Every finding on record at Gardens Healthcare & Rehabilitation Center

Based on interviews and record reviews, the facility failed to obtain food preferences for two of three residents (#63 and #119) reviewed for food in a total of 39 sampled residents. Failure obtain food preferences placed residents at risk of inadequate nutritional interventions and non-compliance. During the initial tour of the facility on 12/07/2025 at 12:30 PM, Resident 119 stated food is always cold and at times does not taste good. He explained that he was not aware if the facility had a substitution menu.On 12/08/2025 at 12:40 PM, Resident 119 was observed in his room with the food tray on the bedside table and the rice serving was untouched. He ate green beans and fish. He stated that the fish was warm. He added that he did not touch the rice because he hated rice. He added that he also hated carrots and squash, and dietary keeps serving these items to him. When asked if the facility reviewed his preferences, he stated no. He confirmed that he had not met anyone from dietary to go over food preferences.In an interview on 12/08/2025 at 12:40 PM, Resident 63 stated that he does not want what is served most of the time because he did not like it and 85% of the time the food is always cold. His plate was on the table with green beans and rice. He confirmed that no one spoke to him about food preferences.Review of the initial nutrition assessments dated 10/31/25 and 11/29/25 for Residents 63 and 119 respectively, revealed that food preferences were not obtained (Copies obtained).An interview was conducted on 12/09/2025 at 10:01 AM with the Dietary Manager and the Regional Director of Operations. The Dietary Manager stated that he met with new admission within 24-48 hours of admission, reviewed the food preferences and documented in the meal tracker. He added that the dietitian conducted the quarterly and annual review and notified him if there were any changes in food preferences. He added that the nurses would notify him as needed when residents have food concerns. When asked about food likes and dislikes, he stated that it was not added to the meal ticket. The meal tracker automatically takes off the item if it is on the menu to be served and places the resident on the alternate meal. When asked to review the food preferences/likes and dislikes for Residents 63 and 119 he reviewed the meal tracker system and confirmed that there was nothing documented. When asked if he had visited these residents, he stated that he could not recall.The Regional Director of Operations added that the Dietary Manager does not have access to Point Click Care (PCC- electronic documentation system) and only documented in the meal tracker. She stated that the dietitian would also document preferences in the nutrition assessment. The Dietary Manager and the Regional Director of Operations reviewed the meals tracker and the nutritional assessments for Residents 63 and 116 and confirmed that food preferences were not addressed.

Based on record review, interviews, and facility Transfer and Discharge policy review, the facility failed to provide a 30-day notice of discharge for one (Resident #1) of 2 residents reviewed for facility-initiated discharges, from a total of 4 residents sampled. As a result of the swift discharge from what had become Resident #1's home, he experienced sadness, loss and regret, and had insufficient time to plan for discharge to another location that would meet his physical, emotional and psychosocial needs. The findings include: A closed record review for Resident #1 revealed he was admitted to the facility on [DATE] and was [AGE] years old. He was discharged on [DATE]. His diagnoses included paraplegia, hypertension, polyneuropathy, neurogenic bowel, neuromuscular dysfunction of bladder and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with a brief interview for mental status (BIMS) score of 15, indicating he was cognitively intact. A review of the Discharge Return Not Anticipated MDS assessment dated [DATE], revealed Resident #1 had an unplanned discharge on this same date to a short-term general hospital. Resident #1 was independent with daily decision making and required some assistance with activities of daily living. Discharge planning for him to return to the community was not occurring while he was in the facility. A record review of the physician's order for Resident #1 revealed an order for him to be sent to the ER (emergency room ) for evaluation and treatment. (Photographic evidence was obtained) Review of the document titled AHCA Nursing Home Transfer and Discharge Notice revealed Resident #1 was transferred to a local hospital. The date the notice was given was 10/23/24, with an effective date 10/23/24, not the required 30-day notice of discharge. Further record review revealed that the Resident Representative section of the transfer form for Resident #1 was shown as unable to sign. and the reason for Transfer/Discharge was listed as Your needs cannot be met in this facility. (Photographic evidence was obtained) Review of a Psychiatry Phone Note dated 10/23/24 read: This provider was notified that resident was admitted to hospital as a [NAME] Act (a law that allows for involuntary examination and treatment for people who may have a mental illness and are a danger to themselves or others). It was reported to provider that patient had sent a message to his wife late Tuesday night, very early Wednesday morning, a suicide note. Staff reports that wife called the facility for staff to check on patient. Upon walking into his room, they noticed resident had tied his phone cord to the trapeze above his bed in attempt to hang himself. Staff cut the cord immediately and patient was able to respond and was still conscious. Per staff, patient will not be returning to this facility. Still in the hospital at this time. (Photographic evidence was obtained) Review of the document titled Nursing Home to Hospital Transfer for Resident #1 dated 10/23/24 at 4:00 am reported he was being sent to the hospital for choking with phone cord wrapped around his neck. Resident's head was observed hanging from a phone type charger, which was around his neck and tied to a trapeze bar above his head. His face was purple, eyes were bulging and the resident was groaning. The cord was cut with scissors. Bleeding was noted from the resident's mouth and nose. Called 911. Resident stated he was trying to commit suicide. (Photographic evidence was obtained) A telephone interview was conducted with Resident #1's spouse and Power of Attorney on 12/10/24 at 1:30 pm. She stated she had received a text from Resident #1. He was in distress, so she called the facility. Staff checked on him, found him in distress and transported him (to the hospital). She called the facility a few hours later and spoke with a staff member in the finance department and begged that the facility please not give away his room. Resident #1 wanted to return to the facility because emotionally it was good for him. He had his own private room there and a great rapport with the staff. A few hours later she received a phone call from the Administrator, who advised her that under the circumstances, she would have to come get Resident #1's belongings. So, she did. While at the facility she sat in the conference room with the Administrator and another facility staff member. Resident #1's wife said, [Resident #1] was not hurting ANYONE there, until that moment when he was in an emotional crisis. The facility just didn't want him back because of that incident. Resident #1 remained in the hospital for a little over three weeks, longer than he should have. The staff there told her after day two he didn't need to be there, but he had a urinary tract infection and was septic (infection in the blood) from it. Because of that, he was not allowed to participate in any counseling at the hospital. The psychiatric doctor told her he was not worried about Resident #1, but not once did he get counseling. Resident #1 was finally discharged on ce his illness resolved, but it was then they had to find someplace for him to go. That took a while. She stated the staff had loved him at the facility. He had been there 6 months. He was not ready to come home yet but was working on that. Resident #1 was happy with the physical therapy department and they would go in and work with him specifically. He also could use the machines in the gym to maintain his strength even though he was not on active PT caseload. Resident #1 was really upset that he was not going back. He wanted his room and the PT he was getting. Resident #1's wife began to cry at this point in the conversation. Resident #1 was currently at another local nursing home. We are not thrilled about it. She cried again as she explained the attempt on his life was unprecedented. That was SO not like him; it was a shock. She concluded by again saying, The staff here LOVED him, I mean they LOVED him. A telephone interview was conducted with the receiving hospital's Clinical Supervisor (CS) on 12/10/24 at 2:10 pm. The hospital's Psychiatric Counselor (PC) was also on the call. The PC stated Resident #1 was sent to them under the [NAME] Act, and the facility refused readmission. Because they anticipated pushback from the facility, they started working on discharging him earlier, but the facility said no. The CS reported that it was Resident #1's wife who told them she had been told to come get Resident #1's belongings the day he was transferred to the hospital. The CS asked the Administrator if he was willing to be fined by the Centers for Medicare and Medicaid services (CMS, a federal agency) and mentioned that the fines could be steep for refusing to allow the resident to return. The Administrator said yeah. It sounded like the decision was over his head, and he understood it was a tough decision to make. The CS stated that the text Resident #1 sent was at 2:00 am. Staff ran, got him off of the [Hoyer] and there were no other patients who saw it. The CS said he and the PC felt it was a very inappropriate refusal, and that Resident #1 had made it very clear he had wanted to go back to the facility. The PC concluded, stating Resident #1 realized his action had an impact and he could not go back to the facility. It affected him strongly at first, realizing that his life had changed so much related to the surgery that left him paralyzed. Then, realizing he could not go back to what was his home. That was one more thing for him to come off of. The resident's wife was definitely upset. A telephone interview was conducted with Resident #1 on 12/10/24 at 2:20 pm. He confirmed he was discharged from the facility and not allowed to come back. He was unfortunately at another nursing home now. The overall culture at the former facility was Let's take care of patients. The facility was wonderful; full of people who cared. He stated he so regretted not being there anymore and referred to the care as excellent. Resident #1 humbly explained his suicide attempt was during a desperate time, and he did a stupid thing. He became tearful as he explained he had an emotional breakdown, and it all came crashing down on him. The (new) facility was just not giving him what he needed as far as care. He said, It just isn't very good. Furthermore, there was very limited equipment in the therapy gym. Resident #1 learned almost immediately after his transfer that he would not be allowed back. He wanted to return but was told he couldn't. They packed up all his stuff and left it for his wife to retrieve. [NAME], bam, thank you ma'am, he was out of there. Resident #1 said he was supposed to receive a 30-day notice, but the facility was willing to pay a fine just to get it over with. Resident #1 concluded by saying he did not want to be where he was now and asked if there was any way the facility could be forced to take him back. An interview was conducted with the Administrator on 12/10/24 at 2:45 pm. The Director of Nursing joined him for the interview. The Administrator explained Resident #1 had been in the facility since April. He had come in as skilled (needing skilled nursing services), and they tried to get Resident #1 to where he could go home with the assistance of his wife. He wasn't strong enough yet. Prior to admission, Resident #1 had been a golfer and having back pain for a while. His friend, a surgeon, convinced Resident #1 to get back surgery and performed the operation. The surgery resulted in Resident #1 becoming paralyzed. Resident #1 was in a private room, so that made him happy. He was always polite, with no major issues. The DON interjected and explained Resident #1 was well-liked; he would talk with the staff and goof around. This incident was a total change for him. Resident #1's wife received an email from him late at night. She opened it and called the facility immediately. The wife advised the staff who answered that Resident #1 might commit suicide. Staff immediately went to the room and upon entry, saw him hanging from a telephone cord tied to his over-bed trapeze. Staff took scissors and immediately cut him down. There were no signs that would happen, and the wife had never voiced any similar concerns. Resident #1 had been seen by psych, and no antecedents were identified. Resident #1 was upset with the staff and told medics he was fading but the staff stopped it. Resident #1 was very close with the staff. It was traumatic. The Administrator said after finding Resident #1, emergency medical technicians were called. They arrived and Baker-Acted Resident #1. The facility assessed the situation and decided not to have Resident #1 return. The facility was not going to be able to meet his needs based on his wanting to harm himself. Facility staff followed him in the hospital for days, but nothing changed. Resident #1 was making no progress and refusing his antidepressants. They notified Resident #1's wife, who asked to come get his belongings. She realized he was not coming back. Ultimately, the Administrator signed off on the decision not to readmit Resident #1, but he certainly doesn't make those decisions alone. Clinical and Regional staff decided to deny Resident #1's return. The Administrator was asked if they considered providing a 30-day notice and one-to-one staffing supervision for the 30-day period leading up to discharge (or appeal hearing) in order to keep Resident #1 safe. The Administrator said they contemplated it, but decided no. He stated the facility sent a 30-day discharge notice to the hospital, but was reminded the date on the notice was the same day of the transfer, not 30 days later. The Administrator said the staff felt they might have been able to do something earlier to stop this resident. Ultimately, he felt he could not keep Resident #1 safe from himself. A telephone interview was conducted with Long Term Care Ombudsman (LTCO) A on 12/10/24 at 1:15 pm. She stated she was just talking with LTCO B, who handles discharges. She said she called the Administrator after this discharge and advised him he needed to accept Resident #1 back per the 30-day discharge notice requirements. The Administrator replied that he would not allow Resident #1 back per his and corporate's decision, as it was not in the best interest of this resident. She reminded him again he needed to take Resident #1 back, and he said no again. When the LTCO spoke with Resident #1 while he was still in the hospital, he told her he wanted to return to the facility. Review of the facility's policy Standards and Guidelines: Transfer and Discharge Implemented/Reviewed/Revised: 1/1/21 found it states: Standard: It is the standard of this facility to provide appropriate transfer and discharge services . The facility will allow for sufficient preparation and orientation by informing the resident where he or she is going to take steps to minimize anxiety. Guidelines: 1. The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . 2. The facility may not transfer or discharge the resident while the appeal is pending, pursuant to S 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to S 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. - Page #2: 30 Day Facility Initiated Discharges (Notice Requirements Before Transfer/Discharge): 1. Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-term Care Ombudsman. 2. The facility should record the reasons for the transfer or discharge in the resident's medical record and include in the notice the following items: 1)The reason for transfer or discharge; [1)] The effective date of transfer or discharge; 2) The location to which the resident is transferred or discharged ; 3) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; 4) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; 5) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 and; 3. The Notice of Transfer or Discharge should be made by the facility at least 30 days before the resident is transferred or discharged except under the following circumstances: The Notice must be made as soon as practicable before transfer or discharge when- a. The safety of individuals in the facility would be endangered; b. The health of individuals in the facility would be endangered; c. The resident's health improves sufficiently to allow a more immediate transfer or discharge; d. An immediate transfer or discharge is required by the resident's urgent medical needs; or e. A resident has not resided in the facility for 30 days. Unplanned Discharges/Emergency Transfers to Hospital: 1. When a change in condition or required transfer to the hospital or other higher level of care is determined, the facility should obtain appropriate transfer orders . 2. Documentation of the change should be reflected in the medical record . 5. In situations where the facility has decided to discharge the resident while still hospitalized , the facility will send a notice of the discharge to the resident and resident representative . (Photographic evidence was obtained) 50968 .

Based on record review, interviews, and facility Resident Return to Facility document review, the facility failed to permit one resident who was admitted for long-term care (Resident #1) to return to the facility following a [NAME] Act transfer to the hospital from a total of two residents reviewed for transfer/discharge. The abrupt discharge for Resident #1 caused him to experience sadness, loss and regret, and gave insufficient time to plan for discharge to another location of his choice that would meet his physical, emotional and psychosocial needs. The findings include: A closed record review for Resident #1 revealed he was admitted to the facility on [DATE] and was [AGE] years old. He was discharged on [DATE]. His diagnoses included paraplegia, hypertension, polyneuropathy, neurogenic bowel, neuromuscular dysfunction of bladder and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with a brief interview for mental status (BIMS) score of 15, indicating he was cognitively intact. A review of the Discharge Return Not Anticipated MDS assessment dated [DATE], revealed Resident #1 had an unplanned discharge on this same date to a short-term general hospital. Resident #1 was independent with daily decision making and required some assistance with activities of daily living. Discharge planning for him to return to the community was not occurring while he was in the facility. A record review of the physician's order for Resident #1 revealed an order for him to be sent to the ER (emergency room ) for evaluation and treatment. (Photographic evidence was obtained) Review of the document titled AHCA Nursing Home Transfer and Discharge Notice revealed Resident #1 was transferred to a local hospital. The date the notice was given was 10/23/24, with an effective date 10/23/24, not the required 30-day notice of discharge. Further record review revealed that the Resident Representative section of the transfer form for Resident #1 was shown as unable to sign. and the reason for Transfer/Discharge was listed as Your needs cannot be met in this facility. (Photographic evidence was obtained) Review of a Psychiatry Phone Note dated 10/23/24 read: This provider was notified that resident was admitted to hospital as a [NAME] Act (a law that allows for involuntary examination and treatment for people who may have a mental illness and are a danger to themselves or others). It was reported to provider that patient had sent a message to his wife late Tuesday night, very early Wednesday morning, a suicide note. Staff reports that wife called the facility for staff to check on patient. Upon walking into his room, they noticed resident had tied his phone cord to the trapeze above his bed in attempt to hang himself. Staff cut the cord immediately and patient was able to respond and was still conscious. Per staff, patient will not be returning to this facility. Still in the hospital at this time. (Photographic evidence was obtained) Review of the document titled Nursing Home to Hospital Transfer for Resident #1 dated 10/23/24 at 4:00 am reported he was being sent to the hospital for choking with phone cord wrapped around his neck. Resident's head was observed hanging from a phone type charger, which was around his neck and tied to a trapeze bar above his head. His face was purple, eyes were bulging and the resident was groaning. The cord was cut with scissors. Bleeding was noted from the resident's mouth and nose. Called 911. Resident stated he was trying to commit suicide. (Photographic evidence was obtained) Review of the document tilted Bed Hold Notice for Resident #1 dated 10/23/24 advised the notice was provided because resident was admitting to the hospital. It stated the facility policy was to remind of the bed-hold information. If the facility stay was paid by Medicaid, the bed would be held at no extra cost to the resident for a maximum of 8 days in a calendar month while hospitalized . If hospitalized beyond that time frame, private funds must be used to pay for and extended hold . if you do not hold your bed and wish to return to the facility, you will be allowed to return to your previous room, if available, or to the first available bed in a semi-private room. This is conditioned upon requiring services and your eligibility . You and your representative must verify that you wish to have your bed held within 24 hours of being admitted to the hospital or your bed will be relinquished . The form was signed by the facility but the resident's signature box stated, Unable to sign. (Photographic evidence was obtained) No documentation in the record was found reflecting communication between the facility and the receiving hospital during Resident #1's stay. A telephone interview was conducted with Resident #1's spouse and Power of Attorney on 12/10/24 at 1:30 pm. She stated she had received a text from Resident #1. He was in distress, so she called the facility. Staff checked on him, found him in distress and transported him (to the hospital). She called the facility a few hours later and spoke with a staff member in the finance department and begged that the facility please not give away his room. Resident #1 wanted to return to the facility because emotionally it was good for him. He had his own private room there and a great rapport with the staff. Then a few hours later she received a phone call from the Administrator, who advised her that under the circumstances, she would have to come get Resident #1's belongings. So, she did. While at the facility she sat in the conference room with the Administrator and another facility staff member. Resident #1's wife said, [Resident #1] was not hurting ANYONE there, until that moment when he was in an emotional crisis. The facility just didn't want him back because of that incident. Resident #1 remained in the hospital for a little over three weeks, longer than he should have. The staff there told her after day two he didn't need to be there, but he had a urinary tract infection and was septic (infection in the blood) from it. Because of that, he was not allowed to participate in any counseling at the hospital. The psychiatric doctor told her he was not worried about Resident #1, but not once did he get counseling. Resident #1 was finally discharged on ce his illness resolved, but it was then they had to find someplace for him to go. That took a while. She stated the staff had loved him at the facility. He had been there six months. He was not ready to come home yet but was working on that. Resident #1 was happy with the physical therapy department and they would go in and work with him specifically. He also could use the machines in the gym to maintain his strength even though he was not on active PT caseload. Resident #1 was really upset that he was not going back. He wanted his room and the PT he was getting. Resident #1's wife began to cry at this point in the conversation. Resident #1 was currently at another local nursing home. We are not thrilled about it. She cried again as she explained the attempt on his life was unprecedented. That was SO not like him; it was a shock. She concluded by again saying, The staff here LOVED him, I mean they LOVED him. A telephone interview was conducted with the receiving hospital's Clinical Supervisor (CS) on 12/10/24 at 2:10 pm. The hospital's Psychiatric Counselor (PC) was also on the call. The PC stated Resident #1 was sent to them under the [NAME] Act, and the facility refused readmission. Because they anticipated pushback from the facility, they started working on discharging him earlier, but the facility said no. The CS reported that it was Resident #1's wife who told them she had been told to come get Resident #1's belongings the day he was transferred to the hospital. The CS asked the Administrator if he was willing to be fined by the Centers for Medicare and Medicaid services (CMS, a federal agency) and mentioned that the fines could be steep for refusing to allow the resident to return. The Administrator said yeah. It sounded like the decision was over his head, and he understood it was a tough decision to make. The CS stated that the text Resident #1 sent was at 2:00 am. Staff ran, got him off of the [Hoyer] and there were no other patients who saw it. The CS said he and the PC felt it was a very inappropriate refusal, and that Resident #1 had made it very clear he had wanted to go back to the facility. The PC concluded, stating Resident #1 realized his action had an impact and he could not go back to the facility. It affected him strongly at first, realizing that his life had changed so much related to the surgery that left him paralyzed. Then, realizing he could not go back to what was his home. That was one more thing for him to come off of. The resident's wife was definitely upset. A telephone interview was conducted with Resident #1 on 12/10/24 at 2:20 pm. He confirmed he was discharged from the facility and not allowed to come back. He was unfortunately at another nursing home now. The overall culture at the former facility was Let's take care of patients. The facility was wonderful; full of people who cared. He stated he so regretted not being there anymore and referred to the care as excellent. Resident #1 humbly explained his suicide attempt was during a desperate time, and he did a stupid thing. He became tearful as he explained he had an emotional breakdown, and it all came crashing down on him. The (new) facility was just not giving him what he needed as far as care. He said, It just isn't very good. Furthermore, there was very limited equipment in the therapy gym. Resident #1 learned almost immediately after his transfer that he would not be allowed back. He wanted to return but was told he couldn't. They packed up all his stuff and left it for his wife to retrieve. [NAME], bam, thank you ma'am, he was out of there. Resident #1 said he was supposed to receive a 30-day notice, but the facility was willing to pay a fine just to get it over with. Resident #1 concluded by saying he did not want to be where he was now and asked if there was any way the facility could be forced to take him back. An interview was conducted with the Administrator on 12/10/24 at 2:45 pm. The Director of Nursing joined him for the interview. The Administrator explained Resident #1 had been in the facility since April. He had come in as skilled (needing skilled nursing services), and they tried to get Resident #1 to where he could go home with the assistance of his wife. He wasn't strong enough yet. Prior to admission, Resident #1 had been a golfer and having back pain for a while. His friend, a surgeon, convinced Resident #1 to get back surgery and performed the operation. The surgery resulted in Resident #1 becoming paralyzed. Resident #1 was in a private room, so that made him happy. He was always polite, with no major issues. The DON interjected and explained Resident #1 was well-liked; he would talk with the staff and goof around. This incident was a total change for him. Resident #1's wife received an email from him late at night. She opened it and called the facility immediately. The wife advised the staff who answered that Resident #1 might commit suicide. Staff immediately went to the room and upon entry, saw him hanging from a telephone cord tied to his over-bed trapeze. Staff took scissors and immediately cut him down. There were no signs that would happen, and the wife had never voiced any similar concerns. Resident #1 had been seen by psych, and no antecedents were identified. Resident #1 was upset with the staff and told medics he was fading but the staff stopped it. Resident #1 was very close with the staff. It was traumatic. The Administrator said after finding Resident #1, emergency medical technicians were called. They arrived and Baker-Acted Resident #1. The facility assessed the situation and decided not to have Resident #1 return. The facility was not going to be able to meet his needs based on his wanting to harm himself. Facility staff followed him in the hospital for days, but nothing changed. Resident #1 was making no progress and refusing his antidepressants. They notified Resident #1's wife, who asked to come get his belongings. She realized he was not coming back. Ultimately, the Administrator signed off on the decision not to readmit Resident #1, but he certainly doesn't make those decisions alone. Clinical and Regional staff decided to deny Resident #1's return. The Administrator was asked if they considered providing a 30-day notice and one-to-one staffing supervision for the 30-day period leading up to discharge (or appeal hearing) in order to keep Resident #1 safe. The Administrator said they contemplated it, but decided no. He stated the facility sent a 30-day discharge notice to the hospital, but was reminded the date on the notice was the same day of the transfer, not 30 days later. The Administrator said the staff felt they might have been able to do something earlier to stop this resident. Ultimately, he felt he could not keep Resident #1 safe from himself. A telephone interview was conducted with Long Term Care Ombudsman (LTCO) A on 12/10/24 at 1:15 pm. She stated she was just talking with LTCO B, who handles discharges. She said she called the Administrator after this discharge and advised him he needed to accept Resident #1 back per the 30-day discharge notice requirements. The Administrator replied that he would not allow Resident #1 back per his and corporate's decision, as it was not in the best interest of this resident. She reminded him again he needed to take Resident #1 back, and he said no again. When the LTCO spoke with Resident #1 while he was still in the hospital, he told her he wanted to return to the facility. Review of the facility's standard Standards and Guidelines: Resident Return to Facility implemented 1/1/21, reviewed/revised 1/1/24 found it states: Standard: It will be the standard of this facility to allow residents to be readmitted per federal and state guidelines unless the resident is deemed inappropriate to be readmitted to the facility for the following reasons: 1. The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs. 2. The resident's health has improved sufficiently so that the resident no longer needs the services of the facility. 3. The resident's clinical or behavioral status endangers the safety of individuals in the facility. 4. The resident's clinical or behavioral status endangers the health of individuals in the facility. 5. The resident has failed to pay for (or to have paid under Medicare or Medicaid) his or her stay at the facility. 6. The facility ceases to operate. Guidelines: 1. The process for readmission of a resident following rehospitalization or therapeutic leave should be followed per the facility bed hold and transfer and discharge policies . 4. The facility may have concerns about permitting a resident to return to the facility after a hospital stay due to the resident's clinical or behavioral condition at the time of transfer. The facility must not evaluate the resident based on his or condition when originally transferred to the hospital. If the facility determines it will not be permitting the resident to return, the medical record should show evidence that the facility made efforts to: -Determine if the resident still requires the services of the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. -Ascertain an accurate status of the resident's condition-this can be accomplished via communication between hospital and nursing home staff and/or through visits by nursing home staff to the hospital. -Find out what treatments, medications and services the hospital provided to improve the resident's condition. If the facility is unable to provide the same treatments, medications, and services, the facility may not be able to meet the resident's needs and may consider initiating a discharge. For example, a resident who has required IV medication or frequent blood monitoring while in the hospital and the nursing home is unable to provide this same level of care. -Work with the hospital to ensure the resident's condition and needs are within the nursing home's scope of care, based on its facility assessment, prior to hospital discharge. For example, the nursing home could ask the hospital to: -Attempt reducing a resident's psychotropic medication prior to discharge and monitor symptoms so that the nursing home can determine whether it will be able to meet the resident's needs upon return; -Convert IV medications to oral medications and ensure that the oral medications adequately address the resident's needs . 6. If the resident chooses to appeal the discharge, the facility must allow the resident to return to his or her room or an available bed in the nursing home during the appeal process, unless there is evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility. (Photographic evidence was obtained)

Based on observations, interviews with staff, and a review of the 2022 Food Code, the facility failed to store and distribute ice in accordance with professional standards for food service safety in two of three ice machines inspected. This had the potential to affect all 103 residents who ate and drank by mouth from a total of 104 residents in the facility. Failure to ensure ice machines are clean and draining properly poses a risk of contamination with mold or bacteria, which could lead to waterborne illness. The findings include: During an initial tour of the kitchen on 1/22/24 at 10:25 AM, the ice machine was inspected. Standing water was pooled at the base of the opening where the ice machine lid closed and came to rest. The location of the pooled water presented a likelihood of splashing into the ice when the lid was closed. (Photographic evidence obtained) The Certified Dietary Manager (CDM), who was present at the time of the tour, acknowledged the pooled water and it's proximity to the ice. She stated it had always been like that. The CDM retrieved some paper towels and began wiping up the water but it splashed back into the ice. The tile floor around the base of the machine was very wet and had shallow, pooled water around the legs of the machine. During a visit to the 500 hallway on 1/22/24 at 12:21 PM, the food pantry's ice machine was inspected. The white plastic face plate concealing the ice chute had what resembled reddish pink bio-slime along the base of the plate. (Photographic evidence obtained) During a revisit to the kitchen on 1/25/24 at 1:40 PM, the ice machine pooling water concern had been resolved. The CDM explained that maintenance assisted with the resolution. She was accompanied to inspect the ice machine on the 500 hall. Upon inspection, she confirmed the presence of the pink substance. The CDM put the machine out of commission by posting a sign. The Maintenance Director (MD) was interviewed on 1/25/24 at 2:01 PM. He was asked about the kitchen ice machine and reported it had been fixed. He explained he had to raise and level it to ensure condensation drained forward to the drain and not back into the ice. The MD was asked how often he monitored the buildup of condensation for that machine. He said daily since the discovery was made days ago. Prior to that, he deep cleaned the machines every three months and did a general cleaning monthly. The MD and the Administrator were accompanied to the 500 hall ice machine. The MD attempted to wipe the area but the substance was embedded in the plastic and would not come off. He confirmed the presence of the substance. A review of the 2022 United States Food and Drug Administration found under section 4-602.11 Equipment Food-Contact Surfaces and Utensils it states: Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. (Photographic evidence obtained) A review of the Internet website (https://www.mytwintiers.com/news-cat/national-news/what-is-that-pink-slime-in-the-ice-machine/) found the biofilm known as pink slime is a frequent sight on ice machines and as buildup anywhere near water. The substance is a bacteria colony that could lead to serious health problems if ingested or if left unattended. Biofilms are the result of microorganisms attaching to a surface and often is a result of mold or fungus that has accumulated from bacteria growth on a surface that is constantly exposed to clinging water droplets and warm temperatures. Once well-developed biofilms establish themselves on surfaces, cleaning and sanitation become much more difficult. Sanitizing might not be enough and the substance must be physically removed from a surface in addition to regular cleaning. (Photographic evidence obtained) .

Based on observations, resident and facility record reviews, and interviews with staff, the facility failed to provide appropriate assistance with nail care for one (Resident #60) of four residents (Resident #60) reviewed for activities of daily living (ADLs), from a total of 29 residents in the sample. The findings include: An observation of Resident #60 was made on 01/23/24 at 9:34 AM. The fingernails on both of her hands were elongated and an unknown dark brown substance was observed under the nail tips. The tips of her nails were jagged and in need of filing. (Photographic evidence obtained) On 1/24/24 at 1:43 PM, Resident #60's fingernails on both hands were observed still in the same condition and with the unknown brown substance under the tips. (Photographic evidence obtained) An interview was conducted with Licensed Practical Nurse (LPN) A on 1/25/24 at 11:24 AM. When asked who was responsible for residents' nail care, LPN A replied that certified nursing assistants (CNAs) provided nail care and were permitted to trim nails unless the resident was diabetic; in that case, the nurses provided the nail care. When asked how staff removed debris from underneath the nails, LPN A said she was not sure if CNAs were using nail brushes or orange sticks. She stated residents' fingernails should be tended to as needed. CNA B was interviewed on 1/24/24 at 2:38 PM. She confirmed that the CNAs were responsible for assisting residents with keeping their fingernails clean. CNAs could file and clean fingernails but not clip them. The nurses were responsible for that. Resident #60 was observed in her room on 1/25/24 at 9:49 AM. She was in bed and had the remains of her breakfast on her overbed table. Upon request, she displayed her fingernails which now appeared neatly filed, but still with the same brown substance under the tips. Resident #60 reported that the nurse had just come in the other day to do them. She asked, They look better, don't they? When shown, she acknowledged the brown substance underneath but could not state what it was or how it got there. The Long Term Care Unit Manager (LTCUM) was interviewed on 1/25/24 at 11:33 AM. She stated CNAs should provide care when a resident's nails were long or in need of cleaning. Orange sticks were available for cleaning underneath the nails but nail brushes were not. CNAs provided hand hygiene before meals by using hand wipes. The LTCUM was accompanied to Resident #60's room to observe her fingernails; however, the resident was receiving personal care. When shown the photographs, the LTCUM confirmed the presence of the dark brown unknown substance under the tips. She was unsure of what the matter was but confirmed Resident #60's need for nail care. A record review for Resident #60 found she was admitted to the facility on [DATE]. She had a quarterly minimum data set (MDS) assessment with an assessment reference date of 11/8/23. Resident #60 had a brief interview for mental status (BIMS) score of 13 out of 15 points, reflecting that she was cognitively intact. Her diagnoses included cancer, Parkinson's disease and renal insufficiency. Resident #60 was care planned on 8/22/23 for her ADL self-care performance deficit related to her activity intolerance, impaired balance, weakness and Parkinson's disease. The goal was to maintain her current level of function through the next review date. Interventions included, but were not limited to, requires extensive assistance of 1 person with personal hygiene. Resident #60 was also care planed on 11/13/23 for a rash to her vaginal area, with the goal to heal by the next review date. Interventions included avoid scratching and keep hands and body parts from excessive moisture and monitor skin rash for increased spread or signs of infection. (Photographic evidence obtained) A review of Resident #60's CNA tasks found that she required physical to total assistance daily with bathing and personal hygiene. The bathing task further asked if nail care was provided during bathing. The task was marked yes for January 5, 10, 17, 19 and 22, 2024, and noted that Resident #60 required physical help to total assistance with nail care. She was independent with eating. (Photographic evidence obtained) A review of the facility's Standards and Guidelines: Nail Care (implemented 1/15/21, revised/reviewed 1/15/2) found: Standard: It will be the standard of this facility to provide nail care to residents per resident preferences and to maintain dignity. Guidelines: .3. Nail care includes regular cleaning and regular trimming, unless contraindicated by resident condition, specific behaviors or resident refusal. .6. Trimmed and smooth nails can help prevent the resident from accidentally scratching and injuring his or her skin. 7. Watch for and report changes in general condition of resident's nails. (Photographic evidence obtained)

Based on observations and interviews with staff, the facility failed to ensure waste and refuse were disposed of properly into one of two dumpsters inspected. Failure to ensure refuse is contained presents unsanitary conditions and the risk of harboring and feeding pests. The findings include: During the initial kitchen tour on 1/22/24 at 10:25 AM, the facility's two commercial garbage dumpsters were inspected. One of the two dumpsters was found with medical waste, food, cardboard boxes and trash strewn about the base of the dumpster. Some of the debris had migrated to the base of electrical equipment nearby. (Photographic evidence obtained) The Certified Dietary Manager (CDM), who was present for the tour, confirmed the condition of the area. She explained garbage pickup was two days a week and as requested. Maintenance was responsible for picking up the trash around the dumpsters. The CDM was asked if maintenance worked weekends but she did not respond. The dumpsters were revisited on 1/25/24 at 1:40 PM. The same one of two dumpsters was now overfilled and the lid was propped open approximately three feet. Cardboard boxes were holding the lid open and boxes and trash were exposed. The CDM recognized the concern and asked for assistance with redistributing the contents of the dumpster in order to get the lid to close. She again stated maintenance was responsible for maintaining the dumpsters. The Maintenance Director (MD) was interviewed on 1/25/24 at 2:01 PM. He was asked about his responsibility with maintaining the condition of the dumpsters and surrounding areas. The MD stated the dietary department was responsible, but he helped and picked up when he saw something. He had spoken to dietary about it. Trash pickup was daily except for Thursdays and Sundays. The MD looked at the photographic evidence and confirmed the unsanitary conditions. .

Based on observations and staff interviews, the facility failed to ensure that two (Residents #85 and #5) of three residents observed during medication administration, from a total sample of 27 residents, were provided privacy during medical treatment. The findings include: On 2/22/22 at 11:00 AM, Registered Nurse (RN) A was observed performing blood glucose monitoring for Resident #85. RN A obtained the necessary equipment, entered the resident's room, and left the door open after verifying the resident's identity. The nurse pricked the resident's finger for blood and obtained a blood glucose result without pulling the resident's curtain to provide privacy. RN A stated the blood sugar was 211 and the resident required insulin. After hygiene, the nurse obtained 2 units of insulin and went back to Resident #85 with the door still open and the privacy curtain not pulled. The nurse administered the insulin in the resident's left lower abdomen. When asked whether she provided privacy during the process, she replied, I completely forgot about that. On 2/22/22 at 11:45 AM, Licensed Practical Nurse (LPN) B obtained the necessary equipment for blood glucose monitoring and entered Resident #5's room. The nurse did not knock on the resident's door, did not ask permission to enter, and left the door open after verifying the resident's identity. LPN B pricked the resident's finger for blood and obtained a blood glucose result without pulling the resident's curtain to provide privacy. Resident #5 was in the bed close to the door and could be observed from the hallway. LPN B stated the blood sugar reading was 463. He added that the blood sugar was beyond the parameters and the resident's physician would have to be contacted. He returned to the resident and stated LPN D/Unit Manager contacted the physician and orders were given to administer 12 units of insulin and recheck the resident's blood sugar after an hour. LPN B obtained the 12 units of insulin, entered the resident's room without closing the door or pulling the curtain for privacy, and administered the insulin in the resident's left upper arm. During a medication administration observation on 2/23/21 at 9:07 AM, LPN C was observed entering Resident #5's room without knocking on the door or requesting permission to enter. LPN C left the door open, and did not pull the privacy curtain closed before administering medication to the resident. In an interview on 2/23/22 at 9:30 AM, LPN C confirmed that she had not provided privacy to Resident #5 during medication administration.

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5%, based on 2 errors with 35 opportunities for error, resulting in an error rate of 5.714%. The findings include: During a medication administration observation on 2/23/21 at 9:07 AM, Licensed Practical Nurse (LPN) C was observed obtaining medication for Resident #5. The nurse obtained and administered one tab of [MEDICATION(S)] 20 milligrams (mg) ( medication to remove excess fluid ), and one tablet of [MEDICATION(S)] 2 mg (medication to help regulate blood sugar) to Resident #5. A review of Resident #5's medical record, revealed that her current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copies obtained) In an interview on 02/23/22 at 9:30 AM, LPN C confirmed that she had administered one [MEDICATION(S)] pill and one [MEDICATION(S)] pill. When asked to review Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I needed to give 2 pills of [MEDICATION(S)] and [MEDICATION(S)]. She stated she would go back and administer the two remaining pills to Resident #5. A review of the facility's policy and procedure titled: Standards and Guidelines: Medication Administration (Last revised on 01/01/2021), revealed the standards read, It will be the standard of this facility to administer medication in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances, such as lack of availability of medication or refusal of medication by the resident. The guideline included: 2. The Director of Nursing services is responsible for the supervision and direction of all personnel with medication administration and duties and functions. 5. Should a dosage seem excessive considering the resident's age and medical condition, or medication orders seem to be unrelated to the resident 's current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that right medication , right dosage right time and right method of administration are verified.

Based on observations in the kitchen on 2/24/2020 through 2/27/2020, and staff interviews, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings include: During an initial tour of the Dishwashing room in the kitchen on 2/24/20 at 11:21 AM, observed the ceiling tiles. There was a black substance on the wall behind the dishwasher sink and the dishroom tiled walls. The blackened area covered the entire area (See photographic evidence). The 2 dish- rack holders were also observed with murky and slimy liquid interspersed with black colored growth. (See photographic evidence) after the last rack was removed to show the evidence. The Certified Dietary Manager was interviewed on 2/24/20 at 11:21am while observing the area. She stated that the walls were power washed every 2 days but the blackened areas returned. She was asked if the kitchen had a mold problem. Staff did not respond. She was asked if the Administrator had been notified of the problem and she said no. The Administrator was called to the kitchen and she was present while the photographic evidence was taken. It was also observed during the same time that there were five serving scoops which were already washed and stored with dried food debris. The can opener was observed impacted. Observed the 2 Plate Lowerators holding clean plates with spillage and food debris. The base of the door leading out of the cleaning equipment room was observed with the kick plate missing but covered with black growth that had destroyed the base of the door. (Photographic evidence) Interview with the Administrator at 11:23 AM on 2/24/2020. The Administrator stated that the facility had not been able to find a replacement door and none of the vendors had a replacement door. The Certified Dietary Manager (CDM) stated that the Dietary aides were responsible for cleaning the dish room walls and the floors. They were to power wash the walls every 2 days. On 2/27/2020 at 12:46 PM, the wall by the dishwasher sink which was cleaned on 2/24/2020 was observed again with some discoloration. Interview with the Dietary aide in charge of cleaning the area at 12:48 PM on 2/27/2020 revealed that the wall was cleaned daily. A review of the Daily cleaning schedule failed to indicate that the Dietary aides were responsible for Power- washing the walls of the dish-room. It noted that between 6:30 PM and 7:15 PM, Log dish temperature and PPM. Send dishes. When finished, wipe down dish machine, counters and walls. The facility had no cleaning schedule for the dishroom walls.

Based on observations, interviews and a review of policies and procedures, the facility failed to store drugs in a locked compartment for three (Residents #2, #7 and #12) of 12 residents in the sample, from a facility census of 105 residents. The findings include: During a 1/9/20 observation of medication administration at 9:46 AM for Resident #2 with Employee A, Licensed Practical Nurse (LPN), Employee A pulled all of Resident #2's scheduled medications from the medication cart except the [MEDICATION NAME] nasal spray (allergy medication), which was not there. He looked in the resident's door and asked her if she had the medication in her room and she responded, Yes, I have it. The nurse continued to collect the rest of the resident's medication for administration. Upon entering her room, he asked again about the nasal spray and she stated it was in her drawer. She would use it when she got out of the shower. The nightstand in her room had no locks on any of the drawers. During a tour of the facility at 11:12 AM, Resident #7 was observed with two bottles of prescription eye medication on her nightstand. During an interview with Resident #7 at the time of the observation, she stated, I brought those (two bottles of eye drops) from the hospital. They (facility nurses) sometimes forget to bring me my eye drops so I use those. I have [MEDICAL CONDITION] and I have to have my drops. At 11:23 AM, Resident #12's room was observed with a bottle of [MEDICATION NAME] nasal spray (allergy medication) sitting on his table. Record reviews were conducted for Residents #2, #7 and #12. There was no evidence that any of these residents had been assessed for self-administration of medication. Their electronic medication records were reviewed, and there was no documentation verifying that these residents self-administered their medications. An interview was conducted with the Regional Nurse Consultant (RNC)/Registered Nurse (RN) on 1/9/20 at 1:17 PM regarding the facility's policy for allowing residents to keep medications at bedside. She stated there was no specific policy for that. The facility had a Self-Administration of Medications evaluation in the electronic documentation system that was completed for residents keeping medications at bedside. When asked whether the facility obtained physicians' orders for medication self-administration, she stated, No, that is kind of loose. We do it if they pass the self-administration assessment. She further stated that the facility had an SG (Standard Guideline) for that, which could be provided upon request. Another interview was conducted with the RNC on 1/9/20 at 2:02 PM regarding medications at bedside. She stated (Resident #7) relinquished her eye drops and her husband was going to take them home. When the RNC was made aware of the observations of the three residents with medications at bedside, she stated , Oh, I thought that was the only one that you found. I guess we ll have to do a facility-wide sweep. She was asked whether assessments had been completed for the residents in question, and she confirmed none of the three had been assessed for self-administration of medication. A review of the facility's Standard Guideline/Policy and Procedure for self-administration of medication revealed the following: Manual: Nursing Standard Guidelines: SG Self-Administration of Meds Policy Number: 12/07.09.049 Section: Medication Issued: 12/1/2004 Revised: 2/1/2010; 7/1/2015 Page 1 of 1 Standard: It is the standard of this facility that residents who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Guidelines: 1. As part of the overall evaluation, the staff and practitioner will assess or evaluate each resident's mental and physical abilities to determine whether a resident is capable of self-administrating medications. 5. Self-administered medications should be stored in a safe and secure place, which is not accessible by other residents (i.e. locked bedside table drawer). If self storage is not possible in a resident's room, the medications of the residents permitted to self-administer medications will be stored on a medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 6. Nursing staff will transfer pertinent information information to the clinical record, appropriately noting the doses of medication were self-administered.

Based on observation, interviews and record review, the facility failed to provide oxygen services according to physician's orders for one (Resident #9) of two residents reviewed for respiratory services in a sample of 34 residents. The findings include: On 10/22/2018 at 11:24 AM, Resident #9 was observed in the TV/Day room across from the North Wing nurses' station. Resident #9 was observed wearing a nasal cannula with tubing attached to an empty oxygen (O2) tank. Resident #9's nurse (Employee A) was observed standing at her medication cart. She was first asked how long Resident #9 was in the TV/day room. She stated about an hour and a half. She was asked to check Resident #9's O2 tank. She confirmed the tank was empty. She removed the tank from the wheelchair and started to walk off. She then came back and put the same tank back on the wheelchair. The nurse (Employee A) then left the area, and went back to work at her medication cart. An observation of the O2 tank at that time found the rate was set at two (2) liters. The nurse (Employee A) then left and brought back a new tank and replaced the empty tank. A few minutes later Employee A was asked to check Resident #9's O2 saturation. She returned to the resident in the day room. She was followed and asked if she knew the orders for Resident #9's oxygen flow rate. She stated she needed to check, and went back to her medication cart. She looked up the orders in her computer, then stated the order was for oxygen at four (4) liters per minute. On 10/23/2018 at 8:55 AM, Resident #9 was observed in bed. She was receiving oxygen from an O2 concentrator that was set at two (2) liters per minute. An interview was conducted with the North Wing Unit Manager on 10/23/2018 at 9:05 AM. She was asked if Resident #9's O2 orders had changed. She looked in the computer and stated no. She went to Resident #9's nurse (Employee F) and informed her that they needed to keep an eye on the resident's O2 and educate the resident's son. A record review for Resident #9 found she was admitted to the facility on [DATE] with the most recent admission on 9/7/2018. [DIAGNOSES REDACTED]. A review of Resident #9's physician's orders found an order for [REDACTED]. A review of Resident #9's care plans found she was care planned for altered respiratory status/difficulty breathing /risk for aspiration related to shortness of breath. The care plan included the intervention, Administer oxygen via O2 concentrator: Continuous at 4 liters via nasal cannula. .

Based on observation, resident record review, and interviews with staff, the facility failed to ensure residents maintained acceptable parameters of nutritional status by failing to address or intervene to prevent significant weight loss for 3 of 4 sampled residents reviewed for nutrition (Resident #20, #38 and #108), out of a total of 29 sampled residents. The findings include: 1. An interview was attempted with Resident #108 on 09/19/2017 at 2:51 PM. When asked about her appetite, she said she did not always eat her lunch, but also denied receiving ice cream or frozen treats with or between meals. She then became confused, stating that she liked to read books, and that her glasses were kept in her lunch period. An interview with Employee A, Certified Nursing Assistant (CNA), on 09/20/2017 at 10:22 AM, found Resident #108 was confused, and needed to be fed at mealtimes. She reported food intake at approximately 75% at breakfast, and 50% at lunch. The CNA stated that she used to get ice cream and shakes, but did not receive those any longer. A clinical record review for Resident #108 revealed an annual minimum data set (MDS) assessment with an assessment reference date of 7/28/17. Resident #108 was noted as rarely or never able to express ideas and wants/needs, and rarely or never understood others. She was assessed with [REDACTED]., and depression. There were no swallowing problems, and no weight loss of 5% or more over the assessment look-back period. Resident #108 was 64 tall and weighed 128 pounds. No therapeutic diet was ordered. Resident #108 was care planned for potential nutritional problems, anorexia and dementia, with possible unavoidable weight loss as her disease progressed. The care plan was updated with notes that nutritional supplements were ordered in July, August and October of 2015. Interventions included nutritional support per the physician's orders [REDACTED]. Resident #108 had physician's orders [REDACTED]. Her intake fluctuated between 0% and 100% according to the medication administration record. She also had orders for [MEDICATION NAME] (an anti-depressant medication that can be used to stimulate the appetite) 15 milligrams every night at bedtime for abnormal weight loss and major [MEDICAL CONDITION], which was started in July 2015. Resident #108 was weighed monthly, and the following weights were recorded: 4/4/17 123.6 pounds (#) 5/2/17 131.2 # 6/1/17 126 # 7/5/17 128 # 8/4/17 127 # 9/6/17 117.7 # This reflected a 7.3% loss between August and September 2017. A total weight loss of 5% or greater in 30 days is considered significant by dietary standards. An annual nutritional assessment completed on 7/20/17 noted Resident #108 weighed 128#. A physician's progress note dated 8/9/17 noted a weight of 127#. There were no additional notes regarding the resident's weight loss between August and September of 2017. An interview was conducted with the Certified Dietary Manager (CDM) on 09/20/2017 at 2:05 PM. He stated the facility had been without an Registered Dietician (RD) for some time. He reviewed the record for Resident #108, confirmed the weight loss, and stated the RD would typically address the loss. On 09/20/2017 at 2:29 PM, the South Wing Unit Manager (SWUM) stated that when a resident had weight loss, the RD would address it. The SWUM was not aware Resident #108 had lost weight, as she had not been notified. 2. An interview was conducted with Employee H, CNA, on 09/21/2017 at 10:28 AM. She stated Resident #38 typically consumed 50% of her meal at breakfast and lunch. The resident received no nutritional supplements to her knowledge. Resident #38 was interviewed on 09/21/2017 at 10:32 AM. She stated her appetite was not so good anymore. She was unaware of any recent weight loss. Resident #38 said she did not receive, and did not want, any nutritional shakes or frozen treats. A record review conducted for Resident #38 revealed a Quarterly MDS assessment with an assessment reference date of 8/16/17. The resident had a brief interview of mental status (BIMS) score of 12 out of a total of 15 points. She required supervision and setup help with eating. [DIAGNOSES REDACTED]. There was no swallowing disorder, and weight was recorded at 137#. No weight loss was coded (5% or more in the last month or 10% in the last 6 months). Resident #38 was care planned for potential nutritional problem due to a body mass index (BMI) above standards of reference, dementia, and [MEDICAL CONDITIONS]. A nutritional supplement was last added on 3/28/17. The goal was not to experience significant weight change through the next review date as evidenced by +/- 5% in 30 days or +/- 10% in 180 days. Interventions included labs/diagnostic work as ordered, offer substitutes if 50% or less was consumed, supplements as ordered, RD to evaluate prn and report unplanned/unexpected weight loss to physician. Resident #38's weights were documented as follows: 4/5/17 145.3# 5/2/17 137# 5/8/17 142.6# 5/16/17 139.8# 6/1/17 137.2# 7/5/17 138# 8/4/17 137# 9/6/17 131# This reflected an overall weight loss of 14.3#, or a total of 9.8% loss in 6 months (significant weight loss is defined as 10% over a 6 month period). Further review of the clinical record found there was no mention of the almost 10% weight loss over the last 6 months. A quarterly Nutritional Progress note authored by the RD dated 9/7/17 noted Resident #38 had fluctuating intake, and no problems chewing/swallowing. Resident #38 was on Ready Care 2.0 (a nutritional supplement) to promote nutritional needs. Her current weight was noted at 131# at the top of the form, but in the summary and recommendation field, the RD referred to a current (incorrect) weight of 137# (6# heavier than the actual weight at the time of assessment). No recommendations were made to prevent further weight loss from escalating to a significant value of 10% over the past 6 months. The South Wing Unit Manager was interviewed on 09/21/2017 at 10:36 AM. She reviewed Resident #38's clinical record and confirmed almost a 10% weight loss over the past 180 days. She confirmed there was no documentation in the record indicating the RD addressed the weight loss in her September 2017 quarterly review. She also confirmed no additional nutritional interventions had been implemented since March 2017. An interview was conducted with the Consulting RD on 09/21/2017 at 11:15 AM. She stated Resident #28 had not triggered in the electronic recording system for a 6 month significant weight loss, even though she was close. The system did not recognize percentages (resident had a 9.8% loss in 6 months. The system would not alert staff until a total loss of 10% had been calculated). She confirmed the resident had lost almost 10% of her weight over a 6-month period. The Consulting RD stated the RD's quarterly recommendations based on a weight 137# (instead of an accurate weight of 131#) was likely an oversight. She stated that the facility would not have been required to notify the physician until a total of 10% loss had been triggered, but that she wanted to initiate something different at this point for Resident #38. She explained there were multiple interventions possible, ranging from changing to whole milk at mealtime, which would provide additional calories, to nutritional shakes or frozen treats. The Consulting RD stated the CDM should have notified the RD, so that preventative interventions might have been considered to prevent further weight loss and a 10% trigger. 3. A record review for Resident #20 found she was admitted to the facility on [DATE] with a readmission on 6/3/2017. Her [DIAGNOSES REDACTED]. Further record review revealed the following weights: 9/6/2017 133.6 8/18/2017 135.6 8/4/2017 144 7/5/2017 142 6/19/2017 142.4 6/13/2017 140.2 6/7/2017 149.2 6/5/2017 148.8 6/3/2017 151.4 6/1/2017 145.6 Record review found the most recent nutritional assessment for Resident #20 was a Nutritional Progress note dated 6/22/2017, with a weight warning and a 6/19/2017 weight of 142.2 pounds with a -5.0% change. The dietician wrote: Patient (Pt) has weight loss and receives a liberal diabetic diet with intake ranging from 50-100% at meals. Pt also receives Sugar Free Ready Care. Will liberalize diet to regular due to weight loss. Continue to monitor patient. Record review also revealed a 6/13/2017 weight warning value 140.2 -5%. Pt receives a liberal diet and intake ranges from 50-100% at meals. Increased ready care due to weight loss. Record review of the resident's nutritional care plan revealed a new approach of a 6/6/2017 new supplement order and a 6/13/2017 new supplement order. During an interview with Resident #20's nurse (Employee E) on 9/20/2017 at 2:36 PM, she stated Resident #20 was receiving the supplement called Redicare. She stated she did not know who got rid of it, as the resident was drinking the Redicare. In an interview with the Registered Dietician Consultant (RD) on 9/20/2017 at 2:52 PM, she stated the order for the supplement came off of the physician's orders [REDACTED]. She further stated that the dietician who was covering was no longer there, and there was no evidence of dietary assessment for July and August because there was no documentation during that timeframe. The North Wing Unit Manager also confirmed the findings. She stated on 9/20/2017 at 3:00 PM, the order for the supplement ended based on the doctor approving the RD recommendation of the supplement through 7/31/2017. She confirmed that the previous RD did not complete further assessments after 6/20/2017 or make further recommendations.

Based on record review and staff interview, the facility failed to ensure collaboration of hospice services and care provided by facility staff for 1 (Resident #61) of 1 sampled residents from a total of 29 residents receiving hospice services. The findings include: A record review for Resident #61 revealed that the [AGE] year-old female was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She required extensive assistance with activities of daily living. Due to shortness of breath, she required continuous oxygen. Resident #61's respiratory condition worsened, and hospice services were ordered. She was admitted to hospice services on 3/15/17 with terminal [DIAGNOSES REDACTED]. Upon admission to hospice, Resident # 61 had a DNR (do not resuscitate) order in place. On 4/15/17, Resident #61 revoked the DNR and was made a full code. A review of the hospice notes and care plans dated 7/27, 8/10, 8/24 and 9/7/17 did not reflect her decision to revoke her DNR status. An interview was conducted with the Social Worker on 9/21/17 at 1:35 p.m. When asked the code status of Resident #61, she stated she was a full code. When she was admitted to hospice on 3/15/17 she was DNR. On 4/18/17 Resident #61 revoked the DNR. When asked who was responsible for notifying hospice staff of the change in condition or physician orders, she replied that the nurses were responsible. When asked if the hospice nurse attended care plan meetings for Resident #61, the social worker stated she would check with the care plan coordinator. She was told that hospice staff were invited to the meetings, and there were copies of notices sent to hospice. The hospice staff did not attend care plan meetings held on 3/23/17 or 6/29/17. A review of the hospice contract signed by the hospice provider and the facility dated 3/2/15, revealed on page 5, The hospice will promote open and frequent communication concerning the hospice plan of care and the hospice patient's needs. The hospice staff will attend the facility's patient care conferences when a hospice patient will be discussed. Also the parties will communicate pertinent information with each other either verbally or in the residential hospice patients record at least weekly and/or at each hospice visit to ensure needs are addressed. Documentation of such communication shall be included in the hospice patients medical record. An interview was conducted with Director of Nursing (DON) on 9/21/17 at 1:55 p.m. When asked the code status of Res #61 she stated she was a full code. She was asked how the facility communicated changes to hospice staff, and she replied that the hospice nurse checked with a facility nurse each time she visited When asked if any facility staff had documented the change in code status to hospice, she stated she would check the clinical record. After review of the record, she stated she could not find documentation that hospice was notified, therefore she could not confirm that hospice had been notified.

Based on observations, record review and interview, the facility failed to provide care for urinary incontinence and follow the care plan for 1 of 1 residents reviewed out of a sample of 29 residents (Resident #163). The findings include: A record review was conducted for Resident #163 which documented an admission date of [DATE] with the following Diagnoses: [REDACTED]. A clinical record review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was occasionally incontinent of urine and was not on a toileting program. A record review of the care plan (updated 8/30/17) reported the resident had a potential for urinary incontinence due to his disease process ([MEDICAL CONDITION]). The goal was to keep the resident clean, dry and comfortable with an intervention to check every 2-3 hours and as required for incontinence, and provide incontinence care as needed. An observation was made of Resident #163 on 9/19/17 at 10:19 AM. The resident was asleep in bed in briefs and a T-shirt. The pad underneath of the resident was wet, and there was a strong odor of urine. An observation was made again at 12:00 PM on 9/19/17, and the pad was still wet. The resident was asleep in bed in the same briefs and T-shirt. A record review of the Certified Nursing Assistant (CNA) documentation for continence care revealed the resident was not checked until 1:29 PM on 9/19/17. The last documentation related to checking the resident was at 2:15 AM on the previous third shift. An observation of the resident's room at 3:10 AM revealed the pad on the bed was changed. An observation was made of Resident #163 on 9/20/17 at 12:30 PM. The resident was sitting on the side of the bed, and the bottom part of his T-shirt was yellow stained and wet. There was a strong odor of urine. The resident stated that the T-shirt was wet. He stated he did not spill anything on it. He stated he toileted himself. He was hard of hearing and would not respond to questions concerning his urinary incontinence. An observation was made of Resident #163 on 9/20/17 at 1:08 PM. There was a strong odor of urine and his T-shirt was still yellow stained. He was eating lunch using the bedside table in his room. Another observation was made at 1:31 PM on 9/20/17, which revealed the urine odor was still strong ,and the T shirt was still yellow stained at the bottom and had not been changed. A record review of the CNA documentation revealed that the last documentation for checking the resident was at 11:10 AM. An observation of the resident's room at 2:08 PM on 9/20/17 revealed that he was not in his room, and the bed had been stripped of it's sheets. A housekeeper was cleaning the bed and reported that the Unit Manager had asked her to clean the bed. The strong odor of urine was no longer present. An interview was conducted with Employee A, CNA, on 9/20/17 at 2:12 PM. Employee A reported the resident could use the bathroom, but he wore a brief and was incontinent at times. Employee A stated, I check him every 2 hours. He likes to sleep a lot. The resident was lying in bed sleeping before lunch. I have not checked him after lunch. Observed resident on 09/20/2017 at 2:36 PM sitting on North Unit reading the paper. The resident was observed wearing a polo shirt and black sweat pants. There was no odor of urine. The resident stated he took the T-shirt off and dressed himself. Observed the resident's room on 09/21/2017 at 9:30 AM. A staff member stated the resident was in the shower. The room smelled strongly of urine and ammonia. The bed was not wet and padding and sheets were not wet. Observed resident in his room sitting on the side of the bed on 9/21/17 at 9:47 AM. The resident stated he had a shower this morning and felt good. There were no odors of urine. A review of the Resident Care Policy and Procedure revised 9/2017 noted under item #4 to provide incontinence care in accordance with physician orders [REDACTED]. A review of the documentation for urinary incontinence for the last 30 days (8/23-9/21/17) revealed that Resident #163 was being checked once per shift for continence or incontinence. The resident was incontinent on multiple days in the time frames checked. The staff were not providing the urinary incontinence care as described in the care plan and the Policy and Procedure for incontinence care. Documentation for 9/19/17 by the CNA reported the resident was checked at 1:49 AM, 1:29 PM and 8:00 PM. Documentation for 9/20/17 reported the resident was checked at 1:49 PM, 11:10 AM and 9:00 PM. The CNA documentation for urinary incontinence noted the resident was incontinent once or twice when checked and occasionally all three times.

Based on interviews and record reviews, the facility failed to immediately inform 2 of 3 residents' (Resident #20 and #51) physicians of low blood sugars as per the physician orders [REDACTED]. The facility also failed to notify the physician of 1 out of 5 residents refusal to take medication in a timely manner. (Resident #20) The findings include: 1. Record review for Resident #20 found the resident was admitted to the facility on [DATE], with a re-admission on 6/3/2017. [DIAGNOSES REDACTED]. Record review of the 9/2017 physician order [REDACTED].#20 found orders for [MEDICATION NAME] R Solution (insulin) 100 units per sliding scale based on the resident's blood sugar reading as follows: 0-200=0 units, 201-250=2, 251-300=4, 301-350=6, 351-400=8, 401-450=10 units, if greater than 450 or lower than 60, notify MD (physician), subcutaneous twice a day related to type II diabetes. (Begin date of orders 6/3/2017) Further review of the 8/2017 physician order [REDACTED].#20 found orders for [MEDICATION NAME] Solution (insulin) 100 units per milliliter (ml)(Insulin [MEDICATION NAME]), inject 36 units subcutaneously at bedtime related to type 2 diabetes mellitus. Start date 6/3/2017 with an end date of 8/24/2017. Record review of the progress notes for Resident #20 found the following: On 8/15/2017 at 5:50 AM - 'Blood Glucose (BG) 46. Resident alert and oriented. Denies signs or symptoms of [DIAGNOSES REDACTED]. OJ (orange juice) with sugar administered along with snack.' There was no documentation to confirm that the physician was notified. On 8/8/2017 - '[MEDICATION NAME] Solution 100 units per milliliter, inject 36 units subcutaneously at bedtime related to type 2 diabetes mellitus. BG 59.' There was no documentation to confirm that the physician was notified. On 8/4/2017 - '[MEDICATION NAME] Solution 100 units per milliliter, inject 36 units subcutaneously at bedtime related to type 2 diabetes mellitus. Blood sugar 46. Held.' There was no documentation to confirm that the physician was notified. Record review of the 8/2017 Medication Administration Record [REDACTED]. In an interview with Resident #20's nurse (Employee E) on 9/20/2017 at 2:40 PM, she stated the resident's 6:00 AM and 4:00 PM nurses took the blood sugars. She stated if she would have taken the resident's blood sugar and it was under 60, she would have notified the resident's physician. During an interview with Resident #20's nurse (Employee D) on 9/21/2017 at 1:40 PM, she stated that anytime the resident's blood sugars fell below 80, she would call the doctor, because that was very unusual for that resident. She stated she was not aware that Resident #20's blood sugar was under 60 in August. During an interview with the North Wing Unit Manager on 9/21/2017 at 1:49 PM, she was asked at what blood sugar would she have expected the nurses to contact the doctor. She said based on nursing judgement, she would go with 60. The facility policy for Glucose Monitoring was provided on 9/21/2017 at 2:00 PM. Record review of #7 of the policy found the following directive: If blood sugar results have resident-specific parameters, on any resident, notify the MD per the Physician Notification Parameters or the resident's specific orders for notification, unless there are standing orders that notification is not necessary. Begin treatment if specific orders exist for the resident. Further review of the 8/2017 MAR found Resident #20 refused the [MEDICATION NAME] Solution 100 units per milliliter, inject 36 units subcutaneously at bedtime on 8/5, 8/12, 8/13, 8/16, 8/17, 8/19, 8/20, 8/21, 8/22, 8/23, and on 8/24/2017. Record review of the progress notes for Resident #20 found the first progress note alerting the resident's physician to her refusal of the [MEDICATION NAME] was in a note dated 8/24/2017 that documented the following: Resident is alert and oriented. Continues to refuse [MEDICATION NAME] on 8/24/2017. Physician informed and it was discontinued. Surveyor: KEERAN, KIMBERLY 2. Resident #51 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Insulin [MEDICATION NAME] 8 units subcutaneously at bedtime was ordered 9/13/17. Insulin [MEDICATION NAME] per sliding scale was ordered subcutaneously before meals and at bedtime on 8/7/17. If blood sugar was less than 70 or greater than 450, the nurse was to call the physician. A review of the Medication Administration Records for August and September 2017 revealed that on 09/04/17 at 11:30 AM, a blood sugar of 36 was noted and insulin was held. A review of the progress notes for the month of September 2017 revealed no documentation to confirm that the physician was notified about the blood sugar of 36 on 9/4/17. An interview was conducted with Employee B, Unit Manager, on 9/21/17 at 11:04 AM. The Unit Manager reviewed the Medication Administration Record [REDACTED]. She was unable to find documentation in the progress notes dated 9/4/17 to indicate that the physician was notified per the physician's orders [REDACTED]. An interview was conducted with Employee C, Licensed Practical Nurse, on 9/20/17 at 10:38 AM. The nurse stated that the staff should call the physician if a blood sugar is under 60, and then give something to the resident to bring the blood sugar up within the paramters. The staff would give Ready Care or orange juice if the blood sugar is under 60.

Based on record review and staff interviews, the facility failed to provide or arrange services by qualified persons in accordance with each resident's written plan of care. The facility failed to ensure that 1 (Resident #151) of 35 residents was provided hourly visual checks following a fall as directed by his plan of care. The findings include: On 11/10/2016 at 12:37 PM, a record review was completed for Resident #151. According to the resident's Fall Care Plan, he was placed on one-hour checks twice, for one week each time, following a fall on 10/05/2016 and a second fall on 10/31/2016. On 11/10/2016 at 2:05 PM an interview was conducted with Employee D, Clinical Educator, regarding Resident #151's falls and care plan. Employee D stated, Yes, the one-hour checks are the only interventions that we put in place for those falls. Employee D provided copies of the one-hour checks related to the resident's last two (2) falls (10/05/2016 & 10/31/2016). Employee D and this surveyor reviewed the documentation together. Employee D was asked about the blank lines on the forms, and she stated,Where the lines are not signed, the documentation was not done. The reviewed forms revealed that documentation was missing on: 10/05/2016 4 PM,5 PM,6 PM,7 PM,8 PM,9 PM,10 PM, and 11 PM. 10/12/2016 8 PM, 9 PM, 10 PM, and 11 PM 11/01/2016 4 PM, 5 PM, 6 PM, 7 PM, 8 PM, 9 PM,10 PM, and 11 PM. 11/02/2016 11 PM On 11/10/2016 at 2:47 PM, an interview was conducted with Employee L, Certified Nursing Assistant (CNA), and she stated, We have to complete the one-hour checks for our assigned residents after a fall, if they are doing the checks. Employee L stated, The nurse tells us in report who has fallen and who has the one-hour checks. The one-hour checks are kept at the desk, and we have to go to the desk and complete them. On 11/10/2016 at 3:33 PM, an interview was conducted with Employee M, Licensed Practical Nurse (LPN), regarding the one-hour checks for one week for residents who have fallen. Employee M confirmed that nursing informed the CNAs in report, and kept the sheets at the desk. Employee M was then asked if it was anyone's responsibility to follow up to make sure the forms were completed at the end of the shift, and he stated, Yes, it's the nurses' responsibility.

Based on observation, record review, and interview, the facility failed to ensure that 1 (Resident #217) of three residents reviewed for pressure ulcers out of a total of 35 sampled residents maintained good skin integrity by not providing appropriate treatment. Lack of treatment can cause worsening of condition, further impairment of skin integrity, and other health complications. The findings include: A pressure ulcer dressing change observation for Resident #217 (a female resident) was made with the Assistant Director of Nursing (ADON) and Employee N (Certified Nursing Assistant (CNA). Resident #217's buttocks around the rectum was observed to be red and excoriated after she was cleansed following a bowel movement (BM). She then had a second BM after which the ADON and Employee N cleansed the area again, wiping from front to back and then back to front. Resident #217 was observed to have a urinary catheter in place at the time of the observation. No peri-care around the Foley catheter was observed after cleansing from back to front following the bowel movement. When the ADON was asked about the peri-care, she stated that Employee N was not the CNA assigned to the room/resident. She stated that it would be the CNA assigned to that room/resident who was responsible for provision of peri-care at the Foley catheter site. After the second BM was cleansed, the buttock area around the rectum was again noted to be red and excoriated. No barrier cream or other treatment was applied to the area prior to changing the resident's brief. Review of Resident #217's medical record prior to the observation of the dressing change on 11/10/2016 at 9:30 AM, did not reveal an order for [REDACTED]. Further review of Resident #217's medical record revealed she was at risk for skin impairment related to urinary and bowel incontinence. An interview was conducted with the ADON on 11/10/2016 at 10:30 AM. She confirmed there had been no order for protective barrier cream to be applied to the buttocks/rectal area of Resident #217. She confirmed that barrier cream had not been applied to the resident's excoriated buttocks/rectal area As a result of the observation and this surveyor's inquiry regarding a skin protectant, an order was then obtained from the physician for barrier cream to be applied to the buttocks/rectal area every shift.

Based on record review and staff interviews, the facility failed to ensure that a resident did not receive an unnecessary medication (wrong antibiotic) for a urinary tract infection [MEDICAL CONDITION] for 1 (Resident #96) of 3 residents sampled with UTIs. The findings include: On 8/23/2016, Resident #96 had an order for [REDACTED]. The culture was pending. On 8/26/2016, there was an order for [REDACTED]. There was then an order on 8/27/2016 for [MEDICATION NAME] Solution, use 400 mg (milligrams) IV, two times a day for Urinary Tract Infection for 5 days. The August/September 2016 MARs revealed this was given until September 1, 2016. There was a 9/1/2016 (at 1:50 p.m.) Health Status Note for Resident #96 revealing the resident received the wrong antibiotic. The resident was previously receiving [MEDICATION NAME] and the medication had been changed due to the sensitivity to the organism. The resident did not appear to have any adverse reactions to the current antibiotic. The correct medication was ordered, and another immediate urine culture was obtained. Resident #96 had a 7/28/2016 plan of care for Potential for a Urinary Tract Infection due to history of UTI, incontinence, dementia, and thickened liquids. The interventions were to administer medications affecting bladder function as ordered and as needed, obtain and monitor diagnostic work as ordered, follow up with the physician, and give antibiotic as ordered. Employee A, one of the staff nurses (Licensed Practical Nurse), was interviewed on 11/9/2016 at 12:20 p.m. She confirmed the medication error for Resident #96. She stated that the [MEDICATION NAME] mixed up because the generic name was very similar. She could not recall the specifics of the medication error. She stated she notified the supervisor and a Risk Management Variance Report would have been completed. The Director of Nursing was interviewed on 11/9/2016 at 1:00 p.m. She stated that the urine was collected on 8/23/2016, and the [MEDICATION NAME] IV was ordered on [DATE]. When the sensitivity came back, a new order was obtained on 8/27/2016 for [MEDICATION NAME] a day for 5 days. The August 2016 and September 2016 MARs were documented indicating that the [MEDICATION NAME] given twice a day from 8/27/2016 - 9/1/2016. The Director of Nurses stated that this was an error. She reviewed the Variance Report and confirmed the [MEDICATION NAME] was given the entire time. The pharmacy never got the order for the IV Cipro, and the nurses continued to give the [MEDICATION NAME]. The daughter of Resident #96 was interviewed on 11/09/2016 at 2:58 p.m. She stated she was told of a medication error with an antibiotic. She was unsure of the specifics, but it sounded like it was a one-time dose error, it was immediately caught, and there were no adverse effects. She was not told that it was a continued medication error for five days. The resident's primary care physician (also the Medical Director of the facility) was interviewed over the phone on 11/9/2016 at 3:27 p.m. He stated he remembered there was a medication error regarding the IV antibiotic. He was not aware that 10 doses were given incorrectly. He stated that the facility did not have a problem with medication errors. It had actually improved in that regard. The Clinical Educator, Employee D, was interviewed on 11/10/2016 at 3:02 p.m. She stated that the resident's physician came in on 8/25/2016 and reviewed the UA from 8/23/2016. The sensitivity was still not back, and he ordered the [MEDICATION NAME], 1 gram IV daily for 7 days. The sensitivity came back later that day, and the doctor changed it to the IV Cipro, which got into the computer the next day. Since the [MEDICATION NAME] was still in the refrigerator, the nurses continued to give it.

Based on observations, record review, and staff interviews, the facility failed to provide 1 of 4 sampled residents (Resident # 69) with the appropriate diet. The findings include: On 11/10/2016 at 8:20 a.m., a dining observation was made in a resident lounge off of the 500 hallway. There were four residents in the room and Employee A, a Licensed Practical Nurse, stated these were dependent diners who needed assistance with meals. Resident #69 was sitting in a wheelchair, and had her meal placed in front of her. Her diet slip revealed a regular mechanical soft diet. At 8:22 a.m., Employee C, a Licensed Practical Nurse, was observed cutting up the resident's french toast, and he stated he was going to assist Resident #69 with her breakfast. He sat down and lifted up the fork and was going to take a portion of the breakfast to feed her. On her plate were scrambled eggs. Her diet slip revealed she had an allergy to eggs. Employee C stated he did not look over the diet slip before assisting with the resident. Someone else already looked over it and placed her meal on the table before he got here. Employee D, the Clinical Educator, came over and looked at the diet slip, and confirmed the allergy to eggs on the diet slip. She removed the resident's tray and called the kitchen for a new tray. The electronic clinical record had a Registered Dietician evaluation on 11/8/2016 that did list eggs as an allergy. The allergy tab on the clinical electronic record also revealed an allergy to eggs with an unknown severity. The Certified Dietary Manager on 11/10/2016 at 8:35 a.m. was told of Resident #69 receiving eggs on her breakfast tray. She stated she did not know how that happened. On 11/10/2016 at 1:05 p.m., Employee D stated that the kitchen had sent out the wrong food on the plate and she had removed the resident's tray and was checking over it. She noticed that she did not have a lid for her drink so she left the tray to get the lid. Employee C thought that she had already checked the diet slip.

Based on observations and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on 2 errors over 32 opportunities; one error for Resident #109, and one error for Resident #203. The two errors resulted in an error rate of 6.25%. The findings include: 1. On 11/8/2016 at 8:45 AM, medication administration was observed for Resident #109. He had an order for [REDACTED]. On 11/10/2016 at 12:14 PM, an interview was conducted with Employee F regarding the B -12 that was administered to Resident #109 on 11/8/16 8:45 AM. Employee F stated, I know he was supposed to receive 50 mg, but I gave him 100 mg. I discovered the error after our medication pass, and immediately reported it. I received education, a medication error was completed, and the doctor was notified. 2. On 11/8/2016 at 9:10 AM, medication administration was observed for Resident #203. He had an order for [REDACTED].#203's [MEDICATION NAME]. On 11/10/2016 at 12:19 PM, an interview was conducted with Employee A regarding the [MEDICATION NAME] that was administered to Resident #203 on 11/08/2016 at 9:10 AM. Employee A was asked about obtaining the resident's pulse, because she had not obtained it during medication pass observation. Employee A stated, I take them all in the morning when I go around with my cuff. Employee A was then asked what time she would have taken the pulse for Resident #203, and she stated, Probably an hour or so before. Employee A was then asked if she had any documentation to show when the pulse was actually taken. Employee A stated, No, I don't have anything to show when the pulse was actually taken. I just enter the pulse in at the time I pass the medications.