Every finding on record at Kindred Hospital South Florida Hollywood

Based on record reviews and interviews, the facility failed to complete and submit Resident Assessments to Centers for Medicare Medicaid Services (CMS), at least quarterly for 6 of 6 sampled residents reviewed for Resident Assessments, Resident #37, Resident #44, Resident #53, Resident #57, Resident #58 and Resident #60. The findings included:1. Record review for Resident #37 revealed an admission date of 11/20/26 and a discharge date of 02/06/26. A Progress note, with a reference date of 02/06/26 documented, transportation arrive with stretcher and EMT x 2. Resident left the facility in stable condition to go home in stretcher and all belongings. Lab results explained and given to resident and daughter. All needs met during short stay. Further review of the resident's electronic health records revealed no evidence that a discharge assessment had been completed and submitted to CMS. 2. Record review for Resident #44 revealed an admission date of 12/24/25 and a discharge date of 02/12/26. A Progress Note, with a reference date of 02/12/26 documented, Patient to be discharged today to home. HH (Home Health) ordered Further review of the resident's electronic health records revealed no evidence that a discharge assessment had been completed and submitted to CMS. 3. Record review for Resident #53 revealed an admission date of 12/15/25 and a discharge date of 02/12/26. A Discharge Note, with a reference date of 02/12/26 documented, the patient was discharged in stable condition. Further review of the resident's electronic health record revealed no evidence of a discharge assessment being completed and submitted to CMS. 4. Record review for Resident #57 revealed an admission date of 11/07/25 and a discharge date of 02/13/26. A discharge note, with a reference date of 02/13/26 documented, Resident was discharged home in stable condition. At the time of discharge, the resident was alert and oriented Further review of the resident's record revealed no evidence of a discharge assessment been completed and submitted to CMS. 5. Record review for Resident #58 revealed an admission date of 12/09/25 and a discharge date of 02/13/26. A discharge note, with a reference date of 02/13/25 documented, Discharge note 02/13/26, Patient left facility in stable condition at 330 PM accompanied by ambulance on a stretcher back to his ALF. Further review of the resident's record revealed no evidence that a discharge assessment had been completed and submitted to CMs. 6. Record review for Resident #60 revealed an admission date of 12/09/25. At the time of the survey, Resident #60 was a resident in the facility and had no additional admissions or re-admissions. Further review of the resident's record revealed that the resident's Quarterly Minimum Data Set (MDS) was initiated on 04/02/26. At the time of the survey, multiple sections of Resident #60's Quarterly MDS still had not been completed. During an interview, on 05/06/26 at 11:54 AM, with the MDS Coordinator, the MDS Coordinator stated that she had been working in the facility for ten (10) days. When asked about the assessments, the MDS Coordinator provided the following details: Resident #37's last assessment was an admission MDS with a reference date of 11/27/25 and the discharge assessment was not completed after the resident had been discharged [DATE] Resident #44's last assessment was an admission MDS with a reference date of 12/31/25 and the discharge MDS was 'still open' after being discharged [DATE]. Resident #53's last assessment was an admission MDS with a reference date of 12/22/25 and the Discharge MDS was 'still open' after being discharged [DATE]. Resident #57's complete assessment was an admission MDS with a reference date of 11/10/25 and the Discharge MDS was 'still open' after being discharged [DATE]. Resident #58's last complete assessment was an admission MDS with a reference date of 12/26/25 and a Discharge MDS was 'still open' after being discharged [DATE]. Resident #60's last complete assessment was an admission MDS with a reference date of 12/26/25. The MDS Coordinator stated, I was working on his. His Quarterly MDS was opened on 04/02/26 and is waiting for me to learn how to submit. When asked about the assessments not being completed and submitted, the MDS Coordinator replied, there has been a few people. They have a remote MDS Coordinator that works out of [another state] with things that he can find documented. The District Case Manager/MDS Coordinator was opening up the assessments. The MDS Coordinator stated that the facility had not had a full time MDS Coordinator since January 29, 2025. The MDS Coordinator stated, There are a lot of February, March and April assessments that we are trying to do right now. The last time the MDS Coordinator was here was in January, there are a lot of February, March and April assessments that we are trying to do right now.

Based on record reviews and interviews, the facility failed to initiate care plans for the use of psychotropic medications for 2 of 5 sampled residents reviewed for unnecessary medications, Resident #67 and Resident #68. The findings included:1. Record review for Resident #67 revealed an admission date of 04/20/26. Resident #67's diagnoses on admission included: Fracture of T5-6 vertebra, Fracture of T9-10 vertebra, multiple fracture of ribs, Atherosclerotic Heart Disease, Cerebral Ischemia, Effusion of right shoulder, Alzheimer's Disease, Hypercholesterolemia, disorders of bone density and structure, Seizures, Abnormalities of gait and mobility, Elevated white blood cells count, Depression, Hypertension, Weakness, Pain, Long-term and current use of aspirin, Old Myocardial Infarction, Unsteadiness on feet, and Insomnia. Resident #67's orders included: Tramadol 50 mg tablet PRN (as needed) every 8 hours starting 04/25/26 for pain. Duloxetine (Cymbalta) 30 mg capsule every day starting 04/20/26 (7 AM to 10:30 AM)Pregabalin (Lyrica) 50 mg capsule PRN every 12 hours starting 04/21/26 for pain Behavior monitoring by shiftAntidepressant side effects by shiftSedative side effects by shift Further review of the resident's record revealed that there was no care plan related to the use of psychotropic medications. 2. Record review for Resident #68 revealed an admission date of 04/10/26. Resident #68's diagnoses included: fracture of neck of right femur, Pain in right hip, Rheumatoid arthritis, Cerebral ischemia, Anemia, Major depressive disorder, Hypertension, GERD, Hyperlipidemia, Hypo-osmolality and hyponatremia, Glaucoma, Abnormalities of gait and mobility, unsteadiness on feet, Muscle weakness. Resident #68's orders included:Oxycodone 5 mg tablet PRN (as needed) every 4 hours for hip pain - 04/11/26Duloxetine (Cymbalta) 20 mg capsule 1 time daily for depressive disorder - 04/11/26Escitalopram (Lexapro) 5 mg tablet 1 time daily for depressive disorder - 04/11/26Pain Assessment by shift - 04/10/26Behavior monitoring by shift - 04/10/26 Further review of the resident's record revealed that there was no care plan for the use of psychotropic medications. During an interview and side by side review of Resident #67 and Resident #68's record, on 05/06/2026 at 11:43 AM, with the District Director of Clinical Education, she stated that she was providing clinical support to the facility educators and the Directors of Nursing (DONs), and was the acting DON for 2-3 weeks prior to the current Director of Nursing. Upon request, the District Director of Clinical Education was unable to produce or locate care plans for psychotropic medications. The District Director of Clinical Education acknowledged that there was no care plan for the use of psychotropic medications for Resident #67 and Resident #68.

Based on observations, interviews and record reviews, the facility failed to provide an environment free from accident hazards with the potential to affect 8of 8 residents capable of ambulating independently, Residents #71, Resident #59, Resident #69, Resident #12, Resident #30, Resident #72, Resident #73 and Resident# 74. The findings included:On 05/03/26 at 9:13 AM, it was noted that the soiled utility room door at the nurse's station was left ajar and there was no staff in the immediate area to prevent residents from entering the room. This Surveyor pushed the door open with minimal effort and entered the room. Once inside of the room, it was noted that the room contained a waste container for biohazardous waste (as indicated by the label on the red receptacle), a refrigerator used for biological samples (as indicated by vials used for collecting blood inside of the refrigerator), a tube feeding apparatus (2 pumps that were attached to poles) and various containers for soiled linens and other soiled items, and a hand washing sink with standing water in the bowl, as well as single use gloves and face masks that appeared to have been used and discarded on the floor On 05/03/2026 12:04 PM, an unidentified staff member was observed entering the Soiled Utility Room at the nurse's station by backing in and did not have to disable any locking mechanism (code on keypad, key) to enter the room. During an interview at the time of the observation, Staff A, Registered Nurse (RN) acknowledged that the door should have been closed. The RN stated that the locking mechanism worked and demonstrated by closing the door and having to put a numeric code into the locking mechanism to open the door. During an observation, on 05/04/26 at 3:52 PM of the facility's Soiled Utility Room, accompanied by the Housekeeping Morning Supervisor, working in the facility for 10 years and the Housekeeping/Culinary Director, working in the facility for 8 years, it was observed that the door was not locked and secured. Neither the Housekeeping Morning Supervisor, nor the Housekeeping/Culinary Director, were able to provide a plausible explanation when asked, as to why the Soiled Utility Room was not locked or secured. On 05/06/2026 at 7:46 AM the soiled utility room door was left ajar and there was no staff in the immediate area to prevent residents from entering the room. During an interview at the time of the observation, with the Administrator, the Director of Nursing (DON) and the Social Services Director acknowledged the concern. The Administrator stated that the door should have closed all of the way and staff should make sure that the door closes all of the way. The DON provided a list of residents that had the ability to ambulate independently and would have been able to enter the room in the conditions that were observed and discussed, including the following residents: Resident #71, with an admission ate of 04/20/26 and documented as alert and oriented times 3 according to an admission Note with a reference date of 04/10/26 Resident #59, with an admission date of 04/07/26. A Medicare 5-day Minimum Data Set (MDS) documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had a moderate cognitive impairment, and required partial/moderate assistance for bed mobility, transfers and walking short distances and ambulated independently with the use of a walker. Resident #69, with an admission date of 04/24/26. An admission Note, with a reference date of 04/25/26 documented that Resident #69 was alert and oriented times 3. Resident #12, with an admission date of 03/26/26. A Medicare 5-day MDS with a reference date of 04/02/26 documented that the resident had a BIMS score of 12, indicating that the resident had a moderate cognitive impairment, and the resident required setup or cleanup assistance for bed mobility and transfers and ambulated independently without the use of a device (wheelchair, walker). Resident #30 with an admission date of 03/31/26. An admission Progress Note with a reference date of 04/01/26 documented that Resident #30 was alert and oriented times 4. Resident #72, with an admission date of 04/15/26. A Medicare 5-day MDS documented that Resident #72 had a BIMS score of 12, indicating that the resident had a moderate cognitive impairment, and ambulated independently with the use of a manual wheelchair. Resident #74, with an admission date of 05/04/26. A Nursing Progress note, with a reference date of 05/05/26 documented that Resident #74 was alert and oriented times 2

Based on observation, interview and record review, the facility failed to post the total number and the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs) with the resident census, in plain view of the residents and visitors on 05/03/26. The findings included:During the initial screening process of the facility, beginning on 05/03/26 at 9:03 AM, it was noted that the actual working hours for the nurses and the CNAs were not posted on the unit. During an interview at the time of the observation, Staff A, RN (Registered Nurse), was asked where the information would be posted, Staff A stated that the information was supposed be posted on the wall, above where the menus are posted by the nurse's station, at the beginning of each shift.

Based on interview and record review, the facility failed to ensure that the agreement reflected that residents and their representatives that entered into a binding arbitration agreement had the right to rescind the agreement within thirty (30) calendar days of signing the agreement. This had the potential to affect all residents that agreed to enter into the agreement. The census at the time of the survey was 30 residents, including 20 residents that were admitted within the previous 30 days prior to the survey. The findings included: Review of the facility's Binding Arbitration Agreement, on 05/03/26 at approximately 2:00 PM, noted the Agreement documented, This agreement may be cancelled by the patient by delivering written notice of revocation to the Hospital not later than 5:00 PM local time on the fifth (5th) business day after signing this agreement. During an interview, on 05/04/2026 at 10:48 AM with the Business Office Manager/Admissions Coordinator, the Business Office Manager/Admissions Coordinator confirmed that the Agreement applied to both the hospital and the Skilled Nursing Unit and acknowledged understanding of the finding.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision to prevent elopement and failed to ensure that safety measures were in place to prevent elopement for 1 of 1 sampled residents reviewed for elopement. The findings included:A review of the education titled Hollywood-Elopement Education (undated) documented the following: when a resident is monitored due to confusion or the concern that they may exit the Unit, this means that a staff member must always have the resident in their visual field. Residents who exit the Unit without staff knowledge, even if they remain inside the hospital, should be reported to facility leadership immediately as a potential elopement. Record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on 6/12/202 with diagnoses of Acute Respiratory Failure, Heart Failure, and Muscle Weakness. The admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 has a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. Record review revealed that on 6/8/2025, Resident #1 was encountered on the first floor just below his Unit, which is on the second floor. Resident #1 waited for a visitor to come up on the elevator to the Unit (2nd floor) and entered the elevator before the doors closed. The 2nd floor Unit has keypads that require a code to be entered to leave the Unit. The elevator on the first floor does not require a code to access it, but it does require a code to exit the 2nd floor Unit. A visitor of another Resident came to the 2nd floor Unit by elevator, and once the doors opened on the Unit, Resident #1 entered the elevator on the second floor and rode back down to the first floor. In an interview conducted on 07/07/2025 at 8:00 AM with Staff B, Security Supervisor, who stated on 06/08/2025, he received a call from Staff J, Security Officer letting him know that while conducting her rounds she observed Resident #1 trying to get out by the East side back door near the Physician ' s parking lot. Staff B instructed Staff J to call the nursing staff on the 2nd floor Unit to come and retrieve Resident #1 from their Unit. According to Staff J, Resident #1 was trying to push the door open to the Physician ' s parking lot and was stopped by Staff F, Registered Nurse, who was just coming inside from the Physicians ' parking lot into the building. Staff B reported that Resident #1 came down from the 2nd floor Unit in his wheelchair and that a code is required to leave the 2nd floor Unit. If the elevator doors open on the 2nd Unit, it is possible to enter the elevator while the elevator doors are open without entering a code. In this interview, this Surveyor was able to see the video of Resident #1 attempting to leave the facility. Resident #1 was noted in his wheelchair wearing a hospital gown near the East side door by the Physician ' s parking lot. Staff A, Housekeeping, was noted passing by Resident #1, opening and closing the door behind her to the outside Physician ' s parking lot. She did not stop or acknowledge Resident #1, who was right by the exit door, as she walked outside the facility.In an interview conducted on 07/07/25 at 9:10 AM with Staff C, Housekeeping Manager, reported Staff A works all units depending on the coverage for the day, and that she worked on the 2nd floor Unit on 06/08/2025. His staff were trained in elopements. If they recognize a resident near a door or attempting to leave, they need to stay near the resident and notify nursing staff and supervisors of the situation. He further said that Staff A was educated with drills on elopement, and when asked to see documentation on education, he could not provide any. In an interview conducted on 07/07/2025 at 10:40 AM with Staff E, Registered Nurse, stated that she worked on the 2nd floor Unit on 06/08/2025 when she observed Resident #1 near the elevator. She was concerned that Resident #1 was attempting to leave the Unit and told Resident #1 to move away from the elevator area. Staff G, Registered Nurse, who was assigned to Resident #1, told her not to worry and that she was watching Resident #1 in the hallway. Staff E walked away to attend to her residents, leaving Staff G to watch Resident #1. Shortly after, they received a call from security informing them that Resident #1 was on the first floor, near the exit door, attempting to leave. In a phone interview conducted on 07/70/25 at 11:00 AM with Staff F, she stated that on 06/08/2025, she was coming back for her lunch break through the Physician ' s parking lot when she noticed Resident #1 wedged between the exit door in his wheelchair. She recognized Resident #1 as a Patient and used her cell phone to call security and nursing staff on the 2nd floor Unit. Staff G came from the 2nd floor Unit, and together they managed to get Resident #1 away from the doorway. Resident #1 was then taken to the 2nd floor Unit by Staff G. A chart review of the facility ' s elopement education revealed the following: an elopement education drill was conducted on 11/15/24 and on 05/13/2025. Closer observation did not show that Staff A or other housekeeping staff received any education on elopement. In an interview conducted on 07/07/2025 at 12:52 PM with the facility ' s Administrator, she acknowledged that Staff A was not educated in the past regarding elopements of residents and patients. The 2nd floor Unit is not a memory locked Unit, but you need a code to get into the elevator to leave the Unit. The Administrator reported that when she spoke to Staff A after the incident, Staff A recognized Resident #1, but did not know that she was supposed to stay with Resident #1 and notify other staff regarding the resident attempting to leave the facility. During her investigation, she also spoke to Staff G, who told her that on 06/08/2025, she kept an eye on Resident #1 near the elevator but had to walk away to administer medication to another Resident and did not know that Resident #1 had left the Unit. In an interview conducted on 07/07/2025 at 1:39 PM with Staff J, she reported noticing Resident #1 by the back door elevator when she looked at the facility ' s cameras. She approached him to ask him where he was going, and Resident #1 told her he was going home. Staff J left Resident #1 by the doors and went to the front desk to get her cell phone to call the nursing staff. When she came back to Resident #1, Staff F was already near Resident #1. When asked if she received an education on elopement in the past, she did not recall. In an interview conducted on 07/07/2025 at 2:27 PM, the facility ' s Maintenance Director stated that a resident can leave the 2nd floor Unit by the elevator, but you need a special code to call the elevator to leave the Unit. There is a chance that a resident can leave the Unit if someone is coming upstairs using the elevator. He was considering installing badge access to control elevator use or installing a keypad inside the elevator. The doors to the outside East Physician ' s parking lot do not have an alarm, as they are a high-traffic door with staff coming in and out. He acknowledged that there are measures that they can improve on in preventing this from happening again.

Based on observations, interviews and record reviews, the facility failed to serve lunch according to the menu and recipe on 12/18/24, with the potential to affect 26 residents that eat by mouth from the kitchen. The findings included: The lunch menu for 12/18/24 documented that residents would be served fried shrimp with waffle fries, and the alternate as baked fish. The recipe for fried shrimp (no reference date), provided by the Culinary Director, documented that one portion of fried shrimp would consist of 6 shrimp that would equal a 4-ounce serving. The recipe for the baked fish (no reference date), provided by the Culinary Director, documented that one portion of the fish would equal a 4-ounce serving. The production sheet for the meal, provided by the Culinary Director, documented that residents would receive 6 fried shrimp for a total weight of 4 ounces or one piece of baked fish that should weigh 4 ounces. During an observation of lunch being assembled in the main kitchen, on 12/18/24 at 11:53 AM, accompanied by the Culinary Director, Staff A, the [NAME] was observed placing 4 pieces of fried shrimp on a plate for staff to cover and place in the cart for the residents in the dining/activity room. Upon the request of the surveyor, Staff A placed 4 pieces that represented a serving of fried shrimp on the calibrated kitchen scale and the shrimp weighed 2 ounces. Staff A then placed one piece of the baked fish on a plate for staff to cover and place in the cart. At the request of the Surveyor, Staff A placed one piece of the baked fish that represented a serving of fish on the calibrated kitchen scale and the fish weighed 2 ounces. Staff A then placed one scoop of mechanically altered shrimp on a plate for staff to cover and place in the cart. At the request of the Surveyor, Staff A placed one scoop of the mechanically altered shrimp that represented one serving on the calibrated kitchen scale and the mechanically altered shrimp weighed 2 ounces. During an interview, on 12/18/24 at approximately 12:30 PM, when the Culinary Director was asked about the amount to be served, she stated that the residents were to be served 4 ounces of the protein for the meal being observed. The Culinary Director acknowledged that the residents were not being served according to the menu, prior to Surveyor intervention.

Based on observations and interviews, the facility failed to provide Maintenance and Housekeeping services to provide a clean and home like environment for residents in 14 of 17 rooms, in the corridor, at the nursing station, and the Supply Room. The findings included: During the initial pool process, beginning on 12/16/24 at 10:12 AM, the following were noted: In room [ROOM NUMBER], a portion of the wall, at the left of the air conditioning unit, the surface was missing, exposing the unfinished surface underneath the paint. In room [ROOM NUMBER], a portion of the wall to the right of the entrance inside of the room, the painted surface was missing, exposing the unfinished surfaces underneath the paint. In room [ROOM NUMBER], the painted surface of the door was chipped at the lower right side of the entrance door, exposing the surface underneath, and there was an accumulation of dust on the air conditioning vent inside of the entrance to the room. During a room-by-room tour of the facility, beginning on 12/17/24 at 9:28 AM, the following were noted: In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent inside of the room entrance and in the restroom. In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent inside of the room entrance. In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent inside of the room entrance. In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent inside of the room entrance. In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent inside of the room entrance. In room [ROOM NUMBER], the painted surface of the door was chipped on the lower right side of the room entry door. In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent inside of the room entrance. In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent inside of the room entrance. In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent inside of the room entrance. In room [ROOM NUMBER], there was a black moldlike substance on a ceiling tile to the left of the air conditioning vent inside of the room entrance. At the nurse's station, there was an accumulation of dust on the air conditioning vent and several ceiling tiles were stained, indicating that moisture had penetrated the tiles. The handrail between room [ROOM NUMBER] and #224, to the left of an electrical panel was cracked in a manner that created multiple sharp splinters and jagged points. The handrail outside of the Equipment and Supply Storage Room was detached from the wall. During the environmental tour, on 12/18/24 at 11:00 AM, accompanied by the Facility Manager, the Facility Manager acknowledged the findings. During an observation of the Equipment and Supply Storage Room on 12/18/24 at 2:40 PM, it was noted that the paint was chipped on the bases of the two (2) Hoyer lifts that were stored in the room. It was also noted that the covers on the motors of both Hoyer lifts were cracked and damaged. When the concern was brought to the attention of the Maintenance Director on 12/18/24 at 2:51 PM, the Maintenance Director acknowledged the findings and stated that the concerns would be addressed.

Based on review of policy and procedure, observation, interview and record review, the facility failed to secure two (2) ordered prescription medications during a Medication Administration Observation for Resident #25, secured two (2) un-ordered prescription eye drop medications during an observational room tour for Resident #4, secure a Wound Care Treatment Cart #2; and, the facility failed to promptly discard nine (9) expired treatment gauze dressings, noted during a Wound Care Treatment Cart storage observation. The findings included: Record review of the facility policy and procedure titled, Storage and Expiration Dating of Medications and Biologicals revised on [DATE], and provided by the Director of Nursing (DON) documented in the Policy Statement: Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. Procedure: .1. Facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law .5. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .10. Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier .14. Facility should ensure resident medication and biological storage areas are locked .19.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room [ROOM NUMBER]. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law, and in accordance with Policy . 1) Resident #25 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Fractured Shaft of Left Tibia, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, and Hypertension. According to the resident's Admission MDS (Minimum Data Set) assessment dated [DATE], he had a BIMS (Brief Interview Mental Status ) score of 14 (cognitively intact). On [DATE] at 9:36 AM, during a Medication Administration Observation for Resident #25, with Staff B, a Registered Nurse (RN), she was observed leaving two (2) prescription pill medications in a cup unattended on the resident's bedside table with the resident. Staff B left the room for almost five (5) minutes or more, to retrieve water for the resident from the nurses' station down the hallway, with the medications out of her line of sight. On [DATE] at 9:38 AM, during interview with Staff B, she acknowledged that the prescription pill medications should not have been left unattended and she said that she should have kept the medication secured, at all times. 2) Resident #4 was admitted to the facility on [DATE] with diagnoses which included Periprosthetic Fracture around Prosthetic Hip, Atherosclerotic Heart Disease, Major Depressive Disorder, Hypertension and Inflammation of Eyelid. Accordimg to the resident's Admission MDS dated [DATE], she had a BIMS score of 14 (cognitively intact). On [DATE] at 11:30 AM, during an observational room tour for Resident #4, it was noted that there were two (2) prescription eye drops including, 1) Loteprednol Etabonate Ophthalmic Suspension) 0.25% with an expiration date of ,d+[DATE] and 2) Tobramycin 0.3% and Dexamethasone 0.1% with an expiration date of [DATE], both located in a cup atop the resident's overbed table, which were left unattended and accessible to other residents, staff members and visitors (Photographic Evidence Obtained). On [DATE] at 11:42 AM, a brief interview was conducted with Resident #4 regarding the two (2) prescription eye drops observed on her table. She stated that they were both from her home and she uses them when needed if her eyes are tired or for dry eye. On [DATE] at 3:22 PM, [DATE] at 9:50 AM, and [DATE] at 3:28 PM, it was noted that the two (2) prescription eye drops both remained in a cup atop the resident's overbed table. An interview was conducted on [DATE] at11:05 AM simultaneously with both Staff D and the DON (Director of Nursing), regarding the prescription eye drop medication bottles observed on Resident #4's bedside table. They both acknowledged that the two (2) prescription eye drop medication bottles should not have been left, unsecured at the resident's bedside. During an interview conducted on [DATE] at 11:14 AM, with the DON, she indicated that Resident #4 does not self-administer any of her own medications and neither was she assessed by the Interdisciplinary Team (IDT) to be able to self-administer. A side-by-side record review conducted with the DON, indicated that Resident #4's hard copy chart nor her computerized medical record indicated that the resident had any self-assessment completed in order for her to be able to administer her own medications. There was no order on file in Resident #4's Medication Administration Record (MAR), nor any orders on the Treatment Administration Record (TAR) for the two (2) prescription eye drop medications: Loteprednol Etabonate Ophthalmic Suspension) 0.25% and 2) Tobramycin 0.3% and Dexamethasone 0.1%, to be administered to this resident. The bottles of two (2) prescription eye drops were not removed from Resident #4's bedside, until after surveyor inquisition. 3) On [DATE] at 9:49 AM, during walking rounds on the North end of the unit, it was observed that there was Wound Care Treatment Cart #2 was left unattended and unsecured in the hallway. (Photographic Evidence Obtained). 4) During a Wound Care Treatment Cart #2 Observation conducted on [DATE] at 9:51 AM with Staff C, an RN, it was observed that there were nine (9) expired Skin Integrity Hydrogel Impregnated Gauze packets, all with expiration dates of ,d+[DATE], located in the 3rd drawer, of Wound Care Treatment Cart #2. (Photographic Evidence Obtained). On [DATE] at 10:52 AM, an interview was conducted with Staff C, regarding the unlocked Wound Care Treatment Cart. The nurse quickly locked the Wound Care Treatment Cart, in the presence of the Surveyor, and she acknowledged that the Wound Care Treatment Cart should have been locked and the expired Skin Integrity Hydrogel Impregnated Gauze packets, should all have been promptly discarded. On [DATE] at 12:42 PM, the DON further acknowledged and recognized that the prescription medications should not have been left at either of the resident's bedsides which were unsecured and unattended, the Wound Care Treatment cart should not have been left unlocked and unattended, and the expired gauze treatment dressings should have been discarded. This was not done.

Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure it cleaned and sanitized a multi-use Glucometer machine in-between resident use during a Glucometer Observation, for 1 of 1 sampled resident observed, Resident #18; and failed to promptly discard outdated/expired resident sample laboratory blood/biological specimen tubes left, unaddressed, in the Soiled Utility Room refrigerator. The findings included: 1. Record review of the facility policy and procedure, titled, Blood Glucose Monitoring using a NovaStat Strip Glucometer, provided by the Director of Nursing (DON) release date ,d+[DATE], documented in the Policy Statement: [NAME] Subacute Units monitors blood glucose monitoring according to Physician's Orders .Rational: Blood glucose tells what the blood glucose level is at any given time and is the main tool to monitor Diabetes control. Good control means that the patient gets as close to normal (non-Diabetic) blood glucose level as possible .Patient Testing: .3. Place cleaned machine on barrier on table/cart 25. Clean the Glucometer using a germicidal wipe between each patient. Allow appropriate contact time according to manufacturer's recommendations for the germicidal wipe being used . Record review revealed Resident #18 was admitted to the facility on [DATE] with a diagnosis which included Diabetes Mellitus Type II. He had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Record review of the Resident #18's Care plan reviewed [DATE] indicated Focus: Prone to Alteration in Blood Sugar (Hypoglycemia / Hyperglycemia). Interventions: Fasting Serum Blood Sugar as ordered by Doctor .Goal: Resident #18 will be free from any signs/symptoms of Hypoglycemia through review date During an Accucheck Observation conducted on [DATE] at 11:52 AM, Staff B, Registered Nurse (RN), for Resident #18, Staff B was not observed as having first cleaned and sanitized the Stat Strip Nova Medical Glucometer machine prior to nor after resident use. The non-specific multi-resident use re-usable Glucometer machine, was first observed as visibly smudged, sitting atop Team-two (2)'s medication cart, uncovered, exposed and out of the nurses' field of vision for a period of more than fifteen minutes. The Glucometer machine had been previously left out and accessible to residents, staff members and visitors. Afterwards, Staff B was observed placing the used Glucometer machine directly into the top drawer of the Team two (2) Medication cart, uncovered, and without being cleaned and sanitized. Staff B then sanitized her hands and donned a clean pair of gloves and proceeded to take Resident #18's blood sugar level (BSL) from the right-hand thumb finger. The BSL result was 216 mg/dl. Staff B threw the used lancets into the sharp's container, removed her gloves and washed her hands for approximately ,d+[DATE] seconds. Next, Staff B removed those gloves primed the ordered insulin pen coverage for the resident. Resident #18 had Lispro insulin pen three (3) units ordered. Staff B dialed up the correct amount of insulin after first wiping on the top with an alcohol wipe, explained to the resident what she was going to do, wipe the upper right thigh with alcohol, and administered the insulin to the resident after having washed her hands again for 35 40 sec. Staff B then discarded the used syringe into the sharp's container. During an interview conducted on [DATE] at 12:08 PM with Staff B, she was asked about cleaning the Glucometer. Staff B stated the Glucometer was multi-use for other residents as well. She acknowledged and confirmed she had not cleaned the Glucometer before nor after this resident use, when she should have done so. She stated that normally she does clean the Glucometer with the Sani-cloth wipes. The Treatment Administration (TAR) documented, Monitor Blood Glucose as needed. The Glucometer machine was not cleaned and sanitized by nursing staff, at that time, until after surveyor intervention. The DON recognized and acknowledged on [DATE] at 3:40 PM that the Glucometer was to be cleaned and sanitized before and after resident use. This was not done. 2. Record review of the facility policy and procedure, titled, Storage and Expiration Dating of .Biologicals, provided by the Director of Nursing (DON), revised [DATE], documented in the Policy Statement: Policy 5.3 sets forth the procedures relating to the storage and expiration dates of .biologicals Procedure: .5. Facility should ensure all .biologicals, . are securely stored .10. Facility should ensure .biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate .until destroyed or returned to the .supplier .22. Facility should destroy or return all discontinued, outdated/expired, or deteriorated .biologicals in accordance with .destruction guidelines and other applicable law, and in accordance with Policy . An observation was made of the Soiled Utility Room on [DATE] at 11:34 AM with the DON. It was noted that there were four (4) blood / biological specimen laboratory tubes all appearing to be filled with old blood / biological-like samples being stored and kept in the Soiled Utility Room's refrigerator, as follows: 1. Is labeled with the name of former Hemodialysis resident, who had been discharged to the Hospital on [DATE]; with a Hemoglobin (Hbg) level less than <7) and an outdated/expired collection date of [DATE]; 2. The other three (3) blood tubes were not labeled with any specific resident's name, date, nor room#. There was only an accompanying face sheet for the former resident, who had been discharged to the Hospital on [DATE]; with a [NAME] Blood Cell Count (WBC) of 30.4. On [DATE] at 10:10 AM, the surveyor and the DON jointly conducted an interview with Staff E, RN, Director of Outpatient Clinical Services, with the Dialysis Center, who provides in-facility dialysis services to the residents on-site. Staff E was interviewed about the four (4) blood/biological specimen laboratory tubes that had been left in the soiled utility room and unaddressed. Staff E stated these blood / biological sample tubes were placed in the refrigerator by a former staff member. She stated that she was not aware that any of these expired and outdated blood / biological samples tubes had been left in the facility's refrigerator. The four (4) laboratory blood / biological sample tubes were not promptly discarded, until after surveyor intervention. The DON further recognized on [DATE] at 11:43 AM that all four (4) laboratory blood sample tubes had been previously collected from two (2) former Hemodialysis residents. She acknowledged these four (4) blood/biological specimen tubes were outdated or expired, not properly labeled, dated or secured, and they should have been promptly removed and not left there.

Based on review of policy and procedure, interview and record review, the facility failed to: 1) treat a resident in a dignified manner, as evidenced by, allowing a resident to leave the facility for a doctor's appointment only wearing a hospital gown and an incontinence brief and waiting at the doctor's office for an extended period of time after the appointment; and 2) contact or notify the resident's responsible party in advance of a Doctor's appointment, in a timely manner, which allowed the resident to attend the appointment alone and unattended for 1 of 3 sampled residents reviewed, Resident #1. The findings included: Review of the facility policy and procedure titled, Quality of Care provided by the acting Director of Nursing (DON) dated 10/2022 documented in the Policy Statement: The Subacute Unit (SAU) identifies and provides needed care and services that are patient centered, in accordance with the patient's preferences, goals for care and professional standards of practice that will meet each patient's physical, mental, and psychosocial needs to ensure each patient receives necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, consistent with the resident's comprehensive assessment and plan of care Procedure: 1. Determine by comprehensive assessment of the highest level of functioning and well-being possible for the patient based on the patient's current functional status and potential for improvement or potential functional decline. 2. Base the clinical care of patients on current evidence-based practice or professional judgment of healthcare professionals. Review of the facility policy and procedure titled Patient Appointments outside the Subacute Unit (SAU) provided the DON dated 10/2022 documented in the Policy Statement: [NAME] SAU will assist with making arrangements for patient visits outside of the Unit. Responsible Discipline: Social Services, Licensed Nurse. Procedure: 1. Notify family/responsible party of the scheduled appointment in advance so they may accompany patient. 2. If family/responsible party is unable to make the scheduled appointment, offer the option to re-schedule the appointment at a time convenient for them. 3. In the event the family/responsible party is unable to accompany the patient, determine if the patient is physically and mentally able to go to the appointment unattended. If the Patient is Physically and/or Mentally unable to be unattended 4. Make arrangements for transportation. 5. Make arrangements for someone to accompany the patient until the patient returns to the SAU. 6. While outside the SAU, remain with the patient unless attended by personnel at the appointment location Documentation Guidelines: 1. Document in the patient's medical record the date and time of scheduled appointment. 2. Document in patient's medical record notification of family/responsible party of time and date of scheduled appointment. 3. Document in patient's medical record: a. Date and time patient left SAU for appointment. b. Name of person accompanying patient. c. How patient left for appointment (i.e. wheelchair, stretcher, etc.) d. How patient was transported (i.e. ambulance, private transport, etc.) e. Paperwork sent with patient if applicable. f. Verification of patient's arrival at physician's office if applicable. g. Date and time patient returned from appointment . Resident #1 was admitted to the facility on [DATE] with diagnoses which included Dementia, Parkinsonism, Diabetes Mellitus Type II, Osteomyelitis, Anemia, Altered Mental Status, Hypertension, Spinal Stenosis, Presence of Cardiac Pacemaker, Essential Tremor and Atherosclerotic Heart Disease. Record review of the Minimum Data Set (MDS) sections A, C and GG dated 08/23/24 for Resident #1 indicated that he used a walker and wheelchair, assistive devices. He had impairment on both sides of his lower extremities. The resident required partial to moderate assistance with eating, oral and personal hygiene, roll left and right, sit to lying and lying to sitting on side of bed. He required Substantial to maximal assistance with upper body dressing, sit to stand, chair/bed to chair transfer, toilet transfer, and he was dependent for toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear. He had a Brief Interview Mental Status (BIM) score of 13, indicating intact cognition. Record review revealed that documentation dated 08/16/24 Hospital Discharge Summary and After Visit Summary documented the following: Discharge Disposition: Skilled Nursing Facility. Discharge Diagnoses: Atrioventricular (AV) Block, Dysuria, Benign Prostatic Hypertrophy (BPH) Serum Total Bilirubin elevated, Normocytic Anemia, Change in Mental Status---Alert, Disoriented. Dementia, Elevated Troponin Level, Insulin Dependent Type 2 Diabetes Mellitus, Right Bundle Branch Block (RBBB) and 1st Degree AV Block and Hypertension. And placement of Cardiac Pacemaker (CPM). The After Visit Summary also included an appointment for the Resident which was originally scheduled for Wednesday August 21st at 2 PM, with the Advanced Registered Nurse Practitioner (A.R.N.P.) at the Hospital. Record review of the facility's Physician's order dated 08/17/24, entered by Staff A, a Licensed Practical Nurse (LPN) documented, follow-up appointment with Advanced Registered Nurse Practitioner (A.R.N.P.) on 08/21/24 at 2 PM. Computerized record review of the Daily Skilled Progress Note dated 08/22/4 at 1:33 PM by Staff B a Registered Nurse (RN), documented for the resident: Mental Status within normal limits: No. Oriented to person, place. Mental Assessment involving: Anxiety, Depressed/Agitated/Disoriented/Confused were all listed as: Yes. There was also an entry by the nurse, He is able to follow simple commands Assistance with care provided as needed. Record review revealed that Facility's Schedule Book for the Cardiology appointment was recorded with instructions for: 11:30 AM appointment with a pick-up time of between 10:20-10:50 AM. And, return time from between12:45 to 1:15 PM. Record review of the Resident #1's Care plan initiated 08/19/24 indicated Focus: Activities of Daily Living (ADL): Resident #1 has an ADL Self-care performance deficit related to status post Pacemaker implanted, Osteoarthritis, Hypertension, Diabetes Mellitus, Cervical Myelopathy, Radiculopathy, Parkinson's Disease, Bowel and Bladder Incontinence with impaired mobility and generalized weakness. Interventions: assist as needed .assist to complete ADLs with limited to extensive assist with ADLs .and total assist with meeting elimination needs assist and monitor safe mobility techniques and transfers with assistive devices Goal: Resident will improve/maintain current level of function in .transfers .dressing, toilet use and personal hygiene through review date. Further record review of the Resident #1's Care plan initiated 08/19/24 indicated Focus: Bowel and Bladder Incontinence: Resident #1 has episodes of Bowel and Bladder incontinence related to impaired mobility with weakness. Interventions: Check for incontinence: clean and dry skin if wet or soiled. Document when Resident is incontinent. Perform assessment of skin. Note areas of redness. Use pads/briefs to manage incontinence .Provide hygiene after toileting to prevent skin breakdown. Goal: Incontinence will be managed by staff without evidence of skin break down over the next 90 days. During a telephone interview conducted on 09/04/24 at 7:06 PM with Resident #1's family member, regarding her Resident #1's doctor's appointment on Thursday, August 22, 2024, she stated that someone from the facility called her and her younger sister, the very same day about 15 minutes or so, before the actual appointment. She further explained that Resident#1 had already left the facility (by a transportation company) and was on his way to the appointment (unaccompanied). The family member stated that multiple other family members had been coming in and out of the facility on a daily basis to visit him, but no one from the facility ever said anything to any of them about this appointment. She said that he was to see a Cardiologist for his 2-week post-surgical follow-up for his Pacemaker placement. Furthermore, she added that none of Resident #1's clothing had been sent over to [NAME] from the hospital. She indicated that after the Doctor's office told her that Resident #1 was only in a hospital gown, she asked [NAME] over the telephone where his belongings were and she said that they told her, he did not have any belongings, and they didn't know anything about them. She further stated that when she asked the facility regarding the appointment, they only initially provided vague information to her and only then provided more specific, detailed information after she asked them about it repeatedly. She said that she questioned why the facility had not tried to contact the other family members who live here and visit him regularly in the facility, much earlier regarding this upcoming appointment so that they could provide clothing for Resident #1, if needed. She further said that the Resident had been picked up two (2) hours after the appointment was finished and as a result, he urinated on himself while only wearing a hospital gown with no underpants and no assistance with personal hygiene care. She said that it greatly disturbed her that Resident #1 told her that he was cold. An interview was conducted with Resident #1 on 09/05/24 at 2:29 PM, in which he provided information to this Surveyor, during a conversation regarding his visit to his last doctor's appointment in the facility. He stated that, one (1) time a driver came to pick him up and drop him off and then he left. And, then Resident #1 said that a different driver picked him up from his appointment and brought him back to [NAME], after a long time. The resident went on to say that he was wearing a hospital gown, and he said that thinks he had a diaper on that day when he urinated on himself, but he said that he wasn't sure and could not remember. Resident #1 ended by saying that, it bothered him to be wearing a hospital gown instead of wearing clothes and dressed, as he prefers. During an interview conducted on 09/05/24 at 2:56 PM with the facility's Staff C, Unit Clerk/Scheduler, she was asked about Resident #1's doctor's appointment scheduled for Thursday August 22, 2024, outside of the facility. Staff C responded first by saying that she was the one responsible for this appointment. She said that she remembered calling one (1) of the Resident's daughters on the day of the appointment but said that she does not remember the exact time of the call, nor the exact conversation, nor which daughter she called; there was no documentation by her to confirm this. By her own admission, Staff C stated that she had not obtained confirmation from the family member indicating that they would be accompanying the resident to the appointment that day. Therefore, she added that the Transportation company was allowed to take the resident to the appointment alone. Staff C verbalized that, she would not do this again. And, she admittingly stated that she had not thought of just re-scheduling the appointment to another, more convenient day, because she did not want the resident to miss his appointment. On 09/05/24 at 5:08 PM a telephone interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) from Resident #1's Cardiology office, in which she was asked briefly about the events that occurred on Thursday August 22, 2024. The ARNP stated Resident #1 was to return there for his 2-week Pacemaker placement follow-up Cardiology appointment visit. However, she said that the Resident was very disoriented, with a diagnosis of Dementia, he had no idea that he was even had a Pacemaker, nor that he was there for his Pacemaker follow-up. And, she added that he was just dropped off alone, in a hospital gown, and waited there for hours in the doctor's office and they had to call the family members to speak with them and find out what was going on. During an interview conducted on 09/05/24 at 5:10 PM with Staff D, Certified Nursing Assistant (CNA), she acknowledged that, Resident #1 did go to an appointment on Thursday August 22, 2024, wearing a hospital gown. She said that she believed he was wearing pull-ups because that was what he would always wear, but she was not sure. And, she added that he was not accompanied by anyone that day to the appointment, that she was aware of. On 09/05/24 at 4:25 PM a telephone interview was conducted with Staff B, a Registered Nurse (RN), on the 7 AM to 7 PM dayshift, in which he was asked about Resident #1's orientation status. Staff B stated that sometimes the Resident is alert and sometimes he is not, and he can be confused sometimes. Staff B further stated that he did not remember exactly what the Resident was wearing that day, nor if the Resident had on a diaper or incontinence brief, to the Doctor appointment. During an interview conducted with the acting DON on 09/05/24 at 5:20 PM, regarding Resident #1's Doctor's appointment on Thursday August 22nd 2024, she indicated that she was not aware of the exact time of the appointment that day and she revealed that she was sitting next to Staff C, on that day and she asked Staff C if she had reached out to the family to see if they could meet Resident #1 at the doctor's office and bring over some clothes to go out to the appointment. The acting DON said that one (1) of Resident #1's daughters, who lives locally, told them that she could not go. The acting DON then said that, at that point, Resident #1 was alert and oriented x3, so he was sent out to the appointment in what he was wearing, a hospital gown with something on underneath. Further investigation revealed there was no nursing clinical documentation on file to show the name and type of Doctor's appointment, nor the exact time of when he left and ultimately returned to the facility, nor whom he left the facility with, nor of his current condition/status at the time of his leaving from the facility. Moreover, there was no documentation to indicate that the resident's responsible party had been notified of this appointment. During an interview on 09/05/24 at 5:40 PM, the Administrator acknowledged that the circumstances surrounding Resident #1's medical appointment should have been handled or addressed more promptly and appropriately with better communication between the facility and the Resident's representatives. This was not done.

Based on observation and interview, it was determined that the facility was not disposing of garbage and refuse properly. The findings included: During the initial kitchen/food service observation tour conducted on 09/05/23 at 9 AM accompanied with the Food Service Manager (FSM), the following was noted: Observation of the facility's commercial dumpster that is located at the facility's receiving dock on 08/05/23 at 9 AM noted that there was a large circular hole of approximately 18 inches located below the dumpster door. Further observation noted the interior to have a large build-up area of black slime within the cavity of the dumpster. It was also noted to have numerous flying insects and an offensive garbage odor. Interview with the FSM at the time of the observation revealed that the Hospital Administration had been notified numerous times over the past 2 months by the SNU (Skilled Nursing Unit) Administration that a new commercial dumpster was required for potential sanitation issues. It was also discussed with the facility Administrator that the issues concerning the improperly covered commercial linen carts are delivered by an outside vendor, directly next to the commercial dumpster.

Based on review of policy and procedure, observation, interview and record review, the facility failed to 1) follow infection control standards for 1 of 1 sampled residents observed, during a Medication Administration Observation (Resident #181); 2) ensure that it followed infection control standards for 1 of 1 sampled residents observed were followed during a Glucometer Observation (Resident #78), and; 3) transport and store resident linens, in a sanitary manner. The findings included: Review of the facility policy and procedure titled, Infection Prevention and Control Program provided by the Director of Nursing (DON) with a release date of ,d+[DATE] documented in the Policy Statement: An Infection Prevention and Control Program is designed to maintain a safe, sanitary, and comfortable environment involving each department. Definitions: Staff----All facility staff (direct and indirect) .others who provide care and services to patients on behalf of the facility Hygienically clean refers to being free of pathogens in sufficient numbers to cause human illness .Standards Precautions .is based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents. Furthermore, equipment or items in the patient's environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents Review of the facility policy and procedure titled, Blood Glucose Monitoring using a NovaStat Strip Glucometer provided by the Director of Nursing (DON) with a release date of ,d+[DATE], documented in the Policy Statement: Policy [NAME] Subacute Units monitors blood glucose monitoring according to Physician's Orders. Rational Blood glucose tells what the blood glucose is at any given time and is the main tool to monitor Diabetes control .6. Prior to initial blood glucose monitoring or storage in the docking/charging station, cleanse exterior of Glucometer with 10% Bleach wipe and dry with damp non-sterile cloth (gauze) .Patient Testing 3. Place cleaned machine on barrier on table/cart .25. Clean the Glucometer using a 10% Bleach solution moistened wipe between each patient. Allow appropriate contact time according manufacturer's recommended for solution being used and wipe any residual Bleach solution off the meter after appropriate contact time . Review of the facility's Policy and Procedures for Linen Handling and Storage noted the following: Purpose: Minimize microbial contamination of linen due to surface contact or airborne disposition Policy: Ensure the proper storage and handling of clean linen. Procedure: 1) All clean linen carts shall be delivered to user areas in covered carts. 1.1; Linen will be covered at all times during transport to user areas. 1.3: Clean linen carts in user areas shall be in enclosed closets or stored with covers. 1) Resident #181, was admitted to the facility on [DATE] with diagnoses which included Displaced Intertrochanter Fracture Left Femur, Anemia, Dysphagia, Anxiety Disorder, Major Depressive Disorder, Adjustment Disorder and Hypertension. He had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). On [DATE] at 9:24 AM, during a Medication Administration observation, Resident #181's dirty open and uncovered urinal (not actively or recently in use by the resident) was observed sitting atop his bedside table adjacent to his clean half-lidded water pitcher with the end of an exposed drinking straw sticking out of the top of the water pitcher, for a period of over one (1) hour; several staff members were observed entering and exiting the resident's room, with no attempts to remove the resident's urinal to a different location (Photographic Evidence Obtained). An interview was conducted on [DATE] at 3:21 PM with Staff B, CNA, in which she was asked about Resident #181's dirty open and uncovered Urinal (not actively or recently in use) sitting atop his bedside table adjacent to his clean half-lidded water pitcher, and if it was acceptable infection control practice and she acknowledged that the urinal should not have been left next to the resident's water pitcher. An interview was conducted on [DATE] at 3:22 PM with Staff C, RN, in which she was asked about Resident #181's dirty open and uncovered Urinal (not actively or recently in use by the resident) sitting atop his bedside table adjacent to his clean half-lidded water pitcher, and if it was acceptable infection control practice and she acknowledged that the urinal should not have been left next to the resident's water pitcher. An interview was conducted with RN, Nurse Manager, on [DATE] at 3:30 PM regarding the Resident #181's dirty open and uncovered Urinal (not actively or recently in use by the resident) sitting atop his bedside table adjacent to his clean partially-lided water pitcher and if it was acceptable infection control practice and the RN, Nurse Manager also acknowledged that the urinal should not have been left next to the resident's water pitcher. 2) Resident #78 was admitted to the facility on [DATE] with diagnoses which included Unspecified Carpal Bone Right Wrist, Diabetes Mellitus Type II, Chronic Kidney Disease Stage 3, Hypertension and Gastroesophageal Reflux Disease. She had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). Record review revealed on [DATE] the physician order documented for Accuchecks to be performed four (4) times per day, before meals and at bedtime. On [DATE] at 11 AM, during a Glucometer Observation with Staff D, RN, was conducted for Resident #78. The nurse donned a clean pair of gloves after washing her hands for approx. ,d+[DATE] seconds and she cleaned the Glucometer with Sanicloth (bleach) wipes and allowed it to air dry for ,d+[DATE] minutes. She then removed her gloves and sanitized her hands and gathered the supplies and went to the resident and she agreed to have this surveyor observe the Glucometer being performed. The nurse then washed her hands again for ,d+[DATE] sec and donned a clean pair of gloves and proceeded to take the resident's blood sugar level from the left-hand index finger. After receiving the results, the nurse threw the used lancets into the sharp's container, removed her gloves and washed her hands for approx. ,d+[DATE] seconds, the nurse was then observed to proceed to the next resident to administer their medications after having placed the dirty/used Glucometer machine on top of medication cart #1. Further observation revealed Staff D did not clean and sanitize the Glucometer again with bleach wipes after completing the Glucometer check until after surveyor inquisition/intervention(Photographic Evidence Obtained). During a brief interview conducted with Staff D, on [DATE] at 11:05 AM, she acknowledged that she had forgotten to clean the Glucometer after resident use, and said that she should have. An interview was conducted with the RN, Nurse Manager, on [DATE] at 3:30 PM regarding the Glucometer not being cleaned. The RN, Nurse Manager acknowledged that the Glucometer should have been cleaned and sanitized after resident use. An interview was conducted on [DATE] at 3:35 PM with the DON regarding Resident #181's dirty open and uncovered Urinal (not actively or recently in use by the resident) sitting atop his bedside table, adjacent to his clean partially lided water pitcher. She acknowledged that the urinal should not have been left next to the resident's water pitcher, and further acknowledged and recognized that the Glucometer should have been cleaned and sanitized after resident use; this was not done. 01948 3) During a routine observation conducted on [DATE] at 7:30 AM, it was noted that a commercial sized clean linen laundry cart (full ) was located at the entry to the elevator on the first floor . The Housekeeping Director who was with the clean linen cart stated that the clean linen cart was going to be delivered to the second floor Skilled Nursing Unit. Further observation noted noted that ,d+[DATE] of the large commercial clean linen cart was not covered and much of the clean linens (Bed linens, bath linen, etc.) were exposed. The Director stated to the surveyor that the linen company is not providing enough plastic wrap to cover the entire cart during transportation and upon delivery . The Director stated he would contact the linen company concerning the issues. The surveyor requested to be informed of the linen company response. Further investigation of the linen cart issues on [DATE] at 8:00 AM, it was noted that there were 7 linen carts which were stored in the first floor hall of the hosptial were not properly covered. It was also noted during the observation that the clean linen carts are delivered to the hospital receiving dock and have to be transported through the soiled room/infectious waste room. Observation of the soiled room on [DATE] at 8:30 AM noted the walls and floors were heavily soiled and stained (Photographic evidence of linen carts and soiled room obtained). During an interview conducted with the representative of the Linen Vendor Accounts Manager on [DATE] at 1:00 PM, she noted to state that she has revived the clean linen process and stated the company was not using the correct size plastic covers to ensure the entire cart and clean linen contents were properly covered during transport and delivery.

Based on observation and interview, it was determined that the facility failed to ensure the kitchen air-conditioning vents (2) and commercial food preparation equipment (steamers X 2) were not in safe operating condition. This effected potentially 23 of the 25 facility residents. The findings included: During the initial kitchen/food service observation tour conducted on 09/05/23 at 9 AM and accompanied with the Food Service Manager (FSM), the following were noted: 1) Two ceiling mounted kitchen air-conditioning vents located in the food preparation area were noted to have a large build-up of condensation. Continued observation noted that the condensation build-up was dripping down onto prepared foods, food preparation surfaces and tables, and staff. It was discussed with the Food Service Manager (FSM) that the dripping condensation could potentially result in food contamination. The FSM stated that the condensation issues was reported to maintenance 1-2 months ago without repair or resolution. 2) Observation of the commercial steamers noted that 1 of the 2 steamers was not working while the other was not working properly. Interview with the cook at the time of the observation noted that foods must be streamed hours in advanced to be properly cooked. It was discussed with FSM that continued cooking and holding of foods will negatively effect the nutritive and appearance of foods. The FSM further stated that the steamer issues was reported 1-2 months ago without or repair or resolution. The issues were discussed with the Hospital Administration on 09/06/23 at 1:00 PM, who confirmed that they were aware of the air-conditioning ventilation issues and the non-operational commercial food steamers for the last 2 months, but had not resolved and repaired the issues. * Photographic Evidence Obtained

Based on observation, interview, and record review, the facility failed to equip 12 semi-private resident rooms with ceiling suspended curtains that assure full privacy for 21 of 21 facility residents. The findings included: During the screening of residents and room observations conducted on 09/05/23, it was noted that the privacy curtains located within semi-private resident rooms did not provide full privacy for the 21 of 21 residents. The surveyor requested that the Housekeeping Director tour the resident rooms to identify the room privacy curtain issues. The rooms identified with the director included the following: room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - not occupied) room [ROOM NUMBER]: (Semi Private - two beds - only 1 occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) room [ROOM NUMBER]: (Semi Private - two beds - occupied) Following the observation an interview was conducted with the Director of Housekeeping and the following was revealed: < Each semi-private room should have been equipped with 2 privacy curtains per resident (total of 4/room) to ensure full privacy. < Privacy curtains over a period of time had been removed for cleaning, replacement, etc. however they were not put back up in the semi-private resident rooms. < There was a adequate supply of privacy curtains for every resident room in storage at the facility on 09/05/23. < There was an insufficient supply of hooks to hang the privacy curtains in in each semi-private room (30 hooks) . < The lack of privacy curtains was estimated to effect 21 of the 25 facility residents. * Photographic Evidence Obtained

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The findings included: During the screening of residents on 09/05/23 and the Environmental Tour conducted on 09/07/23 at 10:30 AM, accompanied by the Corporate Maintenance Director and Director of Housekeeping, the following were noted: 1) Observation of the entrance to the elevator of which residents utilize to come down from the second floor resident rooms to the Skilled Therapy Gym located on the first floor was noted to have a 18 inch by 2 inch wood slat at the opening to the elevator door. Further observation noted a large lip that posed a potential trip hazard to residents entering and/or exiting the elevator. The issues was discussed with the Corporate Maintenance Director at the the time of the observation, who stated the the issues required immediate repair attention. 2) Resident Rooms: room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair, large hole in wall #1, and soiled fan blowing directly towards the resident with a tracheotomy. room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair, privacy curtain was soiled and stained, and night stand dresser drawers would not close. room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair. room base boards in disrepair, and exterior of bathroom entry door was in disrepair. room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair. room base boards in disrepair, and exterior of bathroom entry door was in disrepair. room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair. room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair. room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair, and wall electric cover was not secured to the wall. room [ROOM NUMBER] - Large black scuff marks on walls (3), exterior of bathroom door damaged and in disrepair, and exterior of ovrbed table (B Bed) was worn and exposed wood areas. room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair. room [ROOM NUMBER] - Room walls (3) were noted to be damaged and in disrepair, and bathroom door frame was rust laden. room [ROOM NUMBER] - Bathroom emergency shower call cord was wrapped around handrail. 3) Clean Supply Storage Room - Entry door not locked (broken) and potential resident access to razors (3 boxes) and dialysis chemical products (germicidal and bleach) . Soiled fan stored within the room with clean gastric and IV pumps. Following the tour conducted on 09/07/23 at 10:30 AM, the findings were again confirmed with the Regional Maintenance Director and Director of Housekeeping. The findings were also discussed with the facility's Administrative Staff.

Based on interview, observation and record review, the facility failed to prevent 1 of 29 sampled residents (Resident #1), from leaving a safe area without authorization or supervision; and failed to identify and correct security issues with the potential of allowing elopements. The findings include: Record review revealed the facility's policy titled Wander Risk Assessment, release date 11/28/17, defines Elopement as follows: Elopement is when a patient leaves the premises or a safe area without authorization (e.g., an order for discharge or leave of absence) and/or any necessary supervision to do so. A patient who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Resident #1 was admitted to the facility on [DATE] with the pertinent diagnoses of the following: 1. Obstructive [CONDITION(S)] 2. Nontraumatic Intracerebral Hemorrhage 3. Presence Of Cerebrospinal Fluid Drainage Device 4. Hypertensive Crisis 5. Anxiety Disorder 6. [CONDITION(S)] Following Nontraumatic Intracerebral Hemorrhage Affecting the Left Non-Dominate Side 7. Acute [CONDITION(S)], With [CONDITION(S)] or Hypercapnia 8. Dysphagia following Nontraumatic Intracerebral Hemorrhage Record review revealed on 09/26/22, Resident #1 had a Minimum Data Set (MDS) assessment for a BIMS (Brief Interview of Mental Status) with a score of 13/15, indicating intact cognition. A review of video surveillance showed that on 09/25/22 at 7:09 PM, Resident #1 was propelling himself in his wheelchair away from the nurses' station toward the double door exit that connected the SNU (Skilled Nursing Unit) to the Subacute Hospital. In the video there was a nurse, Staff A, and other staff noted near the nurses' station. Staff A was seen looking directly down the hall towards Resident #1's location. Staff A was noted to have looked in the direction of Resident #1 three times as he proceeded toward the doors. Staff A did not go down the hall to interact with Resident #1. At the same time resident #1 reached the double doors, Staff A went into a locked door that was accessed with a keypad. That door was later established to be the pantry. When Resident #1 reached the double door, he stood up and went to the left hand corner where there was a stairwell with a keypad to open the door to the stairs. Resident #1 appeared to try to put a code into the keypad but did not attempt to open the door. Resident #1 then proceeded to test the double door. Before exiting, Resident #1 was seen looking back as if he was checking that he was not being watched before he exited through the double doors. On 10/17/22 at 10:17 AM, a facility tour was completed with the Business of Manager. It was noted that the exit doors and the elevator have key pads to prevent residents from exiting. On the tour it was noted that there was an exit on the first floor just outside of the elevator to the left as one exited the elevator. This exit door was not, protected by an alarm or a keypad. The door led to the parking garage and ultimately to the street. A mobile resident would be able to leave through this exit without detection and without hindrance. On 10/17/22 at 11:20 AM the Administrator was informed of the finding of the exit door to the parking garage. The Administrator and the Regional Director of Plant Operations, who oversees the Subacute Hospital and the Skilled Nursing Unit (SNU), accompanied the surveyor to view the door to the garage. It was noted that the exit to the street in the stairwell would set off an alarm if opened and required the push bar to be depressed for 15 seconds before opening. The Administrator and the Regional Director of Plant Operations agreed that the door directly to the parking garage should at least have the same security as the other exit door. At this time, the Regional Director of Plant Operations informed the surveyor of video surveillance footage that had been saved from the date of the elopement that showed how Resident #1 exited the Skilled nursing Unit. On 10/17/22 at 12:43 PM, (after viewing the video captured for the date of the elopement) a second tour was made to get a first-hand look of how Resident #1 was able to leave the facility. This tour was taken with the Administrator and the Regional Director of Plant Operations. After exiting the elevator, we turned right and approached the double door. Both the Administrator and the Regional Director verified that this double door was the one that Resident #1 exited through on the video. The door was opened by the surveyor without using the keypad and the alarm did not sound. The Administrator and the Regional Director of Plant Operations agreed that the alarm should not have been deactivated and re-armed the alarm. It was noted soon after that staff went through the door without disarming the alarm, which indicated that staff were used to having the alarm off. The Administrator and the Regional Director of Plant Operations agreed that this was a concern. After passing from the Skilled Nursing Unit to the Sub Acute Hospital, it was noted that the elevator on the Sub Acute side did not have a keypad to prevent access. Using the elevator, the tour proceeded to the first floor and out of the main entrance to the parking lot. To the right of the main entrance as one is leaving there is a dumpster where Resident #1 was documented being found. The Regional Director of Plant Operations was certain that Resident #1 did not exit through the main entrance/ lobby, based upon the surveillance video. Video of where Resident #1 did leave the building had not been found at the time of the investigation. The dumpster in the parking lot was directly across from the Ambulance Entrance/Exit for the facility. It was determined that a person could travel undetected down the hall that led to the Ambulance Entrance/Exit and that the door could be opened from the inside of the building without hindrance because the door was not locked or protected from the inside of the building. On 10/17/22 at 3:54 PM, an interview was conducted with Staff A, a Registered Nurse (RN). Staff A stated Resident #1 was known to walk on the unit with a wheelchair. Staff A stated she was not aware of Resident #1 wandering into other rooms. Staff A stated she saw Resident #1 between 7:05PM and 7:10 PM at the nurses' station, and denied seeing Resident #1 down the hall by the door he exited, and also denied hearing an alarm at around the time Resident #1 left the Unit. Staff A stated that someone asked where Resident #1 was that was when it was noted that Resident #1 was missing. This was around 7:15 to 7:30. She stated that she was one of the nurses who left the floor to search for Resident #1 and reported that she was in the lobby when some of the staff who were in the lobby before her went outside to look. She stated that Resident #1 was found to the right of the building near the dumpster. She stated that Resident #1 was assessed by other staff members and was not sure what Resident #1 said regarding why he went outside. Staff A reported that the nurses had elopement training that dealt with people who were exit seeking and also indicated that the facility did not conduct elopement drills. Staff A further stated that the resident did not always remember what he was told and needed to be redirected. Staff A stated that the facility did go through the unit and re-evaluated residents to see if there were other residents who were wander/elopement risk. On 10/17/22 at 4:17 PM, an interview was conducted with Staff B, a Certified Nursing Assistant (CNA), who worked the 7 AM - 7 PM shift. Staff B stated that she had worked with Resident #1 prior to the elopemen and Resident #1 was ok during the day shift. Staff B stated that when Resident#1 was noted missing when she was making room rounds, she and three other staff members went to the 3rd floor to see if Resident #1 was there. Staff B stated that the alarm by the stairs near the elevator was ringing. The stairs are also adjacent to the doors where Resident #1 exited. Staff B stated, that as far as she knows, the alarm on the door where Resident #1 left is always set. On 10/18/22 at 9:23 AM, an interview was conducted with Staff C, a Licensed Practical Nurse (LPN) who works 7A-7P. Staff C stated that the day before Resident #1 eloped, he had been visited by family. Staff C stated the family took Resident #1 outside during their visit. Staff C stated that the staff was made aware that the family was taking Resident #1 off the unit. Staff C stated that Resident #1 started to go to the elevator and to the double doors repeatedly after the family visited. Staff C stated that this was a change in behavior. Staff C explained that Resident #1 was often redirected to the nurses station, but on the day of the elopement the nurses were occupied with other tasks. Staff C stated that there was no alarm sounding at the time of the elopement. When asked about the alarm for the double doors where Resident #1 left the unit, Staff C stated that during the day, the alarm is not set because the doors are used for staff to be able to go between the Skilled Nursing Unit and the Subacute Hospital. Photographic evidence obtained.

Based on observation and interview, the facility failed to store, prepare, distribute and served food in accordance with professional standards for food service safety. The findings include: During the initial kitchen/food service observation tour conducted on 05/16/22 at 9 AM, accompanied with the Consultant Dietitian and Food service Supervisor, the following were noted: Observation of the ceiling air-conditioning vent that was located within the food production area was noted to have the exterior surface of the vent covered with condensation. Further observation noted that droplets of condensation were falling down from the vent. It was discussed with the facility's representatives at the time of the tour, that there was the potential for the droplets to fall on foods, preparation surfaces and equipment, and staff that could result in food contamination and food borne illness.

Based on observation and interview, it was determined that the facility did not dispose of garbage and refuse properly and the garbage storage area and loading dock were not maintained in a sanitary condition. The findings included: During the initial kitchen/food service observation tour conducted on 05/16/22 at 9 AM, accompanied with the Consultant Dietitian and Food service Supervisor, the following were noted: Observation of the outside garbage/refuse (dumpster) area revealed that there were large areas of unidentified trash and garbage surrounding the ground area of the dumpster. It was also noted that there was a thick heavy build-up of black matter with offensive odor and numerous flying insects also surrounding the ground area. An interview conducted with the Director of Housekeeping at the time of the observation confirmed the surveyors findings and stated that each time the dumpster is removed for emptying, the ground area is to be thoroughly cleaned daily when the dumpster is removed for emptying. it was further stated that the cleaning is not being done on a regular basis. On 05/18/22 at 7:30 AM, the dumpster area was again observed. It was noted that the issues were worsening and that the ground area around and beneath the dumpster was littered with open trash and garbage, offensive odor, and flying insects. The surveyor requested the Administrator and Director of Maintenance to view the dumpster area and confirmed the surveyors findings. The Administrator stated that the area is not being properly cleaned on a daily basis. Observation conducted on 05/19/22 at 8:30 AM again noted that the ground area beneath and around the dumpster was thick with a heavy build-up of trash and garbage. The Administrator was requested to view the observation and confirmed the surveyors findings. The Administrator stated at the time of the observation that the dumpster is too small to contain all of the facility's trash and garbage. It was also stated that the facility is not being notified by the waste company of when the dumpster/compacter is moved from the pad so that facility staff may clean and sanitize the area. * Photo evidence obtained

Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance service necessary to maintain a sanitary, orderly, and comfortable interior. The findings include: During the Environmental Tour conducted on 05/17/22 at 1 PM, accompanied with the Administrator and Director of Maintenance, the following were noted: Room #219: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. Room #220: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. The portable commode chair noted to have areas of rust on the exterior. Room #221: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. The cord to the over-bed light (D-Bed) was missing. Bathroom door in disrepair with peeling paint and large cuff marks. Room #222: The ceiling vent located in the bathroom was dust laden. Room #223: The room base boards were in disrepair and were separating from the room walls. Room #224: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. Room base boards also in disrepair. Room #225: Wet towels on room floor to soak up leak from bathroom. Bathroom door frame had large areas of peeling paint. Room #226: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. the room floor was heavily soiled. Bathroom door exterior was in disrepair which included peeling paint. Room #227: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. The bathroom commode toilet seat was broken in half and could not be used by the residents . Room #228: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. Room base boards also in disrepair. Room chair seat stained and soiled. The privacy curtain is not long enough to provide personal privacy. Room #229: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. Room base boards also in disrepair. Room #230: The room walls were in disrepair that included; large scuff marks, peeling paint, and numerous small holes. Room base boards also in disrepair. Bathroom floor heavily soiled. Bathroom door exterior was in disrepair. Hallway PPE Dispenser: The screws holding the PPE supplies were out of the walls and the dispenser was ready to fall to the floor. Biohazard Room: The entry door exterior was soiled, and large black scuff noted. Storage Room: The entry door exterior was soiled, and large black scuff noted. Central Supply Room: Room floor heavily soiled and large large dust balls noted . Following the 05/17/22 tour, the findings were again confirmed with the Administrator and Director of Maintenance. The Administrator stated that staff are required to document housekeeping/maintenance issues on a log book located at the nurses station . It was further stated that staff are not documenting in the book as required. A review of the maintenance log book on 05/17/22 noted that none of the issues noted during the environmental tour were documented in the April and May 2022 Maintenance Log Book .