Every finding on record at Lake City Center for Nursing and Healing LLC

Based on observations, resident interviews, staff interviews, record review, and policy review, the facility failed to provide sufficient nursing staff to meet the needs of residents. Specifically, the facility had multiple vacant nursing positions and did not have an established, planned staffing level to determine the number and type of nursing staff needed to meet residents' needs. During the review period, residents experienced delays in activities of daily living (ADL) care, repeated delays in medication administration, and a failure to provide ordered nursing services, including enteral nutrition. The facility census was 208 residents. Findings included:1. 1. Resident and Staff Interviews: During an interview on 07/28/2026 at 11:12 AM, Resident (R) 8 stated that some evenings, eating in the main dining room is not an option due to no staff available to sit in the dining room with them while they ate. During an interview with Certified Nursing Assistant (CNA) GG on 07/28/2026 at approximately 11:40 AM, CNA GG stated that the facility had staffing issues, mainly during the 7:00 PM to 7:00 AM shift. CNA GG stated that residents had reported to her that, during the evening/night shift, only one nursing assistant was present to help with care, and residents had to wait hours for care and treatment. CNA GG indicated that the facility administration was aware of the staffing issues during the evening and on weekends. On 07/28/2026 at 12:20 PM, a family member of R6 expressed frustration at never being able to get through when calling the facility on the telephone. The family member stated that staff doesn't answer the telephone and added that frequently the telephone would be answered by a resident in the hall. During an interview with R3, on 07/28/2026 around 2:30 PM, R3 stated that during the evening shift several weeks ago, he lay in his own feces for over two hours waiting on staff to provide care and treatment. R3 indicated that staff came in and cut off the call light, stating they would be back. R3 stated he waited and waited, and that his buttocks got irritated during the wait. R3 stated that he felt embarrassed, upset, and belittled. R3 stated he had a history of pressure wounds. R3 stated, The facility does not have enough staff to care for us during the evening shifts, and this is why we have to wait so long. R3 indicated that this was an ongoing problem at the facility. R3 also indicated that he had informed nursing staff about staffing issues during the evening and weekend shifts, stating that there was only one nursing assistant for more than 30 residents. R3 stated it was not a great feeling to be lying in feces that long. On 07/28/2026 at 2:35 PM, R7 at night they would spend hours itching and waiting to be changed. R7 stated they recently had a really bad urinary tract infection. During an interview with CNA II and CNA JJ on 07/28/2026 at approximately 3:30 PM, both CNAs were asked whether the facility had sufficient staff to meet the needs of the residents. Both staff members indicated, We are short-staffed, but we do what we need to do to provide care for our residents. During a follow-up interview on 07/29/2026 at approximately 2:15 PM, CNA GG stated she had worked on the unit for several months. CNA GG stated that the facility needed more staff. CNA GG indicated there was insufficient staff to provide care for residents who required two or more staff to meet their ADL care needs. CNA GG indicated that R3 required two-person assistance with ADL care and transfers. CNA GG indicated working a lot of overtime due to staff calling in during the evening shift. 2. Late Medications A. A review of the electronic medical record (EMR) revealed that R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, paraplegia, osteomyelitis of the vertebra, sacral and sacrococcygeal region, staphylococcal arthritis of the right hip, Stage 4 pressure ulcer of the sacral region, pressure ulcers of the buttocks, ankles and heels, neuromuscular dysfunction of the bladder, and urinary tract artificial opening status. A review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/01/2026, revealed R2 completed the Brief Interview for Mental Status (BIMS) exam with a score of 14 out of 15, indicating intact cognition. The MDS identified paraplegia as an active diagnosis, documented wheelchair use, and identified three Stage 4 pressure ulcers. A review of R2's Medication Administration Audit Report, for the period 07/16/2026 through 07/30/2026, revealed a recurring pattern of medications being administered two or more hours after their scheduled administration times across multiple dates and shifts. On 07/17/2026, multiple medications scheduled for 9:00 AM, including ferrous sulfate, vitamin C, docusate sodium (stool softener), gabapentin (nerve pain), zinc sulfate, multivitamin, cyanocobalamin, senna, baclofen (muscle relaxant), and MiraLAX, were administered at approximately 1:29 PM, more than four hours after the scheduled administration time. A second dose of gabapentin, scheduled for 2:00 PM, was administered at approximately 6:43 PM. On 07/18/2026, multiple medications scheduled for 9:00 AM were administered at approximately 12:37 PM, more than three hours after the scheduled administration time. Baclofen scheduled for 5:00 PM was administered at approximately 7:08 PM. On 07/21/2026, multiple medications scheduled for 9:00 AM were administered at approximately 1:20 PM, more than four hours after the scheduled administration time. On 07/22/2026, multiple medications scheduled for 9:00 AM were administered from approximately 12:34 PM to 12:35 PM. Gabapentin scheduled for 2:00 PM and baclofen scheduled for 5:00 PM were documented as administered at approximately 8:46 AM on 07/23/2026. On 07/25/2026, multiple medications scheduled for 9:00 AM, including Augmentin, gabapentin, baclofen, ferrous sulfate, vitamin C, docusate sodium, MiraLAX, zinc sulfate, senna, multivitamin, and cyanocobalamin, were administered at approximately 12:15 PM to 12:16 PM, more than three hours after their scheduled administration times. On 07/28/2026, multiple medications scheduled for 9:00 AM were administered at approximately 11:22 AM to 11:23 AM. Hydrocortisone 1% cream scheduled for 9:00 AM was administered at approximately 6:21 PM, more than nine hours after the scheduled administration time. Further review of the Medication Administration Audit Report revealed a recurring pattern of medications scheduled for 9:00 PM being administered after midnight. Medications affected included gabapentin, baclofen, atorvastatin (for cholesterol), Augmentin (an antibiotic), and hydrocortisone. For example, medications scheduled for 9:00 PM on 07/16/2026 were administered at approximately 2:10 AM on 07/17/2026; medications scheduled for 9:00 PM on 07/17/2026 were administered at approximately 1:47 AM on 07/18/2026. B. A record review found R3 was admitted to the facility on [DATE] with diagnoses that included: low back pain; chronic peripheral venous insufficiency; chronic obstructive pulmonary disease (COPD); essential primary hypertension; severe morbid obesity; constipation; other muscle spasm; neuromuscular dysfunction of the bladder; hypothyroidism; chronic systolic congestive heart failure; and non-pressure chronic ulcer of another part of the left lower leg. A review of R3's quarterly MDS assessment, with an ARD of 06/11/2026, revealed R3 had a BIMS score of 15, which indicated intact cognition. R3 was able to communicate all their needs and wants. R3 was dependent on staff and required maximal assistance for all ADLs except eating. A review of R3's Medication Administration Audit Report for the period 07/16/2026 through 07/30/2026 revealed a recurring pattern of medications being administered two or more hours after their scheduled administration times across multiple dates and shifts. On 07/16/2026, multiple medications scheduled for 9:00 AM, including pentoxifylline (improves blood flow), prednisone (a steroid), dapsone (anti-infective agent), amlodipine (blood pressure), rosuvastatin (cholesterol), Symbicort (COPD), oxybutynin (bladder muscle spasms), zinc sulfate, ascorbic acid, metoprolol (blood pressure), Flonase (COPD), gabapentin, and levofloxacin (Thyroid), were administered at approximately 11:45 AM to 11:46 AM, more than two and one-half hours after their scheduled administration times. On 07/17/2026, pentoxifylline scheduled for 12:00 PM was administered at approximately 3:03 PM, approximately three hours after the scheduled administration time. On 07/20/2026, pentoxifylline scheduled for 8:00 AM and multiple medications scheduled for 9:00 AM, including dapsone, prednisone, rosuvastatin, amlodipine, Symbicort, gabapentin, Flonase, metoprolol, ascorbic acid, zinc sulfate, and oxybutynin, were administered at approximately 12:29 PM to 12:30 PM, approximately three and one-half to four and one-half hours after their scheduled administration times. On 07/21/2026, multiple medications scheduled for 8:00 AM and 9:00 AM were administered at approximately 12:44 PM to 12:46 PM, more than three and one-half to four and one-half hours after their scheduled administration times. On 07/22/2026, pentoxifylline scheduled for 8:00 AM was administered at approximately 10:25 AM, and adalimumab (psoriatic arthritis) scheduled for 9:00 AM was administered at approximately 5:32 PM, more than eight hours after the scheduled administration time. On 07/25/2026, pentoxifylline scheduled for 8:00 AM and multiple medications scheduled for 9:00 AM, including prednisone, dapsone, rosuvastatin, amlodipine, Symbicort, gabapentin, Flonase, metoprolol, ascorbic acid, zinc sulfate, and oxybutynin, were administered at approximately 1:20 PM to 1:23 PM, more than four to five hours after their scheduled administration times. On 07/26/2026, pentoxifylline scheduled for 8:00 AM and multiple medications scheduled for 9:00 AM were administered at approximately 11:28 AM to 11:30 AM, more than two hours after their scheduled administration times. On 07/29/2026, ursodiol (for gallbladder issues), scheduled for 2:00 PM, was administered at approximately 7:10 PM, more than five hours after the scheduled administration time, and pentoxifylline, scheduled for 5:00 PM, was administered at approximately 7:10 PM, more than two hours after the scheduled administration time. Further review revealed medications scheduled for 9:00 PM on 07/19/2026, including oxybutynin, Symbicort, melatonin, and gabapentin, were administered at approximately 11:08 PM, more than two hours after their scheduled administration times. Additionally, levofloxacin scheduled for 6:00 AM on 07/23/2026 was not administered until approximately 9:41 AM on 07/24/2026, more than 27 hours after the scheduled administration time. C. Review of the Medication Administration Audit Report for R18 for the period 07/16/2026 through 07/30/2026 revealed a recurring pattern of medications being administered two or more hours after their scheduled administration times across multiple dates and shifts. On 07/16/2026, multiple medications scheduled for 9:00 PM, including cyclobenzaprine (muscle relaxant), 5 mg, gabapentin 100 mg, lacosamide (Vimpat, for seizures) 50 mg, metoprolol tartrate 25 mg, ascorbic acid 500 mg, and apixaban (Eliquis, a blood thinner) 5 mg, were administered at approximately 6:44 AM on 07/17/2026, more than nine hours after their scheduled administration times. Oxybutynin 5 mg scheduled for 10:00 PM was administered at approximately 6:45 AM on 07/17/2026, more than eight hours after the scheduled administration time. On 07/18/2026, cyclobenzaprine, gabapentin, ascorbic acid, metoprolol, lacosamide, and apixaban scheduled for 9:00 PM were administered at approximately 11:29 PM, more than two hours after their scheduled administration times. On 07/20/2026, apixaban, lacosamide, metoprolol, ascorbic acid, gabapentin, and cyclobenzaprine scheduled for 9:00 PM were administered at approximately 11:11 PM to 11:12 PM. On 07/21/2026, cyclobenzaprine, gabapentin, ascorbic acid, metoprolol, lacosamide, and apixaban scheduled for 9:00 PM were administered at approximately 1:08 AM on 07/22/2026, more than four hours after their scheduled administration times. Oxybutynin scheduled for 10:00 PM was also administered at approximately 1:08 AM. On 07/23/2026, apixaban, ascorbic acid, metoprolol, lacosamide, gabapentin, and cyclobenzaprine scheduled for 9:00 PM were not administered until approximately 5:47 AM to 5:49 AM on 07/24/2026, more than eight hours after their scheduled administration times. Oxybutynin scheduled for 10:00 PM was administered at approximately 5:49 AM. On 07/25/2026, cyclobenzaprine, gabapentin, metoprolol, ascorbic acid, and apixaban, scheduled for 9:00 PM, were administered at approximately 1:23 AM on 07/26/2026. Lacosamide, scheduled for 9:00 PM, was administered at approximately 2:48 AM on 07/26/2026. On 07/27/2026, gabapentin, lacosamide, metoprolol, ascorbic acid, cyclobenzaprine, apixaban, and oxybutynin, scheduled for the evening, were administered at approximately 4:43 AM on 07/28/2026, approximately six to eight hours after their scheduled administration times. The audit also identified significant delays during the day shift. On 07/21/2026, multiple medications scheduled for 9:00 AM were administered at approximately 12:51 PM to 12:52 PM. On 07/26/2026, multiple medications scheduled for 9:00 AM were administered at approximately 1:03 PM, approximately four hours after their scheduled administration times. 3. Missed enteral nutrition: A review of R6's physician orders revealed an order for Jevity 1.5 via PEG tube at 60 milliliters (mL) per hour for 22 hours daily, with the feeding initiated at 2:00 PM and discontinued at 12:00 PM the following day. The prescribed target volume was 1,320 mL daily. An observation conducted on 07/29/2026 at 8:40 AM revealed R6 was not connected to the enteral feeding. The feeding pump was turned off, and a bottle of Jevity 1.5 labeled 07/29/2026 at 3:00 AM was hanging at the bedside with approximately 1,300 mL remaining. According to the physician's order, the feeding should have been infusing at the time of the observation. At 3:03 PM, R6 remained disconnected from the enteral feeding. The feeding pump remained turned off, and approximately 1,300 mL remained in the bottle despite a new 22-hour feeding cycle being scheduled to begin at 2:00 PM. During an interview on 07/29/2026 at 3:15 PM, Licensed Practical Nurse (LPN) EE, who was assigned to R6, confirmed she had not connected R6's enteral feeding as ordered. LPN EE stated she forgot to connect the feeding because there were a lot of things going on. A review of additional survey findings identified delays in required ADL care. The facility failed to provide necessary ADL care for three residents reviewed for ADL care, including failure to provide timely incontinence care. During an interview on 07/30/2026 at 11:02 AM, the Director of Nursing (DON) stated the facility did not have a specific number of nursing staff established for each shift and did not have a defined planned staffing level. The DON stated the facility had a lot of open positions, including Registered Nurse (RN), LPN, CNA, and Assistant Director of Nursing positions. The DON was unable to state the number of vacant nursing positions. The DON further stated the facility's Environmental Services Director had recently resigned. When asked how the facility replaced nursing staff following callouts, the DON stated, We try to replace them the best we can. The DON acknowledged the facility had received complaints and grievances regarding insufficient staffing and delays in resident care. When asked whether she was aware of residents experiencing delays in incontinence care, bathing, call-light response, or other ADL care because staff was unavailable or attending to other residents, the DON referred to the instances identified during the survey and stated, These instances you are explaining. The DON was informed that reviews of medication administration records for multiple residents revealed a recurring pattern of scheduled medications being administered several hours after their scheduled administration times, including evening medications administered after midnight or during the following morning. The DON stated, To be honest, I didn't know. The DON stated the facility's acceptable medication administration window was one hour before to one hour after the scheduled administration time. When asked why medications were administered several hours after their scheduled times across multiple dates and shifts, the DON stated, The nurses either forgot to document or they were running late. When asked whether nursing staffing levels, resident assignments, workload, callouts, or use of agency staff could have contributed to the medication delays, the DON stated, It's possible. I'd have to look at it. The DON stated nursing supervisors and administration were not aware that medication passes were routinely extending several hours beyond scheduled administration times. The DON was informed that LPN EE reported failing to initiate R6's ordered enteral feeding because she forgot and there were a lot of things going on. The DON stated LPN EE's assignment was typically approximately 30 residents. When asked whether sufficient nursing staff were available on 07/29/2026 for LPN EE to complete medication administration, treatments, enteral feedings, and other assigned resident care timely, the DON stated, Should have been. When asked how the facility monitored whether nursing staffing levels were sufficient to meet residents' needs, the DON stated, We have audits and stuff. A review of the facility's Nursing Services and Sufficient Staff policy, revised March 2025, revealed it was the facility's policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and the individual plan of care. The policy directed that the facility's census, acuity, and diagnoses of the resident population were to be considered based on the facility assessment. The policy further directed the facility to provide sufficient numbers of licensed nurses and other nursing personnel, including nurse aides, on a 24-hour basis to provide care to all residents in accordance with their care plans. Providing care included assessing, evaluating, planning, implementing resident care plans, and responding to residents' needs. The policy also required licensed nurses and nurse aides to possess the competencies and skills necessary to care for residents' needs as identified through resident assessments and described in their plans of care.

Based on observation, interviews, and record review, the facility failed to implement the comprehensive care plan for one of 16 residents (R) (R6) receiving enteral nutrition. This deficient practice had the potential for residents not to receive nutrition and hydration to meet their dietary needs. Findings included: A review of the facility's Comprehensive Care Plans policy, revised October 2025, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident. The policy directed that all services provided or arranged by the facility, as outlined by the comprehensive care plan, were to meet professional standards of quality. The policy further directed that qualified staff responsible for carrying out interventions specified in the care plan were to be notified of their roles and responsibilities for carrying out the interventions. A review of the electronic medical record (EMR) revealed that R6 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, anoxic brain damage, cerebral infarction, oropharyngeal dysphagia, encounter for attention to gastrostomy, tracheostomy status, myoclonus, epilepsy, and morbid obesity due to excess calories. A review of R6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R6 received 51 percent (%) or more of total calories through parenteral or enteral tube feeding and received 501 milliliters (mL) or more of fluid per day by intravenous (IV) or tube feeding during the assessment period. A review of R6's comprehensive care plan revealed R6 required enteral nutrition related to dysphagia. The care plan included interventions related to maintaining R6's nutritional and hydration status and providing enteral nutrition as ordered. A review of R6's physician orders revealed an order for Jevity 1.5 via percutaneous endoscopic gastrostomy (PEG) tube at 60 mL per hour for 22 hours daily, with the feeding initiated at 2:00 p.m. and discontinued at 12:00 p.m. the following day. The prescribed target volume was 1,320 mL daily. An observation conducted on 07/29/2026 at 8:40 AM revealed that R6 was not connected to the enteral feeding. The feeding pump was turned off. A bottle of Jevity 1.5 labeled 07/29/2026 at 3:00 AM was hanging at the bedside with approximately 1,300 mL remaining. According to the physician's order, the feeding should have been infusing at the time of the observation. An observation conducted on 07/29/2026 at 3:03 PM revealed R6 remained disconnected from the enteral feeding. The feeding pump remained turned off, and approximately 1,300 mL of Jevity 1.5 remained in the bottle. According to the physician's order, a new 22-hour feeding cycle should have been initiated at 2:00 PM; however, the feeding had not been initiated as ordered. During an interview conducted on 07/29/2026 at 3:15 PM, with Licensed Practical Nurse (LPN) EE, assigned to R6, the LPN confirmed she had not connected R6's enteral feeding as ordered. The LPN stated she forgot to connect the feeding because there were a lot of things going on. During an interview conducted on 07/29/2026 at 3:40 PM, the Director of Nursing (DON) was informed that R6's enteral feeding was not connected, and the feeding pump was turned off. The DON stated she would look into it. At approximately 4:00 PM, the DON returned and confirmed that R6's enteral feeding not being connected was an error. The DON stated the facility would initiate a 100% audit and staff education. A review of a nursing note entered on 07/29/2026 at 4:19 PM revealed R6's enteral feeding had been disconnected at the wrong time. Cross-reference F692 and F693

Based on observations, record review, interviews, and review of facility policy, the facility failed to provide necessary activities of daily living (ADL) care for one of three residents (R)(R2) reviewed for ADL care. Specifically, the facility failed to ensure R2 received appropriate bathing services during an extended disruption in hot-water availability. Findings included: A review of the facility policy titled Activities of Daily Living (ADLs), dated October 2025, noted that the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care; and a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal oral hygiene. During an interview with R2 at 3:00 PM on 07/28/2026, R2 voiced concerns about the hot water not working for about three to four weeks during June 2026 going into July 2026. R2 stated he only received bed baths with tepid water during this period due to hot water issues, and he still felt dirty, nasty, and neglected. R2 stated he went without hot showers for at least three weeks, and no provisions were made. R2 indicated that he reported his concerns to staff regarding feeling mistreated and uncared for. A review of R2's quarterly MDS assessment, with an ARD of 05/01/2026, revealed R2 had a BIMS score of 14, which indicated intact cognition. Per the MDS, R2 required partial to moderate assistance with bathing. During an interview with CNA II and CNA JJ, on 07/28/2026 at approximately 3:30 PM, both CNAs confirmed issues with the hot water. The CNAs reported that during the hot water issues, only two residents were able to go upstairs for a shower, and the rest of the residents received bed baths with lukewarm water. The CNAs stated that the hot water issue occurred from the kitchen to the floor, and most of the residents had bed baths during that timeframe. During an interview about the hot water issue with the Director of Nursing (DON) on 07/28/2026 around 4:00 PM, the DON reported that a plan of care was provided for each resident and all the residents on the affected units should have received hot water for baths. The DON stated that individual care plans were not updated, but residents were informed that they could go up to the 200 hall for showers. During an interview on 07/29/2026 at approximately 2:15 PM, Certified Nursing Assistant (CNA) GG stated she had worked on the unit for several months. CNA GG confirmed that R2 did not receive any showers during the several weeks when the hot water was out and indicated that R2's concerns had been reported.

Based on observation, interviews, and record review, the facility failed to ensure that one of 16 residents (R) (R6) receiving tube feeding maintained acceptable parameters related to body weight. Findings included:A review of the electronic medical record (EMR) revealed that R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to, morbid obesity due to excess calories, anoxic brain damage, cerebral infarction, oropharyngeal dysphagia, encounter for attention to gastrostomy, tracheostomy status, myoclonus, and epilepsy. A review of R6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R6 received 51 percent (%) or more of total calories through parenteral or enteral tube feeding and received 501 mL (milliliters) or more of fluid per day by IV or tube feeding during the assessment period. A review of R6's care plan revealed R6 required enteral nutrition related to dysphagia. The care plan included interventions related to maintaining R6's nutritional and hydration status and monitoring for complications associated with enteral feeding. A review of R6's weight records revealed that R6 weighed:243 pounds on 01/21/2026, 213.8 pounds on 04/20/2026, 221 pounds on 05/06/2026, 220 pounds on 06/01/2026, 212.4 pounds on 06/10/2026, and 208 pounds on 07/17/2026.R6 experienced a 35-pound, or 14.4%, weight loss from 01/21/2026 through 07/17/2026. A review of R6's physician orders revealed an order for Jevity 1.5 via PEG (Percutaneous Endoscopic Gastrostomy) tube at 60 mL per hour for 22 hours daily, with the feeding to be initiated at 2:00 PM and discontinued at 12:00 PM the following day. The order provided a target volume of 1,320 mL daily. R6 was also ordered free-water flushes at 50 mL per hour for 22 hours. A review of a Registered Dietitian (RD) Progress Note dated 06/03/2026 at 3:39 PM revealed that R6 was NPO (nothing by mouth) and received Jevity 1.5 via PEG tube at 60 mL/hour for 22 hours, from 2:00 PM until 12:00 PM the following day. The prescribed feeding provided 1,320 mL, 1,980 kilocalories, 84 grams of protein, and 1,003 mL of water. The RD calculated R6's estimated nutritional needs at 1,870-2,200 kilocalories and 76-95 grams of protein daily and recommended continuation of the prescribed enteral feeding regimen. A review of an RD note dated 06/15/2026 revealed the RD identified R6 as triggering for significant weight loss. The RD documented that R6 was NPO and enteral feeding was the resident's sole source of nutrition. The RD determined the prescribed enteral feeding provided adequate nutrition to meet R6's estimated nutritional needs and recommended continuation of the feeding regimen. A review of an RD Weight Review dated 07/28/2026 revealed the RD again reviewed R6's weight trend and nutritional requirements. The RD documented R6's prescribed enteral feeding met the resident's estimated nutritional needs. The RD documented R6 had a Body Mass Index (BMI) of 33.6 and considered the resident's weight loss beneficial due to obesity. During an observation conducted on 07/29/2026 at 8:40 AM, R6 was not connected to the enteral feeding, and the feeding pump was turned off. A bottle of Jevity 1.5 labeled 07/29/2026 at 3:00 AM was hanging at the bedside with approximately 1,300 mL remaining. According to the physician's order, the feeding should have been infusing at the time of the observation. A review of an RD Weight/PAR Review entered on 07/29/2026 at 11:03 AM revealed the RD documented R6 continued to receive enteral feeding as ordered meeting estimated nutritional needs. The RD again documented that R6's weight loss was considered beneficial due to the resident's BMI and obesity. During an observation conducted on 07/29/2026 at 3:03 PM revealed R6 was again not connected to the enteral feeding. The feeding pump was turned off, and approximately 1,300 mL of Jevity 1.5 remained in the bottle. According to the physician's order, the feeding should have been infusing at the time of the observation. During an interview conducted on 07/29/2026 at 3:40 PM, the Director of Nursing (DON) was informed that R6's enteral feeding was not connected and the feeding pump was turned off. The DON stated she would look into it. At approximately 4:00 PM, the DON returned and confirmed that R6's enteral feeding was not connected and that this was an error. A review of the facility's Nutritional Management policy, undated, revealed that a systematic approach was to be used to optimize each resident's nutritional status, including identifying and assessing nutritional status and risk factors, evaluating/analyzing assessment information, developing and consistently implementing pertinent approaches, monitoring the effectiveness of interventions, and revising them as necessary. The policy directed staff to evaluate the care plan to determine if current interventions were being implemented and were effective. The care plan was to be updated as needed when interventions were determined to be ineffective or when new causes of nutrition-related problems were identified. The physician was to be notified of significant changes in weight, intake, or nutritional status.

Based on observation, interviews, and record review, the facility failed to ensure that one of 16 residents (R) (R6) who required enteral nutrition through a gastrostomy tube received the tube feeding in accordance with the physician's orders. Specifically, the facility failed to ensure R6's prescribed Jevity 1.5 was administered at 60 milliliters (mL) per hour for the ordered 22-hour duration when the feeding was disconnected and the feeding pump was turned off during the prescribed administration period. This deficient practice resulted in R6 not receiving the prescribed enteral feeding and required practitioner intervention, including orders for additional, immediate enteral nutrition. Findings included:A review of the facility's Care and Treatment of Feeding Tubes policy, revised October 2024, revealed that feeding tubes were to be utilized according to physician orders, including the type of feeding, caloric value, volume, duration, mechanism of administration, and frequency of flushes. The policy directed staff to ensure administration of enteral nutrition was consistent with and followed the practitioner's orders. The policy further directed staff to periodically evaluate the amount of enteral feeding formula being administered for consistency with the practitioner's orders. A review of the electronic medical record (EMR) revealed that R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to, anoxic brain damage, cerebral infarction, oropharyngeal dysphagia, encounter for attention to gastrostomy, tracheostomy status, myoclonus, epilepsy, and morbid obesity due to excess calories. A review of R6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R6 received 51 percent (%) or more of total calories through parenteral or enteral tube feeding and received 501mL or more of fluid per day by intravenous (IV) or tube feeding during the assessment period. A review of R6's care plan revealed R6 required enteral nutrition related to dysphagia. The care plan included interventions related to enteral feeding, maintaining nutritional and hydration status, aspiration precautions, monitoring for tube dysfunction and complications, and gastrostomy tube site care. A review of R6's physician orders revealed an order for Jevity 1.5 via percutaneous endoscopic gastrostomy (PEG) tube at 60 mL per hour for 22 hours daily, with the feeding to be initiated at 2:00 PM and discontinued at 12:00 PM the following day. The order provided a target volume of 1,320 mL daily. R6 was also ordered free-water flushes at 50 mL per hour for 22 hours. A review of a Registered Dietitian (RD) Progress Note dated 06/03/2026 at 3:39 PM revealed R6 was NPO and enteral nutrition was the resident's sole source of nutrition. The RD documented that R6 received Jevity 1.5 via PEG tube at 60 mL per hour for 22 hours, from 2:00 PM until 12:00 PM the following day, and recommended continuation of the prescribed enteral feeding regimen. During an observation conducted on 07/29/2026 at 8:40 AM, R6 was not connected to the enteral feeding. The feeding pump was turned off. A bottle of Jevity 1.5 labeled 07/29/2026 at 3:00 AM was hanging at the bedside with approximately 1,300 mL remaining. According to the physician's order, the feeding should have been infusing at the time of the observation. A review of an RD Weight/PAR Review entered on 07/29/2026 at 11:03 AM revealed the RD documented R6 continued to receive enteral feeding as ordered, meeting estimated nutritional needs. During an observation conducted on 07/29/2026 at 3:03 PM, R6 remained disconnected from the enteral feeding pump. The feeding pump remained turned off, and approximately 1,300 mL of Jevity 1.5 remained in the bottle. According to the physician's order, a new 22-hour feeding cycle should have been initiated at 2:00 PM; however, the feeding had not been initiated as ordered. During an interview conducted on 07/29/2026 at 3:15 PM with Licensed Practical Nurse (LPN) EE assigned to R6, LPN EE confirmed she had not connected R6's enteral feeding as ordered. She further added that she was unsure who had disconnected the feeding and that she didn't think it [the enteral feeding] was connected when I got here. LPN EE added that she started her shift at 7:00 AM. LPN EE stated she forgot to connect the feeding because there were a lot of things going on. During an interview conducted on 07/29/2026 at 3:40 PM, the Director of Nursing (DON) was informed that R6's enteral feeding was not connected, and the feeding pump was turned off. The DON stated she would look into it. At approximately 4:00 PM, the DON returned and confirmed that R6's enteral feeding had not been connected and that this was an error. Cross-reference F692

Based on observations and interviews, the facility failed to ensure that medications were secured and inaccessible to unauthorized individuals during one of three medication administration observations. During the affected observation, Licensed Practical Nurse (LPN) EE left the medication cart unlocked and unattended at 8:35 AM and again at 8:45 AM. Findings included:On 07/29/2026 at 8:35 AM, during medication administration observations, LPN EE prepared medications for Resident (R)19. LPN EE left the medication cart to enter R19's room and administer the medications. While LPN EE was in R19's room, the medication cart remained unlocked in the hallway and was outside of LPN EE's line of sight. At 8:45 AM, LPN EE exited R19's room and stated she would be right back. LPN EE then took an oxygen cylinder down the hallway to replace it, leaving the medication cart unlocked and unattended. The medication cart remained outside of LPN EE's line of sight while she was away from the cart. During an interview on 07/29/2026 at 8:57 AM, LPN EE stated the medication cart should be locked when left unattended. When asked about leaving the medication cart unlocked during the medication administration observations, LPN EE stated, I normally lock it, but I didn't that time. LPN EE acknowledged the medication cart should have been secured before she walked away from it. During an interview on 07/29/2026 at 10:25 AM, the Director of Nursing (DON) stated that medication carts were expected to be locked whenever they were left unattended or were outside of the nurse's line of sight. The DON stated nursing staff should lock the medication cart before entering a resident's room or leaving the immediate area of the cart to prevent unauthorized access to medications. After the surveyor described the observations involving LPN EE at 8:35 AM and 8:45 AM, the DON stated the medication cart should have been locked on both occasions and that leaving the cart unlocked and unattended was not consistent with the facility's expectations for medication security. During the interview, the DON was asked to provide a copy of the facility's policy related to medication storage and security. The requested policy was not provided before the exit of the survey on 07/30/2026.

Based on observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure food safety protocols and maintain sanitary conditions for two of two resident refrigerators on Hall 100 and Hall 800 and failed to discard expired food in the dry storage area. The deficient practices had the potential to place 201 residents (R) who received an oral diet from the kitchen at risk of contracting a foodborne illness.Findings Include:Review of the facility's policy titled Food Receiving and Storage, issued April 2025, documented: POLICY: Foods shall be received and stored in a manner that complies with safe food handling practices. GUIDELINES: .6. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated. Such foods will be rotated using a first in first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated.During the initial tour of the kitchen on 04/17/2026 at 8:05 AM with the Certified Dietary Manager (CDM), the dry storage area contained five plastic bins of cereal with expired dates of 02/20/2026, 02/27/2026, and 02/28/2026. Additionally, 73 bowls of pre packaged cereal were stored without labels or dates. The CDM confirmed the cereal was expired and acknowledged that staff should have discarded it.During the initial tour on 04/17/2026 at 8:20 AM, the Dietary Aide (DA) AA confirmed that the food items in the refrigerator on Hall 800 (West Wing) were unlabeled and undated, and that some food items were molded. DA AA stated nursing was responsible for the Hall refrigerators.Interview on 04/17/2026 at 8:25 AM with Certified Nursing Assistant (CNA) BB on Hall 800 (West Wing) confirmed the presence of unlabeled and undated food items, including a 2 lb (pound) 6 oz (ounce) veggie tray with a fuzzy green substance, a leftover cooked chicken plate with unidentifiable food items due to fuzzy green substance, and three unlabeled and undated peanut butter and jelly sandwiches. Interview on 04/17/2026 at 8:35 AM with the Unit Manager (CC) on Hall 800 (West Wing) confirmed that the undated food items-including the 2 lb 6 oz veggie tray with a fuzzy green substance, the leftover cooked chicken plate with unidentifiable food items due to fuzzy green substance, and the three unlabeled and undated peanut butter and jelly sandwiches-should have been thrown away. She stated that nursing staff were expected to discard food items after three days.Interview on 04/17/2026 at 8:45 AM with Unit Manager (DD) on Hall 100 (East Wing) confirmed the presence of unlabeled, undated, and leftover chicken, rice, an egg roll, a small plastic container of greens, and a leftover plate of unidentifiable food items due to fuzzy green substance, which was covered with a paper towel and wrapped in a brown plastic bag. Unit Manager DD confirmed that the food items in the refrigerator should have been labeled, dated, and discarded within three to five days. She stated that it was the nursing staff's responsibility to ensure this was done.Interview on 04/19/2026 at 8:25 AM with the CDM and Administrator revealed that their expectation was for staff to date and label all open food items with both an open date and an end date. The CDM stated that they would continue providing education for staff regarding this requirement.Interview on 04/19/2026 at 10:20 AM with the Certified Dietary Manager (CDM) and Dietitian Manager (JJ) reviewed pictures of unlabeled and expired cereal, as well as old food items that were not labeled or dated. They confirmed that the refrigerators on Hall 100 and Hall 800 were found to be in an unsanitary condition. Both individuals stated that the condition of the food items and the sanitation of the refrigerators were unacceptable.Interview on 04/19/2026 at 11:55 AM with the Administrator revealed that she did not have a Performance Improvement Plan (PIP) in place to address the food storage, labeling, and unsanitary condition of the residents' refrigerators located on Hall 100 and Hall 800.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure that nail care was provided for one resident (R) (R92) of 35 sampled residents. This failure could lead to skin impairment resulting from toenail overgrowth.Findings include:Review of the electronic medical record (EMR) revealed R92 was admitted to the facility on [DATE] with diagnoses that included but was not limited to spinal stenosis, cervical region and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the orders revealed Podiatry/Oral/Dental Care as needed with a start date of 01/21/2025.During an interview and observation on 04/17/2026 at 12:40 PM, R92 reported that staff were not cutting toenails.During an interview and observation on 04/18/2026 at 8:43 AM, R92 reported that his toenails and fingernails were as long as they will get. R92 further reported that if someone offered to cut his toenails he would allow it. The toenail on the left great toe was jagged with the other nails curling over the toes due to length.During an interview on 04/18/2026 at 9:06 AM with Social Services Assistant (SSA) it was reported that podiatry was last scheduled in the facility on 04/07/2026 and is scheduled again for 04/30/2026.During an interview and observation on 04/19/2026 at 10:02 AM with Licensed Practical Nurse (LPN) HH 800 Hall, she reported that nurses were responsible for nail care, but podiatry typically cuts toenails. LPN HH reported that Podiatry services come once or twice each month, but the nurse had to notify Social Services to put a resident's name on the list. LPN HH confirmed the long toenails for R92 and reported that she would notify Social Services.During an interview on 04/19/2026 at 12:58 PM the Director of Nursing (DON) reported that SSA will add R92 to the podiatry list and the next appointment is scheduled for 04/30/2026. The DON explained that podiatry services prior to 11/01/2025 are no longer being used and a new podiatrist just started April 2026 and the SSA was unsure of the last time R92 was seen by podiatry.

Based on observations, record review and staff interview, the facility failed to ensure a medication error rate was less than five percent during medication administration review. Three errors were identified from 38 opportunities, resulting in a 7.89 percent (%) medication error rate. The deficient practice placed residents at risk for inaccurate dosing and adverse clinical outcomes.Findings include:1. On 04/18/2026 at 8:50 AM, Licensed Practical Nurse (LPN) FF was observed giving R216 his morning medications. The medications included citalopram 20 mg (milligrams) tablet and hydralazine 50 mg tablet.Review of the Physician Orders dated 04/14/2026 revealed an order for citalopram 10 mg, give one tablet by mouth one time a day for depression; and hydralazine HCl (hydrochloride) 50 mg, give one tablet by mouth every 8 hours related to essential hypertension.Review of the Medication Administration Record (MAR) dated 04/18/2026 revealed a different nurse had already given the hydralazine 50 mg at 6:00 AM.Observation and interview on 04/19/2026 at 9:00 AM, Registered Nurse (RN) Supervisor GG revealed the citalopram 20 mg blister pack was still located in the medication cart on top of the citalopram 10 mg blister pack. She removed the citalopram 20 mg blister pack and stated the nurse that took the order change should have removed the package for 20 mg once the 10 mg came in. She also confirmed the hydralazine 50 mg was given at 6:00 AM and should not have been given again at 9:00 AM. Interview on 04/19/2026 at 10:53 AM, RN Supervisor GG stated that she contacted the physician regarding the medication error and monitored the resident's blood pressure with no adverse findings. 2. On 04/19/2026 at 8:15 AM, LPN EE was observed giving R102 his morning medications. The medications included Mucinex 400 mg tablet.Review of the Physician Order dated 04/08/2026 revealed Mucinex Oral Tablet, Extended Release 12 Hour 600 mg, give one tablet by mouth every 12 hours for cough/congestion for 14 days.During a follow up observation and interview on 04/19/2026 at 10:00 AM, RN Supervisor GG and LPN EE confirmed the resident received the wrong dose of Mucinex. At 10:56 AM, RN GG stated she notified the physician to report the error.Review of the Medication Administration Policy, dated 04/2025 documented Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.10. Ensure that the six rights of medication administration are followed. c. right dosage.e. right time.12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observations, staff interviews, and a review of the facility policy titled Medication Storage, the facility failed to properly lock, secure and discard medications on two of seven medication carts (500 Hall and 200 Hall.) The deficient practice increased the risk of unauthorized access and potential medication diversion.Findings include:Review of the facility policy titled Medication Storage, with a revised date of 10/01/2025 documented under the section Policy Explanation and Compliance Guidelines (1) General Guidelines (a). all drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerator, medication rooms) under proper temperature controls.During an observation and interview on 04/18/2026 at 3:09 AM with Licensed Practical Nurse (LPN) KK revealed the medication cart on the 500 Hall was unlocked and unattended while LPN KK was sitting behind the nurse's station on the computer. In addition, an unsecured round pink pill was observed sitting on top of the medication cart. LPN KK confirmed the medication cart was unlocked while she was putting in her notes and the cart is supposed to be locked when not in use. She stated the unsecured round pink medication pill was found on the floor and she forgot to discard it.During an observation and interview on 04/18/2026 at 11:40 AM with LPN LL revealed the medication cart on 200 Hall was unlocked and unattended while LPN was observed in a resident's room. LPN LL confirmed she was in a resident room retrieving a glucose check while the cart was unlocked and unattended. She stated she is not sure what the protocol was related to unlocked medication carts.

Based on observations, interviews, record review, and review of facility policy titled Resident Nutrition Services, the facility failed to ensure that meal preferences were followed for one resident (R) (R165) of 35 sampled residents. The deficient practice had the potential to affect the quality of life for R165. Findings includeReview of the electronic medical record (EMR) for R165 revealed diagnoses that included but not limited to cerebral infarction, chronic kidney disease stage 5, and type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema left eye.Review of the EMR revealed a Minimum Data Set (MDS) quarterly assessment dated [DATE], Section C: Brief Interview of Mental Status score of 15, which indicated little to no cognitive impairment.During an interview and observation on 04/17/2026 at 8:11 AM, R165 reported that she was sent grits all the time and she did not like hot cereal. Review of the breakfast tray revealed a bowl of grits. Further review of the breakfast tray revealed a meal ticket indicating a list of dislikes that included hot cereal.During an interview on 04/18/2026 at 8:47 AM, R165 reported that she received grits again this morning for breakfast.During an observation on 04/19/2026 at 8:28 AM, R165's breakfast tray was at the bedside and paramedics were preparing R165 for transfer to the hospital. R165 was observed with food in her mouth and a bowl of grits on her breakfast meal tray. Review of the meal ticket located on the tray documented hot cereal as a dislike.During an interview on 04/19/2026 at 10:57 AM, Food Service Director (FSD) reported that the checker (Dietary role) was responsible for ensuring that the food on the tray was correct.Interview with Registered Dietician (RD) JJ and FSD on 04/19/2026 at 11:57 AM, reported that dietary staff were educated to ensure the meal tickets were being followed correctly. RD JJ reported that the meal ticket was updated to reflect grits and oatmeal specifically named and added as dislikes for R165.Interview on 12/19/2026 at 12:34 PM Certified Nursing Assistant (CNA) II, who reported that when passing the meal tray for R165 she had to set her up and let her know what she was eating. When questioned about the meal ticket CNA II reported that she did not read the meal ticket. CNA II stated that the resident can say what she liked and if the resident didn't like something she would take the tray back to the kitchen to get something else. Review of the facility policy titled Resident Nutrition Services, dated April 2024, documented Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance. Documented for Guidelines: .2. Nursing personnel will ensure that residents are served the correct food tray. 3. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure the correct food tray is being served to the resident. If there is doubt, the Nurse Supervisor will check the written Physician's order. 4. If an incorrect meal has been delivered, Nursing staff will report it ot the Nutrition Services Manager so that a new food tray can be issued.

Based on observations, resident, staff, and family interviews, and a review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide ADLs for four of 16 sampled residents (R) (R1, R8, R7, and R6) dependent of staff for care related to: scheduled showers for R1, R8, R7, and R6; nail care for R1 and R8; and shaving facial hair for R1 and R8. This deficient practice had the potential to place R1, R8, R7, and R6 at increased risk of unmet needs. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLs), with a reviewed/revised date 10/2025, revealed: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. A review of the Grievance Missing Property log revealed that from 7/2/2025 to 12/22/2025, seven residents and/or families filed grievances regarding not receiving scheduled baths/showers, shaves, nail care, and not moisturizing their skin. 8/27/25, 9/23/2025, 10/6/2025, 10/23/2025, 11/19/2025, 11/24/2025, and 12/22/2025. 1. Review of R1's admission Record revealed diagnoses of, but not limited to, muscle wasting and atrophy. Review of the resident's most recent Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was assessed as 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) assessed the resident as the staff does more than half of the personal hygiene. Review of the care plan, initiated 7/25/2025, revealed that R1 has a self-care performance deficit. Interventions included that staff assist with all ADLs. Review of R1's Point of Care Response (POC) History for Task: ADL - shower/Bath days are Tuesday, Thursday, Saturday on the 7 am-7 pm shift. In December 2025, a Certified Nursing Assistant (CNA) documented that R1 had a bath/shower on 12/4/2025, 12/18/2025, 12/19/2025, and 12/23/2025. An observation on 12/18/2025 at 2:12 pm of R1 revealed that the resident was unkempt, with disheveled hair and an unshaven appearance. The resident's fingernails on both hands were long, with dirt and brown debris under the nails. An observation on 12/23/2025 at 10:40 am of R1 was unkept, hair disheveled, and unshaven. The resident's fingernails on both hands were long, with dirt and brown debris under the nails. An observation on 12/24/2025 at 8:38 am of R1 was unkept, hair disheveled, and unshaven. The resident's fingernails on both hands were long, with dirt and brown debris under the nails. In an interview on 12/24/2025 at 8:39 am, R1 stated his bath days were Monday, Wednesday, and Friday. The resident stated he likes to have a bed bath, but he has not had one in over two weeks. He stated he would like his nails clipped and to be shaved. In an interview on 12/24/2025 at 8:55 am, Registered Nurse/Unit Supervisor (RN/US) AA confirmed that R1's nails were long, dirty, and had brown debris under the nail. She also confirmed that R1 was unshaven. The RN/US AA stated she would ensure that the resident received a bath/shower, shave, and nail care today. 2. Review of R8's admission Record revealed diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of the resident's most recent MDS Quarterly assessment, dated 11/26/2025, revealed that the BIMS was not assessed. Section GG (Functional Abilities and Goals) assessed the resident as totally dependent on staff for personal hygiene. Review of the care plan, initiated 9/1/2025, revealed that R8 has a self-care performance deficit. Interventions included provide assistance with the staff assistance of two. Review of R8's POC History for Task: ADL - shower/Bath days are Tuesday and Friday, no shift indicated. In December 2025 a CNA documented R8 had a bath/shower on 12/2/2025, 12/5/2025, 12/9/2025, 12/19/2025, and 12/23/2025. An observation on 12/23/2025 at 9:20 am of R8 unshaven, and the resident's fingernails on the right and left hand were long in length with brown debris under the nail. An observation on 12/24/2025 at 9:25 am of R8 unshaven, and the resident's fingernails on the right and left hand were long in length with brown debris under the nail. In an interview on 12/24/2025 at 9:29 am, Unit Manager (UM) BB stated that the residents have scheduled shower/bath days. The UM stated that on the residents' shower/bath day, the resident should have their nails cleaned, clipped, and shaven. The UM confirmed that R8 was unshaven and had long nails. The UM stated she would ensure that the resident had a shower, be shaved, and have nails clipped today. 3. Review of R7's admission Record revealed diagnoses of, but not limited to, gout and nutritional deficiency. Review of the resident's most recent MDS Quarterly assessment, dated 11/17/2025, revealed the BIMS was assessed at 10 (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident was assessed as requiring assistance from staff with personal hygiene. Review of the care plan, initiated 12/12/2025, revealed that R7 had a self-care performance deficit. There were no documented interventions specifying the assistance R7 required. Review of R7's POC History for Task: ADL - Bathing (Scheduled Shower or Tub Bath): Monday, Wednesday, and Friday on the 7:00 pm-7:00 am shift. In December 2025, a CNA documented R7 had a bath/shower on 12/4/2025, 12/5/2025, 12/6/2025, 12/9/2025, 12/10/2025, 12/11/2025, 12/13/2025, 12/15/2025, 12/16/2025, 12/18/2025, 12/19/2025, 12/20/2025, 12/23/2025, 12/24/2025, 12/26/2025, and 12/27/2025. An observation on 12/18/2025 at 9:58 am of R7's skin with UM BB revealed that UM BB removed the resident's shoes and socks. An observation revealed that R7's right and left feet were white, with dry, flaky skin. An interview on 12/24/2025 at 9:29 am, UM BB stated the residents have scheduled shower/bath days. The UM stated that on the residents' shower/bath day, the resident should be cleaned and skin moisturized. The UM confirmed that R7's skin was dry and flaky, and that it had not been moisturized. The UM stated the resident's skin would not look that way if he was getting his scheduled shower/bath. 4. Review of R6's admission Record revealed diagnoses of, but not limited to, collapsed vertebrae. Review of the resident's most recent MDS Quarterly assessment, dated 10/26/2025, revealed that a BIMS was assessed as fifteen (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident was assessed as requiring assistance from staff with personal hygiene. Review of the care plan, initiated 12/12/2025, revealed that R6 has a collapsed vertebra in the thoracic region. Interventions included for staff to assist with all ADL activities. Review of R6's POC History for Task: ADL - Bathing Tuesday, Thursday, and Saturdays on the 7:00 am-7:00 pm shift. In December 2025, a CNA documented R6 had a bath/shower on 12/16/2025, 12/18/2025, 12/24/2025, and 12/27/2025. An observation on 12/18/2025 at 1:20 pm of R6 lying in bed revealed the resident's hair was matted, greasy, and disheveled. In an interview on 12/18/2025 at 1:21 pm, R6 stated her scheduled shower days were Monday and Thursday. The resident stated she had not had a shower in three weeks. The resident stated she had not attended activities because she had not had a shower in three weeks. In an interview on 12/18/2025 at 1:49 pm, CNA DD stated that R6 has not had a shower due to the CNAs being short-staffed. In an interview on 12/31/2025 at 10:43 am, the Director of Nursing (DON) stated her expectation was for staff to provide the residents with their showers as scheduled. She stated the residents were scheduled for three showers a week, and as needed. The DON stated that the residents' nails should be clipped and their faces should be shaved on shower/bath days and as needed. She stated the CNA should review the POC for the resident's shower days. She stated the CNAs are responsible for documenting the resident's showers/bath in the POC. The DON stated that the UM is responsible for ensuring the residents are showered and that the documentation is entered in the POC.

Based on staff interviews and review of the Facility Assessment Tool and the Payroll-Based Journal (PBJ) Staffing Data Report Quarter (Q) 2 2024, the facility failed to ensure there were adequate nursing staff to serve their residents. The deficient practice had the potential to adversely affect the care and services provided to the facility residents. The facility census was 212 residents. Findings include: Review of The Facility Assessment Tool (FAT) 2024 revealed the facility was licensed for 242 beds. The facility's current census was 212 residents. The FAT revealed the average hourly staffing needs per day were 84 hours for licensed nurses providing direct care, 233 hours for nurses' aides. Review of the PBJ Staffing Data Report Quarter 2, 2024 revealed based on the data submitted, the facility triggered Excessively Low Weekend Staffing and for a One-Star Staffing Rating (Failure to submit PBJ data by the deadline, more than 4 days in the quarter without RN (Registered Nurse) Staffing hours, failure to respond to, submit documentation for, or failure to pass a CMS audit designed to discover discrepancies in PBJ data). Interview on 7/18/2024 at 2:40 pm with the Administrator and the [NAME] President of Operation revealed they were both aware of the PBJ's one-star staffing and excessively low weekend staffing rating the facility received for the second quarter of 2024. The Administrator stated they are in the process of hiring to assist with the lack of staffing.

Based on observations, staff interviews, and review of the facility policies titled, Labeling and Dating Foods, Refrigerator and Freezer Temperatures, Cleaning Instructions: Conventional Oven (2020), Hair Restraints, and Cleaning Instructions: Floors, the facility failed to ensure dietary staff contained hair in hair nets, ensure that food was properly labeled, stored and prepared in a sanitary condition to prevent foodborne illness, and failed to monitor and log daily temperature of refrigerator and freezer temperatures to ensure food was preserved per recommended guidelines. In addition, the facility failed to ensure the cleaning of appliances (stove, refrigerator), countertops, floor tiles, and ceiling vents. Additionally, the facility failed to ensure that needed repairs were done for an identified plumbing issue with the drainage system, kitchen exterior door disrepair to prevent access of pests, missing floor tiles, and rust buildup of the stove hood. The deficient practice had the potential to affect 198 residents receiving an oral diet. Findings include: Review of the facility policy titled Labeling and Dating Foods, dated 2020, stated under Guideline: Food stored will be properly labeled according to the following guidelines. Procedure: . 2. Date marking for refrigerated and storage food items. Ready to eat, potentially hazardous food will follow the manufacturers expiration dates. 3. Date marking for freezer storage food items. Frozen food packages removed from the case will be date item was received into the facility and will be stored using the first in-first out method of rotation. Once a package is opened, it will be re-dated with date using the safe food storage guidelines and/or manufacturers expiration date. Review of the undated facility policy titled Refrigerator and Freezer Temperatures, revealed under Guidelines: To ensure all perishable food items stay fresh and palatable, temperature will be recorded on all refrigerators and freezers in use, including unit refrigerators located in nourishment rooms. Review of the facility policy titled Cleaning Instructions: Conventional Oven, dated 2020, stated under Guidelines: Ovens will be cleaned regularly, according to cleaning schedule. Procedure: . 2. Scrape burned particles from inside of oven with scraper. Remove and discard all particles from interior. 4. Wipe off any loosened grease and particles from interior. Scrub interior, shelf ledges, inside of the door, and frame with warm, soapy water. 6. Wash outside of door, door handles and frame with warm soapy water. 7. Self-cleaning ovens should be cleaned according to manufacturer 's instructions. Review of the facility policy titled Hair Restraints, dated 2020, stated under Guidelines: Hair restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Review of the facility policy titled Cleaning Instructions: Floors, dated 2020, stated under Guidelines: Floors will be kept clean and sanitary, washed daily or as needed. Under Procedure: 1. Kitchen floor will be swept and cleaned after meal. 3. Additional steps may be taken to use degreasers or other appropriate floor cleaners in high-traffic cooking areas. Floor drains will be kept covered, cleaned, and free of odors. Review of the facility maintenance form titled Work Order#335-Dietary Back Door documented that on 7/15/2024, a sensor was moved to the middle, which caused the gap to close. This shows they fixed the problem - ? remove or leave? The tour of the kitchen on 7/14/2024 started at 11:00 am and ended at 12:55 pm with the Dietary Manager (DM) and Dietary Aide (DA) ZZ. The following concerns were noted during the tour: 1. Daily temperature logs for the walk-in freezer, walker-in cooler, and reach-in refrigerator were missing from 7/11/2024 through 7/14/2024. 2. The oven had a buildup of dark, thick, greasy substances that coated the inside walls, racks, and oven doors. 3. Observations in the walk-in cooler revealed tilapia fish stored in a large plastic bag, not labeled, with watery, white liquids in the bag; beef tips with bloody, watery liquids stored in a large plastic bag, not labeled; and chicken breast stored in a large plastic bag, not labeled. 4. Observations in the walk-in freezer revealed one bag of biscuits stored in a large plastic bag, unlabeled, and a package of turkey bacon, not labeled. 5. The reach-in refrigerator floor panel was covered with thick, dark reddish liquid substances. 6. The hood vent located above the stove was coated in dark, thick, reddish-brown substances. 7. Four kitchen ceiling vents were coated with dirt, debris, and dark, greyish-black particles. 8. DA VV and DA WW were observed plating food with their hair not completely covered under hair nets. 9. Several flies were swarming around the kitchen and steam table. A fly landed on a plate of food, and the DA discarded it. 10. Observation revealed the kitchen back door was left open for at least three minutes, staff was aware of the door being left open, but no one closed the door until it was brought to their attention by the surveyor. The DM's stated the door was left open due to a staff member bringing in supplies. The DM instructed the staff to close the door. Continued observation of the closed door revealed gaps in the door at the bottom, allowing pests (flies) access to the kitchen. 11. Staff personal items (purses and bookbags) were observed stored on the kitchen counters. 12. Observation revealed water puddles heavily coating the kitchen tiles near the stove and dishwasher area, a buildup of dirt and dark greyish substances was observed in the grooves of the tiles throughout the kitchen. There were missing floor tiles; thick sticky, dark, black-greyish substances coating the baseboard and tiles near the dishwasher area; the drainage system was covered with thick, dark substances; there was a musty smell in the kitchen dishwasher area; missing baseboard, and heavy buildup of dark greasy substances behind the stove and fryer. The DM confirmed the temperatures for the walk-in freezer, walker-in cooler, and reach-in refrigerator were not being logged daily, and the staff failed to ensure all hair was completely contained in hair nets while in the kitchen. She stated her expectation was for the temperatures of the walk-in freezer, walker-in cooler, and reach-in refrigerator to be recorded each shift, food to be labeled and dated, the reach-in refrigerator to be cleaned prior to storing food items, and the oven to be cleaned daily. She reported being unaware of the process of deep cleaning the kitchen floor to remove the grease built up underneath the heavy appliances. She further reported that her staff mopped and cleaned the floor daily and tried to reach all accessible areas. The DM reported that the plumbing problem with the water seeping upward through the drainage system had existed for at least four months. She confirmed the ceiling vents had a buildup of dirt above the food preparation areas. On 7/14/2024 at 1:20 pm, a follow-up kitchen tour was completed with the Assistant Administrator, the DM, and the [NAME] President (VP) of Operations, and all findings were confirmed by the Administrator, DM, and the VP of Operations. The VP of Operations and the Administrator reported that months earlier, the kitchen was identified to have a plumbing problem due to a failed drainage system, causing the water to build up on the floor tiles. They stated the facility had already started the process of obtaining vendors and quotes to correct the problem. They further stated the existing problem was an inability to solicit vendors and contractors. They both confirmed that this was unsanitary conditions with the plumbing problem during food preparations. They stated that the oven was going to be replaced, and the oven and floor tiles should be cleaned and free from grease buildup. They stated the missing floor tiles and baseboards would be addressed. The Assistant Administrator and VP of Operations confirmed the brownish-reddish substances coating the hood vent were rust and confirmed that the kitchen back door needed repairs to prevent flies and pests from having access to the kitchen.

Based on observations, record review, resident and staff interviews, and review of the facility's policies titled, Medication Administration Guidelines and Self-Administration Protocol, the facility failed to assess seven of 55 sampled residents (R) (R98, R30, R73, R14, R44, R65, and R29) for self-administration of medications and failed to store medications safely at the bedside. This failure placed the residents at risk for inappropriate and unsafe medication use. Findings include: Review of the facility's undated policy titled Self-Administration Protocol indicated under Policy: Bedside medication storage is permitted for residents who are willing and able to self-administer medications upon the written order of the prescriber, when it is deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team, and in accordance with state law. Under Procedure:1. If the resident wishes to participate, the Interdisciplinary Team will complete the Medication Self-Administration Assessment. 2. A written order for the bedside storage of medication is placed in the resident's medical record. 3. Bedside storage of medications is indicated on the resident medication administration record (MAR, EMAR) for the appropriated medications. 4. For residents who self-administer some or all medications, the following conditions are met for bedside storage to occur: a. Lockable drawers or cabinets as required by state regulation. 8. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized or unlabeled or expired medications to the charge nurse for return to the family or responsible party. Review of the facility's policy titled Medication Administration-General Guidelines revealed under Policy: Medication is administered as prescribed, in accordance with good nursing principles and practices and only by personnel legally authorized to do so. Personal authorized to administrate medication do so only after they have familiarized themselves with the medication. Policy Procedure revealed: 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, or other personnel authorized by state laws and regulations to administer medications. 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. 3. Residents are allowed to self-administer medications when specifically authorized by the attending physician and the interdisciplinary team and in accordance with procedures for self-administration of medication. 4. Medications are administered at the time they are prepared for each resident, medications are not pre-poured. 15. For residents in the facility not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record/Treatment Administration Record (MAR/TAR) is flagged. When a resident is unavailable, the medication will be administered as near to the scheduled time as able. For the Electronic Medical Records (EMR), the nurse reviews my unsigned records. 1. Review of R98's EMR revealed diagnoses included but were not limited to major depressive disorder, atherosclerosis of aorta, Alzheimer's disease, anxiety disorder, unspecified dementia, moderate, with anxiety, cardiomyopathy, and hypertension. Review of R98's quarterly Minimum Data Set (MDS) dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of three (indicating severe cognitive impairment) and section GG (Functional Abilities and Goals) indicated R98 was independent with Activities of Daily Living (ADLs). During interviews on 7/14/2024 at 3:45 pm and 7/15/2024 at 2:30 pm, R98 revealed that she was alert but not oriented to date and time. Review of a nurse's note dated 12/13/2023 at 9:43 pm revealed at the beginning of the shift staff reported resident taking a hand full of pills. R98 was diaphoretic (perspiring), drowsy, and lethargic. The family member MM was with R98. R98's vital signs were checked 97.7-55-20. Blood Pressure (BP) 100/46 SP02 (a measurement of how much oxygen is in the blood), 99% on room air, and Blood Sugar 138. Nurse Practitioner (NP) was called and new order received for Hypodermoclysis (IV (intravenous) fluids/Subcutaneous infusion) normal saline 100 milliliters (ml)/ hour (hr) X1 liter and to check resident BP every 30 mins (minutes) until blood pressure increase. Resident Blood Pressure was rechecked, and it was 108/58. R98 was alert and verbal and smiling. Hypodermoclysis continues to infuse. Resident blood pressure was checked again, and it was 110/ 56. R98 returned to her usual self. An interview on 7/15/2024 at 7:15 pm with family member MM revealed that on 12/13/2023, R98 was found by a family member with a cup of unknown medications. R98 was in her room and became lethargic with unstable vitals. A family member screamed for help, Licensed Practical Nurse (LPN) NN entered the room and began shoving apple sauce down R98's mouth. LPN OO entered the room and administered an IV. R98 was treated at the facility and was monitored through the night. R98 was stabilized and did not go to the hospital. This incident was not reported to the State agency. The family member spoke with the former Administrator PP and asked for LPN NN providing care for R98 to be reassigned. The former Administrator PP agreed. On 4/3/2024, R98 was found by a family member in her room with a plastic sandwich bag with a sandwich and orange and white pills in the bag. Staff did not know where R98 got the sandwich bag with the medication. The family member spoke with the former Administrator PP and asked again for LPN NN caring for R98 to be reassigned. An interview on 7/16/2024 at 11:12 am with family member MM revealed that R98 was found walking around the facility with a handful of medications during the month of November. As this was the third time that this had happened, a video was taken with the medication in the family member's hand. Family member MM spoke with the former Administrator PP. In an interview on 7/16/ 2024 at 3:15 pm, the Director of Nursing (DON) revealed she was aware of the incident that occurred with R98 during the month of December. She stated it was reported the resident's medication was found by a family member, and one nurse reported three pills, and another staff nurse reported a handful of pills was found. The resident was observed to be drowsy and lethargic with low vital signs. Licensed Practical Nurse (LPN) OO administered IV fluid and monitored her vital signs. Resident vital signs began to go back to normal and R98 began to go back to her normal self. The DON confirmed she completed education via a telephone consultation with LPN NN, who was suspended for three days after the incident. The DON confirmed that the facility did not put any other preventative measures in place to prevent this from happening again. There was no monitoring and no tracking to ensure that this incident would not occur again. The DON stated R98 had an episode like this before which she became lethargic, so she did not feel like it required a trip to the emergency room or labs. The DON stated the NP was notified and the family was present during both incidents. It was reported that a family member found the resident in her room with a sandwich bag with pills in the bag. The DON stated family members kept the bag with the pills. The DON could not identify where the medication came from or what medication was in the bag. The DON stated the family held a meeting with the Administrator and Social Services. The DON confirmed that she knew the family member did not want LPN NN working with R98. The DON stated LPN NN was working on Hall 300 at that time but she was not working directly with R98. After the second incident, LPN NN was moved to Hall 400. An interview on 7/16/2024 at 4:09 pm with LPN NN revealed she was aware of both incidents that occurred in December 2023 and the one in April 2024. She stated that she was blamed because she was the one that was on duty. She said that she does not leave medication at bedside. She gives the medication to the residents and watches them take it. She stated that she did receive a phone consultation and education regarding leaving medication at the bedside. LPN NN stated that the family member was present for the first incident and that the family members had found the bag with a sandwich and medication in it. LPN NN could not identify where the resident would have gotten the medication from. LPN NN confirmed she was not suspended in April but did receive a telephone consultation and was informed the family no longer wanted her working with R98. In an interview on 7/17/2024 at 9:30 am, the Assistant Director of Nursing (ADON) revealed she was aware of both situations. She stated that she confirmed the in-service was held, but no other preventative measures were put in place. In an interview on 7/17/2024 at 10:00 am, the NP revealed she was aware of R98's blood pressure dropping and ordered the IV fluids. The NP stated the Medical Director (MD) was notified. The NP reviewed R98's chart with the surveyor and confirmed the orders. An interview on 7/17/2024 at 3:00 pm with the MD revealed the NP reached out to him on a weekly basis, and in situations like this, she did not have to reach out to him. 2. Review of R30's EMR revealed diagnoses that included hyperlipidemia, depression, anxiety disorder, asthma, and chronic obstructive pulmonary disease (COPD). Review of R30's quarterly MDS dated [DATE] revealed in Section C-Cognitive Patterns a BIMS score of 15, indicating the resident was cognitively intact. Record review revealed R30 did not have a physician's order for Spiriva Respimat 2.5 mcg (micrograms). An observation and interview on 7/14/2024 at 1:37 pm with R30 revealed her to be alert and oriented. Observation revealed a Spiriva Respimat 2.5 mcg inhaler with a date of 2/24 written on it, lying on the bedside table. R30 stated her doctor gave the medication to her at her last doctor's appointment, but the medication was expired. An interview on 7/14 /2024 at 1:55 pm with LPN HH confirmed the medication was expired and should not be in the room. The nurse removed the medication from the room. An interview on 7/16/2024 at 4:30 pm with the DON revealed that medication should not be left with residents. A training regarding medication being left at the resident's bedside was held in April 2024. 45813 3. Review of R73's EMR revealed she was admitted to the facility with diagnoses including but not limited to drug-induced subacute dyskinesia, extrapyramidal and movement disorder, poisoning by unspecified drug/meds biological substance/accidental, major depressive disorder, conversion disorder with seizures or convulsions, bipolar disorder with current hypomanic, anxiety disorder, other psychoactive substance abuse, intentional self-harm by other specific means, poisoning by unspecified drug/meds/biological substance, self-harm substance. Further record review revealed no evidence that an assessment for self-administration of medications was completed, there were no physician orders for the resident to have medications at the bedside for self-administration, and there was no care plan addressing R73's ability to self-administer medications. Review of R73's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Observation 7/14/2024 at 2:01 pm and 2:19 pm, R73 was observed sitting on her bed. Further observations revealed R73 with two oblong, white tablets in a clear plastic medication cup within reach on her bedside table. R73 stated the nurse had a lot of stuff in her hands and had left the medications there. R73 further stated that she had forgotten to take the medications, and they had been left there for about 15 minutes. R73 stated the medication was her evening dose of gabapentin. During an interview and walking rounds on 7/14/2024 at 2:26 pm, LPN GG confirmed she had left R73's 2:00 pm medications at the bedside. LPN GG verified the medications in the cup were gabapentin. LPN GG further stated that she should have stayed and watched R73 take her medications. She stated she left the medications in the room because she was called to another resident's room to administer an inhaler, and she was coming right back. LPN GG stated she knew she was not supposed to leave the medications at the resident's bedside. 4. Review of R14's EMR revealed she was admitted to the facility with diagnoses including seizures, dementia, altered mental status, and Alzheimer's Disease. Further record review revealed no evidence that an assessment for self-administration of medications was completed, there were no physician orders for the resident to have medications at the bedside for self-administration, and there was no care plan addressing R14's ability to self-administer medications. Review of R14's quarterly MDS assessment dated [DATE] revealed a BIMS score of four, indicating the resident was severely cognitively impaired. Observations on 7/14/2024 at 1:56 pm and 2:16 pm revealed an open foil container of ipratropium bromide inhalation solution (0.02% (0.5 mg/2.5 ml) (two vials) nebulizer solution on the bedside dresser along the right side of the resident's bed. Interview and walking rounds on 7/14/2024 at 2:34 pm, LPN GG confirmed the medications at R14's bedside. LPN GG also stated she had been in R14's room today but did not notice the medication on the dresser. LPN GG further stated medication was not supposed to be left in the resident's rooms. LPN GG removed the medication but then stated it was time for R14 to receive the 2:00 pm scheduled nebulizer treatment at this time anyway. Interview on 7/14/2024 at 3:08 pm with the DON revealed currently the facility does not have a resident in the facility who had been assessed and deemed safe to self-administer medications. She further stated medications should not be left in resident's rooms. The DON stated the medication at R14's bedside did not appear to be the medication that they received from their pharmacy, but either way, it should not be in the resident's room. The DON further stated the nurse should not have left the medications at R73's bedside and if she had to leave prior to administering, she should have taken the medications with her and brought them back later. 49675 5. Review of the EMR for R44 revealed the resident was admitted to the facility with diagnoses of but not limited to aphasia, stroke, hemiplegia, and depression. R44's most recent MDS, dated [DATE], revealed a BIMS score of 14, which indicated little or no cognitive impairment. Further record review revealed no assessment for self-administration of medications was completed, there were no physician orders for R44 to have medications at the bedside for self-administration, and there was no care plan addressing R44's ability to self-administer medications. Observation on 7/14/2024 at 2:00 pm revealed numerous pills inside a disposable medicine cup and a tube of hydrocortisone cream sitting on R44's bedside table. Interview on 7/14/2024 at 2:05 pm with LPN AA confirmed she left R44's pills in the disposable cup at the resident's bedside because she had to leave the room to do another task and forgot to remove the pills. She revealed she made an error and should not have left the medications with the resident. LPN AA stated that a Certified Nursing Assistant (CNA) left the tube of hydrocortisone on the bedside table, but after checking the medication administration record (MAR) and physician's orders, she revealed that a family member brought it to the resident. The hydrocortisone was removed. LPN AA revealed that R44 was not assessed to self-administer medications. 6. Review of the EMR for R65 revealed the resident was admitted to the facility with diagnoses including, but not limited to, bipolar disorder, chronic obstructive pulmonary disease (COPD), unspecified, and type 2 diabetes mellitus. R65's most recent MDS, dated [DATE], revealed a BIMS score of 15, indicating little to no cognitive impairment. Further record review revealed no assessment for self-administration of medications was completed, there were no physician orders for R65 to have medications at the bedside for self-administration, and no care plan addressing R65's ability to self-administer medications. Observation on 7/14/2024 at 2:12 pm revealed a bottle of 70 percent isopropyl alcohol on R65's nightstand. Interview and rounding on 7/14/2024 at 5:19 pm with LPN AA revealed resident was not assessed for self-administration of medications and confirmed the resident should not have isopropyl alcohol in his room and removed it. Interview on 7/17/2024 at 9:40 with ADON revealed it is her expectation that medications are not left by the bed side under any circumstances. She revealed there are no residents assessed for self-administration. 7. Review of the EMR for R29 revealed the resident was admitted to the facility with diagnoses of but not limited to pressure ulcer of sacral region, paraplegia, diabetes, major depressive disorder single episode. R29's most recent MDS assessment, dated 5/4/2024, revealed a BIMS score of 15, indicating little to no cognitive impairment. Further record review revealed no assessment for self-administration of medications was completed, there were no physician orders for R29 to have medications at the bedside for self-administration, and no care plan addressing R29's ability to self-administer medications. Observation on 7/14/2024 at 3:17 pm revealed a bottle of hydrogen peroxide on R29's dresser. Interview and rounding on 7/14/2024 at 5:19 pm with LPN AA confirmed R29 should not have hydrogen peroxide at the bedside and further stated R29 was not assessed for self-administration. She revealed her expectations would be that the resident did not have hydrogen peroxide in his possession and to maintain a safe environment.

Based on observations, staff interviews, and review of the facility policy titled, Storage of Items in Resident Rooms, the facility failed to ensure resident personal care items were stored in a manner to prevent cross-contamination in five of 11 bathrooms on the 400 Hall. The deficient practice had the potential to expose residents to infections due to cross-contamination. Findings include: A review of the undated facility policy titled Storage of Items in Resident Rooms revealed the Policy stated Resident's personal items will be orderly and properly stored. The Procedure section stated, 1. Personal items will be clean and stored appropriately. 2. No items shall be stored on floors in resident rooms. 4. Store in bathrooms: b. resident leg bags, bedpans, or graduate cylinders. A basic infection control policy was requested but was not received. Observations on 7/14/2024 at 1:47 pm and 7/15/2024 at 1:25 pm of the shared bathroom between rooms [ROOM NUMBERS] revealed one bedpan on the shelf above the toilet and a urinal lying next to the toilet. The items were not bagged or labeled. Observations on 7/14/2024 at 2:01 pm and 7/15/2024 at 1:26 pm of the shared bathroom between rooms [ROOM NUMBERS] revealed one bedpan on the shelf above the toilet. The items were not bagged or labeled. Observations on 7/14/2024 at 2:38 pm and 7/15/2024 at 1:27 pm of the bathroom for room [ROOM NUMBER] revealed one urinal lying on the floor next to the toilet. The items were not bagged or labeled. Observations on 7/14/2024 at 2:45 pm and 7/15/2024 at 1:28 pm of the bathroom for room [ROOM NUMBER] revealed one urinal attached to a rolling walker. The items were not bagged or labeled. Observations on 7/14/2024 at 3:17 pm and 7/15/2024 at 1:31 pm of the bathroom of room [ROOM NUMBER] revealed two urinals on the shelf above the toilet. The items were not bagged or labeled. During observational rounds with the Director of Nursing (DON) on 7/16/2024 at 9:20 am, she confirmed one urinal and one bed pan, not bagged and labeled, in the shared bathroom for rooms [ROOM NUMBERS], one bed pan on the shelf, not bagged or labeled, in the shared bathroom for rooms [ROOM NUMBERS], one urinal laying on the floor, not bagged or labeled, in the bathroom of room [ROOM NUMBER], one urinal attached to a rolling walker, not bagged or labeled, in the bathroom of room [ROOM NUMBER], and two urinals hanging off a shelf, not bagged and labeled, in the bathroom of room [ROOM NUMBER]. The DON revealed her expectations are that Certified Nursing Assistants (CNAs) rinse the urinals and bed pans then bag and label them with the room number.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident [NAME] of Rights, the facility failed to provide a resident with food preferences for one of 55 sampled residents (R) (R58). Review of the facility policy titled Resident [NAME] of Rights reviewed January 2023 revealed under Facility residents shall have the right to: . 10. Reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.15. Self-determination, which the facility must promote and facilitate through support of resident choice, consistent with his or her interests, assessments and plan of care and make other choices about aspects of his or her life in the facility that are significant to the resident. Including but not limited to: activities, health care schedules (including sleeping, waking, bathing and eating times) and how she or he spends time, both in and outside the facility should be supported to the extent possible. Review of the electronic medical record (EMR) for R58 revealed diagnoses that included but not limited to paranoid schizophrenia, type 2 diabetes, congestive heart failure, obesity due to excess calories, and renal failure. Review of the annual Minimum Data Set (MDS) dated [DATE] for R58 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the care plan revealed that R58's skin breakdown is due to anemia and diabetes. The facility has put interventions in place. The facility will provide snacks, monitor food intake, and provide food as ordered, dietician to evaluate residents' nutritional status and offer food substitutes as needed. A care plan was reviewed for quarterly assessment, and interventions were updated. Observation and interview on 7/17/2024 at 12:30 pm, R58 was brought lunch by Certified Nursing Assistant (CNA) BB. R58 had a sweet potato on her tray. R58 stated she does not eat potatoes, as was listed on the meal card. It was labeled as potatoes, not sweet potatoes. R58 explained she does not eat any potatoes. CNA BB went to the manager to get an alternate lunch for R58. R58 said it would be something she did not want. On interview dated 7/17/2024 at 2:41 pm R58 revealed that the foods were still the same on weekends and stated she chose not to eat breakfast today. R58 revealed she did not want to ask for an alternate meal. She explained that the alternate normally was something she did not want to eat. On 7/17/2024 at 12:14 pm the Dietary Manager (DM) and two RD's revealed they met with each resident. They entered notes about food preferences, diets, restrictions, and allergies. The DM revealed that all those preferences were on the tray meal tickets and that staff acknowledged those preferences. Interview on 7/17/2024 at 12:49 am, the DM revealed that R58 should not have been served sweet potatoes. The DM suggested that if the list was questionable, food servers should have asked her to get clarity from the RD. Interview on 7/17/2024 at 12:47 pm, the RD revealed that the tray meal card stated potatoes, it should have stated what type of potatoes.

Based on observations, staff interviews, and review of the facility policy titled, Resident [NAME] of Rights, the facility failed to ensure that it was maintained in a safe, clean, comfortable environment for two of seven halls, with one room (room [ROOM NUMBER]) on the 300 Hall and three rooms ( room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on the 400 Hall. These rooms had missing paint on the doors and walls; holes, punctures, and dents in the walls; crumbling walls with rocks exposed, dirty floors, and broken and or soiled air conditioning vents. Findings include: Review of the facility policy titled Resident [NAME] of Rights last reviewed in January 2023 revealed under A. Facility residents shall have the right to: . 32. A safe, clean, comfortable home like environment. Observation on 7/14/2024 at 1:23 pm revealed room [ROOM NUMBER]'s bathroom floor with dirt and debris as well as a dead cock roach on the floor. Observation on 7/14/2024 at 1:59 pm revealed the walls of room [ROOM NUMBER] scratched and missing paint. There was food and debris in the air conditioning vent that was broken. The vent that covers the light in the bathroom and the light behind the room's door were loose. There was a missing floor tile at the entry way of the door. Observation on 7/14/2024 at 3:17 pm in room [ROOM NUMBER] revealed a wall crumbling with numerous pieces of rock on the floor. The air conditioning unit's vent was dirty with particles. There was a battery in the vent. Observation on 7/14/2024 at 2:55 pm revealed room [ROOM NUMBER] missing paint on the walls, paint was peeling off the doors and walls, there were holes and dents in wall, and the floors were dirty. Rounding on 7/18/2024 at 10:00 am with the Maintenance Director, Administrator, and Housekeeping Supervisor confirmed all the concerns in rooms 318, 406, 407, and 413. Numerous ceiling tiles throughout the entire building need replacement. The Administrator revealed that she had been at the facility for 3 weeks and upon her start date, she did a walk-through of the building and had the same concerns. She stated they were actively making facility improvements. She revealed that they were in the process of figuring how many ceiling tiles need replacement and were ordering replacements. The Administrator revealed that it was her expectation that the facility provided a clean, safe, and homelike environment for its residents. The Maintenance Director was aware of the holes, dents, and punctures in the walls and was working on repairs.

Based on staff interviews and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two of two residents (R) (R73 and R47) reviewed for PASRR Level II. This deficient practice had the potential to affect the level of care and services provided to R73 and R47. Findings include: 1. A review of the electronic medical record (EMR) revealed that R73 was admitted to the facility with diagnoses including but not limited to drug-induced subacute dyskinesia, extrapyramidal (involuntary and uncontrollable movement disorders caused by certain drugs), and movement disorder, poisoning by unspecified drug/meds biological substance, accidental, major depressive disorder single episode, bipolar disorder with current hypomanic, anxiety disorder, other psychoactive substance abuse, and intentional self-harm by other specific means. A review of R73's admission Minimum Data Set (MDS) dated [DATE] revealed section A (Identification Information) documented the resident had not been evaluated by Level II PASRR, section I (Active Diagnoses) documented bipolar disorder, and section O (Special Treatments and Programs) documented no therapies or treatments were received. A review of R73's care plan revealed a problem initiated on 2/16/2024, indicating the resident had the potential for drug toxicity related to the use of psychotropic medications for diagnoses of bipolar, anxiety, and major depressive disorder. A review of the clinical record revealed a PASRR Level I dated 2/15/2024 did not include the diagnosis of bipolar. There was no evidence that a PASRR Level II assessment was completed. 2. A review of the clinical record for R47 revealed the resident was readmitted to the facility on [DATE] with diagnoses including, but not limited to, bipolar and major depressive disorder. A review of R47's admission MDS dated [DATE] revealed section A (Identification Information) documented the resident had not been evaluated by Level II PASRR, section I (Active Diagnoses) documented depression (other than bipolar) and manic depression (bipolar disease). A review of R47's quarterly MDS dated [DATE] revealed section I (Active Diagnoses) documented depression (other than bipolar) and manic depression (bipolar disease). A review of the PASRR Level I Assessment for R47 dated 1/17/2024 revealed the PASRR Level I documentation was unmarked for bipolar. There was no evidence that a PASRR Level II assessment was completed. In an interview on 7/17/2024 at 2:04 pm, the Admissions Director (AD) stated both R73 and R47 were admitted to the facility from a local hospital. She stated she was only required to ensure residents had an approved PASRR Level I on admission, and she did not check the PASRR Level I for accuracy. The AD confirmed both R73 and R47 had a diagnosis of bipolar disorder, and a PASRR Level II had not been submitted for either. The AD further stated the Director of Nursing Services (DNS) was responsible for checking referrals for diagnoses and ensuring the accuracy of the PASRR Level I. In an interview on 7/17/2024 at 2:51 pm, Licensed Practical Nurse (LPN)/MDS Coordinator DD stated she was responsible for generating face sheets for all resident admissions, which included adding the diagnoses. LPN/MDS Coordinator stated she obtained the diagnoses from the hospital paperwork. She further stated that she does look at the resident's PASRR Level I when she is completing the MDS Assessments, but the Social Services Department was responsible for following up on the PASRR submissions if a qualifying diagnosis was missed. She stated if she sees a qualifying diagnosis on the referral, she alerts the Admission Coordinator to have the hospital apply for PASRR Level II prior to admission, but ultimately the Social Service Department was responsible for checking the records for accuracy. In an interview on 7/17/2024 at 2:56 pm, the Social Service Assistant (SSA) EE revealed she was responsible for updating the list of residents with a PASRR Level II. SSA EE verified that R73's and R47's names were not listed on the current list as having a PASRR Level II. She further stated a PASRR Level II was triggered by psychotropic medications and diagnoses such as bipolar and schizophrenia. SSA EE stated it was her understanding the AD was responsible for the accuracy of the resident's PASRR Level I. In an interview on 7/18/2024 at 9:08 am, the Social Service Director (SSD) stated all residents are admitted to the facility with a least a [NAME] Level I. The SSD further stated the MDS Nurses and the DNS checked the admissions for qualifying diagnoses and alerted her if there was a diagnosis that would potentially trigger a PASRR Level II. She stated when she is informed, she submits for a PASRR Level II. The SSD confirmed that R73 and R47 did not have PASRR Level II and that both residents had been admitted from a hospital. In an interview on 7/18/2024 at 3:36 pm, the Administrator stated the process related to reviewing PASRR Level IIs needed to be reviewed to address a plan to ensure the PASRR Level I was accurate. In an interview on 7/18/202 at 4:45 pm, the Administrator stated the facility did not have a policy for PASRR.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Peripheral and Midline Intravenous Catheter Care and Dressing Changes, the facility failed to provide care according to professional standards for two of two residents (R) (R11 and R261) reviewed for intravenous catheter care. Specifically, the facility failed to follow the physician's orders for dressing changes for a PICC line (a peripherally inserted central catheter [a long, flexible plastic tube that's inserted into a vein in the upper arm and threaded into a large vein near the heart]) and ensure the intravenous (IV) infusion tubing was labeled and dated when in use for R11 and failed to obtain physician orders and provide care for a PICC line for R261. This deficient practice had the potential to increase the probability of infection at the insertion site and systemic infection for R11 and R261. Findings include: A review of the policy titled Peripheral and Midline Intravenous Catheter Care and Dressing Changes, revised November 2022, revealed the Policy stated, The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. The General Guidelines stated, 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). 4. Change the dressing if it becomes damp, loosened, or visibly soiled and: a. at least every 7 days for transparent semi-permeable membrane (TSM) dressing. The facility did not provide a policy for admission physicians' orders. 1. A review of the electronic medical record (EMR) revealed R11 was readmitted to the facility from a local hospital with diagnoses including, but not limited to, sepsis, chronic osteomyelitis involving pelvic region and thigh, wound infection, and osteomyelitis of vertebra, sacral and sacrococcygeal region. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. A review of the EMR revealed a discharge report from a local hospital dated 7/2/2024 that revealed R11 was discharged from the hospital back to the facility with orders for IV antibiotics for 16 days. In an observation and interview on 7/14/2024 at 2:56 pm, R11 stated he was recently in the hospital and returned to the facility on IV antibiotics for an infection of his wounds. R11 further stated he was still receiving the IV antibiotics, but the facility staff had not changed the PICC line dressing since his readmission to the facility. Observation revealed a soiled dressing dated 6/27/2024 intact to the PICC line site on R11's left upper arm. Observation on 7/15/2024 at 2:05 pm revealed R11 in a wheelchair with an IV antibiotic infusing. Further observation revealed the IV tubing was not labeled with a date or infusion time. In addition, the PICC line dressing on R11's left upper arm remained soiled and was dated 6/27/2024. A review of the Physicians Orders for R11 for the month of July 2024 revealed there was an order dated 7/3/2024 to change the PICC line dressing every Monday. A review of the Progress Notes for R11 revealed no documentation related to the condition of the PICC line insertion site, the condition of the PICC line dressing, or that the PICC line dressing was changed. A review of the electronic Medication Administration Record (eMAR) dated July 2024 revealed there was no documented monitoring for signs of infection or dressing changes of the PICC line site. During an interview and walking rounds on 7/15/2024 at 2:24 pm, Licensed Practical Nurse (LPN) FF revealed she was responsible for administering R11's IV antibiotics but was unsure who was responsible for changing the dressing to the PICC line or where documentation was in the EMR of monitoring of the PICC line site or documenting the dressing change. She further stated there should be a physician's order for monitoring of the PICC line site and changing the PICC line site dressing. She also stated the order for the PICC dressing changes had not shown up on her eMAR, therefore she had not changed the dressing. LPN FF stated she was not sure but thought the dressing should be changed weekly and the site should be monitored each shift to prevent infection of the site and systemic infection. LPN FF verified there was no documentation on record in the EMR of the PICC line dressing being changed or monitoring of the PICC line site for signs of infection. LPN FF stated IV tubing should be changed and labeled daily but she was not sure if she labeled R11's IV tubing today. LPN FF observed and verified R11's IV tubing was not labeled or dated and the PICC line dressing was soiled and dated 6/27/2024. In an interview on 7/15/2024 at 2:41 pm, the Director of Nursing Services (DNS) and LPN FF stated there should be a physician's order to monitor PICC line sites for signs of infection and to change PICC line site dressings every seven days. The DNS stated the nurse administering medications was responsible for monitoring the PICC line for infection and changing the PICC line dressing. The DNS stated if monitoring of the PICC line site or dressing changes was not documented on the eMAR, the nurse should document it in the nursing progress notes. The DNS verified there was no documentation in the progress notes or on the eMAR to indicate R11's PICC line dressing was changed or the PICC line site was monitored for infection. She stated she was ultimately responsible for ensuring resident needs were being met but she had not personally visualized R11 or his records to ensure that his care and service needs were being met. The DNS further stated IV tubing was to be changed daily and the nurse should always date the tubing when it was changed. In a follow-up interview 7/17/2024 at 9:03 am, LPN FF revealed she was not aware how her initials were placed on the eMAR for changing the PICC line dressing change on 7/8/2024 for R11. LPN FF also stated she had not changed the PICC line dressing for resident until 7/15/2024, after the issue was brought to her attention by the surveyor. 49138 2. Review of the EMR revealed R261 was admitted into the facility with diagnoses including but not limited to major respiratory failure, intracranial hemorrhage, and medical history of chronic obstructive pulmonary disease (COPD), anemia, and cervical disk myelopathy. A review of R261's admission Minimum Data Set (MDS) revealed the MDS was in process. A review of R261's active Physician Orders, dated July 2024, revealed no physician's orders for the care of the PICC line. Observation on 7/15/2024 at 1:17 pm of R261 revealed a PICC line was inserted in R261's left arm. During observation and interview on 7/15/2024 at 1:27 pm, LPN II confirmed the date on R261's PICC line dressing was 7/3/2024. She also confirmed there were no physician orders for the care of the PICC line or dressing changes. She stated the nurse was responsible for ensuring physician orders were obtained for the resident's care needs. In an interview on 7/18/2024 at 3:40 pm, the Assistant Director of Nursing (ADON) confirmed that R261 did not have physician's orders for the care of the PICC line, including dressing change. The ADON stated physician's orders should have been obtained and the PICC line dressing should be changed weekly.

Based on record review, interview, and policy review the facility failed to develop a comprehensive care plan for one of three sampled residents (R) (R#9) reviewed for pressure ulcers. Findings include: Review of the undated facility policy titled, Comprehensive Person-Centered Care Plan documented, .Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care.Baseline care plan- initial plan of care to be used upon admission and with a change in resident condition until the completion of the comprehensive care plan. Review of the Face Sheet located in R#9's electronic medical record (EMR) revealed R#9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . If not treated immediately, it can lead to kidney damage), metabolic [CONDITION(S)] (is a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), diabetes mellitus, and [CONDITION(S)]. Review of the admission Evaluation of Pressure Ulcer Risk form dated 7/13/22 located in the paper medical record revealed R#9 was at risk for pressure ulcer development. Review of the Baseline Care Plan located in the paper medical record dated 7/13/22 under the section Skin Concerns revealed pressure ulcer and skin risk were checked. Review of the section Skin Interventions revealed no interventions were checked to implement. The Baseline Care Plan was signed by the dietitian, Minimum Data Set (MDS) Coordinator, rehabilitation staff, and recreation staff. Review of the Interdisciplinary Care Plan Team Attendance form dated 7/19/22 located in the paper medical record revealed the team discussed care areas pertinent to R#9 but skin was not checked as reviewed. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/20/22 located in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicates intact cognition, total dependence from staff for bed mobility, occasional incontinence of bowel, an indwelling catheter, range of motion limitation on both upper and lower extremities, and no impaired skin integrity. Review of the Weekly Skin form dated 7/26/22 located in the paper medical record revealed an open area on the coccyx with reddened outer area and whitish inner area. Review of the wound physician's Initial Wound Evaluation & Management Summary dated 7/27/22 located in the EMR revealed an unstageable (due to necrosis) sacrum full thickness pressure ulcer. The wound measured 5.0 centimeter (cm) by 2.2cm by 0.3cm and was 100% necrotic tissue. The area was surgically debrided by the wound physician. An unstageable 4.0cm by 6.0cm Deep Tissue Injury (DTI) of the left heel with partial thickness and an unstageable 2.0cm by 2.0 cm DTI of the right lateral foot with partial thickness. Recommendations included limit sitting for 60 minutes, off-load wound, reposition per facility protocol, float heels in bed, low air loss mattress, and sponge boot. Review of the Care Plan for R#9 located in the EMR revealed that a care plan was not created related to the resident's risk for Pressure Ulcers and impaired skin integrity until 7/27/22 due to the resident presenting with altered skin integrity related to unstageable pressure ulcer on the coccyx, left heel DTI and right lateral foot DTI. In interview on 9/30/22 at 9:40 a.m., the MDS Coordinator stated the baseline care plan is developed by the charge nurse. During the 48-hour meeting, the resident baseline care plan is reviewed, and new interventions implemented, if necessary, in the care plan. The MDS Coordinator could not explain why a pressure ulcer preventive care plan was not initiated on admission due to the resident risk for impaired skin integrity and risk of Pressure Ulcers. The MDS Coordinator said the comprehensive care plan is developed after the MDS is completed and she is responsible to develop that care plan. The MDS Coordinator said she was unaware the resident had a pressure ulcer until 8/2/22. The MDS Coordinator further stated the wound nurse is responsible to review the wound physician's recommendation and notify MDS to include interventions in the care plan. This deficiency was cited based on complaint intake#: GA 564.

Based on record review, interview, and facility policy review, the facility failed to provide the necessary care to prevent pressure ulcer development for one of three sampled residents (R) (R#9) reviewed for pressure ulcers. The facility's failure to provide care, consistent with professional standards of practice, resulted in the resident developing facility-acquired, avoidable unstageable and Deep Tissue Injury (DTI) pressure ulcers. Findings include: Review of the undated facility policy titled, Weekly Skin Audit revealed, A skin audit will be documented on residents weekly. Any identified skin condition will be documented, and treatment initiated. Physician and family will be notified of any abnormalities. Review of the undated facility policy titled, Wound Care Treatment Protocol revealed staff were to, Evaluate the wound daily for signs and symptoms of infection and for signs of healing. Document/Report findings. Provide treatment as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Face Sheet located in R#9's electronic medical record (EMR) revealed R#9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital Discharge Packet, located in the paper medical record and dated [DATE], revealed R#9 had the inability to move all limbs and neck and required constant turns [turning and repositioning to relieve pressure to the skin]. Per the Discharge Packet, the resident was discharged from the hospital with no skin breakdown. Review of the admission nursing assessment revealed that the Evaluation of Pressure Ulcer Risk form dated [DATE] located in the EMR indicated that R#9 did not have any open areas/pressure ulcers but was at risk for pressure ulcer development. Review of this form revealed that R#9's risk factors for pressure ulcer development included incontinence, a past history of pressure ulcers, and desensitization to pain. Per this form, if the resident had any risk factors, staff were to place intervention on care plan. Review of the Baseline Care Plan located in the paper medical record and dated [DATE] under the section Skin Concerns, revealed pressure ulcer and skin risk were checked. Review of the section titled Skin Interventions revealed no interventions were checked for staff to implement. The Baseline Care Plan was signed by the dietitian, Minimum Data Set (MDS) Coordinator, rehabilitation staff, and recreation staff. Review of the Weekly Skin form dated [DATE] located in the paper medical record revealed no impaired skin integrity. Review of the Interdisciplinary Care Plan Team Attendance form dated [DATE] located in the paper medical record revealed the team discussed care areas pertinent to R#9. Although R#9 continued to remain at risk for pressure ulcer development, the care area for skin was not checked as reviewed. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicates intact cognition, and no impaired skin integrity. The assessment further revealed that R#9 had total dependence on staff for bed mobility, occasional incontinence of bowel, an indwelling catheter, range of motion limitation on both upper and lower extremities, and no impaired skin integrity. Review of the Weekly Skin form dated [DATE] located in the paper medical record revealed no impaired skin integrity. Review of the entire EMR and paper medical record revealed no evidence of impaired skin integrity from the [DATE] Weekly Skin form until a Weekly Skin form dated [DATE]. The [DATE] Weekly Skin form showed that the resident had a new, facility-acquired pressure ulcer on the coccyx which was not present on admission. Review of the [DATE] Weekly Skin form revealed contradictory information about the wound, as it described an open area on the coccyx with reddened outer area and whitish inner area. However, the [DATE] Weekly Skin Record then described the measurements for the new wound as length 0, width 0, and depth 0, indicating a lack of an open area. Further review of the [DATE] Weekly Skin record revealed no information about any other skin problems, and there was no evidence of skin breakdown to any other areas of the resident's body, including but not limited to the resident's heels and feet. Although the resident had developed a new, facility-acquired pressure ulcer, review of the preventive equipment section of the [DATE] Weekly Skin form revealed that this section was left blank and new equipment/approaches to relieve pressure were not added. Review of the Nurse's Notes in the EMR revealed no evidence of physician notification when the new pressure ulcer was identified on [DATE]. In addition, review of the Orders tab in the EMR revealed no evidence that orders for treatment were obtained or started when the new pressure ulcer was first identified on [DATE]. R9 was first seen for the new, facility-acquired pressure ulcer on [DATE], when the wound physician was present in the facility, making their routine weekly rounds. Review of the wound physician's Initial Wound Evaluation & Management Summary dated [DATE] located in the paper medical record revealed an unstageable (due to necrosis) sacrum full thickness pressure ulcer. The wound measured 5.0 centimeter (cm) by 2.2cm by 0.3cm and was 100% necrotic (dead) tissue. The area was surgically debrided (cut away) by the wound physician. In addition, an unstageable 4.0cm by 6.0cm Deep Tissue Injury (DTI) of the left heel with partial thickness and an unstageable 2.0cm by 2.0cm DTI of the right lateral foot with partial thickness were identified. Recommendations included to limit sitting for 60 minutes, off-load the wound, reposition per facility protocol, float the resident's heels in bed, use of a low air loss mattress (different than the mattress which was currently in use), and a sponge boot. Further review of the Baseline Care Plan, which was initiated on [DATE] and continued to remain in effect from [DATE] until [DATE], revealed that none of the interventions recommended by the wound physician were added to the care plan. Review of both the paper medical record and EMR revealed no evidence that any of these recommendations were implemented. Review of the comprehensive Care Plan, initiated [DATE] and located in the EMR, revealed a problem onset date of [DATE] of altered skin integrity related to unstageable pressure ulcer on the coccyx, left heel DTI and right lateral foot DTI. Interventions included measure wound weekly, incontinent care following incontinent episodes, if no improvement consult with physician, turn, and reposition resident as needed, use supportive/protective devices as needed, and teach resident risk factors for development of pressure ulcers. The Care Plan dated [DATE] included intervention for wound physician visits, and this care plan remained in effect until the resident expired on [DATE]. In interview on [DATE] at 3:46 p.m., Wound Doctor (WD) 1 that when he first assessed R#9 on [DATE], necrosis was already present on the sacrum. WD1 stated the necrosis identified on R#9's sacrum had to have been visible on the surface for at least a week. WD1 said the facility needs to check residents' skin and notify me before it gets to necrosis, at that point it's late in the road for healing. WD1 further stated that if off-loading and repositioning had been done, the facility-acquired wounds could have been prevented. WD1 stated he discussed the recommendations on [DATE] for R#9 with the facility's Wound Nurse. In interview on [DATE] at 9:00 a.m., Registered Nurse Wound Nurse (RNWN) stated when residents are admitted at risk for pressure ulcer development, she gets involved and implements a pressure prevention plan. This includes off-loading of heels, pressure relieving cushions in the chair, Medilex protective dressing, and turning and repositioning. However, RNWN continued, she was not involved with R#9's admission because she was not at the facility from late June until [DATE]. RNWN stated that another nurse was covering for her, but he no longer works at the facility. RNWN stated that when she returned, the charge nurse told her R#9 had a necrotic area on his sacral/coccyx area, and she added the resident to the wound list for the wound physician's weekly rounds. RNWN could not recall the exact date she was told about the area, but it was when she returned on [DATE] and before [DATE]. RNWN said she did conduct an assessment of the area. RNWN was asked to provide documentation of this assessment, as none was found in either the hard copy record or EMR. RNWN was unable to provide evidence of this assessment and could not explain why there was no documentation in the record. RNWN said she did not obtain a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if she implemented WD1's recommendations on [DATE], she could not recall. RNWN said the MDS Coordinator receives the recommendations and adds any new interventions to the care plan. In interview on [DATE] at 9:40 a.m., the MDS Coordinator stated the baseline care plan is developed by the charge nurse at the time of admission. During the 48-hour meeting, the resident baseline care plan is reviewed, and new interventions implemented, if necessary, in the care plan. The MDS Coordinator could not explain why a pressure ulcer preventive care plan was not initiated on admission. The MDS Coordinator confirmed the resident was at risk and a care plan should have been started. The MDS Coordinator stated that the comprehensive care plan is developed after the MDS is completed and she is responsible to develop that care plan. The MDS Coordinator stated that she was unaware the resident had a pressure ulcer until [DATE]. The MDS Coordinator further stated the wound nurse is responsible to review the wound physician's recommendation and notify MDS to include interventions in the care plan. The MDS Coordinator stated that she was never told about the recommendations from the wound physician on [DATE], and as a result, the physician's recommendations were not added/implemented until [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 10:45 a.m. revealed that the facility documented by exception, and she could provide no further evidence that the resident was turned and repositioned, had their skin regularly checked during routine incontinence and bathing care, and received pressure-relieving devices as needed. This deficiency was cited based on complaint intake# GA 196, GA 009, and GA 564.

Based on review of resident records, review of an undated policy titled, Advance Directives, and staff interviews, the facility failed to ensure residents, family and health care agent choices related to advance directives were clear and accurately reflected in the resident's medical records. The failure to provide staff with clear and accurate information related to the Advance Directive chosen by a resident had the potential to prevent a resident to expire as chosen without the interventions of life sustaining measures against their wishes. Conflicting and inaccurate information in a resident's health care record related to resident choice to be a Full Code had the potential to cause life sustaining measures not to be provided for a resident who had made that choice. This affected three of 30 stage 2 Residents (R), #217, R#290 and R#195. This failure put residents in the facility at risk for serious injury or death without an attempt of life sustaining measures as chosen by the resident to return circulatory system function and respiratory function to a viable state to sustain life. The facility's Administrator and Director of Nurses were informed of the immediate jeopardy on [DATE] at 9:30 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of advanced directive procedures to ensure the accuracy of advanced directives on the chart. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident advanced directive wishes, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing Advanced Directives. Resident records were reviewed to ensure that resident advanced directives, including physicians' orders for advanced directives, was current and accurate. Findings include: 1. Review of the medical record for R#217 revealed admission to the facility on [DATE]. Review of the face sheet for R#217 indicated [DIAGNOSES REDACTED]. Review of the current physician's orders for R#217 revealed an order written [REDACTED]. The physician signed the monthly orders on [DATE]. The facility physician's orders included an order for [REDACTED].>Review of the closed record for R#217 contained a full-page sheet which identified the resident as a Full Code under the advance directive section of the record. Review of a Departmental Note for R#217 dated [DATE] documented an initial family meeting was held with his daughter and a hospice nurse from (Hospice Name). Neither had any concerns nor complaints. The IDT (inter-disciplinary team) had no significant issues nor changes to the initial care plan. The document indicated R#217 plans to remain in long-term care continuing with hospice services. His code status is currently FULL CODE. The note was signed by Social Service (SSA) DD. Review of the plan of care for R#217 dated [DATE] identified a problem onset of Limitrd (sic)Life Expancy (sic) condition Hospice intervention requires Dxx (sic) Cerebral [MEDICAL CONDITION] and Dementia. Resident is a FULL CODE. Review of a hand written interdisciplinary Progress Note, (all other entries in the resident record were entered in the computerized typed record) by Licensed Practical Nurse (LPN) FF dated [DATE], no specified time of the entry, documented the following events: At 1500 (3:00 p.m.) resident in bed alert and oriented x 1. Respiration was labored and uneven. O2 (oxygen) at 2 liters /minute via nasal cannula in progress. Vital signs checked, Blood pressure ,[DATE], Respirations 32, pulse 52, temperature 100.5 and oxygen saturation 99%. Hospice nurse notified of resident's change in condition. Further review of the same hand-written note indicated at 1700 (5:00 p.m.) a Hospice nurse came in to assess R#217. A New order received for [MEDICATION NAME] 875 milligrams (mg) orally 2 x day for 7 days for suspected upper respiratory infection. Medicate R#217 with [MEDICATION NAME] 20 mg/1 ml sublingual every 1 hour x 3 doses for SOB (shortness of breath). If symptoms not resolved call the nurse on call for further evaluation. The medication given with no relief. The same hand-written note continued [DATE] At 2100 (9:00 p.m.) vital signs measured blood pressure ,[DATE], heart rate 118, respirations 40 and oxygen saturation 97%. R#217 on 3 liters of oxygen via nasal cannula and temperatures 99 degrees' axillary. The on-call nurse from Hospice came to evaluate the resident (no time indicated for the time of the visit.) The nurse directed the staff nurse LPN FF to continue with [MEDICATION NAME] 20 mg every 2 hours as needed if resident appeared uncomfortable. Continued review of the hand written interdisciplinary Progress Note for R#217 indicated the nurse called to the room of R#217. Resident #217 noted unresponsive to verbal and tactile stimuli. Unable to obtain pulse, respiration and blood pressure. The Hospice nurse pronounces death at 2226 (10:26 p.m.). The resident's family and physician were notified. Throughout this series of events for R#217 on [DATE] no conversation or discussion, no physician's orders written and no contact with the resident's physician to determine R#217's code status is documented by LPN FF in the resident's record. The record for R#217 continued to evidence the resident code status as Full Code at the time of death. Review of the notes for R#217 from hospice services found in the back section of the record failed to have a plan of care for Advance Directives. The Hospice physician's orders in the record failed to address code status or advance directives for R#217. Review of visit notes in the facility chart at no time identified the resident as a DNR. The attending Physician for R#217 was unavailable for interview during the survey. An interview with the Director of Nursing Services (DNS) on [DATE] at 4:00 p.m. The DNS verified R#217 was identified as a full code on admission [DATE] signed by daughter on [DATE]. The DNS verified a physician's order written on [DATE] and signed on [DATE] directed staff that this resident was a Full Code. The DNS confirmed R#217's plan of care initiated on [DATE] identified the resident was a full code. The DNS confirmed there was no other place in R#217's record identifying that R#217 desired to be a DNR. The DNS acknowledged a copy of R#217' s DNR form on file with hospice, the form was faxed by hospice services on [DATE] at 21:22 (9:22 p.m.) and placed in the record the day after the resident expired. The DNS confirmed the facility advance directive policy was not followed and the medical record failed to be accurate to direct staff to R#217 advance directive choices. A telephone interview on [DATE] at 7:50 a.m. of the family member of R#217 who signed the Full Code dated [DATE] on admission revealed she felt it was her and her fathers wishes that he be allowed to pass as he did. The family member stated I was with him earlier but not there when he passed away. A telephone interview with LPN FF on [DATE] at 7:55 a.m. revealed she began to question the resident's status as a full code when the nurse from hospice gave an order for [REDACTED]. When a second hospice nurse came around 9:00 p.m. and told me to continue to give the resident [MEDICATION NAME] 20 mg every two hours if the resident was uncomfortable that's when I discovered hospice had the resident listed as a DNR. I asked the hospice nurse if there was an order and she told me they had one at their office. I looked in the facility record and we did not have an order for [REDACTED]. I did not provide CPR because the hospice nurse told me the resident was a DNR. When asked if she had any evidence R#217 was a DNR such as a written order, she replied she did not at the time the resident expired. 2. Review of the physician's orders for R#290 revealed on [DATE] the physician ordered this resident readmitted to this facility and directed the resident was an admission to the facility on [DATE]. The resident transferred to the hospital on [DATE] and returned on [DATE] to the facility and back to the hospital on [DATE] and returned on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders for R#290 revealed on [DATE] the physician ordered this resident readmitted to this facility and directed the resident was a Full Code. The physician's orders were signed by the physician on [DATE] and the Full Code remained on the orders. This was verified by Minimum Data Set (MDS) LPN EE on [DATE] at 3:45 p.m. Review of the Advance Directive section indicated R#290 was a DNR. A DNR sticker was placed on the inside of the chart and a full-size sheet of paper referenced resident was a DNR. The paper was signed by the physician on [DATE]. A copy of a physician's telephone order was also under the advance direction section and had been signed by the physician on [DATE] with a note written PT (patient) is DNR. Interview and review of the record for R#290 with Unit Manager (UM) AA on [DATE] at 8:39 a.m. verified the discrepancy in the Advance Directive. UM AA stated the physician's order for full code on [DATE] would be the last order pertaining to the code status for R#290 and should be followed until clarified. Review of the record for R#290 was checked again on [DATE] at 12:31 p.m. The record for R#290 was checked on [DATE] at 2:00 p.m. and remained with conflicting information related to the resident's code status. The physicians order remained on the record Full Code along with the DNR sticker and in the Advanced Directive section of the chart was the signed DNR by the resident and the physician dated [DATE]. The resident did not respond to interview on [DATE] at 2:00 p.m. Interview of facility nurses to determine the understanding of an Advance Directive to include full Code and DNR as follows: Interview of RN HH on [DATE] 5:00 p.m. revealed an unresponsive resident I would check code status on MAR indicated [REDACTED]. Full code would mean CPR (cardiopulmonary resuscitation) and DNR (do no resuscitate) would mean do nothing. Interview of LPN MM on [DATE] at 5:03 p.m. revealed If found a resident unresponsive would get chart and check advance directive if DNR should do nothing would check physician order if full code would have to start code call 911 and attempt to clarify. Interview of RN GG on [DATE] at 5:08 p.m. If I found resident unresponsive check vitals call code check the chart for physician's order for full code and provide CPR Call 911. If noted the advance directive said DNR but the physician's order directed full code and the date of the physician's order was after the date of the DNR signed would have to continue a full code and provide CPR. Interview of LPN AA on [DATE] at 5:15 p.m. If I find a patient with no vital signs dial 911. I would check the chart check Advance Directive if that was a DNR would stop the code. If I checked the physician's order and an order was full code would have to code the resident. Full code means CPR and DNR means do not resuscitate. Review of the record for R#290 was checked again on [DATE] at 12:31 p.m. The record for R#290 was checked on [DATE] at 2:00 p.m. and remained with conflicting information related to the resident's code status. The physicians order remained on the record Full Code along with the DNR sticker and in the Advanced Directive section of the chart was the signed DNR by the resident and the physician dated [DATE]. The resident did not respond to interview on [DATE] at 2:00 p.m. The facility Administrator was notified of the failure to correct this resident record and obtain an order to identify the code status of R#290 on [DATE] at 2:00 p.m. The chart was corrected on [DATE] at 10:35 a.m. Review of the undated facility policy Advance Directives procedure, indicated it is the facility policy to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and or appoint a health care agent to make decision on the behalf of the resident when the residents lack the capacity to do so .Under 2. b. If the resident cannot communicate whether an Advance Directive exists and no Advance Directive is produced, the resident will be treated as if an Advance Directive does not exist .Under the section Definitions: Advance Directives mean written instructions, such as Power of Attorney for Health Care, Living Wills and Do Not Resuscitate Orders which relate to the provision of care when the resident is incapacitated .Under Responsibility: All facility employees, Monitored by Social Services Director and Executive Director .Procedure: 2. b. If any Advance Directive exists a copy will be requested and filed in the resident's record. A sticker may be placed on the record to easily identify the existence of an Advance Directive. 3. According to the Minimum Data Set (MDS) assessment dated [DATE], R#195 was rarely or never understood. Her pertinent [DIAGNOSES REDACTED]. R#195's clinical record was reviewed and revealed a document titled Do Not Resuscitate (DNR) (a legal order written either in the hospital or on a legal form to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS), in respect of the wishes of a patient in case their heart were to stop or they were to stop breathing) located under the Advanced Directive (an advanced directive is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) tab of the clinical record, dated [DATE] and signed by two physicians. There was a physician's telephone order dated [DATE], which read, pt (patient) is DNR. There was a red DNR sticker on the inside of the clinical record and the monthly Physician Orders for March, April and [DATE], revealed R#195 code status was Full Code (a term for a medical directive, which means, if a patient has a cardiac or respiratory arrest, medical personnel are ethically and legally obliged to perform life-saving measures), which conflicted with R#195's advanced directive dated [DATE]. Review of the Medication Administration Records (MARS) for March, April, and [DATE] revealed the resident's code status was Full Code. Review of a document titled Advanced Directive Code Status dated [DATE] Code Status for the East 400 Hall kept in front of the nurses' medication administration book revealed R#195 was a DNR. Review of the comprehensive care plans for R#195 failed to reveal staff had initiated a comprehensive care plan that outlined R#195's advanced directives (cross refer F279). According to a document titled Educational In-Service Record dated [DATE], an in-service regarding advanced directives was provided to the staff and included a review of the facility's policy, resident rights (as they related to advanced directives), and function. Registered Nurse (RN) HH, who provides care for R#195, was interviewed on [DATE] at 12:46 p.m. She stated the resident's code status was listed in the chart. The resident would either be a Full Code or DNR. She indicated that she would look at the resident's chart, which would have a code sticker on the front of the chart to indicate the residents code status, she stated she would review the physician orders and the advance directives located under the advance directives tab of the clinical record. She pulled the clinical record for R#195 clinical record and pointed out the DNR code sticker on the front of the chart, the advanced directives and then looked at the physician orders; however, she did not mention the discrepancy between the advance directives, DNR sticker and full code status on the [DATE] monthly physician orders. She stated that she would look in all three areas to make sure the code status was correct. RN HH was re-interviewed on [DATE] at 5:07 p.m. regarding the discrepancy between the advance directives, code sticker and [DATE] monthly physician orders. She stated that she would need to call and clarify the order. She stated if R#195 were to code (at that moment) she would try to keep the resident alive by doing CPR (which was against the resident's advanced directive) and send her out to the hospital until the order was clarified. During an interview with LPN II on [DATE] at 12:58 p.m., she stated that she would look at the front of the resident's chart for the code sticker. She stated that she would also look at the resident's face sheet; however, she pulled random clinical record and was unable to locate this on the face sheet. She then stated the code status would be noted on the resident MAR. LPN II was re-interviewed on [DATE] at 5:11 p.m., she stated that she would look at the MAR, physician orders, and advance directive. She stated If there was a discrepancy she would run the code (perform CPR), call the social worker and notify her supervisor to get things resolved. She stated that staff could also call the family and physician to notify them what is going on and clarify with them and notify the physician what the family stated. During an interview with Unit Manager (UM) AA on [DATE] at 3:00 p.m., she reviewed R#195's clinical record and acknowledged the monthly physician's orders show that the resident was Full Code; and that the physicians telephone order and advanced directives dated [DATE] shows the resident's code status was changed to a DNR. She also reviewed R#195's MARs, which also revealed the resident was Full Code. She stated she would expect the order to be clarified and reflect the resident's code status and if any changes were made they would need to make the corrections and ensure staff was aware of the changes. She stated that this needed to be closely monitored. She reported that the social service staff and nursing staff monitored the residents advanced directives when they were admitted , discharged and readmitted to the facility. She stated that the nurse practitioner had also been speaking with families to clarify orders on resident wishes. During a second interview with UM AA on [DATE] (time not noted), she stated normally they have a sheet that is printed off in the morning meeting. She stated this document includes changes for residents related to changes in insurance (i.e. Medicare to Medicaid), if they were hospice, returned from the hospital, discharged to the hospital, had room changes, discharged or were a new admission. She stated, staff would usually check the chart for the code status and the code status was also kept on the MARs; however, if the code status was not on the MARs staff could check the chart. If staff were unable to find or determine the residents code states she stated staff would begin CPR and call 911. She stated that we would look at the front cover of the chart for a sticker, then look at the advanced directives, which shows what their code status is. She stated when residents are admitted from hospital and staff were unable to determine what the patients code status was upon admission staff would consider them to be a full code, until they were notified otherwise. She stated that there were no other areas in the chart that they would check other than the sticker and the advanced directive. During an interview with LPN MM on [DATE] at 5:03 p.m., she stated that she would get the chart and check the advanced directive. She stated if the resident was a DNR she would check the physician order, if the physician order showed the resident was a full code (i.e. discrepancy between the advanced directive and physicians order) she would follow the physician order and code the person until she found out differently. During an interview with Registered Nurse (RN) GG on [DATE] at 5:05 p.m., she stated she would check the patient chart and start the code. If the resident turned out to be a DNR she would then stop the code. If there was a discrepancy noted in the resident's code status she would conduct the full code. During an interview with LPN AA on [DATE] at 5:15 p.m., she stated if she finds a resident with no vitals she would call 911 and check the code status in the chart (i.e. sticker and advanced directive) and that is what she would follow. She stated she would not check the physician's orders. During an interview with the Director of Nursing Services (DNS) on [DATE] at 5:20 p.m., she stated nurses were expected to determine the residents code status. If the resident comes in with no orders or paper work, the resident would be considered a full code. She stated upon a resident's admission to the facility, within ,[DATE] days, staff would clarify the resident's code status with family. She stated social services gets all the signed papers and the nurse would get the telephone order from the physician and social services would place the documents in the chart. She stated once all documents are signed social services would place the code status sticker on the chart and advanced directives in the chart. She stated that she would look at the sticker on the front of the resident's chart and then look at the advance directives. If the advanced directives were signed and in place she would turn to the physician order. She stated if she did not see an order to revoke the (signed) advance directive she would honor the advance directive. She stated that if there was a discrepancy noted in the resident's code status she would expect them to turn to the chart and see if these things are in place and if not, staff would need to verify the orders with the family and physician. During an interview with Social Service Assistant (SSA) DD, in the presence of the Social Services Director (SSD) AA, on [DATE] at 2:40 p.m., SSA DD stated that during the [DATE] in-service he reviewed the advanced directive policy with staff, where to find the code status of a resident, resident rights and the fact that residents can changes their advanced directive at any time. SSD AA added that typically the audit was done by SSA CC and was supposed to be done quarterly and reviewed during the care plan meetings. SSD AA stated that if there were discrepancies social services would get if fixed and update the information. SSD AA stated if the resident wanted changes they would get the resident and or family to sign the appropriate forms, which could not be put in place until the physician signs the document. She reported that nurses would notify social services if they found a discrepancy, but social services conduct the audits. SSD AA was interviewed a second time on [DATE] 4:29 p.m., she stated SSA CC was auditing the advanced directives for the entire building. A request was made to speak to SSA CC; however, he had already left for the day. SSD AA stated SSA CC told her when he was completing the audits and would provide nurses with the completed list, which would indicate the resident, hall, and those residents who had a DNR status. She stated that when he would identify inaccuracies he would notify the supervisor for that area. She stated that SSA CC had not brought up issues regarding discrepancies with resident advanced directives to the quality assurance (QA) committee. She stated that she would have expect him to bring identified concerns to her attention and she would bring the concern to the QA committee. She stated that to date SSA CC had not brought any concerns to her attention. A request was made for a copy of the audits conducted by SSA CC. On [DATE] at 4:55 p.m., SSD AA provided a document titled Residents with DNR, however, there was no date and signatures to indicate when the document was created or that the document was the audit conducted by SSA CC. This was simply a list of resident names with DNR noted next to the resident names. During an interview with the Administrator on [DATE] at 4:27 p.m., she reported when residents are admitted to the facility they were asked about their code status and if they wish to be a DNR the process was initiated to execute the DNR. She stated social services would be involved and start the process with getting the appropriate documentation signed by the resident and or family and forward to the physician for the concurrence (capacity evaluation) from the physician. she stated sometime at the end of 2016 or beginning of 2017 a corporate consultant identified a discrepancy in a resident's code status during a routine chart audit. The facility conducted an audit of all resident records; however, did not recall if there were discrepancies identified. She stated that it was her understanding that staff were conducting the audits and providing her with a list of residents who were DNR. She stated that she did not know what the audit consisted of (i.e. sticker, advanced directive, physician orders, etc.) (cross refer F490). A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE] at 1:34 p.m. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE] 100% chart audit was completed reconciling chosen code status, physician orders and consents for code status. The audit was completed by licensed nurses: Minimum Data Set (MDS) and Staff Development. Discrepancies noted on R#195, R#217, and R#290 were clarified. Results of the audit reflected issues with completed consents that did not match the current physician order for [REDACTED]. Labels were added to the chart of two residents. 2. To assure the corrections were brought forward correctly, an additional audit was completed on [DATE] to assure June orders reflect the correct code status for each resident who has executed a DNR, the consent matches the order, the physician order is present and the June MAR indicated [REDACTED] 3. An audit was also completed on [DATE] to assure June orders reflect the correct code status for residents electing Full Code status, the medication administration records (MARs) and physician orders sheet, both reflecting Full Code. 4. On [DATE] a review of the Advance Directives policy was completed and was included in the in-services with social services, medical records, nurse managers, MDS, and admissions. 5. On [DATE] in-services began for licensed nursing staff on code status: reviewing signed consent and written physician's order is located under the Advanced Directive tab in resident's chart. If both are present CPR will not be initiated if neither is present resident is a full code and CPR will be initiated. The in-service content was revised on [DATE] and in services will continue until all licensed nurses have been in-serviced. Licensed nurses will not be allowed to work until he/she has received the in-service. As of [DATE], all licensed staff on duty have been in-serviced for a total of 66% at that time. In-services continued including 1:1 telephone conducted by two licensed nurses. Eighty percent (%) of the licensed nursing staff will be in-serviced by [DATE], with 100 % by [DATE] or the nurse will not be allowed to work until the in-service is complete. 6. On [DATE] in-services began on code status with social services, admission, MDS and medical records staff on DNR process: 100% complete. This in-service reviewed the following. Effective [DATE] social services will initiate the process with the resident and or family by having the resident/family sign the DNR consent. Consent will be forwarded to the physician(s) for their concurrence and signatures along with writing DNR order. DNR order and consent will be placed in the resident's chart under the Advance Directive Tab. Change in code status will be discussed during daily department head meetings starting [DATE]. Nurse manager will ensure code status is reflected on the physician's order sheet and MAR. MDS will ensure care plan reflects code status. Medical records will review the chart for signed consent and written order prior to placing DNR sticker in front of the chart. If all components are not present resident will be considered a full code. Code status (DNR) Binder will be located at each nurse's station at the conclusion of the [DATE] audit. Code status will be reviewed with resident and or family during quarterly care plan review and update by a staff member. 7. On [DATE] any change of status will be discussed during Department head meeting. Nurse manager will have the resident's chart present for review by Medical Records. Medical records will review chart to ensure all components of the DNR status is present (signed consent and written DNR order) - if all components are present medical records will place the DNR sticker on the chart. If there is not a DNR code consent or order medical records will place a full code sticker on the chart. Nurse Manger will ensure code status is reflected on the physician's order sheet and MAR. MDS will ensure code status is reflected in the resident's care plan. 8. In addition, the current code status of residents receiving hospice services is reconciled between the facility and hospice services. In-service with hospice administrators was started on [DATE] and will be complete [DATE] on notification of facility Social Series with any change in code status ongoing reconciliation will be reviewed during care plan update meetings. On [DATE] at 1:04 the facility's Credible Allegation of Compliance (AoC) to remove the immediacy of the deficient practice was validated as follows: 1. Documentation of the in-services provided by the governing body to facilitate resident advanced directives on [DATE] revealed 75 licensed nurses on staff, 63 received education to date for a total of 84% staff educated. Additionally, 100% of the Admissions, MDS, and social services staff were in-serviced. 2. Interviews regarding this in-service were conducted with facility staff on [DATE] at 7:40 a.m., 7:45 a.m., 9:30 a.m. and 9:35 a.m. 3. Those residents identified in the immediate jeopardy (R#195, R#217 and R#290) were reviewed. R#217 expired and the charts for R#195 and R#290 we

Based on record review and staff interview the facility failed to develop a comprehensive plan of care for three of 30 stage 2 sampled residents (R) #217, #45 and #195 which resulted in failure to provide necessary care as identified in the resident assessment. Specifically; -Did not ensure that the resident advance directives wishes were care planned as identified in the resident assessment for R#217 and R#195, (Cross reference F155 for complete details) -Did not ensure that R#45 dental status needs were care planned as identified in the resident assessment. This failure put residents in the facility at risk for serious injury or death without an attempt of life sustaining measures as chosen by the resident to return circulatory system function and respiratory function to a viable state to sustain life. The facility's Administrator and Director of Nurses were informed of the immediate jeopardy on [DATE] at 9:30 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of advanced directive procedures to ensure the accuracy of advanced directives on the chart. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident advanced directive wishes, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing Advanced Directives. Resident records were reviewed to ensure that resident advanced directives, including physicians' orders for advanced directives, was current and accurate. Findings include: 1. Review of the medical record for R#217 revealed admission to the facility on [DATE]. Review of the Face Sheet for R#217 identified the following pertinent [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] under Section J1400 Prognosis: have a condition or chronic disease that may result in a life expectancy less than 6 months the assessment was checked No. Review of Section O0100 Special Treatments and Programs: Other K identified R#217 received hospice services before coming to the facility and after admission to the facility. Review of the plan of care for R#217 dated [DATE] the problem identified Limited Life Expancy {sic}. The plan of care identified the resident as a full code. Cross refer F155 for complete interview with the Director of Nursing Services (DNS) on [DATE] at 4:00 p.m., confirming R#217's plan of care initiated on [DATE] identified the resident was a full code not a DNR. and interview with LPN FF on [DATE] at 7:55 a.m. (Cross refer to F155) 2. According to the quarterly MDS assessment dated [DATE], R#195 was rarely or never understood. Her pertinent [DIAGNOSES REDACTED]. On [DATE] at 12:30 p.m., R#195' s clinical record was reviewed and revealed a documented titled Do Not Resuscitate (DNR), located under the Advanced Directive tab of the clinical record dated [DATE] and signed by two physicians. Further review of the clinical record revealed a monthly Physicians Order form, which indicated the resident was a full code which conflicted with R#195's advanced directive. (Cross refer F155 for complete information related to R#195's advance directive) Review of the comprehensive care plans for R#195 on [DATE] at 12:30 p.m., revealed staff had not initiated a comprehensive care plan that outlined R#195' s advanced directives and how staff would care for R#195 in the event she became unresponsive. During an interview on [DATE] at 3:30 p.m., LPN EE acknowledged the care plans for R#195 did not previously contain a comprehensive care plan regarding R#195' s advanced directives. (Cross refer to F155) 3. According to the annual MDS assessment dated [DATE], sections C0100-C0400 identified R#45 had moderate memory deficits as evidenced by a brief interview for mental status (BIMS) score of 11 out of 15. Section G0100 revealed R#45 required extensive assistance of one person for personal hygiene. Section L0200 revealed R#45 had no natural teeth or tooth fragments. Further review of the MDS revealed the dental care area triggered related to the resident had no natural teeth or tooth fragments. Additionally, the care plan considerations for dental read will not proceed with care plan at this time. Resident with potential for altered oral status and chewing difficulty. Resident is edentulous. Is not having any problems at this time. Is not a wt (weight) loss. Will continue to monitor for any changes and refuse (sic) to dentist as needed . During an interview with R#45 on [DATE] at 2:48 p.m., she stated she wore dentures and that they were broken. She stated that staff was not taking care of the issue, but was unable to state who she reported the issue to. During an interview R#45' s family member on [DATE] at 10:37 a.m., he reported R#45 usually kept her dentures in the top draw of her dresser and he was unsure whether the dentures were broken or not. During an interview with LPN KK on [DATE] at 3:44 p.m., she stated she was not sure if R#45 wore dentures. She went into R#45's room and asked R#45 if she wore dentures. R#45 stated her dentures were in her dresser draw. LPN KK looked through the dresser draw and could not locate her dentures. LPN KK asked certified nurse aid (CNA) AA who stated she had never seen R#45 with dentures. During an interview with LPN AA on [DATE] at 10:36 a.m., she was not aware R#45 had dentures. She entered the resident's room and asked her if she had dentures. R#45 stated that they were broke and in the draw. LPN AA looked through the upper draw on the night stand and found R#45's upper denture, which were lying loosely in the top draw and not properly stored in a denture cup. LPN AA was unable to locate R#45's bottom denture and proceeded to place R#45's upper denture in a denture cup and placed them on the bedside table. During an interview with the MDS Manager on [DATE] at 1:11 p.m., she reported that during a recent care plan meeting with the family there were no issues identified regarding R#45' s dentures. She stated that an annual assessment was done in March (2017), which showed R#45 was not having issues and the original care plan was retired. A copy of the retired care plan was requested and not provided by the end of the survey on [DATE]. On [DATE] at 1:34 p.m. MDS coordinator (MDS LPN) DD stated R45 her own teeth, had not had any problems or weight loss and there had been no complaints from R#45 or her family. She stated that if R#45 had dentures she would create a care plan. On [DATE] at 1:40 p.m., MDS LPN DD went to R#45's room and asked R#45 if she had her own teeth. R#45 stated, no, I wear dentures. MDS LPN DD asked R#45 where her dentures were. R45 stated they were in the dresser draw and had been broken for two years. MDS LPN DD asked R#45 whether she wears her dentures and R#45 stated, Yes, when I go out. MDS LPN DD stated oral care is naturally done for all residents and staff would know she wears dentures through the pocket care guide. MDS LPN DD reviewed the pocket care guide which did not reveal R#45 had dentures or that she wore them when she left the facility. The Assistant Director of Nursing Services (ADNS) was interviewed on [DATE] at 1:52 p.m., she stated staff normally provide oral care for residents with dentures. She stated R#45' s sister oversees R#45' s care. The ADNS stated that she did not recall R#45 with teeth. She stated that she would not expect to see a specific care plan for dentures unless she was at risk for weigh loss due to carious teeth. She indicated that the care plan tells staff what the resident needs and how to approach the resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE] 100% chart audit was completed reconciling chosen code status, physician orders [REDACTED]. The audit was completed by licensed nurses: Minimum Data Set (MDS) and Staff Development. Discrepancies noted on R#195, R#217, and R#290 were clarified. Results of the audit reflected issues with completed consents that did not match the current physician order [REDACTED]. Labels were added to the chart of two residents. 2. To assure the corrections were brought forward correctly, an additional audit was completed on [DATE] to assure June orders reflect the correct code status for each resident who has executed a DNR, the consent matches the order, the physician order [REDACTED]. 3. An audit was also completed on [DATE] to assure June orders reflect the correct code status for residents electing Full Code status, the medication administration records (MARs) and physician orders [REDACTED]. 4. On [DATE] a review of the Advance Directives policy was completed and was included in the in-services with social services, medical records, nurse managers, MDS, and admissions. 5. On [DATE] in-services began for licensed nursing staff on code status: reviewing signed consent and written physician's orders [REDACTED]. If both are present CPR will not be initiated if neither is present resident is a full code and CPR will be initiated. The in-service content was revised on [DATE] and in services will continue until all licensed nurses have been in-serviced. Licensed nurses will not be allowed to work until he/she has received the in-service. As of [DATE], all licensed staff on duty have been in-serviced for a total of 66% at that time. In-services continued including 1:1 telephone conducted by two licensed nurses. Eighty percent (%) of the licensed nursing staff will be in-serviced by [DATE], with 100 % by [DATE] or the nurse will not be allowed to work until the in-service is complete. 6. On [DATE] in-services began on code status with social services, admission, MDS and medical records staff on DNR process: 100% complete. This in-service reviewed the following. Effective [DATE] social services will initiate the process with the resident and or family by having the resident/family sign the DNR consent. Consent will be forwarded to the physician(s) for their concurrence and signatures along with writing DNR order. DNR order and consent will be placed in the resident's chart under the Advance Directive Tab. Change in code status will be discussed during daily department head meetings starting [DATE]. Nurse manager will ensure code status is reflected on the physician's orders [REDACTED]. Medical records will review the chart for signed consent and written order prior to placing DNR sticker in front of the chart. If all components are not present resident will be considered a full code. Code status (DNR) Binder will be located at each nurse's station at the conclusion of the [DATE] audit. Code status will be reviewed with resident and or family during quarterly care plan review and update by a staff member. 7. On [DATE] any change of status will be discussed during Department head meeting. Nurse manager will have the resident's chart present for review by Medical Records. Medical records will review chart to ensure all components of the DNR status is present (signed consent and written DNR order) - if all components are present medical records will place the DNR sticker on the chart. If there is not a DNR code consent or order medical records will place a full code sticker on the chart. Nurse Manger will ensure code status is reflected on the physician's orders [REDACTED]. 8. In addition, the current code status of residents receiving hospice services is reconciled between the facility and hospice services. In-service with hospice administrators was started on [DATE] and will be complete [DATE] on notification of facility Social Series with any change in code status ongoing reconciliation will be reviewed during care plan update meetings. On [DATE] at 1:04 the facility's Credible Allegation of Compliance (AoC) to remove the immediacy of the deficient practice was validated as follows: 1. Documentation of the in-services provided by the governing body to facilitate resident advanced directives on [DATE] revealed 75 licensed nurses on staff, 63 received education to date for a total of 84% staff educated. Additionally, 100% of the Admissions, MDS, and social services staff were in-serviced. 2. Interviews regarding this in-service were conducted with facility staff on [DATE] at 7:40 a.m., 7:45 a.m., 9:30 a.m. and 9:35 a.m. 3. Those residents identified in the immediate jeopardy (R#195, R#217 and R#290) were reviewed. R#217 expired and the charts for R#195 and R#290 were corrected. 4. The DNR and Full Code Audits for all 225 residents residing in the facility were reviewed and compared to the facility census. The review revealed 100% of residents were audited to ensure the consents, DNR order, physicians order and MARs were correct for those residents who wished to be a DNR and a full code order was present and on the MAR for those residents who wished to be a Full Code. 5. DNR Binders were created for each nursing station 6. On [DATE] the Administrator provided education to the Administrators of each contracted hospice provider. 2. According to the quarterly MDS assessment dated [DATE], R#195 was rarely or never understood. Her pertinent [DIAGNOSES REDACTED]. On [DATE] at 12:30 p.m., R#195's clinical record was reviewed and revealed a documented titled Do Not Resuscitate (DNR), located under the Advanced Directive tab of the clinical record dated [DATE] and signed by two physicians. Further review of the clinical record revealed a monthly Physicians Order form, which indicated the resident was a full code which conflicted with R#195's advanced directive Review of the comprehensive care plans for R#195 on [DATE] at 12:30 p.m., revealed staff had not initiated a comprehensive care plan that outlined R#195's advanced directives and how staff would care for R#195 in the event she became unresponsive. During an interview on [DATE] at 3:30 p.m., LPN EE acknowledged the care plans for R#195 did not previously contain a comprehensive care plan regarding R#195' s advanced directives. 3. According to the annual MDS assessment dated [DATE], sections C0100-C0400 identified R#45 had moderate memory deficits as evidenced by a brief interview for mental status (BIMS) score of 11 out of 15. Section G0100 revealed R#45 required extensive assistance of one person for personal hygiene. Section L0200 revealed R#45 had no natural teeth or tooth fragments. Further review of the MDS revealed the dental care area triggered related to the resident had no natural teeth or tooth fragments. Additionally, the care plan considerations for dental read will not proceed with care plan at this time. Resident with potential for altered oral status and chewing difficulty. Resident is edentulous. Is not having any problems at this time. Is not a wt (weight) loss. Will continue to monitor for any changes and refuse (sic) to dentist as needed . During an interview with R#45 on [DATE] at 2:48 p.m., she stated she wore dentures and that they were broken. She stated that staff was not taking care of the issue, but was unable to state who she reported the issue to. During an interview R#45's family member on [DATE] at 10:37 a.m., he reported R#45 usually kept her dentures in the top draw of her dresser and he was unsure whether the dentures were broken or not. During an interview with LPN KK on [DATE] at 3:44 p.m., she stated she was not sure if R#45 wore dentures. She went into R#45's room and asked R#45 if she wore dentures. R#45 stated her dentures were in her dresser draw. LPN KK looked through the dresser draw and could not locate her dentures. LPN KK asked certified nurse aid (CNA) AA who stated she had never seen R#45 with dentures. During an interview with LPN AA on [DATE] at 10:36 a.m., she was not aware R#45 had dentures. She entered the resident's room and asked her if she had dentures. R#45 stated that they were broke and in the draw. LPN AA looked through the upper draw on the night stand and found R#45's upper denture, which were lying loosely in the top draw and not properly stored in a denture cup. LPN AA was unable to locate R#45's bottom denture and proceeded to place R#45's upper denture in a denture cup and placed them on the bedside table. During an interview with the MDS Manager on [DATE] at 1:11 p.m., she reported that during a recent care plan meeting with the family there were no issues identified regarding R#45's dentures. She stated that an annual assessment was done in March (2017), which showed R#45 was not having issues and the original care plan was retired. A copy of the retired care plan was requested and not provided by the end of the survey on [DATE]. On [DATE] at 1:34 p.m. MDS coordinator (MDS LPN) DD stated R#45 her own teeth, had not had any problems or weight loss and there had been no complaints from R#45 or her family. She stated that if R#45 had dentures she would create a care plan. On [DATE] at 1:40 p.m., MDS LPN DD went to R#45's room and asked R#45 if she had her own teeth. R#45 stated, no, I wear dentures. MDS LPN DD asked R#45 where her dentures were. R#45 stated they were in the dresser draw and had been broken for two years. MDS LPN DD asked R#45 whether she wears her dentures and R#45 stated, Yes, when I go out. MDS LPN DD stated oral care is naturally done for all residents and staff would know she wears dentures through the pocket care guide. MDS LPN DD reviewed the pocket care guide which did not reveal R#45 had dentures or that she wore them when she left the facility. The Assistant Director of Nursing Services (ADNS) was interviewed on [DATE] at 1:52 p.m., she stated staff normally provide oral care for residents with dentures. She stated R#45's sister oversees R#45's care. The ADNS stated that she did not recall R#45 with teeth. She stated that she would not expect to see a specific care plan for dentures unless she was at risk for weigh loss due to carious teeth. She indicated that the care plan tells staff what the resident needs and how to approach the resident.

Based on observations, clinical records review, staff interviews and review of the Executive Directors Job Description, the facility was not administered in an effective manner, resulting in Immediate Jeopardy creating the likelihood of death or serious harm (either physical, emotional, or mental) for 3 of 40 residents (R) (R#195, R#217 and R#290) reviewed for Advanced Directives. The total facility census was 225 residents. The findings of the standard/extended survey found Immediate Jeopardy with Substandard Quality of Care at 483.24 (Quality of Life). Advanced Directives for R#195, R#217 and R#290 were inaccurate or inconsistent with the physician orders [REDACTED]. The failure to provide staff with clear and accurate information related to the Advance Directive chosen by a resident had the potential to prevent a resident to expire as chosen without the interventions of life sustaining measures against their wishes. Conflicting and inaccurate information in a resident's health care record related to resident choice to be a Full Code had the potential to cause life sustaining measures not to be provided for a resident who had made that choice. This failure put residents in the facility at risk for serious injury or death without an attempt of life sustaining measures as chosen by the resident to return circulatory system function and respiratory function to a viable state to sustain life (cross refer F155 and F520). The facility's Administrator and Director of Nurses were informed of the immediate jeopardy on 6/1/17 at 9:30 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/30/16. A Credible Allegation of Compliance was received on June 2, 2017. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on June 1, 2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of advanced directive procedures to ensure the accuracy of advanced directives on the chart. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident advanced directive wishes, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing Advanced Directives. Resident records were reviewed to ensure that resident advanced directives, including physicians' orders for advanced directives, was current and accurate. Findings include: A. Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 5/30/17 - 6/2/17. Refer to the following deficiencies for specific details of the noncompliance: a. Resident Rights: 483.10 F253 - Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was cited at an E, potential for harm that was a pattern in scope b. Resident Assessment: 483:20 F279 - Failure to develop comprehensive care plans for four residents (R#45, R#195, R#217 and R#290). This was cited at a D, potential for harm that was isolated in scope c. Quality of Life: 483.24 F155 - Failure to ensure residents, family and health care agent choices related to advance directives were clear and accurately reflected in the resident's medical records (cross refer F155). This was cited at a J, Immediate Jeopardy that was isolated. F248 - Failure to ensure an ongoing activities programs for two cognitively impaired residents (R#28 and R#289). This was cited at a D, potential for harm that was isolated in scope. d. Quality of Care: 483.25 F309 - Failure to ensure coordination of care between the facility and the [MEDICAL TREATMENT] center for R#290. This was cited at a D, potential for harm that was isolated in scope. e. Pharmacy Services: 483.45 F329 - Failure to ensure drug regimen was free from unnecessary drugs for two residents (R#164 and R#217). This was cited at a D, potential for harm that was isolated. F332 - Failure to ensure medication error rate was not greater than (>) five percent (5%). This was cited at a D, potential for harm that was isolated in scope. F431 - Failure to ensure expired medications were immediately removed from use in one of two medication rooms and one of three medications carts out of eight medication carts audited. This was cited at an E, potential for harm at a pattern for scope. f. Administration: 483.70 F490 - Failure to ensure the facility was administered in an effective manner. This was cited at a J, immediate jeopardy that was isolated in scope. g. Quality Assurance and Performance Improvement: 483.75 F520 - Failure to ensure an effective QAA quality assurance and assessment program was in place. This was cited at a J, immediate jeopardy that was isolated in scope. h. Physical Environment 483.90 F465 - Failure to ensure safe/functional/sanitary/comfortable environment related to unclean and damaged walls and floors in the kitchen, this was cited at an F, potential for harm that was widespread in scope. F467 - Failure to ensure adequate outside ventilation in two of two shower rooms by means of windows, or mechanical ventilation, or a combination of the two. This was cited at an E, potential for harm at a pattern scope. B. Review of the Executive Directors (Administrator) Job Description, read in part, the Executive Director leads and directs the overall operation of the facility in accordance with resident needs, government regulations and Facility policies so as to maintain quality care for the residents while achieving the facility's business objectives. Essential Duties included the following: Works with the Facility management staff in planning all aspects of Facility's operations, including setting priorities and job assignments. Monitors each department's activities, communicates policies, evaluates performance, provides feedback and assists, coaches, and disciplines as needed, Conduct regular rounds to verify that resident needs are being addressed. Monitors cleanliness and appearance of Facility, and morale of staff, Verifies that consultants and other support resources are appropriately utilized, Verifies a high level of inter-departmental teamwork is maintained, Maintains a working knowledge and monitors compliance with all governmental regulations and Facility Quality Assurance standards, Monitors employee relations practices to verify compliance with employment laws and Facility policies. Promotes practices that maintain high morale and staff retention, including effective communication, prompt problem resolution and positive reinforcement, Manages turnover and verifies adequate staffing through development of recruitment sources, and through appropriate selection, orientation, training, and staff education, Manages facility budgets and business practices to include labor costs, payable and receivable. Monitors business office activities to verify procedures and standards are followed, Develops and implements a marketing strategy for the facility that reflects service opportunities, competition, potential market area changes, and which maximizes census, payer mix, and ancillary revenues. Leads and monitors key marketing staff and plays an active role in carrying out the marketing plan, Develops positive relationships on behalf of the Facility with the government regulators, families, area health care community, and community at large, Supervises conducts and participates in department and Facility education activities and staff meetings, Demonstrates availability to be on-call 24 hours per day, 7 days per week, Demonstrates knowledge of all State Department of Health rules and regulations and provides adequate instructions regarding such rules and regulations to appropriate staff, and Verifies the safeguarding of the medical record and any other information pertinent to the resident or facility operations. C. Review of the clinical records for three residents (R#195, R#217 and R#290) revealed inaccuracies between the residents advanced directives (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity), physician orders, medication administration records (MARs) and code status sticker. The failure to provide staff with clear and accurate information related to the Advance Directive chosen by a resident had the potential to prevent a resident to expire as chosen without the interventions of life sustaining measures against their wishes. Conflicting and inaccurate information in a resident's health care record related to resident choice to be a Full Code had the potential to cause life sustaining measures not to be provided for a resident who had made that choice. (cross refer F155) During an interview with Administrator on 6/2/17 at 4:27 p.m., she stated that when a resident was admitted to the facility the resident was asked about their core status, if the resident wished to be a DNR then then the process was initiated to execute the DNR. She stated that social services would be involved and start the process of getting the appropriate documentation signed by resident and/or family and forward to the physician for the concurrence of the physician (concurrence is a capacity evaluation completed and signed by two physicians when a resident was incapable). She stated nursing would then obtain the code status orders form the physician. Once that was completed social services would place a copy of the DNR documents in the resident's and update the record. She stated that staff were to follow up on code status during the resident care plan meetings to verify that the resident's code status was accurate. If the resident's code status changed the process would being all over again. She reported that she was aware of the facility's advanced directives policy and that the resident code status was supposed to on the resident's chart. She reported that the last time she knew there was an issue regarding advanced directive was when a corporate consult conducted a routine audit and identified a resident's code status did not match sometime around the end of the year (2016) or beginning of the year (2017), which was brought to her attention. However, she did not recall if they identified any discrepancies. She stated that the issue was not brought to the Quality Assurance (QA) committee for review. She reported that the staff was in-serviced on the process, but was not aware of any significant changes in the process at that time. She stated that it was her understanding that the staff was auditing and provided her with the results of who was a DNR; however, she was not aware of what the audit consisted of (i.e. review of the physician orders, advanced directives, and code status sticker on the chart to ensure they matched). She stated Social Services was responsible for doing the monitoring, and there were no meetings held to discuss any issues. She stated staff has not brought up any further issues to her attention. She stated that she would have expected staff to identify this issue and bring the concern to her attention through the QA process. She stated she thought the monitoring was being done monthly and would have to say (after being brought to her attention during survey) that the process was not being done appropriately. During an interview with the Director of Nursing Services (DNS) on 5/31/17 at 5:20 p.m., she stated staff were expected to determine the residents code status. When residents were admitted with no orders the resident would be considered a full code until the code status could be determined. She indicated that if there were discrepancies in a resident's code status staff would need to verify the code status with the family and physician (cross refer F155). During an interview with the Social Services Director (SSD) AA on 6/2/17 at 4:29 p.m., she indicated that Social Services Assistant (SSA) CC was auditing the advanced directives for the entire building, was providing nurses with an updated list of resident who had a code status of DNR and notified the supervisor when there were discrepancies. A request was made for the audits completed by SSA CC on 6/2/17. On 6/2/17 at 4:55 p.m., SSD AA provided two documents titled Residents with DNR, however, there was no date and signatures to indicate when the document was created or that the document was the actual audit conducted by SSA CC. Additionally, SSD AA stated that SSA CC had not brought any concerns to the attention of the QA committee or to her attention so that she may bring to the attention of the QA committee (cross refer F155 and F520). D. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 5/31/17 100% chart audit was completed reconciling chosen code status, physician orders [REDACTED]. The audit was completed by licensed nurses: Minimum Data Set (MDS) and Staff Development. Discrepancies noted on R#195, R#217, and R#290 were clarified. Results of the audit reflected issues with completed consents that did not match the current physician order [REDACTED]. Labels were added to the chart of two residents. 2. To assure the corrections were brought forward correctly, an additional audit was completed on 6/1/17 to assure June orders reflect the correct code status for each resident who has executed a DNR, the consent matches the order, the physician order [REDACTED]. 3. An audit was also completed on 6/1/17 to assure June orders reflect the correct code status for residents electing Full Code status, the medication administration records (MARs) and physician orders [REDACTED]. 4. On 6/1/17 a review of the Advance Directives policy was completed and was included in the in-services with social services, medical records, nurse managers, MDS, and admissions. 5. On 5/31/17 in-services began for licensed nursing staff on code status: reviewing signed consent and written physician's orders [REDACTED]. If both are present CPR will not be initiated if neither is present resident is a full code and CPR will be initiated. The in-service content was revised on 6/1/17 and in services will continue until all licensed nurses have been in-serviced. Licensed nurses will not be allowed to work until he/she has received the in-service. As of 6/1/17, all licensed staff on duty have been in-serviced for a total of 66% at that time. In-services continued including 1:1 telephone conducted by two licensed nurses. Eighty percent (%) of the licensed nursing staff will be in-serviced by 6/3/17, with 100 % by 6/5/17 or the nurse will not be allowed to work until the in-service is complete. 6. On 6/1/17 in-services began on code status with social services, admission, MDS and medical records staff on DNR process: 100% complete. This in-service reviewed the following. Effective 6/1/17 social services will initiate the process with the resident and or family by having the resident/family sign the DNR consent. Consent will be forwarded to the physician(s) for their concurrence and signatures along with writing DNR order. DNR order and consent will be placed in the resident's chart under the Advance Directive Tab. Change in code status will be discussed during daily department head meetings starting 6/1/17. Nurse manager will ensure code status is reflected on the physician's orders [REDACTED]. Medical records will review the chart for signed consent and written order prior to placing DNR sticker in front of the chart. If all components are not present resident will be considered a full code. Code status (DNR) Binder will be located at each nurse's station at the conclusion of the 6/1/17 audit. Code status will be reviewed with resident and or family during quarterly care plan review and update by a staff member. 7. On 6/1/17 any change of status will be discussed during Department head meeting. Nurse manager will have the resident's chart present for review by Medical Records. Medical records will review chart to ensure all components of the DNR status is present (signed consent and written DNR order) - if all components are present medical records will place the DNR sticker on the chart. If there is not a DNR code consent or order medical records will place a full code sticker on the chart. Nurse Manger will ensure code status is reflected on the physician's orders [REDACTED]. 8. In addition, the current code status of residents receiving hospice services is reconciled between the facility and hospice services. In-service with hospice administrators was started on 6/2/17 and will be complete 6/2/17 on notification of facility Social Series with any change in code status ongoing reconciliation will be reviewed during care plan update meetings. E. On 6/2/17 at 1:04 the facility's Credible Allegation of Compliance (AoC) to remove the immediacy of the deficient practice was validated as follows: 1. Documentation of the in-services provided by the governing body to facilitate resident advanced directives on 6/2/17 revealed 75 licensed nurses on staff, 63 received education to date for a total of 84% staff educated. Additionally, 100% of the Admissions, MDS, and social services staff were in-serviced. 2. Interviews regarding this in-service were conducted with facility staff on 6/2/17 at 7:40 a.m., 7:45 a.m., 9:30 a.m. and 9:35 a.m. 3. Those residents identified in the immediate jeopardy (R#195, R#217 and R#290) were reviewed. R#217 expired and the charts for R#195 and R#290 were corrected. 4. The DNR and Full Code Audits for all 225 residents residing in the facility were reviewed and compared to the facility census. The review revealed 100% of residents were audited to ensure the consents, DNR order, physicians order and MARs were correct for those residents who wished to be a DNR and a full code order was present and on the MAR for those residents who wished to be a Full Code. 5. DNR Binders were created for each nursing station 6. On 6/2/17 the Administrator provided education to the Administrators of each contracted hospice provider.

Based on staff interview and record review, the facility failed to maintain an effective Quality Assurance (QA) program which systematically reviewed, developed, and implemented plans to correct quality deficiencies for all 225 residents living in the facility as of [DATE]. Advanced Directives were inaccurate or inconsistent with the physician orders [REDACTED]. This failure put residents in the facility at risk for serious injury or death without an attempt of life sustaining measures as chosen by the resident to return circulatory system function and respiratory function to a viable state to sustain life (cross refer F155 and F490). The facility's Administrator and Director of Nursing Services were informed of the immediate jeopardy on [DATE] at 9:30 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of advanced directive procedures to ensure the accuracy of advanced directives on the chart. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident advanced directive wishes, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing Advanced Directives. Resident records were reviewed to ensure that resident advanced directives, including physicians' orders for advanced directives, was current and accurate. Findings include: Interview with Administration on [DATE] at 4:27 p.m. revealed when someone is admitted they are asked about their core status and if they wish to be a Do Not Resuscitate (DNR) then the process is initiated to execute a DNR. Social Services (SS) would be involved to start the process with getting the appropriate documentation signed by resident and/or family and forward to the physician for the concurrence of the physician. (concurrence is when resident is incapable and would require two signatures). Nursing will obtain the code status orders from the physician. Once that is completed SS would place a copy of the DNR documents in the chart and update the record. During care plan meetings staff verifies that the resident's code status is accurate and if the code status changes the process begins all over. She reported that she is aware of the facility policy and that the resident code status was supposed to on the resident's chart. She reported that the last time she knew there were issues regarding advanced directive was either the end of last year (2016) or beginning of the year (2017). She stated that the facility conducted an audit of the resident's code status; however, did not recall if they identified any discrepancies. She stated that the issue was not brought to Quality Assurance (QA) committee for review. She stated that a corporate consultant identified an issue with a resident's clinical record where the code status did not match around the end of the year (2016) or beginning of the year (2017) during a routine audit and brought the concern to her attention. She reported that the staff was in serviced on the process, but was not aware of any significant change at that time. She stated it was my understanding that staff were auditing and provided me with the results of who was a DNR. The Administrator further stated, she was not aware of what the audit consisted of (i.e. did they review the orders, advanced directives, and sticker on the chart to ensure they matched). She stated that Social Services was responsible for doing the monitoring, and there were no meetings held to discuss any issues. She stated staff did not bring up any further issues to her attention. She stated that she would have expected staff to identify this issue and bring to her attention through the QA process., She stated, I thought the monitoring was being done monthly. After being brought to her attention during survey, the administrator stated I would have to say the process was not being done appropriately. Interview with Social Services Director (SSD) AA on [DATE] at 4:29 p.m. revealed Social Services Assistant (SSA) CC has been auditing advanced directive status for the entire building. She stated that he would tell her that he was going to do the audits and would provide the nurses with the list of residents he completed and provide the nurses with a copy of the list that he completed, which would indicate the resident, hall, and those residents who were DNR status. When he identified inaccuracies, he would notify the nursing supervisor. She stated the he has not brought this up to the QA committee. She would expect him to bring this to her attention so that she could bring this to the QA committee. She stated that he had not brought this issue to her attention. The QA program failed to identify environment and maintenance concerns to ensure a clean, and well- maintained environment putting resident in the facility at risk of illness from unclean surfaces, cross contamination from improperly stored resident care equipment, potential food contamination, respiratory concerns from inadequate ventilation (cross refer F253, F465, and F467 for specific details of the noncompliance). The QA program failed to ensure monitoring for medication use and side effects putting residents in the facility at risk of unnecessary medication use (cross refer F329). An interview with the Administrator on [DATE] at 11:40 a.m. revealed she heads up the Quality Committee which includes the Director of Nurses, Assistant Director of Nurses, all department heads, activities staff, unit managers, and the Medical Director. The committee tries to meet monthly but at least quarterly. Items brought to the committee include audits, issues on consultant reports, observations, complaints, grievances, missing items, and corporate hotline calls. Families and residents receive information about how to file a complaint in the admission packet and the complaint phone numbers are posted in the facility hallways. The facility has worked to improve several areas recently to include pest issues and re-hospitalization rates. The concerns regarding the advanced directives did not come to the committee. The committee had addressed some environment issues but not the areas found on this survey. There had been some concerns brought to the committee regarding behavior and side effect tracking but the concern was ongoing. Review of the Quality Improvement Committee Policy dated ,[DATE] revealed Review results of previous audits and identify action items for any areas needing improvement. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE] at 1:34 p.m. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident admission/readmission procedures to ensure advance directives were correct. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident advance directives, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. The Supporting documentation reviewed on [DATE] at 1:04 p.m. to ensure the immediacy of the immediate jeopardy is removed included the following: Review of in-service materials and records. A review of the facility education and training revealed the facility had 75 licensed nurses on staff and 63 have received education to date which is 84% of licensed staff. All Admissions, Minimum Data Assessment staff, and Social Services education is complete 100%. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility Policies and Procedures Governing Advance Directives. Staff interviews were conducted to verify understanding of the Advance Directive policy and procedure and the process and actions required on admission to ensure the medical record of every resident contains current and accurate Advance Directive information to include the section of the record marked Advance Directive, placement of a sticker on a record DNR is correct and all information to include the physicians order are consistent with no conflicting information. Interview of LPN HH who works on the 11:00 p.m.-7:00 a.m. shift on [DATE] at 7:40 a.m. Interview of LPN KK ,[DATE] shift on [DATE] at 7:43 a.m. Interview of LPN JJ on [DATE] 9:00 a.m. Interview of RN JJ on [DATE] 9:15 a.m. All licensed staff interviewed demonstrated knowledge as noted in the facility policy and procedure. Resident records were reviewed to ensure that resident care and treatment, including physicians' orders and Advance Directives were current and accurate. A complete audit of 225 resident records out of 226 residents on the census list was completed. One resident was in the hospital and an audit will be completed on his record upon return. A complete audit was conducted by the survey team to verify all resident records were audited. The residents identified in the Immediate Jeopardy and the facility's corrective action included R#217 expired on [DATE]. R#195 on [DATE] at 10:48 a.m. medical record reviewed and evidenced the Advanced Directive in the chart is corseted on the physician's orders [REDACTED]. The Administrator notified each hospice provider Administer for hospice service providers on [DATE] the Lake City facility policy Advance Directive must be reviewed by staff providing services for any resident in the facility.