Every finding on record at Grand Boulevard Health and Rehabilitation Center

Based on observations, staff interviews, and a review of the facility's work order logs, the facility failed to maintain a clean, comfortable, and homelike environment for residents.The findings include: 1. During a tour of the facility conducted on 05/27/2026 at approximately 11:00 AM, it was noted in room [ROOM NUMBER] that five ceiling tiles were bowing from the ceiling and the paint above the wall mounted air conditioning unit appeared warped and peeling. (Photographic evidence obtained) On 05/27/2026 at approximately 11:30 AM, the air conditioner (AC) vents were observed actively dripping condensation from the ceiling onto the floors in the hallways near Rooms 210, 204, 503, 501, 408, 404, 402, and 206 while maintenance staff replaced ceiling tiles. Dust accumulation was observed in the vents in the main conference room and in the hallways near rooms [ROOM NUMBERS]. A leak in the common television area was also noted, with water seeping through ceiling tiles and light fixtures. (Photographic evidence obtained) During an interview with the Maintenance Director conducted on 05/27/2026 at approximately 1:56 PM, he stated he was aware of ongoing condensation and AC issues throughout the building and had been addressing them as quickly as the corporate budget allows. He confirmed that he was the only maintenance staff member for the facility. Review of the Maintenance Work Order Report revealed long standing issues, beginning with a rooftop AC unit on the 600 hall that had been out of operation since 06/25/2024. Additional unresolved issues included an AC unit being out of operation in the facility's common area since 04/28/2025, lack of proper cooling in the laundry room since 06/12/2025, a rooftop unit being out of operation in the rehabilitation gym since 11/10/2025, and a rooftop hallway AC unit being out of operation in the 1000 area since 12/12/2025. More recent issues included an AC electrical problem reported on 05/22/2026. Nine work orders related to ceiling tiles were also noted. During an interview with the Administrator and Regional [NAME] President conducted on 05/28/2026 at approximately 1:00 PM, they reported being aware of the ongoing AC issues since 06/25/2024, confirming the AC units were not functioning at full capacity. They provided correspondence dated 08/01/2025 acknowledging the AC problems and requesting funding for repairs. The Administrator stated they recognized the concern with the approaching summer heat. 2. On 05/26/2026 at approximately 12:45 PM, two unlabeled wash basins were observed on the floor under the sink in the bathroom of room [ROOM NUMBER]. One wash basin contained a toilet insert designed to catch urine for measuring or testing. Dried brownish fluid stained the wall next to the wash basins. On 05/26/2026 at approximately 1:00 PM, a water pitcher was observed holding an uncovered toothbrush and uncapped toothpaste on the bathroom sink in room [ROOM NUMBER]. On the other side of the sink sat a tube of toothpaste in a clear cup and a water pitcher. None of the items were labeled. Follow-up observations were made on 05/28/2026 at 9:45 AM of the bathrooms in rooms [ROOM NUMBERS]. It was noted that staff had not removed the wash basins or urine collecting toilet insert and the wall remained stained in room [ROOM NUMBER]. Staff had not labeled the toothpastes, toothbrush, or water pitcher, and the items remained unchanged in room [ROOM NUMBER]. On 05/28/2026 at 10:07 AM, room [ROOM NUMBER] was toured with the Environmental Services Director (EVS Director). When asked how often staff clean the resident's bathrooms, the EVS Director stated that housekeeping cleaned daily, wiping down high touch areas including sinks and the toilet. The EVS Director stated that staff cleaned the walls during deep cleaning, which occurred when a resident was discharged , passed away, or when the cleaning staff identified an issue. An interview was conducted with Staff N, Certified Nursing Assistant (CNA) on 05/26/2026 at approximately 1:05 PM regarding the unlabeled items in the bathroom of room [ROOM NUMBER]. When asked why the items were not labeled, Staff N stated that neither resident used the bathroom and they were not sure why those items were left there or who they belonged to. A follow up interview was conducted with Staff N on 05/28/2026 10:16 AM regarding the wash basins on the floor in the bathroom of room [ROOM NUMBER]. Staff N stated they were not sure why staff had left the basins on the floor. When asked about the facility's policy regarding storing resident care equipment such as wash basins in a sanitary manner, Staff N stated that staff should label wash basins with the resident's name, place them in a plastic bag, and store them in the drawer in the resident's room. An interview was conducted with the Director of Nursing (DON) on 05/28/2026 10:25 AM regarding her expectations for storing resident care equipment in a sanitary manner. The DON stated that staff should rinse and dry resident care and personal hygiene items such as wash basins, label them, place them in a plastic bag, and store them with the resident's belongings. When a policy was requested on storing resident care equipment, the DON stated the facility did not have a policy. 3. Upon entering the facility's nursing unit hallways on 05/26/2026 at 10:00 AM, a notable foul sewage-like odor was noted. Similarly, while in the facility's main conference room, the same foul odor was noted. The sewage-like odor was noticeable and pungent throughout the survey process. During observations conducted on 05/26/2026, 05/27/2026, and 05/28/2026 on the 500 and 600 units, the following issues were noted: The hallway was observed with ceiling air vents open and uncovered, ceiling tiles bowing from the ceiling, and with black, greenish brown discoloration on them. room [ROOM NUMBER] had broken tiles next to the bed sitting by the window, and a broken dresser. The bathroom flooring was visibly stained, unclean, with a blackish brown discoloration observed at the base of the toilet. room [ROOM NUMBER] had cracks in the wall by the window, cracks in the flooring and on the wall by the air conditioner unit, a rusted three-in-one toilet, a blackish substance in a basin sitting on the bathroom floor, rusted pipes behind the toilet, and stained flooring, room [ROOM NUMBER] had a blackish brown discoloration observed at the base of the toilet and rusted fixtures on the shower wall. room [ROOM NUMBER] had broken furniture, in the bathroom the tub was visibly dirty with used wash cloths lying in the tub, water damage on the wall next to the air conditioner unit, with a black colored substance underneath the air conditioner unit. room [ROOM NUMBER] had hanging lights around the ceiling. room [ROOM NUMBER] was noted to have a brownish discoloration surrounding the base of the toilet and bathroom floors were stained. room [ROOM NUMBER] had broken furniture and clutter with debris on the floor by the resident's bed. The bathroom had cracked ceiling tiles around the sprinkler head, rusted pipes on the wall behind toilet, and a rusted three-in-one toilet. room [ROOM NUMBER] had visible brownish discoloration in three different areas on ceiling tiles in the bathroom. An interview was conducted with the Environmental Services Manager on 05/28/2026 at 11:00 AM. He described the job duties of housekeepers and duties of housekeeping staff. He explained they had a routine cleaning schedule but that they target rooms for residents who tend to have more messes due to dropping food and snacks and spilling drinks on the floor. He further stated if a room required repairs, if it was minor, he would try and help fix those items. The Environmental Manager stated room [ROOM NUMBER] was an example of a target room. When asked about the leaks throughout the facility, he stated the leaks occurred around the AC returns, mostly on the 400 and 600 units. He stated the AC returns had been leaking a while. Probably I would say about 6 months, they have replaced two of the units on the roof, but the new company has yet to replace the others. The roof is flat and the roof-top units leak are not working correctly, also when it rains a lot we get leaks. Upon asking about the foul smell he stated, The pipes are cast iron, there used to be a restroom next door to this conference room, however, it was converted into a nutrition room. If the pipes have an air leak or gas leak, the odor you are smelling is coming from that. An interview was conducted with the Maintenance Director on 05/28/2026 at 12:30 PM. He stated one of the roof-top AC units needed to be replaced. He stated, We are waiting for the final approval from corporate. The PTACs (personal air conditioning units in each room) are working overtime causing water leaks in the facility, mainly on the 400, 500, and 600 units. When asked about the foul sewage smell, he stated he believed it's from a leak from the pipes. He did not offer a solution or repair plan about this issue.

Based upon observations, interviews, and record reviews, the facility failed to review and revise care plans after the comprehensive and quarterly assessments were completed for 2 out of 2 residents reviewed (Resident #9 and #4) The findings include:1. A record review was conducted on for Resident #9. Documentation revealed Resident #9 was admitted to the facility on [DATE] with a diagnosis of a Stroke with right side paralysis and contracture. During review of Resident #9's plan of care, it was noted that an alteration in metabolic balance related to diabetes was initiated on 12/13/2021 with interventions dated for revision on 07/26/2025. Further review of the record indicated that Resident #9 was under the care of an endocrinologist and was started on insulin coverage in April 2026 due to elevated labs and blood sugars. This change in status was not reflected in the plan of care. Additionally, a plan of care was initiated on 12/10/2021 for alteration in activities of daily living (ADL) with interventions that included per therapy [Resident #9] is independent with standby assist by staff for all transfers and ambulation with a walker or cane. The last revision date for this plan of care was 07/26/2025. Therapy notes revealed that on 12/19/2025 through 01/17/2026, Resident #9 received physical therapy services due to a noted decrease with functional capacity, decrease in bilateral lower extremity strength, decline in ambulation and transfer ability, a decrease in balance and coordination impairing safety. On 02/17/2026 through 03/18/2026, a therapy evaluation was completed, and it was documented that therapy was needed for teaching adapting techniques to promote safety awareness, minimize falls, increase lower extremity strength and range of motion, and to decrease level of assistance from caregivers to enhance quality of life. This was not reflected in Resident #9's plan of care.2. A record review was conducted on for Resident #4. Documentation revealed Resident #4 was admitted to the facility on [DATE] with the diagnoses of a wedge compression fracture of the lumbar and thoracic spine, diabetes, and below the knee amputation. A plan of care was initiated for Resident #9 on 08/25/2025 for potential for adverse side effects of psychotropic medications, antidepressants, and antianxiety medications, with no revision date beyond 08/25/2025 for interventions and plan of care. According to the current physician orders, Resident #9 was not prescribed to take antipsychotic medications at the time of the survey.A plan of care was initiated on 08/25/2025 for alteration in ADL function and indicated that Resident #4 required assistance from staff with bed mobility, transfers, dressing, eating, and personal hygiene due to decreased mobility and above knee amputation bilaterally, with current interventions that included weight bearing as tolerated of 2 for bed mobility and weight bearing assist of 2 plus mechanical lift for all transfers initiated on 12/09/2025. A plan of care was initiated on 08/28/2025 with a revised date of 12/09/2025 that stated Resident #4 was at risk for falls related to assistance with transfers, had unsteady gait (ambulation) with the intervention to observe residents' ambulation for steadiness, balance, muscle coordination, and ability to reposition and turn.During observations and interviews conducted on 05/26/2026, 05/27/2026, and 05/28/2026, Resident #4 was not able to ambulate, he did not have any prosthetics available in his room, and he stated he preferred not to get out of bed most days.An interview was conducted with the facility Regional Nurse on 05/28/2026 at 10:02 AM. She stated the Minimum Data Set Coordinator was responsible for gathering data with the clinical team to ensure each resident's functional and cognitive abilities were accurate prior to completing an annual or quarterly assessment. Given the time to independently review the care plans for Residents #9 and #4, the Regional Nurse acknowledged that the current care plans did not reflect the current care status of these two residents.

Based on observations, interviews, and record review, the facility failed to ensure appropriate infection control practices were followed for 3 of 3 residents reviewed for infection control. (Residents #99, #38 and #48)The findings include: 1. An observation of Percutaneous Endoscopic Gastrostomy (PEG) tube care was conducted for Resident #99 on 05/27/2026 at approximately 11:44 AM. (A PEG tube is used to provide long term nutrition for individuals who are unable to eat orally) Staff A, a Licensed Practical Nurse (LPN), was observed performing hand hygiene and donning gloves before the procedure; however, no gown or mask was worn. Hand hygiene was performed again after Staff A completed the care. During an interview following the observation, Staff A stated that Enhanced Barrier Precautions (EBP-an infection control measure requiring staff to wear gowns and gloves during high-contact care) were required during high-contact activities such as PEG tube care, urinary catheter care, and wound care. Staff A demonstrated where the PPE carts were located in each hallway. At about 12:00 PM, Staff D, a Unit Manager, was interviewed, and was asked what Personal Protective Equipment (PPE-the protective gear staff wear to keep themselves and residents safe from germs and infections) should be used when giving care to a resident with EBP. Staff D stated that a gown, gloves, and mask were required during cares. At this time it was observed that an EBP sign was visible outside of Resident #99's room. Review of Resident #99's medical record revealed there was an active physician order for Enhanced Barrier Precautions (EBP) due to the risk of transmitting Multi Drug Resistant Organisms (MDRO) through the PEG tube. Further record review revealed the care plan listed EBP interventions that included educating the resident and representative, ensuring staff follow EBP protocol guidelines, performing hand hygiene per protocol, maintaining PPE and EBP equipment outside the resident's room, and placing appropriate EBP signage on the door. An interview was conducted with Staff F, LPN on 05/28/2026 at approximately 12:00 PM regarding her understanding of EBP. She explained that she associates these precautions with situations involving an active infection, similar to Droplet Precautions, during which she would wear a gown, mask, and gloves. When asked whether any residents currently had active infections, she stated they did not. She further reported that for routine urinary catheter care and PEG tube care, she used only hand hygiene and gloves, as her residents did not have active infections. Staff F noted that she cared for one resident with a urinary catheter and one with a PEG tube and confirmed that she continued to follow only hand hygiene and glove use before and after care for these residents. A follow-up interview with Staff A conducted on 05/28/2026 at approximately 12:08 PM. She acknowledged that she did not wear the appropriate PPE during PEG tube care for Resident #99 and that she had realized her mistake after completing the care. A review of the facility's policy titled Feeding Systems (last review date June 2025), indicated that protective barriers may include handwashing, gloves, gowns, masks, and goggles, as indicated. 2. On 5/26/26 at approximately 10:45 AM, observations were made of indwelling urinary catheters for Resident #38 and Resident #48. During these observations, it was noted that there was no signage posted for EBP on the doors of either resident. It was further noted that there was no PPE available immediately near or outside either of the resident's room. An interview was conducted with Staff I, Certified Nursing Assistant (CNA) on 05/27/2026 at approximately 10:50 AM. Staff I stated she would wear a gown and gloves when providing catheter care for the residents. Staff I was able to locate gloves but not gowns near or outside either of the resident's room. An observation was conducted of Staff G, LPN providing urinary catheter and wound care for Resident #38 on 05/27/2026 at approximately 11:30 AM. During the care, Staff G was noted only wearing gloves, not a gown. Staff G stated she was unaware of what Enhanced Barrier Precautions meant. Staff G further stated she performed hand hygiene and only wore gloves when providing urinary catheter or wound care to residents. A follow up observation was conducted with Staff H, Unit Manager on 05/27/2026 at approximately 11:45 AM. Staff H confirmed signage for EBP along with PPE needed to be placed outside the doors of Resident #38 and Resident #48. Staff H stated a sign would be posted. Review of Resident #38's clinical record revealed they were admitted to the facility on [DATE]. Further review revealed an active physician's order for Enhanced Barrier Precautions. The Comprehensive Care Plan included a care plan focus area for Enhanced Barrier Precautions with interventions. (Photographic evidence obtained.) Review of Resident #48's clinical record revealed they were admitted to the facility on [DATE]. Further review revealed an active physician's order for Enhanced Barrier Precautions. The Comprehensive Care Plan included a care plan focus area for Enhanced Barrier Precautions with interventions. (Photographic evidence obtained.) A review of facility's policy titled Enhanced Barrier Precautions (dated 4/1/24) indicated the EBP referred to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove uses during high contact resident care activities. Enhanced barrier precautions will be initiated for residents with any of the following: wounds (chronic wounds such as pressure ulcers) and/or indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a multidrug resistant organism. Make gowns and gloves available immediately near or outside of the resident's room. (Photographic evidence obtained.)

Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 19 sampled residents to self-administer medications. (Resident #67) The findings include: An observation of Resident #67 was conducted on 02/17/25 at 10:35 AM. A medicine cup with 4 pills was observed sitting on the over bed table. When asked about this, the resident stated, If a nurse is in a hurry, then they leave the medication at the bedside, but they never watch me take my medications. A telephone interview was conducted with Employee C (a Licensed Practical Nurse) on 02/19/25 at 2:01 pm. She stated that she normally doesn't work on Resident #67's hall. She stated that she doesn't remember leaving the medications with the resident but, if she did, then it was an error on her part. She did not watch the resident take the medications. She is not sure if the resident is evaluated to self-administer her medications. A review of the resident's electronic medical record revealed no documentation discussing self-administration of medications. A review of the admission minimum data set with an assessment reference date of 12/24/24 revealed the resident had a BIMS (brief interview of mental status) of 15 indicating she is cognitively intact. A review of the policy Self-Administration of Medication, dated [DATE], states the following, A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team.

Based on record review, staff interviews, and policy review, the facility failed to ensure the minimum data set (MDS) accurately reflected the resident's status for 1 of 1 sampled residents reviewed for pressure ulcers (Resident #57) and 1 of 1 sampled residents reviewed for hospitalization . (Resident #83) The findings include: Resident #57 A review of Resident #57's electronic record revealed the Medicare 5-day MDS with an assessment reference date (ARD) of 2/3/25 indicated in section M that the resident had two stage 2 pressure ulcers present upon admission or re-entry. A review of the weekly wound documentation dated 1/31/25 revealed the right heel and sacral area had stage 2 pressure wounds that were facility acquired. An interview was conducted with Employee A (MDS Coordinator Registered Nurse) on 2/19/25 at 1:32 PM. Employee A reviewed the MDS dated [DATE] and the wound records dated 1/31/25 and confirmed the stage 2 pressure wounds on the right heel and sacrum should have been coded as facility acquired on the MDS. Resident #83 A review of Resident #83's electronic record revealed a discharge MDS with an ARD of 1/20/25 that indicated in section A that the resident was discharged to a short-term general hospital. A review of the record revealed the resident was actually discharged to hospice. The record did not indicate the resident was ever hospitalized . An interview was conducted with Employee B (Registered Nurse Risk Manager) on 2/19/25 at 9:11 AM. Employee B stated the MDS was not correct, and the resident went home on 1/20/25 with hospice care. Review of the facility policy for Certifying Accuracy of the Resident Assessment (dated October 2010) revealed all personnel who complete any portion of the Resident Assessment must sign and certify the accuracy of that portion of the assessment.

Based on observation, staff interviews, and record review, the facility failed to adequately assess 1 of 1 residents reviewed for smoking to ensure adequate supervision to prevent accidents while smoking. (Resident #45) The findings include: On 11/8/23, an observation was made of Resident #45 in the designated smoking area without supervision while smoking tobacco products. No burn marks were noted on her clothing. A review of Resident #45's electronic medical record revealed no care plan for safe smoking. Further review of the electronic medical record revealed there was no safe smoker evaluation conducted by the facility for Resident #45. A review of Resident #45's admission nursing evaluation, dated 9/12/23, revealed that the resident was not a smoker at that time. On 11/8/23 at approximately 12:01 PM, an interview was conducted with the Administrator in Training (AIT) and the Regional Nurse Consultant concerning Resident #45's smoking evaluation and care plan. The AIT stated that Resident #45 did not smoke when she was first admitted to the facility, but she decided to start smoking again a few weeks later. The Regional Nurse Consultant confirmed that there was no safe smoker evaluation or a smoking care plan for Resident #45. The Regional Nurse Consultant stated that it was her expectation that, when a resident starts smoking, that the nurse on that assignment would perform the safe smoking evaluation for that resident at that time or notify the medical records nurse to complete the evaluation and for the resident's care plan to be updated for smoking. On 11/9/23 at approximately 9:30 AM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that there was no care plan for Resident #45 for smoking and stated that she would get that updated right away. The DON went on to state that all residents at the facility required supervision for smoking.

Based on staff interview and clinical record review the facility failed to develop a comprehensive care plan for 1 of 6 (#22) residents reviewed for unnecessary medications and 1 of 1 (#55) for review of falls with major injury. The findings include: Resident #22 was admitted to the facility on [DATE]. She had a [DIAGNOSES REDACTED]. The minimum data set (MDS) quarterly was completed on 1/29/19 and indicated the resident took 7 days of anti-coagulant for Section N 0410. The Quarterly MDS dated [DATE] also indicated the resident received 7 days of anticoagulant. A review of her care plans failed to reveal a care plan for anti-coagulant therapy. An interview was conducted with Registered Nurse (RN) responsible for MDS's on 11/6/19 at 1:57 PM. She was asked if a care plan should have been developed for anti-coagulant therapy for Resident #22 since the MDS shows she is on anti-coagulant therapy. She stated, Yes, I would expect an anti-coagulant care plan in place. She was then asked to check the care plan section for a care plan for anti-coagulant therapy. She said she did not see a care plan for the anti-coagulants. She then said the long term care plans are done by the unit managers. when they review the medications. During the care plan meetings all the medications are reviewed. The Director of Nursing was interviewed on 11/6/19 at 2:41 PM. She was asked about the care plans for anti-coagulants. She said Resident #22 should have had a care plan in for the anti-coagulant and then said we just missed the anti-coagulant therapy. Resident #55 was admitted to the facility on [DATE]. She had a fall resulting in a left [MEDICAL CONDITION] on 8/31/19. She was subsequently hospitalized and returned to the facility on [DATE]. A review of her current medications revealed she is taking the anti-coagulant Eliquis. The 14 day MDS dated [DATE] Section N indicates she is taking an anti-coagulant. The DON was requested to provide a copy of Resident # 55's care plan. A review of the care plan revealed no care plan for anti-coagulant therapy. An interview was conducted with the DON on 11/7/19 at 8:46 AM. She stated that resident #55 did not have a care plan for anti-coagulant therapy and that she would put one in for her.

Based on observations, staff interviews, clinical record review, and policy review the facility failed to ensure staff maintained urinary catheters off the floor in an effort to prevent contamination and infections for 1 of 1 sampled residents with a urinary catheter and urinary tract infection. (resident #51) The findings include: Observations of resident #51 were conducted on 11/5/19 at approximately 8:40 AM and 9:36 AM. The resident was in bed and the urinary catheter was attached to the bedside. The catheter bag was observed to be touching the floor during both observations. No basin was present. (Photographic evidence obtained.) An interview was conducted with the Director of Nursing (DON) on 11/5/19 at 9:36 AM. The DON observed the catheter bag touching the floor and stated the catheter should be in a basin; she also confirmed the resident currently had a urinary tract infection. An interview was conducted with employee A (certified nursing assistant) on 11/5/19 at 3:15 PM. He stated the catheter should have been in a basin and the resident lowers his own electric bed. Review of resident #51's clinical record revealed he was currently being treated for [REDACTED].

Based on observation, staff interview, and policy review the facility failed to ensure staff implemented appropriate infection control procedures during urinary catheter care in an effort to prevent cross contamination for 1 of 1 sampled residents with a urinary catheter. (#51) The findings include: An observation of urinary catheter care for resident #51 was conducted on 11/6/19 at 3:04 PM with employee B (certified nursing assistant). Employee B washed her hands, donned clean gloves and performed urinary catheter care for resident #51. When the employee finished catheter care, she moved the resident's call light and bed control within his reach while wearing the same, soiled gloves she wore while completing catheter care. She turned off the over bed light using the pull cord with the same soiled, gloved hand. An interview was conducted with employee B on 11/6/19 at 3:11 PM. Employee B stated her gloves were considered soiled after performing catheter care. Employee B confirmed she should have removed her gloves and sanitized her hands before touching the call light, bed control and light cord. Review of the facility policy for Urinary Catheter Care (July (YEAR)) revealed after performing catheter care staff should remove gloves and discard into designated container, place the call light within easy reach of the resident, and wash hands.

Based on interviews with emergency management officials, interview with the facility administrator, review of facility documents, emails, and review of public information messages concerning evacuation zones and risks, the facility administration failed to self-initiate an evacuation after discussion with county emergency management authorities following a mandatory evacuation notification. Findings included: A mandatory evacuation notice for Walton County, Florida to include zones A, B, and C was issued on 10/8/2018 at 7:01PM. The mandatory evacuation went into effect on 10/9/2018 at 7:00AM. The facility is located in Walton County, Florida, in evacuation zone C. On 12/19/2018 at approximately 10:58AM, during an interview the administrator stated that the facility was in zone C and that the zones were being monitored (prior to the storm). The administrator confirmed having conversations with the Emergency Medical Services (EMS) Chief of Walton County prior to the storm and informing the EMS Chief of the decision to shelter in place. The administrator did not remember learning there was a mandatory evacuation in place, but stated that the evacuation zones were being watched. The administrator confirmed that the decision was made to shelter in place and added feeling comfortable with that decision. In a follow-up interview with the administrator at 1:10PM, the administrator stated, I don't even know that there was a mandatory evacuation. I was watching the storms, where it was going and what it was doing. I don't even think it came up in conversations with (EMS Chief). The administrator stated that everyone at the corporate office was watching to see if there was a mandatory evacuation, including the corporate president and vice president, and at no time was there a conversation that the facility was in a mandatory evacuation zone. The administrator identified the primary and alternative means of communication as phone, internet, facebook, public radio and television and identified the television and radio stations as WJHG TV and WJAQ radio. During an interview on 12/17/2018 at 10:35AM, the EMS Chief confirmed having a conversation with the administrator on 10/8/2018 and notified the administrator of the mandatory evacuation at that time. The EMS Chief explained that the administrator verbalized intent to shelter in place and was urged that this was a bad idea, if something bad happens there is no one to assist you and you are assuming a lot of liability. On 10/9/18 at 4:00pm, the EMS Chief received communication from the county E[NAME] (emergency operations center) inquiring who made the decision at Grand Boulevard to shelter in place. The EMS chief contacted the administrator and instructed her to contact the E[NAME] regarding the evacuation. At around 5:00pm the EMS chief again spoke with the E[NAME] who was sending transportation to Grand Boulevard to evacuate the residents to the Special needs shelter north of the bay. The EMS chief contacted the facility, and was told by the administrator's supervisor that he was not supportive of evacuating but if he was being forced to he would comply. The EMS chief arrived at the facility around 5:55pm to assist in the evacuation. The EMS chief stated the facility was very cooperative with the evacuation when arrived. An interview was conducted with County Emergency Planner for Walton county (E[NAME]) on 12/12/18 at 9:40am. The Emergency Planner stated that Grand Boulevard was in a Level C zone - and we evacuated up to level C. In the afternoon of 10/9/18, we saw that they were going to shelter in place due to having 96 hours of fuel. 96 hours of fuel will not help them if they are under water. We instructed the administrator to evacuate, he was reluctant. We told him that either he is going to evacuate or we are going to evacuate them. We told them that we were sending buses and ambulances to evacuate them to the special needs shelter. A review of an after action report written by the administrator documented that on 10/09/2018 at 7:39AM a text message was received from the EMS Chief asking if plans (to shelter in place) had changed. About 10:30 AM, facility was notified that local hospital decided to evacuate. The administrator documented that notification was made to update supervisor and continued with the plan to shelter in place. The administrator documented that communication with the EMS Chief continued throughout the day and at 4:15PM the EMS Chief called to say that people wanted to know why the facility didn't evacuate and were not happy with the decision. At 4:36PM the EMS Chief sent a text message to call and during the call the EMS Chief indicated that the facility was being forced to evacuate and buses were on the way. At 5:19PM buses arrived on site along with Walton County Sheriff officers. The administrator documented the details of the evacuation to include the return to the facility. The facility provided staff to care for the residents during the evacuation and at the shelter. A review of the following internet sites verified that posts were made concerning mandatory evacuation of zones A, B, and C in Walton, County Florida: -Walton County Emergency Management Facebook page -Walton County Emergency Management Twitter -https://www.nwfdailynews.com/news/ 008/mandatory-evacuation-order-issued-for-walton-county -https://www.wjhg.com/content/news/Walton-County-Storm-Information- 6411.html -https://www.wkgc.org/2018/10/08/walton-county-mandatory-evacuation-notice-for-hurricane-michael/ -https://www.mypanhandle.com/news/live-update-walton-county-is-preparing-for-hurricane-michael/ -https://www.newsweek.com/mandatory-hurricane-michael-evacuations-hit-floridass-30a-walton-county- 95 An email dated 12/12/2018 at 6:42PM from the Director of Walton County Emergency Management verified public notification of mandatory evacuation of Zone A, B, and C was issued via press release on 10/8/2018 at 5:01PM. Three additional press releases after that also advised that evacuation which was scheduled to begin at 7:00AM on 10/9/2018. The first evacuation notification went out on 10/8/2018 at 7:55PM to landline phones, emails, text messages, and voice mobile phones. A second evacuation notification went out on 10/9/2018 at 1:49PM included all aforementioned means of notification plus the Integrated Public Alert Warning System (IPAWS) using Wireless Emergency Alert (WEA - Amber Alert System). A third notification was sent at on 10/9/2018 at 2:35PM via IPAWS using the Emergency Alert System (EAS - TV/cable override crawl). A review of the emergency management plan indicated in section B, paragraph 1 that weather radios at each nurses' station are kept on 24 hours per day to receive notification of impending disasters directly from the local Emergency Management Office. As a backup, the facility may be notified by telephone. After initial notification the Administrator or designee will assign staff to monitor the radios, and TVs for further bulletins and announcements. Section C, paragraph 1 identified the administrator or charge nurse on duty as responsible for implementation of evacuation - in conjunction with the local Emergency Management Office. Section C, paragraph 2 identified transportation agreements for evacuation. The contract with the transportation company was dated in (YEAR) and was self-renewing. The plan contained a section titled Hurricane Disaster Plan and identified responsibilities of the administrator to include: establishing central communication and monitoring weather scanner and TV for reports of local conditions. Section C, paragraph 4 was labeled Identification of Evacuation Sites: (See evacuation plan) and stated that evacuation routes and alternative routes will be determined at the time of evacuation by the administrator. This plan did not contain possible evacuation sites. During the interview on 12/19/2018 at approximately 10:05AM, the administrator had difficulty in identifying evacuation sites, but eventually produced contracts with a long term care facility in Pensacola, Florida and a long term care facility in Crestview, Florida; both contracts were dated 5/23/2016. A separate document titled Evacuation for Residents and Associates was provided by the administrator and reviewed. This document contained instructions for Hurricanes/High winds - Operational Procedures (page 34 of 67 dated (MONTH) (YEAR)): 1. Classification: a. A hurricane/high winds watch means that conditions are favorable for the development of the approaching event. b. A hurricane/high winds warning means to take immediate action to protect lives and property. 2. Notification of Watches/Warnings: a. there are several methods/devices that the Center may use to be informed of the approaching hurricane/high winds. They are: (1) television station (blank) (2) Radio station (blank) (3) Police/Sheriff's Office (4) Weather Alert Device (5) Emergency Management Agency b. When a hurricane/high winds watch/warning has been issued, procedures outlined within this plan, as well as other established disaster operational procedures, may be implemented. 3. Monitoring of Weather Bulletins: a. when a hurricane/high winds watch/warning advisory is issued, the Center should monitor future messages to ensure that preparations for emergency action are well planned. b. National Weather Service advisories may be monitored and update reports may be provided to the administrator, his/her designee, or to the person in charge. c. Radio station (blank) and TV station (blank) may be monitored when a hurricane/high winds warning is issued.

Based on observation of dumpster, staff interview, and policy review, the facility failed to maintain dumpsters free from debris for 1 of 2 dumpsters. The findings are: An observation was made of the dumpster area of the facility on 12/17/18 at 10:29 am with Employee A, Certified Dietary Manager (CDM). Two dumpsters were observed with the one on the left having limbs and debris piled around it. (Photographic evidence was obtained.) Employee A was asked why the debris was around the dumpster on 12/17/18 at 10:29 am. He said he had no control over that and he guessed a tree needed to be cut down. A review of the policy for Garbage and Rubbish Operations Policy and Procedures Dietary Services (MONTH) (YEAR): #8 of the policy states outside dumpsters provided by garbage pick-up services must be kept closed and free of liter around the dumpster area.

Based on record review, staff interview, resident representative interview,and policy review, the facility failed to immediately notify the resident's responsible party of an accident involving the resident which resulted in injury requiring physician ordered intervention for 1 of 2 sampled residents. (resident #3) The findings included: Review of resident #3's record revealed an accident on 4/25/18. The record revealed another resident had rolled over resident #3's right great toe with a wheel chair. The toenail fell off and there was a substantial amount of bleeding. The physician was notified and an order for [REDACTED]. The section of the form for resident representative notification indicated only hospice was notified of the accident. An interview was conducted with the Director of Nursing (DON) on 6/5/18 at 10:25 AM. The DON stated the facility did not notify the resident's representative of the accident on 4/25/18. She stated the family told the facility they did not notify her. The DON stated they have a contract with the hospice and they are to work with the facility to ensure the family is notified of changes. The facility thought that hospice would notify the family. A telephone interview was conducted on 6/5/18 at 5:25 PM with resident #3's representative. She stated the facility did not inform her of the accident that occurred on 4/25/18 causing resident #3 injury to her toe. The facility policy regarding change in a resident's condition or status was reviewed. The policy stated the center shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition.

Based on record reviews, staff interviews and policy review, the facility failed to provide written information to the resident and family member or legal representative that specified the duration of the bed-hold policy under the state plan, if any, and the facility's policies regarding bed-hold periods at the time of transfer for hospitalization or therapeutic leave for 2 of 3 sampled residents. (#2 and 3) The findings include: Review of resident #2's record revealed the resident was transferred to a hospital on [DATE] for behavior management and stabilization. There was no documentation indicating the resident, family or representative was provided written information specifying the duration of bed-hold, if any, and the facility policy regarding bed-hold periods at the time of the transfer or within 24 hours. Review of resident #3's record revealed the resident was transferred to a hospital on [DATE] for acute care. The bed hold confirmation form dated 4/28/17 stated complete this UDA (user defined assessment) if a resident is transferred or discharged to a hospital, and be sure to make a copy of the bed hold policy that was given to the resident for the resident's medical record. The form indicated the bed hold policy was not sent with the resident at the time of transfer. No other documentation indicating the resident, family or representative was provided written information specifying the duration of bed-hold, if any, and the facility policy regarding bed-hold periods at the time of the transfer or within 24 hours was found in the record. An interview was conducted with the PPS (Prospective Payment System) Coordinator on 5/15/17 at approximately 12:13 PM. She stated she misunderstood the form and documented incorrectly, she thought the form meant the facility was going to hold his bed. An interview was conducted with the Director of Nursing (DON) on 5/15/17 at approximately 12:44 PM. The DON confirmed the facility was not able to provide any evidence that resident #2 and 3, or the responsible party was provided bed hold information at the time of discharge or within 24 hours.

Based on observation, interview and record review the facility failed to follow the residents' plan of care for 1 of 1 residents sampled for tube feeding (#76), and 1 of 1 resident reviewed for accidents (#141). Findings include: A record review was conducted for resident #76, and revealed a care plan (CP) dated 12/04/2016 for an alteration in nutrition. The CP indicated the resident required nutrition/hydration via feeding tube due to right sided [MEDICAL CONDITION] resulting from a stroke. Goals indicated that resident would have nutrition/hydration needs met via feeding tube as evidenced by stable body weight with no further significant weight variances and no signs or symptoms of dehydration through the next review period. Interventions included to instruct staff to administer tube feeding as prescribed by physician. A record review was conducted of physicians orders for resident #76. Order dated 12/06/2016 to provide resident with enteral feeding of [MEDICATION NAME] 1.5 to run at 60cc per hour for 20 hours, totaling 1800 calories, 77 grams of protein, and 912cc of water per every 24 hour period. Review of the residents Medication Administration Record [REDACTED]. Review of the time frame revealed the residents feeding was running for 18 hours daily and not the 20 hours as prescribed in the physician's orders [REDACTED].>An interview was conducted with staff LPN D on 04/23/17 at approximately 2:30 pm. She stated that she followed what was on the MAR, and would take the feeding down between 9:00 and 10:00 am and the next shift would put it up again at 4:00 pm. An interview was conducted with the Director of Nursing on 02/22/2017 at approximately 2:30 pm. She stated that the facility was unaware that the resident's feedings was running for only 18 hours and not the 20 hours prescribed. A review of the care plan for resident #141, dated 2/13/2017, was conducted and revealed the following: Resident #141 was at risk for falls related to a history of gait disturbance (unsteady when standing or walking) following a [MEDICAL CONDITION] (stroke) which resulted in left [MEDICAL CONDITION] (left side of body is now flaccid), and altered safety awareness. The care plan indicated that the goal for resident #141 would be to have no falls through the next review period. Interventions to acheive goal included 15 minute safety checks (which was initiated on 2/15/2017). A review of 15 Minute Check sheets in the medical record of resident #141 revealed that there were sheets for 2/15/2017 and 2/22/2017. No others were able to be located at the time. The sheet dated 2/15/2017 was completed from 12:00 midnight to 2:00pm. The area from 2:15pm to 11:25pm was left blank. The sheet dated 2/22/2017 was blank from 12:00 midnight to 5:45am. Time from 6:00am until 2:00pm was completed. On 2/22/2017 at 2:28pm Resident #141 was removed from facility via stretcher with Emergency Medical Services (EMS) following a fall. On 02/23/2017 at 11:43AM an interview was conducted with Staff Member A. When asked about the procedure for completing 15 minute checks, she stated they are kept on a clip board with the nurses. When they are done with them, they are to be filed in the chart under miscellaneous. She was then asked to locate the 15 minute check sheets for the dates between 2/15/2017 and 2/22/2017. She confirmed that the forms were not located in the medical record for resident #141. She was then asked about the circumstances for which the resident had been sent out to the hospital the previous day. She stated, yesterday afternoon the Certified Nursing Assistant (CNA) reported that she heard a boom from Resident #141's room. We responded immediately but the door to the room was closed. The resident was able to talk, but the nurses were unable to open the door. She further stated that the resident opened the door, and resident #141 was assessed for injuries and cognitive status changes at that time, and was sent out because the fall was unwitnessed, the resident complained of head pain, and was on a blood thinner. She stated that she notified the resident's significant other and the physician. On 2/23/2017 at 2:19pm a brief interview was conducted with the Director of Nursing (DON). At that time she stated that the only 15 Minute Check Sheets that she could locate since the intervention was initiated on 2/15/2017 were for 2/15/2017 and 2/22/2017. She stated that she was hopeful that the facility would eventually be able to better track this through the electronic health record. She was asked to provide the facility policy regarding 15 minute checks and she stated, We do not have a policy for 15 minute checks.

Based on record review and staff interviews the facility failed to ensure each resident received adequate supervision to prevent falls for 1 of 1 residents (#141) sampled for accidents. The findings were: Resident #141 was at risk for falls related to a history of gait disturbance (unsteady when standing or walking) following a cerebrovascular accident (stroke) which resulted in left hemiparesis (left side of body is now flaccid), and altered safety awareness. The care plan indicated that the goal for resident #141 would be to have no falls through the next review period. Interventions to acheive goal included 15 minute safety checks (which was initiated on 2/15/2017). A review of the 15 Minute Check sheets in the chart of resident #141 revealed that there were sheets for 2/15/2017 and 2/22/2017. No others were able to be located at that time. The sheet dated 2/15/2017 was completed from 12:00midnight to 2:00pm. The area from 2:15pm to 11:25pm was left blank. The sheet dated 2/22/2017 was blank from 12:00midnight to 5:45am. Time period from 6:00am until 2:00pm was completed. On 2/22/2017 at 2:28PM Resident #141 was removed from facility via stretcher to ambulance following a fall. On 02/23/2017 at 11:43AM an interview was conducted with Staff Member A. When asked about the procedure for completing 15 minute checks, she stated they are kept on a clip board with the nurses. When they are done with them, they are to be filed in the chart under miscellaneous. She was then asked to locate the 15 minute check sheets for the dates between 2/15/2017 and 2/22/2017. She confirmed that the forms were not located in the medical record for resident #141. She was then asked about the circumstances for which the resident had been sent out to the hospital the previous day. She stated, yesterday afternoon the Certified Nursing Assistant (CNA) reported that she heard a boom from Resident #141's room. We responded immediately but the door to the room was closed. The resident was able to talk, but the nurses were unable to open the door. She further stated that the resident opened the door, and resident #141 was assessed for injuries and cognitive status changes at that time, and was sent out because the fall was unwitnessed, the resident complained of head pain, and was on a blood thinner. She stated that she notified the resident's significant other and the physician. On 2/23/2017 at 2:19pm a brief interview was conducted with the Director of Nursing (DON). At that time she stated that the only 15 Minute Check Sheets that she could locate since the intervention was initiated on 2/15/2017 were for 2/15/2017 and 2/22/2017. She stated that she was hopeful that the facility would eventually be able to better track this through the electronic health record. She was asked to provide the facility policy regarding 15 minute checks and she stated, We do not have a policy for 15 minute checks. A review of the facility exception reports for Resident #141 revealed the following falls and details: On 2/22/2017 CNAs heard a boom from the hallway. They checked and found resident #141 lying on floor in front of the door. Upon entry to the room, the resident stated that he fell and had head and hip pain. He was sent to emergency room for evaluation. On 2/20/2017 Resident #141 was found on the floor in his room after attempting to use the restroom without assistance. He denied hitting his head, no injuries were noted, and vital signs were within normal limits. On 2/24/2017 at 8:49am another interview was conducted with the DON. She was asked who the nurses were at the time of the incident on 2/22/2017. She stated that it would have been Staff Member B and Staff Member C, as they were in the middle of shift change when it occurred. She was then asked to recount what happened from her perspective. She stated that she was told that the CNA's heard a bump from the hallway. They tried to go in the room. Resident #141 was on the floor blocking the door. She stated that the resident believed that he could still walk. She stated that the facility staff have educated him and his significant other, but he does not comply due to cognitive deficits (as a result of the stroke he is unable to remember that he can't walk unassisted). He was on a blood thinner, so the staff wanted to send him out. She stated that it is facility policy anyway, so they sent him out to the emergency room . She said that before he left, resident #141 stated that he knew he was not supposed to do that. His significant other was not in the room at the time. He met him at the hospital. At that time she stated that there was nothing in the computer to cover the missed 15 minute checks. He was sent out at about 2:39pm. On 2/24/2017 at 8:59am an interview was conducted with Staff Member B. She was asked to convey her understanding of the circumstances surrounding the fall and transfer out of resident #141 on 2/22/17. She stated that it happened at 2:00pm during shift change. She stated that she was standing with Staff Member C doing narcotics count and finishing report. She stated that the Certified Nursing Assistant (CNA) told them that Resident #141 fell and they heard him hit. They were unable to open the door because Resident #141 was lying in front of it. She stated that it looked like he tried to stand and support himself with the door and gave way and fell in front of the door. She stated that Resident #141 said he knew he was not to get up without help. At that time he was able to move himself to allow staff in the room. He stated that the back of his head and hip hurt. She said that they started the process to get him sent out to the hospital. They assessed the resident and his vital signs were stable. He stated that he did not black out. She stated, He has a disconnect between what he should and should not do. She said that Resident #141's significant other was not there when it happened, but she notified him. She was asked to explain the procedure for 15 minute checks. She stated that staff just pass by the door or near him to check on him. The CNAs and nurses are responsible for the 15 minute checks. She stated there was nothing more they could have done to prevent the fall other than have him in a sitter situation (when there is a staff member present with the resident around the clock). She stated there were no other places to document 15 minute checks other than paper form that she was aware. On 2/24/2017 at 9:12am an interview was conducted with Staff Member C regarding the fall suffered by resident #141 on 2/22/17. He stated that he was giving Staff Member B report. The CNAs came to say Resident #141 had fallen and was against the door, and the CNAs weren't able to get in the room to him. He stated that he and Staff Member B went to assess Resident #141. Resident #141 was against door blocking entrance, but there was enough space for Staff Member B to squeeze in. He stated Staff Member B was able to move the resident enough for him to get in the room. He stated that he asked Resident #141 how he was feeling. Resident #141 had appropriate responses to the questions asked. Resident #141stated he hit his head and it was hurting. Staff Member C did neurological checks then and stated the responses were within normal limits. While they were transferring resident #141 from the floor to his wheelchair, Resident #141 said that he felt like his hip was hurting. Paramedics were called to take the resident to the hospital for evaluation. When asked about the procedure for 15 minute checks, he stated that all staff are responsible for 15 minute checks. Anyone can write on the paper forms. Anyone can make rounds.

Based on observation, interview and record review the facility failed to follow physicians orders for 1 of 1 residents sampled for tube feeding (#76). Findings include: A review of the medical record for resident #76 showed a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the time frame revealed the resident's feeding was running for 18 hours daily and not the 20 hours as prescribed. An interview was conducted with the Director of Nursing on 02/22/2017 at approximately 2:30 pm in which she stated that the facility was unaware that the residents feedings were running for only 18 hours and not 20 hours as ordered.

Based on family interview, observations, staff interviews, and record review the facility failed to provide adequate resident focused assistance during meals for 1 of 1 sampled resident (#64) for the Activity of Daily Living (ADL) pathway. The facility staff failed to provide consistent interaction, verbal cueing, and meal orientation for the resident that has visual and cognitive impairment. The findings are A telephone interview was conducted with the grandson of sampled resident #64 on 11/5/14 beginning at approximately 9:00AM. When asked if his grandmother receives the assistance she needs with meals, he stated no. He stated she has problems seeing and she used to receive assistance from the facility staff in the assistive dining room, but she no longer goes to that area and no longer get assistance from the staff. He stated her meals are just brought into her room and sat down in front of her and he is afraid she is not eating as well as she would if she had staff assistance. He stated he asked the staff why she no longer attends the assistive dining area and he was told that she no longer needed to attend assistive dining. He stated he believes she does need the assistance so he or one of his staff assist her with her lunch meal, at least as often as they can. He is afraid she is not eating as much as she would because she is not getting staff assistance, she needs the verbal cueing and reminding to eat, she is forgetful and needs to be reminded to eat and what foods she has to eat. Interview with the grandson at 1:45PM at the facility revealed that he visits his grandmother three times a week and then on weekends. He stated he tries to visit during meal time because she does not eat well without verbal cueing. The resident suffers with [MEDICATION NAME] degeneration and her eye sight is very limited. She also is very forgetful and does not recall she has her tray or where her food is on the tray. He states she needs cueing to remind her what food she has and where it is on her plate. Again he feels that she needs assistance from the staff to ensure that she eats. He stated she loves sodas and he keeps her at least 3 cases here at the facility for the staff to provide for her; he believes they are giving them to her but he is not sure. He stated he is aware she eats with her fingers all the time and is okay with this if this makes her comfortable and allows her to eat. He brought the resident two pieces of fried chicken, biscuit and a 20 ounce Dr. Pepper. He stated she loves fried chicken and hamburgers but is unable to have the hamburgers due to stomach problems so he brings her the fried chicken. The grandson provided the resident with her chicken and drink. The resident would eat and spit out some of the chicken but ate at least 50% of the chicken, 2 bites of the biscuit and 50% of Dr. Pepper and asked for boiled eggs which she are the yolks of the eggs and stated she was full. The grandson provided continuous verbal cueing during her eating. He stated he feels she needs the staff verbal cueing and socialization which encourages her to eat. The restorative note dated 3/24/14 indicates the resident has met her goals and is being discontinued to the floor maintenance program. The dietary notes dated 7/18/14 and 10/4/14 indicates the resident is able to feed herself with limited assistance. Defines limited assistance as setup assistance and meal orientation. Minimum Data Set ((MDS) dated [DATE] indicates the resident is supervision with one person physical assist for eating. MDS dated [DATE] indicates the resident is independent set up help only for eating. The Care Plan dated 10/3/14 indicates the resident has dementia, legally blind, and spits out food. The interventions are to provide adequate assistance as needed including set up and meal orientation. If resident becomes irritable then give her time to calm down and try again to assist as needed with the meal. Observation on 11/5/14 at approximately 12:45PM revealed the resident lying in bed with lunch tray at bedside. The lunch tray contained bowl of mashed potatoes which had a white crust over them as if they are cold, string beans, chicken salad sandwich, ground meat, ice cream, mighty shake, milk, roll, apple pie and tea. Observation revealed the resident had drank her tea and appears to have eaten a bite or two of the mashed potatoes. When asked by the surveyor if she was going to eat, she stated "I don't know, have I got anything to eat?" Surveyor informed her of her meal tray foods. She asked if she had a sandwich the surveyor informed her she did. At that time a certified nurses assistant, sampled staff A walked in and asked the resident if she was going to eat and the resident said "no". The C.N.A. encouraged her to eat, the resident did not. The surveyor asked the C.N.A. what do you do when she does not eat, she stated she will return and try and ensure she at least eats her ice cream and drinks her shake. The C.N.A. verbally cued the resident to eat, but she did not. The C.N.A. left the room. The surveyor asked the resident if she was hungry and she stated "I'm starving". The resident sat up and asked the surveyor what food was on the tray and where it was on the tray. The resident was observed to have difficulty seeing and identifying her food. She asked where the sandwich was and tried it and spit most of it out, stating it was not good. She asked where the apple pie was located on the tray and she felt with her hands and found the apple pie and tried a bite of it and said "This is cold" and did not eat it. She stated she wanted some hamburgers. Returned to the resident's room at approximately 1:05PM and the resident was observed lying in bed and her meal tray had been removed. When asked if she had eaten she said "no, what have I got to eat" and closed her eyes. Observations on 11/5/14 at 5:40PM revealed the resident lying in bed with her eyes closed. Her meal tray is sitting on her bedside table which revealed an egg salad sandwich, a bowl of soup and a bowl of desert. She has a glass of tea, a mighty shake and a container of milk. The surveyor asked the resident if she was going to eat and she stated "why do I have food here" "who made it". Surveyor explained to her what she had. The resident simply started her rhyming speech. 5:50PM revealed the resident lying in bed awake, but not eating her meal. Observed several staff walk by her room, none offered to assist her. 5:59PM staff begins serving meals again on the hall from a second cart. 6:02PM staff finish serving the second trays and move to another hall. Multiple direct care staff are observed to pass by the resident's room which has the door open allowing easy observation of the resident not eating her meal, no one offers assistance or verbal cueing to eat. 6:06 PM medication nurse sampled staff B, observed to walk by the resident's room, but does not stop. The resident is observed to continue to lie in bed she is awake but not eating. 6:09PM nurse walks by the resident's room. 6:12PM a nurse, sampled staff G, entered her room and reminded the resident she needed to eat, the resident asked what she had to eat, the nurse told her and she tried to get her to eat her sandwich, encouraged her to sit up, she took bite of sandwich and she spit it out. The resident told her she wanted a coke, and the nurse told her that she had a Dr. Pepper in front of her (this is the Dr. Pepper her grandson bought her during his visit around 2:00PM). The resident told it was not cold. The nurse offered her an alternative to her meal she requested a ham/cheese sandwich. The nurse went to get it for her. 6:18PM the nurse returned with the sandwich, she cut it up for the resident, she encouraged her to taste the sandwich, she refused. 6:20PM the nurse left the resident. The resident did not eat, she began rhyming again. 6:22PM certified nurses assistant, sampled staff C, entered the room and the resident asked her what she had to eat and the resident told she can't see her food. The resident wanted another coke and sampled staff C. told her she had a Dr.Pepper and the resident told her "it's not cold anymore", sampled staff C offered to get her some ice. 6:27pm sampled staff C returned with ice and pour the Dr. Pepper. The resident asked again what she had to eat, sampled staff C answered her. The resident sat up on the side of the bed again. She tried the milk and shook her head "no" and said it's not cold and sat the milk down. The staff stood over the resident never sat down to assist the resident. She did not offer to get her some cold milk; which according to the staff is one of the few things she likes and drinks. She began drinking the mighty shake and stated it was good; sampled staff C told the resident she would go and check on another resident and would come back and check on her. 6:33PM sampled staff C left the room. At that time the resident pushed the table away from herself and laid back down in the bed, she did not eat or drink anymore of the shake when the C.N.A. left the room. 11/5/14 @ 1:17PM sampled staff A, states that resident drank the shake, milk, and tea, states she has eaten less than 25% of meal, and 3 staff have attempted to get her to eat, states she eats well for breakfast or lunch, states she eats all fried chicken and hamburger when family brings it. She stated the resident always drinks her mighty shake and her milk. States she can be instructed as to where things are on the tray and what things are on the tray and will eat if she feels like it. States she is offered alternatives if she is not eating well or does not like what is served. States she does not know of any problems with resident eyesight and identifying her food. She also stated she will not use the eating utensils well. Interview with 11/06/2014 11:28:38 AM the unit manager, sampled staff I, side 1 states no concerns have been brought to her attention concerning this resident and that she has been in restorative and in therapy for assistance. Discussion was done with the unit manager concerning the above observations and she states it is probably time to discuss one-on-one assistance for meals, states she was on restorative dining in from September-January at 6 days a week. states it sounds like she needs to be referred to therapy. When asked what are her expectations of her staff when the resident is continually not eating she stated that she would expect them to stop and sit down with resident and encourage resident to eat. She stated that it sounds like some education is needed. Interview with the Director of Clinical Nutritional Services on 11/6/14 at 2:01PM revealed his nutritional assessment does not determine if a resident needs assistance from staff with meal, it will only reflect what his observations at that moment. In reference to this resident she does require set up and some assistance and some cueing. She will chew up the food and spit out because she had an obstruction and feels as a result she started this spitting out behavior and had not exhibited this behavior prior to this. He reviewed his 10/4/14 assessment and recommended limited assistance which requires set up of the meal, cueing, and orientation of the meal placement. He stated it sounds as if she needs more socialization and more cueing in order to remember to eat. He will refer her to therapy. A interview was conducted with the director of nurses on 11/6/14 at approximately 4:30PM in which she was informed of the above observations concerning sampled resident #64 assistance with meals. She stated if this resident is not eating even with the verbal cueing and offering of alternatives she expects her staff to sit down with the resident to offer her both verbal cueing and reorientation of her meal so that she can eat her meal timely and while it is still palatable and offer any physical assistance if needed.

Based on observation, staff interview, and review of the facility's dining staff assignment, the facility failed to provide sufficient staff to carry out the functions of dietary services in 1 of 5 dining rooms observed (Side 1 Day Room Assisted Dining). There were not enough staff in the dining room to meet the needs of the residents in the dining room. The findings: 1. During the initial dining observation on 11/4/14 at approximately 12:00pm, an observation was made of the Side 1 Day Room Assisted Dining. At the time of the observation a few staff were observed to coming in and out of the dining room to provide assistance to resident. During that time the Unit Manager, Staff F, and a Hospice employee (Staff J) was observed to be setting up residents for their dining. Staff were observed to be in and out the dining room and not consistent to serve residents timely and assist with dining as required. There ended up being only one staff present to assist residents with meal. On 11/4/14 at approximately 12:14pm, Resident #99 was observed to be eating her meal which was a mechanical soft diet texture consisting of pepper steak (ground/MS), rice, roll, tea, water, apple juice, and magic cup. The resident was observed to eat her entire meal with her hands without any facility staff's redirection to use silverware. The resident was also observed to be licking her fingers and eating spilled food off her clothes without any cueing or assistance from the facility's staff. During the observation Staff J, Hospice Aide, was observed to reinforce the resident to eat with her silverware. No reinforcement was offered by any of the facility's staff . Resident #99 was not a Hospice patient. At approximately 12:20pm, a voluntary interview was conducted with Staff J. Staff J does not work for the facility, but works as a Hospice Aide for one of the facility's Hospice Providers. Staff J revealed that she comes in daily around lunch time to assist the facility with dining to help the facility out because there is not enough staff to assist with the dining meal. She revealed that she assist the Hospice patients that she is assigned and any other residents that may need assistance during the time she is in the building. At approximately 12:30, Staff J was observed to leave a table where she was assisting 2 residents (Resident #48 & Resident #37) with dining by physical assistance or cueing to assist another resident. The Unit manager for the unit was observed to go over but did not sit down to assist the two residents. At approximately 12:51pm, both resident were observed to still be sitting at the table unassisted. Resident #48 was observed to be mixing her food together with no redirection or cueing for staff. During this observation Staff F and the Unit Manager were observed to leave the dining room, leaving only Staff J to assist residents in the dining room. 2. A 2nd dining observation was conducted on 11/5/14 at approximately 5:22pm in the Side 1 Day Room Assisted Dining. Staff D was the only staff observed to be present in the dining room. An interview with Staff D revealed that the dining room for residents that require assistance with dining. Staff D revealed she was the only staff assigned to the dining room. There were a total of 8 residents in the dining room that required assistance ranging from setup to total assistance. There were at least 2 resident that required total to extensive assistance with dining. At approximately 5:44pm, Resident #48 was observed to be eating with her hands and mixing her fluids in her plate of food. The resident remained in the dining room for 34 minutes without any cueing from staff. A review of Resident #48's meal ticket indicated that this resident required setup and cueing from staff with her meals. At approximately 5:45pm, Resident #37 was observed to have her meal setup by Staff D but as of 5:50pm Resident observed to be sitting and had not touched her food. At approximately 5:53pm, the resident had not received any assistance or cues from staff other than setup. The resident was observed to eat only half of her hamburger patty leaving the rest of her food untouched. A review of the resident's meal ticket indicated that the resident required cueing during meals. At approximately 5:48pm, Resident #27 was observed to be brought into the dining room by an unidentified C.N.A. The C.N.A setup the resident's tray up and gave the resident her spoon. The resident attempted to eat but was unsuccessful. The resident was not offered any assistance from staff until approximately 6:11pm. A review of the resident's meal ticket indicated the resident required assistance and cueing when the resident will not allow staff to assist her. At approximately 5:50pm, Resident #14 was observed to be left unassisted by an unidentified C.N.A while been assisted to eat. The staff had just setup the resident's tray at 5:49pm. The resident had been sitting in the dining room since 5:00pm. The C.N.A left the room to assist a resident to the bathroom. The C.N.A never returned to the dining room to finish assisting the resident. At 6:06pm, Staff C came in to assist Resident #14, but the resident refused. A review of the resident's meal ticket indicated that the resident required total assistance with dining. An interview conducted with Staff D at approximately 6:45pm, revealed that there is 1 staff assigned to the dining room to assist, but that some times the staff from the halls come assist when they have finished assisting resident on the hall. Staff D confirmed that she was not able to assist residents as indicated on the meal ticket and according to their needs. She revealed that there were too many residents in the dining room for just her to assist and that she was trying her best to assist residents as timely as she could, but that the residents seemed to need a lot more assistance on this evening. 3. A review of the staff dining assignment sheet for 11/5/14 indicated that there was only one staff (Staff D) assigned to Side 1 Day Room Assisted Dining on that evening.

Based on observation, staff interview, and policy review, the facility failed to serve food under sanitary conditions in 1 of 5 dining rooms (Side 1 Day Room Assisted Dining Room). 2 of 7 residents in the dining room (Resident #48 and Resident #58) were affected as a result of this action. Staff was observed to be handling food and touching the milk carton at the opening with bare hands. The Findings: On 11/5/14 at approximately 5:39pm, during an observation of dinner, Staff D was observed to wash her hands and go to the meal cart and retrieve a tray. Staff D served the tray to Resident #48. She setup the resident's tray and attempted to cue the resident to eat. Staff D picked up Resident #48's sandwich with her bare hands and attempted to put the sandwich up to the resident's mouth. She placed the sandwich down on the resident's tray and later return to assist the resident with eating the sandwich without replacing the sandwich. At approximately 5:42pm, Staff D was observed to be assisting Resident #58 with setup of his meal. During the setup, Staff D was observed to open the milk carton by using her bare hands at the mouth of the carton. The resident was not given a straw to drank from the carton. Resident #58 was observed to drink from the milk carton at least twice during the meal. During the time staff were disturbing trays, at least one other staff that came into the dining room to help with the distribution of trays was observed to touch a resident's milk carton at the mouth of the carton without providing a straw to drank from the carton. At approximately 6:45pm, an interview with Staff D confirmed that she had touched Resident #48's sandwich with her bare hands and later assisted the resident to eat the sandwich without changing the sandwich out for another one.

Based on observations and interview the facility failed to provide pharmaceutical services to meet the needs of each resident by maintaining expired medications in 1 of 4 of the facility's medication carts. The findings are: An inspection of the 400/600 hall medication cart was performed on 11/06/14 at approximately 11:04 AM with the medication nurse, sampled staff E. During the inspection the following medication was found to be expired: one blister pack of Risperdal 1mg (milligram) which contained 15 pills with an expiration date of 10/31/14. Interview with sampled staff E at the time of observation confirmed the medications were expired and she removed them from the medication cart.

Based on observation, record review and staff interview, the facility failed to ensure adequate supervision was provided to prevent burns from hot soup for one (1) of four (4) residents reviewed for accidents (Resident #149). The facility did not monitor temperatures of soup prior to service to residents which resulted in Resident #149 being served hot soup, which she spilled in her lap and sustained a second degree burn on her right thigh. The facility did not begin monitoring the temperature of the soup, until sixteen (16) days later. The facility's failure to monitor soup temperatures resulted in actual harm to Resident #149 and placed all other residents, who received soup at meals, at risk for potential harm related to burns. The findings include: 1. Resident #149 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively impaired and required assistance with set-up with meals. Observation of the resident on 5/23/11, during the lunch meal, revealed she required minimal assistance with her food and did not have difficulty eating. Review of the resident's treatment records revealed the resident sustained [REDACTED]. She spilled a cup on hot soup on her legs. Interview with the Wound Care Nurse, 5/24/11 at 10:53 a.m. revealed she assessed the resident on 4/8/11 after the incident occurred. She determined the resident had sustained a second degree burn, because the resident was blistered. She stated she obtained treatment orders for Silvadene Cream, covered it and reassessed it one week later. The Wound Nurse further stated that on 4/23/11 the wound treatment was changed and antibiotic therapy was initiated. The Wound Nurse said, "On 5/12/11, I didn't think the wound was healing well, so I asked for a Physical Therapy (PT) wound consult. PT recommended sharp debridement." Review of the April 2011 food temperature log revealed the temperature of the soup was not recorded on April 8th, the day Resident #149 burned her leg. The facility did not begin recording the temperature of the soup until April 24, 2011, sixteen (16) days later. Interview with the Certified Dietary Manager (CDM) #1 and the Consultant Registered Dietitian (RD), on 5/24/11, at 9;43 a.m. revealed the facility sent soup to the two (2) small dining areas everyday in a "crock pot." CDM #1 said, "We did not begin taking the temperature of the soup until 4/24/11." The CDM further communicated the temperature was not recorded because the soup was not included on the planned menu. The RD stated she expected all prepared food items should have the temperature tested prior to service to residents and she did not routinely review the food temperature logs during her monthly visits. The RD further stated she was unaware of the incident on 4/8/11 when Resident #149 sustained second degree burns from soup. Further review of the April and May 2011 food temperature logs revealed soup was served everyday at the lunch meal. From April 24, 2011 until May 23, 2011, the temperature of the soup ranged from 160 degrees Fahrenheit (F) to 203 degrees F. There was no documentation the facility staff obtained the temperature of the soup at the point of service, in the dining room, after it had been held in the crock pot, to ensure it was at a safe temperature to serve to residents. Interview with the Director of Nursing (DON), and Risk Managers #1 and #2 on 5/24/11, at 10:10 a.m. revealed Resident #149 had spilled soup on her lap during the lunch meal on 4/8/11. The DON stated the resident had not been residing at the facility long when the incident occurred. The DON further stated the resident had not displayed any trouble with eating, being unsteady with meals or requiring any adaptive eating equipment prior to the incident. The DON communicated that immediately after the incident occurred the Certified Nursing Assistants (CNAs) were inserviced to not plug the crock pot in to the power source, to allow it time to cool. The DON presented a sign in sheet which indicated the inservice occurred the day of the incident. Risk Manager #1 indicated the soup was never left unattended. Review of dietary inservice records revealed dietary staff was not inserviced until 4/15/11 regarding soup temperatures. The dietary inservice training read, "Staff was inserviced on soup temps (temperatures). Soups are to be heated to 165 degrees Fahrenheit. Soups are not to be plugged into the heating devices once they have left the dietary department. Only staff members from nursing are to transport soups to dining rooms. They must communicate with dietary dept (department) to be sure soups have been observed for proper temperature. Nursing staff are the only staff members permitted serve soups." During a meal observation in the Side 2 Dining Room, on 5/23/11 at 11:30 a.m., the crock pot containing soup was observed plugged into the power source. The outside of the crock pot was not warm to touch. CNA #1 was interviewed on 5/24/11 at 10:05 a.m. She stated the nursing staff obtained the soup from the dietary department, brought it to the dining room, and plugged it into the power source to maintain the temperature. Interview with CDM #2 on 5/24/11 at 11:53 a.m. revealed the facility had no policy to address taking food temperatures. He stated the only policy the facility had involved food storage. He stated he would expect the temperature of all food to be tested prior to service to residents. The facility had not established a system to ensure soup temperatures were monitored to prevent other residents from being burned and did not identify soup temperatures were as much as thirty-eight (38) degrees Fahrenheit (F) over their own standard on 165 degrees F after the incident occurred.