Every finding on record at Hidden Lakes Senior Living Community

Based on observation, record review, and interview, the facility failed to follow the menu for 1 of 3 observed meals, as evidenced by the failure to follow the recipes for the main entree of Beef Quesadilla and the alternate entree of Savory Baked Chicken Thigh. This resulted in a food complaint by 2 of 10 sampled residents, Resident #7 and a resident who requested to be anonymous. The Certified Dietary Manager (CDM) also added mashed potatoes and gravy to the alternate meal without following their documented process.The findings included:1) Review of the policy Menus and Adequate Nutrition with a Copyright of 2025, documented in part, Policy Explanation and Compliance Guidelines: . 4. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Review of the policy Altering Food Recipes dated 07/08/22, documented in part, Policy: All recipe alterations must be approved by the facility's Registered Dietitian (RD) before implementation. Documentation of changes is required for regulatory compliance and quality assurance. Review of the lunch menu for 02/04/26 documented the main meal consisted of a beef quesadilla, Spanish rice, corn, wheat bread, and a sugar cookie. The alternate meal was documented as a savory baked chicken thigh and roasted carrots. An observation of the tray line was made on 02/04/26 beginning at 11:35 AM. The food taken to the steam table for service included beef quesadillas, chicken thighs, mashed potatoes, and gravy. Staff D, cook, plated four main entrée meals with the quesadilla and eight alternate meals with the chicken thigh, carrots, and mashed potatoes with gravy. During an interview on 02/04/26 after the meal service at approximately 1:15 PM, when asked what ingredients she used in the quesadilla, Staff D stated, I used regular ground beef and peppers only. Review of the Beef Quesadilla recipe included the addition of shredded mild cheddar cheese, green chilies, onions, and taco seasoning to beef fajita strips. The cook confirmed she did not use the beef fajita strips or additional ingredients as per the recipe. During the continued interview, the recipe for the savory baked chicken thighs was reviewed by Staff D, cook. The recipe instructed the cook to brush the chicken with mustard and coat with biscuit mix, then to sprinkle paprika and parmesan cheese over the chicken thighs. When asked if she followed this recipe, the cook stated she did not use the biscuit mix or parmesan cheese for the chicken topping. When asked about the process for menu substitution or recipe alteration, Staff H, cook, stated they would sometimes try to find a recipe in their recipe binder that had the ingredients they already had on hand, and make that recipe instead. When asked why the mashed potatoes were added to that day's menu, the CDM stated because the alternate meal only had chicken and carrots, she felt the meal needed a starch. The CDM stated she spoke with the RD who agreed. The staff were asked for any documentation for that day's substitutions, and none was provided. 2) Review of the record revealed Resident #7 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] document the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview on 02/02/26 at 11:35 AM, when asked how the food at the facility was, Resident #7, stated the food was just bad, they can't cook, and it doesn't taste good. 3) Clinical record review for a resident who requested to remain anonymous revealed that the resident was admitted to the facility on [DATE] with diagnoses that included depression. The admission MDS assessment, with a reference date of 01/21/26, documented a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. On 02/02/26 at 10:16 AM, an interview was conducted with the resident. He was alert, oriented, and coherent. When asked about the facility's food, he complained that the facility should improve the food, stating that it is not good. He reported that there is little variety in the meals, and the same foods are served frequently. He also noted that the scrambled eggs are served cold every morning. Today, he received toast with no butter or jelly. On 02/03/26 at 9:09 AM, the Resident again voiced that the scrambled eggs were served cold. On 02/04/26 at 8:21 AM, the resident was observed lying in bed with his breakfast tray in front of him. When the surveyor asked, Were the eggs served hot? he replied, No. He stated that he ate the eggs and the sausage, but two pieces of French toast and some oatmeal remained on his plate. When asked if he did not have much of an appetite, he said, It's the food here.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 18 residents who ate food by mouth. The census at the time of survey was 18. The findings included:An observation of the kitchen was conducted on 02/02/26 beginning at 10:00 AM with the Certified Dietary Manager (CDM). The following findings were noted and confirmed by the CDM:a) The beverage dispenser had a brown thick liquid substance in the tray.b) A brown liquid spillage and loose dry macaroni noodles were noted on the clear plastic cover of a box in the dry storage area, that contained three cans of chicken and dumplings.c) There was an opened bag of macaroni noodles in the dry storage area.d) Food crumbs were noted along the side of the clean plastic cups stored on a three shelf rolling cart. e) There was debris and food crumbs on the floor at the side of the ovens.f) There was debris and food crumbs on the floor around the feet of all stainless-steel tables.g) All stainless-steel tables had a non-smooth surface along legs and shelving edge, making it unable to be properly cleaned.h) The can opener had a black substance near the cutting edge.i) There was a residue on the metal shelf by the scale and silverware holder.j) The microwave door and framing was chipped.k) A dirty used kitchen rag was left on a rolling cart shelf next to a tray of clean glasses.l) A grease-like substance was found on the outside of a box of carrots in the walk-in refrigerator.m) There were crumbs and food debris in the knife holder. Photographic evidence obtained.

Based on observation and interview, the facility failed to maintain the dumpster area in a clean and sanitary condition as evidenced by the failure to dispose of garbage and refuse properly. This failure had the potential to attract pests.The findings included:An observation of the dumpster area was made with the Certified Dietary Manager (CDM) and the Environmental Service Director on 02/05/26 at 10:51 AM. There were two dumpsters located at the back of the building with a wooden fence around them. On the ground in front of the fence, and inside the fence in front of each dumpster was spilled debris and food. Photographic evidence obtained. The Environmental Service Director stated, I'll get someone to clean this up.

Based on observation, interview, and record review, the facility failed to service food at a safe and palatable temperature for 2 of 3 sampled residents who were served milk during the lunch meal on 02/04/26, Residents #3 and #16, and as evidenced by kitchen processes resulting in resident complaints of cold food by Resident #7, #2, and #10.The findings included:1) A tray line observation was made on 02/04/26 beginning at 11:35 AM. Upon arrival in the kitchen two small open carts and two large open tray carts were noted with the resident's food trays and meal tickets set up on the four different carts. Staff E, Dietary Aide, explained one of the large carts was for the skilled nursing facility (SNF) and the other for the assisted living facility (ALF). Staff D, cook, explained one of the small carts was for the pureed meals and the other for the mechanically altered meals. The cook further explained she preferred to do all the pureed meals first, followed by the mechanically altered meals, and then the regular meals. The Dietary Aide was prepping all of the trays for both the SNF (a 24-bed facility that had 18 residents) and the ALF (a 17-bed facility that had 14 residents), at the same time by placing all the drinks and cold food items on every tray, including milk. On 02/04/26 at 11:40 AM, Staff D, cook, began to take the food from both the stove top and oven and put it on the tray line, and completed the process at 11:50 AM. The cook began to take temperatures of the food at 11:55 AM, and stated she had to reheat the pureed chicken, which was originally at 134 degrees F. (Fahrenheit) and reheated to 168 degrees F., the mashed potatoes, which was originally at 155 degrees F. and reheated to 163 degrees F., and the gravy which was originally at 150 degrees F. and reheated to 171 degrees F. Staff D, cook, began to plate the food at 12:20 PM. The cook took some warmed plates from the upright food warmer, placing the warmed plates on an insulated bottom and covered with an insulated top after plating each meal. There was also a second stack of plates that had not been in the warmer, but had been on a shelf in the kitchen, and used some of those plates as well during the service. The facility did not use any metal insert or any type of cover for the cart. The facility did not have a closed, insulated cart for trays, but used open metal tray carts. Only four residents ate in the dining room, and the remaining 12 residents ate in their rooms. The cook plated the four pureed meals and placed them on the first small cart. The meals were verified by the Certified Dietary Manager (CDM) who told the Dietary Aide they were ready to go. The CMD was asked to replace the milk on the tray for Resident #16 and obtain a temperature of that milk that would have been sent to the resident. The temperature of the milk that would have gone to the resident was 50 degrees F. A safe holding temperature for cold foods is 41 degrees F or below. The cook then plated the six mechanically altered meals on the second small cart. The CDM checked the meals as they were completed by the cook. The cook then plated the 12 regular meals for the residents who ate in their rooms. Upon completion of that service at 12:40 PM, the CDM confirmed the trays were ready to go. The CDM was asked to take the temperature of the milk on the tray for Resident #3, and it read 55 degrees F. When asked the process to ensure the milk was served at a safe cold temperature, the cook stated the milk was put in the freezer prior to service, and further stated, I guess I'll have to go back to putting the milk on ice while in the kitchen. When asked why they prep all the trays with the cold items at one time, the cook stated because it typically was just her and one aide, so she was unable to run a typical tray line that completes the tray with both hot and cold food at the same time and sends out a few at a time to maintain palatable and safe temperatures, since the one Dietary Aide also delivers the carts out to the staff to provide to the residents. 2) Review of the record revealed Resident #7 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview on 02/03/26 at 8:50 AM, Resident #7 was finishing her breakfast. When asked how it was, the resident stated her scrambled eggs were cold as usual. When asked if the food was usually cold or if it has been just that week during the cold snap, Resident #7 stated, not really, confirming the food was usually cold. When asked if she had asked staff to warm her food, the resident stated she didn't think they were allowed to do that. During an interview on 02/04/26 at approximately 9:30 AM, when asked how her breakfast was that morning, Resident #7 stated the eggs were ice cold. 2) Clinical record review revealed that Resident #2 was re-admitted to the facility on [DATE] with diagnoses that included medically complex conditions, atrial fibrillation, and septicemia. The annual Minimum Data Set (MDS) assessment with a reference date of 10/29/25 documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS further indicated that the resident reported feeling down, depressed, or hopeless, with no behavioral symptoms documented. On 02/02/26 at 11:05 AM, during an interview, Resident #2 reported that the facility's food was served cold and stated she disliked cold food.

Based on observation, menu review, and interview, the facility failed to ensure food was prepared to meet the needs for 3 of 3 sampled residents observed, as evidenced by the failure to provide and serve chopped meat to Resident #2 and #21, and failure to cut up meat to bite-sized pieces for Resident #5.The kitchen staff also failed to prepare ground meat on 02/02/26 as per the mechanical soft diet menu.This failure had the potential to affect 7 residents who were on physician ordered mechanical soft diets.The findings included:1) A lunch observation was made on 02/02/26 beginning at 11:49 AM in the main dining room. The posted menu for that day included a roast beef sandwich. Four residents were brought into the dining room and were accompanied by Staff I, Certified Nursing Assistant (CNA), throughout the meal. The lunch trays were served to the four residents, as noted below, and staff failed to compare the meal with the corresponding meal ticket. After the meal service on 02/02/26 at approximately 12:40 PM, Staff D, cook, confirmed she had not prepared any ground meat for the meal nor did she serve any cut up meat for the sandwiches.a) Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the physician order dated 10/27/25, documented the resident's diet texture was mechanical soft with chopped meats.During an observation on 02/02/26 at 12:12 PM, Resident #2 was served a roast beef sandwich on white bread with sliced roast beef. The roast beef was not chopped up in any manner. Photographic evidence obtained. Review of the resident's menu ticket documented the resident should be served a mechanical soft diet with chopped meats.b) Review of the record revealed Resident #21 was admitted to the facility on [DATE]. Review of current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, on a 0 to 15 scale, indicating moderate cognitive impairment. This MDS also documented the resident needed partial to moderate assistance with eating.Review of the physician order dated 10/31/25 documented the resident's diet texture was mechanical soft with chopped meats.During an observation on 02/02/26 at 12:16 PM, Resident #21 was served a roast beef sandwich on white bread with sliced roast beef. The roast beef was not chopped up in any manner. Photographic evidence obtained. Review of the resident's menu ticket documented the resident should be served a mechanical soft diet, but lacked the instructions to include chopped meats as per the physician order.c) Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the admission MDS assessment dated [DATE] documented that the resident had a BIMS score of 3, on a 0 to 15 scale, indicating the resident had severe cognitive impairment.Review of the meal ticket for Resident #5 documented to cut up meat to bite size pieces.During an observation on 02/02/26 at 12:14 PM, Resident #5 was served a roast beef sandwich on white bread with sliced roast beef. The meat was not cut up at all. Photographic evidence obtained.2) An observation of the lunch meal on 02/03/26 revealed Resident #5 in the main dining room. The resident's meal had been placed in front of her and staff had cut up the piece of meat, leaving two of the cut up pieces in large chunks, larger than bite sized. Photographic evidence obtained. Review of the resident's menu ticket documented to cut up meat to bite size pieces.3) A tray line observation was made on 02/04/26 beginning at 11:35 AM. Staff D, cook, started plating the meals at 12:20 PM.The cook plated the 7 mechanically altered meals and placed them on a small cart. The Certified Dietary Manager (CDM) checked the meals as they were completed by the cook. The CDM asked the cook to cut up the whole piece of chicken thigh into bite size pieces for Resident #5. The cook quested the CDM who stated, that is what the meal ticket says.During an interview on 02/04/26 at approximately 1:15 PM, while describing the tray line process, Staff D, cook, stated it was usually completed by only the dietary aide and herself.

Based on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 2 of 10 sampled residents, as evidenced by the inaccurate assessment for range of motion ability, diagnoses, and terminal illness status for Resident #7, and for range of motion ability for Resident #6.The findings included:1) Review of the record revealed Resident #7 was admitted to the facility on [DATE]. Review of the medical diagnosis included quadriplegia (partial or total loss of sensory and motor function in all four limbs and the torso). Review of current orders documented the resident was admitted to Hospice services as of 01/31/25. Review of the Hospice admission information revealed a physician signed the Certificate of Terminal Illness (CTI). This CTI was renewed with each certification period from admission to the present time. Review of the current Annual MDS dated [DATE] documented Resident #7 had no impairment to the lower extremities and had a documented diagnosis of quadriplegia. Review of the Quarterly MDS dated [DATE] documented Resident #7 had no impairment to the lower extremities and had a documented diagnosis of quadriplegia. This MDS also documented that the resident was on Hospice services but did not have a terminal prognosis. Review of the Significant Change assessment for the addition of Hospice services, dated 01/29/25, two days prior to the admission to Hospice services, documented Resident #7 was on Hospice services but did not have a terminal prognosis. During a side-by-side review of the record and interview on 02/05/26 at 12:52 PM, when asked if Resident #7 was a quadriplegic, the Director of Nursing (DON) stated the resident could not stand or walk but was not a quadriplegic. When asked about the contradiction related to the initiation of Hospice services and the lack of a documented terminal illness on the three MDSs reviewed, the DON had no explanation and agreed with the findings. 2) Review of the medical record documented Resident #6 was admitted to the facility on [DATE]. Medical diagnoses included bilateral foot drop (inability to lift the front part of both feet). Review of the Quarterly MDS dated [DATE] documented Resident #6 had no impairment to the lower extremities and a documented diagnosis of difficulty walking. Review of the progress note dated 01/28/26 documented Resident #6 was able to walk with the therapist using bilateral extremity AFO (ankle foot orthoses) which are braces. During a side-by-side review of the record and interview with the DON on 02/05/26 at 1:00 PM, when asked about the discrepancy in the MDS documentation, the DON was unable to explain and agreed with the findings.

Based on observation, interview, and record review, the facility failed to timely assess, monitor, document care, and notify the physician for a resident who exhibited cold-like symptoms for 1of 1 sampled resident, Resident #2, reviewed for change of condition. In addition, the facility failed to assess and document blood pressure prior to administering antihypertensive medication as required by the physician order for 1 of 5 sampled resident, Resident #2, reviewed during the unnecessary medication review task. The findings included: 1) Clinical record review revealed Resident #2 was re-admitted to the facility on [DATE] with diagnoses including medically complex conditions, Atrial Fibrillation, and Septicemia.The annual Minimum Data Set (MDS) assessment with a reference date of 10/29/25 documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS noted the resident reported feeling down, depressed, or hopeless, with no behavioral symptoms documented.On 02/03/26 at 9:06 AM, Resident #2 was observed sitting in her room with untouched food on the tray. The resident was observed repeatedly wiping a continuously running nose. The resident stated she had a cold, her stomach was upset, and she did not have an appetite.On 02/03/26 at 11:47 AM, Resident #2 was observed being transported to the dining room for lunch. The resident stated she felt cold and felt as though she had a cold. Staff A (Certified Nursing Assistant) assisted the resident with a jacket and placed a throw over her legs. The dining room temperature, per the thermo-hygrometer, was 68.9 F at that time.On 02/03/26 at 12:10 PM, Resident #2 was observed sitting in the dining room and continued to state she was not feeling well and was not interested in eating.On 02/04/26 at 8:24 AM, Resident #2 was observed sitting in her wheelchair in her room with a runny nose, repeatedly wiping her nose. Her food was present and untouched. The resident stated she did not have an appetite, had a cold, and was not feeling well. Review of the clinical record at that time revealed no documentation that the physician had been notified, no evidence the resident had been assessed or treated for her symptoms, and no documentation that any diagnostic testing had been performed for respiratory infection.On 02/04/26 at 12:38 PM, Resident #2 was observed in the main dining room and stated she did not feel well and declined additional food stated I don't feel well. I don't need the double meat, but when I'm feeling good, I will take it and eat it.On 02/05/26 at 8:57 AM, Resident #2 was observed sitting in her wheelchair in her room. When asked how she was feeling, the resident stated she was not doing well, reported ongoing cold symptoms that had worsened, and described alternating sensations of feeling hot and cold. The resident reported she did not eat breakfast due to nausea and fear of vomiting. The resident was observed with audible nasal congestion. At that time, there remained no documentation that the physician had been notified, no evidence of assessment or treatment of the resident's symptoms, and no documentation of testing.On 02/05/26 at 9:05 AM, an interview was conducted with Staff B (Registered Nurse). When the surveyor asked Staff B if she had received report from the outgoing nurse of how Resident #2 was doing, Staff B stated she had received report from the outgoing nurse and reported no changes in the resident's condition and no new complaints. Staff B proceeded to review the resident's records and stated review of the resident's electronic medical record showed no new concerns documented.At 9:09 AM, the surveyor accompanied Staff B to speak with Resident #2. During the interaction, the resident reported sneezing, coughing, a runny nose, and stated she had used an entire box of tissues. The resident denied having allergies and reported experiencing alternating sensations of feeling hot and cold. The resident stated the symptoms had been present since the other day.On 02/05/26 at 9:55 AM, an interview was conducted with the Director of Nursing (DON). The surveyor asked if a resident exhibits cold like symptoms, what did she expect the nurses to do? The DON stated that when a resident exhibits cold-like symptoms, nurses are expected to assess the resident and notify the physician. The DON further stated that based on the infection surveillance criteria, diagnostic testing such as laboratory work and chest x-ray may be initiated. The surveyor informed the DON that Resident #2 had been reporting symptoms since 02/03/26.On 02/05/26 at 11:51 AM, Resident #2 was observed in her room with curtains drawn to separate her from her roommate. When asked if she was receiving treatment for her symptoms, the resident stated yes, thank goodness, finally. During this time, a regional nurse consultant came and placed a contact precaution signage on the door.2) Additional clinical record review revealed a physician order dated 10/28/25 for Metoprolol Tartrate 25 mg, to be administered orally once daily for Hypertension, with instructions to hold the medication for systolic blood pressure less than 100 mmHg and diastolic blood pressure less than 55 mmHg.Review of January and February 2026 Medication Administration Records (MARs) and treatment administration records (TARs) revealed the resident's blood pressure was not consistently monitored and documented prior to administration of Metoprolol, despite the physician-ordered parameters.Documented blood pressure readings included:01/03/26 at 8:18 AM: 144/6001/12/26 at 9:24 AM: 108/6501/17/26 at 8:06 PM: 124/7101/21/26 at 10:47 AM: 114/5201/26/26 at 9:38 AM: 141/6001/27/26 at 9:12 AM: 123/77Review of the MAR dated 01/21/26 indicated the resident's diastolic blood pressure was 52 mmHg; however, Metoprolol was administered and signed as given, despite the physician order indicating the medication should have been held.On 02/05/26 at 9:55 AM, during an interview with the DON, she was informed of the lack of consistent blood pressure monitoring prior to administration of antihypertensive medication with ordered parameters. The DON reviewed the records, acknowledged the findings, and stated the medication order format did not prompt nurses to document blood pressure readings.

Based on record review, staff interview, and review of the policy and procedure, the facility failed to ensure supervision and implementation of interventions to prevent falls for 1 of 1 sampled resident, Resident #20, which resulted in the resident sustaining 3 falls within 5 weeks.The findings included: Review of the policy titled, Fall Prevention Program dated 07/2025, documented in part, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Review of the record indicated that Resident #20 was admitted to the facility on [DATE]. Medical history included Metabolic Encephalopathy (a disturbance in brain function that causes confusion), Essential Hypertension (high blood pressure), Muscle Weakness and Idiopathic Peripheral Neuropathy (nerve damage which causes pain, numbness and tingling to the lower extremities).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #20 had a Brief Interview for Mental Status (BIMS) score of 8, on a scale of 0 to15, indicating the resident had moderate cognitive impairment. The MDS also documented Resident #20 had 2 or more falls since the last assessment with no injuries. Resident #20 required maximum assistance from the staff for toileting and was dependent on assistance from the staff with showering and dressing the lower body.Review of the care plan dated 01/12/26 documented that Resident #20 was a Fall risk related to having poor safety awareness due to impaired cognition or disregard for safety and the requirement of assistance with transfers and mobility. Resident #20 had Musculoskeletal symptom (s) which could affect balance or extremity strength. Resident #20 used a wheelchair to maintain mobility with staff assistance. The interventions included: Observe for safety, place resident in a visible area, the staff to make frequent checks on resident to ensure resident is not in need for anything. The staff will keep frequently used items in reach, and the staff will observe any changes in cognition or mobility and notify MD.Review of the practitioner's note dated 10/22/25 documented that Resident #20 was at an increased risk for falls related to symptoms and forgetfulness. However, a review of the record documented Fall Risk assessments for Resident #20 at a low risk for falls, scores 0 to 18. On 11/29/25 the score was 17, 01/08/26 the score 13 and 01/22/26 the score 15. Also, the fall risk assessments did not include the diagnoses of Metabolic Encephalopathy, Muscle Weakness and Idiopathic Peripheral Neuropathy, all of which could contribute to a fall.An interview with the Director of Nursing (DON) was conducted on 02/05/26 at 11:00 AM. When asked about the fall prevention program, the DON reported that when residents fall, there was a protocol that the nurses follow. This included documenting the incident in a statement and doing an incident report. The DON was asked about the fall incidents for Resident #20. The DON confirmed that Resident #20 fell 3 times within the past month, on 01/08/26 at 4;00 PM, 01/21/26 at 5:30 PM and 02/02/26 at 6:10 PM, all occurred when the resident was most alert, Further explained the resident was generally calm and quiet in the morning and most alert and active in the afternoon and evening. The resident also fell on [DATE]. During a side-by-side review of the record, the DON confirmed that the documentation in the record lacked details of the date, time, circumstances, assessment and interventions taken at the time of the fall. The DON stated that Resident #20 does not get family visits as the roommate, so the resident enjoyed the company and the attention of the staff. Resident #20 would use the wheelchair to propel towards the common area but would also slide out of the wheelchair to gain attention. The DON further elaborated that there was a recent staff turnover which impacted Resident #20 because she had developed a rapport with the previous staff. The DON added that the new staff required further orientation in paying close attention to Resident #20 to prevent sliding from the wheelchair and added that on 02/02/26, the date of last fall, the new Certified Nursing Assistant (CNA) did not know Resident #20 well enough to properly supervise.

Based on record review, observation and staff interview, the facility failed to follow the physician's order for feeding tube flush and to obtain weekly weights for 1 of 1 sampled resident, Resident #6, which was required to maintain the resident's nutritional needs and prevent complications. The findings included: 1. Review of the policy and procedure titled, Care and Treatment of Feeding Tubes dated 12/2025, documented in part, Feeding tubes will be utilized according to the physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush.A review of the record documented Resident #6 was admitted to the facility on [DATE]. Medical diagnoses included Chronic Dysphagia (difficulty swallowing). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] the resident was fed by a feeding tube. a) Review of the physician's orders documented as of 08/01/25 that Resident #6 received nutrition via a feeding tube. An additional order dated 11/04/25 instructed staff to administer 200 ml (milliliters) of water to the feeding tube at 6:00 AM, 12:00 PM, 4:00 PM and 8:00 PM throughout the day. During observation of the water administration through the feeding tube on 02/04/26 at 11:55 AM, Staff F, Registered Nurse, flushed the resident's feeding tube with 60 ml of water. In a side-by-side review of the record and interview with Staff F, when asked how much water was used to flush the feeding tube, Staff F confirmed that 60 ml was used. Staff F reviewed the physician's order and then confirmed that the ordered amount of 200 ml was not administered. b) Review of the physician's orders dated 01/09/26 documented for the staff to obtain weekly weights every Monday for 4 weeks. During a side-by-side review of the record and interview on 02/05/26 at 1:00 PM, when asked about who was responsible for obtaining and documenting the residents' weights, the Director of Nursing (DON) stated that all staff are responsible for weight checks and the Registered Nurse (RN) documents in the electronic chart. When the DON was asked about who ensures that the task is completed, the DON indicated that there was an issue with coordination between Nursing and Dietary in getting the residents' weights documented. Review of the documented weights revealed the weights were obtained on 01/21/26, 01/12/26 01/5/26 and 12/5/25. The record lacked any documented weights on 02/02/26 or 01/26/26 as ordered. The DON reviewed the record and agreed that the facility did not carry out the order to obtain weekly weights for 4 weeks.

Based on observation, interview, and record review, the facility failed to ensure the provision of foods as per resident preference for 2 of 4 sampled residents, as evidenced by the failure to ensure ice cream and mashed potatoes daily for Resident #16, and failure to ensure double portions for Resident #2.The findings included:1) Review of the record revealed Resident #16 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score was not done as the resident was rarely or never understood. This MDS also documented the resident was totally dependent upon staff for eating.Review of the current care plan initiated on 11/13/24 and revised on 08/26/25 documented the resident was at increased nutritional risk related to a mechanically altered diet and the need for assistance with all meals. Intervention to this care plan included to provided the diet as ordered.An observation on 02/02/26 at 12:10 PM revealed Resident #16 in the main dining room being fed by Staff I, Certified Nursing Assistant (CNA). The resident's divided plate had pureed meat and pureed carrots. The third divided section of the plate was empty. Photographic evidence obtained. Review of the menu ticket for Resident #16 documented, Preferences: chocolate ice cream daily and mashed potatoes daily. No mashed potatoes were noted on the resident's plate.An observation of the tray line on 02/02/26 at approximately 12:30 PM lacked any mashed potatoes. The lack of potatoes was confirmed by the Certified Dietary Manager (CDM) at that time.An observation of the lunch meal on 02/04/26 at 12:35 PM revealed Resident #16 had not received chocolate ice cream. When asked if the resident's tray was missing anything, Staff A, CNA, who was feeding the resident, confirmed the ice cream had not been served. 2) Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the Annual MDS assessment dated [DATE] documented the resident had a BIMS score of 13, on a 0 to 15 scale, indicating intact cognition. This MDS also documented the resident required set up assistance for eating.During the meal observation on 02/02/26 at 12:12 PM, Resident #2 was served a roast beef sandwich on white bread and with sliced roast beef. The sandwich had the same amount of roast beef and the other two sandwiches served at the same table. Photographic evidence obtained. Review of the menu ticket revealed the resident was on a mechanical soft diet with a double portion protein.An observation of the lunch meal on 02/03/26 at 12:38 PM revealed Resident #2 received a scoop of ground meat. Resident #2 stated I don't feel well today. I don't need double meat. But when I'm felling good I will take it and eat it.During an interview on 02/03/26 at 12:16 PM, Staff H, cook, was asked to put a double portion of ground meat on a plate. The cook stated, Oh did I mess up? An observation of the double portion provided by the cook was more than the portion provided to Resident #2. Photographic evidence obtained. When asked if she gave Resident #2 a double portion of meat, the cook stated, I could have put more.

Based on observation and interview, the facility failed to ensure a clean, comfortable and homelike environment related to dirty carpet in 3 of 18 resident rooms (room [ROOM NUMBER], #9 and #14) and 1 of 24 bedside tables having 1 of 4 bolts missing from the table's surface (room [ROOM NUMBER]). The findings included: During the initial tour of the facility on 08/11/24 at approximately 9:30 AM, the following concerns were observed by the survey team: 1) room [ROOM NUMBER] was missing a large bolt from the bedside table. The carpet had multiple stains. 2) room [ROOM NUMBER] had multiple stains on the carpet. 3) room [ROOM NUMBER] had a large stain on the carpet at the end of the bed. (Photographic evidence obtained) On 08/14/24 at 10:15 AM, the Housekeeping Supervisor was asked about the carpets. She stated the facility was going to rip the carpet out, and she believed the Executive Director had received some quotes for it. She stated the carpet is made up of squares and each one can be individually removed and replaced with a new one. On 08/14/24 at 10:30 AM, an interview and a tour were conducted with the Executive Director. He stated it is his goal to replace the carpet with hard flooring, but he has not started to get any quotes for a new floor. He also stated that each square of carpeting can be removed and replaced with a new carpet piece. During the tour with the Executive Director, he was shown the dirty carpets in Rooms #5, #9 and #14, and the missing bolt from the bedside table in room [ROOM NUMBER]. He confirmed the presence of the dirty carpets and the missing bolt for the bedside table.

Based on record review and interview, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment for 1 of 5 sampled residents, related to the medication usage of Resident #9. The findings included: Review of the record revealed Resident #9 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented Resident #9 was taking an antidepressant medication during the seven-day look-back period of 05/08/24 through 05/14/24. Review of the corresponding Medication Administration Record (MAR) for the month of May 2024 lacked any provision of an antidepressant. Further review of the May 2024 MAR revealed Resident #9 received the antiplatelet medication Clopidogrel (plavix) 75 milligrams (mg) daily during that timeframe, along with the antianxiety medication Buspirone 5 mg daily. Further review of the MDS lacked the indication that the resident received these two additional categories of medications. During an interview and side-by-side record review on 08/14/24 at 12:59 PM, the MDS Coordinator agreed with the inaccuracy of the MDS.

Based on observation, interviews, and record review, the facility failed to: a) provide showers per resident schedule and/or resident choice for 3 of 3 sampled residents reviewed for Activities of Daily Living (ADL) care (Resident #122, #72, and #14); and b) provide timely nail care to 1 of 1 sampled residents reviewed for ADL's related to nail care (Resident #122) The findings included: The Activities of Daily Living Policy and Procedure, dated 06/26/22, states: 2. This [procedure] included the facility ensuring that: a. A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified below: i. Hygiene - bathing, dressing, grooming and oral care . 4. The facility will ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition , grooming, and personal and oral hygiene. 1) During observation and resident interview on 08/11/24 at 10:43 AM, Resident #122 stated she had not had a shower since being admitted , and she would really like a shower. Resident #122's hair appeared oily and her nails were ragged and chipped with a brown substance observed underneath her nails. Also, when leaning close to Resident #122 to better hear her, an unpleasant body odor was detected. On 08/13/24 at 9:42 AM, a Certified Nurse's Aide (CNA) was observed entering the resident's room to provide care to the resident. On 08/13/24 at 10:23 AM, Resident #122 stated she felt better today, as she had just had a bed bath, but she had still not received a shower. Resident #122 again stated, I would really like to have a shower. The resident's nails were still chipped and jagged, with dark discoloration underneath her nails. Record review revealed, Resident #122 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Congestive Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Other Cardiomyopathies, Chronic Pulmonary Edema, Obesity, and Muscle Weakness. Resident went out to the hospital on 07/29/24 due to the resident exhibiting stroke-like symptoms and returned back to the facility on [DATE]. Resident #122 was assessed at the time of admission and re-admission as having a Brief Initial Mental Status score of 12 out of 15, which in indicated moderately impaired cognition. A review of the shower schedule for Resident #122 showed resident was scheduled to have showers on Monday and Thursdays. A review of the shower book revealed only one bed bath had been given since re-admission on 08/05/24; that bed bath was provided on 08/12/24. No showers had been provided to the resident since admission on 07/22/24. On 08/13/24 at 10:50 AM, an interview was conducted with Staff B (CNA). She stated, I work as needed, and last Monday I was not scheduled to work in the nursing home. A Resident's shower schedule is either posted on the wall or in the shower book. All showers and bed baths are put in the shower book. It is the Resident's choice as to the time of day they want a shower. If a resident requests a shower on a day that is not scheduled, we will try to arrange a shower on that day. On 08/14/24 at 9:43 AM, during an interview with the Director of Nursing, she stated, Showers and Bed Baths are to be recorded in the shower book. [Resident #122] came back from the hospital on Monday, 08/05/24, so she probably would have missed that shower day, but she should have had a shower on the following Thursday (08/08/24) and last Monday (08/12/24). All residents are able to get a shower whenever they request one. On 08/14/24 at 9:55 AM, the DON confirmed, after reviewing the shower book, that Resident #122 had only received bed baths since admission. When asked why Resident #122 had not received a shower, the DON replied, She is a 2 person assist for showers. She would need 2 aides to be with her during her showers, and we only have 2 aides on the floor. On 08/14/24 at 10:45 AM, the DON informed the surveyor that Resident #122 just had the best shower ever, and her nails have been cleaned and cut. I personally gave the resident her shower. 25404 2) Review of the record revealed Resident #14 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating moderate cognitive impairment. This same MDS documented it was somewhat important for the resident to choose between a bath and a shower. During an interview on 08/11/24 at 10:14 AM, when asked if he had been receiving a bath or shower as he would like, Resident #14 stated he had not had a shower, and was not even sure if there was a shower at the facility. When asked if he had been offered a shower or was aware of any shower schedule, the resident stated no to both. When asked if he wanted a shower, Resident #14 explained that he could not stand and was not sure if they would want his wheelchair to get wet, but volunteered, I'd like to get some of this dead skin off. Resident #14 explained because of his lack of showers he had been using extra lotion on his skin, trying to get the dead skin off, while pointing to his bottle of lotion. Review of the shower binder identified at the nurse's station by staff revealed Resident #14 was scheduled for a shower on Tuesday and Friday during the 2 PM to 10 PM shift. This binder contained multiple pages of resident's documented showers or bed baths. Review of these pages revealed a shower was provided on 07/23/24, with bed baths provided on and unknown/not documented date, on 07/31/24, and on 08/06/24. Review of the Certified Nursing Assistant's (CNA's) documentation in the electronic medical record revealed only one shower in the past 30 days, on 07/26/24. The additional five scheduled shower days lacked any documentation for the provision or refusal of showers. During an interview on 08/13/24 at 11:25 AM, when asked about the process for resident showers, the Director of Nursing (DON) pulled the shower binder from the nurse's station and revealed the shower schedule. The DON stated the previous DON started the shower book on her last day at the facility, three weeks ago. The DON explained staff were to document on the form the provision of a shower or bed bath for each resident. The DON stated if a resident refused bathing, the nurse would attempt to encourage the resident. The DON stated if the resident still refused, the form would be signed by the CNA, nurse, and the resident. The DON agreed the forms and system in place did not support effective documentation for the provision of showers. 3) Review of the record revealed Resident #72 was admitted to the facility on [DATE]. Review of the New Admission Evaluation dated 08/08/24 documented the resident preferred showers. During an interview on 08/11/24 at 11:02 AM, Resident #72 explained she had been at the facility about three or four days. When asked if staff were helping her with a bath or shower as she would like, the resident stated she hadn't had a bath yet. When asked if she had been given a bed bath, she again stated not yet. When asked about a shower the resident stated, I hope to get one in a day or two. Review of the shower schedule revealed Resident #72 was scheduled for a shower on Monday and Thursday during the 2 PM to 10 PM shift. Review of the shower binder lacked any documented showers. Review of the electronic record lacked any provision of showers. Resident #72 was scheduled for a shower on Monday 08/12/24 during the evening shift. Further review of the electronic record revealed she received a sponge bath on that day and time. The progress notes lacked any documented showers or refusals. During the continued interview and side-by-side record review on 08/13/24 at 11:25 AM, the DON agreed with the concern.

Based on record review, documented monthly pharmacy reviews, and interviews, the consultant pharmacist failed to identify the lack of behavior monitoring for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #9). The findings included: Review of the record revealed Resident #9 was admitted to the facility on [DATE]. Review of the orders revealed the resident had been on the anti-anxiety medication Buspirone since 02/16/24, and the anti-psychotic medication Haloperidol since 02/05/24. Review of the record lacked any behavior monitoring for these medications. (Refer to F757 for details). The anti-anxiety medication Ativan had been added to the resident's regimen as of 07/28/24. Review of the monthly pharmacy recommendations from February 2024 through July 2024 lacked any recommendation related to the lack of behavior monitoring. During a phone interview on 08/14/24 at 3:05 PM, the consultant pharmacist was unable to review his records, but would check later. The consultant pharmacist was told of the concerns related to the lack of behavior monitoring for Resident #9 and was asked to provide any recommendations or information to the Director of Nursing. As of the exit conference, no additional information had been provided.

Based on record review and interview, the facility failed to ensure adequate monitoring of medications for 2 of 6 sampled residents. The facility failed to ensure behavior monitoring for psychotropic medication use for Resident #9, and failed to ensure appropriate antibiotic use for Resident #14. The findings included: 1) Review of the record revealed Resident #9 was admitted to the facility on [DATE], with a diagnosis of Schizophrenia. Review of the orders revealed the resident had been on the anti-psychotic medication Haloperidol since 02/05/24, and the anti-anxiety medication Buspirone since 02/16/24. The anti-anxiety medication Ativan had been added to the resident's regimen as of 07/28/24. Review of the current care plan initiated on 02/06/24 and revised 07/02/24 documented, I have anxious/restless behavior as evident by calling out for help loudly without a need. Resident has a history of providing false information to family and staff for attention seeking purposes. Review of the monthly Medication Administration Records (MARs) from February 2024 through August 2024, along with the progress notes, lacked any documented behavior monitoring for Resident #9. During an interview on 08/14/24 at 11:25 PM, the new Director of Nursing (DON), as of three weeks prior to the survey, was asked about the lack of behavior monitoring for Resident #9. The DON stated it was part of the documentation in the eMAR. When shown the lack of documentation of behavior monitoring for Resident #9, the DON was unsure and referred the question to the MDS (Minimum Data Set) Coordinator. During an interview on 08/14/24 at 12:59 PM, when asked how staff document behavior monitoring at the facility, the MDS Coordinator explained it was part of a batch order set used when a resident was admitted or readmitted , which allowed the nurse to document behaviors on the eMAR. The MDS Coordinator stated the order set may have fallen off during one of the resident's readmissions and no one caught it. 2) Review of the record revealed Resident #14 was admitted to the facility on [DATE] with an indwelling urinary catheter. Further review revealed an order for a urinalysis to be completed on 07/29/24. An order for Cipro (an antibiotic) was written to begin on 07/30/24, to give 500 milligrams (mg) every 12 hours for 14 days. Review of the urinalysis along with the culture and sensitivity, that was collected on 07/29/24 and reported to the facility on [DATE], revealed Resident #14 did have a urinary tract infection (UTI). Further review of the culture revealed the antibiotic Cipro was resistant to the organism, and thus was not appropriate as the treatment for this UTI. Review of the corresponding Medication Administration Records (MARs) revealed Resident #14 was administered the Cipro starting on 07/30/24 at 8:00 AM, twice daily through 08/11/24, thus receiving 22 extra doses of the antibiotic after having been determined to be resistant, or ineffective, as per the laboratory results During an interview on 08/13/24 at 1:38 PM, when asked about the failure to stop the Cipro on 07/31/24, upon receipt of the culture documenting the Cipro was resistant to the organism, the Administrator, who was also a Registered Nurse stated apparently no one looked at the culture and noticed the Cipro was resistant.

Based on record review and interview, the facility failed to complete physician ordered laboratory services timely for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #9 and #72). The findings included: 1) Review of the record revealed Resident #9 was admitted to the facility on [DATE]. Review of the orders revealed the need for a CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) to be drawn on 07/22/24. The record lacked any results for these labs. During an interview on 08/14/24 at 12:36 PM, the Director of Nursing (DON) was asked to locate and provide the CBC and CMP results from 07/22/24. The DON was unable to do so. The DON looked on the laboratory's website and found that four other residents had labs drawn on 07/22/24, and one on 07/23/24, but was unable to locate any for Resident #9. The DON reviewed the laboratory service binder and could not find any requisition page for 07/22/24 or 07/23/24, thus was unable to determine why the labs were not drawn as per order. 2) Review of the record revealed Resident #72 was admitted to the facility on [DATE]. Further review revealed an order dated 08/07/24 for a urinalysis with a culture and sensitivity to be completed. A second order dated 08/07/24 documented a CBC (complete blood count) and CMP (comprehensive metabolic panel) was to be drawn on 08/09/24. The electronic record lacked any results for either of these orders. The progress notes lacked any reason the orders were not completed. During an interview on 08/13/24 at 11:25 AM, when asked about laboratory results, the Director of Nursing (DON) stated they had been having issues with the results not automatically integrating into their electronic record, so they had been scanning the results into the record manually. The DON was asked about the ordered labs for Resident #72, and upon searching on the laboratory services website, the DON found the CBC and CMP was completed on 08/12/24, three days after the ordered date, but was unable to locate any results for the urinalysis. The DON looked in the laboratory binder and could not find any requisition for the urinalysis. During the interview Staff C, Registered Nurse (RN) joined the conversation. When asked the reason for the urinalysis, the RN stated for her behaviors. When asked if she knew why the urinalysis was not completed, the RN stated she did not know, but if the sample wasn't labeled correctly or was too old when the laboratory services arrived, it would be thrown out.

Based on observation, interview and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 1 sampled resident with an indwelling catheter (Resident #14). The findings included: The policy titled Enhanced Barrier Precautions and implemented 04/01/2024 documents in part: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precaution. 9. Enhanced Barrier Precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that places them at high risk. On 05/18/24, Resident #14 was admitted to the facility with diagnosis to include: Urinary Tract Infection, Cerebrovascular Disease, Hypotension, Dementia, and Gout. Resident #14 has a BIMS (Brief Interview for Mental Status) of 11, which indicates moderately impaired mental status. The resident had an indwelling urinary catheter present. On 08/11/24 at 10:24 AM, Resident #14's room was observed; no EBP sign was noted on the door and no gowns were available. Resident #14 has a urinary catheter due to obstructive uropathy. During an interview with Resident #14, he stated that the staff wear gloves but they don't wear gowns during care. On 08/12/24 at 12:27 PM, Staff A, a CNA (Certified Nursing Assistant) was observed donning a gown to deliver a meal tray. The EBP sign was noted on the door with a contact isolation sign also on the door. She was asked why she had donned the gown, and she replied, They told me to put on a gown since I was opening an item on [Resident #14] meal tray. On 08/13/24 at 10:01 AM, Staff B, a CNA, performed urinary catheter care and peri-care on Resident #14. The CNA donned gloves and a gown. The resident asked, I wonder when they will be taking the sign off my door. Staff B replied I think your last one [antibiotic] was yesterday or it may be today, but I just wanted to be on the safe side. On 08/13/24 at 10:50 AM, Staff B was asked why she had worn a gown during the care. She stated that the overnight nurse told her the antibiotic for his ESBL (Extended Spectrum Beta-Lactamase) was up yesterday, and today's nurse said she thought that it was up today, so I used the gown to be safe. When shown and asked about the EBP sign, the CNA read it over and stated, I guess I need to wear the gown. The CNA stated she did not know about the EBP or the need to wear PPE (Personal Protection Equipment) for a resident with a urinary catheter. Staff B further added, I don't think he had that sign or PPE when I worked last time, and he had the Foley. On 08/13/24 at 9:30 AM, Staff C, an RN (Registered Nurse), was interviewed. She was asked why the PPE (Personal Protective Equipment) was on the door for Resident #14. She stated the precautions were for the ESBL in his urine. When shown the sign for EBP, the RN was unaware of the use of PPE during care. The RN stated that prior to his contact precautions, Resident #14 had not been on any type of precaution. Review of the chart revealed no ESBL in the urine and no indication for contact isolation. No order was found for Enhanced Barrier Precautions for Resident #14 and his indwelling urinary catheter. On 08/14/24 at 10:43 AM, the DON (Director of Nursing) was interviewed about the EBP and how the staff is made aware of the precautions for the residents. She stated the last update for the staff on EBP precautions was on 02/14/24. A new policy was initiated on 04/01/24 for EBP. She states no in-services were completed with staff following the implementation of the new policy which includes EBP for urinary catheters.

Based on observation, interview, and record review, the facility failed to ensure an accurate and current menu was posted for residents who eat their meals at the facility. The findings included: On 08/11/24 (Sunday) at 9:00 AM, it was observed that the daily menu posted on the wall at the entrance to the dining room was labeled as being the menu for Monday. This menu documented that the lunch meal to be provided on this day was Cracker Crumb Cod, Potato Wedges, Broccoli, Roll, and Brownie, with the alternate meal being Chili with Beans and Baked Potato. During the meal observation at 08/11/24 at 12:10 PM, the main entree served to the residents was Turkey Shepherd's Pie (Ground Turkey, mashed potatoes, peas/corn/carrots), Dinner Roll, and Cheesecake. The only other meal observed being served at this time was an always available grilled cheese sandwich, tomato soup, and fresh fruit. Observation of a weekly menu posted on the bulletin board in the dining room showed the menu was for Week 1, which included the dates of 08/20/24 - 08/26/24. A search through all the weekly menus posted on the bulletin board did not contain a menu for any dates prior to 08/20/24. While looking at the menus, the surveyor was approached by the significant other of Resident #2 who stated, If you can understand the logic of those menus posted, you are a better person than I am. That daily menu posted on the outside of the dining room has been there since last Monday. It would be nice to know what's being served. An interview conducted with the Certified Dietary Manager on 08/14/24 at 10:08 AM revealed that she had been on vacation and this was her first day back. It seems the daily menus were not changed in my absence. I changed the menu this morning. She also stated that the weekly menus posted on the bulletin board in the dining room should have indicated the menu for Week 5, not Week 1.

Based on clinical and administrative record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This is evidenced by the facility failure to follow the established protocols and policy and procedure regarding COVID outbreak testing and follow-up. The findings included: Review of the facility's policy regarding Infection Outbreak Response and Investigation, Date Implemented [DATE] and Date Reviewed/Revised [DATE] documented, Outbreak Investigation: a. When the existence of an outbreak has been established, an investigation will begin. b. The Infection Preventionist will be responsible for coordinating all activities. c. A case definition will be developed in order to identify other staff and residents who may be affected. or ability to identify all close contacts, the facility should instead investigate the outbreak at the facility-wide or group-level. Broader approaches to testing may be required if the facility is directed by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage or when contact tracing fails to halt transmission. Contact tracing or broad-based testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. (this will typically be at day 1 ( where day of exposure is day 0), day 3 and day 5). Review of the facility's records revealed that the facility had 5 (five) residents (Resident # 1, # 2, # 3, # 4, # 5) who tested positive for COVID on [DATE]; one staff in Activities tested positive for COVID on [DATE]; two more residents tested positive on [DATE] (Resident # 6 and # 7); one additional resident tested positive for COVID on [DATE], Resident # 8. The surveyor requested the facility records for outbreak testing of residents and staff. An interview was conducted on [DATE] at approximately 3:00 PM with the Director of Nursing (DON). The DON reported that the facility only tested those individuals who exhibited symptoms. She further stated that COVID is not transmitted if you don't have symptoms. She further expressed that they no longer have to conduct mass testing. The surveyor further inquired about the testing done regarding those individuals identified as exposed to COVID positive residents or staff. She again stated that the facility only tested those individuals who exhibited symptoms. The surveyor reviewed with the DON on [DATE] the CDC recommendations. The Centers for Disease Control (CDC) Overview of Testing for SARS-CoV-2, the virus that causes COVID-19 documented: Testing asymptomatic people who have had recent known or suspected exposure to SARS-CoV-2 Viral Testing is recommended for individuals who have been exposed to someone with COVID-19. People who have had an exposure to someone known or suspected of having COVID-19 should be tested at least 5 days after the exposure. If symptoms develop before 5 days, they should get tested immediately. Testing people who have recently tested positive, and recovered from COVID-19 If someone has had exposure to someone with COVID-19 and is asymptomatic, but has had COVID-19 within the past 30 days*, testing to identify a new infection is generally not recommended. If someone has become newly symptomatic after having had COVID-19 within the past 30 days*, antigen tests should be used to identify a new infection. If they test negative, they should repeat the antigen test following FDA recommendations. The FDA recommends repeat testing following a negative result whether or not you have COVID-19 symptoms. If you receive a negative result, the test did not detect the SARS-CoV-2 virus at the time of that test. If you have COVID-19 symptoms, test again 48 hours after the first negative test, for a total of at least two tests. If you get a negative result on the second test and you are concerned that you could have COVID-19, you may choose to test again 48 hours after the second test, consider getting a laboratory molecular-based test, or call your health care provider. If you do not have COVID-19 symptoms and believe you have been exposed to COVID-19, test again 48 hours after the first negative test, then 48 hours after the second negative test, for a total of at least three tests. If you get a negative result on the second test, test again 48 hours after the second test. If you get a negative result on the third test and you are concerned that you could have COVID-19, you may choose to test again using an antigen test, consider getting a laboratory molecular-based test, or call your health care provider. If someone had exposure to another person with COVID-19, but the exposed individual has had COVID-19 within the past ,d+[DATE] days*, consider using antigen tests (rather than an NAAT, such as a PCR test) to identify a new infection. They should get tested at least 5 full days after their exposure. If they test negative with an antigen test, they should repeat the antigen test following FDA recommendations. *The clock starts from the day the person is tested (not the day they received their positive test result) or their original onset of symptoms, whichever came first. An interview was conducted on [DATE] at 11:30 AM with the Public Health Preparedness Coordinator for the county's health department. The surveyor initially questioned her generally regarding outbreak testing. She explained about the recent rule changes regarding routine testing previously done in facilities had expired. However in outbreak testing, the facilities are to perform contact tracing and test individuals who were exposed to the COVID positive person. It is also recommended that repeat testing is done 5 days later. The surveyor then questioned her about the practice of testing only if symptomatic. Symptomatic individuals are to be tested immediately. Asymptomatic individuals are to be tested if they have been exposed to the COVID positive person. If the exposed person is negative, then it is recommended that the test is repeated on day 5. The surveyor also inquired about the asymptomatic people's ability of being COVID positive and transmitting the virus to others. She confirmed that there is still the possibility of COVID positive individuals not exhibiting symptoms but could still have the ability to transmit the virus to others. She expressed that the probability is less than a symptomatic positive person but there it is still possible. Thus she emphasize individuals utilizing the practice of universal precautions. The surveyor then specifically asked her regarding the facility. She confirmed receiving the line listing of individuals who tested positive and she was contacted by the Director of Nursing. The facility also had another outbreak in May and one resident expired. Further review of the facility follow-up revealed that Resident # 3 shared a room with Resident # 9, who was admitted to the facility on [DATE] with a diagnosis of Acute Respiratory Failure. There was no testing documented in the clinical record for the resident. However, interview with the Director of Nursing on [DATE] in the afternoon, revealed that the facility tested the resident on [DATE] the results of that test was negative. The facility then moved the resident to another room. However, the facility did not conduct any repeat COVID testing of this resident. Additionally, Resident # 8, who tested positive on [DATE] shared a room with Resident # 10. There was no testing documented in the clinical record for the resident. However, interview with the Director of Nursing on [DATE] in the afternoon, revealed that the facility tested the resident on [DATE], the results of that test was negative. The facility again moved the resident to another room. Again the facility did not perform any repeat COVID testing on Resident # 10. Furthermore, review of the staff testing, revealed that the facility tested on e staff because she exhibited symptoms. The surveyor requested the facility's investigation and contact tracing from the [DATE] outbreak. The facility investigation yielded that the spouse of Resident # 1 visited and exhibited symptoms and tested positive on [DATE]. Resident # 1 was symptomatic with positive test on [DATE]. Resident # 1 and Resident # 2 shared a room (room [ROOM NUMBER]) and attended therapy five (5) times a week in the room and in the wellness center and was on Certified Nursing Assistant Assignment 3. Resident # 2 also tested positive on [DATE]. Resident # 3 (room [ROOM NUMBER]) also attended therapy 5 times a week in the room and in the wellness center. The resident was on CNA assignment 1. Resident # 4 and Resident # 5 shared a room (room [ROOM NUMBER]) and participated in therapy 5 times a week in the room and in the wellness center. The residents were also on CNA assignment 1. Both residents were symptomatic and tested positive on [DATE]. Two more residents Residents # 6 and # 7, who shared a room (room [ROOM NUMBER]) and participated in therapy 5 times a week in the room, were symptomatic and tested positive on [DATE]. The residents were on CNA assignment 1. Resident # 8 (room [ROOM NUMBER]) was symptomatic, tested positive on [DATE]. The resident was on CNA assignment 1. The facility identified 18 staff through contact tracing who were exposed to COVID positive residents (8 Licensed Staff, 7 Certified Nursing Assistant; 3 contract therapy staff) . One staff (Activities) was tested . This staff exhibited symptoms and tested positive on [DATE]. Several staff test themselves on their own because the facility did not offer testing. Additionally, the facility did not perform repeat testing of residents who initially tested negative or offered the staff who self-tested a repeat test as recommended. An interview was conducted with the Director of Nursing on [DATE] at 2:00 PM. She confirmed that the facility did not test the 18 staff identified through contact tracing. The DON also reported the following information regarding the Therapy staff: The full time Physical Therapist tested herself on [DATE] and reported a negative test. The staff did not report experiencing symptoms. This test was not reported, nor did the staff retest. The part-time Occupational Therapist did not test. The DON reported that the therapist had a recent positive COVID test from another facility's identified outbreak. She was uncertain about the time frame of the previous positive COVID test. Another therapist was pregnant and tested herself on [DATE]. She did not exhibit symptoms and the test results were not reported. The staff did not retest as recommended. The facility failed to follow their policy and procedure and the CDC recommendations regarding testing during an outbreak, exposing the residents and staff.

Based on clinical and administrative record review and staff interview, the facility failed to ensure the clinical record provided documentation or evidence that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This failure is evidenced by the review of 5 residents for immunizations history revealed that the facility failed to provide evidence of offering the pneumococcal vaccine to 3 of 5 residents reviewed (Resident #4, #11, #12) and failed to provide evidence of vaccinating 1 of the 2 remaining residents reviewed, when the resident consented to receive the pneumococcal vaccine (Resident #10). The finding included: The facility's policy Infection Control - Influenza and Pneumococcal Immunization for Residents, date 06/08/22, documented regarding Pneumococcal Immunization: 1. Before offering the pneumococcal immunization, each resident and or resident representative receives education regarding the benefits and potential side effects of the immunization. 2. Each resident is offered pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized; 3. The resident and/or resident representative has the opportunity to refuse immunization; and 4. The resident's medical record includes documentation that indicates, at a minimum, the following: i. That the resident or resident representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and ii. That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medication contraindication or refusal. 5. Pneumococcal immunization will be offered in accordance with most updated CDC immunization algorithm. 1) Review of the clinical record on 09/26/23 for Resident #4 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record did not reveal evidence that the resident or her representative was provided education and/or was offered the pneumococcal vaccine. 2) Review of the clinical record on 09/26/23 for Resident #12 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record did not reveal evidence that the resident or her representative was provided education and/or was offered the pneumococcal vaccine. 3) Review of the clinical record on 09/26/23 for Resident #11 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record did not reveal evidence that the resident or her representative was provided education and/or was offered the pneumococcal vaccine. An interview was conducted on 09/26/23 in the afternoon with the Director of Nursing, who confirmed that the clinical record did not provide evidence that the residents had been offered the pneumococcal vaccine. 4) Review of the clinical record on 09/26/23 for Resident #10 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record revealed a Pneumococcal Polysaccharide Vaccine (PPSV23) informed consent signed by the resident on 02/07/22. Additional review of the clinical record failed to provide evidence that the resident was administered the vaccine. An interview was conducted on 09/27/23 in the afternoon with the Director of Nursing. She confirmed the current clinical record did not provide evidence that the resident was administered the vaccine. She will investigate further and inform the surveyor if located. At the time of this writing, no further evidence was provided to indicate that the resident was administered the vaccine.

Based on record review and interview, it was determined the facility failed to honor advance directives for 1 of 6 sampled residents (Resident # 34) as evidenced by a failure to provide cardiopulmonary resuscitation (CPR) to a resident who desired to be resuscitated. This facility action resulted in immediate jeopardy for Resident #34, as the resident did not receive emergency treatment according to her wishes. The resident died on [DATE]. The findings include: Clinical record review conducted on [DATE] revealed Resident # 34 was admitted to the facility on [DATE], status [REDACTED]. The demographic sheet documents code status as, "Resuscitate: Yes full code." The Minimum Data Set (MDS), admission assessment with a reference date of [DATE] documents the resident was assessed as moderately impaired for daily decision making and return to community referral was triggered. There was no prognosis of a terminal illness from the MDS. The Care plan titled, "Advance Directives" dated ,[DATE] documents, the resident has a living will and CPR status and interventions included, Update physician and family with changes in condition. Nursing Notes dated [DATE] at 7:15 AM documents, the certified nursing aide asked the nurse to check the resident. The nurse went into the room to assess the resident. The nurses notes documented, "Immediate call placed to husband/power of attorney if he wanted CPR and hospitalization . Hospice consult pending, husband states to keep her here and no CPR. In to check resident with night nurse. No respirations, no blood pressure, color ashen with no pulses. Husband called, came in to see body. Funeral home, sister, and Advanced Registered Nurse Practitioner (ARNP) notified. 9:30 AM body released..." The clinical record lacked documentation of nursing care provided to the resident when the resident was found unresponsive by Staff A and Staff B. There was a lack of documentation of staff providing or attempting cardiopulmonary resuscitation (CPR) or that the physician was notified of the change in condition. Interview with the Director of Nursing (DON) conducted on [DATE] at 1:54 PM revealed, the DON reviewed the clinical record and confirmed the code status for Resident #34 on [DATE] was a full code. The resident did not have a signed, Do Not Resuscitate (DNR) order. The DON recalled talking to the resident's spouse and explained the spouse was "funny" about the DNR (Do Not Resuscitate) status. He spoke to family members and they were going to make a decision regarding the code status. The spouse was grieving and hopeful that the resident would get better. The DON reported, "I wanted to give the resident every opportunity, because she had gastrointestinal problems and was refusing to eat." Family members were not ready to sign a DNR. The DON explained, the facility protocol is to perform CPR if a resident does not have a signed DNR order. The DON reported, "Most likely, the incident occurred because the nurse knew the family had discussions regarding not wanting CPR, and If the nurse worked on the resident, she would have fractured the resident's ribs and the family did not want that at all." Interview with Staff A, a Licensed Practical Nurse (LPN) conducted on [DATE] at 2:46 PM revealed, she had just arrived for her shift; the nursing aide came to the desk and stated, the resident did not look good and asked the nurse to check on her. Staff A went in the room and found the resident non-responsive with a thready pulse. The night nurse (Staff B), stayed with the resident while she went to check the chart and verified code status, there was no DNR on file. Staff A proceeded to call the spouse to ask him what he wanted her to do. She reported, Hospice had been consulted but had not evaluated the resident. The LPN stated, "I asked the spouse what he wants us to do for the resident, I asked if he wanted the resident sent to the hospital and if he wanted CPR. The spouse did not want the resident transferred to the hospital or for us to start CPR. The conversation between Staff A and the spouse lasted approximately five to ten minutes. She then returned to the resident's room and the resident had no pulse." The LPN explained, if there is no advance directive and DNR orders present in the resident's chart, CPR should be initiated. Phone Interview with Staff B, an LPN, conducted on [DATE] at 3:31 PM revealed the resident was found with a thready pulse and not responding. The day nurse called the husband, and he stated not to do CPR, when the day nurse returned to the room the patient had no pulse. The LPN explained in most cases we start CPR and call EMS (Emergency Medical Services/an ambulance), if we find the resident is unresponsive; we were waiting on the hospice consult and the husband was contacted first. A phone interview with the Physician, who is also the Medical Director, conducted on [DATE] at 4:58 PM revealed, "I did not request the hospice consult, the family requested and the nurse practitioner signed the order." Furthermore, the Physician stated, " I was not aware of a terminal diagnosis. The resident had significant cardiac history and he was not aware of her clinical condition leading to her death." A phone interview with the Advanced Registered Nurse Practitioner (ARNP) conducted on [DATE] at 5:17 PM revealed, " I saw the resident and she had not been eating or drinking, most likely multiple functional decline and the family was considering hospice, so I signed the order for the hospice consult. I do not remember if the resident had a terminal condition; she had Dementia and was of advanced age. The hospice consult was based on family request." Further review of the clinical record indicated that there was no documentation that the resident had a terminal diagnosis, or documentation there is no medical probability of the resident's recovery from her present medical condition. The record provides no evidence cardiopulmonary resuscitation was provided to the resident when found unresponsive with a thready pulse on [DATE]. Review of the facility policy titled, "Care of Residents Who Become Acutely or Critically Ill" last revised [DATE], documents, "If a resident becomes acutely or critically ill the attending physician should be notified immediately by the nurse. The nurse will follow instructions given by the physician. If the physician orders for the resident to go to the hospital, the nurse shall call 911 for the transport. The nurse should complete the proper transfer form to go to the hospital with the resident." This policy was not followed by facility staff. Review of the facility policy titled, "Cardiopulmonary Resuscitation" (CPR) last revised [DATE], documents, "As a general rule in the nursing facility CPR will be performed unless the resident has a signed physician "Do Not Resuscitate" order in his/her chart. This policy was not followed by facility staff.

Based on record review and interview, it was determined the facility failed to notify the physician of a change in condition for 1 of 6 sampled residents (Resident # 34) who desired cardopulmonary resuscitation. The facility's action resulted in immediate jeopardy for resident #34, in that the physician was not notified of the resident's emergent condition. These actions prevented the physician from providing medical intervention and guidance. The resident died on [DATE] and the physician was not notified of the resident's death. The findings include: Clinical record review conducted on [DATE] revealed Resident # 34 was admitted to the facility on [DATE] status [REDACTED]. Review of the Nursing Notes dated [DATE] at 7:15 AM documents, "In to check resident with night nurse, no respirations, no blood pressure, color ashen with no pulses." The record does not indicate the physician was notified when the resident was found unresponsive. An Interview with the Director of Nursing (DON) conducted on [DATE] at 1:54 PM revealed, the Director reviewed the clinical record and confirmed the code status for Resident #34 on [DATE] was a full code. The resident did not have a signed DNR (Do Not Resuscitate) order. The DON explained, the facility's protocol is to notify the physician of changes in condition and verified there is no evidence the nurse on duty notified the physician when the resident was found unresponsive. The DON reported, most likely, the incident occurred because the nurse knew the family had discussions regarding hospice care and not wanting CPR. During interview with Staff A, the Day Shift Licensed Practical Nurse (LPN) conducted on [DATE] at 2:46 PM revealed, she had just arrived for her shift; the certified nursing aide came to the desk and stated the resident did not look good and asked the nurse to check the resident. The nurse went in the room and found the resident non-responsive with a thready pulse. The night nurse (Staff B) stayed with resident while she went to check the chart and verified the code status, there was no DNR on file. The LPN (Staff A) proceeded to call the spouse to ask him what he wanted her to do. The conversation between Staff A and the spouse lasted approximately five to ten minutes. She then returned to the resident's room and the resident had no pulse. The LPN confirmed she did not call the physician immediately when the resident was found unresponsive. The LPN called the practitioner when the resident had expired to release the body to the funeral home. A Phone Interview with Staff B, the Night shift LPN, conducted on [DATE] at 3:31 PM revealed, the resident was found with a thready pulse and not responding, the day nurse (Staff A) called the husband, and he stated not to do CPR. When the day nurse returned to the room, the resident had no pulses. The LPN (Staff B) explained she did not contact the physician, the day shift nurse (Staff A) made all the phone calls and arrangements. Further review of the clinical record failed to provide evidence the physician or practitioner was notified of the change in condition, when the resident was found unresponsive with a thready pulse on [DATE]. The Facility's policy titled, "Care of Residents Who Become Acutely or Critically Ill" last revised [DATE], documents, "If a resident becomes acutely or critically ill the attending physician should be notified immediately by the nurse. The nurse will follow instructions given by the physician. If the physician orders [REDACTED]. The nurse should complete the proper transfer form to go to the hospital with the resident." Facility staff failed to follow this policy.

Based on policy review, clinical record review and interview, the facility failed to ensure quality of nursing care provided to each resident is in accordance with established standards of practice of nursing care, Florida Statues, Chapter 464.003(19) Practice of Practical Nursing, for 1 of 16 sampled residents (Resident # 34) as evidenced by failure to notify the physician of a change in condition, failure to provide nursing services to sustain life and by performing acts outside their scope of practice, by the pronouncement of death. The facility's failure to provide care to the resident in accordance to professional standards resulted in Resident #34 not receiving life sustaining treatment. Resident #34 died on [DATE]. The findings include: Chapter 464.003 (19) "Practice of Practical Nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed practical physician, or a licensed dentist; and the teaching of general principles of health and wellness to the public and to students other than nursing students. A practical nurse is responsible and accountable for making decisions that are based upon the individual ' s educational preparation and experience in nursing. Clinical record review conducted on [DATE] revealed, Resident # 34 was admitted to the facility on [DATE] status [REDACTED]. The demographic sheet documents code status as, "Resuscitate: Yes full code". Review of the Nursing Notes dated [DATE] documents, the nursing aide asked the nurse (LPN Staff A) to check the resident. The nurse went into the room to assess. The nurses notes documented, "Immediate call placed to husband/power of attorney if he wanted CPR and hospitalization . A hospice consult was pending and the spouse stated "keep her here and no CPR. In to check resident with night nurse (LPN Staff B), no respirations, no blood pressure, color ashen with no pulses." The clinical record lacked documentation of nursing care provided to the resident when found unresponsive by the two LPNs, Staff A and Staff B. There was a lack of documentation cardiopulmonary resuscitation efforts were attempted or that the physician was notified of the change in condition. Interview with Staff A, the Day Shift Licensed Practical Nurse (LPN) conducted on [DATE] at 2:46 PM revealed, during change of shift, the nursing aide came to the desk and reported to the nurses the resident did not look good. Staff A went in the room accompanied by the night nurse (Staff B) and found the resident unresponsive with a thready pulse. The night nurse, Staff B stayed with the resident while she went to check the chart and verified code status; there was no DNR (Do Not Resusciate) on file. Staff A confirmed CPR was not performed, the physician was not notified immediately when the resident was found unresponsive with a thready pulse and no emergency nursing care was rendered to the resident. A phone interview with Staff B, the Night Shift LPN, conducted on [DATE] at 3:31 PM revealed, the nurse had been in the resident's room multiple times throughout the night due to frequent loose stools. During change of shift the resident was found with a thready pulse and not responding, the day nurse called the husband, and reported not to do CPR, when the day nurse returned to the room the resident had no pulse. Staff B confirmed no nursing care including CPR was provided to the resident when found unresponsive. Interview with the Director of Nursing (DON) conducted on [DATE] at 5:54 PM revealed, the two licensed nurses pronounced the resident's death. The DON explained, that is not unusual, most of the deaths in the facility are hospice residents and sometimes the hospice nurse does not want to come out if they are busy. The facility does not have a formal training program for licensed practical nurses on pronouncement of death, but they know to assess for respirations, pulse and blood pressure. Further review of the clinical record indicated that there was no documentation that the resident had a terminal diagnosis, or documentation there was no medical probability of the resident's recovery from her present medical condition. The record provides no evidence of cardiopulmonary resuscitation or other nursing care and services were provided to the resident when found unresponsive with a thready pulse on [DATE] by Staff A and Staff B. The record failed to provide evidence the staff notified the physician and obtained treatment orders for the change of condition, as per the facility's policy. A Facility policy titled, "Care of Residents Who Become Acutely or Critically Ill" last revised [DATE], documents, "If a resident becomes acutely or critically ill the attending physician should be notified immediately by the nurse. The nurse will follow instructions given by the physician. If the physician orders [REDACTED]. The nurse should complete the proper transfer form to go to the hospital with the resident." This policy was not followed by facility staff. A Facility policy titled, "Care of Residents in a Medical Emergency" last revised [DATE], documents, "It is the policy that if a resident sustains injuries from an accident or experiences any life threatening or emergency situation, the resident's physician will be notified and the resident will be provided interim staff care."

Based on record review and interview, it was determined the facility failed to provide necessary care and services to 2 of 16 sampled residents (Resident # 34 and Resident # 30 ) as evidenced by a failure to provide emergency nursing care for a resident found unresponsive and failure to apply prescribed stockings, respectively. This facility's action resulted in immediate jeopardy for Resident #34, as the resident did not receive emergency treatment according to her wishes. The resident died on [DATE]. The findings include: 1) Clinical record review conducted on [DATE] revealed Resident # 34 was admitted to the facility on [DATE] status [REDACTED]. The demographic sheet documents code status as, "Resuscitate: Yes full code" . The Minimum Data Set (MDS), Admission assessment with a reference date of [DATE] documents, the resident was assessed as moderately impaired for daily decision making; has [DIAGNOSES REDACTED]. There was no prognosis of a terminal illness from the MDS. A Care Plan initiated for the resident on [DATE] includes the following: "[MEDICAL CONDITION] with risk for complications, including infection, pain, and embolism" documents interventions as assess, record and report to medical doctor signs and symptoms of embolism such as cyanosis and dyspnea. "Risk or bleeding, injury associated with daily use of anticoagulant medications" documents interventions as observe, record and report to medical doctor signs and symptoms of aspirin toxicity, gastrointestinal distress and bleeding. "Advance Directives" documents the resident has a living will and CPR status and interventions include update physician and family with changes in condition. A physician progress notes [REDACTED].# 34 was admitted to the facility for rehabilitation after a fall at home and hip replacement surgery. The Physical exam noted, the patient was alert with no distress and no current complaints, with no neurological deficits. The plan documents continue care and treatment, check laboratory studies and therapy evaluation. The Notes did not provide evidence of terminal condition or decline in function. Social Services Notes dated [DATE] documents, the resident is "Full Code" (which means the resident wishes to be resusciated if her heart or breathing stops), and discharge plan is dependent on resident's progress. The Advanced Registered Nurse Practitioner (ARNP) Progress Notes dated [DATE] documents, "Seeing resident for initial visit; alert with some forgetfulness, baseline for resident." Review of systems documents, weakness with no other abnormalities. The plan noted decrease [MEDICATION NAME] and check lipids. The Notes did not provide evidence of terminal condition or decline in function. A physician's orders [REDACTED]. Review of Nursing Notes dated [DATE] at 7:15 AM documents, the nursing aide asked the nurse (LPN Staff A) to check the resident. The nurse went into the room to assess. The nurses notes documents, "Immediate call placed to husband/power of attorney if he wanted CPR and hospitalization . Hospice consult pending, husband states to keep her here and no CPR. In to check resident with night nurse. No respirations, no blood pressure, color ashen with no pulses. Husband called, came in to see body. Funeral home, sister, and ARNP notified. 9:30 AM body released..." The clinical record lacked documentation of nursing care provided to the resident when found unresponsive by the Staff A and Staff B. There was a lack of documentation of cardiopulmonary resuscitation efforts were attempted or that the physician was notified of the change in condition. Interview with the Director of Nursing (DON) conducted on [DATE] at 1:54 PM revealed, the Director reviewed the clinical record and confirmed the code status for the resident on [DATE] was a full code; the resident did not have a signed DNR (Do Not Resuscitate) order. The DON explained, the facility protocol is to perform CPR if a resident does not have a signed DNR order. Most likely, the incident occurred because the nurse knew the family had discussions regarding not wanting CPR. If the nurse worked on the resident, she would have fractured the resident's ribs and family did not want that at all." Interview with Staff A, the Day Shift Licensed Practical Nurse (LPN) conducted on [DATE] at 2:46 PM revealed, during change of shift, the nursing aide came to the desk and reported to the nurses the resident did not look good. Staff A went in the room accompanied by the night nurse (Staff B) and found the resident non-responsive with a thready pulse. The night nurse, Staff B stayed with the resident while she went to check the chart and verified code status; there was no DNR on file. The LPN did not perform CPR or provide emergency care to the resident. Staff A explained, she proceeded to call the spouse to ask him what he wanted her to do. Hospice had been consulted but, had not completed the evaluation. Staff A stated, "I asked the spouse what he wants us to do for resident, I asked if he wanted the resident sent to the hospital and if he wanted CPR. The spouse did not want the resident transferred to the hospital or for us to start CPR." Staff A explained, if there is no advance directive and DNR orders present in the resident's chart, CPR should be initiated. Staff A also verified nursing care including CPR was not provided to the resident upon discovery of the change in condition. She reported, the phone conversation with the spouse lasted approximately five to ten minutes and when she returned to the room the resident had no pulse. A Phone Interview with Staff B, Night Shift LPN, conducted on [DATE] at 3:31 PM revealed, the nurse had been in the resident's room multiple times throughout the night due to frequent loose stools. During change of shift, the resident was found with a thready pulse and not responding, the day nurse (Staff A) called the husband, and reported not to do CPR, when the day nurse returned to the room the resident had no pulse. Staff B explained, in most cases we start CPR and call EMS (Emergency Medical Services/an ambulance) if we find the resident is unresponsive. We were waiting on the hospice consult and the husband was contacted first. Staff B confirmed, no nursing care including CPR was provided to the resident. A Phone Interview with the Physician, who is also the facility's Medical Director, conducted on [DATE] at 4:58 PM revealed, "I did not request the hospice consult, the family requested it and the nurse practitioner signed the order". Furthermore, the Physician stated, "I was not aware of a terminal diagnosis. The resident had significant cardiac history and he was not aware of her clinical condition leading to her death." A phone Interview with the Advanced Registered Nurse Practitioner (ARNP) conducted on [DATE] at 5:17 PM revealed, "I saw the resident and she had not been eating or drinking, most likely experiencing multiple functional decline and the family was considering hospice, so I signed the order for hospice consult. I do not remember if the resident had a terminal condition; she had Dementia and was of advance age. The hospice consult was based on family request." Further review of the clinical record indicated that there was no documentation that the resident had a terminal diagnosis, or documentation there was no medical probability of the resident's recovery from her present medical condition. The record provides no evidence of cardiopulmonary resuscitation or other nursing care and services were provided to the resident when found unresponsive with a thready pulse on [DATE] by Staff A and Staff B. The record failed to provide evidence the staff notified the physician and obtained treatment orders for the change of condition, as per policy. A Facility policy titled, "Care of Residents Who Become Acutely or Critically Ill" last revised [DATE], documents "If a resident becomes acutely or critically ill the attending physician should be notified immediately by the nurse. The nurse will follow instructions given by the physician. If the physician orders [REDACTED]. The nurse should complete the proper transfer form to go to the hospital with the resident." This policy was not followed. A Facility policy titled, "Care of Residents in a Medical Emergency" last revised [DATE], documents "It is the policy that if a resident sustains injuries from an accident or experiences any life threatening or emergency situation, the resident's physician will be notified and the resident will be provided interim staff care." This policy was not followed. 2. Resident # 30 admitted [DATE] with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of physician's orders [REDACTED]. This order continue to be reflected on the [DATE] physician's orders [REDACTED]. Review Physician's Progress Notes: [DATE]-Physical Examination: includes Extremities: Bilateral pedal ankle [MEDICAL CONDITION] (not new). [DATE]-Physician's Progress Note reveals - Physical Examination: Extremities - Pedal, ankle and calf [MEDICAL CONDITION]. The patient wears compression stockings. Problems include [MEDICAL CONDITION], cerebral vascular disease, history of functional decline, and hypertension. [DATE]-Physician's Progress Notes - Physical Examination include: Extremities: The patient has compression stockings on, Pedal ankle and calf [MEDICAL CONDITION], bilaterally (chronic). Review of Advanced Registered Nurse Practitioner (ARNP) Progress Notes: [DATE]-revealed: Seeing resident to follow up - weight appears to be stable; feeds self with set up; Left Pedal Enema. [DATE]-Seeing resident to follow-up - report that appetite was poor - pedal enema. [DATE]-Nurses' Notes reviewed - left pedal [MEDICAL CONDITION]. [DATE]-Seeing Resident to follow up report of wheezing. On exam, alert; her only complaint is of Left Lower Extremities pain -TEDS were removed - no open area, no redness; left pedal [MEDICAL CONDITION]. Review of Nurse's Progress Notes [DATE] - Bilateral low leg [MEDICAL CONDITION] 2+. TEDS and encouraged to elevate. Review of labs dated [DATE] - Basic Metabolic Panel: BUN 23 (High); Creatinine 1.2. Nutritional Summary dated [DATE] Resident's appetite fluctuates from fair to poor, depends on the mood of the resident. Weight gain noted, likely due to increased [MEDICAL CONDITION]. Care Plan initiated ,[DATE] and reviewed ,[DATE] - Focus: Resident at risk for impaired skin integrity related to contracture, limited mobility, chronic [MEDICAL CONDITION] to lower extremities ([DATE]). Interventions include: encouraged to keep her legs elevated. On [DATE] at 9:17 AM an observation was made of the resident having breakfast in room. The Resident was observed to be wheezing with shortness of breath. The Director of Nursing (DON) was present and stated that she will have to get the resident's nurse to come in and give her a nebulizer treatment. Surveyor pointed out to DON that the resident's feet were swollen and the socks were tight. DON bent down and pulled down the Resident's socks and said "yes, they are too tight and we have been trying to address the issue of her having swollen feet by changing her medications." Resident was not wearing the TEDS hose as prescribed by physician but had on a pair of regular, white ankle high socks; her foot brace was also in place; her feet were on the foot pedals. The wheelchair that the resident was sitting in had no adjustable elevating leg rests for her legs to be elevated as stated in the Care Plan. On [DATE] at 5:33 PM an observation was made of resident at dinner. Resident observed wearing her TED stockings and brace, her feet were resting on the foot pedals of the non-elevating leg rests. On [DATE] at 10:25 AM an interview was conducted with Licensed Practical Nurse (LPN), Staff A. She said that some of the interventions put in place to alleviate the swelling of the resident's feet are to elevate her feet when out of bed, put on the TED stocking when she is out of bed. She said that the resident was not wearing the TED stocking this morning ([DATE]) because they were washed and put out to dry. She said that the resident also wears a brace on her right leg because of paralysis. She said that the resident had on the brace this morning but not the TED stocking. On [DATE] 1:34 PM an interview was conducted with Certified Nursing Assistant, Staff F. She said that she gets the resident dressed and ready for the day when she is on duty. She said that she would put on the resident's Ted Hose and brace each morning. She said the resident likes to sit in her wheelchair and she says that she would put the resident's feet on her wheelchair foot pedals. The CNA says that the resident's wheelchair does not have a raised leg extension, so she cannot elevate the resident's legs. The CNA said that each CNA is given a Cheat Sheet (CNA showed surveyor a copy of the Cheat Sheet she has for her residents) that they keep on their person to remind them of the special care needs for each resident. She said that yesterday ([DATE]) someone else got the resident up out of bed and dressed for her and she does not know if that CNA did not know that the resident required her TED stockings on when out of bed. On [DATE] at 1:52 PM an observation was made of the resident, accompanied by CNA, Staff F. The resident was observed sitting in her wheelchair with her feet down on the foot pedals. She did not have her legs elevated nor does the wheelchair that the resident was sitting in have leg extensions. The CNA said that this is the resident's wheelchair that she uses daily. On [DATE] at 1:56 PM an interview was conducted with Certified Nursing Assistant, Staff D. He said that yesterday they were all helping each other. He said that he got the resident out of bed and got her dressed but he did not remember to put on her TED stockings. He said "I should have looked at my cheat sheet."

Based on administrative record review and interview, it was determined the administrator failed to oversee the facility resources to effectively and efficiently attain or maintain the highest practicable physical, mental and psychosocial wellbeing for 1 of 16 sampled residents (Resident # 34). This was evident by failure to oversee that appropriate nursing care, including honoring a resident's desire to be fully resuscitated, physician notification of changes in condition, and provision of emergency nursing care including cardiopulmonary resuscitation was provided to Resident # 34. Failure to ensure the Resident Rights, Resident Assessment and Quality of Care concerns were identified and appropriate care and services were provided to the resident led to the findings of ongoing immediate jeopardy at F155: Advanced Directives; F157: Inform of significant change; F281: Services provided meet professional standards, and F309: Necessary care of highest practicable well being, with scope and severity level of a J. The administrator's failure to oversee the facility's use of resources resulted in immediate jeopardy for Resident #34 who desired CPR and did not receive this treatment. Resident #34 died on [DATE]. This deficient practice also placed one additional resident at risk (Resident #28) who also desired CPR. Please refer to evidence in citation F155, F157, F281 and F309. The findings include: Review of the Nursing Home Administrator Job Description dated [DATE] revealed, "Basic Responsibilities and Relationships included: To be responsible for working with the President in developing program objectives and specific goals for the retirement center. To plan and implement a Quality Assurance Program in compliance with regulations. To have knowledge of all regulations governing the facility and to keep staff and programs in compliance with those regulations." Clinical record review conducted on [DATE] revealed Resident # 34 was admitted to the facility on [DATE], status [REDACTED]. The demographic sheet documents code status as, "Resuscitate: Yes full code." The Minimum Data Set (MDS), admission assessment with a reference date of [DATE] documents the resident was assessed as moderately impaired for daily decision making and return to community referral was triggered. There was no prognosis of a terminal illness from the MDS. The Care plan titled, "Advance Directives" dated ,[DATE] documents, the resident has a living will and CPR status and interventions included, Update physician and family with changes in condition. Nursing Notes dated [DATE] at 7:15 AM documents, the certified nursing aide asked the nurse to check the resident. The nurse went into the room to assess the resident. The nurses notes documented, "Immediate call placed to husband/power of attorney if he wanted CPR and hospitalization . Hospice consult pending, husband states to keep her here and no CPR. In to check resident with night nurse. No respirations, no blood pressure, color ashen with no pulses. Husband called, came in to see body. Funeral home, sister, and Advanced Registered Nurse Practitioner (ARNP) notified. 9:30 AM body released..." The clinical record lacked documentation of nursing care provided to the resident when the resident was found unresponsive by Staff A and Staff B. There was a lack of documentation of staff providing or attempting cardiopulmonary resuscitation (CPR) or that the physician was notified of the change in condition. Interview with the Director of Nursing (DON) conducted on [DATE] at 1:54 PM revealed, the DON reviewed the clinical record and confirmed the code status for Resident #34 on [DATE] was a full code. The resident did not have a signed, Do Not Resuscitate (DNR) order. The DON recalled talking to the resident's spouse and explained the spouse was "funny" about the DNR (Do Not Resuscitate) status. He spoke to family members and they were going to make a decision regarding the code status. The spouse was grieving and hopeful that the resident would get better. The DON reported, "I wanted to give the resident every opportunity, because she had gastrointestinal problems and was refusing to eat." Family members were not ready to sign a DNR. The DON explained, the facility protocol is to perform CPR if a resident does not have a signed DNR order. The DON reported, "Most likely, the incident occurred because the nurse knew the family had discussions regarding not wanting CPR, and If the nurse worked on the resident, she would have fractured the resident's ribs and the family did not want that at all." Interview with Staff A, a Licensed Practical Nurse (LPN) conducted on [DATE] at 2:46 PM revealed, she had just arrived for her shift; the nursing aide came to the desk and stated, the resident did not look good and asked the nurse to check on her. Staff A went in the room and found the resident non-responsive with a thready pulse. The night nurse (Staff B), stayed with the resident while she went to check the chart and verified code status, there was no DNR on file. Staff A proceeded to call the spouse to ask him what he wanted her to do. She reported, Hospice had been consulted but had not evaluated the resident. The LPN stated, "I asked the spouse what he wants us to do for the resident, I asked if he wanted the resident sent to the hospital and if he wanted CPR. The spouse did not want the resident transferred to the hospital or for us to start CPR. The conversation between Staff A and the spouse lasted approximately five to ten minutes. She then returned to the resident's room and the resident had no pulse." The LPN explained, if there is no advance directive and DNR orders present in the resident's chart, CPR should be initiated. Phone Interview with Staff B, an LPN, conducted on [DATE] at 3:31 PM revealed the resident was found with a thready pulse and not responding. The day nurse called the husband, and he stated not to do CPR, when the day nurse returned to the room the patient had no pulse. The LPN explained in most cases we start CPR and call EMS (Emergency Medical Services/an ambulance), if we find the resident is unresponsive; we were waiting on the hospice consult and the husband was contacted first. A phone interview with the Physician, who is also the Medical Director, conducted on [DATE] at 4:58 PM revealed, "I did not request the hospice consult, the family requested and the nurse practitioner signed the order." Furthermore, the Physician stated, " I was not aware of a terminal diagnosis. The resident had significant cardiac history and he was not aware of her clinical condition leading to her death." A phone interview with the Advanced Registered Nurse Practitioner (ARNP) conducted on [DATE] at 5:17 PM revealed, " I saw the resident and she had not been eating or drinking, most likely multiple functional decline and the family was considering hospice, so I signed the order for the hospice consult. I do not remember if the resident had a terminal condition; she had Dementia and was of advanced age. The hospice consult was based on family request." Further review of the clinical record indicated that there was no documentation that the resident had a terminal diagnosis, or documentation there is no medical probability of the resident's recovery from her present medical condition. The record provides no evidence cardiopulmonary resuscitation was provided to the resident when found unresponsive with a thready pulse on [DATE]. Review of the facility policy titled, "Care of Residents Who Become Acutely or Critically Ill" last revised [DATE], documents, "If a resident becomes acutely or critically ill the attending physician should be notified immediately by the nurse. The nurse will follow instructions given by the physician. If the physician orders for the resident to go to the hospital, the nurse shall call 911 for the transport. The nurse should complete the proper transfer form to go to the hospital with the resident." This policy was not followed by facility staff. Review of the facility policy titled, "Cardiopulmonary Resuscitation" (CPR) last revised [DATE], documents, "As a general rule in the nursing facility CPR will be performed unless the resident has a signed physician "Do Not Resuscitate" order in his/her chart. This policy was not followed by facility staff. Interview with The Administrator conducted on [DATE] at 5:35 PM revealed, the facility discusses all events during the morning meeting. In regards to Resident # 34, the facility honored the resident's rights, the nurse contacted the spouse who was the power of attorney and health care surrogate and he made the decision for Resident #34 not to receive cardiopulmonary resuscitation (CPR) or to transfer the resident to the acute care hospital. The Administrator stated, the facility had consulted hospice and the spouse made the final decision. Interview with The Administrator on [DATE] at approximately 8 AM revealed, after further review of the incident, the facility believes they acted appropriately. Again the staff honored the health care surrogate's wishes as the resident was no longer able to make decisions. The facility had not identified concerns related to the nursing staff contacting the spouse instead of the physician when a change in condition occurred for treatment or care orders, withholding CPR for a resident who did not have signed "Do Not Resuscitate" orders, and overall nursing care provided to Resident #34 at the time of the incident/event.