Every finding on record at Jackson Memorial Perdue Medical Center

F689Based on observations, record review and interviews the facility failed to provide an environment as free of accident hazards as possible for one (Resident # 45) out of two sampled residents who smoke as evidenced by observation of cigarettes and a lighter on the wheelchair in the room of Resident #45. There were 14 residents listed as smokers residing in the facility at the time of survey. The findings include:Observation on 04/27/2026 at 8:15 AM revealed Resident # 45 in bed with no apparent distress; there was a wheelchair positioned before Resident # 45's bed. Two boxes of cigarettes were on wheelchair's cushion and a lighter below the wheelchair's cushion.Record review of Resident # 45's clinical records the resident was readmitted to the facility on [DATE] with diagnosis that included but not limited to: Muscle weakness.Record review of Resident #45's Quarterly Minimum Data Set (MDS) reference dated 04/01/2026 revealed Resident # 45 had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment, was independent for Activities of Daily Living and use a wheelchair and no behavior concerns since admission/entry or reentry or the prior assessment.Record review of Resident # 45's care plans revealed the resident was care planned for smoking cigarette less than hourly, deemed safe smoker if supervised by staff starting on 06/30/2025 and last reviewed/revised on 04/05/2026 with approaches that included: Offer, educate and encourage resident to use smoking apron for safety.Record review of the facility's policy titled, Smoking, Vaping, E-Cigarettes & Contraband Revised: 01/15/2026 indicated: Purpose: To protect the health of all persons within the facility because smoking and contraband are a health risk, fire/safety hazard, and is potentially a danger to self and others. To abide by federal resident rights regulations, which allow residents of nursing homes to smoke in designated areas. This operating procedure also provides standards and guidelines for the search and removal of contraband at JHS. Policy: Smoking is prohibited anywhere on JHS property, except for designated areas in the nursing homes.It is prohibited for all employees, visitors, families, volunteers, contracted personnel, vendors or anyone who is not a resident. Smoking is prohibited in any official JHS vehicle. The possession, consumption or sale of alcohol, or contraband on JHS property is prohibited. It is the policy of JHS that items which pose a significant potential danger to residents, staff or visitors be seized secured by the appropriate department within the facility or law enforcement.A. Residents shall not keep matches nor lighters with them, nor in their rooms. Residents are assessed periodically (annually) to determine level of independence with smoking. Designated smoking areas are located on the North wing patio. Smoking patios are open between and is generally allowed between 8:00 AM - 9:00 PM daily. Smoking after 5:30 PM is highly discouraged, to promote smoking cessation and ensure safety of both residents and staff. The use of E-cigarettes are not permitted at JMPMC. On 04/27/2026 at 8:16 AM Resident # 45 stated: I smoke one cigarette a day around 5:00 PM in the north wing patio. I keep my cigarettes and lighter under the cushion of my wheelchair. I get out the bed on my own and go to smoke. During an interview on 04/27/2026 at 8:23 AM Staff H, Certified Nursing Assistant (CNA) revealed Resident # 45 is independent and goes to smoke in the north wing patio. Surveyor asked if Resident # 45 is allowed to keep smoking supplies and Staff H, CNA replied, He doesn't let you keep anything for him. Interview on 04/27/2026 at 8:27 AM Staff E, Registered Nurse (RN) revealed Resident # 45 goes independently to the north wing patio to smoke and is alert and oriented. The cigarettes and lighters are stored in a safe, and residents cannot keep the lighter.On 04/27/2026 at 8:29 AM Staff C, RN, East Wing Unit Manager stated: Residents who are alert and oriented can keep cigarettes on their person but not lighter. Staff check on a daily basis to make sure there are no lighters because it is a fire hazard.During an interview on 04/27/2026 at 9:09 AM the Director of Nursing (DON) was made aware of the identified concern. The DON stated: All smoking takes place on the north wing patio. We always have someone to supervise on the patio. The person who is supervising gives aprons to those who use them, keep the lighters locked up, and keep the keys. The residents are allowed to keep cigarettes not lighters. We allow residents to keep cigarettes to maintain a level of independence. I would not want them to keep the lighters because it is a safety concern.On 04/27/2026 at 9:59 AM The Risk Manager stated, My goal is to reduce injury; only residents who are alert and oriented and who can smoke independently can keep their cigarettes. Otherwise, a staff member keeps the cigarettes and lighters. Residents should never keep their lighters on them and if the lighter is plain sight we remove it. I spoke to [Resident # 45], and he gave us the lighter.

Based on observations, record review and interviews, the facility failed to maintain an accurate accounting of controlled substances on one of three medication carts reviewed as evidenced by two inaccurate controlled substance records identified for the North Wing's Red Medication Cart. The facility had a total of six medication carts at the time of survey.The findings included:On 04/27/2026 at 11:00 AM, during a medication cart check and narcotic accounting review conducted with Staff F, Registered Nurse (RN) on the North Wing's Red Medication Cart the following narcotic accounting discrepancies.Review of Resident #97's narcotic accounting log for Tramadol Hydrochloride (HCL) 50 milligram (mg) tablet by mouth every 12 hours for non-acute pain documented 22 tablets remaining. However, the medication bingo card had 21 pills (photo). Review of Resident #109's narcotic accounting log for balance of 52 Oxycodone-Acetaminophen 5 per 325mg tablets via gastric tube every 12 hours for nonacute pain recorded 52. However, the medication bingo card had 51 pills (photo). On 04/27/2026 at 11:13 AM, Staff F, RN explained that the facility's policy regarding controlled medication accounting required recording the time in the computer and signing the log to indicate how many pills remained when a controlled medication was removed from the bingo card. Interview on 04/27/2026 at 11:15 AM Staff D, RN/North wing Unit Manager stated: I trained nursing staff to sign the narcotic book at the beginning of the shift and the end making sure the paper matches the bingo card. If a nurse pulls a controlled medication, they sign the book at the time the medication is pulled. On 04/27/2026 at 2:45 PM, the Director of Nursing revealed nurses must sign at the time a pill is removed to keep the reconciliation form accurate. Record review of the facility's policy and procedure titled Controlled Medications date: 11/19/2025 Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Procedures: 6. When a controlled medication is administered, the licensed nurse administering the mediation immediately enters all of the following information on the accountability record: Date and time of administration. Amount administered. Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on observations, interviews and record review the facility failed to ensure kitchen staff were wearing a beard restraint. This has the potential for hair to come in contact with food.The findings included:Record review of the Personal Appearance and Conduct Restraint Policy and Procedure (reviewed 06/11/2025) documented the following: Purpose: To establish standards for nutrition services employees that promote neat appearance that will ensure efficient, safe and sanitary operations in the preparation and service of the food consumed by all residents, staff and guests in the facility; Procedure: 1) Employees working in the Nutrition Services Department wear hairnets or coverings that cover all of the hair.Second observation of the kitchen on 04/29/2026 at 10:56 AM revealed Staff A, [NAME] with a beard and not wearing a beard guard. He was taking temperatures of food items on the lunch tray line.Interview with Staff A, [NAME] on 04/29/2026 at 11:08 AM. He confirmed that he was not wearing a beard guard and he was supposed to have one on.Observation of Staff B, Food Service Worker and the Certified Dietary Manager on 04/29/2026 at 11:13 AM revealed the workers with a beard and not wearing a beard guard.Interview with Staff B, Food Service Worker on 04/29/2026 at 11:14 AM. He confirmed that he was not wearing a beard guard and he was supposed to have one on.Interview with the Certified Dietary Manager on 04/29/2026 at 11:15 AM. He confirmed that he was not wearing a beard guard and should have one on.Interview with the Director of Nutrition Services on 04/29/2026 at 11:16 AM. She stated, I guess going forward, they should be wearing a beard guard, if they have one.Review of the Food Code of the [ ] a federal program, the current standards of practice is that the food service staff must wear hair restraints such as a hairnet, hat, and/or beard restraint to prevent hair from contacting food.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area as evidenced by repeated deficient practices for F0689-Free of Accident and Hazards/Supervision/Devices and F0867; QAPI/QAA improvement activities. There were 147 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed the facility was cited for F689 and F867 during the recertification and Re-licensure survey with an exit date of October 24, 2024. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 02/17/2026, 03/17/2026 and 04/21/2026 revealed the facility had a QAA Committee meet monthly and attendees included: Administrator, Medical Director, Director of Nursing (DON), other department heads and staff members. During an interview on 04/30/26 at 2:45 PM with the Administrator stated, On 04/30/2026 at 2:26 PM The Administrator stated, The members include Medical Director, Nursing home administrator, Pharmacist, Compliance director, Infection Preventionist, and some nurses. We meet every month and as needed to identify trends, provide quality of care quality life and to improve the system we have in place.Record review of the facility's Quality Assurance Performance Improvement Plan Policy and Procedure reviewed on 02/16/2026 revealed Policy:The facility must develop, implement, and maintain a effective, comprehensive, data-driven Quality Assurance and Performance Improvement Committee, Plan and Program (QAPI) program that focuses on indicators of the outcomes of care and quality of life.This committee shall meet on a monthly basis and shall have members consisting of the facility Risk Manager, Administrator, Director of Patient Care Services, Medical Director, Pharmacy Consultant, Infection Control Preventionist, Unit Managers, Maintenance, Environmental Supervisor, Social Work, Dietary personnel, Activities Supervisor and APRN.The Administrator is responsible for the Quality Assurance Performance Improvement Committee, Plan and Program (QAPI).Purpose:To implement a preemptive approach to continually improve the manner in which we care for our residents, staff and visitors, so that we may realize our vision of providing and delivering the highest level of care and quality of life.To address all systems of care and management practices, including clinical care, quality of life, and residents' choices. To utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents in our SNF. To reflect the complexities, unique care, and services that our facility provides.To assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by AHCA, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies.

Based on observations, interviews and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F656 Develop/Implement Comprehensive Care Plans related to the facility failed to implement interventions of place bilateral floor mats by the bed for Resident # 78 and Resident #151 and F689 Free of Accidents Hazards/ Supervision/Devices related to the facility failure to ensure the safety measures were implemented for Resident #78, and Resident #151. there were 154 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated July 13, 2023. F656 Develop/Implement Comprehensive Care Plans was cited related to failure to implement care plan interventions related to bleeding precautions for two residents (Resident # 89, and Resident # 93) and the facility failed to develop and implement a comprehensive care plan related to a nephrostomy tube for one resident (Resident # 89) F689 Free of Accidents Hazards/Supervision/Devices the facility failed to provide a safe environment related to bed side rail pads to prevent accidents for one Resident (Resident# 89). Interview with Administrator on 10/24/24 at 01:49 PM. She stated the Quality Assurance and Performance Improvement (QAPI) committee had the monthly meeting on the third Thursday each month. The committee members include Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Pharmacy Consultant, Dietary Manager, Registered Dietitian, Medical Records, MDS Coordinator, Social Services Director, Maintenance Director, Housekeeping Director, Departments Heads, one nurse and a Certified Nursing Assistant. Reviewing the last time meeting and had a quick discussion. Quality Assurance is monitoring continuously, communicate with the head of the department to always ensure tracking of the issues; always looking at new ideas to enhance and expedite the work being done. For concerns related to Develop/Implement Comprehensive Care Plans and Free of Accidents Hazards/Supervision/Devices, all staff will have in-services education conducted by the Director of Nursing/ Assistant Director of Nursing regarding care plans implemented to residents to ensure the safety of residents. A facility wide audit will be done to ensure all residents with interventions of bilateral floor mats were placed by the bed to prevent falls. Review of the Policy and procedures revealed the facility organization has a comprehensive, date-drive Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Procedure: Program Design and Scope: The entire facility is involved in the QAPI program including all Department Heads and addresses all systems of care and management practices, including clinical care, quality of life, and resident's choices. The overall aim is to improve safety and quality of care, while emphasizing individuality in the daily life of our residents. All best practices are adopted in clinical interventions. Purpose: Our facility purpose is to improve the overall satisfaction of our Residents relating to care, services and disease management, specialized rehabilitative programs and transitions of care, discharge planning and more. We do so by involving al of our TEAM members in ensuring our success. We also strive to implement a preemptive approach to continually improving the manner in which we care for our residents, staff and visitors so we may make our visitors the best choice for providing high quality care.

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one (Resident #158) out of 31 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section for Discharge Status for Resident #158. The facility census was 154 residents at the time of the survey. The findings included: Record review of Resident #158's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] Section for Identification Information in subsection for Discharge Status documented that the resident was discharged to an Acute Hospital. Review of the Physician's Orders Sheet for July 2024 revealed Resident #158 had orders that included but not limited to: Discharge to ALF (Assisted Living Facility), once until 07/24/2024. Review of nurses' progress notes for Resident #158 documented on 07/24/2024 timestamped 12:40: Resident d/c (discharged ) to ALF at 1240 via transport. Resident left via transport. Resident left with w/c, (wheelchair). 0900 all medications administered by assigned nurse prior to discharge. Medication education provided and all upcoming appointments reviewed with resident and verbalized understanding. All safety and comfort measures in place. Further review of the medical records for Resident #158 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Atrial Fibrillation. Resident #158 was discharged on [DATE]. Record review of Resident #158's Care Plan dated 04/29/2024 revealed: Resident's Short Term Discharge Plan: The plan for resident is to be discharged back to ALF. Interventions included: The goal for the resident is to have all needs met related to discharge planning and staff to assist and coordinate with the resident as needed for a safe discharge. On 10/24/2024 at 10:02 AM, during an interview with Registered Nurse, Minimum Data Set Coordinator (Staff E), the surveyor had Staff E check the nurses progress notes documented on 07/24/2024 that noted the resident was discharged to ALF and check the Discharge Minimum Data Set with reference dated 07/24/2024, Section A that documented that the resident was discharged to an acute hospital. Staff E acknowledged the discrepancy. Staff E stated, We get the information from Social Services, and it is also discussed in the morning meeting. Social Services also makes a note to where the resident is being discharged to. The coding of 04 was entered and should be 01. According to the note, resident was discharged to ALF. Review of the facility's policy and procedures titled Nursing Care: MDS - 3.0 Resident Assessment Instrument dated 01/10/2023 states: Purpose - The MDS is used to provide a holistic assessment of each resident to promote optimum quality of care and quality of life. It is also used to identify resident care problems that are addressed in an individualized resident centered care plan, as for Medicare reimbursement. It is imperative that all sections are accurately coded by each discipline.

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one (Resident #158) out of 31 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section for Discharge Status for Resident #158. The facility census was 154 residents at the time of the survey. The findings included: Review of the medical records for Resident #158 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Atrial Fibrillation. Resident #158 was discharged on [DATE]. Record review of Resident #158's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] Section for Identification Information in subsection for Discharge Status documented that the resident was discharged to an Acute Hospital. Review of the Physician's Orders Sheet for July 2024 revealed Resident #158 had orders that included but not limited to: Discharge to ALF (Assisted Living Facility), once until 07/24/2024. Review of nurses' progress notes for Resident #158 documented on 07/24/2024 timestamped 12:40: Resident d/c (discharged ) to ALF at 1240 via transport. Resident left via transport. Resident left with w/c, (wheelchair). 0900 all medications administered by assigned nurse prior to discharge. Medication education provided and all upcoming appointments reviewed with resident and verbalized understanding. All safety and comfort measures in place. Record review of Resident #158's Care Plan dated 04/29/2024 revealed: Resident's Short Term Discharge Plan: The plan for resident is to be discharged back to ALF. Interventions included: The goal for the resident is to have all needs met related to discharge planning and staff to assist and coordinate with the resident as needed for a safe discharge. On 10/24/2024 at 10:02 AM, during an interview with Registered Nurse, Minimum Data Set Coordinator (Staff E), the surveyor had Staff E check the nurses progress notes documented on 07/24/2024 that noted the resident was discharged to ALF and check the Discharge Minimum Data Set with reference dated 07/24/2024, Section A that documented that the resident was discharged to an acute hospital. Staff E acknowledged the discrepancy. Staff E stated, We get the information from Social Services, and it is also discussed in the morning meeting. Social Services also makes a note to where the resident is being discharged to. The coding of 04 was entered and should be 01. According to the note, resident was discharged to ALF. Review of the facility's policy and procedures titled Nursing Care: MDS - 3.0 Resident Assessment Instrument dated 01/10/2023 states: Purpose - The MDS is used to provide a holistic assessment of each resident to promote optimum quality of care and quality of life. It is also used to identify resident care problems that are addressed in an individualized resident centered care plan, as for Medicare reimbursement. It is imperative that all sections are accurately coded by each discipline.

Based on observation, interview and record review the facility failed to implement care plan interventions related to falls for two out of four residents reviewed (Resident #78 and Resident #151). As evidenced by, during several observations Resident #78 and #151 were in bed with only one fall mat on the floor of each resident's bedside. The findings Included: 1) Observation on 10/22/24 at 10:00 AM; Resident #78 was asleep in bed, one floor mat noted on floor next to the bed's right side. Observation on 10/23/24 at 08:02 AM; Resident #78 was asleep in bed, breakfast tray on overbed table, one floor mat noted on floor next to the bed's right side. Review of Resident #78's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Essential (primary) hypertension and Unspecified dementia with behavioral disturbance. Review of Resident #78's Physician Order Sheets for October 2024 revealed orders that included but not limited to: Low bed and Bilateral floor mats when resident in bed every shift, morning, evening and night. Record review of Resident #78 's Care Plans Reference Date 06/30/23 revealed: Resident #78 has a Potential for Falls related to: Decreased functional mobility Decreased Activities of Daily Life functions: Resident has poor safety awareness. Resident is at risk for falls. On 10/26/21 the resident was found on kneeling position. The resident stated that he was attempting to walk to the bathroom. No apparent injuries noted. Denied pain. On 11/07/21 the resident was found sitting on the floor in front of his wheelchair; No apparent injury noted related to this fall. Provider notified. 02/14/22 resident was observed sitting on floor mat next to his bed. No apparent injury noted related to this fall. Provider aware; no new orders. 03/28/23 fall with orders for transfer to local hospital for further evaluation/treatment and management to rule out fracture and/or deformity. 06/30/23 resident was found on the floor, no apparent injury noted related to this fall. Primary provider and guardian were notified. New order carried out. 7/9/23: Resident found sitting on the floor during shift change, bed was in lowest position. Assessment done no injuries noted, denied pain or discomfort, Certified Nursing Assistant (CNAs) ordered to make hourly rounds. Bed kept in lowest position; resident educated to use call light for assistance. 02/09/24 Resident was found sitting on the floor status post fall from wheelchair, denied pain/discomfort. Physician (MD) notified, no new order. 08/01/24: Resident was found lying on the floor on his right side. The resident stated he crawled from his bed to the front door. He is able to move all extremities. No changes noted in his level of consciousness. Education provided on safety and the use of call lights for assistance. Resident acknowledged teachings; however, resident has poor safety awareness and poor insight into his limitations. Goal included: Resident will be free from injurious falls through next review date. Resident will minimize fall incident through the next review date. Resident will maintain safety and will be free from related complications of fall through the next review date. Resident will be assessed with potential strategies and reevaluated based on needs to decrease potential harm secondary to fall through next review date. Interventions included: Keep bed at lowest level at night or when resident is in bed. 02/17/22 Maintain on Low bed and place bilateral floor mats while in bed for safety as resident presents high risk for falls as ordered. Maintain fall and safety precautions at all times. 10/26/21 Educate, review safety precautions and risks of fall, related injuries including physical limitations for safety. Educate to call for assistance at all times. Ensure that assistance is available at all times .Place mats on floor for safety. 02/14/22 Keep resident on close supervision for safety. Continue with more physical rounding on shift for safety and check for incontinence. Continue to re-educate physical limitations for safety and encourage/remind to call for assistance at all times for safety. 08/01/24: Remind and educate safety precautions, risks of falls and physical limitations. Encourage to use call light and ask staff for Review of Resident #78's Physician Order Sheets for October 2024 revealed orders that included but not limited to: Low bed and Bilateral floor mats when resident in bed every shift, morning, evening and night. Review of Resident # 78's Quarterly Minimum Data Set (MDS) dated [DATE] documented in the section for Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicates severe cognitive impairment. The Section for Behaviors indicated no behaviors exhibited. The Section for Functional Status documented the resident is dependent for care and the section for restraints documented no restraints or alarms used. 2) Observation on 10/21/24 at 09:34 AM; Resident #151 was asleep in bed, one floor mat noted on floor next to the bed's left side. On 10/22/24 at 09:50 AM; Resident #151 in asleep in bed, one floor mat in place on the left next to the bed. Review of Resident #151's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Traumatic Subdural hemorrhage with loss of consciousness status unknown, subsequent encounter. Other fracture of lower end of right tibia, subsequent encounter for closed fracture with routine healing. Review of Resident #151's Physician's Orders Sheet for October 2024 revealed orders that included but not limited to: Low bed and bilateral floor mats while resident in bed, patient at high risk for fall. Record review of Resident # 151's Care Plans Reference Dated 11/05/23 revealed: Resident has a Potential for Falls related to: Decreased functional mobility Decreased activities of daily life functions: Resident has poor safety awareness. Goals: Resident will be free from injurious falls through next review date. Resident will minimize fall incident through the next review date. Interventions include maintaining fall and safety precautions at all times. 09/15/24 Maintain on low bed with bilateral floor mats while resident in bed as ordered as resident presents high risks for falls. Review of Resident # 151's Admission Minimum Data Set (MDS) dated [DATE] documented in the section for Cognitive Patterns; a Brief Interview for Mental Status score of 7 out of 15 which indicates severe cognitive impairment. The section for Functional Status documented the resident is dependent for care. The section for medications documented the resident is taking Anticoagulant medications and the section for Restraints documented no restraints or alarms used. During an interview on 10/23/24 at 12:59 PM; Certified Nursing Assistant (CNA) (Staff F) South Wing revealed, during shift meetings staff are told what patients require fall mats. When we make rounds in the morning we check to make sure the residents have their mats while they are in bed, if a resident's floor mat is missing we first look under the bed because we remove the floor mats when providing care and place them under the bed, if the floor mats are not under the bed, we report it to the nurse, the nurse then calls housekeeping to get a replacement mat. Interview on 10/23/24 at 01:05 PM; Certified Nursing Assistant (CNA) (Staff G) South Wing stated: During my rounds I check to make sure my residents who are assigned floor mats have their floor mats and their bed are in the lowest position when they are in bed. If a resident's floor mats are missing, we first look under the bed because we remove the floor mats when providing care and place them under the bed. If the floor mats are not under the bed, we report it to the nurse, the nurse then calls housekeeping to get a replacement mat. Interview on 10/23/24 at 01:14 PM; Registered Nurse (RN) (Staff H) South Wings revealed: Residents are assessed for floor mats and orders are placed in the electronic system for each resident. During shift reports we discuss what resident has what type of orders. During my rounds I check to make sure the residents have their floor mats, if a resident's floor mat is missing, I notify my supervisor and ensure we get a replacement. Interview on 10/23/24 at 01:20 PM; South Wing Registered Nurse (RN) (Staff I) stated: During rounds I check on my residents and check to make sure their floor mats are in place, if the floor mats are missing, I would call the maintenance department and request they bring floor mats for the resident and notify my supervisor. Interview on 10/24/24 at 09:54 AM; the Director of Nursing/Risk Manager stated: All residents get reviewed upon admission and quarterly for falls, when they are at high risk for falls, they are given orders for floor mats, the nurses have access to the orders, the CNAs receive the information from their shift reports. During rounds all nursing staff should be checking the residents to make sure they have their floor mats when the residents are in bed. Review of the facility policy and procedure titled Interdisciplinary Care Planning revision date 10/09/24 indicated: Purpose: To assure that each resident is the recipient of an individualized, interdisciplinary, holistic and therapeutic approach to his/her problems/need.

Based on observation, interview, and record review the facility failed to ensure safety measures were implemented for two vulnerable residents (Resident #78 and Resident #151) out of four residents reviewed for falls. As evidenced by, during several observations Resident #78 and Resident #151 were observed in bed with only one floor mat (fall mats) on the floor of the residents' bedside. The findings Included: 1) Observation on 10/22/24 at 10:00 AM; Resident #78 was asleep in bed, one floor mat noted on floor next to the bed's right side. Observation on 10/23/24 at 08:02 AM; Resident #78 was asleep in bed, breakfast tray on overbed table, one floor mat noted on floor next to the bed's right side. Review of Resident #78's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Essential (primary) hypertension and Unspecified dementia with behavioral disturbance. Review of Resident #78's Physician Order Sheets for October 2024 revealed orders that included but not limited to: Low bed and Bilateral floor mats when resident in bed every shift, morning, evening and night. Review of Resident # 78's Quarterly Minimum Data Set (MDS) dated [DATE] documented in the section for Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicates severe cognitive impairment. The Section for Behaviors indicated no behaviors exhibited. The Section for Functional Status documented the resident is dependent for care and the section for restraints documented no restraints or alarms used. Record review of Resident #78 's Care Plans Reference Date 06/30/23 revealed: Resident #78 has a Potential for falls related to: Decreased functional mobility Decreased Activities of Daily Life functions: Resident has poor safety awareness. Resident is at risk for falls. On 10/26/21 the resident was found on kneeling position. The resident stated that he was attempting to walk to the bathroom. No apparent injuries noted. Denied pain. On 11/07/21 the resident was found sitting on the floor in front of his wheelchair; No apparent injury noted related to this fall. Provider notified. 02/14/22 resident was observed sitting on floor mat next to his bed. No apparent injury noted related to this fall. Provider aware; no new orders. 03/28/23 fall with orders for transfer to local hospital for further evaluation/treatment and management to rule out fracture and/or deformity. 06/30/23 resident was found on the floor, no apparent injury noted related to this fall. Primary provider and guardian were notified . 7/9/23: Resident found sitting on the floor during shift change . Assessment done no injuries noted .Certified Nursing Assistant (CNA) ordered to make hourly rounds. Bed kept in lowest position; resident educated to use call light for assistance. 02/09/24 Resident was found sitting on the floor status post fall from wheelchair, denied pain/discomfort. Physician (MD) notified, no new order. 08/01/24: Resident was found lying on the floor on his right side. The resident stated he crawled from his bed to the front door. He is able to move all extremities. No changes noted in his level of consciousness. Education provided on safety and the use of call lights for assistance. Resident acknowledged teachings; however, resident has poor safety awareness and poor insight into his limitations. Goal included: Resident will be free from injurious falls through next review date. Resident will minimize fall incident through the next review date. Resident will maintain safety and will be free from related complications of fall through the next review date. Resident will be assessed with potential strategies and reevaluated based on needs to decrease potential harm secondary to fall through next review date. Interventions included: Keep bed at lowest level at night or when resident is in bed. 02/17/22: Maintain on Low bed and place bilateral floor mats while in bed for safety as resident presents high risk for falls as ordered. Maintain fall and safety precautions at all times. 10/26/2: Educate, review safety precautions and risks of fall, related injuries including physical limitations for safety .Place mats on floor for safety. 2) Observation on 10/21/24 at 09:34 AM; Resident #151 was asleep in bed, one floor mat noted on floor next to the bed's left side. On 10/22/24 at 09:50 AM; Resident #151 was observed in bed asleep, one floor mat in place on floor at left side next to the bed. Review of Resident #151's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Traumatic Subdural hemorrhage with loss of consciousness status unknown, subsequent encounter. Other fracture of lower end of right tibia, subsequent encounter for closed fracture with routine healing. Review of Resident #151's Physician's Orders Sheet for October 2024 revealed orders that included but not limited to: Low bed and bilateral floor mats while resident in bed, patient at high risk for fall. Review of Resident # 151's Care Plans Reference Dated 11/05/23 indicated the resident has a potential for falls related to decreased functional mobility, decreased activities of daily life functions and poor safety awareness. Goals included: Resident will be free from injurious falls through next review date. Resident will minimize fall incident through the next review date. Interventions included: maintaining fall and safety precautions at all times. 09/15/24- maintain on low bed with bilateral floor mats while resident in bed as ordered as resident presents high risks for falls. Record review of Resident # 151's Admission Minimum Data Set (MDS) dated [DATE]/24 documented in the section for Cognitive Patterns; a Brief Interview for Mental Status score of 7 out of 15 which indicates severe cognitive impairment. The section for Functional Status documented the resident is dependent for care. The section for medications documented the resident is taking Anticoagulant medications and the section for Restraints documented no restraints or alarms used. During an interview on 10/23/24 at 12:59 PM; Certified Nursing Assistant (CNA) (Staff F) South Wing revealed, during shift meetings staff are told what patients require fall mats. When we make rounds in the morning we check to make sure the residents have their mats while they are in bed, if a resident's floor mat is missing we first look under the bed because we remove the floor mats when providing care and place them under the bed, if the floor mats are not under the bed, we report it to the nurse, the nurse then calls housekeeping to get a replacement mat. Interview on 10/23/24 at 01:05 PM; Certified Nursing Assistant (CNA) (Staff G) South Wing stated: During my rounds I check to make sure my residents who are assigned floor mats have their floor mats and their bed are in the lowest position when they are in bed. If a resident's floor mats are missing, we first look under the bed because we remove the floor mats when providing care and place them under the bed. If the floor mats are not under the bed, we report it to the nurse, the nurse then calls housekeeping to get a replacement mat. Interview on 10/23/24 at 01:14 PM; Registered Nurse (RN) (Staff H) South Wings revealed: Residents are assessed for floor mats and orders are placed in the electronic system for each resident. During shift reports we discuss what resident has what type of orders. During my rounds I check to make sure the residents have their floor mats, if a resident's floor mat is missing, I notify my supervisor and ensure we get a replacement. Interview on 10/23/24 at 01:20 PM; South Wing Registered Nurse (RN) (Staff I) stated: During rounds I check on my residents and check to make sure their floor mats are in place, if the floor mats are missing, I would call the maintenance department and request they bring floor mats for the resident and notify my supervisor. Interview on 10/24/24 at 09:54 AM; the Director of Nursing/Risk Manager stated: All residents get reviewed upon admission and quarterly for falls, when they are at high risk for falls, they are given orders for floor mats, the nurses have access to the orders, the CNAs receive the information from their shift reports. During rounds all nursing staff should be checking the residents to make sure they have their floor mats when the residents are in bed. Review of the facility's policy and procedure titled Fall/Accident Prevention/Reduction Program Dated 04/22/23 states: Fall Prevention/Reduction Program: Fall risk assessments are completed on admission, quarterly, annually, with significant changes, post fall and as needed. Residents with high-risk scores will have additional interventions, including but not limited to, floor mats and low beds, or other individualized devices.

Based on observations, interviews and record review the facility failed to follow pharmacy procedure of less than 5% resulting in a of 6.25% medication error rate out of 31 opportunities; as evidenced by an observations of an inappropriate administration of a chewable form of aspirin, an omission of a magnesium 100 mg (milligram) capsule, and administration of insulin without providing privacy while another resident was in the room. There were 154 residents residing in the facility at the time of survey. The findings included: On 10/22/24 at 9:46 AM a medication administration observation was completed with Staff A, Registered Nurse (RN) on Medication Cart number two, in The South Wing Nursing Unit for Resident#107. Staff A, RN verified physician's orders and placed pills into one medication cup which included a chewable form of Aspirin 81 mg tablet. Staff A, RN did not place a prescribed Magnesium 100 mg capsule into medication cup and when asked the reason, Staff A, RN stated, The Magnesium 100 mg capsule was not in the medication cart and the pharmacy is aware and has not delivered it yet. It was last given yesterday. Staff A, RN then placed the cup of pills and a cup of water on top of a Styrofoam plate, knocked on Resident 107's door and asked for permission to enter. Once inside, Staff A, RN introduced self, verified resident by name and provided privacy. Staff A, RN named the medications in the cup to Resident#107, however did not state that there was a chewable form of the Aspirin nor any instruction to chew the pill separately or that the Magnesium capsule was not included. Staff A, RN attempted to administer all medications together and was stopped by surveyor before administration and asked to return to medication cart. The surveyor asked Staff A, RN if it is ok to administer the chewable form of Aspirin with the other medications without instructing the resident to chew? Staff A, RN replied, [Resident#107] usually takes all the medications together, but I can separate it. I can ask the resident if chewing or taking whole is preferred. I will get my supervisor. Staff C, RN Manager for South Wing approached the medication cart and instructed Staff A, RN that Resident#107 needs to be asked in Creole language what is the preference when taking the chewable medication and indicated that a Creole speaking staff member would assist. The surveyor asked Staff A, RN, what the facility's protocol for administering chewable medications to residents. Staff A, RN stated: I don't know the exact protocol and you can find out with the manager. I normally administer all the medications together because the resident does not like to chew the chewable Aspirin; if the resident refuses the medication I will call the physician. Staff C, RN Manager approached cart accompanied by Staff B, a Certified Nursing assistant (CNA). Staff B, CNA, (speaking Creole) asked Resident#107 if she wanted to chew the aspirin, Resident#107 agreed. Staff A, RN then administered chewable form of Aspirin to Resident #107, and Resident#107 chewed the pill. Staff A then administered the remaining medications. Staff C, RN Manager, stated When administering a chewable form of a tablet the nurse is to instruct the resident to chew before administering the medication and then it's the resident 's preference if they want to take it whole. Record review of a demographic sheet for Resident#107 revealed an admitted [DATE] with diagnosis that included: Encounter for prophylactic measures, and Nutritional deficiency. Further review of Resident#107's physician orders revealed an order dated 7/5/23 for Chewable Aspirin 81 mg tablet, chewable directions one tablet by mouth once a day for encounter for prophylactic measures and an order dated 10/11/24 for magnesium glycinate 100 mg capsule once a day at 9:00 AM for supplement. On 10/22/24 at 11:25 AM A blood glucose check and insulin administration observation was done with Staff D, RN on medication cart number one in The South wing nursing unit for Resident#135. Staff D, RN performed a blood glucose check and administered prescribed insulin for Resident #135 and did not provide privacy, there was another resident in the room at the time of the observation. The surveyor asked Staff D, RN How is privacy provided for the residents during medication administration? Staff D, RN replied, I normally close the door or pull the curtain while administering medications or testing blood glucose. I did not pull the curtain around resident or close the door because I wanted to make sure you (the surveyor) can see the procedure. Record review of a demographic sheet for Resident#135 revealed an admitted [DATE] with diagnosis that included: Type 2 diabetes mellitus without complication. On 10/24/24 at 10:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated, If a medication is ordered as chewable it should be chewed depending on resident's preference. The nurse is to instruct the resident to chew the pill before administration. The medication nurse is responsible for reordering medications when the count is low and ensuring the medication is available to be administered. Record review of Policy entitled, Nursing medication subject medication Administration and documentation revised: 4/22/24 revealed Policy: All Medications shall be ordered by an authorized provider and administered in compliance with community standard nursing policy, while accommodating residents'' preferences/requests. Procedures: F. Availability of medication: 1. Medications will be re-ordered at least five days prior to depletion of current stock.

Based on observations, interviews and record review facility failed to ensure medication error rate was below 5% as evidenced by a medication error rate of 6.25% out of 31 opportunities which included an omission and an incorrect administration of a medication. There were 154 residents residing in the facility at the time of survey. The findings included: On 10/22/24 at 9:46 AM a medication administration observation was completed with Staff A, Registered Nurse (RN) on Medication Cart number two, in The South Wing Nursing Unit for Resident#107. Staff A, RN verified physicians and placed pills into one medication cup which included a chewable form of Aspirin 81 mg tablet. Staff A, RN did not place a prescribed Magnesium 100 mg(milligram) capsule into medication cup and when asked the reason, Staff A, RN stated, The Magnesium 100 mg capsule was not in the medication cart and the pharmacy is aware and has not delivered it yet. It was last given yesterday. Staff A, RN then placed the cup of pills and a cup of water on top of a Styrofoam plate, knocked on Resident 107's door and asked for permission to enter. Once inside, Staff A, RN introduced self, verified resident by name and provided privacy. Staff A, RN named the medications in the cup to Resident#107, however did not state that there was a chewable form of the Aspirin nor any instruction to chew the pill separately or that the Magnesium capsule was not included. Staff A, RN attempted to administer all medications together and was stopped by surveyor before administration and asked to return to medication cart. Staff A, RN was asked by and surveyor Is it ok to administer the chewable form of Aspirin with the other medications without instructing the resident to chew? Staff A, RN replied, Resident#107 usually takes all the medications together, but I can separate it. I can ask the resident if chewing or taking whole is preferred. I will get my supervisor. Staff C, RN Manager for South wing approached cart and instructed Staff A, RN that Resident#107 needs to be asked in the Creole language what is the preference when taking the chewable medication and indicated that a Creole speaking staff member would assist. Surveyor asked Staff A, RN What is the protocol for administering chewable medications to residents? Staff A, RN stated, I don't know the exact protocol and you can find out with the manager. I normally administer all the medications together because the resident does not like to chew the chewable Aspirin. Stated if the resident refuses the medication I will call the physician. Staff C, RN Manager approached the medication cart accompanied by Staff B, a Certified Nursing assistant (CNA). Staff B, CNA, (speaking Creole) asked Resident#107 if she wanted to chew the aspirin and Resident#107 agreed. Staff A, RN then administered the chewable Aspirin and Resident#107 chewed the pill. Staff A and RN then administered the remaining medications. Staff C, RN Manager, stated When administering a chewable form of a tablet the nurse is to instruct the resident to chew before administering the medication and then its resident preference if they want to take it whole. Record review of a demographic sheet for Resident#107 revealed an admitted [DATE] with diagnosis that included: Encounter for prophylactic measures, and Nutritional deficiency. Record review of physician's order sheet for Resident#107 revealed an order dated 7/5/23 for Chewable Aspirin 81 mg tablet, chewable directions one tablet by mouth once a day for encounter for prophylactic measures, and an order dated 10/11/24 for magnesium glycinate 100 mg capsule once a day at 9:00 AM for supplement. On 10/24/24 at 10:15 AM An interview was conducted with Director of Nursing (DON) related to the identified concerns. The DON stated, If a medication is ordered as chewable it should be chewed depending on residents' preference. The nurse is to instruct the resident to chew the pill before administration. The medication nurse is responsible for reordering medications when the count is low and ensuring the medication is available to be administered. Record review of Policy entitled, Nursing medication subject medication Administration and documentation revised: 4/22/24 revealed Policy: All Medications shall be ordered by an authorized provider and administered in compliance with community standard nursing policy, while accommodating residents'' preferences/requests. Procedures: F. Availability of medication: 1. Medications will be re-ordered at least five days prior to depletion of current stock.

Based on observation, interview and record review the facility failed to ensure the safety and prevent bodily injury for one Resident (#1) out of 3 sampled residents and is determined to be at a level of harm, as evidenced by: Resident #1 sustaining first and second degree burns from hot coffee being spilled on the chest and abdominal area of his body. There were 153 residents residing at the facility at the time of the survey. The findings included: Observation on 09/09/2024; starting at 8:07 AM with the Director of Hospital Operations, Dietary Manager and Director of Nutrition of the Pantry rooms beginning with the South Station Pantry, East Station Pantry, and lastly the North Station Pantry. The coffee and hot water temperatures in the three pantries were checked using a digital thermometer. The results were: South Pantry-1 Coffee Pot, 1 Hot Water Pot Hot water-146.6 Fahrenheit (F) Hot coffee -162.6 F East Pantry-1 Coffee Pot, 1 Hot Water Pot Hot Water-123.8 F Hot Coffee-149 F North Station- 2 Coffee Pots, 1 Hot water Pot Hot Water-143.6 F Hot Coffee #1-156.2 F Hot Coffee #2 140 F Observation on 9/9/24 at 11:26 AM of the East Station pantry, a digital thermometer was located in the drawer enclosed in a plastic zip bag. Observation on 9/9/24 at 11:47 AM of the South station dining room, staff were serving lunch trays, no hot liquids served to residents from the pantry. Licensed Practical Nurse, Unit Supervisor (Staff H) observed with digital thermometer in her pocket. Observation on 9/9/24 at 11:39 AM with the Director of Nursing (DON) of the North Station Pantry, no thermometer was found in the pantry. Review of the facility policy and procedures titled Serving Hot Liquids reviewed 10/10/23 states: The dietary department will strive to serve hot liquids at temperatures that are safe for residents to handle and palatable for their dining enjoyment. Procedure: item # 6. For dining in the remote dining areas, the kitchen provides all hot beverages and soups for the dining area. Temperature of hot liquids will not exceed 155 degrees at time of delivery to the resident. Review of the facility's policy and procedures titled Safety and Supervision of Residents dated 04/05/2023; documented:: Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance are facility-wide priorities. Procedures: item #8. Implementing interventions to reduce accident risks and hazards are based on resident assessment and observation and shall include the following. a. Communicating specific interventions to all relevant staff b. Assigning responsibility for carrying out interventions c. Documenting Interventions. 9. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed and d. Evaluating the effectiveness of new or revised interventions. Review of the nurse's progress notes dated 08/25/2024 timestamped 11:02 documented-Resident spilled a cup of hot coffee on himself while in the bed. Chest and abdomen red, warm and painful to touch. No open areas or blistering at this time. Advanced Registered Nurse Practitioner (ARNP) notified. Order received for Silvadene cream topically twice a day and wound care evaluation for Monday. Record review of the weekly skin assessment dated [DATE] at 4:30 PM documented chest and left upper abdomen noted with intact blister and redness around status post coffee spilled, treatment in place as ordered, slight tenderness. Record review of the Agency for Health Care Administration (AHCA) Immediate report documented- Date/Time of Incident: 08/25/24; Type of Incident: Neglect/bodily injury; Description of Incident: The resident spilled a cup of hot coffee on himself while in the bed. Chest and abdomen red, warm, and painful to touch. No open areas or blistering at this time. ARNP notified. New ordered Silvadene cream topically twice a day (BID) and wound care evaluation for Monday. On Monday's evaluation by wound care, two blisters were noted on the resident's right abdomen. Record review of the Agency for Health Care Administration (AHCA) Five-Day report documented-Facility Response/Investigation- Head-to-toe assessment was completed on the resident. The provider was made aware, and treatment was provided to the resident as ordered by the provider. Following the event law enforcement was notified on 08/26/2024 at 11:55 AM and arrived at 12:32 PM. The Police Officer arrived at the facility and interviewed Resident #1. Resident #1 reported to the officer that it was an accident. He explained that as he was moving the side table and the coffee tipped over and fell on to his upper abdomen, the lid popped off and spilled the contents of the cup on him causing the burn. No charges or allegations were made by Resident #1 to law enforcement or the facility. [local community-based agency notified] was notified by the Risk Manager at noon and the call was answered at 12:56 PM the report was given and [the local community-based agency] did not take the case. Initial attempt to report online but the system was not working. Resident #1 assigned nurse stated just before lunch, on Sunday 8/25/2024, the resident requested a cup of coffee. I got him a cup of coffee from the floor coffee dispenser and covered it with a lid to bring to the resident's room. I placed the cup of coffee with a lid that was secured and tightened on the table next to a cup of water on the resident's table. The table was otherwise clear, no garbage or clutter on the table or surrounding area. I left the resident's room. When I returned to the nurses' station the resident had his call light on. I returned to the room and the resident had spilled the coffee on himself. The gown was saturated with coffee. I removed his gown and cleaned him up. The chest and upper abdomen were red, and very painful when touched. There were no open areas or blisters at this time. I reported to the supervisor immediately and then called the provider on call. Provider ordered Silvadene cream to be applied and a wound care consult. When the resident was interviewed, he stated that as he was moving the overbed table, the coffee tipped over and fell on to his upper abdomen, the lid popped off and spilled the contents on him causing the burn. The resident denied any abuse by the staff. The resident had a wound care assessment and is receiving treatment. The allegation of abuse/Neglect was unsubstantiated the resident denied any abuse and the staff acted within proper practice and procedure. The resident is alert and oriented X 4 with full function of his upper extremities and capable of feeding himself. The event was not within the facility control and procedures post-event were appropriate. According to the Florida Agency for Health Care Administration (AHCA), hot beverages like coffee, tea, and hot chocolate are typically served at a temperature of 160-180 F (71-82 C) after the facility investigation, all of our coffee Dispenser temperatures were tested and was serving coffee at 151 F, below the typical serving temperature on the AHCA website. Interview on 9/10/24 at 9:16 AM Licensed Practical Nurse (Staff I) stated: On 8/25/24 I was the assigned nurse for [Resident #1] the resident requested a cup of coffee, I gave the coffee to the resident with a lid on the cup, I sat the coffee on the resident's overbed table and left the room, when I was walking to the nurses' station the call light for the resident's room came on, I went back to the resident's room, the resident told me he had spilt his coffee, I started cleaning the resident and took his gown off, I noticed the skin on his left abdomen was red and sensitive to touch. I notified the supervisor and called the ARNP that was on call, I received an order to apply Silvadene twice a day and a wound care consult. I checked on the resident afterwards several times during my shift, the resident was doing well and had no complaints of pain. Interview on 9/10/24 at 9:59 AM Registered Nurse, Wound Care (Staff K) stated: I completed a skin check on 8/26/24 on the resident. I observed redness on the abdomen with an intact blister, I did not do measurements because it was not a pressure ulcer, I assessed the resident for pain to touch, the resident said he was ok. The resident had an order for Silvadene starting on 8/25/25-apply a thin layer of Silvadene to chest and abdomen twice a day, leave open to air. The resident went to the hospital for a wound evaluation on the thigh unrelated to the redness and blister, at the time the treatment was ongoing for the redness and blister, the area still had some redness, and the blister was still intact. Because of the blister the burn would be classified as a second-degree burn, initially on 8/25/24 the area was just red, the redness would be classified as a first-degree burn. Interview on 9/10/24 at 10:32 AM the Director of Nursing (DON) stated she is aware of the incident that happened to the resident. On 8/28/24 the in-service the Certified Nursing Assistants (CNAs) received was a part of the AHCA Five-day investigation and was about safety and hot liquids-for example, if staff. give a cup of coffee to a resident they should put a lid on it, feel the hotness of the coffee, determine if it is safe to serve to the residents. Future trainings will include starting next week-testing of the coffee in the kitchen and recording the temperatures, thermometers on the floor for staff use to check the temperatures of the coffee, making sure staff have and know the correct temperature range for hot liquids, training the trainer on the guidelines of food safety and temperatures, to present to the staff at the trainings, providing guidance to direct care staff on the floor and the other components of the improvement plan. Currently based on the information provided by the nutrition staff, the temperature range for hot liquids is 155-165 F. I am aware our facility policy presented to you (the surveyor) states temperature of hot liquids will not exceed 155 degrees at time of delivery to the residents. The burns the resident sustained on his chest and abdomen were initially redness and the next day blisters appeared, because of the blisters the burns were classified as second-degree burn. Review of the medical records for Resident #1 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Contusion of right thigh, Unspecified cirrhosis of liver, Pressure ulcer of sacral region stage 2, Unspecified open wound right thigh. Resident #1 was discharged on [DATE] to the hospital. Review of the Physician's Orders Sheet for August-September 2024 revealed Resident #1 had orders that included but not limited to: 8/25/24- silver sulfadiazine cream; 1 %; amount: thin layer; topical, Special Instructions: Apply a thin layer to chest and abdomen Twice a Day. Record review of Resident # 1's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status Score unable to be determined. Section GG for Functional Abilities and Goals documented set or clean up assistance for eating. Section M for Skin Conditions documented stage 2 pressure ulcer, present on admission. Section N for medications documented resident is taking antibiotics, anticoagulants and Opioid. Record review of Resident #1 's Care Plans Reference Date 08/23/2024 revealed: Focus: Resident has a Potential for alteration in skin integrity and skin breakdown related to: 08-23-24 Resident currently has pressure ulcer on admission. Resident is at risk for sign and symptoms of wound infection. On 08-25-24 Resident spilled a cup of hot coffee on himself while in the bed. Noted redness on the chest and abdomen area, warm and painful to touch. No open areas or blistering at this time. ARNP notified. Order received for Silvadene cream topically twice a day. Goal: Resident will be free from further skin breakdown thru next review date. Pressure ulcer will be free from sign and symptom of infection through next review date. Interventions: Nursing assistant to check skin during routine care and report to the nurse for any changes. Heel checks/Body/skin audit weekly. Monitor and Document in matrix changes in skin integrity every week. Wound consultation if needed. Care Plans Reference Date 8/28/24 revealed: Resident's Chest and left upper abdomen noted with an intact blister and redness around, coffee spilled incident, treatment in place as ordered with slight tenderness as noted. Goal: Resident blister formation on the chest and left upper abdomen will remain intact and will not develop signs of infection through next review date. Interventions: Apply treatment to chest and left upper abdomen blister as ordered. Observe site for signs of infection during dressing changes, notify provider at once if abnormalities are noted. Ensure safety at all times, supervise when handling beverages at all times. Review of the Facility's Grievance Log from June 2024-August 2024 revealed Resident #1 was not listed on the grievance log. Review of the Abuse/ Neglect Log from June 2024-August 2024 revealed Resident #1 was listed on abuse log on August 2024. Resolution: Unsubstantiated. Review of the In-service on 08/28/24 revealed all Certified Nursing Assistants received training on safe food/liquid temperatures. Education included-always check food/drink temperature before offering to residents, communicate to residents to be careful as the food may be hot before they start to eat and drink, food/liquid drinks temperature is important for food safety, and it is important to keep food out of high temperatures that might cause harm. Review of the Kitchen Daily Temperature Logs starting 8/25/24-9/9/24-revealed temperatures of coffee and hot water are being checked daily before being placed in the pantries on the units. Reviewed the Facility Performance Improvement Plan (PIP) in place to ensure resident s do not sustain burns from hot liquids starting 8/28/24. The components are: 8/28/24-Review incidents and accidents and falls in morning and weekly meetings. 8/28/24-8/30/24-Review requirements for hot liquids 9/4/24-obtain thermometers to be given to the floors 9/11/24-develop a process to minimize resident injury related to hot liquids to floors and report to QAPI (Quality Assurance and Performance Improvement) . 9/11/24-Kitchen to monitor temperatures on distribution 9/16/24-Educating staff regarding the new process monitoring temperatures for food/liquid items. Interview on 9/9/24 at 11:17AM Registered Nurse (Staff A) east unit stated the kitchen brings the coffee in the dispensers every morning on a cart and they take it back with them when we are finished, the nurses and the CNAs served the coffee to the residents from the cart, we do not check the temperatures of the coffee before serving. The coffee is usually hot when we serve the coffee to the resident. Interview on 9/9/24 at 11 25 AM Registered (Staff B), unit manager east wing stated, coffee comes from the kitchen in dispensing coffee pots and is picked up from the floor by the kitchen. Any staff, the CNAs or nurses serve the coffee to the residents, if the residents request coffee, we have thermometers available in the Pantry to check the temperature of the hot beverages before serving. Surveyor went with Unit manager to the pantry room; a thermometer was observed in the drawer in a plastic bag. Interview on 9/9/24 at 11:26 AM Certified nursing Assistant (Staff C) East wing stated: when I serve coffee to residents I go into the pantry, the coffee is in dispensing coffee pots on a black rack in the pantry, I washed my hands, pour the coffee, if the coffee is really steaming, I would use the thermometer located in the drawer to test the temperature before serving to the resident. The acceptable temperature for the coffee is below 155 degrees Fahrenheit. On 9/9/24 at 11:35 AM Registered Nurse (Staff D) North wing stated: I do not serve coffee to the residents, usually the CNAs on the unit serve the coffee to the residents. On 9/9/24 at 11:30 AM CNA. (Staff E) North unit stated: When I serve coffee to the residents, I get the coffee from the pantry and serve the coffee to the residents, the coffee is usually warm to hot and it comes fresh from the kitchen, I just serve the resident the coffee, I am not checking the temperature with any device. We do not heat up the coffee for the resident, we serve the coffee directly from the coffee pot in the pantry. On 9/9/24 at 11:35 AM CNA. (Staff F), North unit stated: I prepare the coffee the way the resident likes it, I make sure the coffee is not too hot, I feel the outside of the coffee cup and look at the amount of steam to estimate the hotness of the coffee, I let the resident know to be careful and then I serve the resident, I do not check the temperature of the coffee with a thermometer. On 9/9/24 at 11:39 AM the surveyor asked the DON to be shown the thermometer in the North unit pantry room, The DON stated after looking in the drawers that she did not find a thermometer in the north pantry. On 9/9/24 at 11:49 AM, CNA. (Staff G) South unit, when asked by surveyor to walk through the steps of preparing and serving coffee to the residents stated: When I serve coffee to the residents, I get the coffee from the pantry, I put the coffee in a cup, put a lid on the coffee and gave it to the resident. The kitchen checks the temperature before the coffee is placed in the pantry. On 9/9/24 at 12:01 PM Licensed Practical Nurse ( Staff H) Unit supervisor reported: the coffee for the residents is dispensed by staff in the pantry and the served to the resident, the coffee comes from the kitchen in dispensing coffee pots and is placed in the pantry, the temperatures are checked by the kitchen staff before the coffee is placed in the pantry but we have a thermometer in the pantry to check the temperature if the staff thinks the coffee is too hot. Staff H took the thermometer out of her pocket and showed the surveyor, at the time the surveyor and supervisor were standing inside the South unit pantry. Staff H stated the coffee is served to residents at a temperature below 155 degrees Fahrenheit. On 9/10/24 at 7:40 AM the Assistant Director of Nursing (ADON)/Risk Manager/ADON revealed; this incident occurred on 8/25/24 at 11:30 AM, the resident requested coffee, Licensed Practical Nurse (Staff I) got a coffee from the coffee dispenser, covered the coffee cup with a lid and placed the cup of coffee on the resident's overbed table. There was only a cup of water on the resident's overbed table at the time. After Licensed Practical Nurse (Staff I) left the room, she went to the nurses' station, she noticed the resident's call light was on, she went back to the room and observed the resident's gown was saturated with coffee. Staff I removed the resident's gown and cleaned the resident, she observed the resident's chest and upper abdomen skin was red, she reported her observations and what occurred to her supervisor and the resident's physician. Staff I received an order for Silvadene to apply to the reddened areas and a wound consult. On 8/26/24 the wound care nurse conducted a skin assessment and observed two intact blisters on the upper left abdomen with mild sensitivity to the area, the treatment orders were as previously prescribed. The ADON stated: I initiated the day one report after the blisters were identified on 8/26/24 at 12:04 PM, the five day was submitted on 8/29/24 at 11:58AM. On 8/26/24 law enforcement was notified, they came to the facility and interviewed the resident (Resident #1), [ Resident #1] stated the nurse (Staff I) brought him coffee and as he was moving the table when the coffee fell on his abdomen, it was an accident, the resident did not press any charges or made any allegations to the officer. [ local community-based agency] was notified, and the case was not accepted. The resident was interviewed by me (ADON)-stated the same explanation of the incident as he told to the Police Officer and denied any abuse by any staff, he stated that it was an accident caused by him. The allegation of neglect and abuse was unsubstantiated. There was no delay in care, the coffee temperature was checked on 8/26/24, it was at 151 F, the resident is alert and oriented and fed himself, he did not require any help with eating and drinking, he was independent. On 8/28/24 the staff (All CNAs) were educated on safe food temperature. Education included always check food/drink temperature before offering to residents. On 9/10/24 at 8:26 AM the Assistant Director of Nursing (ADON)/Risk Manager stated on 8/28/24 the staff (All CNAs) were educated on safe food/liquid temperatures. Education included always check food/drink temperature before offering to residents. There was no direct information on how to check the temperatures. The in-service to the CNAs was facilitated by (IT/education staff). Our policy states temperature of hot liquids will not exceed 155 degrees at time of delivery to the resident. Review of the performance improvement Plan (PIP) with the ADON/Risk manager revealed the next training date for staff on food/liquid temperatures will be on 9/16/24. On 9/10/24 at 8:56 AM Education/training Staff (Staff L) stated on 8/28/24 I provided training to the CNAs about food safety-proper temperatures of food, cold food served old and hot food served hot. Specifically for coffee, when they serve the coffee to the resident, if it is too hot, let the coffee sit for at least 5 minutes before serving to the resident. Visually check the food or the liquid being served to the resident and determine if it is safe to serve to the resident. For example-if the plate or cup is too hot for the CNAs to hold or handle it is probably too hot for the resident. In the training, I did not go over any information with the CNAs about testing the temperatures with a thermometer. Checking temperatures of the food and liquids is done in the kitchen. On 9/10/24 at 9:29 AM the Dietary Manager stated: The coffee is made in the kitchen and taken to the pantry on the units and placed on the countertops. The temperature of the coffee is taken right before it goes on the floor, the range is between 150-160 degrees Fahrenheit and is usually taken an hour before the coffee goes on the floor. We started recording the temperature readings of the coffee on the daily temperature logs starting on 8/25/24, prior to 8/25/24 we did not record the temperature of the coffee before sending the coffee out to the unit pantries. Fresh coffee is made three times a day for each meal and placed in the pantry on each unit. If the temperature is lower than 150 degrees, we would rebrew the coffee, if the temperature is higher than 160 degrees, we would either add ice to cool the coffee down or let it sit for a while and then recheck the temperature. Once we transport the coffee to the units, the staff get the coffee from the pantry when requested by the resident or if it is on the meal ticket. I am aware that the facility policy states temperature of hot liquids will not exceed 155 degrees at time of delivery to the resident. On 9/10/24 at 9:40 AM The Nutrition Director stated: Currently the kitchen does the testing of the temperature of coffee after it is brewed and before it is delivered to the floor. This started once the incident occurred on 8/25/24 and I was notified of the incident. We make coffee for breakfast, lunch and dinner and check the temperatures before the coffee goes out on the floor. The temperature range of the coffee should be between 155-165 degrees Fahrenheit, if the coffee is below 155, we toss and remake the coffee, if the temperature is above 165 we add ice or let it sit for a while and recheck the temperature. If a resident complains the coffee is too hot or cold, the floor staff have access to a thermometer that they can use to check the temperatures. These thermometers are usually kept with the nursing manager on duty. The staff should be aware of the acceptable temperature range for the coffee 155-165, we are in the process of training all nursing staff and kitchen staff. I am aware that the facility policy states temperature of hot liquids will not exceed 155 degrees at time of delivery to the resident, we are working on revising our policy. On 9/10/24 at 10:12 AM the facility's Administrator revealed the performance Improvement plan was started on 8/28/24, and in-services started after the incident involving Resident #1,. Regarding food/liquid temperatures.

Based on observations, interviews, and record review, the facility failed to implement care plan interventions related to bleeding precautions for two residents (#89, #93) and failed to develop and implement a comprehensive care plan related to a nephrostomy tube for one resident (#89) out of 30 residents sampled. This had the potential to affect the 150 residents residing in the facility receiving care at the time of this survey. The Findings Included: 1. During observation on 07/10/23 at 09:37 AM, Resident #89 was in bed awake, with a right side quarter side rail pad on the floor, and a left side quarter side rail pad was attached to the bed rail on the upper inside of the bed. The urinary tubing leading from the resident's left side to the drainage bag was attached to the lower bed rail. Resident #89 stated, he is doing great today. On 07/11/23 at 08:25 AM, Resident #89 was observed in bed eating breakfast, there was no distress noted, bilateral quarter rail pads were in place and the urinary tubing was present. On 07/12/23 at 08:47 AM, Resident #89 was observed in a high-back wheelchair in the hallway, the resident stated, he just went to therapy, and he even walked a little bit yesterday. The urinary drainage bag was in a privacy bag. Record review of Resident # 89's Care Plan with a Reference Date of 07/12/23 revealed: Resident is at risk for abnormal bleeding or hemorrhage related to: Anticoagulant use/Eliquis as ordered. Interventions: Monitor for signs and symptoms (S/S) of bleeding every shift (bleeding gums or nose, unusual bruising, dark/tarry stools, pink/discolored urine). Maintain on bleeding precautions every shift. Document if abnormalities noted, notify provider at once for appropriate interventions needed. Record review of Resident # 89's Care Plan Reference Date 07/12/23 revealed: 05-12-23 Left nephrostomy tube (FR8) inserted on 05-12-23. Diagnosis Left urinary tract obstruction proximal left ureter calculus. Interventions included: Assess urine output every shift. If abnormalities noted- scanty or no output: Record the amount, type, color, odor. Observe for leakage. Notify provider at once if abnormal s/s noted for appropriate interventions. Follow up Nephrology consultation as ordered. Report at once to provider signs and symptoms of Urinary Tract Infection (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine) for appropriate intervention. Educate and encourage resident to report pain and/or persistent flank pain on shift. Notify provider at once if suspects blockage. Left Nephrostomy site care: Monitor and document urinary output from Urostomy bag every shift. Empty bag at the end of each shift. Keep the drainage bag low to avoid urine from backing up. Keep drainage tube secured to avoid dislodgement. Review of the medical records for Resident #89 revealed, the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Clinical diagnoses included but were not limited to: Malignant neoplasm of prostate (History of), Atrial Fibrillation and other seizures. Review of the Physician's Orders Sheet for June-July 2023 revealed, Resident #89 had orders that included but were not limited to: Nephrology consult: Left nephrostomy tube inserted on 05/12/23. Dx. Left urinary tract obstruction proximal left ureter calculus. 07/12/23-Bleeding Precautions. Monitor for signs of bleeding every shift and report to provider. Special Instructions: Resident on Eliquis. Medications included: Eliquis (apixaban) tablet; 5 Milligram (mg)-Give one tablet daily for Atrial fibrillation. Record review of Resident #89 's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 12, on a 0-15 scale indicating the resident is cognitively moderately impaired. Section G for Functional Status documented Total Dependence for transfer and toileting, Extensive assistance for bed mobility with one person assistance, and Eating-independent. Section H for Bowel and Bladder documented, Resident has an Indwelling catheter (including suprapubic catheter and nephrostomy tube), always incontinent of bowel. Section J for Health Conditions documented resident received scheduled pain medications in the last 5 days, shortness of breath when sitting at rest and lying flat. Section K for Nutritional Status documented, no unknown weight loss/gain. Section M for Skin Conditions documented no skin issues. 2. During observation on 07/10/23 at 09:16 AM Resident #93 in wheelchair in room, stated today is a great day. On 07/11/23 at 08:21 AM, Resident #93 was in the wheel chair in the room eating breakfast, the oxygen equipment dated 7/10/23, stated, today is a good day. On 07/12/23 at 10:00AM, Resident #93 was in the wheel chair in the hallway, and stated everything is great today. Record review of Resident # 93's Care Plan with a Reference Date 06/25/23 revealed: Resident is at risk for abnormal bleeding or hemorrhage related to: Anticoagulant use/Eliquis: Paroxysmal Atrial Fibrillation. Interventions: Obtain labs as ordered, notify provider at once of abnormal result. Monitor for s/s of bleeding every shift (bleeding gums or nose, unusual bruising, dark/tarry stools, pink/discolored urine). Maintain bleeding precautions every shift. Document if abnormalities noted, Notify provider at once for appropriate interventions. Administer anticoagulant medication as ordered. Review of the medical records for Resident #93 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Paroxysmal atrial fibrillation. Review of the Physician's Orders Sheet for June-July 2023 revealed, Resident #93 had orders that included but were not limited to: 7/12/23-Bleeding Precautions. Monitor for signs of bleeding every shift and report to provider. Special Instructions: Resident on Eliquis Every Shift Morning, Evening, and Night. Medications Included: Eliquis (apixaban) tablet; 5 mg-Give one tablet twice a day for Atrial Fibrillation. Record review of Resident #93 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 15, on a 0-15 scale indicating the resident is cognitively intact. Section G for Functional Status documented Total Dependence for Activities of Daily Living. Section H for Bowel and Bladder documented Resident is always incontinent of bowel and bladder. Section M for Skin Conditions documented no skin issues. Section N for Medications documented resident received antidepressant, anticoagulant and insulin in the last 7 days. Interview on 07/12/23 08:11 AM with Registered Nurse (Staff A) showed surveyor order for resident's Eliquis, stated she will check the treatment Electronic Medication administration Record (EMAR) for monitoring parameters for Eliquis, Staff A checked treatment orders with the surveyor, there was no order for monitoring the resident for bleeding or bruising. Staff A stated, the residents on anticoagulants usually have orders for monitoring for bleeding and bruising. Staff A stated, this resident is stable and he is able to verbalize his needs, when the Nursing Aides provide care to the resident, they would report any issues with the resident to the nurse. Interview on 07/12/23 at 08:18 AM with the Registered Nurse Unit Manager for the East wing (Staff B) stated, she will look into the resident's medical record related to bleeding precautions monitoring and discuss with the resident's physician and let the surveyor know. Interview on 07/12/23 at 02:47 PM with the Director of Nursing (DON), when asked about residents' #89 and #93's care plan intervention for anticoagulant therapy proceeded to look up the resident's medical records, the DON stated, the interventions states to monitor the resident for signs and symptoms of bleeding, when asked how are the direct care staff monitoring the resident, the DON proceeded to check the resident's orders, the DON stated there are no orders in place and there should be an order for monitoring the residents for bleeding precautions. Additionally, the DON stated an order was created today on 7/12/2023 on the medication flow sheet and EMAR to monitor bleeding precautions for the residents. The DON stated, there should have been an order in place for monitoring the residents (Bleeding Precautions). The DON stated I will be doing audits for residents on anticoagulants, identify that there is documentation that the residents are being monitored for signs and symptoms of bleeding and being signed off by the nurse. Interview on 07/12/23 at 03:00 PM, the DON when asked about what type of catheter Resident #89 currently has, proceeded to check the resident's medical records, and stated, this resident uses a condom catheter and has a left nephrostomy tubing with a drainage bag that was placed on 5/12/23 during the most recent hospital admission. After reviewing Resident #89's care plans, the DON stated this resident does not currently have a care plan for the nephrostomy tube, the most recent Minimum Data Set (MDS) dated [DATE] documented the resident has an indwelling Catheter (the includes a nephrostomy). The resident does not currently have a care plan for the nephrostomy tube. The Minimum Data Set (MDS) team completes the resident's MDS' and the care plan, according to the medical records there is no care plan currently in place for the resident's nephrostomy. The DON spoke with the MDS team, and reported a care plan will be implemented for the resident's nephrostomy tube, an audit will be conducted for all residents with indwelling catheters to make sure they are coded correctly, and the care plans are in place. Review of the facility's policy and procedure titled, Interdisciplinary Care Plan revision date 04/08/2022 states: Planning of Care: Care plans are resident centered with measurable goals. There are basic steps to progress care planning: Assessment-Individual and comprehensive (MDS) Planning-CAA (care area assessment) Analysis and Recommendation Identification of Problem/Need-with Team Measurable goals and meaningful approaches Implementation of the Plan Evaluation of the effects of the approaches on the goals Nursing Assistant's input is critical to the care planning process. Goals can take different forms-improvement, maintenance, preventative, palliative and coping and change between quarters. Approaches need to be clear and responsibility in application assigned. Any member of the care team can and should update the plan of care when new information is appropriate and different from what exists at the time.

Based on observation, record review and interview, the facility failed to provide adequate and appropriate health care, related to occupational therapy services for two (Resident #65 and 88) out of two residents reviewed. There were no hand rolls observed in the residents hands. The findings included: 1. Resident #65 face sheet review showed the initial admitted [DATE], with diagnoses including but not limited to, Hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side Primary. Observation of Resident #65 on 07/10/23 at 09:29 AM revealed, the resident was observed sitting in his wheelchair with the left hand contracted, and no splints were observed. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 05/29/23 revealed, Sections C - Cognitive Patterns - 03 out of 15, indicating severe cognitive impairment, Section E - Behavior - Behavior not exhibited, Section F - Preferences for Customary Routines - N/A, G - Functional Status (including bed mobility, transfer and ROM status) -Total dependence/one, I - Active Diagnoses - Anemia, Hypertension, Diabetes Mellitus (DM), Hyperlipidemia, Seizure Disorder or Epilepsy, Malnutrition, Depression, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Other specified diabetes mellitus with diabetic neuropathy, unspecified, Nutritional deficiency, unspecified, Other muscle spasm, Constipation, unspecified, Sleep apnea, unspecified, Pain, unspecified, Essential (primary) hypertension. Section J - Health Conditions - Pain and Falls - Yes, received pain medication, and Section O - Special Treatment/Proc/Prog - OT (O0400B)(Occupational Therapy) - None, PT (Physical Therapy) (O0400C) - None, and restorative nursing program (O0500). Record review of the residents Physician's orders revealed an order dated 07/07/23 for a Wash cloth roll to the left hand to be worn at all times. Remove for skin checks and for hygiene and to change roll. Special Instructions: At all times Every Shift Morning, Evening, Night. Review of resident #65's Care Plans Dated 07/11/23 revealed: Problem: Decreased in ADL (Activities of Daily Living) functions: Decreased in functional mobility Resident requires total assistance x1 person with bed mobility, dressing, personal hygiene, toilet use and bathing activity. [Resident is able to eat independently with meal tray set up=Revised] [Resident needs supervision for safety with meal tray set up=02-26-22 Revised] Resident needs total assistance x1 person when eating at this time. =revised. Resident is able to eat independently with set up. Resident fluctuates with eating assistance. Resident prefers to be feed almost all the time. He tends to eat longer with a lot of encouragement when supervised but is able to establish normal pace when provided assistance with meals as requested. He requires total assistance x2 person with transfer for safety using mechanical lifter. He is non ambulatory. He needs total assistance x1 person to move on and off the unit while in wheelchair. Resident is at risk for fluctuation in status related to multiple medical conditions. DX: DM DX: HTN History of CVA (Cerebrovascular Accident) with left hemiparesis. Goal: Resident will maintain comfort and hygiene on a daily basis and will receive the total care needed with dignity thru next review date. Resident will not show s/s (signs and symptoms) of further decline in ADL functions and related complications thru next review date.e.g., ROM (Range of Motion) and mobility schedules including types of interventions, positioning interventions, assistance devices, type of splinting [e.g., splint, hand roll, arm trough], pain, care of contracture). During an interview with the Physical Therapist Rehab Manager on 07/13/23 at 09:04 AM, it was stated, I know he has it; I think. A hand roll towel is supposed to be there every day as tolerated. I know that he does not have it because sometimes the towel moves. Interview with Staff F, a Registered Nurse on 07/13/23 at 09:53 AM it was reported, the order is that he has to have the towel roll every day, but I do not know why he did not have it. Sometimes the resident is the one who takes it off. Interview with Staff G, a Certified Nursing Assistant(CNA) on 07/13/23 at 09:53 AM, it was reported, she has been working in the facility for [AGE] years, Her schedule is five days a week from 7:00 AM to 3:30 PM. I am supposed to put the towel every day, I do not know what happened, that he did not have it when you saw him. 2. Resident #88 face sheet review showed the initial admitted [DATE], with diagnoses including but not limited too: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Peripheral vascular disease, unspecified, Type 2 diabetes mellitus with other specified complication, and Contracture, right hand. Observation of Resident #88 on 07/10/23 at 09:06 AM revealed, the resident was lying in bed with a right hand contracted. There was no roll observed in the residents hand. Second observation on 07/13/23 09:40 AM revealed, the resident lying in bed with a towel roll in his hand, the resident stated; they just put it on. Record review of the residents Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 05/15/23 Sections C - Cognitive Patterns - Left blank, Section E - Behavior - Behavior not exhibited, Section F - Preferences for Customary Routines - None, G - Functional Status (including bed mobility, transfer and ROM status) -Total dependence/Two+, Section I - Active Diagnoses - Heart Failure, Hypertension, Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD), Diabetes Mellitus (DM), Hyperlipidemia, Non-Alzheimer's Dementia, Hemiplegia or Hemiparesis, Malnutrition, Depression, Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease, Disorder of the skin and subcutaneous tissue, unspecified, Partial traumatic amputation of one left lesser toe, subsequent encounter, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant, Paroxysmal atrial fibrillation, Unspecified injury of flexor muscle, fascia and tendon of other finger at wrist and hand level, subsequent encounter, Contracture, right hand, Gastro-esophageal reflux disease without esophagitis, Constipation, unspecified, Pressure-induced deep tissue damage of right heel, Other muscle spasm. Section J - Health Conditions - Pain and Falls - None, and O - Special Treatment/Proc/Prog - OT (O0400B) - None, PT (O0400C) - None, and restorative nursing program (O0500) - Range of motion (passive). Record review of the Physician's orders revealed an order dated 03/07/23 for a Roll to Rt hand at all times to prevent skin breakdown in palm and thumb region. Special Instructions: Clean hand and provide roll to hand. Every Shift Morning, Evening, Night. Record review of the residents Care Plans Dated 05/01/23 revealed: Problem: [Use of bedside rails as enabler Use of bedside rails as enabler/support: Resident presents impaired balance & gait. Use of bed side rails will assist resident with bed mobility/enable safe transfers to and out of bed/improve balance while sitting at the edge of the bed.] DISCONTINUE PLAN OF CARE INCLUDING GOALS AND APPROACHES. Goal: Resident will be able to facilitate movement and benefit with the use of bedrails as enablers and reduce related complications e.g., minimize risks of pressure ulcer development and/or bodily injury thru next review date. Resident bed mobility will not be impeded and will not prevent resident from physically moving freely and will not be physically confine and restricted thru next review date. Problem: Resident admitted for rehabilitation. Resident has hx/o (history of) homelessness. LTC (Long term care) is likely the plan of choice. Resident admitted under guardianship. Goal: Will continue receiving the level of care and medical attention from the SNF. Will communicate needs and concerns. Will accept daily care and treatment. Will accept redirection from staff as needed. Problem: ADL's functional Status/Rehabilitation potential. Decreased in ADL functions: Decreased in functional mobility, Resident needs total assistance x1 person with bed mobility=revised. Resident needs extensive assistance x1 person with bed mobility. He needs extensive assist x1 person with dressing, toileting, bathing, and personal hygiene=revised. Goal: Resident will maintain comfort and hygiene on a daily basis and will receive the total care needed with dignity thru next review date. Approach: PT evaluation and treatment as ordered. OT evaluation and treatment as ordered. During an interview with the Physical Therapist Rehab Manager on 07/13/23 at 08:57 AM, it was stated We just put a towel roll when he tolerates it, but he does not like to use it. The towel roll is supposed to be put daily but I do not know exactly at what time. The Resident tends to remove them without us knowing it. Usually, the CNA is supposed to put the towel roll every day after the morning care. The last screening/evaluation was conducted on 05/26/23, the outcome was that he did not desire to participate in any restorative services. Interview with Staff D, a Registered Nurse on 07/13/23 at 09:42 AM it was reported, the resident has the order for a towel roll for every shift, we have to check to make sure that he has it on. We check on the resident every two hours and we have to make sure that he is using the towel roll. Sometimes the resident removes the towel because he does not like it. Interview with Staff E, a CNA, on 07/13/23 at 09:47 AM it was stated, I am in charge of taking care of the resident, I am supposed to put the towel roll every day and check on him every two hours. The Resident sometimes drops the towel, thus why he does not have it. Record review of the Policy and Procedure titled, Splinting Program, Policy No. 2250, revisied 03/23/2022 revealed: I. Purpose Devices such as hand rolls, hand, wrist, ankle or knee splints or upper extremity sling may be used to immobilize a joint to: 1. Prevent a contracture. 2. Reduce a contracture. 3. Provide extremity support to improve function. III. Procedure 1. Resident deficit/need/problem is identified by Nurse, Occupational Therapist or Physical Therapist assessment. 2. If hand roll is indicated, the Medical Director (MD)/Advance Practice Registered Nurse (APRN)/Therapist may write order for them. 3. Occupational Therapist or Physical Therapist writes a specific order stating type of splint to be used, area to which splint is applied, duration of application time, duration of removal time, and other special instructions. 4. Occupational Therapist, Physical Therapist provides necessary education to guarantee appropriate and usage of splint.Facility failed to provide adequate health care related to occupational therapy for resident # 88 and # 65

Based on observations, interviews, and record review, the facility failed to provide a safe environment related to bed side rail pads to prevent accidents for one Resident (#89) out of one sampled resident. This had the potential to affect the 150 residents receiving care in the facility at the time of the survey. The Findings Included: During observation on 07/10/23 at 09:37 AM, Resident #89 was in bed awake, a right side quarter side rail pad was on the floor, the left side quarter side rail pad was attached to the bed rail on the upper inside of the bed, the bed was not in the lowest position. Resident #89 stated, he is doing great today. On 07/11/23 at 08:25 AM, Resident #89 was observed in the bed eating breakfast, no distress was noted, bilateral quarter rail pads were in place, the bed was not in the lowest position. On 07/12/23 at 08:47 AM, Resident #89 was observed in a high-back wheelchair in the hallway, and stated he just went to therapy, and he even walked a little bit yesterday. Review of the medical records for Resident #89 revealed, the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Clinical diagnoses included but were not limited to: Atrial Fibrillation and other seizures. Review of the Physician's Orders Sheet for June-July 2023 revealed, Resident #89 had orders that included but were not limited to: 5/18/23-Bilateral bed Side Rail Padded for Seizure Precautions Special Instructions: Use & monitoring of Side Rails For seizure/convulsion activities. Every Shift Morning, Evening, Night. Medications included: 5/17/23-Keppra (levetiracetam) tablet; 1,000 Milligram (mg) give one tablet twice a day for seizures. Record review of Resident #89 's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 12, on a 0-15 scale indicating the resident is cognitively moderately impaired. Section G for Functional Status documented Total Dependence for transfer and toileting, Extensive assistance for bed mobility with one person assistance, and Eating-independent. Section H for Bowel and Bladder documented Resident has an Indwelling catheter (including suprapubic catheter and nephrostomy tube), always incontinent of bowel. Section J for Health Conditions documented resident received scheduled pain medications in the last 5 days, shortness of breath when sitting at rest and lying flat. Section K for Nutritional Status documented no unknown weight loss/gain. Section M for Skin Conditions documented no skin issues. Review of Resident #89's Care Plans with a Reference Date 06/26/23 revealed: Use of bedside rails with pads as safety device related to Seizure Disorder. Interventions Included: Monitor for any seizure activities on shift. Notify provider at once for appropriate intervention necessary. Maintain on seizure precaution at all times. Keep bed in lowest position with padded side rails in place at all times. Educate safety precautions and allow resident to demonstrate use of side rails: resident's ability to be physically free from confinement. Assess medical condition/cognitive and behavioral status that presents potential risk for entrapment. Apply two side rails up 1/2 top and 1/2 bottom with pads for safety. Review of the nursing progress note dated 05/07/2023 time stamped 09:00 documented, resident left the facility via 911, family unable to contact. Physician (MD) aware. On 05/07/2023 timestamped 08:45 Resident noted continuously jerking movements unable to speak or follow commands. Vital Sings: B/P 185/116, P-124, R- 32, T-97.7, O2 Sat-92. MD was called and gave order to Call 911. Review of the Physician's notes on 05/19/2023 time stamped 00:06 documented: Patient admitted to hospital from 5/7/23 to 5/17/23. Chief complaints: new onset seizure. History of Present illness: [AGE] year-old . with essential hypertension, diabetes, prostate cancer with bone Mets sent from the nursing home after having a seizure. In the emergency department (ED) patient was unable to complete thoughts or sentences. In the ED he was febrile. He was found to have acute kidney injury. admitted under Medicine for further evaluation and treatment. Found to have the left hydroureter with hydro nephrosis. Blood culture positive for Proteus mirabilis. Started on IV antibiotics. Subsequent cultures negative. Nephrostomy done in the left on 5/12/23. Patient also with atrial flutter. Being followed by cardiologist. Started on metoprolol, amiodarone apixaban. Interdisciplinary team (ID) recommended Bactrim to complete 14 days of Antibiotics. Patient also with Hypokalemia and low magnesium level. Interview on 07/12/23 at 08:15 AM with Registered Nurse, (Staff A) it was stated, the resident started with seizure problems about two months ago, he is stable now, he goes to therapy but he likes to be in bed, the quarter rail pads is for protection if he has a seizure, he went out to the hospital 911 for a seizure, the rail pads should be on at all times when the resident is in bed. Interview on 07/12/23 at 08:36 AM with the Registered Nurse Unit Manager (Staff B) it was stated, we do have an order for the resident to have the rail pads on the bed, so we will have to educate the resident and staff about why the seizure pads are in place and to make sure that the rails pads are always on when the resident is bed. Interview on 07/12/23 at 08:51 AM with Certified Nursing Assistant (CNA)(Staff C) stated, I have been working here for two years, I am assigned this resident today, when asked about the resident's bed rail pads, the CNA stated the rail pads need to be on the bed when the resident is in the bed and the bed in low position, I have received training in the past about this resident's care. Review of the facility's policy and procedures titled, Safety/Accidents and Supervision of Residents dated 04/05/2023 states: Our facility strives to make the environment as free from accidents hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility wide priorities. Purpose: Each resident will receive adequate supervision and assistive devices to reduce/prevent accidents.

Based on observations, interviews, and record review, the facility failed to follow doctor's orders related to Oxygen administration for one resident (Resident #77) out of two residents who were investigated for oxygen administration. The finding included: Observation on 07/10/23 at 11:46 AM, the Resident was lying in bed, alert and oriented, call light within reach, TV on, he stated, he gets dialysis three times a week, oxygen in place at 1.5 Liters. (Photo evidence) Observation on 07/11/23 at 10:22 AM, the Resident was not in room, the oxygen machine running and reading between 1-1.5 Liters. (Photo evidence) Observation 07/11/23 at 10:37 AM, the Resident was in a Geri chair, in the activities room, watching TV, no oxygen cannula observed at this time. Observation on 07/12/23 at 11:38 AM, the Resident was lying in bed, watching TV, the call light was within reach, no nasal cannula observed on resident, the oxygen machine was off, the resident stated, I just came back from dialysis and I'm a little tired. Record Review of Resident #77's Minimum Data Set (MDS)-Quarterly Review dated 06/05/2023, Most recent admission: 02/23/2023, Previously admitted on [DATE], Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Section G-Functional Status revealed: Bed mobility-Total dependence, Transfer-Total dependence, Locomotion in and out of unit-Total dependence, Eating-Extensive Assistance, Toilet use-Total dependence, Bathing-Physical help in part of bathing activity, Section O- Special Treatments, Procedures, and Programs revealed: Oxygen therapy while a resident, Dialysis while a resident. Review of Resident #77's diagnoses revealed, the resident has diagnoses of but not limited to: End stage renal disease, Essential (primary) hypertension, Paroxysmal atrial fibrillation, Adult failure to thrive, Left ventricular failure, unspecified, Heart failure, unspecified, Acute and chronic diastolic (congestive) heart failure, Shortness of breath dated 12/30/2022, and Hypoxemia dated 03/22/2023. Review of the Physician's orders revealed: an order dated 03/21/2023-Check nasal cannula every shift for hygiene and skin check, Every Shift, Morning, Evening, Night, and an order dated 03/21/2023-Oxygen at 2L via nasal cannula continuously. Call MD if oxygen less than 92, Every Shift, Morning, Evening, Night. Review of Resident #77's care plan with category: Medical, start date 06/29/2023 and last reviewed/revised 06/29/2023 at 14:27 revealed, Problem: Resident requires continuous Oxygen therapy as ordered related to: Shortness of breath with Approach: Monitor Vital Signs as ordered, notify provider at once if abnormal s/s noted, Assess and document resident's respiratory status and notify provider at once if any changes in condition noted, Ensure flow rate is accurate, Observe Oxygen precautions per protocol. Change oxygen tubing weekly on Sunday and as needed. Check nasal cannula every shift for hygiene and skin check. Apply and change humidified sterile water, date bottle as needed, Apply Oxygen 2Liters Per Minute (LPM)/ nasal cannula continuous as ordered. Check oxygen saturation on shift if needed. Document if abnormal and notify provider at once if oxygen therapy is not effective. Review of Resident #77's vitals revealed the following: 07/10/2023 oxygen (O2) Saturation: 96%, Oxygen Use: Yes-Liter flow-2. 07/10/2023 at a11:16, O2 Saturation: 97% Oxygen Use: No, 07/10/2023 at 22:42 O2 Saturation: 98%, Oxygen Use: Yes - Liter flow-2, 07/11/2023 at 01:20, O2 Saturation: 100%, Oxygen Use: Yes-Liter flow-2, 07/11/2023 at 01:37, O2 Saturation: 100%, Activity: Resting, Location: Right Upper Digit, Oxygen Use: Yes-Liter flow-2, 07/11/2023 at 10:00, O2 Saturation: 100%, Oxygen Use: Yes - Liter flow-2, 07/11/2023 at 16:59, O2 Saturation: 98%, Oxygen Use: No, 07/12/2023 at 02:03, O2 Saturation: 100%, Oxygen Use: Yes - Liter flow-2, 07/12/2023 at 12:01, O2 Saturation: 99%, Oxygen Use: Yes - Liter flow-2. Review of progress notes revealed, a note dated 07/11/2023 at 22:45-Resident lying in bed in stable conditions, resident awake and alert. Medication given as ordered and well tolerated. Oxygen at 2 liters via nasal cannula, a note dated 07/13/2023 08:34 11-7 SHIFT: Post dialysis state satisfactory. Vitals signs stable (VSS), oxygen (O2) at 2 liters via nasal canula (n/c), O2 saturation 95 in room air, insisting on using O2, education provided, blood pressure (B/P) 144/60, Pulse 56. Left femoral dialysis catheter intact with clean dry and intact dressing, will continue to monitor. Call light at his reach. During an interview on 07/12/23 at 11:40 AM with Staff H-Registered Nurse on North Wing revealed, when asked about Resident #77's oxygen use, she stated he uses oxygen, it is continuous, he always needs it. When asked about the time Resident #77 came back from dialysis, she stated, I have to check the computer, she proceeded to check the computer and stated, I do not see it here, let me get the paper to check, I gave him his medication. Staff H went to get paper then she came back and stated, let me check the Medication Administration Record (MARs), he came at round 11:00 as I gave him hydralazine at 11:15 AM. When asked about who is in charge of placing oxygen on resident when coming back from dialysis, she stated the nurse is in charge to place the oxygen back, and he immediately calls if he needs as he is alert. When asked whether the resident had the oxygen in place at the time of the interview, she stated, if he hasn't taken it off, he has it, and sometimes we take it off for repositioning, when they come, we receive them. Surveyor asked Staff H to come to the room to check the oxygen, she entered the room and stated, he doesn't have it, where is his oxygen. Staff H proceeded to grab the nasal cannula and it dropped on the floor, then she exited the room and stated, I am going to get a new nasal cannula as the other one touched the floor. Staff H came back to the room, proceeded to place the nasal cannula on a paper towel on the resident's overbed table, she washed her hands and talked to the resident about putting on the oxygen. Asked, how many liters he needed, she stated, it has to be at 2 liters, it was off and when it is off, it falls down completely. She turned on machine and adjusted oxygen level, and placed the nasal cannula on the resident. Surveyor then proceeded to check the oxygen liters on the oxygen machine, machine stills read 1.5 liters at this time. Surveyor pointed out to Staff H about the liters on the machine and she stated, the problem is I'm looking from up top not down there. She adjusted the oxygen and had a hard time placing it to 2 liters. After surveyor intervention, review of progress notes on 07/12/23 revealed a note dated 7/12/23 with Date/Time 07/12/2023 at 11:00, Created Date 07/12/2023 at 11:47 Created By Staff H-Resident returned from dialysis procedure, stable conditions, O2 99% at room air, resident stated no need for 02 at this time. Will notify MD (Medical Doctor) for further recommendations. During an interview on 07/12/23 at 02:54 PM with Staff H-Registered Nurse on the North Wing, about the note, she stated I checked his saturation and since it was good I talked to the doctor, and she stated that it was not continuous, the oxygen, when I put the oxygen on I check, when you left I checked the saturation and it was fine. I told the doctor and I checked his saturation, she gave me a new order, this was at around 1:00, when I talked to you, and I asked him how he was feeling, he said fine. During an interview on 07/12/23 at 03:02 PM with Staff I-Registered Nurse/Charge Nurse on North Wing. When asked about following the oxygen order for Resident #77, she stated, the nurse is in charge of checking the order, every shift for the oxygen, he went to dialysis, he goes to dialysis Monday, Wednesday, and Friday, previously his oxygen was continuous, and he is improving, and they evaluated him today, as he is doing better and we have changed the order to as needed (PRN), previously the order was at 2 Liters continuously. Staff H called the doctor that the patient is doing pretty good for the saturation, and the doctor came to see him, she was here with the nurse practitioner, she was here around noon. During an interview on 07/13/23 at 11:35 AM with the Director of Nursing (DON), when asked the protocol to follow for checking on oxygen machines to which she stated, the protocol depends on the order, if continuous, they will put it continuously or PRN when it is necessary to use, the nurse has to look at it, and see whatever the order is, then that it is. When asked about the way the oxygen machine can be read, she stated, I would think that you will be eye level, but I do not know if that is necessary, to be able to balance the flow meter at any height you should be able to see it, you do not have to be at a certain position. When asked about Resident #77's order, she stated, continuous means all the time, the order was changed, what should happen as far as that order, is concerning if they are noticing that the pulse oximetry is good or at 100%, you do not need it, they are taking the pulse oximetry all the time if there is an appropriate level, they probably don't need it. I would think they will have to bring it up to the floor, if you see that the pulse oximetry is 100% all the time, so why would he be on oxygen all the time, that is probably something we should have identified that he did not need it sooner. Review of the facility policy and procedure for Oxygen Therapy dated, 2/20/2022 revealed, The purpose of the procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physicians orders or facility protocol for oxygen administration.

Based on observation, interview and record review the facility failed to monitor over the counter medications in a resident's room, as evidenced, an over-the-counter medication found on the side table of Resident # 110. There were 55 residents residing in the facility at the time of this survey. the findings included: Observation on 06/06/22 at 2:15 PM revealed Resident #110 was not in the room; A sealed box labelled Natural Health Product High Performance Antioxidant , Norwegian Spruce Extract, Fountain of Life (an over the counter medication) was observed on the bed table. (Photographic evidence) Review of Resident #10's Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Care Plan revealed no care plan for self-administration of medications. Review of Resident #110's clinical records indicated a care plan for Cognitive Impaired/Dementia with start date 07/29/2021 and revised on 04/24/2022; documented that the resident upon admission to the facility on [DATE] was awake, alert, oriented times one (AAOX1) to name. Resident is severely impaired in cognition. She is severely impaired to make informed decisions for daily living and healthcare decisions. Resident rarely and or never is able to make self-understood. She sometimes is able to understand others but responds adequately to simple, direct communication only. Resident is at risk for further decline in cognition as disease process progress to deterioration. Diagnosis (DX): Acute Ischemic left middle cerebral artery (MCA) stroke. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] section C for Cognitive Pattern indicated a score of 99 meaning the resident was unable to complete the interview. The Quarterly MDS Section C dated 04/30/2022 revealed the resident cognitive skills for daily decision making was severely impaired. Review of Section G -Functional status dated 04/30/2022 revealed the resident needed limited assistance with one-person physical assistance for bed mobility. the resident needed total dependence with two persons physical assistance for transfer, toilet use and locomotion. The resident needed extensive assistance with one person physical assistance for locomotion, dressing and personal hygiene. The resident is independent with set up only for eating. On 06/09/22 at 11:34 AM, during an interview Registered Nurse (RN) Staff A, stated the resident is alert and oriented times 3 but she is not verbal. She uses a board to communicate with the nurse. Resident has speech therapy. Resident has over the counter medication and following doctor's orders. Staff A revealed there was no order for the medication observed in the resident's room. On 06/09/22 at 11:40 AM, the Unit Manager (Staff B) reported that the family brought the medication over the weekend, and on Monday staff informed her of the medication on top of the side table and she picked the medication up, stored it in her office and she called the family to take the medication back because medications had to be ordered by a doctor. Further inspection at the time of this interview revealed the medication was sealed and identified with the resident's name.(Photographic evidence)

Based on observation, record reviews, and interviews the facility failed to implement the care plan related to smoking for one (resident #98) out of 32 residents whose care plans were reviewed. The findings included: On 01/14/20 at 10:08 AM during observation and interview resident #98 took out a cigarette that he handed to another resident to light and started smoking. Resident # 98 stated I buy my cigarettes. There was one staff member present on the patio assisting a non-alert resident to smoke. The staff member did not intervene during the exchange of lighting with cigarettes between residents. Resident #98 was not wearing a smoking apron. There were no fire blankets observed in the area. Review of care plan dated 8/27/2019 with revision dated 11/21/2019 revealed resident #98 is a smoker. Revised care plan dated 11/28/2019 revealed : Resident smokes 4 sticks of cigarette/day revised. Resident stated he smokes 5 cigarettes per day. Smoking cessation plan was offered, and he declined to participate. He has potential for injury such as: cigarette burn and other side effects from tobacco use such as drug interactions, behavior problem related to nicotine addiction. He requires staff supervision when smoking to maintain safety, otherwise unsafe smoker if left unsupervised when smoking. Resident has poor safety awareness. Diagnosis: [REDACTED]. He smokes at designated smoking area. He is self-sufficient once in wheelchair to independently move on and off the area. He declined the use of smoking apron for safety despite a lot encouragement and education. Revised care plan dated 12/10/18 : He accepted to use of smoking apron for safety at this time. Approach: start date 08/27/2019 Supervise resident when smoking. On 01/16/2020 at 11:11 am the Care Plan Coordinator, staff D a Registered Nurse, stated that resident #98 can be a safe smoker if supervised by the staff. We have a monitor on the patio that supervises them. Staff D explained that the care plan revealed the resident requires staff supervision when smoking to maintain safety, otherwise unsafe smoker if left unsupervised. Resident has poor safety awareness. Diagnosis: [REDACTED].# 98 does require close supervision, he is not allowed to light or have other residents light cigarettes and is required to wear an apron while smoking. We encourage them to wear the apron, educate and we do supervision. Staff D reported that the assessment and the care plan matched, but the incident that was witnessed was not ok because the patio must be monitored. Review of the facility's Policy and procedure titled Smoking and Contraband revised 06/06/2018 revealed: Smoking Policy items: B. Residents who have been assessed and determined by the interdisciplinary care team as safe may be allowed to keep their cigarettes and smoking supplies in their possession. C. Residents who are considered unsafe and wish to smoke may not be allowed to possess lighting devices. All residents who smoke will be supervised. However, lighting materials will be kept by designated staff to assist the unsafe smoker.

Based on observations, record reviews and interviews, the facility failed to provide supervision during smoking for one (resident #98) out of thirty residents who smoke. There were 162 residents residing in the facility at the time of the survey. The findings included On 01/14/20 at 10:08 AM during observation and interview resident #98 took out a cigarette that he handed to another resident to light and started smoking. Resident # 98 stated I buy my cigarettes There was one staff member present on the patio assisting a non-alert resident to smoke. The staff member did not intervene during the lighting of cigarettes between residents. Resident #98 was not wearing a smoking apron. There were no fire blankets observed in the area. Review of care plan for resident #98's dated 8/27/2019 and revised 11/28/2019 revealed: The resident is a smoker. He smokes 4 sticks of cigarette/day. Resident stated he smokes 5 cigarettes per day. Smoking cessation plan was offered, and he declined to participate. He has potential for injury such as: cigarette burn and other side effects from tobacco use such as drug interactions, behavior problem related to nicotine addiction. He requires staff supervision when smoking to maintain safety, otherwise unsafe smoker if left unsupervised when smoking. Resident has poor safety awareness. Diagnosis: [REDACTED]. He smokes at designated smoking area. He is self-sufficient once in wheelchair to independently move on and off the area. He declined the use of smoking apron for safety despite a lot encouragement and education. Revised 12/10/18 : He accepted to use of smoking apron for safety at this time. Approach: start date 08/27/2019 Supervise resident when smoking. On 01/15/2020 at 4:42 PM staff A , Certified Nursing Assistant (C NA) revealed that staff is rotated on the patio for smoking . Staff A explained that when the residents that smoke come to the patio, they are given an apron and staff lights the cigarettes for the residents. Staff A stated that if a resident refuses assistance and refuse to wear the apron it would be reported to the Nurse. Staff A revealed they have a list of residents who are safe to smoke. Staff A stated it is not safe for resident to light cigarette for each other . Staff a stated we are supposed to be lighting the cigarettes for all residents. Interview with staff B a Registered Nurse (RN) on 01/16/2020 at 9:10 am revealed, resident # 98 is oriented x 3, can follow commands and understand needs. Staff B stated that resident #98 smoked every day and was care planned for smoking. Staff B stated; we have a smoking patio, we have a CNA all the time to supervise, we have to monitor him at all times, they are supposed to wear the aprons, the CNA assisting the resident has to light the cigarettes at all times for the residents, they must do this for all residents. Interview with staff C, a Certified Nursing Assistant on 01/16/2020 at 10:50 am revealed she was assigned to the patio and further explained how the patio assignments are done. Staff C stated that the C N A assigned to the patio responsibilities includes, making sure when the residents come to the smoking area they are wearing appropriate clothing without holes. Staff C explained that when a resident asks to smoke, each resident is provided with an apron that has the resident's name and room number. Each month we have a meeting stating that the resident must follow the rule, when they are going to smoke, I have the lighter to light each of the resident's cigarettes. I am responsible for lighting the cigarettes they cannot have a lighter, the ones that have a lighter are reported to the nurse and we explain to them why they can't have a lighter. They are not supposed to light each other's cigarette. The CNA that is here is supposed to light the cigarettes. Staff C stated that if she sees a resident light up the other resident's cigarette, they must explain to the resident that it cannot be done, and if they don't listen, they report it to the nurse. Staff C stated that is not safe for residents to light up each other's cigarette. On 01/16/2020 at 11:11 am, the care plan coordinator ,staff D a Registered Nurse stated that if supervised by the staff, resident #98 can be a safe smoker and the facility has a monitor on the patio that supervises the residents. Staff D revealed that the Care Plan indicates that resident #98, requires staff supervision when smoking to maintain safety because resident #98 has poor safety awareness it would be unsafe if resident #98 was left unsupervised while smoking. Staff D stated that resident #98 does require close supervision, he is not allowed to light other residents cigarettes and is required to wear an apron while smoking. We encourage them to wear the apron, educate and we do supervision. Staff D stated that the incident witnessed by state surveyor when resident #98 was not wearing a smoking apron, self-lighting cigarette and passing of cigarettes between residents for lighting was not ok and the patio must be monitored. Review of the facility's Policy and procedure titled Smoking and Contraband revised 06/06/2018 revealed: To protect the health and safety of all persons within the facility because smoking and contraband are both a health and fire/safety hazard, and potentially a danger to self and others.The facility shall provide the following to ensure residents' safety Smoking Policy items: B. Residents who have been assessed and determined by the interdisciplinary care team as safe may be allowed to keep their cigarettes and smoking supplies in their possession. C. Residents who are considered unsafe and wish to smoke may not be allowed to possess lighting devices. All residents who smoke will be supervised. However, lighting materials will be kept by designated staff to assist the unsafe smoker.

Based on observation, interview, and record review, the facility failed to demonstrate effective plans of action were implemented to correct identified quality deficiencies in problem-prone areas, related to accident hazards, and implementation of care planning. Evidenced by repeated deficient practices identified in these areas during consecutive annual surveys. The findings included: Record review of the facility's survey history revealed that on the annual survey with an exit date of 11/6/2018, deficient practice was cited related to quality of care; Free of accident hazards/Supervision/Devices (citation F689). Deficient practice was also cited related to comprehensive resident centered care plans; Develop/ Implement comprehensive care plan (citation F656) . Both deficient practices were also identified and cited during the previous survey in (MONTH) (YEAR). Interview on 1/16/20 at 4:13 PM with the Facility's Administrator revealed, the facility Administrator also served as the chairperson of the facility's Quality Assurance /Quality Assurance Performance Improvement committee (QA/QAPI committee). The Administrator reported, during the previous survey the facility was cited for smoking; after a resident sustained [REDACTED]. The Administrator explained that their plan for correction included but not limited to updating all care plans for smoking residents. The role of QA included care planned supervision of residents, staff and resident education, as well as close monitoring. During the interview, the Administrator reported that the above-mentioned issues identified during the previous surveys remained as part of their QAPI discussions. Monitoring and monthly discussions during this survey year revealed no concerns with supervision of residents that smoked. The Administrator agreed that if the same deficiencies were identified during this survey related to smoking supervision, and or care planning, it might be an indicator that the QAPI plan needs revising. On 01/16/2020 during the exit for this annual survey, repeated deficient practices were identified. Deficient practices related to the facility's failure to provide adequate supervision for one resident out of thirty residents that smoke. (Cross Reference to F0689). Deficient practice was identified related to the facility failure to implement care plan for a resident that smokes. (Cross Reference to F0656).

Based on observation, interview and record review the facility failed to 1) Adequately supervise a cognitively impaired resident while smoking resulting in an injury for one (resident #85) out of thirty eight residents who smoked in the facility and 2) Ensure safe hot water temperatures on one of three resident units. The findings included: 1) Record review of the facility's policy and procedure titled, Smoking and Contraband, dated 10/09/2017, Revised 06/06/2018, revealed, To protect the health and safety of all persons within the facility because smoking and contraband are both a health and fire/safety hazard, and potentially a danger to self and others.The facility shall provide the following to ensure residents' safety: Support for residents who require total assistance to designated areas to smoke within the designated time frames. Designated smoking patios on the North and East units. Electronic lighters and appropriate ashtrays on designated smoking patios. Smoking aprons are available for all residents to use and highly encouraged for residents who are deemed 'unsafe.' Fire extinguishers will be available near the designated smoking areas. Record review of the Annual Minimum Data Set (MDS) for resident #85, dated 06/15/2018, revealed the Brief Interview for Mental Status (BIMS) test could not be performed; resident rarely or never understood. Resident #85 was coded as being severely impaired for decisions regarding tasks of daily life. The resident was total dependent on staff for bed mobility, transfers, dressing, and personal hygiene. In addition, resident #85 was coded as having impairment on one side of the upper and lower extremities, and for current tobacco use. Observation on 11/13/2018 at 9:33 a.m. revealed, resident #85 on the outside patio, with staff present, seated in his wheelchair next to the red smoking receptacle. The resident was not interviewable, nor was the resident smoking cigarettes. Further observation revealed, resident #85 wearing a yellow shirt that appeared to have multiple burn holes in it. Record review of the Nurses' Notes revealed, a note dated 02/27/2018, which was a late entry for 02/26/2018, revealed that during the 3 PM to 11:30 P.M. shift, resident #85 was noted to have an open blister to the right mid thigh; an area circular in diameter. He did not complain of pain from the area with the blister. An order was received from the Advanced Registered Nurse Practitioner (ARNP) for treatment. Record review of the physician's orders [REDACTED]. Cover with dry dressing daily, and as needed until resolved. Record review of the smoking assessments for resident #85 revealed, on 10/18/2017 he was assessed and indicated to be a safe smoker, despite having cognitive impairment. He was reassessed on 02/28/2018, after the incident, and was noted to be an unsafe smoker with a score between 19-27; resident #85 subsequently assessed for smoking on 06/22/2018 and 09/19/2019. Through the assessments the resident was indicated to have a minimal problems with carelessness of smoking materials (dropping cigarette/cigar butts or matches on the floor, furniture, self, or others). Further review of the smoking assessments revealed no documentation in the notes section of additional smoking precautions. Record review of the smoking care plan dated 10/03/2017, revised 02/26/2018, 02/28/2018, and 06/16/2018, revealed resident #85 was care planned for smoking; with a goal date of 12/15/2018. It was noted on the care plan that the resident sustained [REDACTED]. A new smoking assessment was completed and the resident was deemed an unsafe smoker. Interventions included, but not limited to, ensure the use of smoking apron at all times when smoking, which was added after the incident on 02/26/2018. Interview with the Certified Nursing Assistant (Staff H) on 11/15/2018 at 10:44 a.m. revealed, she normally worked from 7 a.m. to 3 P.M. When she worked she supervised the patio, and she paid attention to the residents that could not control their smoking; she provided aprons to these residents. She cleaned up the cigarette butts around the patio as well, and provided cigarettes and would light the cigarettes for the residents who were unable to do this on their own. Staff H kept the lighters; residents were not supposed to have lighters in their possession. Resident #85 smoked cigarettes, which were provided to him by other residents. She lit his cigarettes because he could not do it on his own, and put on his smoking apron. Even though resident #85 was able to smoke cigarettes, she had to monitor him because he would drop ashes and they would fall on his apron. Once he was finished smoking, he would drop the cigarette butt on the ground and she would have to pick it up and put it in the receptacle. Resident #85 had never burned himself when she was present, but once she was told that he suffered a small burn to his stomach from smoking. This was a long time ago, and she could not remember the date. Staff H said that there was always someone on the outside patio when residents were smoking, they were never left unsupervised. Record review of the medical record for resident #85 revealed no documentation related to the resident suffering a burn to his stomach, other then the incident on 02/26/2018. Interview with the Certified Nursing Assistant (Staff J) on 11/15/2018 at 11:54 a.m., via telephone, revealed that he worked the 3 PM to 11 PM shift. When he was providing care to resident #85 on 02/26/2018, he observed a mark on the right inner thigh, four inches above the knee. The resident was not able to say what happened due to his cognition. Staff J reported it to the nurse, she came and assessed the resident, and provided treatment to the site; it was healed in three days. When he saw the mark, he thought that it was a burn from a cigarette because resident #85 would smoke cigarettes on the patio. During Staff J's shift there was always someone on the patio supervising the residents while smoking. If the assigned staff member for the patio did not come to work, then each staff member during his shift had to take turns supervising the patio. Resident #85's right side was paralyzed, so he used his left hand to smoke. As a result of the resident's right side being paralyzed and his confusion, the resident probably did not scream out in pain when he burned himself. Whenever resident #85 smoked outside he wore an apron, but sometimes the residents could move them, which was why they needed to be supervised. He could not explain what happened with the resident. Interview with the Unit Manager (Staff I) on 11/15/2018 at 12:20 P.M. revealed, at the time of admission residents were assessed for safe smoking. They assessed them for a history of smoking, their medical [DIAGNOSES REDACTED]. A safe smoker was a resident that was alert and oriented, able to make their decisions on their own, and may or may not need an apron. If a resident needed an apron for smoking, this meant they were not a safe smoker and may throw ashes on themselves and were not alert. There was always someone on the smoking patio, for all shifts. There was a machine on the wall on the patio where residents could light their cigarettes, and staff would also assist the residents with lighting their cigarettes. Resident #85 was not a safe smoker, which was why he needed an apron and needed to be supervised. Staff I had not heard anything about the resident burning himself with a cigarette. Interview with the Minimum Data Set Coordinator (Staff K) on 11/15/2018 at 2:04 P.M. revealed, he completed smoking assessments for residents at the time of admission, quarterly, and if there was a significant change in their condition. When the residents were assessed, he looked at their frequency of smoking, what kind of smoking materials was used, and if they were safe to smoke independently. If the residents were not safe to smoke by themselves, then they needed to be supervised on the patio, and whoever was on the patio had to monitor the resident and assist them. Some of the residents needed to wear smoking aprons such as resident #85, and he reassessed the resident after the incident in (MONTH) (YEAR). Staff K said that he considered the resident a safe smoker; as long as he was supervised and monitored, and he was wearing his smoking apron. Record review and interview with the Risk Manager on 11/16/2018 at 8:39 a.m. revealed, that a safe smoker was someone who understood how to use the smoking materials, and were able to dispose of the cigarettes. The smoking policy was explained to the residents. There was always someone supervising the residents while smoking on the patio; there was always someone on the patio from 7 a.m. to 11 P.M., and if a resident wanted to smoke outside of that timeframe then arrangements were made for them to go out and be supervised. With regards to resident #85, on 02/26/2018, when the Certified Nursing Assistant (CNA) was providing activities of daily living (ADL) care, there were no burn holes in the resident's clothing, but after undressing the resident the CNA saw the mark on the resident. It was assumed that it could have been from the resident smoking. The Risk Manager said that through her investigation she found out that it was assumed it was from a cigarette, but there was no proof. Resident #85 was not verbal, and could not explain what happened. When asked the Risk Manager stated that [MEDICATION NAME] cream could be used for burns, and open skin areas; not lacerations. His open area was monitored, another smoking assessment was completed and he was deemed an unsafe smoker who required supervision, and they implemented the smoking apron. Smoking aprons were always offered on the patio, but when someone was deemed an unsafe smoker the patio monitor would offer the smoking apron even though the resident could still refused. Residents had to be educated on the use of the apron, and in resident #85's case he wore the apron. The Risk Manager stated that the burn was smoking related, but based on the resident's smoking assessments completed by Staff K, he answered the questions accordingly; the resident was properly assessed for smoking. However, in the smoking assessments nursing staff should include any special precautions that are needed for residents that smoke in the notes section. With regards to supervision, Staff H who was the patio monitor was present with the resident on 02/24/2018 and 02/25/2018. Resident #85 never had a burn on his stomach, and had no other smoking related issues since (MONTH) (YEAR). 2) Observation on 11/14/18 at 8:57 A.M. on the South Wing revealed the hot water temperature in room [ROOM NUMBER] registered 118 degrees Fahrenheit (F). Both residents in the room were alert and oriented and able to mix the hot and cold water to adjust the temperature. Observation on 11/14/18 at 9:01 A.M. on the South Wing revealed the hot water temperature in room [ROOM NUMBER] registered 122 degrees F. Both residents in the room were dependent on staff and unable to use the sink without assistance. Observation on 11/14/18 at 9:03 A.M. on the South Wing revealed the hot water temperature in room [ROOM NUMBER] registered 120 degrees F. One resident in the room was alert and oriented and able to mix the hot and cold water to adjust the temperature. The other resident in the room does not use the sink. Observation on 11/14/18 at 9:07 A.M. on the South Wing revealed the hot water temperature in room [ROOM NUMBER] registered 126 degrees F. Both residents in the room were dependent on staff and unable to use the sink without assistance. Observation on 11/14/18 at 9:10 A.M. on the South Wing revealed the hot water temperature in room [ROOM NUMBER] registered 126 degrees F. Both residents in the room were dependent on staff and unable to use the sink without assistance. Observation on 11/13/2018 at 1:17 P.M. of room [ROOM NUMBER] on the south unit revealed that the sink hot water temperature was taken with a thermometer and was 138 Fahrenheit. The resident in the room was not alert and non-ambulatory. Observation on 11/13/2018 at 1:20 P.M. of room [ROOM NUMBER] on the south unit revealed that the sink hot water temperature was taken with a thermometer and was 120 Fahrenheit. The resident in the room was not alert and non-ambulatory. Observation on 11/13/2018 at 1:24 P.M. of room [ROOM NUMBER] on the south unit revealed that the sink hot water temperature was taken with a thermometer and was 122 Fahrenheit. The resident in room [ROOM NUMBER] noted that she bathed herself but mixed the hot and cold water. Observation on 11/13/2018 at 1:37 P.M. of room [ROOM NUMBER] on the south unit revealed that the sink hot water temperature was taken with a thermometer and was 118 Fahrenheit. The resident in the room was not alert and non-ambulatory. Observation on 11/13/2018 at 2:11 P.M. of room [ROOM NUMBER] on the south unit revealed that the sink hot water temperature was taken with a thermometer and was 130 Fahrenheit. The resident in room [ROOM NUMBER] A was not alert and non-ambulatory and the resident in room [ROOM NUMBER] B said he adjusted the water himself and it was not too hot. Observation on 11/13/2018 at 2:15 P.M. of room [ROOM NUMBER] on the south unit revealed that the sink hot water temperature was taken with a thermometer and was 130 Fahrenheit. A photo was taken for evidence. The resident in the room was not alert and non-ambulatory. Observation on 11/13/2018 at 2:19 P.M. of room [ROOM NUMBER] on the south unit revealed that the sink hot water temperature was taken with a thermometer and was 130 Fahrenheit. The resident in the room [ROOM NUMBER] A was not alert and non-ambulatory and the resident in room [ROOM NUMBER] B was able to ambulate with a wheel chair and was able to adjust the temperature of the water. Observation on 11/13/2018 at 2:21 P.M. of room [ROOM NUMBER] on the south unit revealed that the sink hot water temperature was taken with a thermometer and was 124 Fahrenheit. The resident in room [ROOM NUMBER] was alert, ambulated with a wheel chair and was able to adjust the hot water temperature. Observation and interview on 11/14/2018 at 9:41 A.M. with the maintenance supervisor and manager of environmental services revealed, We go through every Monday and check the sinks and get the thermometer. The hot water temperature has to be between 105 Fahrenheit (F) to 115 F. There are two boilers in the back. The maintenance director noted that there were three units. Walk-through of hot water temperatures on the south unit in resident rooms with the maintenance director revealed the following on 11/14/2018: Observation on 11/14/2018 at 9:45 A.M. of room [ROOM NUMBER] revealed that the sink hot water temperature was taken with a facility's thermometer and was 128 Fahrenheit. Observation on 11/14/2018 at 9:53 A.M. of room [ROOM NUMBER] revealed that the sink hot water temperature was taken with a facility's thermometer and was 120 Fahrenheit. Observation on 11/14/2018 at 9:55 A.M. of room [ROOM NUMBER] revealed that the sink hot water temperature was taken with a facility's thermometer and was 117 Fahrenheit. Observation on 11/14/2018 at 9:58 A.M. of room [ROOM NUMBER] revealed that the sink hot water temperature was taken with a facility thermometer and was 138 Fahrenheit. A photo was taken as evidence. Interview on 11/14/2018 at 10:08 A.M. with the maintenance supervisor, manager of environmental services and facility technician revealed, they checked the temperature of the hot water in the resident's sink and made sure it was not too hot or too cold. The facility technician noted that two boilers supported the hot water for the whole building. The staff technician mentioned that a hot water temperature in the resident's room on the south unit of 138 Fahrenheit was a concern and was too high. They kept the hot water temperatures below 115 Fahrenheit. The technician explained that the east and south units shared the same valve and this had to do with the distribution. The facility technician showed the setting of the hot water indicator that supplied the boiler in the boiler room and it was set at 141 Fahrenheit. The facility technician concluded: We are in the process of adjusting the wings. The facility technician lowered the hot water boiler indicator to 115 Fahrenheit. Interview on 11/16/2018 at 4:52 P.M. with the maintenance director and the administrator revealed that they monitored the water temperatures every Monday, chose four random rooms and would write them down on the log. The facility water temperature log was shown from (MONTH) (YEAR) until the current date. Review of the facility hot water temperature log dated 11/21/2018 revealed that the highest water temperature was 109 Fahrenheit on the south unit. The maintenance director explained, We recently changed to a pneumatic system and worked with a compressor. There were problems with hot water. The plastic hose of the pneumatic system would get corroded. We changed to the newer [MEDICATION NAME] system about 3 to 4 months ago. When there is a power surge in the building, the [MEDICATION NAME] try to adjust themselves. The maintenance director noted that a vendor came on Wednesday, but there was no documentation yet. They would send an invoice for this. The maintenance director stated that the hot water temperature in the resident's rooms should be between 105 to 115 Fahrenheit. The maintenance director mentioned that he could not say why the hot water temperatures on the south unit were high in the resident's rooms. They were not aware of any residents having any injuries from the hot water and they reviewed the incident log. The maintenance director remarked regarding the sink hot water temperature in the resident's room on the south unit this week that: It is a concern to have hot water temperatures at 138 F. Record review of the facility's policy revised on 6/12/2018 revealed, To define the proper temperature for hot water. The maintenance director will monitor the heat exchange. Thermometer will be calibrated prior to taking any water temperatures to assure accuracy. When checking hot water temperatures place the thermometer probe under the running water for 3 to 5 seconds or until the temperature stops rising on the thermometer. Maintenance will take a minimum of 4 temperatures on each nursing unit, one in each section of the unit on a weekly basis. If the temperatures are out of range 105 to 115 degrees Fahrenheit then nursing administration and the maintenance supervisor must be notified immediately. Hot water temperatures are documented on the maintenance hot water temperature form along with any action.

Based on observation, interview and record review, the facility failed to provide care and services to attain and/or maintain the highest practicable well being for for one (resident #55) of two residents reviewed out of five residents receiving [MEDICAL TREATMENT] services. This was evidenced by 1) failure to monitor fluid intake to ensure a physician ordered fluid restriction was maintained and 2) failure to coordinate treatment to ensure effective [MEDICAL CONDITION] control to include medication administration and review of laboratory results. These practices resulted in harm to the resident as evidenced by episodes of fluid overload and ongoing failure to improve [MEDICAL CONDITION] control. The findings included: 1) Review of the Policy and Procedure titled Fluid Restriction: (undated) The fluid intake of the resident will be limited and/or not to exceed the maximum prescribed by the physician. The intake will be recorded in the Intake and Output Section. The amount of fluids given to each of these of these resident will be recorded in the I and O section. This amount will be deducted from the totals listed as provided by the dietitian. Record review revealed resident #55 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of resident #55's physician's orders [REDACTED]. This order was received 12/14/14. An order was received on 7/17/2015 for [MEDICATION NAME] 40 mg twice daily for 30 days. Ancillary orders included [MEDICAL TREATMENT] treatment on Monday, Wednesday and Friday. Review of resident #55's physician order [REDACTED]. Document percentage (%) consumed. The POSs included the total amount of fluid allotted for each shift, but did not designate how much is provided by dietary and nursing. Review of resident #55's medication administration records (MAR) for May, June and July 2015 reflected the fluid restriction, not to exceed 1200 ml/day, document amount consumed. The July 2015 MAR indicated [REDACTED]. Review of the July 2015 MAR from the 1st through the 21st reflected the fluid restriction section was blank for 9 of 21 days on the 7-3 shift, 5 of 21 days on the 11-7 shift, and the 3-11 shift was not documented on this MAR. Review of the June 2015 MAR upon readmission to the facility from 6/17/15 - 6/30/15 reflected fluid restriction not to exceed 1200 ml/day: 11-7 shift 300 ml, 7-3 shift 500 ml, and 3-11 shift 400 ml, record amount consumed. The documentation reflected intake generally 100 ml per shift. The May 2015 MAR from 5/16/15 through 5/25/15 while the resident was present in the facility reflected fluid restriction not to exceed 1200 ml/day: 11-7 shift 300 ml, 7-3 shift 500 ml and 3-11 shift 400 ml. The MAR indicated [REDACTED]. Review of the clinical record revealed no 24 intake records were maintained. The MAR for May 10 -13th reflected fluid restriction, not to exceed 1200 ml/day. This MAR indicated [REDACTED]. Review of a physician progress notes [REDACTED].#55 was transferred to the hospital for [DIAGNOSES REDACTED]. Beginning 7/21/15 resident #55's fluid distribution order was changed to include fluid restriction not to exceed 1200 ml/day, 600 ml on trays (breakfast 240 ml, lunch 120 ml, dinner 120 ml, and HS (hour of sleep) 120 ml; 600 ml on the unit divided between 3 shift 11-7 100 ml, 7-3 300 ml, 3-11 200 ml. This distribution was listed on the MAR for each meal, HS snack and medication pass beginning 7/21/2015. Review of the C N A (Certified Nursing Assistant ) General Flow Sheet beginning 7/21/2015 reflected: no water pitcher at bedside. Only give fluids on meal tray (7-3 240 ml at breakfast, 120 ml at lunch, 120 ml at dinner and 120 ml at HS. During interview with with the Licensed Practical Nurse (staff V) on 07/22/2015 at 12:52 PM, she said resident #55 was on a fluid restriction. The amount of fluid provided by nursing was on the MAR. The amounts given by nursing for medication pass was divided by shift. We measure the water before administration. The CNAs were aware of the fluid restriction. Dietary and the doctor decided how much fluid the resident could receive and also they decided the distribution between dietary and nursing. This order was received 7/21/2015. During interview with the Licensed Practical Nurse (staff X) on 07/23/2015 at 8:54 AM, she said resident #55 is on a fluid restriction. Dietary sends a certain amount of fluid on the trays. We have to monitor how much fluid she takes with her meal and then we make up the difference. It is divided up for medication pass. Her restriction is 1200 ml/day. Dietary sends 600 on her trays (total) and nursing divides up the remaining 600 with medications. I know as the nurse I cannot give her more than a half a cup of water with her medication. We record and track the amount of fluid accepted. The CNAs' document on the flow sheet how much was taken at meals and the nurses' document on the MAR indicated [REDACTED]. Prior to 7/21/2015 the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. When asked how much of the 400 ml per shift could be given by nursing the LPN said, all I know is that they were sending 600 from dietary and we could split the rest. I thought there was an intake sheet, but I don't see one. She could not provide any documentation of the amount provided by nursing out of the 400 per shift that was on the MAR. She said, there used to be an I and O (intake and output) sheet, but I don't see them anymore. The LPN could not produce any completed I and O records. During interview with the Registered Dietitian (RD) on 07/23/2015 at 10:26 AM, she said the MAR previously reflected the 1200 ml fluid restriction and the MAR indicated [REDACTED]. This was the total for the day including what is given on the trays. She stated now as of 7/21/15 we are to do a breakdown of the fluid distribution to determine how much is given at each meal. The remainder is now being distributed between the the nursing shifts for medication pass. It is obvious that we have to do more teaching. During interview with the Director of Patient Care Services (DPCS) on 07/23/2015 at 3:36 PM, she said when I reviewed a chart on Monday for a resident on a fluid restriction the information provided by dietary included the total amount of fluids per shift including what is allotted for both meal and medication pass. So when I met with the dietitian on Tuesday we decided that we have to quantify that. When the total for the trays is determined, that specific amount must be placed on the MAR indicated [REDACTED]. Starting Tuesday 7/21/2015 we revised the MARs so the specific amounts can be quantified. The Dietitian has previously determined the distribution but it did not go through the physician to become an order and therefore was not specific on the MARs. Resident #55 is on a 1200 ml fluid restrictions. The MAR indicated [REDACTED]. There was no tracking of the total amount of intake. They were not using an intake record. There was no intake record and the only record that was used was the documentation on the MAR. Observation on 07/24/2015 at 8:41 AM revealed resident #55 in her room eating breakfast. Her tray contained 8 ounces fat free milk, 4 ounces of soy milk, and 4 ounces of coffee. Resident #55 reported the soy milk came on her tray and she asked the C N A for the coffee and the skim milk. She accepted all of the fat free milk and coffee, but not the soy milk. Observation at the bedside was a bagged lunch labeled with her name. The bagged lunch contained a sandwich, 4 ounces of juice, and fruit cocktail in juice. Review of the tray ticket revealed 1200 ml fluid restriction. Beverages included: Breakfast 4 ounces of soy milk, lunch 4 ounces of soup, dinner 4 ounces of soy milk and HS snack included a sandwich, but the 4 ounces of fluid was not scheduled to be sent. During interview with the CNA (staff Y) 07/24/2015 at 9:04AM, she said she was assigned to care for resident #55 today. I delivered her breakfast tray and she requested a carton of blue milk, but we did not have that so I gave her the purple carton. I am not aware of any diet restriction that she has. If a resident asks for something I usually tell the nurse first to see if she can have it. I did not ask the nurse today because I usually let her have whatever she asks for. I know she is on a fluid restriction, but she (the resident) said, she does not care. I did not tell the nurse today, but in the past when I ask the nurses they say, if the resident says she does not care, just give it to her. During interview with Licensed Practical Nurse (staff Z) on 07/24/2015 at 9:08 AM, she said she was not aware the CNA gave her extra fluid. I know she frequently asks for extra fluids, but I was not made aware she got extra milk today. The CNA did not say anything to me. Review of resident #55's minimum data sets (MDS) including the admission assessment dated [DATE] and the most recent quarterly assessment dated [DATE] revealed resident #55 was on a Therapeutic diet and special treatments included [MEDICAL TREATMENT]. Review of resident #55's care plan implemented 8/26/14 revealed, the resident was on [MEDICAL TREATMENT] related to a [DIAGNOSES REDACTED]. Resident at high nutrition risk with potential risk for weight fluctuations related to multiple medical problems, altered labs, polypharmacy, obesity with [MEDICAL CONDITION] to bilateral lower extremities and [MEDICAL TREATMENT] needs. On fluid restriction 1200 ml/day. Goals included fluid restriction will be within amount through next review date. Approaches included, but were not limited to diet and medications as ordered and resident to comply with diet and fluid restriction, provide fluid of choice within restrictions (not to exceed 1200 ml daily) as per [MEDICAL TREATMENT] center, divide the amount of all per shift and document. 2) Review of resident #55's clinical record reflected the only laboratory results on file were dated 8/14/2014. Review of resident #55's [MEDICAL TREATMENT] Communication Forms used by the facility to communicate pertinent information between the facility and the [MEDICAL TREATMENT] center revealed resident #55 was receiving Epopen (a prescription medicine used to treat a lower than normal number of red blood cells ([MEDICAL CONDITION]) caused by [MEDICAL CONDITION] in patients on [MEDICAL TREATMENT] to reduce or avoid the need for red blood cell [MEDICAL CONDITION]) and Venifer (a drug used to treat [MEDICAL CONDITIONS] in people with kidney disease). [MEDICAL CONDITION] is a lack of red blood cells in the body. Review of the POS [REDACTED]. During interview with the RD on 07/24/2015 at 1:38 PM, she said, she is in contact with the [MEDICAL TREATMENT] center dietitian because they draw labs monthly and they are supposed to fax them to us. We are usually in contact to discuss what is going on with the resident and they will discuss needed changes with us. At 4:46 PM, the RD said sometimes the lab results forms are faxed to me from the [MEDICAL TREATMENT] center and sometimes they are faxed to the floor/unit. The nurses will then put them in the chart. Review of the clinical record confirmed the only lab results on file were dated 8/14/14. The RD reported, she keeps the lab results that are faxed to her in her office. The lab results provided by the RD revealed no indication that they had been reviewed by the primary care physician. When asked if resident #55 received any additional medications at [MEDICAL TREATMENT] to improve her [MEDICAL CONDITION] control, the RD said, she did not know she would have to check the chart. After reviewing the chart she said, there were no orders for any medications to be given at the [MEDICAL TREATMENT] center. The facility provided [MEDICATION NAME] and Folic Acid, but I guess she does not get [MEDICATION NAME]. During interview with the DPCS on 07/24/2015 at 4:43 PM, she said the labs from the [MEDICAL TREATMENT] center should be on file in the clinical record. Review of the clinical record with the DPCS confirmed the only lab results on file were dated 8/14/2014. She said, the RD is supposed to be coordinating care with the RD from the [MEDICAL TREATMENT] center. Once the labs are received they should be placed in the chart for the doctor to review. In reference to medications administered at the [MEDICAL TREATMENT] center, she said, we did not get orders from the primary care physician for medications given at the [MEDICAL TREATMENT] center. These medications are administered and managed by the [MEDICAL TREATMENT] center. The dietitian has to review the medications and the labs and coordinate care with the dietitian at the [MEDICAL TREATMENT] center. Review of resident #55's Nutritional Progress Notes: Progress note dated 7/22/15 revealed, labs from [MEDICAL TREATMENT] 6/20/2015: RBC (red blood count) 2.8 (low) H/H (hemoglobin and hematocrit) 8.4/26.3 (low). Progress note dated 6/19/2015 revealed medications included [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITIONS]). Labs 6/15/2015 revealed RBC 2.85 (low), H/H 8.5/25.8 (low). Progress note dated 5/26/2015 revealed labs 5/15 H/H 8.3/25.4 (low). Review of resident #55's laboratory results revealed the normal reference ranges for RBC 4.20-5.40, hemoglobin 12.0-16.0, and hematocrit 37.0-47.0. Resident #55's laboratory results as noted above were significantly below the reference range.