Every finding on record at Glades Health Care Center

Based on observation, record review, and interview, the facility failed to ensure staff speak to and treat 1 of 21 sampled residents in a dignified manner as evidenced by the failure to respond appropriately to Resident #28's request for a glass of orange juice.The findings included:Review of the record revealed Resident #28 was admitted to the facility on [DATE] and was admitted to Hospice services as of 01/12/26. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 6, on a 0 to 15 scale, indicating the resident had severe cognitive impairment.Review of the current care plan initiated on 01/12/26 documented Resident #28 was at risk for dehydration or potential fluid deficit related to diuretic (medications to remove excess fluids) use.During an interview on 04/13/26 at 10:06 AM Resident #28 asked the surveyor for a glass of orange juice. An empty glass that appeared to have remnants of juice was noted on the resident's over-the-bed table. The resident was asked to use the call bell to request the juice from the staff. The resident did, and Staff A, the resident's direct care Certified Nursing Assistant (CNA) for the day responded. Resident #28 asked for another glass of orange juice and Staff A responded, I already told you there will be apple juice for lunch. The resident stated he shouldn't have to wait so long, to which the CNA stated, You have water right there. Resident #28 stated, I don't want no water. Staff A stated, Okay and left room. After the CNA left, Resident #28 stated, It's not like I'm asking for 4 or 5 juices.During an observation on 04/13/26 at 10:55 AM, the empty orange juice glass from breakfast and a glass of water remained on the bedside table. Photographic evidence obtained. At that time and again at 11:45 AM the resident confirmed he did not receive the requested juice.During an interview on 04/13/26 at 11:50 AM, when asked if there was a reason Resident #28 did not receive his requested orange juice, Staff A, CNA, stated, I told him there would be apple juice for lunch and he had water. Staff B, Registered Nurse (RN) was present and volunteered, I gave him an Ensure. When asked again if there was any reason the resident did not receive his requested orange juice, neither staff had a reason. When asked if she had gone to the kitchen to see if they had orange juice for the resident, the CNA stated no.During an observation and interview on 04/13/26 at 2:34 PM no orange juice was observed, but there were two glasses of untouched apple juice and water. When asked again if he received his requested orange juice, Resident #28 stated he did not. When asked how it made him feel, the resident stated, Kinda bad . like they don't care.During an interview on 04/16/26 at approximately 4:00 PM, when told of the observations and a concern with dignified treatment for Resident #28, the Director of Nursing (DON) stated okay and that the CNA should have gotten the resident his requested orange juice.

Based on observations, interviews and record reviews, the facility failed to ensure resident assessments accurately reflected the use of bed rails for 3 of 3 sampled residents reviewed for Physical Restraints, Resident #8, Resident #11 and Resident #28; The facility failed to accurately assess for nutritional status for 1 of 6 sampled residents reviewed for nutrition, Resident #10; and the facility failed to ensure the accuracy of medications was reflected in resident assessments for 1 of 5 sampled residents reviewed for Unnecessary Medications, Resident #5 The findings included: The facility's policy, titled 'Proper Use of Bed Rails', with no reference date, documented, in part: Definitions: Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: a. Is attached to or adjacent to the resident's body; b. Cannot be removed easily by the resident; and c. Restricts the resident's freedom of movement or normal access to his/her body. Resident Assessment 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavior symptoms b. Size and weight c. Sleep habits d. Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility (in and out of bed) l. Risk of falling The facility will assess to determine if the bed rail meets the definition of restraint. A bed rail is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently. If it is determined to be a restraint, the facility will follow their procedures related to physical restraints 8. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom or functional reason for the use of the bed rail. 1). Record review for Resident #8 revealed an admission date of 04/01/22. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 01/21/26, documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 05, indicating the resident had severe cognitive impairment. The assessment documented that the resident required supervision or touching assistance for bed mobility and partial/moderate assistance for transfers and ambulating in manual wheelchair. Resident #8's diagnoses included: Hypertension, Diabetes, Osteoporosis, Cachexia, Gastroesophageal Reflex Disease Dysphagia and Need for assistance with personal care. Section P of the assessment for 'Physical Restraints' documented that the resident did have bed rails used daily as a physical restraint. Resident #8's care plan for bed rails documented, Resident is limited in physical mobility related to Cerebrovascular Accident (Stroke) and right sided weakness. Bed rails used to promote independence. Date Initiated: 01/29/2025 Created on: 10/16/2025 Revision on: 02/12/2026. The goal of the care plan was documented as, Resident will be free from negative affects related to side rail use Date Initiated: 01/29/2025 Created on: 10/16/2025 Revision on: 01/13/2026; Target Date: 04/15/2026 Interventions in the care plan included: Bed rails while in bed to aid in mobility Date Initiated: 01/29/2025 Created on: 10/16/2025 Instruct resident in proper bed mobility techniques for safety Date Initiated: 01/29/2025 Created on: 10/16/2025 Instruct with use of bed rails and assistance as needed Date Initiated: 01/29/2025 Created on: 10/16/2025 Provide assistance for repositioning/transferring as needed Date Initiated: 01/29/2025 Created on: 10/16/2025 Staff use of side rails during care Date Initiated: 01/29/2025 Created on: 10/16/2025 On 04/14/2026 at 8:46 AM, Resident #8 was observed in bed with one rail to resident's right side of the bed in raised position from the head of the bed to approximately middle of the bed and no rails to the resident's left side of the bed. It was determined that the resident was not interviewable. The record review also revealed that there was a Quarterly Side Rail Assessment, with a reference date of 01/15/26, that was not completed. The only part of the evaluation that was completed was the section for the Current Status of the review and no further assessment completed. 2). Record review for Resident #11 revealed an admission date of 01/13/26. Resident #11's diagnoses upon admission included: Parkinson's disease, Sequelae of cerebral infarction, dementia, Chronic Obstructive Pulmonary Disease (COPD), Protein-calorie malnutrition, Hypertension, Adult failure to thrive, Emphysema , Osteoarthritis, Muscle weakness and Rhabdomyolysis. According to the resident's most recent complete assessment, a Medicare 5-day MDS, Resident #11 had a BIMS score of 7, indicating the resident had a severe cognitive impairment. The assessment documented that the resident required partial/moderate assistance for bed mobility and transfers. Section P of the assessment for 'Physical Restraints' documented that the resident did have bed rails used daily as a physical restraint. Resident #11's care plan for side rails documented, Resident has limited physical mobility related toWeakness, requiring the use of side rails to promote independence Date Initiated: 01/15/2026 Created on: 01/15/2026 Revision on: 02/12/2026. The goal of the care plan was documented as, Will remain free of complications through the next review date. Date Initiated: 01/15/2026 Created on: 01/15/2026 Revision on: 02/03/2026 Target Date: 06/07/2026. Interventions in the care plan included: Staff use of side rails during care Date Initiated: 02/13/2026 Created on: 02/13/2026 On 04/13/2026 at 11:26 AM Resident #11 was observed in bed sleeping with bilateral rails in a raised position from head of the bed. On 04/14/2026 at 8:56 AM Resident #11 was observed in bed sleeping with bilateral rails in a raised position from head of the bed. During an interview with Resident #11, on 04/15/2026 at 4:23 PM, the resident stated that he used the rails daily to move about the bed and for support for transfers. During the interview, Resident #11 demonstrated that the rails did not keep him from transferring from the bed and was able to manipulate and lower the rails. 3). Record review for Resident #10 revealed an admission date of 06/09/24. According to the resident's most recent complete assessment, a Quarterly MDS with a reference date of 03/06/26, Resident #10 had a BIMS score of 07, indicating a severe cognitive impairment. The assessment documented that Resident #10 required setup or clean up assistance for eating and that the resident was on prescribed weight loss regimen. Resident #10's diagnoses included: Idiopathic peripheral autonomic neuropathy, Type 2 diabetes mellitus, (T2DM) Asthma, Lack of coordination, Alzheimer's disease, Dementia, Anemia, Epilepsy, Adjustment disorder with anxiety, Hypokalemia, Anxiety disorder, Depression, Dyspepsia, Muscle weakness, Hypertension, Gastro Esophageal Reflux Disease (GERD). Resident #10's diet orders included: Low concentrated sweets/no added salt diet, Regular texture, Thin consistency - 10/01/25 with a revision date of 10/30/25. Glucerna -BID (two times a day) - 12/14/25 Resident #10's care plan for diet documented: Resident current diet is No Added Salt and No Concentrated Sweets with regular texture foods and thin liquids. Date Initiated: 10/25/2025 Created on: 10/25/2025 The goal of the care plan was documented as, Maintain adequate PO (by mouth) Intake and adhere to current diet orders. Date Initiated: 10/25/2025 Created on: 10/25/2025 Revision on: 03/09/2026; Target Date: 06/07/2026 Interventions in the care plan included: Independent with feeding requiring tray setup assistance. Date Initiated: 10/25/2025 Created on: 10/25/2025 Resident prefers to eat in room. Date Initiated: 10/25/2025 Created on: 10/25/2025 Offer substitutes for foods not eaten. Date Initiated: 10/25/2025 Created on: 10/25/2025 Provide and serve diet as ordered. Monitor and record % consumed. Date Initiated: 10/25/2025 Created on: 10/25/2025 Resident #10's care plan for nutrition documented, Resident at risk for nutrition related complications including changes in weight/intake and altered labs related T2DM, GERD, obesity, History of variable meal intake, dementia, prescribed diuretic, depression, and possible food/medication interactions. 12/14-significant weight loss x 6 months 4/10- unplanned weight loss x 6 months Date Initiated: 11/19/2025 Created on: 11/19/2025 Revision on: 04/13/2026 The goals of the care plan included: Maintain nutrition related labs within normal limits/baseline through review date Date Initiated: 11/19/2025 Created on: 11/19/2025 Revision on: 03/09/2026 Target Date: 06/07/2026 The resident will maintain adequate nutritional status as evidenced by no significant weight change, no signs/symptoms of malnutrition, and consuming at least 50% of meals daily through review date. Date Initiated: 11/19/2025 Created on: 11/19/2025 Revision on: 03/09/2026 Target Date: 06/07/2026 The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Date Initiated: 11/19/2025 Created on: 11/19/2025 Revision on: 03/09/2026 Target Date: 06/07/2026 interventions in the care plan included: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Date Initiated: 11/19/2025 Created on: 11/19/2025 Invite the resident to activities that promote additional intake. Date Initiated: 12/14/2025 Created on: 12/14/2025 Monitor/record/report to MD (Medical Doctor) as needed signs/symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 12/14/2025 Created on: 12/14/2025 Provide and serve snack as ordered 12/14-Glucerna twice per day Date Initiated: 11/19/2025 Created on: 11/19/2025 Revision on: 12/14/2025 Provide, serve diet as ordered. Monitor intake and record q (every) meal. Date Initiated: 11/19/2025 Created on: 11/19/2025 RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed) Date Initiated: 11/19/2025 Created on: 11/19/2025 Resident #10's weight summary in the electronic health record documented Resident #10's ideal body weight (IBW) as 131-159 pounds A Quarterly Nutrition assessment, with a reference date of 03/05/26 documented Resident #10s IBW: 99-121# (pounds) Resident with significant wt (weight) loss (noted hospitalization 11/11-11/16 with wt loss upon readmission). Quarterly nutrition assessment with a reference date of 03/05/26, documented, Unexpected weight loss reported due to hospitalization in November.Glucerna BID (twice per day) added to increase calorie needs.On Mirtazapine at dose to promote appetiteOn Lasix 10 mg q (once) per dayCurrent diet and nutrition POC (Plan of Care) remain appropriate at this time Intake remains varied despite Mirtazapine.Weight loss trend continues.Will continue with weekly weights to more closely monitor trend. On 11/17/25, the resident weighed 169 lbs. On 04/06/2026, the resident weighed 148 lbs which is a -12.43% Loss. During an interview, on 04/14/2026 2:50 PM with the Registered Dietitian (RD/LDN), when asked about the resident being on a prescribed weight loss regimen as documented in the Quarterly MDS, the RD/LDN replied, she was on Lasix and the weight loss was expected. IBW is 110 based on formula. The focus shifted from weight loss and more on getting her to eat better and slow down the weight loss. We wanted to improve her intake with Mirtazapine, she is on Glucerna twice daily, and weekly weights x 4 weeks. The RD/LDN (Licensed Dietician Nutritionist) acknowledged that there was a discrepancy between an assessment that documented Resident #10 was on a prescribed weight loss program while all of the care plan interventions and orders for supplements reflect preventing weight loss. When asked about the discrepancies in the IBW in multiple nutrition assessments, the RD/LDN acknowledged the findings. 4) Review of the record revealed Resident #28 was admitted to the facility on [DATE]. Review of the Quarterly MDS dated [DATE] documented Resident #28 was utilizing bed side rails daily as a restraint. During an observation on 04/13/26 at 10:04 AM Resident #28 was lying in bed with bilateral half bed side rails noted. During an interview on 04/15/26 at 1:07 PM when asked if Resident #28 can move himself about, Staff B, Registered Nurse (RN) stated he can't get up out of bed by himself but can move independently in bed. When asked if he uses the side rails to move the RN confirmed he did and agreed they did not restrict his movement. During an interview on 04/15/26 at 3:22 PM, when asked the definition of a restraint, the MDS Coordinator stated something confining a resident's movement. When asked about side rails coding in the MDS, the RN stated that the DON (Director of Nursing) had told her a while back that she was miscoding the side rails and she also confirmed that information with a corporate MDS person. When asked what she did about it, the RN stated when the next assessment comes due, she will correctly code the new assessment. When asked if she was able to run a report to identify all the residents who were coded with restraints the RN stated she could. When asked if she ran that report to correct the issues identified, the RN stated she had not. When asked if she was directed by management to correct the issues the RN stated she was not. 5) Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the Annual MDS dated [DATE] documented the resident was being administered insulin, antipsychotics, antidepressants, antiplatelets, and hypoglycemic medications. Review of the Medication Administration Record (MAR) for March 2026 confirmed the resident was administered those classes of medication, but also documented the administration of gabapentin, an anticonvulsant and buspirone, an antianxiety medication. During a side-by-side record review and interview on 04/16/26 at 11:24 AM, the MDS Coordinator agreed with the findings.

Based on observation, record review, and interview, the facility failed to ensure oxygen equipment maintenance for 1 of 1 sampled resident, as evidenced by a dust-ladened oxygen concentrator filter for Resident #45.The findings included:Review of the record revealed Resident #45 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was utilizing oxygen.Review of the current physician orders documented an order for continuous oxygen use at 3 liters per minute. The orders and care plans lacked any documented instruction for oxygen maintenance for the filters.During an observation on 04/13/26 at 9:54 AM, Resident #45 was not in his room. An oxygen concentrator was running at 3 liters with the tubing hanging over the bedside table. The oxygen filter on the back of the concentrator was dust-laden to the point that the plastic grates were not visible. Photographic evidence obtained.During an interview on 04/15/26 at 4:44 PM, when asked who was responsible for oxygen cleanliness and maintenance, Staff B, Registered Nurse (RN) stated the night shift nurses change out the oxygen tubing weekly. When asked about the filter, the RN questioned, What filter? When shown the back of the oxygen concentrator for Resident #45 the nurse stated they have an oxygen man who services the machines and he was here yesterday, but he obviously didn't clean this one.

Based on observations, interviews and record reviews, the facility failed to ensure the accuracy and completeness of assessments for the use of bed rails for 3 of 3 sampled residents reviewed for physical restraints, Residents #8, Resident #11, and Resident #28; and the facility failed to obtain orders for the use of side rails for 3 of 3 sampled residents reviewed for physical restraints. Resident #8, Resident #11, and Resident #28. The findings included:1). Record review for Resident #8 revealed an admission date of 04/01/22. According to the resident's most recent assessment, a Quarterly Minimum Data Set, with a reference date of 01/21/26, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 05, indicating the resident had severe cognitive impairment. The Assessment documented that the resident required supervision/touching assistance for bed mobility, partial/moderate assistance for bed mobility and transfers and ambulated with supervision/touching assistance via manual wheelchair. Resident #10's diagnoses included: Hypertension, Diabetes Mellitus, Human immunodeficiency (HIV), Osteoporosis, Cachexia, Gastroesophageal Reflux Disease (GERD), Dysphagia, Need for assistance with personal care. Section P of the assessment 'Physical Restraints', documented bed rails used daily as a restraint. Resident #8's care plan for mobility documented, Resident is limited in physical mobility related to cerebrovascular accident (CVA) and right sided weakness. Bed rails used to promote independence. Date Initiated: 01/29/2025 Created on: 10/16/2025 Revision on: 02/12/2026 The goal of the care plan was documented as, Resident will be free from negative affects related to side rail use Date Initiated: 01/29/2025 Created on: 10/16/2025 Revision on: 01/13/2026 Target Date: 04/15/2026 Interventions in the care plan included: Bed rails while in bed to aid in mobility Date Initiated: 01/29/2025 Created on: 10/16/2025 Instruct resident in proper bed mobility techniques for safety Date Initiated: 01/29/2025 Created on: 10/16/2025 C Instruct with use of bed rails and assistance as needed Date Initiated: 01/29/2025 Created on: 10/16/2025 Provide assistance for repositioning/transferring as needed Date Initiated: 01/29/2025 Created on: 10/16/2025 Staff to maintain body in functional alignment when at rest; do not allow resident to lie too close to side rails Date Initiated: 01/29/2025 Created on: 10/16/2025 Staff use of side rails during care Date Initiated: 01/29/2025 Created on: 10/16/2025. On 04/14/2026 at 8:46 AM Resident observed in bed with rail to resident's right side of the bed in raised position from HOB to approximately middle of the bed. It was determined that the resident was not interviewable based on not being able to answer simple questions. During a review of a Side Rail Evaluation, with a reference date of 01/15/26, it was noted that the only section of the evaluation that was completed was the first section that documented the 'Current Status' (use of the rails), while the remaining sections of the evaluation that determined if the rails were still appropriate were not completed, including the sections for: Evaluation, Recommendations, Education and Conclusion. Further review of the resident's record revealed that there were no orders for the use of the rails. 2). Record review for Resident #11 revealed an admission date of 01/13/26. Resident #11's diagnoses upon admission included: Parkinson's disease, Sequelae of cerebral infarction, dementia, Chronic Obstructive Pulmonary disease, Protein-calorie malnutrition, Hypertension, Adult failure to thrive, Emphysema, Osteoarthritis, Muscle weakness, Rhabdomyolysis. According to the resident's most recent complete assessment, a Medicare 5-day MDS with a reference date of 02/03/26, Resident #11 had a BIMS score of 07, indicating severe cognitive impairment. The assessment documented that the resident required partial/moderate assistance for bed mobility and transfers and ambulated with set up assistance via manual wheelchair. Resident #11's care plan for the use of bed rails documented, Resident has limited physical mobility related to weakness, requiring the use of side rails to promote independence Date Initiated: 01/15/2026 Created on: 01/15/2026 Revision on: 02/12/2026. The goal of the care plan was documented as, Will remain free of complications through the next review date. Date Initiated: 01/15/2026 Created on: 01/15/2026 Revision on: 02/03/2026 Target Date: 06/07/2026. Interventions in the care plan included: Staff to maintain body in functional alignment when at rest; do not allow resident to lie too close to side rails Date Initiated: 02/13/2026 Created on: 02/13/2026 Staff use of side rails during care Date Initiated: 02/13/2026 Created on: 02/13/2026 Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury Date Initiated: 01/15/2026 Created on: 01/15/2026 Revision on: 01/15/2026 Provide gentle range of motion as tolerated with daily care. Date Initiated: 01/15/2026; Created on: 01/15/2026; Revision on: 01/15/2026. On 04/13/2026 11:26 AM, Resident #11 was observed in bed sleeping with bilateral rails in a raised position. On 04/14/2026 8:56 AM [NAME] in bed sleeping with bilateral side rails in a raised position. During an interview, on 04/15/2026 at 4:23 PM, when asked about the use of the rails, Resident #11 stated that he used the rails daily to move about the bed and for support for transfers. Further review of the resident's electronic and paper-based health record revealed no orders for the use of the rails. 3) Review of the record revealed Resident #28 was admitted to the facility on [DATE] and admitted to Hospice services as of 01/12/26. Review of the Quarterly MDS assessment dated [DATE] documented the daily use of bed side rails. Review of the current physician orders lacked any order for the use of side rails. Review of the current Side Rail Evaluation dated 01/13/26 documented the current status for Resident #28 was the use of bilateral half rails and that the nurse was re-assessing for continued need. The rest of the form to include the evaluation, recommendations, education and conclusion was left blank. An observation on 04/13/26 at 10:04 AM, and throughout the four-day survey, revealed Resident #28 in bed with bilateral half side rails observed daily. During an side-by-side record review and interview on 04/16/26 at 11:34 AM, when asked if she completed the side rail assessments, the MDS Coordinator stated she completes them upon admission and quarterly. When asked if she completes the entire form each time, the MDS Coordinator stated upon admission she does, but then quarterly if there are no changes, she just fills in the first section. When asked how she was documenting the quarterly assessment for use of the side rails if she wasn't completing that form, and the MDS Coordinator stated, Good question. During an interview on 04/16/26 at 11:45 AM, when informed of the findings, the Director of Nursing (DON) stated the entire form should be completed with each assessment.

Based on record review and interview, the facility failed to provide written notice to resident's representative and the ombudsman of reason for transfer to hospital for 1 of 2 sampled residents reviewed for hospitalization, Resident #19. This had the potential to affect any resident transferred out of the facility since 01/01/26, as the facility stopped providing the notices.The findings included:Review of the record revealed Resident #19 was admitted to the facility on [DATE], transferred to the hospital on [DATE], and returned to the facility on [DATE]. Although the record documented a call was placed to the spouse regarding the transfer, the record lacked any documented evidence the resident's representative was provided written notification of the transfer and reason for the move.During an interview on 04/15/26 at 12:19 PM, when asked how a resident's representative was made aware of a transfer to the hospital, Staff B, Registered Nurse (RN) stated she would make a call to the family prior to sending the resident out to the hospital, and another call if and when they received an update from the emergency room. When asked if any written notice of transfer was provided to the representative, the RN stated not that she was aware, and suggested the Social Services Director (SSD).During an interview on 04/16/26 at 9:57 AM, when asked if she provided any written notice of transfer to the hospital to a resident's representative and / or the ombudsman, the SSD stated no and suggested the Medical Records staff. During an interview on 04/16/26 at 11:28 AM, when asked if she sends any written notice to the family when a resident is transferred out to the hospital, the Medical Records staff stated, I used to but was told to stop. She would not say who told her to stop. The Minimum Data Set Coordinator, who was in the same room stated, Wasn't it because they didn't want to do the certified mail thing. When asked if she informs the ombudsman of the transfers and discharges from the facility, the Medical Records staff stated she used to but hadn't gotten confirmation the ombudsman was receiving the information in quite some time so she stopped doing that as well. When asked when she sent the information last, the Medical Records staff stated back in 2025 and confirmed none had been sent in 2026.During an interview on 04/16/26 at 11:43 AM, the Director of Nursing (DON) was unaware the notices were not being sent to the resident representatives or to the ombudsman.

Based on interviews and record review, the facility failed to ensure that clinical nutritional assessments were completed within the scope of practice for 1 of 1 sampled resident reviewed for nutrition (Resident #30). This had the potential to affect 51 out of 60 residents on the facility's current census. The findings included: A review of the Certified Dietary Manager (CDM) scope of practice dated 01/20/20 showed the following: Gather Nutrition Data. Interview and identify client-specific nutritional needs/problems. Review nutrition screening data and calculate nutrient intake. Document in the medical record. Identify food customs and nutrition preferences based on race, culture, religion, and food intolerances. Utilize standard nutrition care procedures following ethical and confidentiality principles and practices. Participate in care conferences and review the effectiveness of nutrition care. Provide nutrition education. A Review of the Revised 2024 Scope and Standards of Practice for the Registered Dietitian Nutritionist by the Academy of Nutrition and Dietetics showed the following: The Registered Dietitian is responsible for reviewing reported nutrition screening data or conducting nutrition screening, if applicable; completing nutrition assessments; determining the nutrition diagnosis or diagnoses; developing care plans; implementing the nutrition intervention; evaluating the patient's/client's response; and supervising the activities of professional, technical, and support personnel assisting with the patient's/client's nutrition care. They also assign duties that are consistent with the individual scope of practice. Record review showed that Resident #30 was admitted to the facility on [DATE] with diagnoses of Diabetes, Hypertension, Congestive Heart Failure and Anemia. The initial nutrition assessment was conducted on 01/25/24 and was completed by the facility's Dietician. The quarterly assessment dated [DATE] was completed by the CDM and revealed the daily nutritional requirements, nutritional need and protein and caloric requirement for Resident #30. The assessment was signed and completed by the CDM with no oversight or review by the Dietitian. The next quarterly assessment dated [DATE] was also completed by the CDM with no oversight or review by the Dietitian. An interview was conducted with the CDM on 12/03/24 at 11:45 AM. She stated the Dietician comes once a week and does the initial and annual assessments and she does the quarterly assessments. She stated the dietician looks over her assessments and she calls and emails him when she has a question but stated she does not think he signs off on the assessment after he looks at them. She stated the Dietician had given her a formula to use for nutritional needs for the residents. She has been doing the quarterly assessments for years. An interview was conducted with the Dietician on 12/04/24 at 1:00 PM. He stated he has been the Dietician at this facility for approximately [AGE] years. He comes into the facility on ce a week on Wednesday. He does breakfast rounds. When new admissions come in, the CDM calls him or texts him. He does the initial, annual and quarterly nutritional assessments on the residents with tube feedings, dialysis and weight loss. The CDM does the majority of the other quarterly assessments. She will text him of a weight loss or gain. He decides who will be on weekly weights. The CDM does the quarterly care plans and he does the annual and initial care plans. In a subsequent interview with the Dietician on 12/04/24 at 2:14 PM he stated he did not realize that the CDM should not do the quarterly assessments. He stated he looks at the assessments but does not acknowledge that he reviews them.

Based on observation, menu review, and interview, the facility failed to follow their approved menu for 1 of 2 meals observed, as evidenced by the failure to prepare all foods on the lunch menu on 12/04/24, and substituted with foods not on the menu, affecting sampled Residents #13 and #2, with the potential of affecting 4 of 56 residents who consume food. The findings included: Review of the approved lunch menu for 12/04/24 documented, in part, the provision of an alternate vegetable of corn on the cob, the mechanical soft vegetable of cooked carrots, and the alternate mechanical soft vegetable of lima beans. An observation of the posted lunch meal for 12/04/24 docmented the meat as BBQ ribs with a side of baked beans. The alternate meal was listed as fried fish with corn on the cob. During an observation of the lunch meal service on 12/04/24 beginning at 11:20 AM, Staff G, lead cook for the day, placed the prepared food on the steam table, to include in part, chicken thighs, green beans, pureed chicken, and pureed green beans. After completion of the the food temperatures at 11:35 AM, when shown the approved menu and asked about the documented corn on the cob, carrots, and lima beans, the cook stated those items had not been prepared, further stating, they (the residents) usually like the green beans instead of the carrots. The cook had no explanation for the lack of corn on the cob or lima beans. When asked about the chicken, the cook stated some of the residents liked the chicken instead of the fish. The cook also confirmed she did not have any ground or pureed fish for the alternate meals. During an interview on 12/04/24 at 12:20 PM, the Kitchen Manager/Certified Dietary Manager (CDM), was asked about the missing vegetables. The CDM stated she believed there was corn on the cob in the freezer but had no explanation as to why it wasn't cooked. The CDM confirmed there were no carrots or lima beans, but again had no explanation. Review of the Resident Dislikes List documented four of the 56 residents who consume food orally, had pork listed as a disliked item. The main entree for the 12/04/24 lunch meal was pork BBQ ribs. The fried fish was served to Resident #13, who disliked pork, and the other three residents who did not like pork received chicken, including Resident #2. During an interview on 12/04/24 at 12:25 PM, Resident #13 stated the fish was good. When asked about the alternate vegetable, she stated she would have enjoyed the corn on the cob. During an interview on 12/04/24 at 3:56 PM, the CDM confirmed the corn on the cob and carrots were missed during the lunch meal that day. The CDM stated they did not have lima beans, and further stated the mechanical soft alternate vegetable should have been corn, since the alternate vegetable was corn on the cob, and the alternate pureed vegetable should have also been corn. During an interview on 12/05/24 at 9:08 AM, Resident #2 confirmed he had chicken the previous day for lunch, and further stated he was not told what the alternate meal was. Resident #2 had a documented dislike of pork. The resident further confirmed he liked but was not offered the fried fish, the alternate that was documented on the menu.

Based on the facility policy, centers for disease control (CDC) review, observations and record review, the facility failed to ensure appropriate infection control practices by failure to implement enhanced barrier precaution (EBP) process for residents with wounds, and indwelling medical devices including feeding tubes, and foley catheter for 4 of 4 sampled residents, with the potential to affect 6 residents identified as needing EBP. This involved Resident #1, #20, #22, and #44. The facility failed to ensure appropriate hand hygiene during wound care. This involved (Resident #22). The facility failure to ensure appropriate hand hygiene during perineal/catheter care. This involved Resident #44. The findings included: The Policy reviewed, titled handwashing practices dated March 19, 2020, indicated handwashing shall be regarded by this organization as the single most important means of preventing the spread of infections. 1) all personnel shall follow our establishing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2) appropriate of 20 seconds minimum handwashing must be performed under the following condition: F. after handling used dressings. H. after handling items potentially contaminated with blood, body fluids, accretions, or secretions. J. always after removing gloves. Review of CDC guideline updated date 04/02/24, explained, the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include Dressing, Bathing/showering, Transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requiring a dressing and Tube Feeding. 1) Record review reveled Resident #22 was admitted to the facility on [DATE] with a diagnosis including Dementia. Review of the significant change Minimum Data Set assessment, reference date 11/07/24, indicated Resident #22 was rarely understood. No behaviors recorded. Review of the December 2024 medication administration record revealed a physician order of Jevity 1.5 calories at 45ml per hour for 22 hours daily. Additional review of physician orders, medication and treatment administration record, and care plans lacked evidence of the EBP process. Further review of care plans with revised date of 11/12/24, indicated all of Resident #22's nutrition and hydration needs were met via feeding tube. On 12/02/24 at 9:46 AM Resident #22 was observed lying in bed, she was receiving tube feeding, there was no EBP in place; no signage, no Personal Protective Equipment kit (PPE kit). On 12/03/24 at 8:39 AM, an observation was conducted of Resident #22, as she was receiving tube feeding, there was no evidence of EBP in place. On 12/04/24 at 8:54 AM Resident #22 was observed lying in bed, receiving tube feeding, there was no EBP in place. On 12/05/24 at 10:20 AM, an interview process was held with the Infection Preventionist (IP), during that time, she was asked about the facility's Enhance Barrier Precaution process. The IP revealed, the facility did not have an EBP process in place until 12/04/24, after the surveyor's intervention. The IP was made aware for three days, Resident #22 did not have sn EBP process in place and she has tube feeding. The IP agreed. 2) Clinical record review revealed, Resident #44 was admitted to the facility on [DATE], with diagnosis including End Stage Renal Disease. Review of the quarterly Minimum Data Set assessment, reference date 08/29/24, documented a Brief Interview for Mental Status score of 03, which indicated Resident #44 was severely cognitively impaired. Under section M for skin status, it was recorded that Resident #44 had an unhealed pressure ulcer at a stage four. Review of physician orders dated 09/27/24, indicated to cleanse sacrococcygeal ulcer with normal saline, blot dry, apply messalt pad, then cover with hydro cellular foam dressing with silicone adhesive border daily and as needed. Review of the documented wound measurements dated 12/02/24, showed evidenced that the sacral wound was measured as followed: 7.5cm x 7.5 cmx 2.5cm, 100% granulation, 0% slough, 0% eschar, no odor, undermining, no tunnelling. An observation was made of Resident #44 on 12/02/24 at 10:47 AM, she was observed lying in bed alert, there was no EBP process in place (no signs, and no PPE kit). On 12/03/24 at 9:32 AM, an observation was made in Resident #44's room, there was no EBP process in place. On 12/04/24 at 9:09 AM, an observation was conducted on Resident #44 while Staff A, a License Practical Nurse, was performing the wound care and Staff I, a Certified Nursing Assistant, was assisting in holding and turning Resident #44 during the care. The mentioned staff did not wear a gown. As Staff I turned and held Resident #44 to her side, Staff I's uniform was observed touching the resident. As Resident #44 turned, the nurse removed the old dressing, the sacrococcygeal was observed with a huge open wound and drainage. Staff A cleansed the wound with normal saline, she removed the soiled gloves, and applied new gloves without hand hygiene in between gloves changes. Subsequently she patted dry the wound, she removed her gloves, and applied new gloves, without hand hygiene in between. She then proceeded to pack the wound with messalt dressing, covered the wound with gauze, and foam dressing. She removed her gloves and applied new gloves, without hand hygiene in-between gloves changes. During the wound care process, Staff A's uniform was observed touching the bed linens as she leaned over to get to the wound. On 12/04/24 at 12:06 PM, an interview was held with Staff A; an inquiry was made regarding EBP process. Staff A voiced her understanding of EBP was when touching bodily fluids, or saliva during patient care, staff were to wear gloves. Staff A voiced she was never told to wear gowns during wound care. Staff A explained, she had asked her manager about wearing gowns during wound care back in 2021 (whether nurses needed to wear a gown during wound care), but was told, this was not part of the facility's policy. During further interview, the Surveyor spoke to Staff A regarding the facility's policy, which indicated staff were to conduct handwashing after removing gloves. She agreed that she did not conduct hand hygiene in-between gloves changes during the wound care. On 12/05/24 at 10:20 AM, an interview was held with the IP. During that time the IP was made aware that for three days (as of 12/02/24, 12/03/24 and 12/04/24), Resident #44 did not have EBP process in place and she has an open wound. The IP agreed. During that time, the IP provided a list of residents who had indwelling medical devices and wounds, which included: Resident #20 (tube feeding), and Resident #28 (tube feeding). Review of Resident #20's annual comprehensive assessment, reference date 09/10/24, revealed he was admitted to the facility on [DATE] with diagnosis that included Dementia. This assessment showed a Brief Interview for Metal Status score of 01, which indicated Resident #20 was severely cognitively impaired. On 12/02/24 at 12:46 PM, an observation was conducted of Resident #20. There was no EBP process was in place. Review of Resident #28 quarterly comprehensive assessment reference date 09/30/24, revealed, the resident was admitted to the facility on [DATE], with diagnosis that included: Dementia. This assessment showed, the resident was rarely understood. No behaviors recorded. For three days, during the survey process (12/02/24, 12/03/24, and 12/04/24) there was no EBP process observed for Resident #28. 25404 3) Review of the record revealed Resident #1 was admitted to the facility on [DATE]. The record revealed the resident had an urinary catheter related to bladder obstruction. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4, on a 0 to 15 scale, indicating the resident as severly cognitively impaired. This MDS also documented the resident was totally dependent upon staff for toileting and that the resident had an indwelling urinary catheter. Review of the current care plan initiated on 09/18/23 documented Resident #1 had the potential for complications related to the use of an indwelling catheter. This care plan was updated with a hand-written note that the resident was colonized with the bacteria E. Coli (Escherichia coli, part of the normal human intestinal flora, but should not be part of the urinary system when proper care is provided). An observation on 12/02/24 at 12:34 PM revealed Resident #1 in bed with an Urinary catheter tubing noted with bedside drainage. Observations on 12/02/24 at 12:34 PM and on 12/03/24 at 10:01 AM revealed Resident #1 in bed with the urinary drainage device to bed side drainage. There was no observed sign for Enhanced Barrier Precautions (EBP) or any personal protective equipment, other than gloves, readily available (Photographic Evidence Obtained). An observation of personal care for Resident #1 was made on 12/04/24 beginning at 9:36 AM, with Staff E, Certified Nursing Assistant (CNA). The CNA was asked to perform the personal care she would normally complete for Resident #1. The CNA gathered her supplies and donned gloves, but no other PPE (personal protective equipment). The CNA provided direct care to Resident #1. During an interview on 12/04/24 at 11:02 AM, when asked if she knew what Enhanced Barrier Precautions or what EBP was, Staff E, CNA questioned, Like washing your hands? When asked about the use of PPE during care for Resident #1 who had an indwelling catheter, the CNA questioned if she needed to wear goggles, a hair net, and a gown. When asked if there were any gowns available for use, the CNA stated yes, and took the surveyor to the supply area at the East nurse's station and was unable to find any. The CNA went to Central Supply and asked the Central Supply person for gowns, and there were none there. The Central Supply person found boxes of disposable gowns in the main supply area in the back hall of the facility. When asked about EBP the Central Supply CNA was unaware of what it was. During an interview on 12/04/24 at 11:11 AM, when asked if she was aware of EBP, Staff F, Licensed Practical Nurse (LPN) stated, When a resident has a Foley or something and has infection we put them on contact precautions. The LPN was unaware and unable to explain PPE use related to Enhanced Barrier Precautions.

Based on observation, interview and record review, the facility failed to ensure of accurate Minimum Data Set (MDS) assessments for 3 of 3 sampled residents (Resident #33, #15, and #8), specifically a resident with hearing loss, this involved Resident #33; a resident with limited range of motion, this involved Resident #15; and a resident for medication usage, this involved Resident #8. The findings included: 1) Clinical record review revealed that Resident #15 was admitted to the facility on [DATE] with diagnosis that included: Dementia. Review of the quarterly MDS assessment, reference date 10/08/24, indicated Resident #15 was rarely/never understood. No moods or behaviors were recorded in this MDS. Under section GG for functional abilities and goal. It was documented Resident #15 had no impairment in his upper extremity (shoulder, elbow, wrist, and hand). Review of Therapy evaluation/summary dated 04/10/24 revealed Resident #15's proper hand function and skin integrity were impacted by the need for a right hand splint. Review of restorative care plans dated 04/11/24 revealed Resident #15 needed contracture Passive Range of Motion exercises to both upper extremities and splinting 3 times per week until further orders, for diagnosis of right sided weakness. Interventions included: application of right-hand splint 2 to 4 hours. Review of progress notes dated 12/03/24 recorded Resident #15 had right sided weakness. On 12/02/24 at 9:40 AM, an observation was conducted of Resident #15, whereas he was noted lying in bed, his right hand was tightly closed, contracture noted and no splint in place. On 12/02/24 at 1:15 PM Resident #15 was observed in his room lying in a recliner chair, with his right hand tightly closed, contracture noted, and no splint in place. On 12/05/24 at 9:33 AM, an interview with the MDS Coordinator and a side-by-side review of Resident #15's record was also conducted. She agreed the MDS coded no impairment in the resident's upper extremities. 2) Clinical record review revealed Resident #33 was admitted to the facility on [DATE] with a diagnosis that included: Hypertension (high blood pressure). The quarterly MDS assessment with a reference date of 09/04/24, recorded a Brief Interview for Mental Status score of 02, which indicated Resident #33 was severely cognitively impaired. Further review of the MDS under section B for hearing, speech, and vision, it was recorded Resident #33 had adequate hearing (no difficulty in normal conversation, social interaction, and listening to TV). Review of the care plans, which was revised on 09/10/24, recorded Resident #33 had potential for impaired communication, activity involvement related to hearing loss. Review of progress notes dated 11/11/24 evidenced Resident #33 had potential for impaired communication and activity involvement related to hearing loss. On 12/02/24 at 10:26 AM, Resident #33 was noted lying in bed. When the Surveyor attempted to talk to the resident, he did not answer. His family member, who was near by the room, came over and voiced Resident #33 had severe hearing loss, and he could not hear. On 12/05/24 at 9:42 AM, an interview with the MDS Coordinator and a side-by-side review of Resident #33's MDS was conducted. She agreed the MDS coded no impairment for the hearing. On 12/05/24 at 10:00 AM, another interview was conducted with Resident #33's family member, she revealed Resident #33 used to have two hearing aids, but he threw them away. She further stated right now he does not have any hearing aids, and a family member was planning on getting him new hearing aids. 25404 3) Record review revealed Resident #8 was admitted to the facility on [DATE]. Review of the current orders documented as of 11/09/23 Resident #8 had been receiving the anti-platelet medication Clopidogrel (Plavix) 75 mg daily related to a history of a stroke. Review of the current Minimum Data Set (MDS) assessment dated [DATE] lacked the documented use of any anti-platelet medication. Review of the corresponding Medication Administration Record (MAR) for October 2024 confirmed the administration of the anit-platelet medication to Resident #8. During a side-by-side review of the record and interview on 10/03/24 at approximately 3:00 PM, when asked if anti-platelet medications were coded on the MDS assessment, Staff C, Registered Nurse (RN)/MDS Coordinator stated they were. When asked specifically about the anti-platelet medication for Resident #8, Staff C agreed with the failure to code the medication on the current MDS assessment.

Based on interview and record review, the facility failed to develop a care plan for 2 of 17 sampled residents (Resident #58 related to an actual fall and Resident #17 for use of bed rails). The findings included: 1) Resident #58 was admitted to the facility on [DATE] with diagnoses that included Falls, General weakness, Hypertension, and Rhabdomylosis (a breakdown of skeletal muscle). Record review revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 5 on the annual Minimum Data Set (MDS) assessment dated [DATE]. This indicated the resident had severe cognitive impairment. Further record review revealed on 10/05/24, the resident sustained a fall when he was walking to the bathroom, felt dizzy and fell on his side. A review of the resident's care plans revealed a care plan with a start date of 01/09/24 for potential for significant injury related to fall (edited 10/07/24). Approaches included: redirect prn (as needed) (created on 10/07/24) and keep call light and personal items within his reach (edited 10/07/24). Existing approaches included, remind to observe safety at all times (created on 07/08/24) and anticipate and meet his needs (created 01/09/24). On 10/29/24 the resident sustained another fall from the left side of the bed at 5:49 AM. He was found in the right lateral position, with bilateral upper extremities extended slightly forward per record review. A progress note written by the Director of Nursing (DON) dated 10/29/24 revealed the DON was called to room by nurse, resident c/o (complained of) mild pain to left thumb and swelling. An x-ray of the left hand was ordered and the results were dislocation of the distal phalanx of the thumb. There may be a fracture through the base of the distal phalanx as well. Consider repeat radiographs following reduction. The resident was sent to an orthopedic doctor on 10/31/24 for left thumb pain and swelling post injury. The orthopedic notes stated Unable to do a closed reduction under local anesthesia. Short arm splint applied. A review of the care plans revealed an additional care plan for potential for significant injury related to fall (edited 11/15/24). Approaches revealed keep call light within his reach, and encourage to use it for assistance during transfers (edited 10/29/24), remind to observe safety at all times. Redirect prn (edited 10/29/24) and anticipate and meet his needs (edited 01/09/24). An interview was conducted with the MDS Coordinator on 12/04/24 at 10:16 AM. She was asked if there was a care plan for the actual fall with injury and she said she did not see one. She stated there should be a care plan for significant injury from the fall on 10/29/24 and there should be a care plan related to splint care but she did not see that on any care plan that she reviewed. The only update to the potential for significant injury related to fall care plan was encourage to use (call bell) for assistance during transfers. 25404 2) Review of the record revealed Resident #17 was admitted to the facility on [DATE]. A Side Rail Assessment Form dated 11/09/24, documented the use of bilateral side-rail use for Resident #17. An observation on 12/02/24 at 11:20 AM revealed Resident #17 in a low bed with bilateral quarter rails noted and in use. Additional observations throughout the survey on 12/03/24 through 12/05/24, while passing by the resident's room, revealed the bed side rails in an upright position and in use. Review of the current care plans revealed no documentation of care plans that included the use of the bed side rails. During a side-by-side review of the record and interview on 12/05/24 at 12:23 PM, when asked if the use of bed side rails should be care planned, Staff C, MDS Coordinator, stated yes and explained that she was new at the facility and had noted an inconsistency in the care plans. The MDS Coordinator stated she was going to start adding the bed side rail use to the ADL (activities of daily living) care plans, as appropriate. The MDS Coordinator agreed with the failure to include the use of bed side rails in the care plans for Resident #17.

Based on policy review, observation, interview, and record review, the facility failed to ensure complete and proper personal care for 1 of 1 sampled resident who had an urinary drainage device, as evidenced by the failure to perform hand hygiene prior to donning gloves, failed to provide peri-care (personal care) during catheter care, and failed to ensure proper catheter care for Resident #1. The findings included: Review of the policy titled, Foley Catheter Care and Maintenance revised 05/19/22, documented in part, Procedures: Foley (urinary drainage device) Catheter Maintenance . 4. Wash your hands with soap and water for at least 20 seconds, then apply gloves. 5. Using mild soap and water, or approved cleaner, clean your genital area. 8. Clean your urethra (urinary opening), which is where the catheter enters your body. 9. Clean the catheter from where it enters your body and then down, away from your body. Review of the record revealed Resident #1 was admitted to the facility on [DATE]. The record revealed the resident had an urinary catheter related to bladder obstruction. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4, on a 0 to 15 scale, indicating severe cognitive impairment. This MDS also documented the resident was totally dependent upon staff for toileting and that the resident had an indwelling urinary catheter. Review of the current care plan initiated on 09/18/23 documented Resident #1 had the potential for complications related to the use of an indwelling catheter. This care plan was updated with a hand-written note that the resident was colonized with the bacteria E. Coli (Escherichia Coli, part of the normal human intestinal flora, but should not be part of the urinary system when proper care is provided). An observation on 12/02/24 at 12:34 PM revealed Resident #1 in bed with an Urinary catheter tubing noted with bedside drainage. An observation of personal care for Resident #1 was made on 12/04/24 beginning at 9:36 AM, with Staff E, Certified Nursing Assistant (CNA). The CNA was asked to do the personal care she would normally complete for Resident #1. The CNA gathered her supplies and donned gloves without performing any type of hand hygiene. The CNA applied soap to the cloth and cleaned the urinary catheter tubing, then wiped off the resident's left groin, then continued to clean the catheter tubing. The CNA rinsed and dried the tubing, checked to see if the resident had a bowel movement, which he had not, and completed her task by covering the resident. The CNA failed to complete any personal (peri) care for Resident #1. When asked if she was to provide peri-care as well, the CNA stated, Was I supposed to? When asked if she had done any type of personal care for Resident #1 that morning, the CNA stated, No this is my first round with him. When asked if she completed any type of hand hygiene prior to donning her gloves, the CNA confirmed she had not.

Based on recipe review, observation, and interview, the facility failed to follow cooking instructions and ensure prepared fried fish was at a safe temperature, for 1 of 1 sampled resident who ordered that meal (Resident #13). The findings included: Review of the Production Recipe for the breaded cod, the fried fish on the lunch menu for 12/04/24, documented in part, Crunchy Breaded Cod Fillet 1. Deep fry from frozen at 360 degrees F for 3 to 5 minutes. Final internal cooking temperature must reach a minimum of 145 degrees F, held for a minimum of 15 seconds. Hot foods held for later service must maintain a minimum internal temperature of 135 degrees F. An observation of the lunch meal service was made on 12/04/24 beginning at 11:20 AM. Staff G, lead cook for the day, placed the prepared foods into the steam table and took the food temperatures. When asked about fried fish, the cook stated it would be fried a little later, as the resident who requested it was served on the last cart. At about 12:00 PM, Staff H, assistant cook for the day, fried three pieces of fish and placed them on the steam table. Staff failed to obtain a final temperature of the fried fish upon taking it out of the fryer. At 12:14 PM, Staff G, lead cook, took one of the three pieces of cooked fish from the steam table and placed it on a plate to put on the lunch tray of Resident #13. As kitchen staff were preparing to place plates on the tray to load onto the food cart, a request to obtain the temperature of the fish was made by the surveyor. The fried fish temperature was 125 degrees F. The lead cook told the assisting cook to fry the fish longer. After further cooking and surveyor intervention the temperature was 164 degrees F. During an interview on 12/04/24 at 12:20 PM the Kitchen Manager/Certified Dietary Manager (CDM) agreed staff failed to properly temp the fried fish upon completion of cooking, and failed to hold the cooked fish at a safe temperature.

Based on policy review, interview, and record review, the facility failed to act upon a grievance voiced by a resident regarding care for 1 of 2 sampled residents (Resident #266). The findings included: Policy titled complaints/grievances of resident/family member. Revised date January 2018. Department approval: Director of social services. The objective included: to ensure that all residents have complaints addressed to their satisfaction; to provide a mechanism for residents to access a grievance process. The procedure included: Complaints received by social services or staff member: 1.the staff member brings the complaint to their department manager immediately. 2.the social service director or department manager arranges a meeting with the involved discipline and the resident and/or family member where attempts shall be made to resolve the issues. 3.a resident/family complaint/grievance resolution form is completed and forwarded to the director of social services who will present the data at the quality assurance/performance improvement committee meeting. Record review revealed Resident #266 was admitted to the facility on date 09/07/23. The admission Minimum Data Set (MDS) assessment, reference date 09/18/23 documented a brief interview for mental status score (BIMS) of 15, indicating Resident #266 was cognitively intact. This MDS documented no mood and behavior issue. The MDS revealed Resident # 266 required total assistance from the staff with activities of daily living (ADLs), including: bed mobility, locomotion on and off unit, toilet use and personal hygiene. Review of the comprehensive care plan dated 09/14/23 revealed Resident #266 needed total assistance in almost all aspects of care. Interventions included: to anticipate and meet her needs, explain plan of care, and Promote dignity by ensuring privacy. Review of the grievance log dated for September 2023 revealed no documented evidence of grievance for Resident #266. Review of progress note dated 09/18/23 (a late entry note) written by the social worker, the note indicated, on Friday 09/15/23 I (social worker) received a message from Resident (#266's) daughter that Resident (#266) was complaining that she needed to be changed. Upon speaking to nursing staff, the attending nurse advised that (Staff A) was Resident (#266's) certified nursing assistance (CNA). The attending Nurse stated that Staff A was with another resident giving care and had already spoken with Resident (#266) and told her that she would change her when she's done giving care to the other resident. It was explained to Resident (#266) that CNA had other residents and would provide care to her when finished. Resident (#266) verbalized understanding. On 09/18/23 at 9:31 AM an interview was held with Resident #266, she revealed that she's been at the facility for 2 weeks, for rehabilitation, status post stroke, and she can't walk, she depends on the staff for all aspects of her care. During the interview, Resident #266 explained that last Friday, September 15, she needed help changing her soiled adult depends, she couldn't find the call light, it was on the floor, therefore she called the front desk via her cell phone and ask for her CNA. The assigned CNA, who was (Staff A), came in the room and scolded Resident #266, yelling at her, stating why you had to call the front desk!? In a rude manner. Then Staff A continued to state she has other residents to care for, she then left the room and did not help Resident #266. Subsequently, Staff A returned to the room and started arguing with Resident #266. Staff A accused Resident #266 of cursing her out. Resident #266 explained, Staff A voiced to her that the attending nurse had informed her (Staff A) that Resident #266 had cursed her out when Staff A had left the room. Resident #266 further explained, Staff A stated, you're not going to disrespect me! and continued to argue with her. Resident #266 voiced, ever since the altercation with Staff A, she has been having headaches, because Staff A upset her. When inquired if she reported the incident to anyone in the facility? Resident #266 voiced she think her daughter may have reported the concern to someone in the facility, she's not sure. On 09/21/23 at 9:16 AM, an interview process was started with the Director of Nursing (DON), regarding Resident #266, when inquired about how the facility addressed Resident #266's concern regarding her care and concern with Staff A, the DON was oblivious about the incident, she revealed she had no knowledge of the incident (after the surveyor had explained what Resident #266 had reported). The DON advised the surveyor to speak with the Social Worker (SW) about the concern. On 09/21/23 at 9:55 AM, a subsequent interview was held with Resident #266 in the presence of the SW. During that time, Resident #266 explained the same concern she had reported to the surveyor on Monday (09/18/23 at 9:31 AM) to the SW. On 09/21/23 at 10:01 AM, an interview was held with the SW, the SW voiced she knows Resident # 266 well, the resident used to be her co-worker, she speaks to Resident #266 often. The SW voiced, she knew about the concern, she said Resident #266 had reported the exact same concern to her on Friday September 15. The SW explained, she documented a note and placed it in the resident's chart, she voiced she did not treat the concern as a grievance, she didn't know she needed to treat it as a grievance. She did not initiate any grievance process/investigation. On 09/21/23 at 10:28 AM, a subsequent interview was held with the DON, again she voiced she had no knowledge of this concern, because the SW never brought the concern to the morning meetings with the interdisciplinary team (IDT). The DON voiced that had she knew about the concern, she would have started a grievance process, she would have brought the involved CNA in, obtain her statement, and provide education. The DON agreed a grievance process and investigation should have started.

Based on interview and record review, the facility failed to offer residents Binding Arbitration Agreements in a manner that the residents or their representatives would be able to make an informed decision. The findings included: During the entrance conference, on 09/18/23 at 9:11 AM, when the Administrator was asked if the facility offered Binding Arbitration Agreement to residents as a means for dispute resolution, the Administrator stated that the facility did. The Administrator stated that the facility had not had any disputes resolved using the Binding Arbitration Agreement. Record review revealed the Admission Packet documented, Optional Arbitration Clause: if the parties of this Agreement do not wish to include the following arbitration provision, please indicate so by marking an X through this clause. Both parties shall also initial that X to dignify their agreement to refuse arbitration. Any controversy or claim arising out of or relating to the Agreement or the breach thereof, shall be settled in arbitration in accordance with the provisions of the Florida Arbitration Code found at Chapter 682, Florida Statutes, and judgement upon the award rendered by the arbitrator (s) may be entered in any court having jurisdiction thereof. Further review of the Admission Packet revealed that there was no other reference to the Agreement in the admission packet and the acknowledgement form in the admission packet was a blanket form that did not make reference to the Binding Arbitration Agreement. During an interview, on 09/20/23 at 2:40 PM, with the Director of Social Services/Admissions Coordinator, when asked for a copy of the Agreement, the Director of Social Services/Admissions Coordinator was not able to provide the document. When asked to provide details of the Agreement, she stated that she was not familiar with the Agreement and was not able to demonstrate knowledge of the Agreement.

Based on facility policy, record review, observation, and interview, the facility failed to maintain in-dwelling urinary catheters according to facility policy for 2 of 2 sampled residents (#44 and #54). The findings included: Facility policy titled: Foley Catheter Care and Maintenance effective date 01/01/2020 reads, 1. Keep the drainage bag below the level of your bladder and off the floor at all times. 2. Keep the catheter secured to your thigh to prevent it from moving. 1). Record review revealed Resident #44 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly assessment on 04/09/2022 documented the resident as being severely cognitively impaired and having a functional status of total dependence on staff performance for all activities of daily living and care. A Physicians order dated 03/22/2022 documented,, Foley catheter care every shift per facility protocol Care Plan dated 01/26/2022 documented, Catheter care per facility protocol. Keep drainage bag off the floor. During observations for Resident #44 on 05/09/2022 at 7:55 AM, the in-dwelling urinary catheter drainage bag was noted to be lying on the floor on the right side of the bed. At 10:25 AM the catheter drainage bag was again noted on the floor (photographic evidence obtained). During an observation of wound care performed by the Director of Nurses (DON) at 2:09 PM, it was noted the in-dwelling urinary catheter was not secured to the resident's thigh and pulled tight during turning. On 05/10/2022 at 10:30 AM, during an observation of catheter care for Resident #44, performed by Staff A assisted by Staff B and Staff C, it was again noted that the in-dwelling urinary catheter was not secured to the thigh. Post urinary catheter care, the bed was lowered, and the catheter drainage bag was noted on the floor. 2) Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment on 04/22/2022 documented the resident as being severely cognitively impaired and having a functional status of total dependence on staff performance for all activities of daily living and care. A Physicians order dated 04/12/2022 documented, Foley catheter care every shift per facility protocol Care Plan dated 04/15/2022 states, Catheter care per facility protocol. Keep drainage bag off the floor. During observations for Resident #54 on 05/09/2022 at 8:55 AM, the in-dwelling urinary catheter drainage bag was noted to be lying on the floor on the right side of the bed. At 9:37 AM, the catheter drainage bag was again noted on the floor (photographic evidence obtained). On 05/10/2022 at 7:35 AM, Resident # 54's urinary catheter drainage bag was noted to be on the floor (photographic evidence obtained). At 9:35 AM, during an observation of catheter care performed by Staff B and Staff C, it was noted the catheter was not secured to the resident's thigh. Post urinary catheter care, the bed was lowered, and the catheter drainage bag was noted on the floor. On 05/10/2022 at 10:30 AM, Staff A stated they currently do not have any catheter leg straps. She stated the resident came from the hospital with one, but it had become soiled and was causing leg irritation, so it was removed. On 05/10/2022 at 11:30 AM, the Director of Nurses stated that urinary catheter drainage bags must be kept off the floor. She stated she had removed the leg strap from Resident #44 due to irritation and stated they needed to order more replacements.

Based on interview, observation, and record review, the facility failed to prevent the elopement of 1 of 56 sampled residents, reviewed for an elopement (Resident #1), and who did not have an elopement risk evaluation completed. The findings included: Review of the facility's policy, titled, Elopement, revised June 2009, revealed the policy does not define elopement. Record review revealed Resident #1 was admitted to the facility on [DATE], with admitting diagnoses, in part, of Altered Mental Status (AMS) and weakness. The purpose of the admission was for rehabilitation services. Resident #1 had medical diagnoses that included but were not limited to the following: [CONDITION(S)] (brain disease that alters brain function or structure), Type 2 Diabetes and Acute Kidney Failure. Prior to the elopement, Resident #1 had a Quarterly Minimum Data Set (MDS) completed on 11/10/21. After the elopement, Resident #1 had his Annual Minimum Data Set (MDS) completed on 02/01/22. The findings of the Quarterly MDS corresponded to the findings of the Annual MDS. The following are the findings of the Annual MDS assessment: Section B: Hearing- Adequate without hearing aids, Vision - adequate without corrective lenses, Speech - able to be understood, and understands others. Section C: Brief Interview for Mental Status (BIMS) 5/15 - indicating severely cognitively impaired Section D: Mood Score - 00 no issues with mood Section E: Behavior Score - there were no behavior issues identified. Section G: Activities of Daily Living (ADLs) Sub-item C walk in room - Supervision with set-up help only Sub-item D walk in corridor - Limited assistance with one-person physical assist Sub-item E Locomotion on Unit - Supervision with set-up help only Sub-item F Locomotion off Unit - Limited assistance with one-person physical assist Sub-section G0600- Resident #1 was documented as not using any Mobility Devises. Review of the facility's documentation revealed Resident #1 was identified as missing from the facility on 12/28/21 at approximately 5:00 AM, was found by staff on 12/28/21 at 6:30 AM and was returned to the facility. Resident #1 informed the facility that he left to bring Christmas presents to his family. On 02/16/22 at 11:11 AM, an interview and a walking tour of the facility was taken with the facility's Administrator. The tour extended to include the outside of the facility and the surrounding area. The Administrator showed the surveyor where Resident #1 was found on the morning of 12/28/21, the date of the elopement. The Administrator stated that a bag of toiletries was found on the side of the paved driveway where Resident #1 was found. The Administrator stated that, by the location of the bag, it was assumed that Resident #1 had traveled along the paved driveway. The Administrator stated that Resident #1 later identified the bag and items as his. The route was walked by the surveyor to determine the potential dangers encountered by Resident #1. Walking from the front door, Resident #1 turned right and walked Northwest up the paved drive to the two-way residential street that is adjacent to the facility and provides the only access to the facility. Resident #1 then crossed the street to the sidewalk on the west side of the street. The residential street runs north and south. The Administrator stated, that on 12/28/21, the date of the elopement, the street was closed at the southern end which eliminated the possibility of through traffic; Resident #1 had fallen and abraded (scratched) his right knee during his travels. It was assumed that he fell where his bag was found. After crossing the street, Resident #1 made a right turn and walked North to the fourth house across the street from the facility. At that point, Resident #1 stopped and sat upon a chair that was on the front porch of the house. It was at this location that Resident #1 was found by two Certified Nursing Assistants (CNAs), who had been searching for the resident, at approximately 6:30 AM on 12/28/21. This house is approximately one-tenth (0.1) of a mile from the facility as determined by Google Maps. The surrounding area of the facility had little danger that would cause a person the experience serious harm or death. Review of facility documentation revealed Resident #1 was found to be dressed in street clothes and a heavy jacket with a hood. According to the web site TimeandDate.com, the weather was 54 degrees F (Fahrenheit) with fog at the time Resident #1 was out of the facility. The Administrator explained that Resident #1 showed the Administrator how he unlocked the door and pushed it open to get out of the facility. The Administrator explained that at the time of the elopement, Resident #1 was able to leave because the front, sliding glass doors did not have an alarm or keypad that required a code to prevent the door from being opened. The Administrator further explained that the door was locked from the outside but could be unlocked from the inside. The Administrator stated that all other doors are locked and alarmed at all times. The Administrator went through the steps that Resident #1 showed him on how Resident #1 eloped. Resident #1 unlocked the doors from the inside and pushed apart the sliding doors to open them. The Administrator explained that the [MEDICATION(S)], the part of the door that allows it to open automatically, was turned off at night but the doors have to be able to open by being pushed on as part of life safety requirements. The Administrator stated that he had the alarm with keypad lock installed immediately after the elopement on 12/28/21. This was verified during observation and return demonstration by the Administrator during the facility tour on 02/16/22, which concluded at 11:11 AM. On 02/16/22 1:22 PM, an interview was conducted with Staff A, a Certified Nursing Assistant (CNA), who was assigned to care for Resident #1. Staff A-CNA, who works the 7:00 PM to 7:00 AM shift, stated that she started her shift at 7:00 PM on 12/27/21. Staff A-CNA stated that when she comes in to work, she always walks around checking on her residents. Staff A-CNA stated that she first saw Resident #1 at approximately 7:15 PM on 12/27/21. Staff A-CNA stated that Resident #1 was in his room watching television. Staff A-CNA stated that she gave Resident #1 a snack at 7:30 PM and she would check on her residents every hour. Staff A-CNA stated that after 5:00 AM on 12/28/21, she noticed Resident #1 was not in his room. Staff A-CNA stated she checked around the bed and in the bathroom before determining Resident #1 was missing. Staff A stated that she then told the nurse that Resident #1 was missing. At that time, the nurse and Staff A checked the other rooms to see if Resident #1 was in someone else's room. Staff A-CNA stated that she and the nurse informed the other staff present that Resident #1 was missing. Staff A-CNA stated that the other staff checked the facility including the perimeter of the building outside. Staff A-CNA stated that when Resident #1 was still not found, the nurse notified the DON (Director of Nursing), the Administrator, the primary physician, the family and the nurse placed a 911 call to the police. According to Staff A-CNA, the nurse acted as directed in the facility's policy for elopement. Staff A-CNA stated that she and another CNA went driving in the neighborhood to find Resident #1. Staff A-CNA stated that she and her co-worker were out about an hour when they found Resident #1 sitting in a chair on the porch of a house across the road from the facility. Staff A-CNA stated that the road was in good condition at the time. The road is currently under reconstruction. Staff A-CNA stated that she and her co-worker then drove Resident #1 back to the facility, where he was examined and cared for by the nurse. Staff A-CNA stated that Resident #1 had a scrape on his right knee and had a slight limp that she believed was related to the knee injury. On 02/16/22 at 2:48 PM an interview was conducted with the Minimum Data Set Coordinator (MDSC) regarding Resident #1 not being identified as a wander / elopement risk on his Annual assessment dated [DATE].The MDS Coordinator stated the assessment had a look back period of 2 weeks and at the time of Resident #1's assessment he had not been exhibiting wandering or exit seeking behavior for that period. On 02/16/22 at 2:55 PM, an interview was conducted with the Social Services Director (SSD). A progress note, dated 12/28/21, indicated that when the family was notified that Resident #1 had eloped, the family then revealed that Resident #1 had been placed in the nursing facility because of repeated times where Resident #1 left home and wandered off. The SSD was asked if the facility had been informed of Resident #1's wandering from home would the facility have accepted Resident #1? The SSD stated that probably not because the facility did not have a locked unit and it would not have been a safe admission. The SSD stated that at the time of admission the facility had been informed by the family that Resident #1 was weak and not walking. On 02/16/22 at 3:20 PM, an interview was conducted with Staff B, a Registered Nurse (RN) who was the primary nurse, for Resident #1 at the time of his elopement. Staff B-RN stated she was notified at about 5:15 AM that Resident #1 was not in his room. Staff B-RN stated that the staff searched the facility and the outside grounds. Staff B-RN stated that when the resident was not found she notified the DON and called 911. The nurse stated that Resident #1 had not shown any elopement or wandering behavior prior to the elopement. Staff B-RN stated that the CNAs do rounds (check on the residents) every two hours and when she is working, she will round a half hour after the CNA. On 02/17/22 at 9:35 AM, an interview was conducted with the Administrator. The Administrator (NHA) informed this writer that he (NHA) lives in an apartment on campus during the week, as his residence is four hours away. The Administrator stated he was notified of the elopement at approximately 5:41 AM on 12/28/21. He stated he walked from his apartment across the parking lot to the facility and was on site in approximately 10 to 15 minutes, ahead of the first responders. The Administrator stated that there were no moving cars, or any people present at the time of the incident. According to the administrator it was unlikely anyone could have been hit by a car. The streetlights and parking lot lights were on at that time. The Administrator stated the parking lot was well lit. During the walking tour, the surveyor observed lights in question, which appeared to be in good condition and were likely functioning at the time of the elopement. The Administrator stated it was chilly, light jacket weather, but it was not cold. On 02/17/22 at 10:28 AM, an interview was conducted with the DON. The DON stated that the elopement of Resident #1 was the first time Resident #1 had shown any exit seeking behaviors in the 10 months he had been a resident. The DON stated that the facility did not have a tool to evaluate if a resident is a wander or elopement risk. The DON stated that they rely upon the MDS assessment to determine if a resident is an elopement risk. The DON explained that the facility has a disaster book located at each nurses' station that has a packet, including picture, for each resident in case of any emergency including elopement. The DON stated that the facility does not have a separate elopement binder. On 02/17/22 at 11:14 AM, an interview was conducted with Resident #1, who resided in the same room that he resided in at the time of the elopement. Resident#1 stated he remembered when he left the facility. When asked why he left, Resident #1 replied he wanted to go home. He stated, I've been here too long and want to go home. When asked how long he has been in the facility, Resident #1 stated I've been here 14 months, it's time to go home. When asked how he was going home, Resident #1 stated his father was going to get him. Resident #1 pointed out the window and stated, I live right over there. Resident #1 was pointing at a section of the building in the back of the facility where there are no residences. On 02/18/22 at 1:03 PM, an interview was conducted with Staff C, a Licensed Practical Nurse (LPN). Staff C-LPN stated that in-service education was conducted immediately after the elopement. Staff C-LPN stated that the in-services covered elopement, abuse / neglect and the new lock and alarm system for the front door and elopement drills. Staff C-LPN explained that an elopement happens anytime a resident leaves the facility without supervision. Staff C-LPN stated that the staff were instructed on how to search the building and the grounds for a resident once a determination was made that the resident was not in his room or the bathroom. Staff C-LPN further explained that the staff would work as teams to search inside the building as well as the perimeter outside, and would call the police as well as the DON and the Administrator. On 02/18/22 at 1:08 PM, an interview was conducted with Staff D, a Housekeeper. Staff D explained that in-services were conducted after the elopement, and that if a resident is missing the nursing staff searches the rooms and other staff search the outside of the building. Staff D further explained that the nurses give the staff a picture of the person who is missing so the person can be identified. Photographic evidence obtained.

Based on observation and interview the facility failed to prepare and serve food in a sanitary manner in accordance with professional standards for food safety. The findings included: During the initial kitchen tour, on 05/10/21 at 9:16 AM, accompanied by the Certified Dietary manager the following concerns were observed: (1) The Ice Machine had spots of dust on the ledge over the drum that was filled with ice. (2) There was an accumulation of dust on the ceiling vents over the food production area. (3) The stove and oven were encrusted with burnt food matter. (4) The drip pan under the stove was noted to have a greasy residue and was noted to be dirty. (5) The Fryer was encrusted with residue and the oil need to be change. (6) Containers of baked chicken in the reach in refrigerator were not dated or covered. (7) The inside the bottom of the steam table was full of rust. During the follow up kitchen tour, on 5/12/21 at 11:30 AM, the concentration of the quarternarry [MEDICATION(S)] that was being used as a sanitizer in a red bucket and in the three compartment manual ware washing sink was less than 150 parts per million During an interview, on 5/13/21 at 2:00 PM, with the Certified Dietary Manager, she was was informed of the findings.

Based on observation and interview, the facility failed to provide a safe, clean, and home like environment. The findings included: During observations on 05/10/21 at 10:44 AM, the following concerns were noted: 1) In room East 19-B, it was noted that the walls were chipped and there was an accumulation of dead bugs in a light over the hand washing sink and that the plumbing in the bathroom showed signs of corrosion. 2) In room East 25-B, it was noted that the right side arm rest of the resident's wheelchair was in disrepair, exposing the foam and part of the frame and the plumbing in the bathroom showed signs of corrosion. 3) In room West 15-B, it was noted that there was a leak in the basin/drain of the hand sink in the bathroom, leaving a puddle of water underneath the sink, and the plumbing in the bathroom showed signs of corrosion. 4) In room West 16-B, It was noted that the plumbing in the bathroom showed signs of corrosion. 5) In room West 24-B, it was noted that the handle of the door to the room did not secure the door closed and that the room did not have any type of privacy curtain. The plumbing in the bathroom showed signs of corrosion. 6) I the medication storage room on the West unit, the sink that was in the Medication Storage Room did not have any running water. 7) Throughout the facility, there was a wall bumper guard below the hand rail that was covered with carpeting that was found to be uncleanable and absorbent. During an environmental tour of the facility, on 05/12/21 at 12:22 PM, the concerns were brought to the attention of the Director of Facilities. The Director of Facilities verbally acknowledged understanding of the concerns. When asked how the bumper guard that was covered with carpeting material was cleaned, the Director of Facilities stated, we scrub it. When asked how staff disinfect the bumper guard, the Director of Facilities stated, we don't. When asked about the sink in the West Unit Medication Storage room, the Director of Facilities stated, one of the nurses broke it and didn't report it, I found out a week or so ago. We are already working on it. 8) Resident #56 was admitted to the facility on [DATE]. According to the resident's most recent assessment, an admission MDS (Mininmum Data Set) dated 05/04/21, Resident #58 had a BIMS (Brief Mental Status) score of 12, indicating 'cognitively intact'. During observation on 05/10/21 at 10:44 AM, it was noted that the door to room number 24 on the West unit, was not secured closed, as the locking mechanism failed to latch and secure the door in a closed position. The surveyor was able to open the door with minimal effort and without using the door handle. Once inside of the room, it was noted that there was no privacy curtain in the room. The room is a two person room as evidenced by having two beds in the rooom. During a second observation and interview, on 05/11/21 at 3:37 PM, it was again noted that the door was not secured closed as the locking mechanism failed to latch and secure the door in a closed position. This surveyor was able to open the door with minimal effort and without using the door handle. Once inside of the room, it was noted that there was again, no privacy curtain in the resident's room. Resident #56 stated that he was aware of the missing privacy curtain, but was not aware of the door not being secured. During an interview on 05/12/21 at 4:11 PM, Staff A, LPN (Licensed Practical Nurse) stated that she was not aware that the door handle had not been working properly. During an interview, on 05/13/21 at 12:22 PM, with the Director of Facilities, it was noted that the door handle and closing mechanism had been repaired. The Director of Facilities acknowledged that there was no privacy curtain in the room. A review of the facility's policy titled, Resident Rights with regards to Privacy in their Rooms dated January 2004, and most recently reviewed/revised May 2020, did not address privacy of a single resident that is in a room designed for two residents.

Based on observation, interview and record review, the facility failed to ensure correct use of side rails, assess the residents for risk of entrapment from side rails, failed to obtain informed consent prior to use of side rails and failed to conduct regular maintenance checks on side rails for 4 of 8 sampled residents. These residents included Resident #12, Resident #29, Resident #32, and Resident #17. The findings include: On 05/10/21 at 11:19 AM, during observation, Resident #12 was resting in bed. Half-rails in the middle of both sides of his bed (chest to thigh range) were noted in the up position. His roommate, Resident #29, had the same on the center of both sides of his bed in the up position. As facility touring continued, Resident # 32 was observed with half-rails in the up position on his bed. Record review revealed assessments in each aforementioned resident's chart titled Side Rail Assessment were found. The assessments had three sections with check boxes regarding physical abilities, interventions, and recommendations however, there was no instruction or system to determine whether a resident was qualified or disqualified for bed rail use. In the afternoon of 05/11/21 the surveyor asked the DON (Director of Nursing) for the policy and procedure that went along with the side-rail assessment, but it had not been provided by the end of the day. On 05/12/21 at 9:50 AM, during wound care observation for Resident #17, it was noted that he also had side rails, in use on his bed. Most of the resident beds were observed to have side rails attached whether they were occupied or not. On 5/12/21 at 2:00 PM, the surveyor met with the DON and the MDS Nurse regarding the side rail assessments. The DON said there is no further instruction, policy, or procedure to go along with the bed-rail assessment. She said the assessment is all we've got. On 5/12/21 at 3:35 PM, the Admissions Nurse was asked if there was any kind of a consent form in the admissions packet for the use of the side rail. She stated, I don't know that there is one. On 05/12/21 at 4:20 PM, during an interview with Staff E, an LPN (Licensed Practical Nurse), she said neither Resident #12 or Resident #29 could help with their own repositioning, they were completely dependent on staff. On 05/12 at 4:30 PM, Staff F, a CNA (Certified Nursing Assistant), reported Resident #12 and #29 cannot reposition themselves, she has to turn them. On 05/13/2021 at 2:15 PM, an interview was conducted with the MDS Nurse who also develops care plans. When asked about the assessments and how they help to determine which residents need side rails, she stated that she asks CNAs and the residents if they need bed rails, adding that the residents use them to hold on to when the resident is receiving care. She explained that half rails are from the head to trunk but not below the abdomen. She agreed that chest to the thigh/knee area is also a half rail. The MDS nurse said she was not aware of any policy, procedure or documentation for the side rails and confirmed they do not obtain any consent from resident's or family members before they use the side rails. When asked about totally dependent residents needing side rails she stated, For the ones that are cognitively impaired usually they put half rails too. Sometimes they have involuntary movement so I guess you could say they are for safety also. She further stated, If they are alert and oriented and independent .if they can get out of bed by themselves and if they are responsive, we ask if they want them but usually, they do not because it is easier for them to get out of bed without them. Asked if they use the side rails to keep residents from rolling out of bed and she said yes then added, like I said earlier . the CNA's like them for the resident to hold onto when they are doing care. Then added, It became a habit to have the side rails. Regarding use of the assessment, she stated that they do it within 48-72 hours of admission for everyone and that's how they decide if someone needs siderails. The MDS Nurse reported she had not encountered any medical or psychological diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She also confirmed that they don't talk to the families about using side rails before they use them. When asked how they know the side rails are safely used with the bed she stated, Well, maintenance will fix it if they notice something. Then she was asked if anyone checks to ensure the siderails, bed and mattress all go together safely, and she said she thinks maintenance does that. She was asked why a resident who cannot hold onto the side rails would need them. She said, The staff thinks it prevents the resident from falling or something. She also added the side rails were not on anyone's care plans because, I didn't think that I should. Her opinion on the use of side rails despite the risks was, Yea, there could be a risk, but I didn't think it was bad because it's not the full side rails. On 05/13/2021 at 2:58 PM, the NHA (Nursing Home Administrator) was interviewed about the use of bedrails in the facility. He said, It may be a mobility device, some people may roll out of bed. They roll out of bed and it should be care planned. Some people may want that for their own use. It has to be care planned for whatever reason it's used. He also stated that the DON should be able to answer any questions about consents for the use of side rails. When the NHA was questioned about safety and maintenance checks on the beds and siderails the NHA called the Maintenance Director to his office. On 05/13/21 at 3:20 PM, the Maintenance Director (MD) and Staff G from maintenance were interviewed about the resident's beds and asked if they were new. The MD and Staff G decided the beds arrived new in 2007 or 2008 and that the beds came with the side rails attached. They were asked about their responsibility was regarding the beds and side rails. Staff G said, We make sure they are working, tight and stuff like that. He also stated there are no routine maintenance checks on them because a CNA would tell them if there was a problem with one adding that they were dependent on the CNAs to notify them and they (CNAs) were really good at that. When asked about mattresses fitting safely in the beds, they said no one was checking that, adding some mattresses were new and some were old, but Staff G said, I make sure they fit. There is a bar underneath, they fit nice, no gaps. Finally, Staff G was asked when they remove the side rails and he said he doesn't remove them and confirmed all the beds have side rails. At that time, the surveyors, NHA, MD and Staff G went to the closest resident room, W 01-B and checked the bed of Resident #43 who was out of the building. The surveyor grabbed the side rail closest to the door and found it to be loose and unstable. When pulled away from the bed there was a gap of 4.5 inches between the bed/mattress and the side rail. The NHA stated he would have Staff G remove it when he returned. Record review for Resident #12 showed he was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set) dated 12/10/2020 and 03/02/21 documented the resident required total care for all ADLs (Activities of Daily Living). More specifically, his bed mobility required total assistance with staff providing all the effort as the resident was not able to participate. He was also completely dependent for all transfers requiring full staff performance of two people to complete and the resident was not able to participate. His BIMS (Brief Interview for Mental Status) could not be completed which indicates severe cognitive impairment. His Side Rail assessment dated [DATE] showed side rails are indicated and serve as an enabler to promote independence however the resident is not able to use them. Side rails were not documented on this resident's care plan however it did specify that he required total care with all his ADLs. Review of Resident #29's record showed an initial admission on 08/01/18 and a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He has scheduled pain medications for [CONDITION(S)] three times daily and has physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He was in the hospital earlier this month for recurrent pneumonia. His MDS Quarterly Assessment on 03/24/2021 reflected a BIMS score of 10, a mild-moderate cognitive deficit without behaviors. It also indicated the resident requires total care for all ADLs (Activities of Daily Living). More specifically, his bed mobility requires total assistance with staff providing all the effort as the resident is not able to participate. He is also completely dependent for all transfers requiring full staff performance of one person to complete, indicating the resident can contribute less than 25% of the effort. His functional limitations for his range of motion were documented as both right and left sides of his body and both his arms and legs. His Side Rail assessment dated [DATE] showed side rails are indicated and serve as an enabler to promote independence however the resident is not able to use them. Side rails were not documented on this resident's care plan however it did specify that he required total care with all his ADLs. Record review for Resident #32 showed an initial admitted [DATE] revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His MDS assessments from 01/06/21 and 03/28/21 both reflect the resident requires total care for all ADLs (Activities of Daily Living). More specifically, his bed mobility requires total assistance with two staff persons providing all the effort as the resident is not able to participate. He is also completely dependent for all transfers requiring full staff performance of two persons to complete, indicating the resident cannot participate in the work. His functional limitations for his range of motion are documented as being both sides of his body and both arms and legs. His Side Rail assessment dated [DATE] has half rails selected. Record review for Resident #17 showed an initial admitted [DATE] and revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent MDS assessment from 03/12/21 (significant change), documented a BIMS score of 15 which shows no cognitive decline. His functional status showed his bed mobility required only limited assistance (meaning the resident is highly involved in activity with staff providing guided maneuvering of limbs or other non-weight bearing assistance). He did however require extensive assistance transferring from surface to surface with staff providing all the weight-bearing support. His functional limitations for weight bearing indicated he has impairment on one side of upper extremities and one side of his lower extremities. His Side Rail Assessment, which was not dated, also checks the half rails box with no other interventions noted.

Based on observation, interview and record review, the facility failed to follow through on a resident's request for DNR (Do Not Resuscitate) status and to promptly include the order in the medical record for 1 out of 6 sampled residents with DNR status, Resident #22. The findings include: On 05/11/21 at 10:06 AM, during preliminary record review of Resident #22's chart, the surveyor observed a completed form entitled Advance Directives for Health Care. It was also noted at the same time, neither the required yellow State of Florida - Do Not Resuscitate Order nor any other signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE], the same day she completed the advanced directive form. On 05/12/21 at 3:00 PM, during an interview with the DON (Director of Nursing), she verbalized that the admissions department would have a copy of the yellow DNR form that should be in the chart for any resident who has DNR status. On 5/12/21 at 3:35 PM, during an interview with the Admissions Director, an LPN (Licensed Practical Nurse), she was asked if she had a copy of the yellow DNR order for Resident #22. She said she did but when she looked in the resident's file it was not there. She was asked whose responsibility it is to follow through on advanced directives and she said she was supposed to do it. She stated that she was certain the resident did not have one and she took full responsibility for the omission and stated it was her mistake. She said she is supposed to give it to the physician to sign and place it in the chart when it has been completed. She further explained that she is supposed to give the form to the physician and put it in the chart when it has been completed. She also stated, I know she wants to be a DNR because she told me herself. On 05/12/21 at 5:25 PM, the Admissions Director presented a yellow copy of a DNR order for Resident #22. She said she found it misplaced in another resident's admissions record in her office. It was signed by the resident on 04/09/21 and by the physician on 04/13/21 which was six weeks after she originally said she wanted to be a DNR and signed the advanced directives form presented to her on admission. On 05/12/21 at 5:35 PM, during an interview with Staff E, an LPN, regarding residents with DNR status. She was asked how she would know a resident is Do Not Resuscitate status. She said sometimes they received the information at shift reports, and we look in the chart for the yellow sheet (DNR order). Resident #22's care plan included a desire for a Do Not Resuscitate code status. It was initiated on 02/24/21 with the following goal: Her code status will be followed thru the next review date. The interventions were as follows: Ensure assurance of her code status; Inform her that a code status could be changed at any time; and Send a copy of Advanced Directives with her upon transports/transfers to another facility. All were initiated on 02/24/21. On 05/13/21 at 10:00 AM during a brief follow up interview with Staff E, she was asked if there was a list of residents who were DNR or some way they passed the information to each other in shift reports. She said no, only if they are a new resident it is repeated in shift report. If it's not a new resident, they look in the chart for the yellow DNR order. On 05/13/21 following the interview with Staff E, the surveyor located the yellow DNR order signed on 04/09/21 which had been placed in Resident #22's chart.