dietary Note dated 06/19/19 at 9:13 AM documents 'Nursing reported Resident #1 was having difficulties with mechanical soft consistency diet. He was unable to complete his dinner meal on 06/18 due to problems chewing/swallowing. Diet consistency was downgraded to puree. ST (Speech Therapist) to screen and follow up.' Review of a ST Progress Note dated 06/19/19 at 1:54 PM documents 'Resident #1 observed to have extreme difficulty managing mechanical soft diet texture at breakfast on report. Observed by ST to not manage mechanical soft texture at lunch, resulting in coughing and sudden expectoration of the bolus. Swallow evaluation completed at lunch today. Tolerated puree texture. Diet recommendations are for pureed texture; all liquids to be thickened to nectar consistency.' Resident #1's nutritional [DIAGNOSES REDACTED]. Review of a Dietary Quarterly assessment dated [DATE] documents 'Resident on no added salt puree with nectar thick liquids. Requires assistance with meals. On mechanical altered therapeutic diet; nectar thick liquids is appropriate to promote safe swallowing.' Review of Resident #1's quarterly MDS (Minimum Data Set) comprehensive resident assessment dated [DATE], under Section C - Cognitive Patterns documents Resident #1 has a BIMS (Brief Interview for Mental Status) of 5 out of a score of 15, indicating the resident has severe cognitive impairment. Review of documentation under Section K - Swallowing/Nutritional Status documents 'Coughing or choking during meals or when swallowing medications - YES. Remains on a mechanically altered therapeutic diet.' Review of a quarterly Social Services assessment dated [DATE] at 4:24 PM documents 'Speech pattern - Unclear speech; Ability to express ideas and wants - Sometimes understood; Understanding verbal content - Sometimes understands; BIMS - 5.0 Severe Impairment.' Review of a Social Services Progress Note dated 02/05/20 at 2:58 PM documents in part, 'Team discussed resident's diet; resident receives assistance with feeding. Resident continues to self-propel in wheelchair down hallways to attend open gym daily.' Review of Resident #1's Care Plans documents 'Resident has impaired cognitive function and impaired thought processes. Has impaired decision making - will benefit from cues and supervision and or assistance in decision making. Intervention to include - The resident needs supervision and or assistance with all decision making.' Further review of the Care Plans documents 'Resident has an alteration in ability to communicate needs (unclear speech) related to impaired cognitive ability. Intervention to include: Limit sensory input when resident is agitated as needed.' Review of a dietary Care Plan documents 'The resident is at nutritional risk related to past medical history of [REDACTED]. Requires mechanical altered foods and nectar thick liquids due to history of dysphagia. Intervention to include - Provide dining assistance as per assessed needs as needed.' Review of a Nursing Progress Note dated 02/08/20 at 4:53 PM, completed by the resident's evening Licensed Practical Nurse (LPN) Staff 'L' states in part, 'Propelled resident in wheelchair back to his room. No distress voiced or noted. Left in room watching TV. Resident stated, I am ready to eat. Further review of the Nursing Progress Notes completed by Resident #1's evening LPN dated 02/8/20 at 7:02 PM documents, 'While on lunch writer informed that resident vital signs blood pressure 200/115, pulse 110, Oxygen saturation 68% and non-responsive. Non-rebreather applied saturation increased 76%. Floor nurse called 911. When writer arrived, paramedics were transporting resident to hospital for evaluation. MD notified, (family member) of resident notified.' On 02/25/20 at 10:40 AM, the Risk Manager (RM) provided the facility Adverse Incident Log which documented the Federal Immediate report was submitted on 02/10/20; the Federal 5- day report was submitted on 02/17/20; and the 15 day Adverse Incident report was submitted on 02/21/20 documenting after their investigation it was determined an allegation of neglect was Unsubstantiated. A request was made to the RM for their investigation notes. On 02/25/20 at 10:55 AM, the Administrator and RM provided the facility investigation notes for the incident with Resident #1 on 02/08/20. The RM stated after their investigation they determined it was not an adverse incident. The RM stated in a puzzled expression 'they found a Brussel sprout in the resident's throat.' Further the RM stated in their investigation, they did not consider leaving a resident requiring supervision with food, unsupervised, an act of neglect however could not speak to how they made that determination. An inquiry was made who was Resident #1's roommate at that time to which they identified and confirmed it was Resident #4. Review of the hospital record Emergency Department (ED) physician note dated 02/08/20 at 6:50 PM states in part, 'The patient apparently was eating food and possibly may have choked. EMS arrived the patient was in severe respiratory distress with agonal (abnormal breathing pattern) respirations. They started bagging (manual respirations provided by an oxygen apparatus) the patient and brought him here to the emergency department . The patient was noted to be tachypneic (increased respirations) in the 40's, oxygen saturation 89-90%, blood pressure was 172/116 and heart rate 112. Due to concern about his increased work of breathing patient was thus intubated (breathing tube inserted down the trachea) without difficulty. Subsequently while NG (nasogastric tube placed down the esophagus into the stomach) was being placed he was found to have full Brussel sprout in his throat which was removed No evidence for aspiration pneumonitis (inflammation of lung tissue) at this time based on chest x-ray but did have Brussel sprout in throat raising concern for aspiration.' Further review of the hospital records in brief summation revealed - Resident #1 was transported via 911 emergency to the ED in severe respiratory distress. He was intubated and mechanically ventilated. He had a NG tube inserted into his stomach and during this procedure a whole Brussel sprout was discovered. He had a Foley urinary catheter inserted with subsequent urinalysis indicating he had a urinary tract infection. He required intravenous (IV) sedation while on the ventilator. Due to the IV sedation, his blood pressure was low and he required IV medication to maintain his blood pressure within normal parameters. Diagnostic tests included chest x-rays, a CT scan of his chest and an electroencephalogram (EKG). He was administered IV fluids and started on IV antibiotics. From the ED he was transferred to the Intensive Care Unit for continuous monitoring. On 02/25/20 at 2:55 PM an interview was conducted with the evening LPN Staff 'A', the nurse who responded to the emergency with Resident #1 on 02/08/20. The RM was also present. The events of the evening of 02/08/20 were reviewed with the explanation Resident #1 was brought back to his room after a visit with a family member and placed next to his bed, left to watch television. His roommate, Resident #4, who usually ate his meals in the dining room was in bed and did not want to go to the dining room for dinner that evening. The evening CNA Staff 'B' brought in Resident #4's dinner tray which she had to collect from the dining room and brought it to the resident in his room and placed it on Resident #4's bedside table. CNA Staff 'B' then left the room to get a clothing protector and on her way back to the room stopped and answered 2 call bells before going back to Resident #1 and Resident #4's room. CNA Staff 'B' left a second time to get a gown for Resident #4. LPN Staff 'A' stated Resident #1 was not on her assignment but she was at the nursing station when she heard CNA Staff 'B' coming down the hall screaming she needed a nurse and when LPN Staff 'A' entered the resident's room she observed Resident #1 in his wheelchair looking like he was choking and could not breathe so she did the [MEDICATION NAME] maneuver, tapped on his back and looked in his mouth but did not see anything. She stated the resident passed out for a few seconds and they got him into bed and elevated the head of the bed. LPN Staff 'A' stated they called a Rapid Response and started Resident #1 on oxygen and did vital signs and called 911 emergency. LPN Staff 'A' stated 911 arrived fast and they took over the resident's care and took him to the hospital. An inquiry was made regarding if Resident #1 always eats in his room and Resident #4 always eats in the dining room and LPN Staff 'A' confirmed that was the case except on this evening, Resident #4 wanted to eat in his bed. An inquiry was made about Resident #1's eating ability to which she stated he requires assistance with meals but does try to help out and is able to use his hands and propel himself in his wheelchair. The RM stated Resident #1's dinner tray had not even arrived yet when the incident occurred, and the aide had to go to the dining room to get Resident #4's tray as he eats in the dining room. An inquiry was made to LPN Staff 'A' regarding what was Resident #1's diet to which she stated he was on puree with nectar thick liquids. An inquiry was made regarding what was Resident #4's diet to which she stated he was on a regular diet. Review of the dinner meal ticket for Resident #4 from 02/08/20 documented 'Restorative -1 LCS/NAS (low concentrated sweets/no added salt) mechanical soft. Puree Meat. Mechanical soft roast turkey, gravy, cornbread dressing, Brussel sprouts, fruit crisp, minestrone soup, sugar free beverage; plate guard.' Review of the Individual Service Care Plan Report for Resident #1, which CNAs use as a reference to identify what diets their residents were on, revealed no section for Eating/Nutrition documented to indicate what the resident's eating and dietary restrictions/requirements were. On 02/26/20 at 3:40 PM, an interview was conducted with Resident #1's family member who was extremely distraught about what happened to Resident #1, stating 'they almost killed him. She stated how could they feed him something that he can't have. It was a Brussel sprout and he is on puree and cannot have Brussel sprouts.' On 02/26/20 at 4:00 PM, an interview was conducted with CNA Staff 'B' who had Resident #1 and Resident #4 on her assignment the evening of 02/08/20. The RM was also present during the interview. A request was made to explain the events that occurred on the evening of 02/08/20 with Resident #1. CNA Staff 'B' confirmed Resident #1 and Resident #4 shared a room. She stated Resident #4 was in bed, so she went to the dining room to get his dinner tray. She stated she placed the tray on the table between the 2 beds. She confirmed Resident #1 was watching television. She stated she left the room to get a clothing protector and stopped at 2 resident rooms to answer call lights, then went back to Resident #1 and Resident #4's room. She stated she set up the tray and started to feed Resident #4, then left again to get a gown. An inquiry was made regarding if she put the lid back on the dinner plate when she left to which she stated she did not remember. An inquiry was made regarding where was Resident #1 when she was in the room and when she left and came back, to which she stated she did not remember. An inquiry was made regarding what happened to Resident #1 to which she stated she was feeding Resident #4 and then heard Resident #1 not breathing right so she called the nurse right away and they got him into bed and the nurse took over. An inquiry was made reagdring if Resident #4 usually ate in the dining room to which she stated he usually eats in the dining room but on that evening when she started her shift he was in bed. An inquiry was made regarding if Resident #1 always eats his meals in his room to which she stated he always has his dinner in his room and he needs assistance with eating, however CNA Staff 'B' did not indicate Resident #1 should be supervised during meals at all times. An inquiry was made regarding if Resident #1 was able to self-propel his wheelchair around, was he able to assist with eating, to which CNA Staff 'B' stated Resident #1 gets around in his wheelchair and he can move his arms and hands and can hold onto things. She stated Resident #1 was on a puree diet and he was a 'Feeder', just like Resident #4, but Resident #1 could move his hands and would try to take some things from his tray. The RM added, they try to encourage residents to do as much as they can and Resident #1 could assist with meals. An inquiry was made to CNA Staff 'B' regarding where would she look to see what a resident's diet was to which she stated it is on the paper on the tray and there is a Book. An inquiry was made regarding where the Book was to which she stated she would have to find it, but she can look on the paper on the tray. On 02/26/20 at 5:00 PM, a conference was held with a facility panel including the Administrator, Risk Manager, Director of Social Services and the Regional Nurse. The incident with Resident #1 was recapped. There was a failure to provide adequate supervision of Resident #1 leading to a choking incident and subsequent emergent hospitalization . Additionally, Resident #1 was able to self-propel in his wheelchair and had mobility of his upper extremities to be able to grasp objects. The resident was left unattended with a dinner tray left in plain view which was not intended for him. Review of nursing notes documented when the resident was brought back to his room after visiting with family the resident commented 'I am ready to eat.' His roommate, Resident #4, who usually eats his meals in the dining room was in bed at the time of dinner, so the aide went to the dining room to retrieve his dinner tray. After she brought it to the room, she left on 2 occasions leaving Resident #1 alone with a tray he may have thought was his as he always ate in his room. The facility Adverse Incident investigation documented Resident #1 had never attempted to take food off other resident's trays. Resident #1 would not have had the opportunity to take food off of other resident's trays if he always ate in his room with assistance and supervision of an aide, and Resident #4 always ate in the dining room. Resident #1's dinner tray had not yet arrived and CNA Staff 'B' began feeding Resident #4 because his dinner tray was retrieved from the dining room which was served before meal tray delivery to the rooms. Resident #1 was left unsupervised with a meal tray not intended for him which consisted of a diet that put the resident at risk for harm. Resident #1 was readmitted to the facility on [DATE], 19 days after the choking incident. Resident #1 was readmitted with a gastric feeding tube and no longer is able to eat or drink anything by mouth. The facility's Immediate Jeopardy removal plan dated 03/06/20 included the following: Identification of other residents to be affected by deficient practice - All residents with a [DIAGNOSES REDACTED]. Systemic Corrective Actions: On 02/10/20 the Federal Immediate Report was submitted. On 02/17/20 the Federal 5 Day report was submitted. On 02/21/20 the 15-day State Adverse Incident report was submitted. Diet order and level of assistance residents require with meal audits were initiated on 02/10/20 and completed on 02/10/20. Audit of all resident's diets were initiated on 02/10/20 and completed on 02/10/20. Resident diet care plan audits were initiated on 02/10/20 and completed on 02/10/20. Audit of resident diets on the electronic charting system and Plan of Care banner were initiated on 02/10/20 and completed on 02/10/20. Staff were educated re resident care plans reflecting resident's current diet and level of assistance residents required with meals are not to be left unattended during meal time was initiated on 02/10/20 and remains ongoing. In-service how to perform the [MEDICATION NAME] maneuver and signs and symptoms of choking was conducted on 02/10/20 for the day and evening shift licensed nurses and CNAs. On 02/10/20 in-services were conducted for the day, evening and night shift staff on abuse and neglect. Random audits on tray accuracy and diet orders was initiated on 02/11/20 and is ongoing. Random audits on assistance provided to residents that require assistance with meals was initiated on 02/11/20 and is ongoing. Random audits on knowledge of different diet consistencies and CNA knowledge of resident's diets was initiated on 02/11/20 and is ongoing. Random audits on CNA knowledge of resident's diet on the plan of care was initiated on 02/28/20 and is ongoing. Random audits on supervision provided with resident meals was initiated on 02/28/20 and is ongoing. A Performance Improvement Plan was developed and implemented on 02/10/20 and revisions implemented on 02/26/20 related to CNAs were not able to verbalize accurately where to locate a resident's diet with further education required in addition to providing assistance and supervision during meals. A Quality Assurance Performance Improvement meeting was held on 02/28/20 reviewing the Performance Improvement Plan. On 03/06/20 the information in the facility's removal plan was verified. Six day shift CNAs and nine evening shift CNAs were interviewed and all were able to demonstrate on the electronic documentation kiosk where to locate resident diets. Additionally, they all stated they have received education on not leaving residents unsupervised during meal times or if they are around food. Review of the facility employee roster verification sheet revealed 41 of 66 CNAs, to include CNA Staff 'B' had received in-service training on residents that require assistance with meals are not to be left unattended at meal times and ensuring resident's care plans accurately reflect the resident's current diet. Additionally, 20 of 38 licensed nurses; 3 of 4 activities staff; 20 of 20 dietary staff; 3 of 3 MDS staff; 12 of 14 rehabilitation staff and 3 of 3 social services staff have been verified as receiving this in-service training. Interviews conducted on 03/06/20 with the Director of Nursing, Dietary Director, Assistant Food Service Manager, Registered Dietician, Speech Therapist, MDS Director, Risk Manager and Regional Nurse confirmed staff training and audits have been and will continue to be conducted related to supervision to be provided during resident meals; CNA knowledge of resident's diets; CNA knowledge of resident diet consistencies; ensuring accurate diet orders and meal tray accuracy. Resident #1 was observed on 03/06/20 to be residing in a semiprivate room with a resident who is alert and oriented and able to stop Resident #1 from access to his meal trays. The facility's Immediate Jeopardy was removed on 03/06/20 at 8:15 PM.

Based on facility staff interview, clinical record review and facility policy review it was determined on 02/26/20 the facility failed to ensure adequate supervision was provided on 02/08/20 for 1 of 1 sampled residents with a [DIAGNOSES REDACTED].#1. Resident #1 was left unsupervised in close proximity to a dinner meal not intended for him. Resident #1 choked on his roommate's food requiring immediate intervention by facility staff and and subsequent emergent transfer to the hospital for medical treatment. A return to the facility for additional information was conducted on 03/06/20. On 03/06/20 it was determined the findings of the survey posed Immediate Jeopardy to the health and safety of the residents in the facility. The Administrator was informed of the Immediate Jeopardy on 03/06/20 at 2:30 PM. The Immediate Jeopardy was identified on 03/06/20, as beginning on 02/08/20 and removed on 03/06/20. The scope and severity was decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 02/10/20 and verified by interview, observation and record review on 03/06/20. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. Cross Reference - F600 The findings included: Review of the facility policy for Safety and Supervision of Residents states in part, 'Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. System Approach to Safety: Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.' Review of the clinical record for Resident #1 revealed he was admitted to the facility on [DATE] for long term care residency. Resident #1 is dependent on facility staff for all ADLs (activities of daily living) and requires assistance and supervision with meals. Resident #1 resided in a semiprivate room and on 02/08/20 his roommate was Resident #4. Review of a Dietary Note dated 06/19/19 at 9:13 AM documents 'Nursing reported Resident #1 was having difficulties with mechanical soft consistency diet. He was unable to complete his dinner meal on 06/18 due to problems chewing/swallowing. Diet consistency was downgraded to puree. ST (Speech Therapist) to screen and follow up.' Review of a ST Progress Note dated 06/19/19 at 1:54 PM documents 'Resident #1 observed to have extreme difficulty managing mechanical soft diet texture at breakfast on report. Observed by ST to not manage mechanical soft texture at lunch, resulting in coughing and sudden expectoration of the bolus. Swallow evaluation completed at lunch today. Tolerated puree texture. Diet recommendations are for pureed texture; all liquids to be thickened to nectar consistency.' Resident #1's nutritional [DIAGNOSES REDACTED]. Review of a Dietary Quarterly assessment dated [DATE] documents 'Resident on no added salt puree with nectar thick liquids. Requires assistance with meals. On mechanical altered therapeutic diet; nectar thick liquids is appropriate to promote safe swallowing.' Review of Resident #1's quarterly MDS (Minimum Data Set) comprehensive resident assessment dated [DATE], under Section C - Cognitive Patterns documented Resident #1 had a BIMS (Brief Interview for Mental Status) of 5 out of a score of 15, indicating the resident has severe cognitive impairment. Review of documentation under Section K - Swallowing/Nutritional Status documents 'Coughing or choking during meals or when swallowing medications - YES. Remains on a mechanically altered therapeutic diet.' Review of a quarterly Social Services assessment dated [DATE] at 4:24 PM documents 'Speech pattern - Unclear speech; Ability to express ideas and wants - Sometimes understood; Understanding verbal content - Sometimes understands; BIMS - 5.0 Severe Impairment.' Review of a Social Services Progress Note dated 02/05/20 at 2:58 PM documents in part, 'Team discussed resident's diet; resident receives assistance with feeding. Resident continues to self propel in wheelchair down hallways to attend open gym daily.' Review of Resident #1's Care Plans documented 'Resident has impaired cognitive function and impaired thought processes. Has impaired decision making - will benefit from cues and supervision and or assistance in decision making. Intervention to include - The resident needs supervision and or assistance with all decision making.' Further review of the Care Plans documents 'Resident has an alteration in ability to communicate needs (unclear speech) related to impaired cognitive ability. Intervention to include: Limit sensory input when resident is agitated as needed.' Review of a dietary Care Plan documents 'The resident is at nutritional risk related to past medical history of [REDACTED]. Requires mechanical altered foods and nectar thick liquids due to history of dysphagia (difficulty swallowing). Intervention to include - Provide dining assistance as per assessed needs as needed.' Review of a Nursing Progress Note dated 02/08/20 at 4:53 PM, completed by the resident's evening Licensed Practical Nurse (LPN) Staff 'L' stated in part, 'Propelled resident in wheelchair back to his room. No distress voiced or noted. Left in room watching TV. Resident stated, I am ready to eat. Further review of the Nursing Progress Notes completed by Resident #1's evening LPN dated 02/8/20 at 7:02 PM documents, 'While on lunch writer informed that resident vital signs blood pressure 200/115, pulse 110, Oxygen saturation 68% and non-responsive. Non-rebreather applied saturation increased 76%. Floor nurse called 911. When writer arrived, paramedics were transporting resident to hospital for evaluation. MD notified, (family member) of resident notified.' On 02/25/20 at 10:40 AM, the Risk Manager (RM) provided the facility Adverse Incident Log which documented the Federal Immediate report was submitted on 02/10/20; the Federal 5 day report was submitted on 02/17/20; and the 15 day State Adverse Incident report was submitted on 02/21/20 documenting after their investigation it was determined an allegation of neglect was Unsubstantiated. A request was made to the RM for their investigation notes. On 02/25/20 at 10:55 AM, the Administrator and RM provided the facility investigation notes for the incident with Resident #1 on 02/08/20. The RM stated after their investigation they determined it was not an adverse incident. The RM stated in a puzzled expression 'they found a Brussel sprout in the resident's throat.' Further the RM stated in their investigation, they did not consider leaving a resident requiring supervision with food, unsupervised, an act of neglect however could not speak to how they made that determiniation. An inquiry was made regarding who was Resident #1's roommate at that time to which they identified and confirmed it was Resident #4. Review of the hospital record Emergency Department (ED) physician note dated 02/08/20 at 6:50 PM states in part, 'The patient apparently was eating food and possibly may have choked. EMS arrived the patient was in severe respiratory distress with agonal (abnormal breathing pattern) respirations. They started bagging (manual respirations provided by an oxygen apparatus) the patient and brought him here to the emergency department . The patient was noted to be tachypneic (increased respirations) in the 40's, oxygen saturation 89-90%, blood pressure was 172/116 and heart rate 112. Due to concern about his increased work of breathing patient was thus intubated (breathing tube inserted down the trachea) without difficulty. Subsequently while NG (nasogastric tube placed down the esophagus into the stomach) was being placed he was found to have full Brussel sprout in his throat which was removed No evidence for aspiration pneumonitis (inflammation of lung tissue) at this time based on chest x-ray but did have Brussel sprout in throat raising concern for aspiration.' Further review of the hospital records in brief summation revealed - Resident #1 was transported via 911 emergency to the ED in severe respiratory distress. He was intubated and mechanically ventilated. He had a NG tube inserted into his stomach and during this procedure a whole Brussel sprout was discovered. He had a Foley urinary catheter inserted with subsequent urinalysis indicating he had a urinary tract infection. He required intravenous (IV) sedation while on the ventilator. Due to the IV sedation, his blood pressure was low and he required IV medication to maintain his blood pressure within normal parameters. Diagnostic tests included chest x-rays, a CT scan of his chest and an electroencephalogram (EKG). He was administered IV fluids and started on IV antibiotics. From the ED he was transferred to the Intensive Care Unit for continuous monitoring. On 02/25/20 at 2:55 PM an interview was conducted with the evening LPN Staff 'A', the nurse who responded to the emergency situation with Resident #1 on 02/08/20. The RM was also present. The events of the evening of 02/08/20 were reviewed with the explanation Resident #1 was brought back to his room after a visit with a family member and placed next to his bed, left to watch television. His roommate, Resident #4, who usually ate his meals in the dining room was in bed and did not want to go to the dining room for dinner that evening. The evening CNA Staff 'B' brought in Resident #4's dinner tray which she had to collect from the dining room and brought it to the resident in his room and placed it on Resident #4's bedside table. CNA Staff 'B' then left the room to get a clothing protector and on her way back to the room stopped and answered 2 call bells before going back to Resident #1 and Resident #4's room. CNA Staff 'B' left a second time to get a gown for Resident #4. LPN Staff 'A' stated Resident #1 was not on her assignment but she was at the nursing station when she heard CNA Staff 'B' coming down the hall screaming she needed a nurse and when LPN Staff 'A' entered the resident's room she observed Resident #1 in his wheelchair looking like he was choking and could not breathe so she did the [MEDICATION NAME] maneuver, tapped on his back and looked in his mouth but did not see anything. She stated the resident passed out for a few seconds and they got him into bed and elevated the head of the bed. LPN Staff 'A' stated they called a Rapid Response and started Resident #1 on oxygen and did vital signs and called 911 emergency. LPN Staff 'A' stated 911 arrived fast and they took over the resident's care and took him to the hospital. An inquiry was made regarding if Resident #1 always eats in his room and Resident #4 always eats in the dining room and LPN Staff 'A' confirmed that was the case except on this evening, Resident #4 wanted to eat in his bed. An inquiry was made about Resident #1's eating ability to which she stated he requires assistance with meals but does try to help out and is able to use his hands and propel himself in his wheelchair. The RM stated Resident #1's dinner tray had not even arrived yet when the incident occurred and the aide had to go to the dining room to get Resident #4's tray as he eats in the dining room. An inquiry was made to LPN Staff 'A' what was Resident #1's diet to which she stated he was on puree with nectar thick liquids. An inquiry was made regarding what was Resident #4's diet to which she stated he was on a regular diet. Review of the dinner meal ticket for Resident #4 from 02/08/20 documented 'Restorative -1 LCS/NAS (low concentrated sweets/no added salt) mechanical soft. Puree Meat. Mechanical soft roast turkey, gravy, cornbread dressing, Brussel sprouts, fruit crisp, minestrone soup, sugar free beverage; plate guard.' On 02/26/20 at 3:40 PM, an interview was conducted with Resident #1's family member who was extremely distraught about what happened to Resident #1, stating 'they almost killed him. She stated how could they feed him something that he can't have. It was a Brussel sprout and he is on puree and cannot have Brussel sprouts.' On 02/26/20 at 4:00 PM, an interview was conducted with CNA Staff 'B' who had Resident #1 and Resident #4 on her assignment the evening of 02/08/20. The RM was also present during the interview. A request was made to explain the events that occurred on the evening of 02/08/20 with Resident #1. CNA Staff 'B' confirmed Resident #1 and Resident #4 shared a room. She stated Resident #4 was in bed so she went to the dining room to get his dinner tray. She stated she placed the tray on the table between the 2 beds. She confirmed Resident #1 was watching television. She stated she left the room to get a clothing protector and stopped at 2 resident rooms to answer call lights, then went back to Resident #1 and Resident #4's room. She stated she set up the tray and started to feed Resident #4, then left again to get a gown. An inquiry was made regarding if she put the lid back on the dinner plate when she left to which she stated she did not remember. An inquiry was made regarding where was Resident #1 when she was in the room and when she left and came back, to which she stated she did not remember. An inquiry was made regarding what happened to Resident #1 to which she stated she was feeding Resident #4 and then heard Resident #1 not breathing right so she called the nurse right away and they got him into bed and the nurse took over. An inquiry was made regarding if Resident #4 usually ate in the dining room to which she stated he usually eats in the dining room but on that evening when she started her shift he was in bed. An inquiry was made regarding if Resident #1 always eats his meals in his room to which she stated he always has his dinner in his room and he needs assistance with eating, however CNA Staff 'B' did not indicate Resident #1 should be supervised during meals at all times. An inquiry was made if Resident #1 was able to self propel his wheelchair around, was he able to assist with eating, to which CNA Staff 'B' stated Resident #1 gets around in his wheelchair and he can move his arms and hands and can hold onto things. She stated Resident #1 was on a puree diet and he was a 'Feeder', just like Resident #4, but Resident #1 could move his hands and would try to take some things from his tray. The RM added, they try to encourage residents to do as much as they can and Resident #1 could assist with meals. On 02/26/20 at 5:00 PM, a conference was held with a facility panel including the Administrator, Risk Manager, Director of Social Services and the Regional Nurse. The incident with Resident #1 was recapped. There was a failure to provide adequate supervision of Resident #1 leading to a choking incident and subsequent emergent hospitalization . Additionally, Resident #1 was able to self-propel in his wheelchair and had mobility of his upper extremities to be able to grasp objects. The resident was left unattended with a dinner tray left in plain view which was not intended for him. Review of nursing notes documented when the resident was brought back to his room after visiting with family the resident commented 'I am ready to eat.' His roommate, Resident #4, who usually eats his meals in the dining room was in bed at the time of dinner, so the aide went to the dining room to retrieve his dinner tray. After she brought it to the room, she left on 2 occasions leaving Resident #1 alone with a tray he may have thought was his as he always ate in his room. The facility Adverse Incident investigation documented Resident #1 had never attempted to take food off other resident's trays. Resident #1 would not have had the opportunity to take food off of other resident's trays if he always ate in his room with assistance and supervision of an aide, and Resident #4 always ate in the dining room. LPN Staff 'A' stated during the interview on 02/25/20 at 2:55 PM, Resident #1 passed out for a few seconds and they got him into his bed. Resident #1's dinner tray had not yet arrived and CNA Staff 'B' began feeding Resident #4 because his dinner tray was retrieved from the dining room which was served before meal tray delivery to the rooms. Review of Resident #1's Care Plans revealed he has a history of agitation. Resident #1 was left unsupervised with a meal tray not intended for him which consisted of a diet that put the resident at risk for harm. Resident #1 was readmitted to the facility on [DATE], 19 days after the choking incident. Resident #1 was readmitted with a gastric feeding tube and no longer is able to eat or drink anything by mouth. The facility's Immediate Jeopardy removal plan dated 03/06/20 included the following: Identification of other residents to be affected by deficient practice - All residents with a [DIAGNOSES REDACTED]. Systemic Corrective Actions: On 02/10/20 the Federal Immediate Report was submitted. On 02/17/20 the Federal 5 Day report was submitted. On 02/21/20 the 15 day State Adverse Incident report was submitted. Diet order and level of assistance residents require with meal audits were initiated on 02/10/20 and completed on 02/10/20. Audit of all resident's diets were initiated on 02/10/20 and completed on 02/10/20. Resident diet care plan audits were initiated on 02/10/20 and completed on 02/10/20. Audit of resident diets on the electronic charting system and Plan of Care banner were initiated on 02/10/20 and completed on 02/10/20. Staff were educated re resident care plans reflecting resident's current diet and level of assistance residents required with meals are not to be left unattended during meal time was initiated on 02/10/20 and remains ongoing. In-service how to perform the [MEDICATION NAME] maneuver and signs and symptoms of choking was conducted on 02/10/20 for the day and evening shift licensed nurses and CNAs. On 02/10/20 in-services were conducted for the day, evening and night shift staff on abuse and neglect. Random audits on tray accuracy and diet orders was initiated on 02/11/20 and is ongoing. Random audits on assistance provided to residents that require assistance with meals was initiated on 02/11/20 and is ongoing. Random audits on knowledge of different diet consistencies and CNA knowledge of resident's diets was initiated on 02/11/20 and is ongoing. Random audits on CNA knowledge of resident's diet on the plan of care was initiated on 02/28/20 and is ongoing. Random audits on supervision provided with resident meals was initiated on 02/28/20 and is ongoing. A Performance Improvement Plan was developed and implemented on 02/10/20 and revisions implemented on 02/26/20 related to CNAs were not able to verbalize accurately where to locate a resident's diet with further education required in addition to providing assistance and supervision during meals. A Quality Assurance Performance Improvement meeting was held on 02/28/20 reviewing the Performance Improvement Plan. On 03/06/20 the information in the facility's removal plan was verified. Six day shift CNAs and nine evening shift CNAs were interviewed and all were able to demonstrate on the electronic documentation kiosk where to locate resident diets in addition to stating they have received education regarding supervising residents during meal times. Review of the facility employee roster verification sheet revealed 41 of 66 CNAs, to include CNA Staff 'B'; 20 of 38 licensed nurses; 3 of 4 activities staff; 20 of 20 dietary staff; 3 of 3 MDS staff; 12 of 14 rehabilitation staff; and 3 of 3 social services staff have been verified as receiving in-service training on residents that require assistance with meals are not to be left unattended at meal times and ensuring resident's care plans accurately reflect the resident's current diet. Interviews conducted on 03/06/20 with the Director of Nursing, Dietary Director, Assistant Food Service Manager, Registered Dietician, Speech Therapist, MDS Director, Risk Manager and Regional Nurse confirmed staff training and audits have been and will continue to be conducted related to supervision to be provided during resident meals; CNA knowledge of resident's diets; CNA knowledge of resident diet consistencies; ensuring accurate diet orders and meal tray accuracy. Resident #1 was observed on 03/06/20 to be residing in a semiprivate room with a resident who is alert and oriented and able to stop Resident #1 from access to his meal trays. The facility's Immediate Jeopardy was removed on 03/06/20 at 8:15 PM.

Based on record review, interview and observation the facility failed to allow 1 of 40 sampled residents (Resident #75) to exercise her rights as a resident of the facility and as a citizen or resident of the United States. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. Resident #75 requested to have a thermostat lock box removed in order for her to adjust her own temperature in the room and she was denied the right to adjust the temperature to her comfort needs. Resident #75 spent numerous days, nights and weekends in an unbearable state of undesirable discomfort. The findings included: Review of the clinical record revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview conducted on 12/15/15 at 09:16 AM with Resident #75 she verbalized that the thermostat has a locked box that is limiting her access to adjust the temperature in her room to maintain a comfortable temperature. The lock was placed by the previous administrator and the previous social service director. The resident stated that she has had numerous conversations with the current administrator and he refuses to allow her access and unlock the box. She verbalized that the administrator stated too bad for her, because he cannot get any other roommates for my room because of my demands and the administrator is very rude to her. She stated that only the administrator and maintenance has the key to unlock the box. If they are not there on the evening, nights and weekend, no one in the building can adjust the temperature for her. It is unbearable. On many occasions she has to leave her room in order to get some fresh air, because the room is too hot or too cold. At night she has to deal with the temperature too hot or cold. She verbalized that she feels like the administrator is punishing her, because she is the only resident in the building with a locked thermostat box. She stated that she complained to the nurses and C.N.A's (Certified Nursing Assistants) that care for her routinely and nothing can be done. She stated that in the morning the sun is directly at her; as a result it is very hot and in the evening its cooler because of no sun directed into the room. She also indicated that I am not a confused person, I have a brain, why is the administrator treating me like this. Observation on 12/15/15 of the locked thermostat box reveals a clear box with temp >80 degree, Resident #75 is sweating in the room, facial skin with noticeable moisture, appears very frustrated and angry, due to discomfort from the temperature. I felt extremely hot myself while in the room talking to resident. The window curtains were open, with the visible sun shining into the room. Call bell at the bedside and bathroom are functional. Interview was conducted on 12/15/15 at 09:50 AM with the administrator and he states that Resident #75 is very manipulative. Because of her I cannot admit any resident into the room. Her demands are unreasonable. She keeps the room too hot or too cold. I cannot get anyone to stay in the room. The last resident and family in the room was very upset. This is a Medicaid bed; I have to be able to admit other residents. The surveyor requested for the administrator to remove the lock per resident request. Interview was conducted on 12/16/2015 at 9:11:06 AM with the Resident #75 and she verbalized how comfortable and happy she is today. She stated that, I have not been happy for about a year, since the thermostat box has been locked. You saved me, thank you for listening. This problem had a great impact on my life. it made me very anxious, upset and the administrator was making me suffer on purpose. The administrator would say to me, you keep the room too warm or too cold that ' s why I am locking the box, he would not listen to me. I always go to him directly, because he is the one with the key and everyone knows it and they are not authorized to unlock the box. Interview conducted on 12/16/2015 at 9:41: AM with the DON (Director of Nursing) revaled that Resident #75 has not complained about the locked thermostat box to her. She stated, the resident requests to interview all residents coming into the room because she does not get along with anyone. The DON stated that she was not aware when the resident last had a roommate. Interview was conducted on 12/16/2015 at 9:44 AM with the unit manager/RN (registered nurse) who stated that the resident has never asked her to unlock the box. The nurses or C.N.A.s have not informed me that Resident #75 had any concern with the locked thermostat box. There is no key at the nursing station for the thermostat box. Interview was conducted on 12/16/2015 at 9:45 AM with the C.N.A on duty and she stated that they locked it when she had another resident in the room. Nothing can be done to unlock the box after hours and weekends. I have no idea what else to do, I do report it to nursing, when the resident complains about it, I even told maintenance, and they do not have the key. Resident #75 has been complaining for a long time. I am happy now that she is happy with the box unlocked. Interview was conducted on 12/16/2015 at 9:56 AM with maintenance who stated that Resident #75 has requested to turn on and off the thermostat, maybe about 30 days. I do have a key, I only adjusted it one time. The administrator and I have the key to the lock box. After 4PM there is no coverage for maintenance in the building. Someone is on call for emergency only. I have been called for after hours, but not to unlock the box. I am at the facility on Saturday and no one is here on Sunday. Interview conducted on 12/16/2015 at 10:20 AM with the plant operations director revealed that the resident has been complaining. The lock box was placed a 1 year and 1/2 ago with the previous administrator. I have not come up to the room and talked to the resident. The maintenance person has been up to her room several times to adjust the temp. He has mentioned it to me, but it is the administrator's decision to keep the lock on the box. We did leave a key with the nurses. The nurses have not complained that they needed a key for the box. The resident asked for the lock box to be taken off and the new administrator asked to have it put back on when he started working at the facility. It was off for a few months and 2 to 1-1/2 month ago it was put back on per the current administrator's order. Interview was conducted on 12/16/2015 at 10:35 AM with the Social Worker/Grievance coordinator who stated that she has had discussions about the box. The lock box was put on in January 2015 and it was discussed with the resident before and after. The resident's roommate complained it was too hot. As a result they put the lock box on. The resident was informed. She was told that there was a key at the nursing station; she can request for it to be adjusted. I am not sure the exact date of the last time she had a roommate. The resident has not complained to me about the lock box since January 2015. No one in nursing has complained to me about the resident concern in regard to the lock box. The social worker was not able to provide any evidence of grievances filed for Resident #75 for the last year. Interview conducted on 12/16/2015 at 11:06 AM with the LPN (licensed practical nurse) on duty revealed that she has a key in her key chain for a lock box. She stated, but to be honest, I am not sure how long the key has been there on the key chain. I did not know what the key was for. I have seen them in there to check the box and unlock it. The resident has complained many times and I report it to the administrator. Interview was conducted on 12/17/2015 9:35 AM with Administrator. He stated that it was always my understanding that nursing had a key, for the lock box. I have not attempted to put a roommate in there and we are not able to. The resident has very high demands and keeps the room too hot or too cold. That's the issue we are having. The resident agreed to the lock box and temperature. He also confirmed that Resident #75 is the only resident in the entire building with a locked thermostat box. Interview conducted with the Admission Director revealed Resident #75 has not had a roommate since 09/05/2015 and the last roommate was not able to complain because of mental status and she was in the room from 03/01/2015 - 09/05/2015. The last resident admitted in room [ROOM NUMBER] D with a complaint about Resident #75 was admitted on [DATE] - 12/31/2014. The grievance log from January 2015 to current was reviewed on 12/18/15 and no grievance was ever filed on behalf of Resident #75's concerns regarding the locked thermostat box. The facility grievance and concern policy indicated that all concerns and/or comments be recorded on the grievance/concern/comment log. The facility failed to follow their policy.

Based on observation, interview and record review the facility failed to maintain a comfortable temperature level for 1 of 40 sampled residents (Resident #75) out of a census of 92 residents. The findings included: Review of the clinical record revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview conducted on 12/15/15 at 09:16 AM with Resident #75 she verbalized that the thermostat has a locked box that is limiting her access to adjust the temperature in her room to maintain a comfortable temperature. The lock was placed by the previous administrator and the previous social service director. The resident stated that she has had numerous conversations with the current administrator and he refuses to allow her access and unlock the box. She verbalized that the administrator stated too bad for her, because he cannot get any other roommates for my room because of my demands and the administrator is very rude to her. She stated that only the administrator and maintenance has the key to unlock the box. If they are not there on the evening, nights and weekend, no one in the building can adjust the temperature for her. It is unbearable. On many occasions she has to leave her room in order to get some fresh air, because the room is too hot or too cold. At night she has to deal with the temperature too hot or cold. She verbalized that she feels like the administrator is punishing her, because she is the only resident in the building with a locked thermostat box. She stated that she complained to the nurses and C.N.A's (Certified Nursing Assistants) that care for her routinely and nothing can be done. She stated that in the morning the sun is directly at her; as a result it is very hot and in the evening its cooler because of no sun directed into the room. She also indicated that I am not a confused person, I have a brain, why is the administrator treating me like this. Observation on 12/15/15 of the locked thermostat box reveals a clear box with temp >80 degree, Resident #75 is sweating in the room, facial skin with noticeable moisture, appears very frustrated and angry, due to discomfort from the temperature. I felt extremely hot myself while in the room talking to resident. The window curtains were open, with the visible sun shining into the room. Call bell at the bedside and bathroom are functional. Interview was conducted on 12/15/15 at 09:50 AM with the administrator and he states that Resident #75 is very manipulative. Because of her I cannot admit any resident into the room. Her demands are unreasonable. She keeps the room too hot or too cold. I cannot get anyone to stay in the room. The last resident and family in the room was very upset. This is a Medicaid bed; I have to be able to admit other residents. The surveyor requested for the administrator to remove the lock per resident request. Interview was conducted on 12/16/2015 at 9:11:06 AM with the Resident #75 and she verbalized how comfortable and happy she is today. She stated that, I have not been happy for about a year, since the thermostat box has been locked. You saved me, thank you for listening. This problem had a great impact on my life. it made me very anxious, upset and the administrator was making me suffer on purpose. The administrator would say to me, you keep the room too warm or too cold that ' s why I am locking the box, he would not listen to me. I always go to him directly, because he is the one with the key and everyone knows it and they are not authorized to unlock the box. Interview conducted on 12/16/2015 at 9:41: AM with the DON (Director of Nursing) revaled that Resident #75 has not complained about the locked thermostat box to her. She stated, the resident requests to interview all residents coming into the room because she does not get along with anyone. The DON stated that she was not aware when the resident last had a roommate. Interview was conducted on 12/16/2015 at 9:44 AM with the unit manager/RN (registered nurse) who stated that the resident has never asked her to unlock the box. The nurses or C.N.A.s have not informed me that Resident #75 had any concern with the locked thermostat box. There is no key at the nursing station for the thermostat box. Interview was conducted on 12/16/2015 at 9:45 AM with the C.N.A on duty and she stated that they locked it when she had another resident in the room. Nothing can be done to unlock the box after hours and weekends. I have no idea what else to do, I do report it to nursing, when the resident complains about it, I even told maintenance, and they do not have the key. Resident #75 has been complaining for a long time. I am happy now that she is happy with the box unlocked. Interview was conducted on 12/16/2015 at 9:56 AM with maintenance who stated that Resident #75 has requested to turn on and off the thermostat, maybe about 30 days. I do have a key, I only adjusted it one time. The administrator and I have the key to the lock box. After 4PM there is no coverage for maintenance in the building. Someone is on call for emergency only. I have been called for after hours, but not to unlock the box. I am at the facility on Saturday and no one is here on Sunday. Interview conducted on 12/16/2015 at 10:20 AM with the plant operations director revealed that the resident has been complaining. The lock box was placed a 1 year and 1/2 ago with the previous administrator. I have not come up to the room and talked to the resident. The maintenance person has been up to her room several times to adjust the temp. He has mentioned it to me, but it is the administrator's decision to keep the lock on the box. We did leave a key with the nurses. The nurses have not complained that they needed a key for the box. The resident asked for the lock box to be taken off and the new administrator asked to have it put back on when he started working at the facility. It was off for a few months and 2 to 1-1/2 month ago it was put back on per the current administrator's order. Interview was conducted on 12/16/2015 at 10:35 AM with the Social Worker/Grievance coordinator who stated that she has had discussions about the box. The lock box was put on in January 2015 and it was discussed with the resident before and after. The resident's roommate complained it was too hot. As a result they put the lock box on. The resident was informed. She was told that there was a key at the nursing station; she can request for it to be adjusted. I am not sure the exact date of the last time she had a roommate. The resident has not complained to me about the lock box since January 2015. No one in nursing has complained to me about the resident concern in regard to the lock box. The social worker was not able to provide any evidence of grievances filed for Resident #75 for the last year. Interview conducted on 12/16/2015 at 11:06 AM with the LPN (licensed practical nurse) on duty revealed that she has a key in her key chain for a lock box. She stated, but to be honest, I am not sure how long the key has been there on the key chain. I did not know what the key was for. I have seen them in there to check the box and unlock it. The resident has complained many times and I report it to the administrator. Interview was conducted on 12/17/2015 9:35 AM with Administrator. He stated that it was always my understanding that nursing had a key, for the lock box. I have not attempted to put a roommate in there and we are not able to. The resident has very high demands and keeps the room too hot or too cold. That's the issue we are having. The resident agreed to the lock box and temperature. He also confirmed that Resident #75 is the only resident in the entire building with a locked thermostat box. Interview conducted with the Admission Director revealed Resident #75 has not had a roommate since 09/05/2015 and the last roommate was not able to complain because of mental status and she was in the room from 03/01/2015 - 09/05/2015. The last resident admitted in room [ROOM NUMBER] D with a complaint about Resident #75 was admitted on [DATE] - 12/31/2014. The grievance log from January 2015 to current was reviewed on 12/18/15 and no grievance was ever filed on behalf of Resident #75's concerns regarding the locked thermostat box. The facility grievance and concern policy indicated that all concerns and/or comments be recorded on the grievance/concern/comment log. The facility failed to follow their policy.