Every finding on record at Ft Lauderdale Health & Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed to accurately assess residents for a psychiatric diagnosis for 1 of 2 sampled residents reviewed for Preadmission Screening and Resident Review (PASARR), Resident #15. The findings include:Record review revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Schizoaffective Disorder, Bipolar type and Major Depressive Disorder, recurrent, moderate. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 15, which indicates no cognitive impairment. Record review revealed Resident #15 had a diagnosis of bipolar disorder on 05/10/24, schizoaffective disorder, bipolar type on 05/10/24 and major depressive disorder, recurrent and moderate on 12/02/24. Record review revealed Resident #15 was admitted to the facility with a hospital discharge diagnosis of recent UTI [Urinary Tract Infection], with a history of Hypertension, history of Hyperlipidemia, history of Diabetes Mellitus and schizoaffective disorder bipolar type. In an interview conducted on 03/12/26 at 12:00 PM, the Director of Social Services revealed that she has been working for the facility for 4 years. She further stated that residents are admitted to the facility essentially with a PASARR level 1. An admission evaluation is completed by Social Services and the admission PASARR is reviewed. Upon the review, a brief review of the hospital documentation and the resident's admitting diagnosis is evaluated to see if there are any behaviors and psychiatric diagnosis. If any corrections need to be made, she communicates with admission or the care plan coordinator to make the necessary changes. Review of Resident #15's PASARR dated 03/17/24 from the hospital revealed there was no psychiatric diagnosis documented on the discharge paperwork from the hospital. Record review indicated that an updated PASARR with the psychiatric diagnosis was done on 11/15/25. In an interview conducted on 03/12/26 at 12:20 PM with the MDS Coordinator, she stated that she has been working in the facility for 4 years now. She further stated that she is the one responsible for inputting the diagnosis in point click care (PCC). Per surveyors' question about the origin diagnosis of schizoaffective disorder, bipolar type, major depressive disorder, recurrent, moderate and bipolar disorder, current episodic manic without psychotic, the MDS Coordinator explained that it came from a psychiatric note written by the Psychiatric Nurse Practitioner and not from the hospital record. In a phone interview conducted on 03/12/26 at 1:15 PM, the Psychiatric Nurse Practitioner stated that he started working with Resident #15 about a year ago and asked for an audit on the diagnosis of bipolar disorder and major depressive disorder for about 6 months now. He also explained that the two previous diagnoses can get discarded because the only sustainable diagnosis is schizoaffective disorder, bipolar type. In an interview conducted on 03/12/26 at 1:45 PM, the Director of Nursing (DON) stated that they have monthly psychiatric meetings and were not aware of an audit being requested by the Psychiatric Nurse Practitioner regarding Resident #15. The DON also acknowledged that a diagnosis of Schizoaffective disorder Bipolar type is different from a diagnosis of Schizoaffective disorder and another diagnosis of Bipolar disorder. A review of the progress notes indicated that on 03/12/26, after surveyors' intervention, a note was put in place stating: Based on the patient's recent clinical presentation and behavioral observations, the diagnosis of bipolar disorder has been discontinued due to insufficient clinical evidence supporting the presence of manic or hypomanic episodes.

Based on review of policy and procedure, record review and interview, the facility's failed to ensure that it followed physician's orders and documented nursing interventions for a resident's elevated Blood Sugar Levels (BSL), when out of range, for 1 of 4 sampled residents reviewed for Nutrition, Resident #146.The findings included:Review of the facility's policy, provided by the Director of Nursing (DON), documented in the Policy Statement, as follows, Purpose: To provide guidelines for the safe administration of insulin to residents with Diabetes. Preparation:.3. The type of insulin dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. 4. The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin.Steps in the Procedure (Insulin injections via Syringe).2. Check blood glucose per physician's order or facility protocol.Documentation: 1. The resident's blood glucose result, as ordered. 2. The dose and concentration of the insulin injection; 3. Size and gauge of the needle used for injection; 5. How well the resident tolerated the procedure. Reporting:.2. Notify the physician if the resident has signs and symptoms of Hypoglycemia that are not resolved by following the facility protocol for hypoglycemic management. Record review revealed Resident #146 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Encephalopathy, Diabetes Mellitus Type II, Dementia, Hypertensive Heart and Chronic Kidney Disease (stage 4 severe), Unspecified Convulsions and Major Depressive Disorder. She had a Brief Interview Mental Status (BIMS) score of 00, indicating severe cognitive impairment.Further record review revealed the following:On 09/22/25 the physician's order documented, Novolin R FlexPen Injection Solution Pen-injector 100 unit/ml Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units if greater than 400 give 10 units and call MD.On 02/07/26 at 16:42 PM, the February 2026 Medication Administration Record (MAR) documented, Novolin R FlexPen Injection Solution Pen-injector 100 unit/ml Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units if greater than 400 give 10 units and call MD, per Staff G.On 02/22/26 at 12:34 PM and at 16:39 PM, again the February 2026 MAR, Novolin R FlexPen Injection Solution Pen-injector 100 unit/ml inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units if greater than 400 give 10 units and call MD, subcutaneously before meals for DM 2 Hold for BG less than 70; Notify MD 10 units w/ routine given, per Staff G.Review of Resident #146's Diabetes Mellitus II Care plan, initiated on 07/01/25 and revised on 01/13/26, documented as follows, Focus: Diabetes Mellitus- Resident is at risk for complications related to diagnosis of Diabetes Mellitus. Interventions:. Medication as ordered. Monitor blood sugar as ordered with Accu check and administer coverage insulin as ordered and needed. Notify physician if problems occur. Observe for signs and symptoms of complications of disease process and report problems. Observe for signs and symptoms of hyper/ hypoglycemia reaction and report episode to physician. Goal: Resident will remain free of hyper/hypoglycemia episodes with insulin sliding scale through next review date. will remain free of complications related to diabetes through next review date. Review of the February 2026 MAR revealed documentation that Resident #146 had two (2) routine insulin orders as follows: 1) Insulin Glargine Subcutaneous Solution 100 units/ml (Insulin Glargine) inject thirty (30) unit subcutaneously at bedtime for Diabetes Mellitus II and 2) Novolin R Flex Pen Injection Solution Pen-injector 100 units/ml (Insulin Regular (Human) inject eight (8) units subcutaneously (SQ) before meals for Diabetes Mellitus II hold for blood glucose less than (<) 70; Notify Medical Director (MD).Further review of the February 2026 MAR revealed that Staff G had initialed and recorded on three (3) different occasions: 02/07/26 at 16:42 PM, 02/22/26 at 12:34 PM, and 02/22/26 at 16:37 PM, that Resident #146's Blood Sugar Level (BSL) measured well over 400 mg/dl as: 471.0 mg/dL, 407 mg/dl and 411 mg/dl, respectively.However, there was no notation anywhere in the MAR or nurses notes to show that Resident #146's physician had ever been notified of the resident's elevated BSL, as ordered. Nor was there any documented response to this, in the record, from the physician.Record review of Resident #146's BSL ranges from 01/01/26 thru 03/11/26 revealed that they were from 80 mg/dl up to 471 mg/dl.On 03/12/26 at 11:10 AM an interview was conducted with Staff B regarding the process by which a nurse is to follow for a resident when there is a physician's order to administer insulin to the resident, as well as call or notify the physician if the resident's BSL is above 400 mg/dl. She stated that when the nurse administers the sliding scale insulin and initials the MAR box, this order only populates on the MAR, and in the nurses' progress notes. She went on to say that the nurse would still have needed to document the follow-up, or re-checked the BSL in order to determine the effectiveness of the sliding scale insulin medication to see if it remained greater than (>) or less than (<) 400, or not, in order to have an accurate reading to contact the physician for a clear directive.An interview was conducted on 03/12/26 at 1 PM with Staff A LPN, in which she acknowledged that there were three (3) different instances in which the resident displayed an episode of elevated BSL greater than 400 in which there was no documentation of Resident #146's physician being notified, as ordered.Am interview was conducted on 03/12/26 at 1:15 PM with Staff F, Registered Nurse (RN)/Unit Manager (UM) for 2nd and 3rd floors, regarding the process by which a nurse is to follow for a resident when there is a physician's order to administer insulin to the resident, as well as call or notify the physician if the resident's BSL is above 400 mg/dl. Staff F stated that when the nurse administers the sliding scale insulin with parameters and initials the MAR box, this order only populates on the MAR, and in the nurses' progress notes. She went on to say that the nurse would still have needed to document in the nurses' progress note that a follow-up, or re-checked BSL was done in order to determine the effectiveness of the sliding scale insulin medication to see if it remained greater than (>) or less than (<) 400, or not, in order to have an accurate reading to contact the physician for a clear directive. She also acknowledged that there were three (3) different instances in which the resident displayed an episode of elevated BSL greater than 400 in which there was no documentation of Resident #146's physician being notified, as ordered.Interview conducted on 03/12/26 at 1:25 PM with ADON, RN/Assisted Director of Nursing (ADON)/Nurse Supervisor, in which she also acknowledged that three (3) different instances in which the resident displayed an episode of elevated BSL greater than 400 mg/dl, in which there was no documentation to show that Resident #146's physician had been notified, as ordered.A telephone interview was conducted on 03/12/26 at 1:40 PM with Staff G, in which she acknowledged that there were three (3) different instances that she recorded and documented, in which the resident displayed an episode of elevated BSL greater than 400 in which there was no documentation of Resident #146's physician being notified, as ordered.During an interview on 03/12/26 at 1:27 PM, the DON acknowledged that the physician's order should have been followed and the nurse should have notified the physician, as ordered and documented her interventions in the resident's record.

Based on interview, record review, and observation, the facility failed to accurately assess residents for safe smoking for 1 of 2 sampled residents reviewed for smoking, Resident #81. The findings included:The findings include:Record review revealed the facility's smoking evaluation contained the following assessment prompt: Resident smokes safely. (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). Record review revealed Resident #81's last Quarterly MDS (Minimum Data Set) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 5/15, which indicates severe cognitive impairment. Further record review revealed Resident #81 was last evaluated as a safe smoker on 01/01/26. On 03/11/26 10:21 AM, Staff F, a Certified Nursing Assistant (CNA) was observed and interviewed while on the smoking patio related to smoking safety. Staff F was asked to identify Resident #81 and stated, that's her and pointed to a women sitting in a wheelchair, with a table in front of her, near the center of the covered patio. Observations revealed Resident #81 was hunched forward in her wheelchair with her head down and her hands below the tabletop. Resident #81's face was not clearly visible because of her posture, and her hands could not be seen by the surveyor who was standing next to Staff F who was sitting behind her supply cart approximately 10 to 15 feet away from Resident #81. Staff F was asked if Resident #81 frequently sits in that position, to which Staff F stated yes, always. Staff F stated she always checks Resident #81 to make sure she is not sleeping before she offers the resident a cigarette. Staff F was observed offering Resident #81 her cigarette and lit it for the resident. The resident resumed her slouching position with her hands and the lit cigarette near her left leg and below the table. The surveyor then introduced himself to Resident #81 and continued the observation. Resident #81 took a puff on her cigarette and then lowered her hand to just above her left knee. The surveyor engaged Resident #81 in conversation while she held her cigarette in the same position. Resident #81 allowed her cigarette to burn without smoking it while answering questions about her care in the facility. The surveyor noted the length of ash on the cigarette and reminded Resident #81 about her cigarette. A small amount of ash had fallen to the ground before Resident #81 tapped the rest of it off in the ashtray. The surveyor then noted a hole on left pant leg by her knee. The resident was asked where the hole came from, she stated it was from this, indicating from her cigarette. She stated she leaves a trail of them on her clothes all the time. Resident #81 stated she has never burned herself from cigarettes. Resident #81 stated she smokes twice a day. On 03/11/26 at 1:12 PM, an interview was conducted with the Assistant Director of Nursing (ADON) regarding Resident #81's smoking evaluation, which the ADON had performed. The ADON was asked if a resident smokes leaning over, below the table level, with her hands near her lap is the resident a safe smoker? The ADON admitted that the resident would not be a safe smoker. The ADON was then asked if she observed Resident #81's clothing for burn marks or holes. The ADON stated she was not aware of any holes or burn marks on the resident's clothing. The ADON stated the holes observed by the surveyor could be from when the resident was at home or another facility. The ADON was asked that since Resident #81 had indicated the hole observed was from smoking and she has a history of burning her clothes would she (the ADON) re-evaluate the resident for safe smoking. The ADON admitted that she had not considered old holes as being an indication of unsafe smoking. The ADON stated that she would do another assessment for safe smoking and reeducate the attendants on safe smoking guidelines.

Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure it performed Foley Catheter and Peri-care in a sanitary manner for 1 of 1 sampled residents observed, Resident #10.The findings included: Review of the facility's policy provided by the Director of Nursing titled, Urinary Catheter Care revised on September 2014, documented in the Policy Statement: The purpose of this procedure is to prevent catheter-associated urinary tract infections.Preparation: 1. Review the resident's care plan to assess for any special needs of the resident.General Guidelines: 1. Following aseptic.technique.Infection Control: 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.Steps in the Procedure:.7. Wash the resident's genitalia and perineum thoroughly with soap with water. Rinse the area well and towel dry. 8. Pour wash water down the commode. Flush the commode.10. Put on clean gloves. 11. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly.17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.Record review revealed Resident #10 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Metabolic Encephalopathy, Sepsis, Diabetes Mellitus Type II, Obstructive and Reflux Uropathy and Hypertensive Heart Disease Foley Catheter in place. She had a Brief Interview Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment.Further record review revealed on 02/15/26 the physician's orders documented, Indwelling urinary catheter to bedside drainage bag.Reason for catheter: Obstructive and Reflux uropathy.During a Foley/Peri-care Observation conducted on 03/11/26 at 10:30 AM, Resident #10 was observed resting in bed with head of the bed elevated on her right side. The resident provided permission for the surveyor to observe her peri-care. Foley Catheter and Peri-care was observed being performed by Staff L who was assisted by Staff M. The staff members retrieved wearable personal protective equipment (PPE), washed their hands and gathered all of their supplies to begin and complete the resident's Foley Catheter and frontal Peri-care procedure. Next, both staff members turned the resident over on her side and washed her entire buttock area; completing both the Peri-care and Foley catheter care procedure. Afterwards, both staff members were observed turning the resident back over on her back. Staff L then proceeded to return to cleaning and washing the resident's foley catheter tubing area again, without changing her gloves. She was observed using the same cross contaminated water that she had just used previously, for the resident's buttock area. Staff L was not observed changing her gloves frequently throughout the procedure; she wore the same pair of gloves during and throughout the entire peri-care and Foley Catheter care procedure, from front to back and back to front.Review of Resident #10's Bowel and Bladder Care plan initiated on 03/16/23 and revised 02/23/26 indicated Focus: is incontinent of bladder, history of Urinary Tract Infection (UTI). And is incontinent of bowel, at risk for constipation due to impaired mobility.Foley inserted for Obstructive Uropathy Interventions: Change Foley bag per orders. Enhanced Barrier Precaution (EBP) as ordered. Foley catheter care every shift, change bag and catheter as ordered. Keep perineal area clean and dry.Notify MD of signs and symptoms of UTI. Observe for color, odor, and clarity of urine, and report signs and symptoms of infection.Provide incontinence care as needed for bowel incontinence, includes incontinent pads and barrier cream. Use barrier cream as needed to peri area with incontinence care. Goal: Resident will have regular bowel movement with aid of medication through next review date. Resident will have a patent Foley through next review date. Resident will be free of complications from incontinent of bowel thru next review date. On 03/11/26 at 11:24 AM, an interview was conducted with Staff L and with Staff M, regarding the CNA not changing her dirty/contaminated gloves, nor changing the dirty/contaminated basin water, between back and front peri-area care, during the Foley and Peri-care observation and both acknowledged that Staff L should have changed her gloves, and the basin water during the procedure.An interview was conducted on 03/11/16 at 12:08 PM with Staff J, Licensed Practical Nurse, in which she acknowledged that Resident #10's water basin and the CNA's gloves should have been changed during the Foley and Peri care procedure to avoid cross-contamination.An interview was conducted on 03/11/26 at 12:12 PM with Staff F Registered Nurse (RN)/Unit Manager (UM) for 2nd and 3rd floors, in which she acknowledged that Resident #10's water basin and the CNA's gloves should have been changed during the Foley and Peri care procedure to avoid cross-contamination.An interview was conducted on 03/11/26 at 12:17 PM with the RN/Assisted Director of Nursing (ADON)/Nurse Supervisor, in which she also acknowledged that Resident #10's water basin and the CNA's gloves should have been changed during the Foley and Peri care procedure to avoid cross-contamination.The DON further recognized and acknowledged on 03/11/26 at 1:30 PM that appropriate technique should have been performed during Foley catheter and Peri-care in order to avoid cross-contamination.

Based on observations, interviews and record reviews, the facility failed to follow oxygen orders and ensure the MDS (Minimum Data set) assessment was accurate. for 1 of 2 sampled residents reviewed for oxygen therapy (Resident #79). which has the potential to affect 8 residents on oxygen therapy; and the facility failed to obtain physicians order for oxygen therapy administration for 1 of 2 sampled residents reviewed for oxygen therapy (Resident #138).The findings included:Review of the facility policy titled Oxygen Administration provided by the Director of Nursing (DON) revised October 2010 documented in the Policy Statement: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.Documentation: after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for PRN (as needed). administration. 6. All assessment data obtained before, during and after the procedure. 7. How the resident tolerated the procedure.9. The signature and title of the person recording the data. 1). Record review revealed Resident #138 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Pneumonia, unspecified organism, Chronic Obstructive Pulmonary Disease (COPD) with (acute) exacerbation, Respiratory Failure, unspecified, unspecified whether with hypoxia or hypercapnia, Spondylosis without Myelopathy or Radiculopathy, Lumbar region, Pulmonary Fibrosis, unspecified, Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Encephalopathy, unspecified. She had a Brief Interview Mental Status (BIMS) score of 15, indicative of intact cognition. On 03/09/26 at 10:21 AM Resident #138 was observed with Oxygen infusing via nasal cannula at two (2) liters via Oxygen Concentrator. During a brief interview conducted on 03/09/26 at 10:24 AM with Resident #138, she stated that she wears her Oxygen most times during the day and continuously at night, due to having shortness of breath, at times, and she added that she has done so, since being re-admitted into the facility back in September of last year 2025. On 03/09/26 at 4:28 PM through 03/11/26 at 10:08 AM, Resident #138 was still observed with Oxygen infusing via nasal cannula at two (2) liters via Oxygen Concentrator. Record review of Resident #138's Respiratory Care plan originally initiated on 05/11/21 and revised on 12/03/25 indicated Focus: Resident has potential for alteration in breathing pattern related to COPD, shortness of breath, and requires oxygen via nasal cannula as needed. History of Respiratory Failure Interventions: Auscultate lung sounds as needed, elevate head of bed, Lab as ordered, Medication as ordered, Nebulizer treatments as ordered, change tubing per order, O2 per cannula as ordered/as needed (PRN), Oxygen (O2) saturations as needed and O2 tubing changed as ordered. Goal: Resident will be free of respiratory distress through review period. Review revealed that the last discontinued physician's order for Oxygen for Resident #138 was written back on: 08/22/25 at 19:00 PM as: Oxygen at two 2 liters/minute via nasal cannula as needed (PRN) for Shortness of Breath (SOB) by Resident #138's attending physician and recorded by Staff H Licensed Practical Nurse (LPN). Additionally, a physician's order dated 09/26/25 documented, SOB while lying flat in bed - monitor every (Q) shift. There was no current physician's ordered in place for the Oxygen therapy administration with parameters. However, record review of the nurses' progress notes revealed that Resident #138 was re-admitted to the facility on [DATE] at 20:55 PM, with. Oxygen documented as currently and actively infusing at two (2) liters .as recorded by Staff I, LPN. Further record review of the nurses' progress notes dated 10/27/25 at 20:06 PM thru 01/27/26 at 19:33 PM, also recorded Resident #138 as currently and actively receiving. Oxygen two (2) liters via nasal cannula. Computerized record review also revealed Resident #138's recorded Oxygen saturation levels via nasal cannula from 12/09/25 at 14:31 PM through 03/10/26 at 05:37 AM with a range from 90% to 99%. There was no order in the Medication Administration Record (MAR), nor in the Treatment Administration Record (TAR) for Oxygen administration therapy, with parameters. A side-by-side record review and interview was conducted on 03/11/16 at 12:08 PM with Staff J, LPN, in which she acknowledged that Resident #138 was receiving Oxygen therapy administration via nasal cannula, without a current physician's order, in place. An interview was conducted on 03/11/26 at 12:12 PM with Staff F, Registered Nurse (RN)/Unit Manager (UM) for 2nd and 3rd floors, in which she acknowledged that Resident #138 was receiving Oxygen therapy administration via nasal cannula, without a current physician's order, in place. An interview was conducted on 03/11/26 at 12:17 PM with the RN/Assisted Director of Nursing (ADON)/Nurse Supervisor, in which she also acknowledged that Resident #138 was receiving Oxygen therapy administration via nasal cannula, without a current physician's order, in place. A physician's order was not obtained for Resident #138's Oxygen therapy administration, until after surveyor intervention. The DON (Director of Nursing) further recognized and acknowledged on 03/11/26 at 1:30 PM that a physician's order should have been obtained for the Oxygen Administration Therapy. 2). Record review revealed Resident #79 was admitted on [DATE] with diagnosis of Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview of Mental Status (BIMS) score is 00, which indicates that they were unable to conduct the interview due to severe cognitive impairment. A review of section O (Special treatments, Procedures and Programs) of the MDS indicated that Resident #79 was not coded for oxygen therapy on admission or while in the facility. A review of the Physician's Orders indicated that on 06/09/24 an order for oxygen concentrator with humidifier was placed in for 2 liters per minute via nasal cannula to keep oxygen saturation above 92%. A review of the care plan dated 12/25/25 documented that Resident #79 has alteration in breathing pattern related to history of Chronic Obstructive Pulmonary Disease. Goals are to maintain resident free of respiratory distress. The interventions included setting oxygen and tubing changed as ordered. In an observation conducted on 03/09/26 at 11:05 AM, Resident #79 was seen lying in bed with the oxygen in place and functioning. The oxygen was set at 4 liters per minute. In an observation conducted on 03/10/26 at 11:30 AM, Resident #79 was seen lying in bed with the oxygen in place and functioning. The oxygen was set at 4 liters per minute. In an observation conducted on 03/11/26 at 12:15 PM, Resident #79 was seen lying in bed with the oxygen in place and functioning. The oxygen was set at 4 liters per minute. In an interview conducted on 03/11/26 at 12:20 PM with Licensed Practical Nurse (LPN), Staff A stated that she has been working in the facility for less than a month. She further stated that the nurses are the ones responsible for recording the oxygen saturation. The nurses are the parties responsible for regularizing the oxygen concentrator per medical order. They also have someone from the insurance company that comes in the morning and records the vital signs. She was made aware of the oxygen saturation number set for Resident #79, and she stated that the saturations are not correct. In an interview conducted on 03/11/26 at 12:30 PM with LPN, Staff B stated that she has been working in the facility for 22 years now. She was made aware of the findings and stated that it's impossible for a resident with diagnosis of COPD to saturate 99% on room air. She explained that the nurses are the ones responsible to set the concentrator based on orders. In an observation conducted on 03/11/26 at 12:45 PM, this surveyor accompanied LPN, Staff B and LPN Staff A to Resident #79. They acknowledged that the oxygen concentrator was set at 4 liters and the order was for 2 liters. In an observation conducted on 03/11/26 at 12:47 PM, this surveyor accompanied Staff LPN, Staff B with the oxygen saturation machine and staff took the oxygen saturation of Resident #79 and at that time it was 99% with oxygen in use. Per interview Staff stated that without the oxygen the expectation is for Resident #79 to saturate less due to medical condition. She further explained that it's not possible for Resident #79 to be saturating the same amount on room air and on oxygen therapy. In an interview conducted on 03/11/26 at 2:00 PM, the Assistant Director of Nursing (ADON) stated that she has been working in the facility for less than 6 months. She further stated that setting up the concentrator and recording the oxygen saturation is done by the nurses. It would be accurate if a resident is saturating 99% on room air and 97% on oxygen therapy. The ADON was showed the photographic evidence that Resident 79's was on 4 liters when the order was 2 liters. Having oxygen at 4 liters is very damaging to the resident and eventually worsens the COPD. The insurance staff members cannot document into Point Click Care (PCC) and they have their own system. In an interview conducted on 03/11/26 at 3:30 PM, the MDS Coordinator stated that she has been working in the facility for years now. She further explained that when a Resident is on oxygen therapy it should be coded under section O. Per review of Resident #79's medical record, the Quarterly MDS dated [DATE] was not coded for receiving continuous oxygen therapy on admission and while being a resident at the facility. The MDS Coordinator acknowledged the findings.

Based on observations, interviews, and record reviews, the facility failed to accurately reconcile controlled medications and failed to ensure discontinued controlled medications were removed from the medication cart for 3 of 12 sampled residents reviewed for controlled medications reconciliation, Resident #37, Resident #172 and Resident #156. The findings included: Review of the facility's policy titled, Controlled Substances, dated December 2012, included the following: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances. 4. If the count is correct, an individual resident controlled-substance record must be made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of the resident;b. Name and strength of the medication. 1. Record review for Resident #37 revealed the resident was admitted to the facility on [DATE] with a re-admission on [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebrovascular Disease Affecting Left Non-Dominant Side; Type 2 Diabetes Mellitus Without Complications and Mononeuropathy. The Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated she was moderate cognitively impaired. Review of the Physician's Orders showed that Resident #37 had an order dated 01/05/26 for Tramadol HCl tablet 50 mg to give 1 tablet by mouth every 8 hours (6:00 AM, 2:00 PM, and 10:00 PM) for moderate to severe pain for non-acute pain.Review of Resident #37's March 2026 Medication Administration Record (MAR) documented, Tramadol 50 mg, every 8 hours was administered on the following dates: 03/07/26 at 2200 (10:00 PM)03/08/26 at 6:00 AM03/08/26 at 1400 (2:00 PM)03/08/26 at 10:00 PM03/09/26 at 6:00 AM03/09/26 at 2:00 PM03/09/26 at 10:00 PMHowever, review of Resident #37's Medication Monitoring /Control Record revealed there was no nurse's signature or that Tramadol 50 mg was administered on 03/08/26 at 1400 (2:00 PM). 2. Record review for Resident #172 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing. The 5-Day MDS dated [DATE] revealed Resident #172 had a BIMS score of 11, which indicated she was moderate cognitively impaired. Review of the Physician's Orders showed that Resident #172 had an order dated 02/18/26 for Tramadol HCl tablet 50 mg to give 1 tablet by mouth every 6 hours as needed (PRN) for Acute Pain exception 7-10 (pain levels).Review of the February 2026, MAR documented Resident #172 was administered Tramadol 50 mg PRN on the following dates: 02/20/26 at 2100 (9:00 PM)02/21/26 at 10:00 AM02/22/26 at 2:42 AM02/23/26 at 4:07 AMHowever, review of Medication Monitoring /Control Record revealed Resident #172 was administered Tramadol 50 mg PRN on the following dates and time: 02/20/26 at 3:00 AM (not documented in the MAR)02/20/26 at 2100 (9:00 PM)02/21/26 at 10:00 AM, Error was written and the date and time was crossed out02/22/26 at 2:42 AM 02/23/26 at 9:53 AM 3. Record review for Resident #156 revealed the resident was admitted to the facility on [DATE] with a re-admission on [DATE] with the following diagnoses: Polyneuropathy, Type 2 Diabetes Mellitus, Gout, Pain in Unspecified Joint, and Low Back Pain. The MDS dated [DATE] revealed Resident #156 had a BIMS score of 14, which indicated she was cognitively intact. Review of the Physician's Orders showed that Resident #156 had an order dated 02/23/26 Oxycodone HCl 5 mg tablet to give 1 tablet by mouth every 8 hours PRN for severe pain level 7-10, with a discontinued date of 02/25/26.Review of the February 2026, MAR revealed Resident #156 was administered Oxycodone HCl 5 mg tablet PRN on:02/24/26 at 2:51 AM with a pain level of 6 of 10.02/24/26 at 1424 (2:24 PM) with a pain level of 6 of 10.On 02/25/26 Oxycodone HCL 5 mg was discontinued.Review of Resident #156's Medication Monitoring/Control Record documented on 03/08/26 at 5:30 AM that one tablet of Oxycodone HCL 5 mg was removed from the locked drawer of the medication cart. Record review of the nursing progress notes revealed no documentation showing that Oxycodone 5 mg was administered to the resident on 03/08/26. In addition, there was no progress note showing communication with Resident #156's medical provider for an order to renew the medication.During an interview conducted on 03/12/26 at 4:04 PM with the Director of Nursing (DON), who stated the controlled medications that are discontinued are to be removed as soon as possible from the medication cart. She stated two nurses verify the orders for discontinued medications and bring them to her, then she double locks the controlled medication until the pharmacist comes in and then the medication is destroyed. The DON stated as per protocol the count of the controlled medications in the medication cart drawer is compared to the number in the Medication Monitoring / Control Record, and this is done every shift. When asked if anyone (unit manager/DON) randomly conducts periotic reconciliation of controlled medications, she stated, no. At this time, a side-by-side review of Resident #37, Resident #172 and Resident #156's Medication Monitoring/Control Record and their MARs were conducted with the DON. The DON acknowledged there were discrepancies between them.

Based on review of policy and procedure, observation, interview and record review, the facility failed to 1) ensure that it secured and locked three (3) over-the-counter (OTC) topical cream medication tubes for the sampled residents observed, Resident #138, 2) to promptly discard one (1) expired OTC topical cream medication tubes for Resident #138. 3) secure and lock the Medication cart located on the South wing, for 1 of 8 Medication carts observed, 4) properly label topical medications stored in Medication Storage rooms on the second floor for 1 of 6 Medication Storage rooms observed.The findings included:Review of the facility policy and procedure titled Storage of Medication provided by the Director of Nursing (DON) revised [DATE] documented in the Policy Statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner.2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1) Record review revealed Resident #138 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Pneumonia, unspecified organism, Chronic Obstructive Pulmonary Disease with (acute) exacerbation, Respiratory Failure, unspecified, unspecified whether with hypoxia or hypercapnia, Spondylosis without Myelopathy or Radiculopathy, Lumbar region, Pulmonary Fibrosis, unspecified, Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Encephalopathy, unspecified. She had a Brief Interview Mental Status (BIMS) score indicative of intact cognition. During an observational room tour conducted on [DATE] at 10:21 AM, Resident #138 was observed with three (3) different tubes of OTC (over the counter) topical cream medications left unsecured and unattended, at the resident's bed side, which included: 1) Salonpas with Lidocaine Plus 4% with an expiration date of 02/2027, for which the resident stated is applied by staff.; 2) Maximum Strength Blue Emu with 4% Lidocaine numbing pain relief cream (highest concentration without a prescription), with an expiration date of 01/2020; and 3) [NAME] anti-itch cream containing Pramoxine Hydrochlorozide 1%, Menthol 0.5% (an external analgesic lotion), with an expiration date of 02/2027. A brief interview was conducted at the time of observation, with Resident #138, in which she was asked about the topical OTC medicated creams at her bedside. She stated that they were used primarily for her hands and other dry skin areas. On [DATE] at 4:21 PM through [DATE] at 10:10 AM, Resident #138's room was observed having the same three (3) different tubes of OTC topical cream medications left unsecured and unattended, at the resident's bed side on her nightstand and on her overbed table An interview and side-by-side record review was conducted on [DATE] at 12:08 PM with Staff J, Licensed Practical Nurse (LPN), regarding the three (3) different tubes of OTC topical cream medications left unsecured and unattended, at the Resident #138's bedside on her nightstand and on her overbed table. She acknowledged that the OTC topical cream medications should not have been left there and that the expired topical OTC cream should have been promptly discarded. During an interview conducted on [DATE] at 12:12 PM with Staff F, Registered Nurse (RN)/Unit Manager (UM) for 2nd and 3rd facility floors, in which she indicated that Resident #138 does not self-administer any of her own medications and neither was she assessed by the Interdisciplinary Team (IDT) to be able to self-administer. An interview was conducted on [DATE] at 12:17 PM with the RN/Assisted Director of Nursing (ADON)/Nurse Supervisor regarding the three (3) different tubes of OTC topical cream medications left unsecured and unattended, at the resident's bedside. She acknowledged that the OTC topical cream medications should not have been left there and the expired topical OTC cream should have been promptly discarded. 2). On [DATE] at 11:16 AM during a hallway tour, it was observed that the medication cart located on the South wing, containing medication for a total of thirty (30) residents residing on the wing, was left unlocked and attended by nursing staff, with no nursing staff in-sight; accessible to residents, staff member and visitors. An interview was conducted on [DATE] at 11:18 AM with Staff K, Licensed Practical Nurse (LPN), in which she acknowledged that the medication cart had been left unlocked and unattended. An interview was conducted on [DATE] at 11:22 AM with Staff B, LPN, Unit Manager South wing, in which she also acknowledged that the Medication cart had been left unlocked and unattended. On [DATE] at 1:30 PM the Director of Nursing (DON) further acknowledged that the OTC topical cream medications should not have been left at resident's bedside and that the expired topical OTC medication, should have been promptly discarded. She also mentioned that medication carts must always be kept locked and secure. 3). On [DATE] at 10:37 AM, a medication storage room on the second floor of the facility (rooms 201-219) was inspected with Staff F, Unit Manager. It was observed that on the bottom of a metal rack there was a blue container containing plastic bags with topical medications. Further observation revealed a few opened topical creams in plastic bags only labeled with just numbers written on the box. One of the opened medication boxes had 36B written on the box (the second floor does not have a room [ROOM NUMBER]B). Photographic evidence obtained. An interview was conducted on [DATE] at 10:41 AM with Staff F, Unit Manager, who stated she has worked at the facility for 4 years. She stated the protocol is to store residents' topical medications in the storage room and not in the medication carts. She then stated all the topical medications are labeled for the residents that are on the floor and removed once the resident is discharged . Staff F stated that she, along with the evening nurses, is responsible for ensuring the medication storage room stays current and properly maintained.

Based on observations, interviews and record reviews, the facility failed to follow the approved menu for lunch on 03/11/26. The deficient practice had the potential to affect 90 residents with orders for regular texture foods. The census at the time of the survey was 161 residents. The findings included:A review of records indicated that the approved lunch menu for March 11, 2026, specified a 3-ounce serving of 'Pork Chop BBQ' for residents.During a kitchen observation conducted on March 11, 2026 at 11:27 AM, with the Food Service Director (FSD) present, it was observed that the pork that was plated to be served consisted of thinly sliced, bone-in pork chop portions. Upon request from the surveyor, the FSD weighed a portion of the plated pork, which measured 2.5 ounces including the inedible bone.The FSD acknowledged these findings at the time of observation and subsequently instructed staff to add an additional half portion of pork chop to each plate to ensure a total serving of 3 ounces of Pork Chop BBQ was provided.

Based on observations, interviews and record review, the facility failed to serve food in appropriate form to meet the needs of 1 of 43 residents with orders for mechanical soft foods, Resident #72. The findings included:Record review for Resident #72 revealed an admission date to the facility on [DATE]. According to Resident #72's most recent complete assessment, a Quarterly Minimum Data Set, with a reference date to the facility on [DATE], the resident had a Brief Interview for Mental Status score of 07, indicating the resident had severe cognitive impairment. Resident #72's diagnoses at the time of the assessment included: Non-Alzheimer's Dementia, Malnutrition, Chronic lung disease, Gastro-esophageal reflux disease (GERD). The assessment documented that the resident experienced 'complaints of pain when swallowing' during the 7-day look back period. Record review revealed Resident #72's diet orders included: Regular diet, Mechanical Soft texture, Thin consistency - 10/24/23 with a revision date of 10/31/25 Resident #72's care plan for nutrition documented:Resident is at risk for an alteration in: nutrition and/or hydration related to: receives mechanically altered diet, dementia, CAD (Coronary Artery Disease), GERD, COPD (Chronic Obstructive Pulmonary Disease), Protein/Calorie malnutrition, low BMI (Body Mass Index) with diagnoses of muscle wasting/atrophy. Date Initiated: 05/08/2023 Revision on: 02/20/2026. Interventions to the care plan included: Provide diet as ordered. Offer and provide alternate as needed Record review revealed Resident #72's care plan for dental care documented:Resident has natural teeth with some missing. Denies mouth pain or chewing problems with current diet. Date Initiated: 07/26/2025 Revision on: 08/04/2025 Interventions included: Diet as ordered. Date Initiated: 05/02/2023 During an observation of lunch served in the dining are on the first floor, on 03/09/2026 at 12:33 PM, it was noted that Resident #72 was served a hot dog that was cut into large chunks. During an interview, on 03/09/26 at 12:52 PM, with the Food Service Director, (FSD) when shown the photographic evidence of the concern, the FSD acknowledged understanding of the concern. The FSD demonstrated that the hot dog in the form that it was served was not appropriate for a resident with an order for mechanical soft food. By using a fork, the FSD was not able to push the fork completely through the skin of the hot dog. During an interview, on 03/12/26 at 2:06 PM the Speech Language Pathologist (SLP), the SLP acknowledged that the hot dog served to the resident was not appropriate, based on the photographic evidence and the demonstration by the FSD.

Based on observations, interviews, and record review, the facility failed to clean and disinfect the glucometer as per manufacturer's instructions and properly perform hand hygiene for 1 of 1 sampled resident reviewed for blood glucose monitoring (Resident #197). The facility also failed to implement measures for infection control practices during intravenous (IV) antibiotic therapy for 1 of 1 sampled resident reviewed for infection control (Resident #175). The findings included: Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, dated October 2011, included the following:Purpose: The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level.Steps in the Procedure:3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. 19. Remove gloves and discard into designated container.20. Wash hands.Review of the facility's policy titled, Cleaning and Disinfection of Glucometer Machine undated, included the following: Glucometer Machines will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne pathogens standards. Policy Interpretation and Implementation:1) Glucometer machine will be cleaned and disinfect with a commercially available disinfectant (i.e. Microdot, Dispatch, Sani-cloth with orange top) that has 1:10 dilution of bleach and detergent.2) The nurse will use gloves while cleaning the glucometer machine.3) The glucometer machine will be wiped with the Bleach wipes until completely wet.4) After the glucometer machine has been wiped and left wet, it will be wrapped with the Bleach wipes towel for a total of 3 or 5 minutes depending what the manufacturers guidelines.5) When the required wet times have passed, then the nurse will wipe and dry the glucometer and ready for use for another resident. 1. Record review for Resident #197 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus without Complications, and Chronic Obstructive Pulmonary Disease. The Minimum Data Set (MDS) dated [DATE] revealed Resident #197 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that she was cognitively intact.Review of the Physician's Orders showed Resident #197 had an order dated 03/05/26 for Novolin R. (insulin) Flex Pen 100 UNIT/ML Solution pen-injector (Inject as per sliding scale: if 150 - 200 = 2 unit; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units Greater than 400 =12 Units AND Call MD For Hyperglycemia) to inject subcutaneously before meals and at bedtime.During an Accu-Chek observation conducted on 03/11/26 at 11:38 AM with Staff C, Registered Nurse (RN), who stated she was ready to check the blood glucose level for Resident #197 and the Glucometer was cleaned. On a foam tray, she had prepared the Glucometer, 2 lancets, alcohol wipes and 2 test strips. Staff C, RN, locked the medication cart, grabbed the foam tray and entered the room. Then grabbed a pair of gloves from the wall and put them on (no hand hygiene was conducted); with the gloves on she used the bed remote to raise the head of the bed for Resident #197, then inserted the test strip into the Glucometer still wearing the same gloves. Staff C, RN, performed the blood glucose level test and then gathered all the sharps in a cup and discarded her gloves. Without washing her hands, she exited Resident #197's room and placed the Glucometer and the cup (containing sharps) on top of the medication cart. She then asked the surveyor how she did, and at this time she was asked if she had used hand sanitizer during the procedure. Then she used the hand sanitizer and put the sharps in the sharp container; grabbed the Glucometer and stored it in the top drawer of the medication cart (without disinfecting it). During an interview conducted on 03/11/26 at 11:45 AM with Staff C, RN, who stated she has worked at the facility for one month. She was asked when she would clean the Glucometer after using it on a resident. She stated that she has a few more residents to check the blood glucose levels, she cleans the Glucometer then. At this time, Staff C removed the Glucometers (there was another Glucometer in the drawer) out of the drawer and placed them on top of the medication cart. Then she stated she does not have the wipes in the cart to clean the Glucometers. An interview was conducted on 03/11/26 at 12:04 PM with the Director of Nursing (DON) and was made aware of the above concerns. 2. Record review for Resident #175 revealed the resident was admitted to the facility on [DATE] with a re-admission date on 03/04/26 with diagnoses that included: Cerebral Infarction, Bacteremia, Pneumonitis Due To Inhalation of Food and Vomit. The Quarterly MDS dated [DATE] revealed Resident #175 had a BIMS score of 08, which indicated that she was moderately cognitive impaired.Review of the Physician's Orders showed Resident #175 had an order dated 03/06/26 for Vancomycin HCl (antibiotic) Intravenous (IV) Solution Reconstituted 1 GM, to use 1 gram intravenously one time a day every other day for Staph epimeriids bacteremia until 03/18/26.On 03/12/2026 at 9:29 AM an IV medication administration observation was conducted with Staff D, RN for Resident #175. She stated she has worked at the facility for 3 months. She washed her hands, don on Personal Protective Equipment (PPE), including a gown (which she did not tide behind her waist and the tides of the gown were dragging on the hallway floor), and gloves. She entered the room with the IV medication bag, IV tubing and the gown untied. Staff D stated she would check Resident #175's IV site then stated she would prime the tubing (the process to remove air in the tube) and tide her gown at the waist. As she was trying to spike the IV medication bag, she dropped the tubing and the IV medication bag on the floor. She picked up the tubing and threw it away, then picked up the IV medication bag (without wiping it down) removed her PPE, washed her hands and she and the surveyor exited the room. Staff D went to the storage medication room holding the IV medication bag. She then returned to the medication cart which was located by Resident #175's room; washed her hands and don on PPE, then entered the room holding the IV tubing and the dirty IV medication bag with her gloved hands. She again struggled to spike the IV medication bag but finally was able to prime the IV tubing. She walked to the IV pole and hung the medication bag. Without changing her gloves, she started to get the IV tubing into the machine touching the IV tubing and holding the IV connector (Clave) with her left gloved hand. Finally, Staff D, RN, was able to connect the IV tubing with the machine; then used an alcohol wipe to clean the IV tubing Clave (which now she was holding with her right hand) and used another alcohol wipe to clean the resident's IV connector. Staff D, RN, stated she needed another alcohol wipe, she let go of the resident's IV connector and reached for another alcohol wipe to clean the IV tubing Clave but not the resident's IV connection. She then opened the IV tubing to allow the medication to flow and stated she would stay with Resident #175 for 5 minutes to ensure no infiltration. She was then asked if she felt she followed Infection Control protocol and she stated yes. On 03/12/26 at 12:10 PM the above concerns were discussed with the DON and the Infection Preventionist.

Based on observations, interviews and record reviews, the facility failed to ensure infection control practices were implemented, as evidenced by Enhanced Barrier Precautions (EBP) for infection control for perineal care for 1 of 1 perineal care observation, Resident #5; failed to follow professional standards of practice for 1 of 1 wound care observation, Resident #5; and failed to follow the Center for Disease Control (CDC) guidelines for Enhanced Barrier Precautions (EBP) for 14 of 14 residents on Enhanced Barrier Precautions (EBP). The findings included: Review of the CDC guidance related to EBP documented the following: Everyone must clean their hands, including when both entering and leaving the room. (https://www.cdc.gov/long-term-care facilities/media/pdfs/) A review of facility's policy titled, Enhanced Barrier Precautions revised 07/2025, documented the following: Staff shall be adequately trained in various aspects of EBP to ensure appropriate decision making in various clinical situations (2). EBP shall include the following practices. o Hand hygiene refers to hand washing with soap (anti-microbial or non-antimicrobial) or using alcohol barrier and rubs (gels, foams, rinses) that do not require access to water. o Change gloves, as necessary, during the care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean site). 1) Record review revealed Resident # 5 was admitted to the facility on [DATE] with diagnoses that included in part Peripheral Vascular Disease, Type 2 Diabetes Mellitus without Complications, Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. A review of quarterly Minimum Data Set (MDS,) assessment dated [DATE], under Section C of the Brief Interview for Mental Status (BIMS) revealed a score of 8, indicating moderate cognitive impairment. An electronic review of the physician orders dated 07/23/24 documented EBP for wound, every shift. An additional review of physician orders dated 08/22/25 documented to clean the right lateral foot with normal saline soaked gauze, apply collagen with gauze dressing, daily, every day shift for vascular ulcer. a. During a perineal care observation on 10/02/25 at 12:08 PM, Staff F, Certified Nursing Assistant (CNA) was observed cleaning the sacral area of Resident #5. Staff F was observed looking for something, left the resident's side proceeded to completely open the door using the same gloves she was using for perineal care. She was observed to go back and continued cleaning the resident's sacral area without removing her gloves. An interview was conducted with Staff F, on10/02/25 at 11:00 AM, when she was asked why she did not change her gloves and performed hand hygiene during the perineal care, when she touched the door with the same gloves she used during a perineal care and she did not respond. b. During a wound care observation on 10/02/25 at 1:45 PM, Staff F was observed to put down the right foot on the resident's bed after it was cleansed and dried with clean gauzes by a Wound Care Registered Nurse (RN). The Wound Care RN continued with the application of collagen and Kerlix dressing, after she observed blood in the area. She did not re-cleanse and redried the area. She did not tell Staff F to keep the right foot up after it was cleansed and dried, to prevent the newly cleansed area from making contact with the chuck's barrier, where the right foot with dirty dressing was placed at the beginning of wound care. When Staff F was asked why she put the right foot down after it was cleansed and dried by the Wound Care RN, she did not respond. When the Wound Care RN was asked why she did not tell Staff F to keep the right foot elevated after it was cleansed, she did not respond. When she was asked why she did not re-cleanse the right foot after the blood was observed, she did not respond. 2. During the facility tour it was noted that there were many Enhance Barrier Precautions identified rooms throughout the facility. An observation was made of the 100 Unit where there were six rooms identified with Enhanced Barrier Precautions (EBP), but the required Personal Protection Equipment (PPE) for the rooms was not observed in the hall or in the rooms. Staff E, CNA, was asked where the PPE was kept. She replied she thought at the nurses' station. The PPE was not visible and readily accessible at the nurses' station. An observation of the 200 Unit on the second floor identified eight rooms with EBP signs on the doors. The 200 Unit has two long hallways that are on either side of the elevators. On the walls closest to the elevators, the facility had PPE caddies mounted. These caddies were sparsely filled with PPE. On 10/02/2025 at 3:10 PM, An interview was conducted with Staff I, Registered Nurse (RN), while on the third floor, which is the 300 Unit. During the interview, it was noted that the 300 Unit had PPE caddies mounted near the elevators like the 200 Unit. Staff I was asked about the placement of PPE for Enhanced Barrier Precautions (EBP), and she stated she believed the rooms should have PPE on the door or on the wall next to the room. Staff I stated that they only have two caddies on the floor, and it is too far away from the end of the hall. Staff I stated that she believed people would not use PPE if they were at the end of the hallway away from the PPE caddies. At approximately 3:30 PM on 10/02/2025, the surveyor noted that in the 100-unit, the facility had hung two caddies for PPE that had been previously absent on 10/02/25 at 10:22 AM. On 10/02/25 at 3:35PM, an interview was conducted with Staff H CNA. Staff H was asked if she was working with someone on EBP and got feces on her gown would she get a new one? Staff H stated she would call for help to have someone bring a new gown for her. When asked what would she do if no one was available. Staff H stated she would make sure the resident was safe and then walk down the hall to get a new gown. When asked if having the caddies on the door or between two rooms would be easier for her and her co-workers, she admitted that it would be easier to get a new gown if that were the case.

Based on observations and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for 9 out of 100 rooms and elevator areas.The findings included:1). On 06/30/2025 at 2:20 PM, an observation revealed that room [ROOM NUMBER] and 51 had no toilet tissue. Further observations revealed room [ROOM NUMBER]'s floor, near the bathroom door, was ladened with dirt and had numerous dark gray spots.2). On 06/30/2025 at 2:45 PM, an observation revealed that there were food crumbs on the floor of room [ROOM NUMBER], near the resident, and the paint was scuffed and peeling off the lower bathroom door.3). On 06/30/2025 at 2:51 PM, an observation revealed that room [ROOM NUMBER] had multiple flies on the residents' bed and furniture. During the observation, the resident expressed the need to get rid of all the flies.4). On 06/30/2025 at 3:05 PM, an observation revealed that the soap dispenser of bathroom [ROOM NUMBER] was broken and placed above the toilet on a PVC pipe and unreachable.5). On 06/30/2025 at 3:15 PM, an observation revealed that the wardrobe drawers (6) of room [ROOM NUMBER] could not fully close and one of the handles was positioned incorrectly.6). On 06/30/2025 at 3:20 PM, an observation revealed that in the bathroom of room [ROOM NUMBER], 1 of 2 toilet paper rolls was placed on a PVC pipe above the toilet, and unreachable.7). On 06/30/2025 at 3:40 PM, an observation revealed that the elevator carpeting and the carpeting in front of the elevators on the 1st and 3rd floor were ladened with dirt and had black stains.8). On 06/30/2025 at 3:45 PM, an observation revealed that the lower bathroom shower tiles of room [ROOM NUMBER], were lifted from the wall. The cover of a side light on the room wall was positioned incorrectly. 9). On 06/30/2025 at 4:00 PM, an observation revealed the bathroom sink of room [ROOM NUMBER] was clogged.A tour of the facility was conducted on 06/30/2025 at 4:30 PM with the Assistant Director of Nursing, in which she acknowledged the findings.

Based on observation, interview, and record review, it was determined that the approved menu and portion sizes were not followed for 137 of 145 facility residents who eat by mouth. The findings included: During the review of the approved menu for the lunch meal of 09/18/24, it was noted the following entrees were documented to be served: Regular Diet: Shrimp Fried Rice (4 ounces of Shrimp) Mechanical Soft Diet: Ground Sauteed Shrimp (4 ounces) Pureed Diet: Pureed Sauteed Shrimp (4 ounces) Consistent Carbohydrate Diet: Shrimp Fried Rice (4 ounces of Shrimp) No Added Salt Diet: Shrimp Fired Rice (4 ounces of Shrimp) Renal Diet: Salisbury Steak (4 ounces beef) During the observation of the lunch tray line in the main kitchen on 09/18/24 at 12:15 PM, it was noted that Breaded Popcorn Shrimp was being served over cooked rice for the entrees. Interview with the Certified Dietary Manager (CDM) at the time of the observation was noted to state that plain non-breaded Shrimp was not delivered, and the Breaded Popcorn Shrimp was substituted. During the tray line observation, a random portion of the Breaded Popcorn Shrimp was weighed using the facility's calibrated food portion scale. The weighing was performed by the CDM, and an average Breaded Popcorn Shrimp was recorded at 4.5 ounces. Following the weighing a review of the manufacturer's nutrient analysis (Nutrient Facts) documented that a 4-ounce portion of the breaded Shrimp provided only 15 grams of Protein. It was further discussed with the CDM and Corporate Food service Director that an 8-ounce portion of the Breaded Shrimp was required to ensure that 4 ounces of Shrimp protein was being provided in each resident portion. The surveyor provided the mathematical equation and agreed that the menu portion for the Shrimp (4 ounces Protein) was not being provided. A random portion of the Breaded Salisbury Steak (entree alternate) was also requested by the surveyor to be weighed via the facility's food portion scale, and it was noted that the beef entree was recorded at only 2.5 ounces. It was again discussed with the CDM and Corporate Food Service Director that only 19 grams of Protein was being served in the entree. It was further reviewed that a 5-ounce portion of the breaded Salisbury Steak should have been served to ensure that a 4-ounce protein (28 grams) was being served to facility residents. It was further discussed that the facility had purchased an insufficient portion of the steak (3 ounce per steak patty) and should have purchased a 5-ounce steak patty to ensure that a cooked 4-ounce portion of the beef patty was being served, as per the approved menu. Following the lunch observation conducted in the main kitchen on 09/18/24 the findings were discussed with the facility's Administrator and confirmed the surveyor's findings.

Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure that the MDS (Minimum Data Set) Resident Comprehensive Assessment was completed in a timely manner for 6 of 42 sampled residents reviewed for MDS Assessments, (Resident #77, Resident #40, Resident #24, Resident #33, Resident #39, and Resident #23). The findings included: Review of the facility policy and procedure titled, MDS Completion and Submission Timeframes revised July 2017 and provided by the Director of Nursing (DON) documented in the Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessment is based on the current requirements published in the Resident Assessment Instrument Manual. 3. Submission of MDS records to the QIES ASAP is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of fifteen (15) months from the date submitted. Review of the facility policy and procedure revised December 2002, titled Resident Assessment Instrument (RAI) Assessment Scheule Summary, provided by the DON documented for Record Type: Quarterly .no later than 14 days after the Assessment Reference Date (ARD) 1) Resident #77 was admitted to the facility on [DATE] with diagnoses which included Unilateral Primary Osteoarthritis, Right Knee, Hypertension and Dementia. She had a Brief Interview Mental Status (BIM) score of 5, indicating severe cognitive impairment. Record review revealed that Resident #77's Quarterly MDS ARD was 08/03/24. The due date for the Assessment to have been completed was 08/17/24. Staff D, lead full-time RN, MDS Coordinator, had not electronically signed the MDS Comprehensive Assessment as completed until Saturday 09/14/24, approximately four (4) weeks after the ARD date. 2) Resident #40 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Alzheimer's Disease and Atherosclerotic Heart Disease. She had a Brief Interview Mental Status (BIM) score of 14, indicating intact cognition. Record review revealed that Resident #40's Quarterly MDS ARD was 08/10/24. The due date for the Assessment to have been completed was 08/24/24. Staff D had not electronically signed the collective MDS Comprehensive Assessment as completed until Saturday 09/14/24, approximately three (3) weeks after the ARD date. 3) Resident #24 was readmitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection, Diabetes Mellitus Type II, Epilepsy, Myasthenia Gravis and Hypertensive Chronic Kidney Disease. She had a Brief Interview Mental Status (BIM) score of 13, indicating intact cognition. Record review revealed that Resident #24's Quarterly MDS ARD was 08/10/24. The due date for the Assessment to have been completed was 08/24/24. Staff D had not electronically signed the collective MDS Comprehensive Assessment as completed until Saturday 09/14/24, approximately three (3) weeks after the ARD date. 4) Resident #33 was admitted to the facility on [DATE] with diagnoses which included Degenerative Disease of Nervous System, Paraplegia, Hypertension and Atherosclerotic Heart Disease. He had a Brief Interview Mental Status (BIM) score of 3, indicating severe cognitive impairment. Record review revealed that Resident #33's Quarterly MDS ARD was: 08/03/24. The due date for the Assessment to have been completed was 08/17/24. Staff D had not electronically signed the collective MDS Comprehensive Assessment as completed until Saturday 09/14/24, approximately four (4) weeks after the ARD date. 5) Resident #39 was readmitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder, Schizoaffective Disorder, Anxiety Disorder, Encephalopathy and Hypertension. She had a Brief Interview Mental Status (BIM) score of 1, indicating severe cognitive impairment. Record review revealed that Resident #39's Quarterly MDS ARD was: 08/03/24. The due date for the Assessment to have been completed was 08/17/24. Staff D had not electronically signed the collective MDS Comprehensive Assessment as completed until Saturday 09/14/24, approximately three (3) weeks after the ARD date. 6) Resident #23 was readmitted to the facility on [DATE] with diagnoses which included Calculus of Gallbladder with Chronic Cholecystitis without Obstruction, Major Depressive Disorder, Psychotic Disorder with Hallucinations, Alzheimer's Disease and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. She had a Brief Interview Mental Status (BIM) score of 3, indicating severe cognitive impairment. Record review revealed that Resident #23's Quarterly MDS ARD was 08/10/24. The due date for the Assessment to have been completed was 08/17/24. Staff D had not electronically signed the collective MDS Comprehensive Assessment as completed until Saturday 09/14/24, approximately four (4) weeks after the ARD date. A side-by-side record review was conducted with Staff D, of the six (6) MDS Quarterly Comprehensive Resident Assessments for the month of August 2024, in which it was noted that for all six (6) Assessments, Staff E, RN, MDS Coordinator, was assigned to complete. Further record review indicates that none of the above listed six (6) collective MDS Quarterly Resident Comprehensive Assessment types had been completed in a timely manner, until at least three (3) or four (4) weeks later, after their individual ARD dates. During a simultaneous interview conducted on 09/18/24 at 10:37 AM with Staff E and Staff D, it was stated that the Social Services Director, had not completed any of her six (6) Resident Social Work Assessment sections until Saturday 09/14/24. Additionally, both Staff E and Staff D both acknowledged that the collective MDS Resident Comprehensive Assessments needed to be completed in a timely manner to ensure that the Residents are accurately, timely assessed and evaluated, in order to carry out the correct and appropriate plan of care. On 09/18/24 at 10:42 AM an interview was conducted with the Social Services Director, who indicated that she had not completed any of the six (6) MDS Resident Social Work Assessment sections until Saturday 09/14/24. The Social Services Director also indicated that she was not able to provide any specific reasoning as to why this had not been done. The DON further acknowledged that on 09/18/24 at 11:37 AM, that the collective MDS Resident Comprehensive Assessments should have been completed in a timely manner by all facility departments. This was not done.

Based on observations, interviews and record review, the facility failed to ensure residents received foot care (Podiatry) in a timely manner for 2 of 2 sampled residents reviewed for Podiatry Care (Resident #4 and #130). The findings included: 1) Review of Resident #4's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Heart Failure, Generalized Anxiety Disorder, Dementia, Peripheral Vascular Disease, Venous Insufficiency (Chronic) Muscle Weakness and Difficulty in Walking. Review of Resident #4's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 10, indicating that the resident had moderate cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to complete the activities of daily living including putting footwear on, dressing and bathing. Review of Resident #4's care plan titled [Resident Name] exhibits the following behaviors: resists cares and will refuse to shower at times, initiated on 05/07/24. Interventions to include, to anticipate care needs and provide them before resident becomes overly stressed. The Care Plan did not address refusal of foot care. Review of Resident #4's physician orders dated 10/31/24 documented May consult podiatry .services as needed. Review of Resident #4's clinical record revealed the last documented Podiatry consult was dated 02/20/24. On 09/16/24 at 11:18 AM, observation revealed Resident #4 in bed with her toes uncovered. Observation revealed Resident #4's right and left foot with elongated toenails. Subsequently, an interview was conducted with Resident #4 who stated she was not sure if she had seen a foot doctor or not. The resident was asked permission to take a picture of her toenails to discuss the care with the Director of Nursing, the resident agreed. On 09/17/24 at 9:24 AM, observation revealed Resident #4 out of bed sitting in a wheelchair, well dressed, groomed and wearing tennis shoes. On 09/17/24 at 2:32 PM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA) assigned to Resident #4. Staff B stated she gave a full bath in bed to the resident. Staff B was asked if she report anything related to the care of Resident #4 to the nurse, like her nails, skin or toenails, and replied she had nothing to report to the nurse. Staff B added sometimes the resident did not want her to cut the nails. Staff B was asked how were Resident #4's toenails and replied, they are okay. Staff B confirmed the resident was dependent on the staff for her activities of daily living and can only feed herself. On 09/17/24 at 2:51 PM, a side-by-side observations of Resident #4's toenails was conducted with Staff A, Licensed Practical Nurse (LPN) and Staff B, CNA. Staff B stated Resident #4's toenails needed to be done. Staff A reported that Resident #4 fights and scratches the staff, Staff B was made aware that there was no written documentation related to Resident #4 refusing toenail care. Subsequently, a side-by-side review of the Podiatry consult log binder was conducted with Staff A. The review revealed Resident #4 was not listed to be seen by the Podiatrist. On 09/17/24 at 2:55 PM, an interview was conducted with the facility's Podiatrist who stated he comes to the facility twice a week. The Podiatrist stated the visit frequency depends on the resident's insurance and that most of them can be seen every 60 days. The Podiatrist was made aware of the status of Resident #4's toenails. On 09/17/24 at approximately 3:15 PM, observation revealed the Podiatrist ready to do Resident #4's, toenail care and stated her nails were long. On 09/19/24 at 9:50 AM, an interview was conducted with the Unit Manager who stated each floor has a Podiatrist book for the staff to log in residents who needs to be seen. The Unit Manager was apprised that Resident #4 was not on the current list to be seen. On 09/19/24 at 9:52 AM, a joint interview was conducted with the Regional Nurse and the Unit Manager, and they were apprised of Resident #4's elongated toenails. (Photographic evidence showed). 2) Review of Resident #130's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Pneumonia, Restless Legs Syndrome, Major Depressive Disorder, Convulsions, Difficulty in Walking, Muscle Weakness, Sepsis, Intraspinal Abscess and Granuloma, Osteomyelitis of Vertebra, and Pressure Ulcer of Sacral Region. Review of Resident #130's MDS assessment dated [DATE] documented a BIMS score of 15, indicating that the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff for most of his Activities of Daily Living (ADLs) including bathing and putting on footwear. Review of Resident #130's care plans record revealed no care plan related to foot care refusal. Review of Resident #130's physician orders dated 06/18/24 documented May consult podiatry .services as needed. Review of Resident #130's clinical record revealed a lack of a written Podiatry consult. On 09/16/24 at 11:40 AM, an interview was conducted with Resident #130 who stated he has been in the facility for 3 months and had not seen a Podiatrist. The resident agreed for the surveyor to look at his toenails. The Resident's private duty aide was in the room and removed the resident's non-skid socks. Observation revealed Resident #130's right and left foot toenails were elongated. The resident agreed with further investigation related to the elongated toenails. On 09/17/24 at 2:39 PM, an interview was conducted with Staff B, CNA who stated Resident #130's toenails were okay and did not need to tell the nurse anything about his toenails. On 09/17/24 at 2:47 PM, a side-by-side observation of Resident #130's toenails was conducted Staff A, LPN and Staff B, CNA. Staff A stated that the foot doctor comes in 2 to times a week and she will have him see Resident #130. During the observation Resident # 130 stated he did not like people to see his toenails but will allow the foot doctor in. On 09/17/24 at 2:55 PM, an interview was conducted with the Podiatrist who asked if Resident #130 was new and was informed the resident had been in the facility since June 2024. The Podiatrist stated he will see the resident today. On 09/19/24 at 9:51 AM, an interview was conducted with the Unit Manager who stated each floor has a Podiatrist book for the staff to log in the residents who needed to be seen. The Unit Manager was apprised that Resident #130 was not on the list to be seen. On 09/19/24 09:52 AM, a joint interview was conducted with the Regional Nurse and Unit Manager, and they were apprised of Resident #130's elongated toenails.

Based on record review, observations and interviews, the facility failed to obtain a variety of Gluten Free products to honor 1 of 1 sampled resident reviewed for Therapeutic Gluten Free Modified Diet (Resident #130). The findings included: Review of Resident #130's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Celiac Disease, Vitamin Deficiency, Muscle Weakness, Sepsis, Osteomyelitis of Vertebra, and Pressure Ulcer of Sacral Region. Review of Resident #130's Minimum Data Set assessment dated [DATE] documented a Brief Interview Mental Status score of 15, indicating that the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff for most of his Activities of Daily Living (ADLs). Review of Resident #130's care plan titled [Resident name] is at risk for an alteration in: nutrition and/or hydration related to: receives therapeutic diet-gluten free, has variable, oral intake, Celiac Disease .Anemia, impaired skin integrity, low (body mass index) BMI with 5% loss 6/24-7/24. Frequent preference changes for food and supplements. The care plan was initiated on 06/20/24; Interventions included: Provide diet as ordered. Offer and provide alternate as needed. Review of Resident #130's clinical record documented a physician order dated 06/19/24 for a Regular Diet Modified for Gluten Free. Review of Resident #130's Nutrition/Dietary Note dated 06/20/24 documented .Gluten Free menu style to be provided . Review of Resident #130's Nutrition/Dietary Note dated 07/14/24 documented .care plan meeting held with family and resident and food preferences were updated . Review of Resident #130's Dietary Progress Note dated 09/11/24 documented .food preferences routinely updated . On 09/16/24 at 11:45 AM, an interview was conducted with Resident #130 who stated he had Celiac Disease for 3 years and the facility promised him that they will provide a Gluten Free diet for him. The resident stated he was only getting Gluten Free bread and that he had to order out to get his special diet. The resident added it is frustrating because he asked for other Gluten Free products beside bread, and they said they don't have it. The resident added that his family and himself met with the Dietitian and promises were made that they will have Gluten Free meals for him. On 09/16/24 at 12:57 PM, during dining observation, Resident #130's meal ticket documented Early Tray-Regular-Gluten Free Diet .Gluten Free Bread .Allergies: Gluten. On 09/17/24 at 9:25 AM, an interview was conducted with Resident #130 who stated he had an Early tray because if he could not eat what they brought in, he would order out. The resident stated he got Gluten Free bread for breakfast. On 09/18/24 at 9:46 AM, a joint interview was conducted with the facility Registered Dietitian (RD) and Agency for Health Care Administration (AHCA) Registered Dietitian Surveyor. The RD stated Resident #130 was on a Gluten Free modified diet due to Celiac Disease, and added the resident had a history of extreme weight loss. The RD was asked what Gluten Free products the facility had in house for Resident #130 and replied they buy Gluten Free bread, pasta and added she will check for what else they had in house. The RD was apprised about Resident #130 stating he would like to have pasta, and the facility did not have it and that he was ordering food out because of limited products as only Gluten Free bread. The RD stated they had met with the resident and discussed his preferences, added the resident prefers to order out and in the last 30 days had not heard concerns or complaints related to his diet. The RD stated that she thought the preferences/concerns were rectified and added that the Certified Dietary Manager (CDM) had worked on multiple preferences for Resident #130. On 09/18/24 at 9:56 AM, a tour to the kitchen was conducted with the RD, the CDM, the Food Service Supervisor (FSS), and AHCA RD surveyor. The CDM was asked what Gluten Free products they had available for Resident #130 and stated bread. The FSS was asked if she had Gluten Free pasta or flour in-house and stated she did not. The CDM stated he could not order Gluten Free flour or pasta because it was not on the ordering list. The CDM provided the facility's order guide which did not included Gluten Free flour. The RD provided the facility's Diet Manual-Gluten Free Diet sheet that documented if gluten free restricted is ordered-use resident preferences to design menu. On 09/18/24 at 10:14 AM, an interview was conducted with Resident #130 who stated that there was a cake on his tray, sometime this week and he did not eat it. Resident #30 was asked why he wrote order out on the menu selection for 09/19/24 dinner, 09/21/24 lunch and dinner. He stated because there was nothing Gluten Free for him to order. The resident added that the Kitchen Manager told him that they put wheat in the soups and bread crumbs on the meatballs, so he could not have neither. He added he was afraid he will eat something that was not Gluten Free, so he had to order out. The 09/19/24 dinner menu documented Corn Chowder, Alternative choice-Hamburger on a Bun . The 09/21/24 lunch menu documented Crispy chicken .dinner menu-chicken noodle soup, tuna salad on wheat-alternative choice-beef meatballs . On 09/18/24 at 10:34 AM, an interview was conducted with the RD who stated she spoke with Resident #130, and he would like to have Gluten Free pasta. The RD stated we can accommodate him better and do a better job. The RD further stated they can have small, prepared meals for the resident. The RD stated they will purchase additional gluten free items for Resident # 130. On 09/19/24 at 11:19 AM, an interview was conducted with the RD who stated that on 07/10/24, Resident # 130 and his sister complained of limited options of Gluten Free products and on 07/16/24, the FSS met with the resident and updated the preferences. The RD added the FSS was talking with the resident every week. The RD was asked if the FSS documented her weekly visit with Resident #130 and stated she did not. The RD stated the FSS note dated 07/16/24 did not document details of the resident's preferences update.

Based on observation, interview, and record review, it was determined that, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 123 of the 145 facility residents, who eat food by mouth. The findings included: 1) During the initial kitchen/food service observation tour conducted on 09/16/24 at 9 AM and accompanied with the facility Certified Dietary Manager (CDM), the following were noted: (a) Observation of the food preparation sink noted that two 10-pound plastic sleeves of ground beef were thawing in a large pan that had running water flowing into the pan. Further observation noted that the cold-water faucet was tuned on full capacity, however the water felt lukewarm to the touch. At the request of the surveyor, the temperature testing of the running water was taken with the facility's calibrated digital food thermometer. The test noted that the temperature of the running water coming from the top of the cold-water faucet was recorded at 80.9 degrees Fahrenheit. A second testing recorded 5 minutes later was again recorded at 80.9 degrees F (Fahrenheit). An interview conducted with the CDM by the surveyor at the time of the second testing revealed that the regulatory requirement for cold water thawing of potentially hazardous food was 70 degrees F or below. It was further discussed with the CDM that the facility's cold-water temperature was approximately 11 degrees F over the regulatory requirement and that continued thawing (time & temperature) would result in food borne illness. The surveyor requested that the practice of thawing meats in cold water be halted immediately and to thaw in the alternate thawing procedure in the refrigerator at 41 degrees F of below for a maximum of 3-days. The surveyor also requested that the thawed ground beef be discarded and not utilized for the residents. (Photographic Evidence Obtained). (b) Review of the facility's Policy & Procedure: for the Dishwashing Machine Use/Cleaning, noted the following: #10 - De-lime Dish machine once a month. If build up occurs increase the de-liming until dish machine is satisfactory. Run rubber skirts assemblies through the dish machine daily to maintain clean and debris free. During the observation of the dish machine, it was noted that the high temperature machine contained 3 separation curtains (entrance, internal, and exit) within the interior of the machine. At the request of the surveyor, the curtains were removed and observed. The observation noted that that all 3 curtains had a heavy build-up of decayed/rotting food matter. It was also noted that there was a heavy build-up of lime (hard water build-up) on the curtains and the stainless-steel dish run that exited the machine. It was discussed with the CDM at the time of the observation that the curtains were not being maintained as per facility policy that included cleaning and sanitizing after each meal and de-liming the machine and dish runs on a regular basis. It was also discussed that as dishes passed and exited through the machine, the soiled curtains and water come into contact with resident dishware, resulting in contamination. The surveyor requested that the curtains be cleaned and sanitized and the machine de-limed prior to continued use of the dish machine. (Photographic Evidence Obtained). (c) Observation of the exhaust hood, which is located over the machine food preparation equipment noted that the front of the hood was covered with a large wood plank that was approximately 15 feet long. Further observation of the wood noted peeling paint down the entire surface of the wood plank. It was discussed with the CDM at the time of the observation that peeling paint was falling onto the equipment and food being prepared under the hood, resulting in food contamination. The surveyor requested that wood surface be prepped and repainted prior to the next meal service. (Photographic Evidence Obtained). (d) Observation of 4 food preparation skillet food preparation pans that were in use were noted to have a heavy build-up of black carbon matter on the interior and exterior surfaces. The surveyor requested that the pans be discarded and replaced as soon as possible to prevent food contamination during food preparation. (Photographic Evidence Obtained). (e) Soiled food cleaning cloths were noted to be stored directly on food preparation surfaces, clean utility carts, and 3-compartment sinks. The surveyor discussed with the CDM that regulatory requirement was to store all cleaning cloths in a sanitizing solution when not in use. (Photographic Evidence Obtained). (f) Observation of the entrance into the dietary department noted that 2 full carts of dishes were being stored outside of the dietary department. Further observation noted that carts were not covered and that food trays were full of exposed garbage and trash. The surveyor discussed with the CDM that the regulatory requirement was to always cover all garbage and trash completely. 2) During a second kitchen/food service observation tour conducted on 09/17/24 at 7:15 AM and accompanied with the Corporate Food Service Director (CFSD), the following were noted: (a) Temperatures of foods located on the tray assembly line were taken by the CDM with the use of the facility's calibrated digital food thermometer. The results of the temperature testing noted that hot foods were not being held at the regulatory temperature of 135 degrees F or above, and cold foods were not being held at the regulatory temperature of 41 degrees F or below, as per the following: < Fried Eggs (8 servings) = 88 degrees F. The surveyor requested that the eggs be discarded. < Orange Juice (50 servings) = 72 degrees F. Further investigation noted that the juice dispenser (orange, apple, cranberry) was not working properly and was not chilling the juice to the regulatory temperature of 41 degrees F or below. (b) Observation of the dish machine noted that the wash temperature was recorded at 125 degrees F. It was discussed with the CDM that the machine wash temperature did not meet the regulatory requirement of 150-165 degrees F. The CDM investigated the matter and reported to the surveyor that dietary staff failed to turn on the machine's hot water booster. (c) Observation of the dish machine room noted that there was a heavily soiled ladder being stored in the clean section of the room. The surveyor requested that the ladder be removed. (Photographic Evidence Obtained). (d) Observation of the 3-compartment sink area noted that an air-conditioning vent was located over the clean section of the sink area. Further observation noted that exterior of the vent was covered in a black mold type matter. The surveyor discussed with the CDM that the mold could result in clean food preparation equipment becoming contaminated and requested that the vent be cleaned and sanitized before use of the 3-compartment sink. (Photographic Evidence Obtained). (e) Observation of the 3-door reach-in refrigerator located in the main food preparation area was noted to have 2 internal food storage racks that were rust laden and in need of replacement. (Photographic Evidence Obtained). (f) Observation of the Convection Oven located underneath the hood exhaust system was noted to have 4 legs that were rust laden. (Photographic Evidence Obtained).

Based on interviews and record reviews, the facility failed to provide an appropriate discharge and failed to provide discharge documents in a language that the resident can understand for 1 of 1 sampled resident reviewed for discharge rights (Resident #1). The findings included: Review of the facility's policy titled Transfer or Discharge Documentation, revision date January 2023 revealed the following: Each resident will be permitted to remain in the facility and not be transferred or discharged unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. If a resident exercises his or her right to appeal the transfer or discharge notice, he or she will not be transferred or discharged while the appeal is pending. If the resident is being transferred or discharged because his or her needs cannot be met at the facility, the facility must document why the needs cannot be met. Resident #1 was admitted to the facility on [DATE] and was discharged on [DATE] to another Skilled Nursing Facility. Resident #1 had an elopement incident on 09/30/23 and was found by the facility's administration nine hours later and brought back to the facility via private vehicle. Review of the Nursing Home Transfer and Discharge Notice form that was provided to Resident #1 upon his dischargeon 10/02/23 revealed this form did not document a Reason For Discharge or Transfer. It was also discovered that the paperwork provided to Resident #1 was in English; it was identified during his stay at the facility that Resident #1 did not speak (was nonverbal); he did not read English but rather Creole. Review of the Care Plan initiated on 09/27/23 revealed that Resident #1 was in the facility for short term stay placement related to rehab services and that he expressed a desire to discharge from the facility. It further revealed the facility would keep involved in the discharge process and discuss discharge plans with the resident, provide discharge documents in layman's terms, and assess future placement setting to determine if resident's needs are met. In an interview conducted on 10/03/23 at 3:25 PM with the facility's Social Services Director (SSD), she stated that she only dealt with Resident #1 minimally and that she was the one who handled his discharge paperwork. She revealed that Resident #1 was a Creole speaker and that she used Staff F, Licensed Practical Nurse (LPN) to assist her in translating the discharge information to Resident #1 in Creole. According to the SSD, Resident #1's home situation was not conducive but that his plan was to go home. Knowing that Resident #1 was unable to speak, the SSD stated she sat with him and Staff F to explain to him that she had found a new facility that would be more suitable for him. When asked to clarify, she stated the new facility had like minded residents and residents who speak Creole. She provided him the paperwork, which the surveyors noted was in English and not in Creole, which she agreed was Resident #1's native language. In this interview, the SSD stated she did not tell Resident #1 that he had a choice to appeal this discharge decision but that she just asked him to sign the paperwork. When asked by surveyors if he made his own decisions and signed the paperwork, she said yes. When asked if she should have marked a Reason for Discharge on the Nursing Home Transfer and Discharge Notice, she stated yes and acknowledged that it was not marked, indicating there was no reason for the discharge. In an interview conducted on 10/03/23 at 2:34 PM with Staff F, LPN, she confirmed that she assisted the SSD in translating Resident #1's discharge paperwork to him in Creole. She stated when she told Resident #1 that he was discharging to another facility, he nodded his head yes in agreement and signed the paperwork. A secondary interview was conducted with Staff F on 10/04/23 at 8:45 AM. She was asked to clarify what she told Resident #1 when she assisted the SSD in translating the discharge information. She revealed that she told Resident #1 he would be going to a facility in the Miami area and shortly after that he would be going home. She stated that is what the SSD asked her to translate. She said she further asked Resident #1 if he was ok with the transfer and he nodded his head yes. When asked if Resident #1 was told that he had the option to appeal the transfer, Staff F stated no. Staff F further reported that she did not tell Resident #1 the reason he was leaving the facility. In an interview conducted on 10/04/23 at 1:31 PM with the facility's Administrator, she reported that the facility made the decision to start the discharge process for Resident #1. She stated that they thought that a smaller facility would be better for him. She further stated that she was concerned with the circumstances where he was living before, and she was unsure if he could go back there. In an interview conducted on 10/04/23 at 1:41 PM with the facility's Social Services Assistant, he stated that Resident #1 did not understand English but only Creole. He further stated he was unable to communicate with him, so he spoke with Resident #1's emergency contact upon his admission. The emergency contact stated the plan was to have Resident #1 fly back to Haiti upon discharge. When asked what appropriate discharge reasons are, he stated the following: progressing in therapy, family request for discharge, and insurance ceasing to cover services. He was asked by surveyors who made the decision to discharge Resident #1. He stated he did not know, but then stated he heard it was due to the elopement but was unsure as to why. When asked about any progress notes or admission notes regarding Resident #1's discharge planning, he stated that he did not follow up on Resident #1's progress or complete any notes regarding the discharge planning.

Based on interviews and record reviews, the facility failed to prevent elopement by not educating staff in identifying residents at risk for elopement for 1 of 2 sampled residents reviewed for elopement (Resident #1). The findings included: Review of the facility's policy titled Wandering, Unsafe Resident, revision date October 2023 revealed the following: The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable factors related to unsafe wandering. If the resident was not authorized to leave, page CODE PINK, initiate a search of the building and premises. Review of the facility's policy titled Elopements, revision date October 2023 revealed the following: Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Resident #1 was admitted to the facility on [DATE] for rehabilitation services. Resident #1 had a medical history of Stroke, Non-Verbal, and Weakness. Review of the Comprehensive Nursing Evaluation, Elopement Evaluation documented on 08/30/23 at 11:12 PM showed Resident #1 was not at risk for elopement. Review of the Care Plan initiated on 09/25/23 revealed that Resident #1 was at risk for elopement and that he displayed exit seeking behaviors. It further showed the staff would make sure he does not leave the facility without supervision, keep a photo with a copy of his face sheet located at the reception desk, observe him for and report any elopement risk behaviors, and redirect him during inappropriate behavior episodes. Review of the Nursing Note dated 09/19/23 showed that Resident #1 was found in the lobby attempting to leave the facility. He was returned to his unit by the facility staff and the staff were instructed to place a Wanderguard. Review of Physician's orders revealed that an order was written on 09/19/23 for place Wanderguard per protocol for attempted elopement. In a telephone interview conducted on 10/03/23 at 10:55 AM with Staff A, the facility's weekend Receptionist, she stated that on the morning of 09/30/23 at approximately 8:15 AM, she noticed Resident #1 in the lobby area sitting at the right side of her desk on a chair. While sitting down, she said good morning to him, and he smiled at her but did not verbally respond. Resident #1 then walked to the Admissions Office (which was located next to the front desk) and attempted to open the door, but it was locked. She stated she recognized that he was a resident because of the band on his arm. She asked him to go back to his room and he left, taking the elevator up. When asked if she told anybody about Resident #1 wandering around the lobby near the front door, she said no. When asked about the Risk for Elopement binder that was located at the front desk, she said that it contains a picture of each resident in case they walk out and the picture needs to be used for identification. Staff A further reported that she did not know that Resident #1 was at risk for elopement. According to Staff A, Resident #1 went back down to the lobby area at approximately 10:20 AM. She stated she did not see Resident #1 initially. She stated she was in the process of buzzing a visitor out of the front door and Resident #1 came from the left side of her desk (where her view is obstructed) and he had reached the front door before she recognized him as the same resident who had been in the lobby earlier that morning. She stated she yelled for him to stop, but he pushed past the visitor and out the front door. She then ran outside and yelled for help and noticed that Resident #1 was running to the west. She reentered the facility to call the weekend supervisor to alert her of the situation while other staff members were looking for Resident #1. She was then asked by the surveyors if she thought that Resident #1 wanted to escape when she first noticed him in the lobby area that morning, she stated no. She further reported that that day was the first time she saw this resident and did not think there was anything unusual about him or that he intended to elope. According to Staff A, she did not know that Resident #1 was at risk for elopement and she said that if she knew that he intended to leave the facility earlier that day, she would have taken him by the arm and walked him back to his room and notified the supervisor of his behavior. In an interview conducted on 10/03/23 at 11:36 AM with Staff B, the facility's weekday Receptionist, he stated that when a resident elopes, he has been instructed to call a CODE SILVER to alert the rest of the facility staff of the elopement. When asked how he knew if a resident is at risk for elopement, he stated there is a binder located in the lobby that contains the resident's pictures and is to be updated on a weekly basis. Staff B was asked if he knew Resident #1 before his elopement on 09/30/23 and he stated he saw him in the past in the front lobby area near the Admissions Office but did not know what day. He recalled that time, Resident #1 did not have a Wanderguard bracelet on and he did not think he was at risk for elopement because he walked around looking as if he were lost. In an interview conducted on 10/03/23 at 12:14 PM with Staff E, Registered Nurse (RN), he stated he worked with Resident #1 on 09/19/23 when he attempted to elope the first time. He recalled that he received a call from the lobby on 09/19/23 letting him know that Resident #1 tried to leave the facility through the front door. He then asked the caller why Resident #1's Wanderguard did not go off. He was told by the caller that Resident #1 did not have a Wanderguard on. Staff E was then instructed to put a new Wanderguard in place on Resident #1. According to Staff E, the first Wanderguard was placed on Resident #1's right ankle prior to the elopement attempt on 09/19/23 and a second one was placed on 09/19/23 on his left ankle. When asked by surveyors why was the first Wanderguard placed shortly after Resident #1's admission, he stated he often wandered around and attempted to get into the elevator. When asked if there was an order for the first Wanderguard, Staff E stated there must have been. An Elopement Risk Evaluation done on 09/19/23 at 11:25 AM documented Resident #1 was at low risk for elopement. Staff E further stated that he did not know there was an elopement binder in the lobby with a list of residents who have Wanderguards and he also stated he did not update the elopement binder letting the other staff members know that Resident #1 was at risk for elopement and that a new Wanderguard had been placed. Staff E stated the order for a Wanderguard to be placed would trigger an automatic updating of the elopement risk residents in the computer system. Staff E confirmed after the second Wanderguard was placed on Resident #1, he was observed wandering around the unit almost daily. He stated Resident #1 was watched by the staff to ensure he did not enter the elevator alone. In an interview conducted on 10/03/23 at 4:44 PM with the facility's Administrator, she stated there is an elopement binder located in the nursing supervisor's office and a second binder is located in the main lobby. She stated once a Wanderguard is placed on a resident, the elopement binders are updated and all staff members are notified immediately. In an interview conducted on 10/04/23 at 7:23 AM with the facility's Admissions Director, she stated that when Resident #1 eloped, she could hear Staff A yelling No in the lobby. She then asked Staff A who it was that just escaped through the main door, but Staff A did not know Resident #1's name. Staff A told her that Resident #1 was seen all morning in the main lobby walking back and forth and attempting to enter the Admissions Office which was locked. She stated she then went outside to look for Resident #1 and when she didn't see him, she reentered the building and asked Staff A again who the resident was that just escaped. Staff A again said, I do not know. She was then told by another staff member that it was Resident #1 who had eloped and a picture of him was taken out of the elopement binder located in the lobby, which was a bad copy. She then printed another copy so she could use it to identify Resident #1. The Admissions Director told the surveyor the fact that Resident #1 was seen in the lobby earlier that morning was a red flag indicating that Resident #1 wanted to leave the facility. Review of the facility's 5-day report revealed that Resident #1 was able to return to his personal apartment, change his clothes and shoes, and remove his Wanderguard while staff members were searching for him. He was later found by the facility's administration while he was walking to see his children in another apartment building. He was located by the facility's administration who picked him up in a personal vehicle and brought him back to the facility for assessment. Two days later, Resident #1 was discharged to another Skilled Nursing Facility.

Based on interviews and record reviews, the facility failed to develop, implement, and maintain an effective elopement training program for all new and existing staff. The facility failed to have effective communication training on the appropriate steps to take if an elopement occurs for 1 of 2 sampled residents reviewed for elopement (Resident #1). The findings included: Review of the facility's Elopement Guidelines for a missing resident who was seen leaving the premises provided by the facility's Administrator on 10/04/23 showed the following: Employees should attempt to prevent the departure courteously. Get help from other staff members in the immediate vicinity. Page CODE PINK to the designated area of the facility. Notify the Supervisor and Unit Manager that a resident left the premises. Print the Face sheet and picture of the resident. If the resident has already been identified to be at risk for elopement, obtain the copies from the Elopement Binder located at each nurse's station and on the 1st floor by the receptionist area. The nurse supervisor and Unit Manager will assign staff which area to search for: a. Description of what the resident was wearing. b. Walking the perimeter of the facility. c. Drive around the vicinty of the facility. d. Notify the Administrator, Director of Nursing and Risk Manager. Record review revealed that Resident #1 was admitted to the facility on [DATE]. A Wanderguard was placed for a risk of elopement on Resident #1. On 09/19/23, Resident #1 was observed attempting to leave the facility, and on 09/30/23, he successfully eloped through the front door of the facility and was out of the facility for approximately 9 hours until the facility's administration found him and brought him back to the facility. In a telephone interview conducted on 10/03/23 at 10:55 AM, Staff A, the facility's weekend Receptionist, stated that on 09/30/23, the morning of the elopement, she was working in the main lobby when Resident #1 was walking around the main entrance. She stated she did not know Resident #1 was at risk for elopement or that had a Wanderguard on his ankle. She further stated that around 10:20 AM, Resident #1 ran out of the main door, and she yelled after him to stop. When asked what he was wearing when he eloped, she stated she noticed he had a gray t-shirt on and was carrying a plastic bag. She continued by stating that Staff J, a facility Housekeeper, and the facility's Admission Director exited the building to attempt to locate Resident #1. Staff A stated she reentered the facility and called the weekend supervisor to tell her what had happened. When asked when she last received training on elopements, Staff A stated that she last participated in an elopement drill two years ago when she was a new employee. She stated she was told verbally what to do in case of an elopement and what steps to follow. She further stated she was told to call CODE SILVER, which, she said she was told, was the code for an elopement, and provide a picture of the missing resident from the binder in the main lobby so everyone can recognize the resident while they are looking for them. When asked if she knew how to identify residents at risk for elopement, Staff A said everyone was at risk and this was why the main front door needed to be locked. In an interview conducted on 10/03/23 at 11:36 AM with Staff B, the facility's weekday Receptionist, he stated that the last time he participated in an elopement drill was shortly after he was hired, which was around March of 2023. When asked what the steps are that the staff is supposed to follow in an elopement, Staff B said he would call CODE SILVER and alert the other staff members and the Administrator of the elopement. He stated he would also describe the missing resident and provide a print of the sheet with the resident's picture. When asked how he knows which residents are at risk for elopement, Staff B said that there was a binder in the main lobby with images of all residents at risk for elopement, which needs to be reviewed weekly. In an interview conducted on 10/03/23 at 12:14 PM, Staff E, Registered Nurse (RN), stated that there was an elopement binder on the 2nd floor (his unit). Staff E stated he knew Resident #1 was at risk for elopement and had a Wanderguard in place, but he never updated the binder on his unit with Resident #1's picture. When asked who was responsible for updating the elopement binder, Staff E stated he did not know. Staff E recalled participating in elopement education during his employment, but could not give the date of when it took place. Staff E was asked what the guidelines are to follow in an elopement of a resident who is seen leaving the facility, and he did not know. In an interview conducted on 10/03/23 at 4:44 PM, the facility's Administrator stated that there was an elopement binder in the Nursing Supervisor's office and another binder in the main lobby of the facility. The Administrator further stated when the staff visually sees a resident escaping the facility, the Supervisor oversees dispatching staff by foot or car to look for the eloped resident. When asked if they have a set of protocols to follow that is given to the staff members in case of an elopement, she said no and that it is only verbal instructions given to the staff. She stated elopement drills are done upon hire during orientation and again on a monthly basis by the facility's Staff Developer. In an interview conducted on 10/04/23 at 7:23 AM with the facility's Admissions Director, she stated that she started working in the facility approximately two months ago and had not received training in elopement education or an elopement drill since being hired. The morning of the elopement on 09/30/23, she heard Staff A screaming, and she went to the lobby area. She was told by Staff A that a resident had escaped, but she did not know who it was. She only knew that the resident was wearing a red t-shirt. The Admissions Director exited the facility to look for a resident with a red t-shirt and a plastic bag but she could not see him. She came back into the building and asked Staff A again as to who it was who eloped, and she did not know. The Admissions Director called the Administrator to let her know what had happened. At that point, other staff members were able to tell her which resident had escaped, and she printed a better copy of his picture from the medical records to distribute to the staff. In an interview conducted on 10/04/23 at 8:14 AM with Staff J, a facility Housekeeper stated that he heard Staff A screaming in the lobby that a resident had escaped. He stated he entered the main lobby area and saw a resident leaving through the front door. He stated he initially ran after the resident but was told by another staff member (he did not know who) not to follow the resident but rather to go into the kitchen and ask for a Creole-speaking staff member. Staff J stated he went to the kitchen and tried to find a staff member who spoke Creole but was unsuccessful so he went outside again. He stated he ran around the perimeter of the building but did not find Resident #1. Staff J stated he was not given a picture of Resident #1, but when he saw him running out, he tried to follow him. In an interview conducted on 10/04/23 at 3:00 PM with the facility's Administrator, she was informed of the findings and areas of concern.