Every finding on record at Lanier Rehabilitation Center

Based on kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility kitchen staff failed to follow proper dish sanitation procedures, wash their hands between glove changes, and to allow for air drying after washing dishes to prevent the outbreak of foodborne illness. Hand hygiene, dish sanitation, and air drying is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe sanitation practices represent a potential source of pathogen exposure. The findings include: During the initial kitchen tour on 2/17/2025 at 9:25 AM, the hand sink did not have soap in the soap dispenser. On 2/17/2025 at 9:27 AM, an observation of the dish room and dish washing processes revealed Dietary Aide (DA) J loading the dish machine and running it. The dish machine temperature gauge was observed during the wash cycle and the rinse cycle. The temperature for each cycle did not rise above 69 degrees Fahrenheit ('F). The Certified Dietary Manager (CDM) stated it was a low temperature machine, and it used chlorine bleach to sanitize the dishes. Two staff members were working in the dish room. DA J was loading the dish machine. DA K was scraping and rinsing the dishes in a tub full of soapy water. The CDM explained that the staff filled the tub with hot water from the coffee machine and then put soap in it. Then they ran the dishes through the dish machine. DA J was asked to test the machine's sanitizer level. She did not understand at first due to her first language being Spanish. DA K stated she would test it. She took the test strips and tested the machine. She handed the test strip to the CDM. The test strip was observed to be a very dark purple color, indicating 200+ parts per million (ppm) of chlorine in the water. The CDM was asked how many parts per million of bleach were supposed to be in the water. She stated 50 to 100 ppm. She was asked if the test strip indicated a toxic level of sanitizer in the water. She stated yes, it indicated 200+ ppm, the chlorine level in the dish machine was at a toxic level. (Photographic evidence obtained) During an interview with the CDM on 2/17/2025 at 9:35 AM, she stated the facility's water heater for the kitchen has been out of order for a while now. She then stated she was not sure, but she thought it had been several weeks to a couple of months since the water heater had worked. She said the new water heater was at the facility sitting in a box in the hallway outside the kitchen. The problem is that the company that is contracted to put it in has not been able to come to the facility to do it. The new hot water heater was observed. She stated they had purchased two different water heaters but had to send them back because they were not the right one. She further stated they had been using the dish machine to clean the dishes every day since the water heater broke. She thought that since the sanitizer level was good it wouldn't matter how hot the water was. They were trying to make sure the wash water was hot by using the water from the coffee maker. During an interview with the Maintenance Director on 2/17/2025 at 10:33 AM, he stated the hot water heater had been out for a few weeks. The old heater rusted through. The supply company sent them the wrong water heater three times and he had to send them back each time, which took time. Finally, they decided to go through a different vendor and now they have the right water heater. We have the new water heater here. The contracted maintenance provider has to install it because it has a gas feed. I'm just waiting on them to come out and do it. The technician that is qualified to do it is on another huge job somewhere else. He stated it was a job that could be done in one day. A review of the manufacturer's specifications for the facility's dish machine ES-4000 read: Low temperature machine. Operating temperatures - Wash cycle 120 'F, Sanitizing Rinse cycle 120 'F. Incoming temperature (minimum) 120 'F. Incoming temperature (recommended) 140 'F. (Copy obtained) A review of work order form #102580 for the initial service call, dated 11/22/2024 between the facility and the contracted provider for the water heater replacement read: Description: Water heater for kitchen/laundry not igniting. Work performed: Found the heat exchanger cracked and unable to repair leak. Shutting water supply off will kill the equipment in the kitchen, recommend monitoring leak and leaving water on. Heater will need to be replaced. (Copy obtained) A review of the shipping receipt for the water heater, dated 1/27/2025, revealed that the water heater was delivered to the facility on this date. (Copy obtained) A review of a letter sent to the facility on company letterhead from the contracted maintenance provider for the installation of the new water heater revealed it read: To whom it may concern: [Contracted Maintenance Provider] is scheduled to install a new water heater at [Facility] on 02/18/2025. (Copy obtained) During a follow-up tour of the kitchen on 2/19/2025 at 11:35 AM, the lunch meal service was observed. DA I was observed plating food on the tray line. She had donned a pair of disposable gloves. At 11:55 AM, she changed gloves without washing her hands in between. She again changed gloves without washing her hands in between at 12:33 PM. On 2/19/2025 at 12:13 PM, DA L doffed her disposable gloves, threw away three #10 cans in the garbage near the rear door of the kitchen and donned new gloves without washing her hands first. On 2/19/2025 at 12:20 PM, DA J was observed preparing a cake. She had disposable gloves on. She poured the batter into a large sheet pan and then took the pan to the oven and put it in. She took off the disposable gloves she had donned and put them in a cardboard box near the rear door of the kitchen. She then donned new gloves without washing her hands in between at 12:34 PM. She went to the refrigerator, took out a carton of milk, opened it with her gloved hands, and poured the milk in the mixing bowl, then proceeded to mix up the dry frosting mix. She took a wiping cloth and wiped down the prep tables. She doffed the contaminated gloves in the cardboard boxes near the rear door of the kitchen. Without washing her hands, she went to take the cake out of the oven. She donned oven mitts, took the cake to the prep table and donned new gloves without washing her hands. She proceeded to drizzle the frosting over the cake. She then went to the knife storage rack on the wall and took a long serrated cutting knife out of the rack. As she walked back across the kitchen, she dropped the knife on the floor. She picked it up and took it to the ware washing sink, dunked it into the soapy water, rinsed it off in the rinse sink and wiped it with the wiping cloth she had used to wipe down the prep tables. She took the knife over to where the cake was sitting on the prep table and laid it down. She was preparing to cut the cake into servings when she was asked if she thought the wiping cloth had re-contaminated the knife and if she was supposed to allow the knife to air dry after washing it and prior to using it. She did not appear to understand the questions. The CDM explained to her that she could not use the knife and needed to use a clean knife. A review of the dietary staff training for hand washing and glove use, dated 10/22/2024, revealed that DA J attended the training. Staff training was held on 11/1/2024 on hand washing and glove use. Dietary Aides (DAs) J, K, and L attended the training. Staff training was held on 9/7/2024 related to checking the sanitation level ppm in the dish machine. DA K attended the training. The flyer used during the trainings on hand hygiene read: Single use gloves must never be used in place of handwashing, should be used when handling ready-to-eat food. (Copy obtained) A review of the facility's Dishwashing Procedure training flyer revealed it read: Objective: Participants will understand the correct dishwashing procedures and how to record the dish machine temperature and ppm. Air dry dishes and keep in clean area to avoid contamination. Record the dish machine temperatures. Low temperature machine Wash 120 'F - 150 'F, Rinse 120 'F - 150 'F. Any inaccurate temperatures must be brought to the attention of the Dietary Manager immediately. Convert to paper service until temperature is correct. The concentration of the sanitary solution during the rinse cycle is 50 - 100 ppm with chlorine sanitizer on low temperature dish machines. (Copy obtained) A review of the Testing Sanitizer and Temperature in Low Temperature Dish Machines policy and procedure (revised 08/2023) revealed it read: Purpose: Test sanitizing solution and temperature before cleaning each meal's dishes. A proper level is 50 ppm chlorine in rinse water. An appropriate temperature is 120 'F - 160 'F. 7a. Do not exceed 100 ppm on chlorine sanitizing solutions. (Copy obtained) A review of the manufacturer's specifications for the facility's dish machine ES-4000 Dish machine read: Low temperature machine. Operating temperatures Wash cycle 120 'F, Sanitizing Rinse cycle 120 'F. Incoming temperature (minimum) 120 'F. Incoming temperature (recommended) 140 'F. (Copy obtained) A review of the facility's policy and procedure titled Food and Nutrition - Operational (revised 08/2023) revealed it read: Purpose: Food service employees comply with strict time and temperature requirements and use proper food handling techniques to prevent the occurrence of foodborne illness. Procedures: 1. Clean and sanitize all utensils and food contact surfaces according to center policy or guidelines and per chemical manufacturer's directions. 2. Practice good personal hygiene. Wash and sanitize hands regularly. 4. Use gloves or clean utensils when handling raw or cooked foods which will not be heated prior to serving. b. Change gloves as frequently as handwashing would indicate. Change gloves before and after non-food contact and between contact with raw and cooked food. 11. After dishes are sanitized, do not touch any food contact surfaces. This includes knife blades. (Copy obtained)

Based on observations, resident and staff interviews, a review of resident records, and the Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to implement it's performance improvement plan's (PIP) corrective actions to reduce the risk of falling for one (Resident #64) of four residents reviewed for falls, from a total survey sample of 27 residents. The findings include: An observation of Resident #64 on 2/17/25 at 10:03 AM found her lying on the far left side of her bariatric bed (a hospital bed designed for obese individuals) on the edge of the mattress. There was no bed rail or enabler in place. The room was decorated with multiple personal items on the left side of the bed on the floor and bedside table. A reacher/grabber tool was observed on a chair against the far wall at the foot of the bed, out of her reach. There were no fall mats and no signs posted in the room. (Photographic evidence obtained) Resident #64 explained that she had four falls but was unaware of any interventions to prevent future falls. Additional observations of Resident #64 conducted on 2/18/25 at 10:48 AM and on 2/19/25 at 10:03 AM, found her still in bed. There were no fall mats, no signage in place, and the reacher was still out of her reach. When asked during the latter observation (2/19/25) how she retrieved her personal items, she stated she could not reach her reacher and asked that it be handed to her. Observation on 2/20/25 at 9:30 AM, found the room still void of fall mats or signage. (Photographic evidence obtained) A review of Resident #64's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses include traumatic brain injury, lack of expected childhood development, mood disorder, abnormalities of gait and mobility, muscle weakness, osteoarthritis, major depressive disorder, anxiety disorder, and obesity. Resident #64 was care planned on 2/17/25 for risk for falls/ fall related injury related to muscle weakness and limited mobility. The goal was to reduce the risk by the next review date. Interventions included, but were not limited to, a fall program sign in her room and a low bed with mats on the door side of her bed. (Photographic evidence obtained) A review of Nursing Progress notes found that Resident #64 had two falls on 12/30/24 and another on 2/5/2025. An Interdisciplinary Team (IDT) progress note dated 2/5/2025 revealed that the IDT recommended a fall mat on the left side of her bed. A Focus IDT Note dated 2/13/2025 revealed that the team met again to discuss the fall, and that preventative fall measures included a fall mat on the door side of bed . (Photographic evidence obtained) On 2/20/25 at 9:43 AM, during an interview with Certified Nursing Assistant (CNA) D who was assigned to Resident #64, she confirmed that the resident had no fall mats or a posted sign in her room per the care plan. Licensed Practical Nurse (LPN) C also confirmed the absence of the interventions during an interview on 2/20/25 at 10:02 AM. A review of the facility's Performance Improvement Plan (PIP) titled Fall Management (dated 12/19/24), revealed it was spearheaded by the Regional Director of Clinical Services (DCS). It identified that the system correction needed was: 1. Education on fall management program. 2. Education on Code Purple. 3. Ensuring all incident reports were completed correctly, and; 4. Ensuring all interventions were in place. (Photographic evidence obtained) A Fall Assessment QAP (FAQ) form, dated 12/19/24, revealed that Resident #64 fell at 8:40 AM. A huddle at the nurses' station was conducted at 8:40 AM and included five participants including the Registered Nurse (RN)/Unit Manager, LPNs and CNAs. The form indicated that the resident fell in her room trying to get in her bed and indicated that all interventions were in place from the care plan. Frequent checks were initiated to prevent future falls. The form was signed by the Unit Manager. (Photographic evidence obtained) A FAQ form reported that Resident #64 fell on [DATE] at 8:20 AM. A huddle at the nurses' station was conducted at 8:40 AM and included four participants including the Registered Nurse (RN)/Unit Manager, LPNs and CNAs. The form indicated Resident #64 had attempted to walk unassisted. It also asked if all interventions were in place from the care plan, which was answered, yes. The action to be completed by the QAPI team was Fall Program Sign. The form was signed by the Unit Manager. (Photographic evidence obtained) No similar form was available yet for the February 2025 fall. An interview was conducted with the Regional Director of Clinical Services (DCS) on 2/20/25 at 2:47 PM. She explained that she recently sat in on a facility clinical meeting following a fall. She recognized staff were not following the post-fall process properly. In response, she created the fall management PIP and educated the management team, who then educated staff. The Director of Nursing (DON) had the responsibility of monitoring to ensure fall prevention interventions were in place. At least that is what should have been implemented. The DCS was asked for any audits that had been completed since the development of the PIP. The audit tool did not have a section to indicate fall interventions were in place in resident rooms. When asked if the DON was actually going to resident rooms to verify that care plan interventions were in place, the DCS said she was not sure. The DCS was shown the FAQ recommendation that Resident #64 have a fall program sign posted. She was also advised that the fall mats were not in place during the four-day survey, per the resident's care plan. The DCS acknowledged that despite the PIP's corrective action, there was no evidence a system had been implemented to ensure Resident #64's, or other residents with falls, care plan interventions were being verified. She could provide no explanation for this. An interview was conducted with the DON on 2/20/25 at 2:57 PM. He explained that falls were reviewed each morning during a meeting. Depending on the recommended interventions, the UM was responsible to go to that specific room after the meeting to ensure all interventions were in place. Fall interventions were also discussed at weekly fall focus meetings. The observations in Resident #64's room were shared with him. He shook his head and said, That shouldn't have happened. He acknowledged the actions to correct the identified problem in the fall management PIP were not being implemented as written. A review of the facility's policy titled Florida Risk Management and QA&A (Quality Assurance and Assessment) Committee/QAPI Program (revised 8/2923) found it stated the purpose of the committee was to assess resident care practices, review and analyze quality indicators and incident reports as well as opportunities for improvement. Develop plans of action to correct and respond quickly to identify quality deficiencies. (Photographic evidence obtained)

Based on kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to ensure that all mechanical equipment in the kitchen was maintained in safe operating condition. The water heater for the kitchen was not operating, thereby the dish machine temperatures failed to reach the appropriate levels. Failure to ensure the dish machine wash and rinse temperatures reached the proper temperature required by the manufacturer's specifications may result in the risk of serious complications from foodborne illness. The findings include: During the initial kitchen tour on 02/17/2025 at 9:27 AM, observation of the dish room and dish washing processes revealed that Dietary Aide (DA) J was loading the dish machine and running it. The dish machine temperature gauge was observed during the wash cycle and the rinse cycle. The temperature for each cycle did not rise above 69 degrees Fahrenheit ('F). The Certified Dietary Manager (CDM) stated it was a low temperature machine and it used chlorine bleach to sanitize the dishes. Two staff members were working in the dish room. DA J was loading the dish machine. DA K was scraping and rinsing the dishes in a tub full of soapy water. The CDM explained that the staff filled the tub with hot water from the coffee machine and then put soap in it. Then they ran the dishes through the dish machine. During an interview with the CDM on 2/17/2025 at 9:35 AM, she stated the facility water heater for the kitchen had been out of order for a while now. She then stated she was not sure but she thought it has been several weeks to a couple of months since the water heater had worked. She said the new water heater was at the facility sitting in a box in the hallway outside the kitchen. The problem is that the company that is contracted to put it in has not been able to come to the facility to do it. The new hot water heater was observed. She stated they had purchased two different water heaters but had to send them back because they were not the right one. She further stated they had been using the dish machine to clean the dishes every day since the water heater broke. She thought that since the sanitizer level was good it wouldn't matter how hot the water was. They were trying to make sure the wash water was hot by using the water from the coffee maker. During an interview with the Maintenance Director on 2/17/2025 at 10:33 AM, he stated the hot water heater had been out for a few weeks. The old heater rusted through. The supply company sent them the wrong water heater three times and he had to send them back each time, which took time. Finally, they decided to go through a different vendor and now they have the right water heater. We have the new water heater here. The contracted maintenance provider has to install it because it has a gas feed. I'm just waiting on them to come out and do it. The technician that is qualified to do it is on another huge job somewhere else. He stated it was a job that could be done in one day. A review of the manufacturer's specifications for the facility's dish machine ES-4000 read: Low temperature machine. Operating temperatures - Wash cycle 120 'F, Sanitizing Rinse cycle 120 'F. Incoming temperature (minimum) 120 'F. Incoming temperature (recommended) 140 'F. (Copy obtained) A review of work order form #102580 for the initial service call, dated 11/22/2024 between the facility and the contracted provider for the water heater replacement read: Description: Water heater for kitchen/laundry not igniting. Work performed: Found the heat exchanger cracked and unable to repair leak. Shutting water supply off will kill the equipment in the kitchen, recommend monitoring leak and leaving water on. Heater will need to be replaced. (Copy obtained) A review of the shipping receipt for the water heater, dated 1/27/2025, revealed that the water heater was delivered to the facility on this date. (Copy obtained) A review of a letter sent to the facility on company letterhead from the contracted maintenance provider for the installation of the new water heater revealed it read: To whom it may concern: [Contracted Maintenance Provider] is scheduled to install a new water heater at [Facility] on 02/18/2025. (Copy obtained)

Based on resident interviews, Resident Council (RC) minutes review, staff interviews, and facility policy and procedure review, the facility failed to 1) Ensure that the Dietary Manager attended the February 2025 meeting at the group's invitation to discuss food concerns, 2) Ensure issues of resident care and life in the facility were addressed by failing to review resident rights and inform residents of updates to the facility's policies and procedures, even though Resident Council forms were marked as though they had. The findings include: During an interview on 02/17/25 at 11:55 AM with the Resident Council President, Resident #23, and Resident #56, who both attend the meetings on a regular basis, Resident #23 stated he did not get to read the Resident Council minutes. He did not sign off on them to verify whether or not they were correct. He did not receive copies of the minutes. He stated usually the staff from the Activities Department attended the meetings and took the minutes. The Activities Director (AD) wrote notes on a sticky note or whatever she can find. He used to be asked to read the minutes and sign off on them to verify that they were correct, but he had not been permitted to do so in at least the last six months. He could not remember exactly how long it had been. The previous month's minutes were not read at the meetings to ensure that they had been recorded accurately. He said he thought they should be read as part of the appropriate process for the council meetings. He was aware that the council could meet without facility staff present but stated they had never tried to do so. He thought that some of the residents who attended the meetings were afraid to voice concerns due to fear of retribution. He stated the Social Services Director (SSD) was vindictive and attended the meetings. He did not want to give specific examples of why he thought this was true. He was hesitant to speak about it. Resident #56 stated the SSD just stands there and glares at us. She stated it made her feel uncomfortable and intimidated. Resident #23 gave this writer verbal permission to read the monthly meeting minutes. He again stated he did not know what was in them. He was not sure that all of the concerns expressed by the residents during the meetings were being documented, but he agreed to review the minutes with this writer to ensure that the minutes were accurate. He stated the staff did not go over the old business to ensure prior concerns had been addressed. They only talked about new business. He was told that he had to invite the appropriate department head to the meeting if the residents had a concern with a certain department. Resident #56 stated she attended the meetings. She confirmed everything the President, Resident #23, stated. Neither resident was sure about how to contact the Ombudsman for assistance, and they confirmed that this information had not been discussed or provided by facility staff during their council meetings. They both confirmed that the facility staff did not review any of the residents' rights during their council meetings. A review of the quarterly Minimum Data Set (MDS) assessment, dated 01/13/2025 for Resident #23, revealed he was assessed as having a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. A review of the quarterly Minimum Data Set (MDS) assessment, dated 12/10/2024 for Resident #56, revealed she was assessed as having a BIMS score of 13 out of a possible 15 points, indicating no cognitive impairment. A BIMS score of 13-15 points indicates intact cognition. Copies of a summary of the meeting minutes were provided on 02/18/2025 for the months of 12/2024, 01/2025 and 02/2025. For each month, a type-written summary of the meeting was typed up on a piece of plain copy paper. They were not on a standard facility form. (Copies obtained) At the bottom of each month's summary were the signatures of the Activities Director (AD), Resident #23 and the Administrator. A review of the summary for the month of December 2024 revealed it covered smoking rules, residents who were a fall risk waiting for assistance in the cafeteria, the monthly party, outings to Walmart, not giving money to staff-go only to the business office for financial transactions, keeping hallways clear for housekeeping, laundry and floor techs. (Copy obtained) A review of the summary for the month of January 2025 revealed it covered the smoke porch, customer service by nursing staff, vending machine purchases-do not ask staff. Dietary will be invited to a meeting to discuss dietary concerns. (Copy obtained) A review of the summary for the month of February 2025 revealed it covered the monthly outing to a buffet restaurant, not giving money/personal items to staff, a new computer for residents' use in the dayroom, and a reminder to respect each other and staff. (Copy obtained). On 02/18/2025 copies of the Resident Council minutes for the months of 09/2024, 10/2024 and 11/2024 were requested, and on 02/19/2025 the standard facility forms for the Resident Council minutes were provided for the months of 09/2024 through 02/2025. (Copies obtained) A review of the Resident Council Minutes facility form for the month of September 2024 read: Start time 10 AM. Resident #23, President, present. Three other unsampled residents were noted to have been in attendance. The AD and the SSD were present. The minutes from the previous meeting were not read and approved or read and corrected. Old business was resident choice of activities and monthly parties. No new business was recorded. In the section for review of residents' rights, the word yes was documented. Which rights were discussed was not documented. In the section for review of the facility's policies and procedures that had been developed/revised/updated in the past 30 days, the word yes was documented. Which policies and procedures were discussed was not documented. The signature of Resident #23 was not on the form. (Copy obtained) A review of the Resident Council Minutes facility form for the month of October 2024 read: Start time 1 PM. Residents #23, #56 and #57 were present. Five other unsampled residents were documented as having been in attendance. The AD and the SSD were present. The minutes from the previous meeting were not read and approved or read and corrected. Old business was left blank. No new business was recorded. In the section for review of residents' rights, the word yes was documented. Which rights were discussed was not documented. In the section for review of the facility's policies and procedures that had been developed/revised/updated in the past 30 days, the word yes was documented. Which policies and procedures were discussed was not documented. The signature of Resident #23 was not on the form. (Copy obtained) A review of the Resident Council Minutes facility form for the month of November 2024 read: Start time 1:35 PM. Residents #23 and six unsampled residents were documented as present. Five other unsampled residents were in attendance. The SSD was present. The minutes from the previous meeting were read and approved and read and corrected. Old business was left blank. New business was recorded as food/snacks/drinks, cigarettes and once a month outings. All preference for food, drink or other items such as cigarettes you would like to purchase, you must go to the business office or social services. All financial transactions will only be done in the business office. No staff are allowed to get residents money/credit card to buy items. In the section for review of residents' rights, the word yes was documented. Which rights were discussed was not documented. In the section for review of the facility's policies and procedures that had been developed/revised/updated in the past 30 days, the word yes was documented. Which policies and procedures were discussed was not documented. The signature of Resident #23 was on the form. (Copy obtained) A review of the Resident Council Minutes facility form for the month of December 2024 read: Start time 10 AM. Residents #23 and twelve other unsampled residents were documented as having been in attendance. The AD and the SSD were present. The minutes from the previous meeting were read and approved or read and corrected. Old business read: No old business. New business was recorded as smoke porch, Walmart, birthday parties, happy hours. In the section for review of residents' rights, the word yes was documented. Which rights were discussed was not documented. In the section for review of the facility's policies and procedures that had been developed/revised/updated in the past 30 days, the word yes was documented. Which policies and procedures were discussed was not documented. The signature of Resident #23 was on the form. (Copy obtained) A review of the Resident Council Minutes facility form for the month of January 2025 read: Start time 1 PM. Residents #23, #57 and thirteen other unsampled residents were documented as having been in attendance. The AD, the SSD, the Director of Nursing, and the Administrator were noted as present. The minutes from the previous meeting were read and approved or read and corrected. The Old Business section was left blank. New business was recorded as concerns about the smoke porch, and residents talking inappropriately to other residents/staff. In the section for review of residents' rights, the word yes was documented. Which rights were discussed was not documented. In the section for review of the facility's policies and procedures that had been developed/revised/updated in the past 30 days, the word yes was documented. Which policies and procedures were discussed was not documented. The signature of Resident #23 was on the form. (Copy obtained) A review of the Resident Council Minutes facility form for the month of February 2025 read: Start time 10 AM. Residents #23, #57, #17 and eight other unsampled residents were documented as having been in attendance. The AD and the SSD were present. The minutes from the previous meeting were read and approved or read and corrected. The Old Business section was left blank. New business was recorded as Walmart, buffet, outings, smoke porch, do not give staff money/gifts, and where to find assignment boards. In the section for review of residents' rights, the word yes was documented. Which rights were discussed was not documented. In the section for review of the facility's policies and procedures that had been developed/revised/updated in the past 30 days, the word yes was documented. Which policies and procedures were discussed was not documented. The signature of Resident #23 was on the form. (Copy obtained) During an interview on 02/19/25 at 11:43 AM with Resident #23, he stated on 02/18/2025, first the AD came and asked him to sign the summaries of the RC meeting minutes. He saw that the Administrator had already signed the forms. He skimmed over the minutes provided and then signed them. About an hour and a half later, the SSD came and asked him to sign another set of the minutes. He told her that he had already signed them. He stated he had never seen the forms before being asked to sign them. During an interview on 02/20/25 at 2:24 PM with Resident #23, he reviewed all the documents provided to this writer regarding the meetings. He took out a magnifying glass and examined the documents and then stated, No, this is not my signature. I thought this might happen. He stated he thought the documents were just made and did not exist prior to this survey. He took bank receipts out of his nightstand and stated, This is my signature. He confirmed that he had attended all of the meetings even though his name was not on some of the forms. He stated his signature was missing on the forms for September and October 2024 because he had never seen the forms before. He stated he thought someone else was signing his name on the forms. During an interview with the Certified Dietary Manager on 02/20/25 at 2:37 PM, she stated she had not been notified that she needed to attend the RC meeting on 02/12/25. She did not know that the residents had concerns about the menu/food. She had attended the meetings in the past, but it had been several months since she did attend. She stated no Resident Council Concern Form was sent to her indicating a concern. During an interview on 02/20/25 at 3:14 PM with Resident #57, she stated she did not remember staff telling them about their rights, and the Dietary Manager did not speak with the group. During an interview on 02/20/25 at 3:21 PM with Resident #17, he stated he went to the February Resident Council meeting. He confirmed that the staff members present did not go over resident rights with the group. They did not read the minutes from the previous meeting. They did not go over the old business. They only talked about new business. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 revealed she was assessed as having a BIMS score of 08 out of a possible 15 points, indicating moderate cognitive impairment. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed he was assessed as having a BIMS score of 15 out of a possible 15 points, indicating no cognitive impairment. During an interview on 02/20/25 at 3:50 PM with the Administrator, she confirmed that the summaries of the meetings that had been provided were typed up by the SSD. The minutes for the RC meetings should be on the standard form and all sections should be filled in with the concerns brought to the council by the residents. There should be a time to address old business to make sure the residents' concerns were being met, and the solution to the concerns should be documented or the rationale for not meeting the wishes of the residents should be documented. The staff should go over the resident rights with them and document what rights were covered in the meeting. If there was a concern with one area of care, that department should address the council during the next meeting. She stated, We can do better. During an interview on 02/20/25 at 4:05 PM with the Regional Nurse Consultant, she confirmed that the standard forms were to be used to document the Resident Council Meeting minutes and when a concern was raised, that concern should be put on a grievance form and logged on the grievance log so it could be followed up on. The log should indicate that the concern was voiced during the Resident Council meeting. A review of the policy and procedure titled Resident Council (effective 01/2023 and updated 09/2023) read: Purpose: The Resident Council provides a formal, organized means of resident input into center operations. General Guidelines Information: The center will allow residents to organize into a council group without interference. The center will provide the group with space, privacy for meetings, and staff support. Guidance Steps in the Process: 1. The center provides space and supports the efforts of residents to form a council. 2. a. This representative participates in council meetings only as requested by council members. C. Council minutes will document requests for the center representative's (and other team members') participation. 4. The Council meets for the purpose of: Assisting in the development of policies and procedures, evaluating the center operations, studying problem areas and recommending solutions, making recommendations for improving the center's services, assisting in the development of resident grievances and complaint procedures; assisting in defining resident rights and responsibilities. 5. The Council maintains minutes of all meetings. 6. Grievance process will be followed and reported as required by regulation. 7. The Administrator reviews the minutes, takes appropriate actions, and follows up with the council regarding identified areas of concern and interest. Documentation: Resident Council Minutes (Copy obtained) A review of the facility's policy and procedure titled Grievances - Resident Rights (revised 08/2023) read: Procedure: 4. Upon receipt of a grievance report, the Grievance Official or designee will refer it to the appropriate department head for investigation. 8. The resident, or anyone acting on their behalf filing the grievance, will be communicated with regarding the conclusion of the investigation and the corrective actions that will be taken. 10. The Resident Council are additional forums for voicing grievances. Grievances received from these Councils will be acted upon in accordance with this procedure. (Copy obtained)

Based on a review of resident records, observations, resident and staff interviews, and a review of facility policies and procedures, the facility failed to implement the person-centered care plan to meet residents' assessed needs for fall prevention for one (Resident #64) of four residents reviewed for falls, from a total survey sample of 27 residents. The findings include: A review for Resident #64's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included personal history of traumatic brain injury, lack of expected normal physiological development in childhood, mood disorder due to known physiological condition, abnormalities of gait and mobility, generalized muscle weakness, osteoarthritis of knee, major depressive disorder, anxiety disorder and obesity. A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #64 had a brief interview for mental status (BIMS) score of 15/15 points, indicating that she was cognitively intact and independent with daily decision making. She used a walker to ambulate and was receiving antianxiety, antidepressant, diuretic and anticonvulsant (used to treat seizure disorders or mood disorder) medications. Resident #64 was care planned on 2/17/2025 for risk for falls/ fall related injury related to muscle weakness and limited mobility. The goal was to reduce the risk by the next review date. Interventions included: Call light within reach; Educate to ask for assistance prior to showers; Encourage rest periods throughout the day; Fall Program Sign; Low bed with matts to door side of bed; Maintain safe environment; Non-skid footwear (socks and/or shoes). (Photographic evidence obtained) A review of the nursing progress note dated 12/30/2024 revealed that Resident #64 was found on the floor on her knees next to her bed. Notes indicated she had been assisted to the floor in the shower room this same day. A progress note dated 2/5/2025 noted Resident #64 was observed lying on the floor on the left side of her bed. She stated she wanted to walk and promised she would not do it again. An Interdisciplinary Team (IDT) Progress Note dated 2/5/2025 read, IDT met to review fall from 2/5/25. Resident observed on floor by left side of bed. IDT recommends fall mat to left side of bed. Care plan updated. Will continue POC (plan of care). A Focus IDT Note dated 2/13/2025 read, Resident at risk meeting in progress with IDT to discuss resident's fall on 2/5/2025. Resident was observed by the staff on the floor beside her bed. Assessment revealed no injury or c/o (complaints of) pain. Resident presented with a fall score of 14 (high risk for falls). Preventative fall measures include fall mat to door side of bed . (Photographic evidence obtained) A review of Resident #64's February 2025 medication administration record (MAR) found she received Wellbutrin XL 150 milligrams (mg) daily for depression (can cause dizziness), buspirone hydrochloride (HCL) 15 mg three times a day for anxiety (can cause dizziness), trazodone (HCL) at bedtime for depression (may cause drowsiness, dizziness), lasix (a diuretic that may increase the need to urinate) 20 mg daily for fluid overload, Eszopiclone 2 mg (a controlled drug that may cause drowsiness) daily at bedtime for insomnia, and depakote (a seizure medication that can be used for mood and may cause fatigue/drowsiness) 250 mg three times a day for mood disorder. (Photographic evidence obtained) An interview was conducted with Resident #64 on 2/17/2025 at 10:03 AM. She stated she has had four falls. When asked what interventions were in place to prevent falls, she said none. Resident #64 explained that she was unable to reposition herself and stand. She slipped in the shower once from a standing position. Before her last fall she said she could walk. She explained that she tried to get out of bed once and fell , and was unsure of whether she could bear weight on her legs or walk. During the interview the resident was lying on the left side of her bed near the edge of the mattress. There was no bed rail or enabler in place. The resident was on a bariatric mattress and bed (a hospital bed designed for obese individuals). A reacher/grabber tool was observed on a chair against the far wall at the foot of Resident #64's bed. It was out of her reach. The room was decorated with multiple personal items on the left side of the bed on the floor and bedside table. (Photographic evidence obtained) An observation of Resident #64 on 2/18/2025 at 10:48 AM found her still in bed. There were no fall mats, no sign posted in the room and the reacher was across room on the chair against the far wall. (Photographic evidence obtained) Resident #64 was observed on 2/19/2025 at 10:03 AM in bed with no fall mats on the floor, no posted signage and the reacher still across the room on the chair. Her belongings were still stacked to her left on the table and floor. When asked how she retrieved her personal items, she stated she was unable to reach her reacher. It was handed to her per her request. Additional observations on 02/19/2025 at 2:29 PM, and on 2/20/25 at 9:30 AM, found Resident #64's room remained void of fall mats or signage. (Photographic evidence obtained) An interview was conducted with Certified Nursing Assistant (CNA) G on 2/19/2025 at 1:55 PM. She stated she knew the interventions in the plans of care for all residents because they were in the Kardex (a quick reference form that lists care plan interventions) in the electronic medical record keeping system. An interview was conducted with Unit Manager F on 2/19/2025 at 2:37 PM. When asked about the fall program signs referenced in the resident's care plan, Unit Manager F presented a sign explaining that it was supposed to be posted in resident rooms. The sign was 8x10 inches in size on bright orange paper and laminated. It read, Call, Don't fall. An interview conducted with CNA D on 2/20/2025 at 9:43 AM. She stated when she arrived in the mornings, she conducted rounding with the offgoing CNA. Changes in residents' care plans were communicated to the CNAs by the nurse and showed up in the Kardex. CNA D explained that she provided care for Resident #64 who had not ambulated after the last fall. Prior to that fall, she was very active and required minimum assistance with ambulation and daily care. The CNA was asked to review the Kardex for fall interventions. She read the fall interventions, which instructed: Call light within reach, encourage rest periods, fall program sign, low bed with mats to the door side, and non-skid footwear. (Photographic evidence obtained) CNA D returned to Resident #64's room with this writer and confirmed that the resident did not have fall mats at the bedside and there was no signage alerting staff that she was a fall risk. An interview was conducted with Licensed Practical Nurse (LPN) C on 2/20/2025 at 10:02 AM. LPN C stated she conducted a walk through and bedside reporting with the offgoing nurse daily. Any changes to the care plan were communicated to the staff by the Unit Manager (UM) after the morning meeting. The Nurse then provided that information to the CNAs. Residents with frequent falls were placed in the Fall Focus program. LPN C stated she was familiar with the care required for Resident #64 and stated the last fall for this resident was on 2/5/2025; however, she was unaware of the interventions put in place after that fall and would have to contact the MDS (minimum data set)/Care Planning designee. LPN C was asked to review Resident #64's most recent care plan and verify interventions in place for falls. After reviewing the care plan, she stated the interventions for falls included: Call light within reach, encourage rest periods, fall program sign, low bed with mats to the door side, and non-skid foot wear. LPN C returned to Resident #64's room with this writer and confirmed that there were no fall mats on the door side of the bed or signage indicating the resident was in the fall program per the resident's care plan. An interview was conducted with the Director of Nursing (DON) on 2/20/2025 at 2:57 PM. He explained that falls were reviewed each morning and depending on the interventions, the UM was responsible for going to that specific room after the meeting and ensuring that all interventions were in place. The Fall Focus meetings were held weekly and interventions were discussed. They conducted rounds first, then had the focus meeting and placed an IDT note in the chart. Residents were reassessed after falls. The observations of Resident #64's room all four days of the survey were shared with him. He shook his head and said, That shouldn't have happened. A review of the facility's Fall Management Process (undated) instructed under the section titled IDT Review of Fall Management Process that falls would be reviewed at an IDT Fall Focus Meeting by members such as the DON (Director of Nursing), Assistant DON, Staff Development Coordinator, Unit Manager, Rehab Program Manager, etc . The Follow Up Meetings section instructed: Each week at the fall focus meeting, enter an updated summary note in the record; Ensure intervention(s) are in place; Update interventions as needed, and; Document effectiveness of current interventions and any new recommendations. (Photographic evidence obtained)

Based on a review of resident records, observations, resident and staff interviews, and a review of facility policies and procedures, the facility failed to 1) Ensure resident rooms were free of accident hazards per the plan of care, and ensure assistive devices were available to prevent accidents for one (Resident #64) of four residents reviewed for falls, and 2) Ensure residents' safe use and storage of personal cleaning products to prevent accidental access by other residents for one (Resident #24) of five residents reviewed for environmental safety, from a total survey sample of 27 residents. The findings include: 1. A record review for Resident #64 revealed that she was admitted to the facility on [DATE]. Her diagnoses included a personal history of traumatic brain injury, lack of expected normal childhood physiological development, mood disorder, abnormalities of gait and mobility, generalized muscle weakness, osteoarthritis of knee, major depressive disorder, anxiety disorder and obesity. A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #64 had a brief interview for mental status (BIMS) score of 15/15 points, indicating that she was cognitively intact and independent with daily decision making. She used a walker to ambulate and was on antianxiety, antidepressant, diuretic and anticonvulsant (used to treat seizure disorders or mood disorder) medications. Resident #64 was care planned on 2/17/2025 for risk for falls/ fall related injury related to muscle weakness and limited mobility. The goal was to reduce the risk by the next review date. Interventions included: Call light within reach; Educate to ask for assistance prior to showers; Encourage rest periods throughout the day; Fall Program Sign; Low bed with mats to door side of bed; Maintain safe environment; Non-skid footwear (socks and/or shoes). (Photographic evidence obtained) A review of Nursing Progress Notes revealed that Resident #4 had two falls on 12/30/2024, and another on 2/5/2025. An Interdisciplinary Team (IDT) Progress Note dated 2/5/2025 read, IDT met to review fall from 2/5/25. Resident observed on floor by left side of bed. IDT recommends fall mat to left side of bed. Care plan updated. A Focus IDT Note dated 2/13/2025 read, Resident at risk meeting in progress with IDT to discuss resident's fall on 2/5/2025. Resident was observed by the staff on the floor beside her bed. Preventative fall measures include fall mat to door side of bed . (Photographic evidence obtained) A review of Resident #64's February 2025 medication administration record (MAR) found she received wellbutrin XL 150 milligrams (mg) daily for depression (can cause dizziness), buspirone hydrochloride (HCL) 15 mg three times a day for anxiety (can cause dizziness), trazodone (HCL) at bedtime for depression (may cause drowsiness, dizziness), lasix (a diuretic that may increase the need to urinate) 20 mg daily for fluid overload, eszopiclone 2 mg (a controlled drug that may cause drowsiness) daily at bedtime for insomnia, and depakote (a seizure medication that can be used for mood and may cause fatigue/drowsiness) 250 mg three times a day for mood disorder. (Photographic evidence obtained) An interview was conducted with Resident #64 on 2/17/2025 at 10:03 AM. She stated she has had four falls. When asked what interventions were in place to prevent falls, she said none. Resident #64 explained that she was unable to reposition herself and stand. She slipped in the shower once from a standing position. Before her last fall, she said she could walk. She explained that she tried to get out of bed once and fell , and was unsure of whether she could bear weight on her legs or walk. During the interview, the resident was lying on the left side of her bed near the edge of the mattress. There was no bed rail or enabler in place. The resident was on a bariatric mattress and bed (a hospital bed designed for obese individuals). A reacher/grabber tool was observed on a chair against the far wall at the foot of Resident #64's bed. It was out of her reach. The room was decorated with multiple personal items on the left side of the bed on the floor and bedside table. (Photographic evidence obtained) An observation of Resident #64 on 2/18/2025 at 10:48 AM found her still in bed. There were no fall mats, no sign posted in the room, and the reacher was across room on the chair against the far wall. (Photographic evidence obtained) Resident #64 was observed on 2/19/2025 at 10:03 AM in bed with no fall mats on the floor, no posted signage, and the reacher was still across the room on the chair. Her belongings were still stacked to her left on the table and floor. When asked how she retrieved her personal items, she stated she was unable to reach her reacher. It was handed to her per her request. Additional observations on 2/19/2025 at 2:29 PM, and 2/20/2025 at 9:30 AM, found Resident #64's room remained void of fall mats or signage. (Photographic evidence obtained) An interview was conducted with Unit Manager F on 2/19/2025 at 2:37 PM. When asked about the Fall Program signs referenced in the resident's care plan, Unit Manager F presented a sign explaining that it was supposed to be posted in resident rooms. The sign was 8x10 inches in size, on bright orange paper, and laminated. It read, Call, Don't fall. An interview conducted with Certified Nursing Assistant (CNA) D on 2/20/2025 at 9:43 AM. She stated she conducted rounding with the offgoing CNA when she arrived in the morning. Changes in residents' care plans were communicated to the CNAs by the nurse and were in the Kardex (quick reference document for care plan interventions). CNA D stated Resident #64 had not ambulated since her last fall. Prior to that fall, she was very active and required minimal assistance with ambulation and daily care. The CNA was asked to review the Kardex for fall interventions. She did, and reported it instructed: Call light within reach, encourage rest periods, fall program sign, low bed with mats to the door side. (Photographic evidence obtained) CNA D returned to Resident #64's room with this writer and confirmed that the resident did not have fall mats at the bedside or signage alerting staff she was fall risk. An interview was conducted with Licensed Practical Nurse (LPN) C on 2/20/2025 at 10:02 AM. LPN C stated she conducted a walk through and bedside reporting with the offgoing nurse daily. Any changes to the care plan were communicated to the staff by the Unit Manager (UM) after the morning meeting. The nurse then provideed that information to the CNAs. Residents with frequent falls were placed in the Fall Focus program. LPN C stated she was familiar with the care required for Resident #64 and explained that the last fall for this resident was on 2/5/2025; however, she was unaware of the interventions put in place after that fall. LPN C was asked to review Resident #64's most recent care plan and verify interventions in place for falls. Upon reviewing the care plan, she stated the interventions for falls included: Call light within reach, encourage rest periods, fall program sign, low bed with mats to the door side, and non-skid foot wear. LPN C returned to Resident #64's room with this writer and confirmed that there were no fall mats on the door side of the bed or signage indicating the resident was in the fall program per the resident's care plan. An interview was conducted with the Director of Nursing (DON) on 2/20/2025 at 2:57 PM. He stated falls were reviewed each morning and depending on the interventions, the UM was responsible for going to that specific room after the meeting and ensuring all interventions were in place. The Fall Focus meetings were held weekly and interventions were discussed. They conducted rounds first, then had the focus meeting and placed an IDT note in the chart. Residents were reassessed after falls. The observations of Resident #64's room all four days of the survey were shared with him. He shook his head and said, That shouldn't have happened. A review of the facility's Fall Management Process (undated) instructed under the section titled IDT Review of Fall Management Process, that falls would be reviewed at an IDT Fall Focus Meeting by members such as the DON, Assistant DON, Staff Development Coordinator, Unit Manager, Rehab Program Manager, etc . The Follow Up Meetings section instructed: Each week at the Fall Focus meeting, enter an updated summary note in the record; Ensure intervention(s) are in place; Update interventions as needed, and; Document effectiveness of current interventions and any new recommendations. (Photographic evidence obtained) 2. An observation of Resident #24's room was conducted on 2/17/2025 at 10:19 AM. The room was double occupancy and Resident #24's bed was on the window side of the room. A can of aerosol disinfectant spray was observed on his bedside table, which was on the door side of his bed between his bed and his roommate's. Only a privacy curtain divided the room. On the window side of his bed, between the bed and the wall, was a plastic container of bleach wipes. Resident #24 was in his bed, but his eyes were closed and he did not respond to the surveyor's presence. On 2/18/2025 at 10:02 AM, the aerosol disinfectant spray in Resident #24's room was still present on his overbed table on the central side of the room. The bleach wipes were still in the same location. (Photographic evidence obtained) Observation of Resident #24's room on 2/19/2025 at 1:38 PM, found the can of aerosol spray was gone. The bleach wipes remained on the window side of his bed. Resident #24 was awake and stated, They took my Lysol! Why did they take my Lysol? I use that and the wipes to keep my room sanitized so I don't catch everything that comes into this building. He said the man in charge removed the can. Resident #24 was asked if other residents ever wandered into his room confused that it might be their room. He stated yes, that did happen on occasion. He was asked if he had been offered a key to his bedside table top drawer, which had a lock on it. Resident #24 stated that due to limited or no use of both of his hands, he would not be able to use a key to unlock and lock his top drawer. He demonstrated that he could depress a can of aerosol with the side of his thumb. Resident #24 stated he wanted his Lysol spray back and asked if he was going to get in trouble. A review for Resident #24's medical record found he had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact and able to make decisions independently. He not been assessed or care planned for safe storage of personal cleaning supplies. The Administrator was asked for a policy or protocol on keeping cleaning supplies at bedside on 2/19/2025 at 2:35 PM. She stated she would look. On 2/19/2025 at 2:50 PM, the Regional Clinical Director (RCD) came to the conference room to report that there was no written protocol. The facility offered lock boxes to residents who were safe to keep such items at bedside. She was advised of the observations, and that Resident #24 did not have fine motor skills in either hand, so would be unable to manipulate a key and lock. The RNC said in that case, they would offer to keep the items at the nurses' station. When asked if the resident's assigned CNA should have recognized cleaning supplies in his room she said, yes, she would have expected that to be reported. An interview with Resident #24 on 2/20/2025 at 9:44 AM revealed that no one had come to discuss the safe keeping of his cleaning supplies, nor had they returned his supplies.

Based on interview and record review, the facility failed to inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident became eligible for Medicaid of (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in S483.10(g)(17)(i)(A) and (B) of this section for three of three residents randomly selected for review of Beneficiary Notification Review. The findings include: An Entrance Conference was conducted with the Administrator and Director of Nursing on 4/3/2023 at 9:45 a.m. They were asked to provide a list of the residents who were discharged from a Medicare Part A-covered stay with benefit days remaining in the last six months. On 4/4/2023, the Administrator advised that the Business Office Manager (BOM) recently resigned, and they were not sure if all residents made the facility's original Medicare beneficiaries list. He stated he had been assisting with the process and would contact the Regional BOM for assistance with the information requested. On 4/5/2023 at 2:43 p.m., three residents were randomly selected from the list provided. The Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form CMS-20052, containing the names of the three randomly selected residents, was given to the Administrator for completion. On 4/6/2023 at 11:17 a.m., the Administrator returned the SNF Beneficiary Protection Notification Review forms for review. He explained that the Advanced Beneficiary Notice form CMS-10055, had not been given to any of the residents. He stated he reviewed the policy prior to returning the forms for review, and he acknowledged that each of the residents should have been issued the form. He again stated the previous BOM had recently left the facility, and prior to this interview, the Social Services Director had been educated on the policy and procedure for issuing the required notices, as she would be assisting in the process until a new BOM was hired.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment as well as housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for the 94 residents in its census, facility staff and visitors. The findings include: During a tour of the facility on 4/3/2023, multiple walls and flooring tiles in the halls on the units were observed to be in need of repair. Chipped paint, broken baseboards, stained floors, and broken tile were also observed. Resident rooms were in need of repair and/or cleaning, with resident room doors observed to be splitting and in need of repair as follows: At 11:34 a.m., the bathroom in room [ROOM NUMBER] was observed. The faucet was loose from the sink during water temperature testing. The the wall behind the sink had been patched with a thick substance, which had not been sanded down prior to being repainted. A large watermark stain was observed above the resident's toilet. A thick white substance was observed around the resident's toilet. The toilet was not secured to the floor. A dried dark brown liquid was observed on the floor extending out from the thick white substance and space between the toilet. The step leading to the resident's walk-in shower had been covered with a thick substance then repainted without proper sanding. The paint was peeling and separated from that step. During an interview at the time of these observations, the resident stated the bathroom had been like this for some time. He could not provide an exact timeframe. He stated the toilet leaked from the bottom. The resident stated in the past, repairs were attempted but the toilet continued to leak. He stated they came in and patched up some things in the bathroom, however, repairs were still needed. He stated he was told everything would be fixed but there was no follow through. (Photographic evidence obtained) At 12:08 p.m. in room [ROOM NUMBER], the baseboards behind and on the side of the resident's bed (Bed B) were broken and the paint was chipped. Further observation revealed spider webs containing several small, round, white objects. The floors were not clean. Dried substances, empty pill cups, food wrappers, and miscellaneous debris were observed on the floor. Chipped, discolored, and bubbling paint was observed on the wall above the air conditioning unit. The resident in Bed B was asked about the observations. The resident was alert and oriented but was nonverbal. The resident was asked if housekeeping cleaned her room. She nodded her head and mouthed yes. She was asked if she saw any bugs in her room. She nodded her head and mouthed sometimes. (Photographic evidence obtained) At 1:22 p.m. in room [ROOM NUMBER], broken and missing base boards were observed. The paint on the room walls was chipped. A broken piece of base board with an unidentifiable object (blue in color) was pushed down between the wall and baseboard. Miscellaneous debris was behind the broken baseboards. A dried substance was located next to Bed B. The resident was not interviewable and was unable to answer questions regarding the observations. (Photographic evidence obtained) At 2:01 p.m., in room [ROOM NUMBER], the resident in Bed B was receiving enteral feeding. A dried, dark beige substance was splattered on the pole holding the feeding bottle and device, the feeding device used to monitor/administer the feeding, the wall behind the pole, the floors around the pole, and on the resident's privacy curtain. The resident was non-interviewable and was unable to answer questions regarding the observation. (Photographic evidence obtained) During subsequent tours of the facility, conducted on 4/4/2023, the environmental concerns observed during the initial tour on 4/3/2023 were again observed. On 4/5/2023 at 12:01 p.m., after a tour of the facility with Maintenance Director A, the Life Safety Surveyor confirmed the observations made by the survey team on 4/3/2023 and 4/4/2023. He advised that the concerns related to the bathroom in room [ROOM NUMBER], the walls in rooms [ROOM NUMBERS], the baseboards, and the walls and broken tiles in the hallways were addressed with the Administrator and Maintenance staff. On 4/5/2023 at 3:50 p.m., staff were observed in room [ROOM NUMBER]'s bathroom with miscellaneous tools and supplies. There was no actual observation of repairs. A tour of the facility was conducted on 4/6/2023 at 1:25 p.m., Maintenance Director A. He advised that he had been in his position since October 2021. He stated he was aware of the repairs needed in the facility. He stated the cracks in the floor tiles were being filled with grout in an effort to decrease fall hazards. He stated there was new maintenance department staff. He advised that he was making the repairs as he was able. He acknowledged repairs were actively being made to the bathroom in room [ROOM NUMBER]. He advised that facility repairs would be an ongoing process. A tour of the facility was conducted on 4/6/2023 at 3:27 p.m., Interim Housekeeping Supervisor E. She advised that previously she had occupied the role for approximately nine years and recently returned until the facility could hire someone for the position. She stated there were currently four housekeepers, four laundry workers, and a floor tech. The housekeepers were scheduled from 7:00 a.m. to 3:00 p.m. seven days a week. They were responsible for emptying the trash, cleaning the residents' bathrooms, wiping surfaces with any food particles, and sanitizing and polishing furniture at least once a week and as needed in the residents' rooms. She stated the certified nursing assistants (CNAs) were responsible for changing the residents' linens. She stated the housekeepers were to inspect the privacy curtains in order to determine which ones need to come down to be cleaned. She stated either herself or the floor tech was responsible for taking the curtains down, and she typically took down four to five curtains per day. She stated the housekeepers should be inspecting the curtains. She stated sweeping and mopping was done every day seven days a week. She stated the housekeepers informed her of any repairs needed. She added, they also had a maintenance log at the nurses' station and Maintenance checked the log books throughout the day, so they could go in and fix the problem. During the tour, the housekeeping supervisor was directed to room [ROOM NUMBER]. The trash, pill cup, and stains remained under Bed B. She was advised of the initial observation of the room in this condition on 4/3/2023. She shook her head and stated this should have been cleaned by housekeeping. She was then directed to room [ROOM NUMBER] Bed B. The dried, dark beige substance previously observed was still present on the floor near the resident's bed as well as the wall, on the pole holding the enteral feeding device as well as on the device itself. She confirmed that the dried, dark beige substance was the resident's enteral feeding. She advised that the enteral feeding liquid would always leak. She stated she was working with nursing and the CNAs to make it a team effort to keep the area clean. She acknowledged the liquid was dried and stated it's easier to clean when it's wet. She was advised of the initial observation on 4/3/2023 and stated, They'll just have to work to find a way to make sure it stays clean. She confirmed that the privacy curtain was stained and should have been taken down. A review of the facility's Maintenance Report Log revealed the initial report regarding the toilet in room [ROOM NUMBER] was made on 12/4/2022 by an employee who reported, Water seeps from under toilet in room [ROOM NUMBER]. (Photographic evidence obtained)

Based on observations, interviews, and record reviews, the facility failed to accurately assess a resident's requirements for assistance to eat for one (Resident #44) of one residents reviewed for nutrition, from a total of 32 residents in the sample. The findings include: Review of the medical record for Resident #44 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was unable to complete the interview. The assessment identified the resident as requiring supervision to eat. On 08/09/21 at 12:33 PM, Resident #44 was observed sitting in her geri-chair in her room. Her tray table was positioned in front of her. Her lunch meal was on the tray table. Spaghetti was on the plate. Resident #44 was observed picking up one spaghetti noodle from her plate using her right hand and then struggling to bring the noodle to her mouth. She repeated this process each time she attempted to eat. On 08/10/21 at 12:10 PM, Resident # 44 was observed sitting in her geri-chair in her room. The chair was reclined and Resident #44 was covered with a white sheet which was littered with a brown cake substance. Her tray table was positioned in front of her. Her lunch meal was on the tray table. She was struggling to use a spoon to cut and eat her dessert. She had difficulty manipulating the spoon. A review of the resident's comprehensive care plans revealed a focus area for malnutrition. The care plan directed staff to assist the resident with meals as needed. (Photographic evidence obtained) Continued review of the medical record revealed a nutrition comprehensive evaluation, dated 6/24/2021 and completed by the Registered Dietician, that indicated the resident was underweight and that she required assistance with meals. (Photographic evidence obtained) On 08/11/21 at 12:35 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She confirmed she was assigned to Resident #44. She was asked whether the resident required assistance with eating and she replied, yes. When asked whether the resident was able to feed herself she replied, No. On 08/12/21 12:12 PM An interview was conducted with Employee G, Certified Nursing Assistant (CNA). She confirmed that she was assigned to Resident #44 and that she was familiar with the resident's care. She explained that the resident was able to feed herself sometimes but staff needed to assist her more often than not. On 8/12/21 at 3:02 PM an interview was conducted with Employee F, LPN (Unit Manager). The Director of Nursing (DON) directed the survey team to her for MDS questions. She reviewed the MDS assessment dated [DATE] and the documentation that was used to complete the assessment. From 6/24/2021 to 6/30/2021, there were 20 documented meals. Of those 20 meals documented, the resident required total assistance 8 times and extensive assistance 1 time. After reviewing the documentation, Employee F stated, Yes. It looks wrong to me but I wasn't the one who completed this assessment.

Based on observations, interviews, and record reviews, the facility failed to provide appropriate nutritional services by failing to provide assistance to eat for one (Resident #44) of two residents reviewed for nutrition, from a total of 32 residents in the sample. The findings include: A review of the medical record for Resident #44 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was unable to complete the interview. The assessment identified the resident as requiring supervision to eat. On 08/09/21 at 12:33 PM, Resident #44 was observed sitting in her geri-chair in her room. Her tray table was positioned in front of her. Her lunch meal was on the tray table. Spaghetti was on the plate. Resident #44 was observed picking up one spaghetti noodle from her plate using her right hand and then struggling to bring the noodle to her mouth. She repeated this process each time she attempted to eat the spaghetti. A readycare shake carton was on the tray. The shake carton had not been opened. On 08/10/21 at 12:10 PM, Resident # 44 was observed sitting in her geri-chair in her room. The chair was reclined and Resident #44 was covered with a white sheet which was littered with a brown cake substance. Her tray table was positioned in front of her. Her lunch meal was on the tray table. She was struggling to use a spoon to cut and eat her dessert. She had difficulty manipulating the spoon. The remainder of the lunch meal was untouched. A readycare shake carton was on the tray. The shake carton had not been opened. A review of the resident's comprehensive care plans revealed a focus area for malnutrition. The care plan directed staff to assist the resident with meals as needed and to provide supplements as ordered. (Photographic evidence obtained) Further review of the medical record for Resident #44 revealed a nutrition comprehensive evaluation, dated 6/24/2021, and completed by the Registered Dietician, that indicated the resident was underweight and that she required assistance with meals. (Photographic evidence obtained) A nutrition comprehensive evaluation dated 7/29/2021 and completed by the Registered Dietician, indicated taht Resident #44 required assistance with meals and that she was receiving house shakes during meals to assist with calorie/protein needs. The assessment also indicated the resident was receiving [MEDICATION(S)] as an appetite stimulant. (Photographic evidence obtained) A review of the resident's weights revealed a weight of 115.4 on 8/5/2021 and 111.6 on 8/11/2021. On 08/11/21 at 12:35 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She confirmed, she was assigned to Resident #44. She was asked whether the resident required assistance with eating and she replied, Yes. When asked whether the resident was able to feed herself she replied, No. On 8/11/21 at 2:44 PM, an interview was conducted with Employee B, Certified Nursing Assistant (CNA). She confirmed that she was assigned to Resident #44. She explained that the resident was completely independent with meals and that all we have to do is take the tray in and set it up. On 08/12/21 at 12:12 PM, an interview was conducted with Employee G, CNA. She confirmed that she was assigned to Resident #44 and that she was familiar with the resident's care. She explained that the resident was able to feed herself sometimes but staff needed to assist her more often than not.

Based on record review, staff interview and policy and procedure review, the facility failed to adequately monitor laboratories as ordered by a physician for one (Resident #15) of five residents reviewed for unnecessary medications, from a total of 32 residents in the sample. The findings include: A medical record review for Resident #15 revealed she was admitted on [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #15 current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) There was no documentation in the medical record for Resident #15 that the above-mentioned laboratory orders were completed. The previous CBC, CMP, A1C, TSH and VPA were completed on 3/5/21. (Copy obtained) Further review of Resident #15's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last laboratory test on 3/5/21 for Resident #15 revealed a VPA level of 9.4, which is below the reference range of 50-100 microgram/milliliter. The Medical Doctor reviewed the lab results, but there were no other orders to check until 6/4/21. An interview was conducted with the Director of Nursing (DON) on 8/12/21 at 3:03 PM. She confirmed the lab order for Resident #15 was not done on 6/7/21. The physician was notified on 8/12/21, that the laboratory was not completed as ordered. A review of facility policy, titled [CONDITION(S)] Medication Assessment and Monitoring dated 10/30/18, stated each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: without adequate monitoring. (Copy obtained)

Based on observations, resident and staff interviews and record reviews, the facility failed to ensure the resident's right to make choices about aspects of his or her life in the facility for 2 (Residents #75 and #77) of 3 residents reviewed for activities. The findings include: 1. A clinical record review revealed that Resident #75 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 4/23/18 at 3:16 PM, Resident #75 was observed lying in bed awake. The television was not on. When asked whether she participated in any of the facility's activities, she stated that she would like to, however the staff would not assist her to the activity. She was reliant on staff for mobility assistance. She stated that she was unaware of the specific activities being provided, as she was unable to get out to the hall in order to look at the activity calendar. When asked whether she was provided with a calendar in her room, she replied that there was a calendar on the bathroom door, which she could not see from her bed. When asked whether she could hear the staff announcing the activities, she replied that she could not. Activities announcements were not heard by the survey team until 4/25/18. A 4/25/18 interview with Reident #75 at 11:00 AM, revealed that she had not been provided with any books or magazines. None were observed on her side of the room. She stated that no one came around to see whether she would like something to read. On 4/25/18 at 3:22 PM, Resident #75 was observed lying in bed awake. The television was not on. No books or magazines were observed. The resident stated that she had not heard from any of the activities staff yet that day. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #75 enjoyed books, newspapers and magazines in her room, and that having them was very important to her. Doing things with groups of people was not very important. A review of the Quarterly MDS assessment dated [DATE], revealed the resident required extensive assistance with bed mobility, total assistance with transfers and was non-ambulatory. A review of the care plan dated 6/25/15 revealed that the resident required encouragement to participate and assistance with getting to and from activities. Also listed in the inteventions was Provide monthly calendar. A 4/25/18 interview with the Acitivities Director at 10:50 AM, revealed that he had been employed with the facility for approximately two weeks. When asked about activities calendars he stated that they had been placing one calendar in the resident rooms previously, depending upon the resident's cognitive status. He was changing that now and each resident would be provided with their own calendar. When asked where the calendars were posted in the resident rooms, he confirmed that they were placed close to the door or on the resident's door. Then he stated that now there should be a calendar on the window bed resident's wall as well. He confirmed that the size of the calendars was 11 x 17 and that he had received complaints that the writing was too small to read. When asked about one to one visits with the residents, the Activities Director stated that he had initiated a list which was kept in a binder. The list reflected all residents who were currently on one to one room visits, and a form was completed whenever a one to one visit was completed. He stated that prior to his employment, he was unaware of any records maintained to reflect one to one visits with the residents. He would ask the Administrator. When the Actiities Director's current one to one room visit binder was reviewed, Resident #75 was listed on one page. The page was dated 4/24/18 (during the survey), and it indicated that a room visit was not conducted as the resident was at [MEDICAL TREATMENT]. During an interview with the Administrator on 4/25/18 at 11:00 AM, she was asked for the previous Activities Director's one to one room visit notes. This documentation was provided on 4/25/18 at 2:30 PM, and was reviewed. The paperwork provided was dated from 9/2/17 through 12/15/17, and indicated the following: On 9/2, 9/5, 10/10, 10/14, 1017, 1021, 1024, 1028, 11/4, 11/7, and 12/11/17, the forms were either blank or indicated that the resident was out at [MEDICAL TREATMENT]. On 10/3/17, a sensory activity was completed. On 11/27, the resident was noted as sleeping. On 12/4, the documentation indicated that the resident would like to attend more activities. On 12/8/17, documentation indicated the resident was sleeping. On 12/15/17, the staff reminded the resident of activities. There was no other documentation for this resident related to participation in activities for (YEAR) or prior to (YEAR). There was no indication that the activities staff attempted to provide one on one when the resident was in the facility and not at [MEDICAL TREATMENT]. there was no documentation to indicate that when the resident was sleeping, the activities staff tried back later. There was no documentation of provision of activities for this resident thoughout the months of January, (MONTH) or (MONTH) of (YEAR). Documentation in (MONTH) (YEAR) began on 4/17/18 and indicated that a friendly room visit was conducted. There was no other documentation for (MONTH) of (YEAR). A review of the resident's activity assessment dated [DATE] revealed that the resident attended activities, but also liked to spend time alone in her room. She preferred to attend activities in her room, the activity room or the day room. The family was noted as visiting often, and aside from that and church, the resident did not attend activities. She was on the friendly room visit list. A review of the activity assessment completed on 12/14/17 revealed that the resident did not attend religious activities, was well-adjusted, and received friendly room visits. She preferred to remain in her own room, and preferred 1:1 or independent leisure activities. 'Resident currently does not leave her room for activities and is on the Friendly Room Visit list for encouragement to attend activities of her choosing.' During a 4/25/18 interview with the activities assistant at 2:30 PM, she was out on the covered patio with a group of residents playing a ball toss game along with the Activities Director. She stated that she had been working in the facility for 'about a year', and had been working in activities for 'a couple of months'. 'When I first started in Activities, before (Activity Director) came, we were doing 1:1 room visits 7 days a week. We had a lot of residents on 1:1 room visits. Now that (Activity Director) is here, we are seeing the residents for 1:1 visits 5 days a week from Monday through Friday. A review of the facility's policy and procedure, Activity Programs, updated on 1/5/18, revealed that the activities programs were designed to encourage maximum individual participation and were geared toward the individual resident's needs. Activities were scheduled 7 days a week. Activities included individual, small and large group activities that were designed to meet the needs and interests of each resident. Activities schedules were posted on the resident bulletin board and were also provided individually to residents who could not access the bulletin board. 2. A clinical record review revealed that Resident #77 was admitted to the facility on [DATE]. His date of birth was 4/10/1961. His [DIAGNOSES REDACTED]. A 4/23/18 observation of Resident #77 at 10:27 AM, revealed that he was lying in bed awake. No television was on and he was alone. No music was playing, no items for activities were observed. Both hands were contracted. This resident was unable to answer all questions appropriately, even when questions only required a yes or no answer. He answered every question with Yes Ma'am. A 4/24/18 observation of Resident #77 at 3:35 PM, revealed that he was lying in bed awake. No television was on and he was alone. No music was playing, no items for activities were observed. Both hands were contracted. A 4/26/18 observation of Resident #77 at 10:15 AM, revealed that he was lying in bed awake. Both hands were contracted. Both televisions in the room were on with conflicting programs. The resident's roommate was not present. The resident's remote control was on the bedside table. He was unable to reach it or use it due to bilateral hand contractures. When asked whether he would like one of the televisions turned off, he answered Yes Ma'am. When asked whether he was watching both programs, he replied Yes Ma'am. A review of the 1:1 (one to one) Activity Log covering dates from 9/2017 through 4/25/18 revealed no documentation of room visits for Resident #77. A review of the Activities Attendance Sheets covering (MONTH) and (MONTH) of (YEAR) revealed that this resident was not in attendance at any group activities. Other than these two months, the facility was unable to provide any Activities Attendance sheets to verify that any resident attended any activity. A review of the resident's quarterly activity assessment dated [DATE] revealed that the assessment was incomplete/essentially blank. A review of the resident's admisson activities assessment dated [DATE] revealed the resident enjoyed the outdoors, fishing and listening to music. Resident currently has not been involved in any activities since he has been here. Prefers activities in his own room or the day/activity room, no time involved in activities, prefers 1:1 or small group activities. Enjoys watching TV. 'Told the wife about friendly room visits and she thought that would be great.' A review of the care plans revealed that there was no activities care plan for this resident. A review of the resident's Admission MDS assessment dated [DATE], revealed that he enjoyed going outside for fresh air during good weather; he enjoyed keeping up with the news; he enjoyed listeniong to music, and he enjoyed doing things with groups of people. His Brief Interview for Mental Status (BIMS) score was a 4 out of a possible 15, indicating significant cognitive impairment. He require extensive assistance of two people for bed mobility, transfers and mobility required extensive assistance from one person. During a 4/26/18 interview with the Activities Director at 12:45 PM, he stated that he was still unfamiliar with all of the residents as he had only been employed for two weeks. When asked what activities were being provided for this resident, the Activities Director pulled up the Admission Activities Assessment in the computer to check. He stated that honestly, he was just getting his footing in the activities department. He was working on provision of activities for all residents, but did not have everyone's plan in place yet. He stated that he would go see this resident and ensure that he was offering activities based on the resident's wants and needs. During a 4/25/18 interview with the activities assistant at 2:30 PM, she was out on the covered patio with a group of residents playing a ball toss game along with the Activities Director. She stated that she had been working in the facility for 'about a year', and had been working in activities for 'a couple of months'. 'When I first started in Activities, before (Activity Director) came, we were doing 1:1 room visits 7 days a week. We had a lot of residents on 1:1 room visits. Now that (Activity Director) is here, we are seeing the residents for 1:1 visits 5 days a week from Monday through Friday. A review of the facility's policy and procedure, Activity Programs, updated on 1/5/18, revealed that the activities programs were designed to encourage maximum individual participation and were geared toward the individual resident's needs. Activities were scheduled 7 days a week. Activities included individual, small and large group activities that were designed to meet the needs and interests of each resident. Activities schedules were posted on the resident bulletin board and were also provided individually to residents who could not access the bulletin board. (Photographic evidence and/or copies of all documentation noted above was obtained.)

Based on observation, record review, and staff and resident interview, the facility failed to develop a comprehensive care plan for contact isolation for Resident #212 and failed to implement the plan of care to prevent pressure ulcers for Resident # 37; 2 of 37 sampled residents. The findings include: 1. Record review for Resident #212 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 1:30 PM, a sign was observed on the Resident's door (room [ROOM NUMBER]). It was a private room assigned to Resident #212. The sign directed visitors to see the nurse before entering. A nurse, Employee M, was outside of the resident's room. She stated the resident was on contact isolation for [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) in his foot. She told the surveyor to wear gloves and a gown when going into the room. On 4/24/2018 at 1:50 PM, there was still a sign on the door instructing visitors/staff to see the nurse. The resident's nurse, Employee N, only donned gloves before entering the room. No gown was worn. The resident stated he was not on isolation anymore. He did not know why the sign was still up, or why the barrels (for separate trash and soiled linens) were still there. The Unit Manager, Employee M, on 4/24/2018 at 2:00 PM, stated she was not sure of the contact isolation precautions status. She went to talk to the Physician's Assistant and came back a few minutes later. Employee M stated the isolation could be discontinued because the resident's intravenous antibiotics had finished. A record review revealed a 4/5/2018 care plan for Skin Integrity (Resident has a wound infection (VRE) to left foot). There were only three approaches: medications as ordered, observe area daily for any changes, and treatment to left foot as ordered. The care plan did not include any interventions related to placing the resident on contact isolation. A record review did not reveal any physician's orders for placing the resident on isolation precautions or discontinuing them. On 4/26/2018 at 2:45 PM, the Director of Nursing confirmed there were no physician's orders for contact isolation. Employee H, the Minimum Data Set (MDS) Coordinator was interviewed on 4/26/2018 at 3:15 PM. She confirmed she did not include any interventions for contact isolation precautions for this resident, and she should have. She did not see a physician's order for it. 2. On 4/24/2017 at 8:40 AM, Resident #37 was observed in bed covered with a blanket. The surveyor pushed the resident's call light and about a minute later, Employee A, a Certified Nursing Assistant (CNA), entered the room. Employee A was asked to uncover the resident's legs to expose her feet. The resident's bare feet were lying on the air mattress. Employee A stated Resident #37 should have a booty on her left foot and a normal tennis shoe on her right foot. Employee A stated she did not have to float her heels while in bed but she would elevate the foot of the bed. Employee A stated she changed the resident's brief around 8:20 AM and did not put the boot and tennis shoe on her feet. Employee G, a Registered Nurse (RN), was interviewed on 2/26/2018 at 8:40 AM. She printed the resident's care plans and stated one care plan dated 2/3/2017 revealed an unstageable deep tissue injury to the left heel upon admission which had healed. A record review revealed a 2/6/2018 care plan for risk for pressure ulcers related to a history of left heel pressure ulcer, incontinence, decreased mobility, dementia, insulin therapy, and anticoagulant use. Approaches for treatment included boot on left foot at all times (ordered on [DATE]), Prevalon boot as ordered (ordered 11/9/2017), off load heels as ordered (11/8/2017) . The MDS Coordinator, Employee H, was interviewed on 2/26/2018 at 8:50 AM. She confirmed the care plan had two interventions for the feet that were unclear. She would clarify it. She did state that when in bed the heels should be floated. A review of the CNA care plan revealed Prevalon boots and float heels. Employee H on 4/26/2018 at 12:30 PM stated she just clarified the order with the physician. Resident # 37 only needed the Prevalon boots worn to both feet when in bed. She and the surveyor went to the resident's room and found the Prevalon boots in a clear bag in her closet. Employee H removed the bag and brought it to the soiled utility room. On 4/26/2018 at 12:35 PM, Employee H stated that the Prevalon boots should have been worn bilaterally at all times, but now only while in bed. She confirmed the CNA care plan did not specify when the boots were to be worn.

Based on observations, interviews and record reviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of each resident for 2 (Residents #75 and #77) of 3 residents reviewed for activities. The findings include: 1. A clinical record review revealed that Resident #75 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 4/23/18 at 3:16 PM, Resident #75 was observed lying in bed awake. The television was not on. When asked whether she participated in any of the facility's activities, she stated that she would like to, however the staff would not assist her to the activity. She was reliant on staff for mobility assistance. She stated that she was unaware of the specific activities being provided, as she was unable to get out to the hall in order to look at the activity calendar. When asked whether she was provided with a calendar in her room, she replied that there was a calendar on the bathroom door, which she could not see from her bed. When asked whether she could hear the staff announcing the activities, she replied that she could not. Activities announcements were not heard by the survey team until 4/25/18. A 4/25/18 interview with Reident #75 at 11:00 AM, revealed that she had not been provided with any books or magazines. None were observed on her side of the room. She stated that no one came around to see whether she would like something to read. On 4/25/18 at 3:22 PM, Resident #75 was observed lying in bed awake. The television was not on. No books or magazines were observed. The resident stated that she had not heard from any of the activities staff yet that day. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #75 enjoyed books, newspapers and magazines in her room, and that having them was very important to her. Doing things with groups of people was not very important. A review of the Quarterly MDS assessment dated [DATE], revealed the resident required extensive assistance with bed mobility, total assistance with transfers and was non-ambulatory. A review of the care plan dated 6/25/15 revealed that the resident required encouragement to participate and assistance with getting to and from activities. Also listed in the inteventions was Provide monthly calendar. A 4/25/18 interview with the Acitivities Director at 10:50 AM, revealed that he had been employed with the facility for approximately two weeks. When asked about activities calendars he stated that they had been placing one calendar in the resident rooms previously, depending upon the resident's cognitive status. He was changing that now and each resident would be provided with their own calendar. When asked where the calendars were posted in the resident rooms, he confirmed that they were placed close to the door or on the resident's door. Then he stated that now there should be a calendar on the window bed resident's wall as well. He confirmed that the size of the calendars was 11 x 17 and that he had received complaints that the writing was too small to read. When asked about one to one visits with the residents, the Activities Director stated that he had initiated a list which was kept in a binder. The list reflected all residents who were currently on one to one room visits, and a form was completed whenever a one to one visit was completed. He stated that prior to his employment, he was unaware of any records maintained to reflect one to one visits with the residents. He would ask the Administrator. When the Actiities Director's current one to one room visit binder was reviewed, Resident #75 was listed on one page. The page was dated 4/24/18 (during the survey), and it indicated that a room visit was not conducted as the resident was at [MEDICAL TREATMENT]. During an interview with the Administrator on 4/25/18 at 11:00 AM, she was asked for the previous Activities Director's one to one room visit notes. This documentation was provided on 4/25/18 at 2:30 PM, and was reviewed. The paperwork provided was dated from 9/2/17 through 12/15/17, and indicated the following: On 9/2, 9/5, 10/10, 10/14, 1017, 1021, 1024, 1028, 11/4, 11/7, and 12/11/17, the forms were either blank or indicated that the resident was out at [MEDICAL TREATMENT]. On 10/3/17, a sensory activity was completed. On 11/27, the resident was noted as sleeping. On 12/4, the documentation indicated that the resident would like to attend more activities. On 12/8/17, documentation indicated the resident was sleeping. On 12/15/17, the staff reminded the resident of activities. There was no other documentation for this resident related to participation in activities for (YEAR) or prior to (YEAR). There was no indication that the activities staff attempted to provide one on one when the resident was in the facility and not at [MEDICAL TREATMENT]. there was no documentation to indicate that when the resident was sleeping, the activities staff tried back later. There was no documentation of provision of activities for this resident thoughout the months of January, (MONTH) or (MONTH) of (YEAR). Documentation in (MONTH) (YEAR) began on 4/17/18 and indicated that a friendly room visit was conducted. There was no other documentation for (MONTH) of (YEAR). A review of the resident's activity assessment dated [DATE] revealed that the resident attended activities, but also liked to spend time alone in her room. She preferred to attend activities in her room, the activity room or the day room. The family was noted as visiting often, and aside from that and church, the resident did not attend activities. She was on the friendly room visit list. A review of the activity assessment completed on 12/14/17 revealed that the resident did not attend religious activities, was well-adjusted, and received friendly room visits. She preferred to remain in her own room, and preferred 1:1 or independent leisure activities. 'Resident currently does not leave her room for activities and is on the Friendly Room Visit list for encouragement to attend activities of her choosing.' During a 4/25/18 interview with the activities assistant at 2:30 PM, she was out on the covered patio with a group of residents playing a ball toss game along with the Activities Director. She stated that she had been working in the facility for 'about a year', and had been working in activities for 'a couple of months'. 'When I first started in Activities, before (Activity Director) came, we were doing 1:1 room visits 7 days a week. We had a lot of residents on 1:1 room visits. Now that (Activity Director) is here, we are seeing the residents for 1:1 visits 5 days a week from Monday through Friday. A review of the facility's policy and procedure, Activity Programs, updated on 1/5/18, revealed that the activities programs were designed to encourage maximum individual participation and were geared toward the individual resident's needs. Activities were scheduled 7 days a week. Activities included individual, small and large group activities that were designed to meet the needs and interests of each resident. Activities schedules were posted on the resident bulletin board and were also provided individually to residents who could not access the bulletin board. 2. A clinical record review revealed that Resident #77 was admitted to the facility on [DATE]. His date of birth was 4/10/1961. His [DIAGNOSES REDACTED]. A 4/23/18 observation of Resident #77 at 10:27 AM, revealed that he was lying in bed awake. No television was on and he was alone. No music was playing, no items for activities were observed. Both hands were contracted. This resident was unable to answer all questions appropriately, even when questions only required a yes or no answer. He answered every question with Yes Ma'am. A 4/24/18 observation of Resident #77 at 3:35 PM, revealed that he was lying in bed awake. No television was on and he was alone. No music was playing, no items for activities were observed. Both hands were contracted. A 4/26/18 observation of Resident #77 at 10:15 AM, revealed that he was lying in bed awake. Both hands were contracted. Both televisions in the room were on with conflicting programs. The resident's roommate was not present. The resident's remote control was on the bedside table. He was unable to reach it or use it due to bilateral hand contractures. When asked whether he would like one of the televisions turned off, he answered Yes Ma'am. When asked whether he was watching both programs, he replied Yes Ma'am. A review of the 1:1 (one to one) Activity Log covering dates from 9/2017 through 4/25/18 revealed no documentation of room visits for Resident #77. A review of the Activities Attendance Sheets covering (MONTH) and (MONTH) of (YEAR) revealed that this resident was not in attendance at any group activities. Other than these two months, the facility was unable to provide any Activities Attendance sheets to verify that any resident attended any activity. A review of the resident's quarterly activity assessment dated [DATE] revealed that the assessment was incomplete/essentially blank. A review of the resident's admisson activities assessment dated [DATE] revealed the resident enjoyed the outdoors, fishing and listening to music. Resident currently has not been involved in any activities since he has been here. Prefers activities in his own room or the day/activity room, no time involved in activities, prefers 1:1 or small group activities. Enjoys watching TV. 'Told the wife about friendly room visits and she thought that would be great.' A review of the care plans revealed that there was no activities care plan for this resident. A review of the resident's Admission MDS assessment dated [DATE], revealed that he enjoyed going outside for fresh air during good weather; he enjoyed keeping up with the news; he enjoyed listeniong to music, and he enjoyed doing things with groups of people. His Brief Interview for Mental Status (BIMS) score was a 4 out of a possible 15, indicating significant cognitive impairment. He require extensive assistance of two people for bed mobility, transfers and mobility required extensive assistance from one person. During a 4/26/18 interview with the Activities Director at 12:45 PM, he stated that he was still unfamiliar with all of the residents as he had only been employed for two weeks. When asked what activities were being provided for this resident, the Activities Director pulled up the Admission Activities Assessment in the computer to check. He stated that honestly, he was just getting his footing in the activities department. He was working on provision of activities for all residents, but did not have everyone's plan in place yet. He stated that he would go see this resident and ensure that he was offering activities based on the resident's wants and needs. During a 4/25/18 interview with the activities assistant at 2:30 PM, she was out on the covered patio with a group of residents playing a ball toss game along with the Activities Director. She stated that she had been working in the facility for 'about a year', and had been working in activities for 'a couple of months'. 'When I first started in Activities, before (Activity Director) came, we were doing 1:1 room visits 7 days a week. We had a lot of residents on 1:1 room visits. Now that (Activity Director) is here, we are seeing the residents for 1:1 visits 5 days a week from Monday through Friday. A review of the facility's policy and procedure, Activity Programs, updated on 1/5/18, revealed that the activities programs were designed to encourage maximum individual participation and were geared toward the individual resident's needs. Activities were scheduled 7 days a week. Activities included individual, small and large group activities that were designed to meet the needs and interests of each resident. Activities schedules were posted on the resident bulletin board and were also provided individually to residents who could not access the bulletin board. (Photographic evidence and/or copies of all documentation noted above was obtained.)

Based on observations, record reviews and staff and resident interviews, the facility failed to provide care and treatment in accordance with professional standards of practice by failing to provide services for elimination for Resident #37; to provide treatments per physician's order for a surgical wound for Resident #212, and failure to refill medications in a timely fashion resulting in lapse of medications for Resident #10; 3 of a total Stage II sample of 37 residents. The findings include: 1. On 4/24/18 8:40 AM: Resident #37 was observed lying in her bed. She stated she was nauseated and threw up last night. She stated she still felt queasy and had a headache. On 4/24/2018 at 9 AM, the surveyor told the resident's nurse (Employee C) of the resident's condition. Employee C stated she was aware through shift report that the resident was not feeling well last night. She was not aware that she threw up last night or was still feeling ill. She would look into the situation and provide medication if she could. On 4/24/18 at 4:30 PM, Resident #37 stated she still had a bad headache and no one gave her any type of medication for discomfort yet. On 4/24/2018 at 4:35 PM, the resident's evening nurse, Employee D, was interviewed. Employee D was asked what was done for the resident's nausea or headache today. Employee D looked up the Medication Administration Record [REDACTED]. Employee D was asked if the facility had a bowel protocol, and she stated that she was not sure if they had a policy, but then produced an IPC Nursing Guideline page in a book on her medication cart. For constipation, if no bowel movement in 48 hours, medication was to be started. That was what she would use. A record review for Resident # 37 revealed a 4/20/2018 11:31 AM progress note: 'Resident was alert and oriented to self. Resident started to speak Gibberish language. The resident's CNA informed the writer that her mental status was altered and that she was not herself. The Nurse Practitioner was called and stat labs were ordered.' The next progress note was dated 4/23/2018 at 3:39 AM. 'No bowel movement was noted documentation and bowel protocol initiated. Will continue to monitor.' On 4/24/2018 at 11:58 AM the next progress note revealed that the resident had complained of nausea and headache this shift. 'Resident started on bowel protocol on prior shift. Physician notified and no new orders given at this time. Advised to wait until the end of the shift to see if resident has a bowel movement. As needed Tylenol given with good effect after 30 minutes.' On 4/24/2018 at 2:43 PM, the progress note revealed, 'Resident had a large bowel movement this shift. Resident expressed some relief of nausea. Physician was notified and no new order.' Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. There was no additional laxative medication ordered or administered for Resident #37 on 4/23/2018 per the progress note indicating the bowel protocol was initiated. There was a new order dated 4/24/2018 for [MEDICATION NAME] once a day PRN (as needed), but it was not administered until 7:02 PM. Record review of bowel movement activity from (MONTH) 18, (YEAR) until (MONTH) 24, (YEAR) (from electronic medication administration record) only revealed 1 large bowel movement on 4/24/2018 at 2:37 PM. There was no bowel movement activity documented from (MONTH) 18, (YEAR) through (MONTH) 23/2018 (5 days). (Photographic evidence obtained) The Unit Manager on 4/24/2018 at 5 PM was asked for a print out of the bowel movement activity for Resident #37 over the last month . On 4/24/2018 at 5:30 PM, the surveyor had still not received this print out, and went to the Administrator to obtain it. She stated the Unit Manager would have it to the surveyor shortly. On 4/24/2018 at 5:35 PM, the bowel movement activity for Resident #37 was given to the surveyor for the month of (MONTH) (YEAR). It showed a large bowel movement on 4/24/2018 at 2:47 PM. It also showed a medium bowel movement on 4/21/2018 at 7:36 PM (which was not on the surveyor's photographic evidence). The bowel movement documented prior to this one was on 4/8/2018 at 3:00 AM. The Corporate Compliance Consultant (Employee J) on 4/24/2018 at 6:00 PM, confirmed that the bowel movement documented on 4/21/2018 was not entered into the computer until 4/24/2018. There was no late entry note entered into the computer at this time for this entry. The DON was asked on 4/24/2018 at 6:03 PM where the new entry came from on 4/21/2018 for this medium bowel movement. She stated that the Unit Manager just entered this within the past half hour. It was a late entry. Additional documentation was requested and produced to show that this entry was indeed created on 4/24/2018 at 5:37 PM; 3 days after the occurrence. The DON confirmed that the Unit Manager did not enter this correctly as a late entry. The Unit Manager was interviewed on 4/24/2018 at 6:05 PM. She stated that when she printed up the bowel movement record for Resident #37, she noticed that there had a been a long length of time without documentation of a bowel movement, so she went to talk to the resident. The resident was coherent and told her that she had a bowel movement on Saturday, so she entered it into the computer. The Administrator went with the Surveyor to the room of Resident #37 and interviewed Resident #37 on 4/24/2018 at 6:20 PM. Resident #37 made conflicting statements about when she had bowel movements and stated she was given a white liquid on Sunday to drink, but it did not produce a bowel movement. She stated she did not have a bowel movement today either. This statement conflicted with the documentation. The clinical documentation revealed a 4/11/2018 Monthly Summary revealing the resident had short-term memory loss, and had moderately impaired cognitive skills for daily decision making. She also had [DIAGNOSES REDACTED]. The DON on 4/24/2018 at 6:33 PM, stated she did not know where the Unit Manager got the exact time of 7:36 PM to document the medium bowel movement on 4/21/2018. She doubted the resident was able to give her that exact time. The DON stated they did not have a facility Policy for bowel movement protocol, and the one shown by Employee D was only the guideline for one physician here, and Resident #37 was not his patient. The MDS Coordinator, Employee H, on 4/26/2018 at 8:50 AM was interviewed. She stated that if a resident did not have a bowel movement at least every 72 hours, then the bowel protocol should be initiated (start laxatives). When asked to see the resident's bowel protocol, she produced the IPC Nursing Guidelines for Constipation and the protocol was 48 hours. She produced a Risk for Constipation (2/6/2018) care plan related to decreased mobility. Approaches were to document frequency of bowel movements and administer medications as ordered. Employee J on 4/26/2018 at 10:55 AM, confirmed no bowel movement from (MONTH) 9 to the 21st. The accuracy of the documentation was questioned. This was not in compliance with facility bowel protocol. Employee K, the Advanced Registered Nurse Practitioner (ARNP) on 4/26/2017 at 11:25 AM, was interviewed. She stated the best standard of practice was to begin a bowel protocol within 48-72 hours and notify her if there were any problems. She stated she was was told at some point there was an issue with constipation, and the resident was given [MEDICATION NAME] on 4/24/18 with results, but she was not sure when she was contacted. 2. On 4/23/2018 at 5:15 PM, a treatment for [REDACTED].#212 was observed to be completed by the Wound Care Nurse. Resident #212 had a dressing in place on his left foot. This dressing was dated 4/20/2018. The resident confirmed that the dressing had not be changed in a few days. The Wound Care Nurse confirmed the date on the dressing. He stated that the resident's wound treatment was scheduled daily. The Wound Care Nurse stated he only worked Monday-Friday, and the weekend nurse(s) were responsible for the daily treatments to be done over the weekend. A record review for Resident #212 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) Treatment Administration Record (TAR), revealed two different nurses signed the treatment of [REDACTED]. The 4/19/2018 physician's order was to clean the left great toe [MEDICAL CONDITION] site with normal saline and pat dry. Then skin prep to the periwound, then apply Santyl to wound bed and cover with Alginate and rolled Kerlix gauze daily and as needed. Further review revealed a 4/14/2018 physician's order to cleanse the left foot with normal saline, apply non adherent dressing, wrap with stretch gauze, secure with tape, wrap with ace bandage, and change daily. On (MONTH) 15 and (MONTH) 16 (Saturday & Sunday), nurses documented that the treatment was not administered because it was done by wound care. There was no additional information by wound care that the treatment was provided on those days. The first treatment order for this wound was obtained on 4/7/2018, and was a daily treatment until 4/14/2018. There were no treatment orders at all from 4/4/2017 to 4/7/2018. A record review for Resident #212 also revealed a progress note on 4/5/2018 at 2:16 PM. The resident was on contact isolation for VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) infection. The resident had history of uncontrolled diabetes. Wound care has observed to the resident's foot. A graft was in place. Dressing was applied. The Director of Nursing (DON) was interviewed on 4/24/2018 at 8:28 AM. She stated that the Wound Care Nurse had alerted her of the two nurses signing off for the (MONTH) 21st and 22nd wound treatments for Resident #212, although the dressing on the resident was dated the 20th of April. She stated that she was investigating what happened. The DON was asked to research the other discrepancies in the treatment record. On 4/24/2018 at 9:01 AM, the DON confirmed she could not find documentation that the nurses performed wound care/treatment per the physician's order on (MONTH) 14th and 15th. She also confirmed that upon admission there was no order for treatment to the wound until the 7th of (MONTH) (YEAR). She confirmed the 4/5/2018 progress note indicated that a dressing was applied, and there was no physician's order to do so. 3. During the initial interview held with Resident #10 on 4/23/18 at 3:24 PM, the resident related that the nurses at the facility allowed her medications to run out before they called for refills, resulting in a 3 -4 day lapse in her receipt of the medications. She stated that she had chronic pain, and because her pain medications were not provided as ordered, her pain was not managed as it should have been. A review of Resident #10's medical record listed her [DIAGNOSES REDACTED].>[MEDICAL CONDITION] with exacerbation. Chronic [MEDICAL CONDITIONS] [MEDICAL CONDITION] [DIAGNOSES REDACTED] Obstructive sleep apnea(adult) (pediatric) [MEDICAL CONDITION] disorder, recurrent . A review of the electronic record's physician's orders revealed her medications were ordered as follows: [MEDICATION NAME](OTC)capsule 325 mg (milligrams) administer 650 mg po (orally) q6hrs (every 6 hours) PRN (as needed) [MEDICATION NAME] capsule 500 mg po before meals at bedtime for E-coli. Aripiprazole tablet 15 mg po qd (daily) for [MEDICAL CONDITION] disorder Aspirin tablet 325 mg po qd (OTC - over the counter) for [MEDICAL CONDITIONS] Atorvastatin 10 mg po qd for [MEDICAL CONDITION] [MEDICATION NAME] 160 mg tab po qd for [MEDICAL CONDITION] [MEDICATION NAME] 150 mg tab po at HS (bedtime) for [MEDICAL CONDITION]. [MEDICATION NAME] 4 mg po q 8 hrs (every 8 hours) for muscle spasms and chronic pain. [MEDICATION NAME] q 12 hrs for [MEDICAL CONDITION] [MEDICATION NAME] HCL ([MEDICATION NAME]) 150 mg tab po bid (twice daily) for [MEDICAL CONDITION] reflux disease (GERD) [MEDICATION NAME] 5 mg PO q 12hrs for pain. [MEDICATION NAME]-Schedule II Patch 72 hour ; 12 mcg/hr. Administer 12mcg/hr; [MEDICATION NAME] every 72 hours for severe pain. (mcg = micrograms) During the review, the surveyor observed that the [MEDICATION NAME] was held 5 times in the month of April. On 4/26/2018 at 1:39 PM the Director of Nursing (DON) was asked why the medication was held. She said that she would have to ask the physician. There were no nurses' progress notes over those 5 days to explain why the medication was held. The DON returned at 1:50 PM and expressed that the 'Hold' on the MAR indicated [REDACTED]. She confirmed that she did not know why the medication was on hold for so long. The [MEDICATION NAME] was to be given q 72hrs (every 72 hours). The (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the nurses' notes for the corresponding dates of 4/9, 4/12, 4/15, 4/18 and 4/21/18, revealed that the 3 nurses did not write any progress notes to explain why the medication was on hold. On 4/26/18, at 3:00 PM, Resident #10 was asked about the patch. She stated that the nurses let the patches run out before they requested more from pharmacy. She revealed that the patches were delivered this week and applied 2 days ago. Further review of all of her pain medications revealed that [MEDICATION NAME] was on hold twice on (MONTH) 12th and 13th. No nursing progress notes could be found explaining the reason for the hold.

Based on observation, policy review and staff interview, the facility failed to ensure hand hygiene was performed in order to prevent the spread of infections for 2 of 37 sampled residents, Residents #37 & #45. The findings include: 1.On 4/24/2017 at 8:40 AM, Resident #37 was observed in bed covered with a blanket. Employee A, a Certified Nursing Assistant (CNA) entered the room. Employee A removed the resident's blanket to expose her feet. Employee A, with her bare hands, lifted each of the resident's feet individually to show the surveyor the skin condition of her heels. Employee A placed a preventative booty to the resident's left foot, and then placed the blanket back over the resident. Employee A then walked out of the resident's room without performing hand hygiene. Employee A immediately walked into room [ROOM NUMBER], and picked up a breakfast tray and came back into the hallway. Employee A on 4/23/2018 at 8:50 AM was interviewed. She confirmed she did not perform hand hygiene when leaving the room of Resident #37 after direct patient contact. She stated she should have. 2.On 4/25/2018 at 9:45 AM, Employee B, CNA, was observed in the room of Resident #45 bagging used linens and soiled items after performing perineal care (cleansing the genitals). Employee B, with gloved hands holding the bagged items, left the room without performing hand hygiene. Employee B was stopped halfway down the hall and was asked about the lack of hand hygiene. Employee B stated she was going to wash her hands in the soiled utility room down the hall. She admitted that the facility's policy was that she should wash hands before leaving the room. A review of the facility's Handwashing/ Hand Hygiene (updated 1/4/2018) policy revealed hand hygiene is the primary means to prevent the spread of infections. Employees must wash their hands for at least 15 seconds using soap and water before and after direct (touch) resident contact. If hands are not visibly soiled, an alcohol based hand rub can be used. The Infection Control Nurse, Employee F, was interviewed on 4/26/2018 at 11:50 AM . He stated he had worked in the facility for 'about a month'. He stated that staff should wash hands after direct patient care.

Based on observations, record reviews and interviews, the facility failed to consult with the resident's physician regarding a change in health status requiring an alteration in treatment for one (Resident #4) out of 7 sampled residents. The findings include: 1. A record review for Resident #4 revealed a date of admission of 1/7/2016 and a discharge on 1/5/2018. [DIAGNOSES REDACTED]. A review of Resident #4's laboratory results from 11/13/2017 @ 6:00 AM, revealed the following abnormal results: Urine is amber & cloudy, 1+ blood, Leukocyte Esterase 3+, Protein 1+, Red Blood Count (RBC) 5-10 (ref range 0-4) White blood count (WBC) 51-100 (reference range 0-4) WBC clumps many, Bacteria trace (reference range negative), Squamous [MEDICATION NAME] cells 11-20 (reference range 0-4) Mucous many present. A review of nurses' notes for Resident #4 dated 11/22/2017 at 11:23 PM read,Resident has been very lethargic this evening. Resident has been in bed for writer's shift. Vital signs 160/94, 90 pulse, respirations 16, and temperature 98.5. Resident would mumble something at times but did not move much. She would not take her oral medications this evening. Resident usually wakes up and states that she is cold or gets upset that someone uncovered her legs. This evening the resident did not budge or make noise. Resident did not eat her dinner. Staff will continue to monitor resident. There was no documentation the physician was notified. A nurse's note dated 11/23/2017 @ 3:22 PM read, Resident is alert with confusion. Power of attorney (POA) informed that resident refused 9:00 AM medications; resident preferred to sleep. Resident left the facility with the daughter at 12:00 PM. Will continue plan of care. There was no documentation the physician was notified of the resident's refusal of medications. A nurse's note dated 11/23/2017 at 11:51 PM read, Resident arrived at facility at 8:30 PM. Resident appeared lethargic. Resident's blood pressure is 180/90, pulse 87, temperature 102.7, respirations 20. Resident was given Tylenol 650 mg (milligrams) and Dr. notified and gave order for resident to be sent to the hospital. A review of hospital records for Resident #4's emergency room visit revealed that the resident was admitted for acute [MEDICATION NAME], altered mental status, hypertension, [MEDICAL CONDITION], and chronic pancytopenia. The History and Physical dated 11/24/2017 read, Resident #4 typically is a wanderer and over the past 2 weeks she has gradually become less and less interactive and finally her family wanted her to come to the Emergency department when she was no longer able to feed or dress herself. A review of 11/24/17 hospital urine test results revealed the following abnormal results: Protein 30+, [MEDICATION NAME] positive, Leukocytes large amount, red blood cells - 12 (reference range 0-5), white blood cells 78 (reference range 0-5) white blood cell clumps 2 ( reference range - rare), bacteria 3+ (A) ( reference range - none) BUN/Creatnine 25 ( reference range 6-22). A nurse's noted dated 12/30/2017 @ 1:52 PM read, Resident was lying in bed yesterday. On a normal day she would be walking around the facility, however that did not occur. Vital signs 143/80, 97% 18, 98. She did eat lunch but was slow with her movement. There was no documentation to indicate that the doctor was made aware of the resident's change in status. A nurse's note dated 12/31/17 at 1:56 PM read, Resident was given all medications and still remains to have the slow movement. The physician assistant was made aware of the behavior. Resident did not eat her food today as well. A nurse's note dated 12/31/2017 at 3:51 PM revealed that due to family's request, resident was sent to the hospital due to a change in mental status. A review of the physician's progress notes revealed no documentation of the resident becoming lethargic or any physician's visits due to the change in the resident's status. A review of a Physician Assistant note dated 11/30/2017 (after resident hospitalization ) read, Patient reportedly developed a fever along with inability to feed or dress herself, and her daughter asked to transfer her to acute care hospital for assessment. The patient was apparently treated with Intra-venous antibiotics ([MEDICATION NAME]) and then converted to [MEDICATION NAME] for 5 days. A review of facility care plan for Resident #4 revealed the resident was at risk for complications related to incontinence, such as pain, urinary tract infection [MEDICAL CONDITION], and skin breakdown. Interventions included but were not limited too: Give meds (medications) as ordered, toilet as needed, encourage fluids, obtain labs as ordered, and report signs of UTI (acute confusion, urgency, frequency, and bladder spasms, etc.). During an interview with Employee B, Physician Assistant (PA), on 1/11/2018 at 12:50 PM, he stated that a resident was not started on antibiotics for a positive urine culture unless the culture came back positive and they were having symptoms. If the resident was having symptoms , another urine test would be obtained. The PA confirmed the facility staff did not notify him that Resident #4 was lethargic and had a change in her mental status. He stated, I don't recall, but if they had told me that, I would have treated her. The PA confirmed the resident was admitted to the hospital with [REDACTED].

Based on observations, record reviews and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (Residents #4 and #5) out of 7 sampled residents as evidenced by a failure to assess for change in status and follow up appropriately. Failure to assess and identify changes in physical, mental or psychological status can result in undesirable/detrimental outcomes for the resident (s) involved. The findings include: 1. A record review for Resident #4 revealed a date of admission of 1/7/2016 and a discharge on 1/5/2018. [DIAGNOSES REDACTED]. A review of Resident #4's laboratory results from 11/13/2017 @ 6:00 AM, revealed the following abnormal results: Urine is amber & cloudy, 1+ blood, Leukocyte Esterase 3+, Protein 1+, Red Blood Count (RBC) 5-10 (ref range 0-4) White blood count (WBC) 51-100 (reference range 0-4) WBC clumps many, Bacteria trace (reference range negative), Squamous [MEDICATION NAME] cells 11-20 (reference range 0-4) Mucous many present. A review of nurses' notes for Resident #4 dated 11/22/2017 at 11:23 PM read,Resident has been very lethargic this evening. Resident has been in bed for writer's shift. Vital signs 160/94, 90 pulse, respirations 16, and temperature 98.5. Resident would mumble something at times but did not move much. She would not take her oral medications this evening. Resident usually wakes up and states that she is cold or gets upset that someone uncovered her legs. This evening the resident did not budge or make noise. Resident did not eat her dinner. Staff will continue to monitor resident. There was no documentation the physician was notified. A nurse's note dated 11/23/2017 @ 3:22 PM read, Resident is alert with confusion. Power of attorney (POA) informed that resident refused 9:00 AM medications; resident preferred to sleep. Resident left the facility with the daughter at 12:00 PM. Will continue plan of care. There was no documentation the physician was notified of the resident's refusal of medications. A nurse's note dated 11/23/2017 at 11:51 PM read, Resident arrived at facility at 8:30 PM. Resident appeared lethargic. Resident's blood pressure is 180/90, pulse 87, temperature 102.7, respirations 20. Resident was given Tylenol 650 mg (milligrams) and Dr. notified and gave order for resident to be sent to the hospital. A review of hospital records for Resident #4's emergency room visit revealed that the resident was admitted for acute [MEDICATION NAME], altered mental status, hypertension, [MEDICAL CONDITION], and chronic pancytopenia. The History and Physical dated 11/24/2017 read, Resident #4 typically is a wanderer and over the past 2 weeks she has gradually become less and less interactive and finally her family wanted her to come to the Emergency department when she was no longer able to feed or dress herself. A review of 11/24/17 hospital urine test results revealed the following abnormal results: Protein 30+, [MEDICATION NAME] positive, Leukocytes large amount, red blood cells - 12 (reference range 0-5), white blood cells 78 (reference range 0-5) white blood cell clumps 2 ( reference range - rare), bacteria 3+ (A) ( reference range - none) BUN/Creatnine 25 ( reference range 6-22). A nurse's noted dated 12/30/2017 @ 1:52 PM read, Resident was lying in bed yesterday. On a normal day she would be walking around the facility, however that did not occur. Vital signs 143/80, 97% 18, 98. She did eat lunch but was slow with her movement. There was no documentation to indicate that the doctor was made aware of the resident's change in status. A nurse's note dated 12/31/17 at 1:56 PM read, Resident was given all medications and still remains to have the slow movement. The physician assistant was made aware of the behavior. Resident did not eat her food today as well. A nurse's note dated 12/31/2017 at 3:51 PM revealed that due to family's request, resident was sent to the hospital due to a change in mental status. A review of the physician's progress notes revealed no documentation of the resident becoming lethargic or any physician's visits due to the change in the resident's status. A review of a Physician Assistant note dated 11/30/2017 (after resident hospitalization ) read, Patient reportedly developed a fever along with inability to feed or dress herself, and her daughter asked to transfer her to acute care hospital for assessment. The patient was apparently treated with Intra-venous antibiotics ([MEDICATION NAME]) and then converted to [MEDICATION NAME] for 5 days. A review of facility care plan for Resident #4 revealed the resident was at risk for complications related to incontinence, such as pain, urinary tract infection [MEDICAL CONDITION], and skin breakdown. Interventions included but were not limited too: Give meds (medications) as ordered, toilet as needed, encourage fluids, obtain labs as ordered, and report signs of UTI (acute confusion, urgency, frequency, and bladder spasms, etc.). During an interview with Employee B, Physician Assistant (PA), on 1/11/2018 at 12:50 PM, he stated that a resident was not started on antibiotics for a positive urine culture unless the culture came back positive and they were having symptoms. If the resident was having symptoms , another urine test would be obtained. The PA confirmed the facility staff did not notify him that Resident #4 was lethargic and had a change in her mental status. He stated, I don't recall, but if they had told me that, I would have treated her. The PA confirmed the resident was admitted to the hospital with [REDACTED]. 2. A record review for Resident #5 revealed a date of admission of 3/29/2013 and a readmission date of [DATE]. [DIAGNOSES REDACTED]. A nurses progress note for Resident #5 dated 12/20/2017 read, CNA (certified nursing assistant) notified this writer around 1:30 PM of change in the resident leg after she gave her a shower. Resident left leg is flaccid, slightly swollen around the knee joint, and is not warm to touch. During assessment the resident has no complaints of pain at this time. Medical Doctor (MD) notified and orders for a stat X-RAY of the left leg received. A review of the portable X-ray report for Resident #5 dated 12/20/2017 @ 3:02 PM read, There is an acute impacted [MEDICAL CONDITION] femur seen. Old healed injuries of the proximal tibia and fibula are noted. Mild to moderate DJD ([MEDICAL CONDITION] joint disease) noted. [MEDICAL CONDITION]. A review of nurses progress note dated 12/21/2017 at 8:00 PM (late entry 12/21/2017 @ 12:32 AM) reads, Resident received a stat X-ray of the left knee at 5:00 PM. Results are there is acute impacted [MEDICAL CONDITION] femur seen. [MEDICAL CONDITION] is seen. Mild to moderate [MEDICAL CONDITION] joint disease noted there is no focal bone lesion. Writer assessed resident left knee, now noted slightly bigger than right knee. A review of the facility Accident/Incident report log revealed no listing of the femur fracture for Resident #5 sustained on 12/20/2017 after receiving a shower from facility staff. An interview with the Director of Nursing (DON) on 1/11/2018 at confirmed the facility did not list the fracture for Resident #5 on the facility Accident/Incident log. She stated, This was a spontaneous/pathological fracture and there is nothing we could have done about it. The DON confirmed the facility never conducted an investigation and was not able to provide information that Resident #5's record which revealed her fracture was spontaneous/pathological. She confirmed the X-ray report for Resident #5 read she had [MEDICAL CONDITION] and due to that the fracture was considered spontaneous or pathological. (Photographic evidence obtained) A review of the facility's Policy and Procedure for Accident/Incident investigating and reporting dated 7/2016 read, Facility staff is to immediately report all accidents or incidents to the Nurse Supervisor/Charge Nurse or direct supervisor. Types of incidents/accidents include but may not be limited to: Unusual activity or occurrence. (Photographic evidence obtained)

Based on observations, record reviews, and staff interviews, the facility failed to ensure residents where equipped to call for staff assistance through a communication system which relayed a call directly to a centralized staff work area for 14 residents (Residents #19, #7, the North Wing nursing station, and residents in rooms 401, 701 A & B, 702 C, 703 A & B, 705 B, 707 A, 710, 407 B, 201 A, and 102 B) with the potential to affect all 116 residents currently living in the facility due to the audible alarm component of the call light system not being able to be heard by staff. The findings include: An observation was conducted on 1/11/2018 at 8:34 AM of the dietary staff delivering the breakfast tray for Resident #19. The resident was not able to set up her breakfast tray and this surveyor obtained permission from the resident to activate her call light to request assistance. This surveyor activated the call light for Resident #19 on 1/11/2018 at 8:35 AM. This surveyor then left resident room and observed multiple staff members walking by the room without answering the call light or offering the resident assistance. This surveyor then walked to the nurses station for the North Wing and no audible alarm could be heard for the call light for Resident #19. An interview with Employee D, Registered Nurse (RN), on 1/11/2018 at 8:36 AM, confirmed no audible alarm could be heard at the nurses' station for the call light that was activated for Resident #19. An interview was conducted on 1/11/2018 at 8:37 AM with Employee E, Certified Nursing Assistant (CNA), and Employee E confirmed the audible alarm for the call light system was not working in the North Wing and she would put a call in to maintenance. An interview with the Director of Nursing (DON) on 1/11/2018 at 8:39 AM confirmed the audible alarm for the call light system for the North Wing was not alarming at the desk. This surveyor then activated the call light for room [ROOM NUMBER] on 1/11/2018 at 8:40 AM. A light could be visualized on the ceiling outside the resident's room but no audible alarm could be heard. An interview with the DON on 1/11/2018 at 8:41 AM confirmed that the facility nursing staff were not able to hear the audible alarm system if they were not sitting at the nurses' station, and must check the hallways to observe for activated call lights (lights on the ceiling) to know if a resident's call light had been activated. The call light in room [ROOM NUMBER] A & B was activated on 1/11/2018 at 8:45 AM, and both the audible and visual call lights were found not functioning. An interview on 1/11/2018 at 8:47 AM with Employee F, Licensed Practical Nurse (LPN), confirmed the call lights for room [ROOM NUMBER] A & B bed were not working. The call light for 703 B bed was activated on 7/11/2018 at 8:48 AM and was observed not functioning. An interview with Employee F was conducted at that time and confirmed the call light was not working. The call light for 703 A bed was activated on 1/11/2018 at 8:49 AM and was not functioning. An interview with Employee G, certified nursing assistant (CNA), and the Administrator at that time confirmed the call light was not working. The call light for room [ROOM NUMBER] B bed was activated on 1/11/2018 at 8:52 AM and was found not working. An interview with Employee H, CNA on 1/11/2018 at 8:53 AM confirmed the call light was not working. An interview was conducted for Resident #7 on 1/11/2018 at 9:05 AM confirmed her call light has not been working for a long period of time. She stated, We have told them so many times that it doesn't work. It will work for awhile, but then it doesn't work again. The resident confirmed she had to sit in her own feces and urine due to the long wait time to get assistance. An interview with Employee E, Registered Nurse (RN), on 1/11/2018 at 9:24 AM, confirmed the audible alarm for the call light system for the North Unit was very faint and difficult to hear, and was not able to turn the volume up. The call light for room [ROOM NUMBER] A was activated on 1/11/2018 at 9:45 AM. The light on the hallway ceiling outside the room was found to be lit, but no audible alarm could not be heard. An interview with Employee C, LPN, on 1/11/2018 at 9:48 AM confirmed the call light for room [ROOM NUMBER] was activated but Employee C was not able to hear the audible alarm at the South Wing nurses' station. An audit was conducted of the facility call light system by this surveyor which revealed the following call lights were not functioning: on 1/11/2018 at 11: 15 AM room [ROOM NUMBER] A bed was found not working. on 1/11/2018 at 11: 17 AM room [ROOM NUMBER] A bed was found not working. on 1/11/2018 at 11:18 AM room [ROOM NUMBER] both A & B bed and the bathroom call lights were not working. on 1/11.2018 at 11:20 AM room [ROOM NUMBER] C bed was not working. on 1/11/2018 at 11: 28 AM room [ROOM NUMBER] call light was found not working. on 1/11/2018 at 12:15 PM room [ROOM NUMBER] B bed was found not working. on 1/11/2018 at 12:07 PM room [ROOM NUMBER] B bed was found not working. An interview with Employee K, Maintenance Director, on 1/11/2018 at 11:32 AM confirmed he had been the maintenance director for 3 months, and during that time had not performed routine audits on the call light system. An interview with Employee I, CNA, on 1/11/2018 at 11:55 AM confirmed she could only see the call light which is lit on the ceiling and never paid attention to the audible alarm. An interview with Employee F, LPN, on 1/11/2018 at 12:00 PM confirmed that if you were not standing by the nurses' station you couldn't hear the call light sounding. When asked whether Employee F knew that the call light for room [ROOM NUMBER] wasn't working, Employee F replied, I thought it was fixed. Maintenance was told months ago. We have been having issues with the call lights. Sometimes the bed touches the cord and it affects the call light coming on. An interview with Employee H, CNA, on 1/11/2018 at 12:00 PM stated, There are wire shortages in the call light cords in some of the residents' rooms. The employee confirmed she knew that a resident was asking for assistance by checking the lights on the ceiling, but said she couldn't hear the audible alarm. An observation was conducted of Employee F, LPN, on 1/11/2018 at 12:08 PM, which confirmed she could not hear the audible alarm that was activated at the North Wing nurses' station that she was standing adjacent to. An interview with Employee J, CNA, on 1/11/2018 at 12:09 PM confirmed she did not know the facility had an audible alarm to the call light system, and she had to walk into the hallway to see if a call light was activated. An interview was conducted with the family of Resident #20 on 1/11/2018 at 11:50 AM, and the family member confirmed that his mother had to wait a long time (as long as 2 hours) for her call light to be answered and receive assistance. He stated that she waited so long that she had soiled herself waiting to be assisted. I don't know if it's because it doesn't work, but it takes a long time for her to get help.

Based on observations, interviews, and record reviews, the facility failed to administer physician-ordered medication according to accepted standards of clinical practice for 9 (Residents #1, #3, #4, #5, #6, #7, #9, #10 and #11) of 11 sampled residents. The findings include: During a complaint investigation conducted on 11/29/17, four Licensed Practical Nurses (LPNs) were scheduled to pass medications during the 7:00 a.m. to 3:00 p.m. shift. LPN C and LPN D were assigned to medication carts on the South Unit, and LPN E and LPN F were assigned to medication carts on the North Unit. An interview was conducted with Resident #1 and the resident's son on 11/29/17 at 9:00 a.m. The resident was visibly tremulous, especially of the bilateral upper extremities. Both the resident and son reported that the resident frequently received her anti-[MEDICAL CONDITION] medication an hour before or 1-3 hours after it was scheduled to be administered. The son stated that when they reported this to the Director of Nursing (DON), she told them that the nurses could administer the medication up to two (2) hours after it was ordered. Resident #1 complained that due to the variance in the times that the staff administered her anti-[MEDICAL CONDITION] medication, she felt that her symptoms were getting worse. She complained about not receiving the medication earlier on this day (11/29/2017). A review of Resident #1's Electronic Medication Administration Record [REDACTED]. In an interview with Employee F, LPN, on 11/29/17 at 11:18 a.m., she reported that she was currently administering 9:00 a.m. medications, and that she had started the medication pass at 7:30 a.m. At 11:39 a.m., Employee F reported that she was still currently administering 9:00 a.m. medications, and she showed the surveyor the e-MAR revealing that four residents (Residents #5, #6, #7, and #8) had still not received their 9:00 a.m. medications. An observation of Employee C, LPN, was conducted on 11/29/17 at 12:02 p.m. She reported that she was passing 9:00 a.m. medications. At 12:05 p.m., she was observed preparing the medications for Resident #9, and she marked in the e-MAR that the reason for late administration was charted late. When the surveyor asked Employee C why she chose that rationale, she logged back into the system at 12:04 p.m., looked at the options, and changed the reason to administered late. Review of the November 2017 MAR for Resident #11 revealed that her 9:00 a.m. medications were charted at 11:01 a.m., and were noted as Late Administration, Charted Late, administered on time by Employee C, LPN. During an interview at 12:16 p.m. on 11/29/17 with Employee D, LPN, she stated that she just completed her morning medication pass. She reported that she generally did not need to give medication outside of the ordered timeframes, but that if she did give a medication late, she would choose the rationale charted late versus administered late, and would document that the resident was in the shower, or at therapy, etc. This surveyor conducted a review of 11 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) e-Mar records for the months of October and November 2017, which revealed that medications were administered more than one hour before or after they were ordered on many occasions for 9 (Residents #1, #3, #4, #5, #6, #7, #9, #10 and #11) of 11 residents as follows: Review of the October 2017 Medication Administration Record [REDACTED]. (October 1, 2, 8, 9, 18, 19, 22, and 29) Review of the November 2017 MAR indicated [REDACTED]. (November 1, 4, 6, 10, 11, 14, 18, and 21) (Evidence obtained) Review of the October 2017 MAR for Resident #3 revealed that at least one of his daily doses of [MEDICATION NAME]-levidopa 25-250 milligrams (mg) on each day from October 2-20, 2017 was administered late or charted late, as evidenced by (AEB) Late Administration: Charted Late; Comment: given or administered on time. At least one of his daily doses on October 24, 25, 30, and 31, 2017 was administered late or charted late, AEB Late Administration: Charted Late; Comment: given or administered on time. (Evidence obtained) During medication pass at 11:17 a.m. on 11/29/17 with Employee E, LPN, she was observed removing [MEDICATION NAME] 5 mg orally for Resident # 4. As she removed the medication for the resident, she clicked the box on the eMAR for administration, and the system flagged the medication as late. Employee E then documented, Late administration. Med given at 11:21 a.m. This surveyor left Employee E while she continued removing the resident's remaining 9:00 a.m. medication from the cart. The time was 11:39 a.m. Later the same day this surveyor reviewed the MAR for Resident #4. Other medications scheduled at 9:00 a.m. for this resident were reviewed and the following was noted: Aspirin was documented at 11:39 a.m., and was noted as Given on time. [MEDICATION NAME] was documented at 11:39 a.m., and was noted Issues with computer. Given on time. [MEDICATION NAME] was documented at 11:39 a.m., and was noted Issues with computer. Given on time. [MEDICATION NAME] was documented at 12:14 p.m., and was noted as Given on time. Review of the November 2017 MAR for Resident #4 revealed that on 10 occasions, his 9:00 a.m. [MEDICATION NAME]/[MEDICATION NAME] was administered more than one hour before or one hour after it was scheduled. (Evidence obtained) Review of the November 2017 MAR for Resident #5 revealed that on 6 occasions, her 9:00 a.m. medication was administered more than one hour before or one hour after it was scheduled. The MAR indicated [REDACTED]. (Evidence obtained) The surveyor observed on 11/29/2017 at 11:39 a.m., that Resident #5 had still not received her 9:00 a.m. medication. Upon reviewing the MAR indicated [REDACTED]. Review of the November 2017 MAR for Resident #6 revealed that there were eight occasions during which her 9:00 a.m. medications were administered more than one hour before or one hour after they were scheduled. (Evidence obtained) Review of the November 2017 MAR for Resident #7 revealed that on 12 occasions, his 9:00 a.m. medication was administered more than one hour before or one hour after it was scheduled. (Evidence obtained) Review of the November 2017 MAR for Resident #8 revealed that on 11 occasions, her 9:00 a.m. medication was administered more than one hour before or one hour after it was scheduled. (Evidence obtained) Review of the November 2017 MAR for Resident #9 revealed that the 11/29/17 9:00 a.m. medications were signed off at 12:04 p.m., and were marked as Late Administration. Administered late. Review of the November 2017 MAR for Resident #10 at 12:48 p.m. revealed that all 9:00 a.m. medications for today (11/29/17) had not yet been marked as given. A re-check of the MAR indicated [REDACTED]. No documentation was present. (Evidence obtained) Review of the November 2017 MAR for Resident #11 revealed that her 11/29/17 9:00 a.m. medications were charted at 11:01 a.m., and were noted as Late Administration, Charted Late, administered on time by Employee C, LPN. (Evidence obtained) A review of the facility's policy and procedure entitled Administering Medications, under section Policy Interpretation and Implementation, stated: #4 - Medications must be administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). It also stated: #3 - Medications must be administered in accordance with the orders, including any required time frame. In an interview with the South Unit Manager on 11/29/17 at 2:15 p.m., she stated that she was unaware that 9:00 a.m. medications were being administered at 12:00 p.m. She stated that she did not perform audits on the times at which medications were administered by the floor nurses. In an interview with the Director of Nursing on 11/29/17 at 12:47 p.m., she confirmed that it was her expectation that all nurses administer medications within an hour before or an hour after they were ordered. She continued on to say that if the medication was given outside of this time frame, a rationale should be documented. They shouldn't be documenting administered late/charted late/and given on time, because there's no way to definitively determine when the medication was given. We need to keep accurate records.

Based on observation, record review, and staff interview, the facility failed to ensure that services provided met professional standards of quality for 1 resident (Resident #95) who developed avoidable pressure ulcers, resulting in harm, out of 2 residents reviewed for pressure ulcers, out of 9 pressure ulcers in the facility. Professional Standard of Care is defined in Chapter 766.102 as "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers." According to the Florida Nurse Practice Act, Chapter 464.003: (3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (e) "Nursing diagnosis" means the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal. (f) "Nursing treatment" means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. The findings include: Record review for Resident #95 revealed that she was readmitted to the facility from the hospital on [DATE] with a fracture to her right tibia. Past medical history included stroke, [MEDICAL CONDITION], dementia, and diabetes. Review of physician's progress note for Resident #95 dated 8/22/14 revealed right tibial plateau fracture. Continue knee immobilizer. Review of Resident #95's Nursing Admission Evaluation dated 8/24/2014 revealed admitting [DIAGNOSES REDACTED]. Pain to right lower extremity. Skin was described as no skin problems. Additional skin findings, boggy heels, dry skin, right knee swelling, healed abdominal surgical scar, bilateral forearm bruising. Review of Resident #95's skilled note dated 8/31/2014 stated skin intact. Review of Resident #95's MDS assessment dated [DATE] revealed that Resident #95's skin was intact. On 8/30/14 the 5 day MDS assessment recorded the skin as intact. On 9/4/14 the 14 day MDS assessment recorded the skin as a stage 2 pressure ulcer dated 9/1/14. On 9/16/2014 the Significant Change MDS coded skin with a stage 2 pressure ulcer and an unstageable pressure ulcer described with slough/eschar. Record review revealed a care plan for Resident #95 dated 7/1/13 for risk for pressure ulcer related to decreased mobility, incontinence, fragile skin, noncompliance with turning and offloading, and cognitive impairment. There were no updates to the care plan related to Resident #95's recent fracture and leg brace. Record review of Resident #95's physical therapy notes dated 9/1/2014 revealed: "Resident #95 was noted to have developed reddened area/blister on the left bony prominence of lateral aspect of the knee from her knee immobilizer worn too tight over the weekend." Note dated 9/2/2014 revealed: "Today another reddened area on right knee joint bony prominence observed by physical therapy before application of treatment, secondary to knee immobilizer not properly placed and was too tight." Record review of Resident #95's physicians orders dated 9/1/2014 revealed an order to apply skin prep and foam dressing every other day to right lateral knee. Record review of Resident #95 Weekly Skin Evaluation dated 9/9/2014. Stated patient's brace to right lower extremity causing pressure to this area. Spoke with physical therapy and patient's nurse and her nurse is calling doctor to see if brace can be downgraded to using it only when patient is out of bed since it is causing more pain and issues. The note described Resident #95's right lateral lower leg wound as an in-house wound, unstageable, with necrotic tissue and [DIAGNOSES REDACTED]. Record review of Resident #95's wound care evaluation dated 9/26/14 revealed the resident was [AGE] years old, weight 86 pounds, with an unstageable (due to necrosis) pressure wound of the right, lateral shin of at least 14 days duration, wound size 5.0 x 3.0 x not measurable centimeters (cm), 90% eschar (dead tissue). There is light serous exudate associated with the wound. Wound developed from brace injury. Wound debrided (removal of dead tissue) via surgical excision and subcutaneous tissue removed along with necrotic tissue. Indication: Remove necrotic (dead) tissue and establish the margins of viable tissue. Post-debridement depth 0.1cm. Record review of Resident #95's wound care evaluation dated 10/9/14 revealed wound size 5.2 x 3.5 x 0.2 cm. Further surgical debridement and removal of subcutaneous tissue along with necrotic tissue. Post-debridement depth 0.3 cm. Record review of Resident #95's wound care evaluation dated 10/21/14 revealed further surgical debridement. muscle removed along with necrotic tissue. Wound size 4.8 x 3.0 x 0.2 cm. Wound progress deteriorated. 90% yellow necrotic tissue. Record review of Resident #95's physician's orders [REDACTED]. Record review of a telephone order dated 9/9/2014 for Resident #95 stated to discontinue leg brace in bed. Record review revealed Hospice was contacted on 9/10/14, and Resident #95 started Hospice services on 9/11/2014 for terminal [MEDICAL CONDITION] diagnosis. Record review of Resident #95's physician's orders [REDACTED]. Record review of Resident #95's August, 2014 treatment record revealed an order for [REDACTED]. On 11/12/2014 at 10:09 AM an observation of Resident #95's right lower lateral leg revealed a wound with 75 % eschar (dead tissue) and 25 % red beefy tissue. There was a moderate amount of drainage on the dressing. The wound was approximately 4 x 3 centimeters (cm) with a depth of 0.2 cm. On 11/12/2014 at 11:25 AM in an interview with Employee D, Licensed Practical Nurse (LPN) and wound care nurse, she stated that Resident #95 was admitted with a brace from the hospital due to a fracture of her right leg. She said the brace was causing friction and caused the pressure ulcers on the leg and knee (healed). She said that previously the resident did not have any pressure ulcers. She said nursing should have been checking the resident's skin under the splint every day. On 11/12/2014 at 11:35 PM in an interview with the Physician Assistant she stated that orthopedics ordered the brace when Resident #95 was in the hospital. She said the brace caused the pressure ulcer on the resident's right lateral leg. On 11/12/2014 at 5:15 PM in an interview with the DON she stated that Resident #95 developed a pressure ulcer to her right leg because of the knee brace. She said the nurses should have checked the resident's skin under the brace every shift and documented it. Record review of the investigative protocol for pressure ulcer dated 9/16/2014 for Resident #95, completed by the DON, revealed question number 4 stated, "Did the assessment identify conditions that put the resident at risk for pressure ulcers such as: physical splints," and the question was answered "Yes." A comment written by the DON stated, "Splint/brace was discontinued due to causing breakdown and pressure." The section for pressure ulcer avoidable/unavoidable was not signed by the physician. Interview on 11/13/2014 at 12:15 PM with the DON revealed she determined the pressure ulcer to be unavoidable because Resident #95 was declining. On 11/13/14 at 9:30 AM in an interview with Employee F, physical therapist, he stated that the resident had a right splint immobilizer for the tibia plateau fracture, one of the longest to heal fractures. He stated it is standard of care to release the knee immobilizer and check the skin every 2 hours during turning and positioning. He applied Resident #95's right knee immobilizer to his knee and it went all the way down to his lower calf, about 2/3 down, to the same location as the pressure ulcer on Resident #95's right lateral leg. There was a hard area observed to the splint on the right lateral side, lightly covered with material. Employee F said he had to complete an in-service with nursing to apply the immobilizer correctly, due to nursing was applying it too tight. Review of Resident #95's Minimum Data Set (MDS) 5 day assessment dated [DATE] revealed the resident required limited assistance of one person for locomotion on the unit. Review of Resident #95's MDS significant change assessment dated [DATE] revealed the resident required extensive assistance of one person for locomotion on the unit. On 11/13/2014 at 11:00 AM in an interview with Resident #95 she said the wound on her leg hurts when staff do the dressing change, or when they move her in the bed. She said when she is lying in bed it does not hurt. She said she isn't sure how it happened. She said they don't apply the splint to her leg anymore. On 11/13/2014 at 11:09 AM in an interview with the Hospice aid she stated that Resident #95 complains of pain to her right leg. She said the resident gets out of bed sometimes. She said it's been about 2 weeks since she got her up. On 11/13/2014 at 11:46 AM in an interview with Employee E, Certified Nursing Assistant, he stated he has been assigned to Resident #95 for a few months. He said he got Resident #95 up a few times before she went to the hospital. He said he hasn't gotten the resident up in at least a month due to her decline. On 11/13/2014 at 11:56 AM in an interview with Employee D, LPN, she stated that Resident #95 would get up in the wheelchair before she developed the wounds. She stated the resident seldom gets up anymore. On 11/13/2014 at 12:12 PM in an interview with Employee C, LPN, she stated that the restorative aides were applying and removing Resident #95's splint. She said after morning care they would apply it and in the evening they would remove it, around 7:00 PM. She stated we did not document any of that. She stated a splint is usually left on for 8 hours. On 11/13/2014 at 12:20 PM in an interview with the Assistant Director of Nurses she stated that when Resident #95 was readmitted , there were no orders for the splint application, or monitoring of Resident #95's skin every shift. Review of facility policy and procedure titled Rehabilitative Nursing Care, revised April 2007, stated rehabilitative nursing care was provided for each resident and included application and removing of assistive devices (splints, braces and etc.) according to doctors orders. .

Based on observation, record review, and staff interview, the facility failed to ensure that a resident did not develop pressure ulcers unless the individual's clinical condition demonstrates that it was unavoidable for 1 of 2 sampled residents with pressure ulcers, (Resident #95), resulting in harm. The findings include: Record review for Resident #95 revealed that she was readmitted to the facility from the hospital on [DATE] with a fracture to her right tibia. Past medical history included stroke, [MEDICAL CONDITION], dementia, and diabetes. Review of physician's progress note for Resident #95 dated 8/22/14 revealed right tibial plateau fracture. Continue knee immobilizer. Review of Resident #95's Nursing Admission Evaluation dated 8/24/2014 revealed admitting [DIAGNOSES REDACTED]. Pain to right lower extremity. Skin was described as no skin problems. Additional skin findings, boggy heels, dry skin, right knee swelling, healed abdominal surgical scar, bilateral forearm bruising. Review of Resident #95's skilled note dated 8/31/2014 stated skin intact. Review of Resident #95's MDS assessment dated [DATE] revealed that Resident #95's skin was intact. On 8/30/14 the 5 day MDS assessment recorded the skin as intact. On 9/4/14 the 14 day MDS assessment recorded the skin as a stage 2 pressure ulcer dated 9/1/14. On 9/16/2014 the Significant Change MDS coded skin with a stage 2 pressure ulcer and an unstageable pressure ulcer described with slough/eschar. Record review revealed a care plan for Resident #95 dated 7/1/13 for risk for pressure ulcer related to decreased mobility, incontinence, fragile skin, noncompliance with turning and offloading, and cognitive impairment. There were no updates to the care plan related to Resident #95's recent fracture and leg brace. Record review of Resident #95's physical therapy notes dated 9/1/2014 revealed: "Resident #95 was noted to have developed reddened area/blister on the left bony prominence of lateral aspect of the knee from her knee immobilizer worn too tight over the weekend." Note dated 9/2/2014 revealed: "Today another reddened area on right knee joint bony prominence observed by physical therapy before application of treatment, secondary to knee immobilizer not properly placed and was too tight." Record review of Resident #95's physicians orders dated 9/1/2014 revealed an order to apply skin prep and foam dressing every other day to right lateral knee. Record review of Resident #95 Weekly Skin Evaluation dated 9/9/2014. Stated patient's brace to right lower extremity causing pressure to this area. Spoke with physical therapy and patient's nurse and her nurse is calling doctor to see if brace can be downgraded to using it only when patient is out of bed since it is causing more pain and issues. The note described Resident #95's right lateral lower leg wound as an in-house wound, unstageable, with necrotic tissue and [DIAGNOSES REDACTED]. Record review of Resident #95's wound care evaluation dated 9/26/14 revealed the resident was [AGE] years old, weight 86 pounds, with an unstageable (due to necrosis) pressure wound of the right, lateral shin of at least 14 days duration, wound size 5.0 x 3.0 x not measurable centimeters (cm), 90% eschar (dead tissue). There is light serous exudate associated with the wound. Wound developed from brace injury. Wound debrided (removal of dead tissue) via surgical excision and subcutaneous tissue removed along with necrotic tissue. Indication: Remove necrotic (dead) tissue and establish the margins of viable tissue. Post-debridement depth 0.1cm. Record review of Resident #95's wound care evaluation dated 10/9/14 revealed wound size 5.2 x 3.5 x 0.2 cm. Further surgical debridement and removal of subcutaneous tissue along with necrotic tissue. Post-debridement depth 0.3 cm. Record review of Resident #95's wound care evaluation dated 10/21/14 revealed further surgical debridement. muscle removed along with necrotic tissue. Wound size 4.8 x 3.0 x 0.2 cm. Wound progress deteriorated. 90% yellow necrotic tissue. Record review of Resident #95's physician's orders [REDACTED]. Record review of a telephone order dated 9/9/2014 for Resident #95 stated to discontinue leg brace in bed. Record review revealed Hospice was contacted on 9/10/14, and Resident #95 started Hospice services on 9/11/2014 for terminal [MEDICAL CONDITION] diagnosis. Record review of Resident #95's physician's orders [REDACTED]. Record review of Resident #95's August, 2014 treatment record revealed an order for [REDACTED]. On 11/12/2014 at 10:09 AM an observation of Resident #95's right lower lateral leg revealed a wound with 75 % eschar (dead tissue) and 25 % red beefy tissue. There was a moderate amount of drainage on the dressing. The wound was approximately 4 x 3 centimeters (cm) with a depth of 0.2 cm. On 11/12/2014 at 11:25 AM in an interview with Employee D, Licensed Practical Nurse (LPN) and wound care nurse, she stated that Resident #95 was admitted with a brace from the hospital due to a fracture of her right leg. She said the brace was causing friction and caused the pressure ulcers on the leg and knee (healed). She said that previously the resident did not have any pressure ulcers. She said nursing should have been checking the resident's skin under the splint every day. On 11/12/2014 at 11:35 PM in an interview with the Physician Assistant she stated that orthopedics ordered the brace when Resident #95 was in the hospital. She said the brace caused the pressure ulcer on the resident's right lateral leg. On 11/12/2014 at 5:15 PM in an interview with the DON she stated that Resident #95 developed a pressure ulcer to her right leg because of the knee brace. She said the nurses should have checked the resident's skin under the brace every shift and documented it. Record review of the investigative protocol for pressure ulcer dated 9/16/2014 for Resident #95, completed by the DON, revealed question number 4 stated, "Did the assessment identify conditions that put the resident at risk for pressure ulcers such as: physical splints," and the question was answered "Yes." A comment written by the DON stated, "Splint/brace was discontinued due to causing breakdown and pressure." The section for pressure ulcer avoidable/unavoidable was not signed by the physician. Interview on 11/13/2014 at 12:15 PM with the DON revealed she determined the pressure ulcer to be unavoidable because Resident #95 was declining. On 11/13/14 at 9:30 AM in an interview with Employee F, physical therapist, he stated that the resident had a right splint immobilizer for the tibia plateau fracture, one of the longest to heal fractures. He stated it is standard of care to release the knee immobilizer and check the skin every 2 hours during turning and positioning. He applied Resident #95's right knee immobilizer to his knee and it went all the way down to his lower calf, about 2/3 down, to the same location as the pressure ulcer on Resident #95's right lateral leg. There was a hard area observed to the splint on the right lateral side, lightly covered with material. Employee F said he had to complete an in-service with nursing to apply the immobilizer correctly, due to nursing was applying it too tight. Review of Resident #95's Minimum Data Set (MDS) 5 day assessment dated [DATE] revealed the resident required limited assistance of one person for locomotion on the unit. Review of Resident #95's MDS significant change assessment dated [DATE] revealed the resident required extensive assistance of one person for locomotion on the unit. On 11/13/2014 at 11:00 AM in an interview with Resident #95 she said the wound on her leg hurts when staff do the dressing change, or when they move her in the bed. She said when she is lying in bed it does not hurt. She said she isn't sure how it happened. She said they don't apply the splint to her leg anymore. On 11/13/2014 at 11:09 AM in an interview with the Hospice aid she stated that Resident #95 complains of pain to her right leg. She said the resident gets out of bed sometimes. She said it's been about 2 weeks since she got her up. On 11/13/2014 at 11:46 AM in an interview with Employee E, Certified Nursing Assistant, he stated he has been assigned to Resident #95 for a few months. He said he got Resident #95 up a few times before she went to the hospital. He said he hasn't gotten the resident up in at least a month due to her decline. On 11/13/2014 at 11:56 AM in an interview with Employee D, LPN, she stated that Resident #95 would get up in the wheelchair before she developed the wounds. She stated the resident seldom gets up anymore. On 11/13/2014 at 12:12 PM in an interview with Employee C, LPN, she stated that the restorative aides were applying and removing Resident #95's splint. She said after morning care they would apply it and in the evening they would remove it, around 7:00 PM. She stated we did not document any of that. She stated a splint is usually left on for 8 hours. On 11/13/2014 at 12:20 PM in an interview with the Assistant Director of Nurses she stated that when Resident #95 was readmitted , there were no orders for the splint application, or monitoring of Resident #95's skin every shift. Review of facility policy and procedure titled Rehabilitative Nursing Care, revised April 2007, stated rehabilitative nursing care was provided for each resident and included application and removing of assistive devices (splints, braces and etc.) according to doctors orders. .

Based on health record review, interview of the facility staff, interview of [MEDICAL TREATMENT] facility staff, and interview of the facility medical director the facility failed to notify the medical director, resident and family of one of three sampled residents (#1) of information from the [MEDICAL TREATMENT] clinic on 3/9/11, which would cause a significant change in treatment by limiting the amount of daily fluid the resident could have to 1000 cc. This failure in dissemination of information created a lack of needed care for the resident by the certified dietary manager, the registered dietician, the medical director and led to harm to Resident #1. This harm occurred by allowing the resident to drink additional fluid, causing excessive fluid overload and resulted in hospitalization on [DATE]. The findings include: Health record review for Resident #1 revealed that he was admitted into the facility on [DATE] and discharged on [DATE]. Review of the interdisciplinary discharge summary dated 04/05/2011 revealed that the resident was sent directly to the hospital from the [MEDICAL TREATMENT] clinic due to apparent fluid overload on 04/04/2011. Interview with the unit manager and unit clerk on the south wing on 04/08/2011 at 11:11 a.m. revealed that the [MEDICAL TREATMENT] communication sheets were kept in a separate record book by the unit clerk. The [MEDICAL TREATMENT] clinic communications were observed in a large pile on the desk at the nurses' station. The unit manager stated that the communications from [MEDICAL TREATMENT] that were in the record book were from 2010. The unit clerk stated that she was working on the [MEDICAL TREATMENT] communication book thinning it. During the interview on 4/8/2011 at 11:11a.m., the unit manager stated that the communication form was sent from the facility to the [MEDICAL TREATMENT] clinic and the [MEDICAL TREATMENT] clinic was responsible to send the communications back to the facility. If the communication from the clinic was pertinent, the facility staff would contact the physician or physician assistant to get orders. Then the communications forms were supposed to be filed in the record book. During review of the [MEDICAL TREATMENT] communication sheets with the unit manager on 04/08/2011 at 12:52 p.m., the two following communication sheets dated 03/21/2011 and 3/25/2011 revealed special considerations documented by the [MEDICAL TREATMENT] clinic. On 3/21/2011, to "please be liberal with protein food and provide protein supplement. Patient may need to be on [MEDICATION NAME] Binders". Review of the [MEDICAL TREATMENT] communication sheet dated 03/25/2011 revealed special considerations documented by the [MEDICAL TREATMENT] clinic to "PLEASE watch fluid, gain to much fluid weight between treatments". The unit manager stated the [MEDICAL TREATMENT] communication sheets should have been reviewed and given to our physicians to determine if there was something that should be ordered for Resident #1. Additionally, the unit manager stated that she could not find documentation in the nurses' notes acknowledging the communication from the [MEDICAL TREATMENT] center. On 04/15/2011 at 11:45 a.m. a second review of the closed record for Resident #1 revealed a [MEDICAL TREATMENT] communication sheet special considerations dated 03/09/2011 with recommendations from the [MEDICAL TREATMENT] clinic for Renal Diet/High Protein/1000 milliliter (ml) fluid restriction (FR). The recommendations suggested by the [MEDICAL TREATMENT] clinic were not addressed in the health record by the nurses, registered dietician or the physician. Interview with the certified dietary manager (CDM ) on 04/15/2011 at 12:17 p.m. revealed that Resident #1 came in with a reduced concentrated sweets (RCS)/no added salt (NAS)/Liberal renal diet. The CDM stated that she does not usually receive the [MEDICAL TREATMENT] communication forms unless pertinent to dietary but the registered dietician may receive faxed communication from the [MEDICAL TREATMENT] clinic, labs and other things suggested to her. If there were any labs from the [MEDICAL TREATMENT] clinic, the RD would have put them in the chart. The CDM printed out everything related to Resident #1 when he was discharged and provided a copy on 04/15/2011. Review of the Resident Profile record dated 04/08/2011 that was provided by the CDM on 04/15/2011 at 12:30 p.m. revealed that the facility identified a two thousand six hundred and eighty six (2686) milliliter (ml) minimum fluid each day requirement for Resident #1. The facility documented on the Resident Profile that Resident #1 consumed 2686 ml each day. Review of the Resident Profile record dated 04/08/2011 also revealed that Resident #1 weighed one hundred and seventy three (173) pounds on admission into the facility on [DATE] and weighed one hundred ninety seven (197) pounds on 04/01/2011 three days before discharge. There was no documentation of a fluid restriction on the Dietary Resident Profile Record. On 04/15/2011 at 1:30 p.m. a telephone interview was conducted with the [MEDICAL TREATMENT] clinic manager. The [MEDICAL TREATMENT] clinic manager stated that she spoke to the social worker at the [MEDICAL TREATMENT] clinic, and that Resident #1 was not happy at the facility because he was unable to eat what the nursing facility was providing. Regarding the communication sheet dated 03/21/2011, the [MEDICAL TREATMENT] clinic changed orders often regarding [MEDICATION NAME] binders which renal patients take with their food. The renal patients' bodies don't do what they should with Phosphorus so they they have to take binders. Generally, when we send information to the facility we expect the facility to follow up with their physician. Our [MEDICAL TREATMENT] clinic physician and our dietician do not write orders for the facility residents. Regarding the communication sheet dated 03/09/2011 [MEDICAL TREATMENT] patients can't have a lot of fluid we communicate the fluid restriction with the nursing home. Resident #1 weighed 198 pounds on the day we sent him to the hospital in fluid overload. Interview with the Medical Director on 04/15/2011 at 2:00 p.m. revealed that he was not notified of the fluid restriction communication from the [MEDICAL TREATMENT] clinic for Resident #1. The physician stated that if he had been notified he would have ordered the 1000 cc fluid restriction. An interview was conducted with the facility DON and Administrator on 04/15/2011 at 3:00 p.m. regarding the additional information reviewed in the closed record for Resident #1, regarding the facility failure to address the special considerations of a 1000 cc fluid restriction that was communicated to the facility from the [MEDICAL TREATMENT] clinic on 3/9/2011. The lack of failure in dissemination of information led to actual harm to Resident #1 by not ensuring that the resident received a 1000 cc fluid restriction, which led to hospitalization on [DATE] due to fluid overload. The DON and administrator acknowledged that the facility failed to communicate the fluid restriction request to the appropriate personnel.

Based on health record review, family interview, review of communication sheets from the [MEDICAL TREATMENT] center, staff interview, [MEDICAL TREATMENT] center staff interview, and interview of the facility medical director, the facility failed to ensure that information provided by the [MEDICAL TREATMENT] clinic on 3/9/11 that the resident was to be on a 1000 cc fluid restriction was communicated as needed and changes were discussed with the resident and family during care plan meeting on 3/15/2011 in order to have a current up to date care plan. The failure to ensure that pertinent information was communicated, and added to the resident's care plan allowed for the resident to have extra fluid as dietary had determined that the resident was to have 1965 cc to 2358 cc of fluid a day. The outcome of the extra fluid allowed for the resident to develop fluid overload and be sent to the hospital on [DATE]. The findings include: Closed health record review revealed that Resident #1 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the interdisciplinary discharge summary dated 04/05/2011 revealed that the resident was sent directly to the hospital from the [MEDICAL TREATMENT] clinic on 4/4/2011 due to apparent fluid overload. An initial assessment was done on 3/8/11 by the certified dietary manager (CDM). She noted a diet order of restricted concentrated sweets (RCS)/ no added salt (NAS)/Liberal renal diet. The resident was seen for an initial evaluation by the dietician on 3/8/11. The assessment also noted fluid needs of 1965 cc to 2358 cc with no fluid restriction. On 04/15/2011 at 11:45 a.m. health record review of the [MEDICAL TREATMENT] communication sheet special considerations dated 03/09/2011 revealed communication from the [MEDICAL TREATMENT] clinic for Renal Diet/High Protein/1000 CC fluid restriction. Interview with the certified dietary manager on 04/15/2011 at 12:17 p.m. The CDM stated that she does not usually receive the [MEDICAL TREATMENT] communication forms unless pertinent to dietary but the registered dietician (RD) may receive faxed communication from the [MEDICAL TREATMENT] clinic, labs and other things suggested to her. If there were any labs from the [MEDICAL TREATMENT] the RD would have put them in the chart. The facility did an interim care plan on 3/8/11 which included [MEDICAL TREATMENT]. But this was not updated regarding the information from the [MEDICAL TREATMENT] clinic for the fluid restriction. There was also a care plan meeting with the resident and family on 3/15/11 and 4/4/11, without mention of the fluid restriction. Due to information from the [MEDICAL TREATMENT] clinic not being communicated to nursing or dietary, the resident's care plan was not able to be updated, and the resident continued to receive extra fluid that led to hospitalization for fluid overload on 4/4/11.

Based on closed health record review, facility staff interview, [MEDICAL TREATMENT] clinic staff interview, and facility medical director interview the facility failed to provide the necessary care and services to meet the needs for one of three sampled residents (#1). The facility failed to ensure that communications from the [MEDICAL TREATMENT] clinic regarding changes to care and treatment for [REDACTED]. Lack of disseminating the information led to harm to the resident as the resident did not have a fluid restriction put into place, resulting in fluid overload and the resident being sent to the hospital. The findings include: Closed health record review revealed that Resident #1 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the interdisciplinary discharge summary dated 04/05/2011 revealed that the resident was sent directly to the hospital from the [MEDICAL TREATMENT] clinic on 4/4/2011 due to apparent fluid overload. An initial assessment was done on 3/8/11 by the certified dietary manager (CDM). She noted a diet order of reduced concentrated sweets (RCS)/ no added salt (NAS)/Liberal renal diet. An assessment was also done by the dietician on the same day. The assessment noted fluid needs of 1965 cc to 2358 cc with no fluid restriction. On the final assessment information, it was noted that admission weight was 173 and final weight was 193 on 3/28/2011. Interview with the certified dietary manager on 04/15/2011 at 12:17 p.m. The CD stated that she does not usually receive the [MEDICAL TREATMENT] communication forms unless pertinent to dietary but the registered dietician (RD) may receive faxed communication from the [MEDICAL TREATMENT] clinic, labs and other things suggested to her. If there were any labs from the [MEDICAL TREATMENT] the RD would have put them in the chart. Interview with the unit manager on the South wing on 04/08/2011 at 11:11 a.m. revealed that the [MEDICAL TREATMENT] communication was kept in a separate record book by the unit clerk. The [MEDICAL TREATMENT] center communications were observed in a large pile on the desk at the nurses' station. The unit manager stated that the communications from [MEDICAL TREATMENT] that were in the record book were from 2010. The unit clerk stated that she was working on the book thinning it. The unit manager further stated that the communication form was sent from the facility to the [MEDICAL TREATMENT] center and the [MEDICAL TREATMENT] center was responsible to send the communications back to the facility. If the communication from the center was pertinent, they contact the physician or physician assistant to get orders. Then the communications were supposed to be filed in the [MEDICAL TREATMENT] record book. On 04/15/2011 at 11:45 a.m. health record review of the [MEDICAL TREATMENT] communication sheet special considerations dated 03/09/2011 revealed communication from the [MEDICAL TREATMENT] clinic for Renal Diet/High Protein/1000 CC fluid restriction. Review of the [MEDICAL TREATMENT] communication sheet dated 03/21/2011 for Resident #1 revealed special considerations documented by the [MEDICAL TREATMENT] center to "please be liberal with protein food and provide protein supplement. Patient may need to be on [MEDICATION NAME] Binders". There was no action documented by the facility for the recommendations. Review of the [MEDICAL TREATMENT] communication sheet dated 03/25/2011 for Resident #1 revealed special considerations documented by the [MEDICAL TREATMENT] center to "PLEASE watch fluid, gain to much fluid weight between treatments". There was no action documented by the facility for the recommendations. [MEDICAL TREATMENT] communication sheets were reviewed with the unit manager on 04/08/2011 at 12:52 p.m. The unit manager stated the [MEDICAL TREATMENT] communication sheets should have been reviewed and given to our physician to determine if there was something that should be ordered for Resident #1. Additionally, the unit manager stated that she could not find documentation in the nurses' notes acknowledging the communication from the [MEDICAL TREATMENT] center. The changes suggested by the [MEDICAL TREATMENT] center were not addressed in the health record by the nurses, registered dietician or the physician. On 04/15/2011 at 1:30 p.m. a telephone interview was done with the [MEDICAL TREATMENT] clinic manager regarding Resident #1; 1) Regarding the communication sheet dated 03/09/2011 [MEDICAL TREATMENT] patients can't have a lot of fluid we communicate the fluid restriction with the nursing home. Resident #1 weighed 198 pounds on the day we sent him to the hospital in fluid overload. 2) Regarding the communication sheet dated 03/21/2011 the [MEDICAL TREATMENT] center changed orders often regarding [MEDICATION NAME] binders which renal patients take with their food. The renal patient's body doesn't do what they should with Phosphorus so they they have to take binders. Generally, when we send information to the facility we expect the facility to follow up with their physician. Our [MEDICAL TREATMENT] clinic physician and our clinic dietician do not write orders for the facility residents. Interview with the facility Medical Director on 04/15/2011 at 2:00 p.m. revealed that he was not notified of the communication from the [MEDICAL TREATMENT] clinic regarding the fluid restriction for Resident #1. The physician stated that if he had been notified he would have ordered the 1000 cc fluid restriction. During an interview with the facility DON and Administrator on 04/15/2011 at 3:00 p.m. regarding the information reviewed in the closed record for Resident #1. A discussion was held regarding the facility's failure to address the special considerations of a 1000 cc fluid restriction that was communicated to the facility from the [MEDICAL TREATMENT] center on 3/9/11, two days after admission that directly impacted the care and services for Resident #1. The DON and administrator acknowledged that the facility failed to communicate the fluid restriction request to the appropriate personnel.