Every finding on record at Martin Coast Center for Rehabilitation and Healthc

Based on record reviews and interviews, the facility failed to act promptly upon grievances voiced at resident council meetings for 5 residents (Resident #116, #54, #52, #10, #48) of 11 sampled residents, who attended the Resident Council Meeting held during the survey, and for 1 resident (Resident #28) who complained during the initial screening process. The findings included:1 .Record review of monthly resident council meetings revealed complaints about long wait times for provision of services after residents used the call light. Delays in call light response times were mentioned in the monthly resident council meetings that were held on 02/24/26, 01/27/26, 12/30/25, and 11/25/25. The notes from the meeting held on 01/27/26 documented that the nursing staff had long delays in answering call lights most frequently during the night shifts. Record review of the monthly resident council meetings documented ongoing concerns regarding staff speaking foreign languages in resident rooms. This concern was noted in the resident council notes for the meetings held on 03/31/26, 02/24/26, and 12/30/25. 2. Record review revealed Resident #28 was admitted to the facility on [DATE]. His medical diagnoses included Muscle Wasting and Atrophy, Morbid, Severe Obesity due to Excess Calories, and Lymphedema. He had Congestive (Diastolic) Heart Failure, and he was administered a diuretic two times each day for Edema (diuretics increase urination). A quarterly assessment dated [DATE] revealed that Resident #28 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that he was cognitively intact. The focus of his Activities of Daily Living (ADL) Care Plan described his dependence on staff for personal hygiene care that was related to his ADL deficit. He depended on staff for assistance with repositioning, toileting, and getting dressed. An interview was conducted with Resident #28 on 04/06/2026 at 10:00 AM during the initial screening process. Resident #28 said that he has waited for assistance from one to four hours after pressing the call light. He told about a time when he waited for three and a half hours to have his undergarment brief cleaned after a bowel movement. He said that his buttocks was stinging with pain from sitting in the dirty brief for so long. When asked how frequently he had long wait times, Resident #28 answered: Every day. 3. Record review revealed Resident #48 was admitted to the facility on [DATE]. Her diagnoses included Metabolic Encephalopathy, Type 2 Diabetes, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Major Depressive Disorder, Recurrent, Moderate. Review of Resident #48's quarterly assessment dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 14. This indicated that she was cognitively intact. Review of the quarterly assessment dated [DATE] revealed that Resident #48 required supervision or touching assistance for toileting. Her care plan documented that she had a self-care deficit and needed staff's assistance to perform and complete activities of daily living (ADLs). An intervention listed in the care plan dated 12/11/25 was to encourage the resident to use the bell to call for assistance. Resident #48 had a medication order for Tramadol HCL that was dated 04/06/26. It was prescribed as needed, for pain. An interview was conducted with Resident #48 in her room on 04/06/2026 at 2:53 PM. When asked if she used the call bell when she needed help with something, Resident #48 answered: Good luck with that! She explained that she could not walk. Resident #48 said when she presses the call light no one comes. It may be 3:00 AM or 4:00 AM, and if no one comes she climbs into the chair and wheels herself into the bathroom. Resident #48 said she was afraid of falling. Resident #48 also pressed the call light at night when she needed pain medication for the pain in her leg or shoulder. She said one consequence of waiting too long for help was that she was in pain longer. At the Resident Council meeting on 4/08/2026 at approximately 2:20 PM Resident #48 said that she had pushed the button and pushed the button and pushed the button, and no one came. 4. Record review revealed Resident #10 was admitted to the facility on [DATE]. Her diagnoses included Invertebral Disc Degeneration, Lumbar Region, Immunodeficiency, and Sciatica. A quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score equal to 15. This indicated Resident #10 was cognitively intact. An interview during the Resident council meeting was conducted on 4/08/2026 at 2:20 PM. Resident #10 said she heard the call bell activated by another resident the other night and it rang continuously for 35 minutes. When asked how she knew it was 35 minutes, Resident #10 said that she timed it. She said she watched the clock just outside of her room. Resident #10 said the long waits for a response to the call bell was usually at night. 5. Record review revealed Resident #52 was admitted to the facility on [DATE]. Her diagnoses included Muscle Wasting and Atrophy, Right Lower Leg, and Muscle Weakness Generalized, Other Reduced Mobility. She had two prescriptions ordered to treat pain. The medication order for Biofreeze Cool Pain External Gel dated 09/30/25 was ordered for lower back pain. She requested Acetaminophen at times for headaches. An interview was conducted with Staff C on 04/09/2026 at 11:51 AM. When asked what type of pain Resident #52 described when she requested Acetaminophen, Staff C said that sometimes she complained of a headache. An interview was conducted with Resident #52 during the Resident Council meeting on 04/08/26 at approximately 2:30 PM. Resident #52 said that in one instance after she pressed the call light, someone on the floor came in and shut the light off. The CNA told Resident #52 that her assigned CNA will be in. Then, after 15-20 minutes, no one came, and I needed to press the call light again. When Resident #52 was asked if the delayed response to the call bells occurred more during one shift or another, Resident #52 said the delay happened most often during the 3:00 PM -11:00 PM and the 11:00 PM - 7:00PM shifts. She said the delay was a problem when she had a massive headache and had to wait for a long time in pain. 6. Record review revealed Resident #116 was admitted to the facility on [DATE]. His diagnoses included Type 2 Diabetes Mellitus, With Hyperglycemia, PVD (Peripheral Vascular Disease) and Diastolic Congestive Heart Failure. A quarterly assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15. This indicated that Resident #116 was cognitively intact. An interview was conducted with Resident #116 during the Resident Council meeting on 04/08/2026 at approximately 2:30 PM. Resident #116 said that the residents bring up problems at the Resident Council meetings, and nothing gets resolved. According to Resident #116, the problems with the call lights were not resolved. He said on one occasion he pressed the call bell when he needed water, and it was a challenge to get water or ice. He added that he had a problem when the CNAs spoke in a different language. When asked how often this occurred, Resident #116 said that it happens constantly, every day.7. Record review revealed Resident #54 was admitted to the facility on [DATE]. His diagnoses included Spinal Stenosis Cervical Region, Immunodeficiency, Morbid Severe Obesity due to Excess Calories, Adjustment Disorder with Mixed Anxiety and Depression, and Heart Failure. An assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15. This indicated he was cognitively intact. An interview was conducted with Resident #54 during the Resident Council meeting on 04/08/2026 at approximately 2:30 PM. After Resident #116 said he had a problem when CNAs spoke in a foreign language, Resident #54 said: You never know if they're talking about you or what they're saying. He said that the CNAs were warned many times to avoid speaking in another language in front of residents, but they continued to do it. An interview was conducted with Staff B, the Unit Manager (RN) on 04/09/26 at 7:05 AM. When asked if she had received complaints about it taking too long to answer the call bells, she answered yes. She told surveyor about audits that were performed, and she said that the results showed that the delays happened most frequently at meal times and shift changes. Staff B said it had been about 2 weeks since they started doing audits.When asked how much time she thought was reasonable to answer a call light, she answered about 10 minutes. When asked how long was too long, she said 30 minutes, or 1 hour. She told of 1 random resident, who told her it took forever. When asked to view the audits, Staff B said that the Administrator had the documents. The RN provided the surveyor with copies of the audits and the PIP (performance Improvement Plan). She also provided a copy of the Survey Readiness In-service that included the words call lights that was given on 03/27/26. An interview was conducted with the Administrator 04/09/26 at approximately 12:50 PM. She said that the facility was aware of the issues regarding the delays with the call lights. The Administrator said they have been working on making improvements and they have seen improvements since the audits began.

Based on observations, record review, and interviews, the facility failed to provide the minced and moist diet to 3 of 3 sampled residents (Resident #77, Resident #132, and Resident #3). This had the potential to affect 9 residents who were on the minced and moist diet.The findings included: A record review of the facility's Policy on the International Dysphagia Diet Standardization Initiative (IDDSI) Implementation revealed that following the specific prescribed food textures was necessary to ensure the safety and well-being of residents with swallowing difficulties. The Level 5 - Minced and Moist Diet specified that foods are finely minced or chopped into small (approximately 4 mm) in size and then moistened with gravy. The IDDSI Handout for people on the Minced and Moist Diet specifies that foods that are dry, hard, crispy, and crusty should be avoided. Photographic Evidence of Facility's Policy was obtained. Reference to the Minced and Moist Handout can be obtained from 5_minced_moist_adults_consumer_handout_30jan2019.pdf. 1 Record review showed that Resident #77 was admitted to the facility on [DATE]. Her diagnoses included Immunodeficiency, Dementia, Moderate, with Anxiety, and Oropharyngeal Dysphagia (swallowing difficulty). A Brief Interview for Mental Status (BIMS) performed on 03/25/26 revealed a score of 4. This meant that Resident #77 had severe cognitive impairment. The electronic medical record revealed a doctor's order for a Regular diet, Minced and Moist texture (MM5), with Thin Fluids consistency since 04/16/25. An observation of the lunch meal on 04/08/26 at 12:20 PM in the main dining room revealed that Resident #77 was served clusters of crispy fried chicken with thick light brown gravy. The gravy was on top of the chicken and it covered approximately 70% of the surface area on top of the chicken. The gravy was not mixed into the chicken. The meal specified that she was to receive the Regular diet, with Minced and Moist texture foods, and Thin Liquids. The chicken should have been minced into pieces that were small, approximately 4 mm in size, and then moistened with gravy. Photographic Evidence Obtained. 2. Record review showed that Resident #132 was admitted to the facility on [DATE]. Her diagnoses included Immunodeficiency, Unspecified, Muscle wasting and atrophy, and Gastroesophageal Reflux Disease. A Brief Interview for Mental Status (BIMS) performed on 04/01/26 revealed a score of 13. This meant that Resident #132 was cognitively intact. The electronic medical record revealed a doctor's order for a Regular diet, Minced and Moist texture (MM5), with Thin Fluids consistency since 04/01/26. According to the Nutrition Risk Evaluation dated 04/03/26, Resident #132 had a history that included a procedure that removed retained food from the esophagus. An observation of the lunch meal in the Memory Support Dining Room on 04/08/26 at 12:33 PM revealed that Resident #132 was served an entree that had mostly minced chicken and 1 piece of chicken that was approximately one inch in length. That piece of chicken had dark crusty edges and it was not minced. Photographic Evidence Obtained. 3. Record review revealed Resident #3 was admitted to the facility on [DATE]. Her diagnoses included Immunodeficiency, Muscle Weakness, Generalized, Chronic Obstructive Pulmonary Disease and Dementia, Unspecified Severity, with Other Behavioral Disturbance. An assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03. This indicated she had severe cognitive impairment. The physician's order for a Regular diet, with Minced and Moist (MM5) texture, and thin fluids consistency was dated 01/15/26. An observation of the lunch meal in the Memory Support dining room on 04/08/26 at 12:42 PM revealed that Resident #3 was served minced chicken with thick light brown gravy on top of approximately 35-40% of the minced chicken. There were areas of minced chicken that had no gravy. The Registered Dietitian was present in the Memory Support dining room. An interview was conducted with the Registered Dietitian in the dining room on 04/08/26 at 12:42 PM. When she was asked if she saw any parts of the chicken entree that were dry, she said that there was no gravy on the chicken that was on the edges of the plate. She added, If it were mixed in, it would be adequate. An interview was conducted with the Dietary Manager and the Registered Dietitian on 04/08/26 at 1:15 PM. The kitchen manager showed the surveyor a plastic container of chicken that was not breaded, it was chopped up and she said we put this in the ninja and/or robocoup blender before it was served. The surveyor clarified the concern was for the Minced & Moist diet, and the kitchen manager agreed. Per the Kitchen Manager, the aides normally mix it up. The Kitchen Manager viewed the photo of Resident #3's meal plate that showed several pieces of chicken without gravy. The kitchen manager agreed with this finding.

Based on observations interview and record review the facility failed to follow their policy to assure the drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 8 sampled residents reviewed for medication reconciliation (Resident #20 and #50). The findings included:Review of the facility's policy titled, Discarding and Destroying Medications with no date documented in part the following: Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. 1. Record review for Resident #20 revealed a physician's order dated 05/27/25 for Lorazepam 0.5mg give half tab by mouth once daily as needed for 30 days. The medication was discontinued on 06/26/25.On 04/09/26 at 10:40 AM a review of the 300 unit med (medication) cart was completed with Staff K, Licensed Practical Nurse (LPN), including controlled medications. The monitoring/control records included Lorazepam 0.5mg for Resident #20 and the medication continued to be on the med cart in spite of having been discontinued on 06/26/25.During an interview conducted on 04/09/26 at 10:40 AM with Staff K LPN who was asked about controlled medications, she said they are removed from the cart upon discontinuation of the medication.2. Record review for Resident #50 revealed an order dated 02/05/26 for Lorazepam 0.5mg give 2 tablets by mouth every 6 hours as needed. The medication was discontinued on 02/06/26.On 04/09/26 at 11:45 AM a review of the 400 unit med cart was conducted with Staff L Licensed Practical Nurse (LPN) including controlled medications. The monitoring/control records included Lorazepam 0.5mg for Resident #50 and the medication continued to be on the med cart in spite of having been discontinued on 02/06/26.During an interview conducted on 04/09/26 11:45 AM with Staff L LPN who was asked when controlled medications are removed from the cart, she said when they are discontinued, she will bring them to the Director of Nursing.During an interview conducted on 04/09/2026 11:50 AM with Staff H, Registered Nurse Unit Manager, who was asked when controlled medications are discontinued when they are removed from the medication cart, she said it should be immediately. When asked about the Lorazepam for Resident #20 she acknowledged there was no active order and the medication should have been removed from the medication cart upon it being discontinued. When asked about the Lorazepam for Resident #50 she acknowledged there was no current order for the medication and it also should have been removed from the medication cart upon it being discontinued.

Based on observations, interviews and record review the facility failed to ensure they provided a safe, clean, homelike environment for 7 of 13 rooms on the 300 unit (Rooms 306, 307, 311, 312, 313, 314, and 315)The findings included:1.On 04/06/26 at 9:45 AM, an observation was made in room [ROOM NUMBER] of the emergency cord in the bathroom that was approximately 3 feet from the floor. 2. On 04/06/26 at 9:42 AM, an observation was made in room [ROOM NUMBER] of the bathroom emergency cord threaded through the toilet tissue dispenser and tied in a knot. The toilet was missing a toilet seat cover. 3. On 04/06/26 at 9:52 AM, an observation was made in room [ROOM NUMBER] of the bathroom emergency cord threaded through the toilet tissue dispenser and wrapped around the grab bar. The bathroom bottom windowpane was of clear glass with no window covering for privacy. 4. On 04/06/26 at 9:53 AM, an observation was made in room [ROOM NUMBER] of the inside of the bathroom door with a crack in the door at the bottom. 5. On 04/06/26 at 9:54 AM, an observation was made in room [ROOM NUMBER] of the inside of the bathroom door with a crack in the door on the left side. 6. On 04/06/26 at 9:57 AM, an observation was made in room [ROOM NUMBER] of the bathroom emergency cord threaded through the toilet tissue dispenser and wrapped around the grab bar. 7. On 04/06/26 at 9:59 AM, an observation was made in room [ROOM NUMBER] of the bathroom emergency cord wrapped around the toilet tissue dispenser and tied in a knot, approximately five feet above the floor. There were holes inside of the bathroom door. During an interview conducted on 04/07/26 at 3:12 PM with the Director of Maintenance who was asked about emergency cords, he said they should be free hanging and function when pulled. During a side-by-side tour conducted on 04/07/26 at 3:18 PM with the Director of Maintenance, who acknowledged the above concerns and stated they are working on renovating some of the areas and the 300 unit has just been started. He acknowledged the emergency cords in the bathrooms should be freely hung and be no more than approximately six inches from the floor

Based on observations, interviews and record review the facility failed to ensure tracheostomy care was performed and documented; and failure to ensure of emergency equipment at bedside for residents with tracheostomy for 1 of 1 sampled resident reviewed for tracheostomy (Resident #7).The findings included:Review of the facility's policy titled, Tracheostomy Care with a revised date of August 2013 included in part the following: Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. Site and Stoma Care: Document the procedure, condition of the site and the resident's response. Record review for Residet #7 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Malignant Neoplasm of Larynx, Malignant Neoplasm of Anterior Surface of Epiglottis, Paralysis of Vocal Cords and Larynx, and Tracheostomy Status. Review of the Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response. Review of the Physician's Orders for Resident #7 included in part, the following:An order dated 04/06/26 for resident to perform self-laryngectomy care and nebulizer self-administration medication; returned demonstration noted and resident education form uploaded. Report abnormalities to provider when applicable.An order dated 04/08/26 for resident to perform trach care every day shift and as needed.An order dated 04/09/26 for Suction as needed: Oral/Nasopharyngeal/Tracheal as needed for Respiratory Secretions.Review of the Medication Administration Record and Treatment Administration Record for Resident #7 revealed no documentation of trach care having been performed (by staff or resident) from 03/23/26 to 04/06/26.Review of the Nursing Progress Notes from 03/23/26 to 04/06/26 revealed no documentation of trach care having been performed (by staff or resident)Review of the Care Plan for Resident #7 dated 10/24/23 with a focus on the resident has Laryngectomy tube; he does his own Laryngectomy care and refuses to let staff do treatment of trach. The goal was for the resident to have no signs/symptoms of infection through the review date. The interventions included in part the following: Ensure that trach ties are secured at all times. May self-administer nebulizer treatments as ordered. Monitor/document respiratory rate, depth and quality. Check and document every shift as ordered. Suction as necessary. On 04/06/26 at 12:14 PM an observation was made of Resident #7 sitting on the edge of the bed with a tracheostomy in place. There was no suction machine observed in the room. During an interview conducted on 04/06/26 at 12:14 PM with Resident #7, who was able to communicate by writing on a pad of paper with pen, when he was asked who provides the care for his tracheostomy, he communicated he does all of the care himself. During an interview conducted on 04/08/26 at 8:37 AM with the resident's Primary Physician, who was asked about Resident #7, he said he did not recall this resident but has so many patients that he sees. When reminded that this resident has a stoma in his throat, he said he still did not recall the patient. When asked in general whether he would have orders for cleaning or monitoring the stoma, he said there should be standing orders for stoma site care. He said no staff has reached out to him regarding any stoma care. Again, he stated it should be in the standing orders and directed the surveyor to speak with nursing staff. During an interview conducted on 04/08/26 at 9:30 AM with Staff F, Nurse Practitioner, who was asked in general about tracheostomy care, she said the facility would need to follow their protocol. She stated she would expect the tracheostomy care to be provided daily minimally and documented as such. When asked about emergency supplies at the bedside, she stated she would expect to see a suction machine, an Ambu bag and replacement tracheostomy tube at the bedside. When asked about Resident #7 she said the resident has a well healed tracheostomy stoma and feels he is quite capable of performing self-care of the tracheostomy stoma. During an interview conducted on 04/08/26 at 10:15 AM with Staff H, Registered Nurse Unit Manager, who was asked about Resident # 7 if he would need any emergency equipment at the bedside due to having a tracheostomy, she said he should have a suction machine, and an inner cannula at the bedside. She acknowledged Resident #7 did not have a suction machine at the bedside.

Based on observations, record review and interview, the facility failed to remove bed rails for residents that were assessed not to have them (Resident #69 and Resident #78); and failed to get obtain appropriate assessments for a resident was able to have bedrails (Resident #11) for 3 of 3 residents renewed for bedrails. 1. Review of Resident #11 medical records revealed the resident was admitted to the facility 12/19/22 with a diagnosis to include Dementia with Psychotic Disturbances, Anxiety Disorder, Parkinson's Disease, and Wandering. Her quarterly Minimum Data Set (MDS) assessment documents her Brief Interview for Mental Status (BIMS) was 00, indicating severe cognitive impairment. During multiple observations from 04/09/26-04/09/26, the resident was seen with side rails / enablers up on her bed. Review of the physician orders, dated 03/19/26, documented for side rails. Review of the care plan documents for adaptive equipment: Bilateral adaptive side rails for bed mobility dated 03/31/23. Resident #11 had a consent in her records, but it was not filled out or signed. The record had 4 'Side Rail Assessments' that were dated 12/20/23, 03/18/24, 12/13/24 and 03/13/25. All of the documents show that there is a quarterly assessment and only two questions had been answered: A. Reason for evaluation? Quarterly and is resident immobile? Yes (If yes, evaluation is complete. Do not proceed further), and B. Side rail Determination: Not completed since Yes was answered above. 2. Review of Resident #69's records revealed the resident was admitted to the facility 10/02/23. Her diagnosis included Dementia and Depression. Her quarterly MDS assessment dated [DATE] documents her BIMS score of 00 indicating severe cognitive impairment. Review of the physician order dated 03/26/26 documented for Adaptive Equipment: Bilateral adaptive side rails for bed mobility. Monitor for proper functioning every shift. Review of the last quarterly side rail assessment, dated 10/03/25, documents the reason for evaluation as: Quarterly and then asks is resident immobile. Yes (if yes, evaluation is complete. Do not proceed further). Section B documents the side rail determination. This section cannot be opened if staff answered yes to section A. Review of the care plan,, dated 01/15/26, documents that Resident #69 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to muscle weakness and has Adaptive Equipment: Bilateral adaptive side rails for bed mobility. During multiple observations from 04/09/26 to 04/09/26, the resident was seen with side rails / enablers up on her bed. 3. Review of Resident #78's medical records revealed Resident #78 was admitted to the facility on [DATE] with a diagnosis to include a Fracture Left Hip, Diabetes Mellitus, Major Depressive Disorder. Review of the Medicare 5 Day MDS dated [DATE] documents a BIMS score of a 5 indicating severe cognitive impairment. A side rail evaluation and consent were not located in her electronic record but Staff H, Unit Manager, who is also the relative of this resident showed the surveyor on her computer the evaluation and consent dated 03/10/26. Further review revealed a physician's order for the adaptive side rails was put in place on 04/08/26 while the surveyors were onsite as well as the Care Plan for side rails that was dated 04/08/26. During multiple observations from 04/09/26 to 04/09/26, the resident was seen with side rails / enablers up on her bed. During an interview on 04/08/26 at 12:05 PM with the Director of Nursing (DON), the DON reviewed Resident #11, Resident #69 and Resident #78's medical records for the bed rail assessments, physician orders, care plans, and consents. The DON acknowledged the surveyor findings. She acknowledged that when doing the evaluation when you answer yes if the resident is immobile then you do not go any further, and that the resident is not appropriate for the side rails.

Based on policy review, interview, and record review, the facility failed to ensure timely right to self-administer medications with the interdisciplinary team (IDT) assessment for 2 of 5 sampled residents reviewed for choices (Resident #104 and #7).The findings included:Review of the policy Self-Administration of Medications Program issued 06/2020, documented in part, Procedure: 1. The facility will allow the resident to self-administer drugs if the interdisciplinary team, has determined that this practice is safe. 7. The admitting nurse or designee will complete the Self-Administration of Medication Evaluation and report eh findings to the Unit Manager or designee. 8. The interdisciplinary team must also determine: a. Who will be responsible (the resident or the nursing staff) for storage; If medications are stored at the resident's bedside, a lockbox or locked drawer must be used to store the medication(s); b. Who will be responsible (the resident or the nursing staff) for documentation of the administration of drugs; If the resident is responsible for documentation, maintain a Medication Administration Record (MAR) in the resident's room for the resident to sign and maintain a duplicate MAR for nursing staff; as well as, c. The location of the drug administration (e.g., resident's room, nurses' station, or activities room). 9. Once the resident has been deemed safe by the IDT an order will be obtained from the resident's physician or physician extender listing the medications(s) that may be self-administered, where the medications will be stored, who will be responsible for documentation and the location of administration. 10. Appropriate document of the above determinations will be documented in the resident's care plan. 1) Review of the record revealed Resident #104 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #104 had a Brief Interview for Mental Status (BIMS) score of 11 on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. This MDS documented the resident's diagnoses to include Heart Failure and Respiratory Failure. Review of the initial admission Evaluation dated [DATE] documented the resident did not have the desire to self-administer medications. The progress notes and care plans lacked any documentation related to self-administration of medications. During an interview on [DATE] at 10:20 AM, when asked how he was doing that morning, Resident #104 stated angrily, I was fine until they took my meds away this morning. Resident #104 further explained he was diagnosed with asthma since age 7 and does not go anywhere without his inhalers as he never knows when he would need them. The resident explained he had three inhalers, tums, and Gas X at his bedside and they took them this morning, further stating they were sneaky about it as a nurse came in, stated she was going to look in the top drawer of his bedside stand, and she took the meds. Resident #104 stated he has had those medications at his bedside for the 6 weeks ever since he had been at the facility. The resident further volunteered some of the nurses just told him to put the medications in that top drawer and it would be OK. An order dated [DATE] documented unsupervised self-administration of the rescue inhaler Ventolin, 2 puffs every six hours as needed for shortness of breath or wheezing. During a supplemental interview on [DATE] at 10:25 AM, Resident #104 stated he now had his inhaler and a lock box with a key for storage. The resident explained they left him overnight Monday without his inhaler stating, What if I would have needed it in the middle of the night? During an interview on [DATE] at 10:10 AM, when asked the process for a resident to self-administer a medication, Staff B, Unit Manager stated she would contact the physician to get an order, would do an education on safely administering the medication and safe storage, and would issue a key. When asked what documentation was completed besides the physician order, the Unit Manager stated she fills out a Resident/Family Education sheet and pulled up the one completed by her for Resident #104 on [DATE]. This documented the resident was accepting to learn and demonstrated correctly. This form lacked any documentation as to the storage of the medication or the inclusion of the IDT. When asked how she became aware of the medications at bedside, the Unit Manager explained she had gone into his room Monday ([DATE]) morning and saw the inhaler and Tums at bedside. She stated that the rescue inhaler was expired and there were two other non-rescue inhalers as well. The Unit Manager stated she ordered the rescue inhaler from the pharmacy for immediate replacement. When asked when the resident received the replacement, the Unit Manager stated it came into the facility Monday evening, and the nurse just put it in her medication cart. The Unit Manager provided the medication to the resident on Tuesday. When asked if the facility utilized any self-administration assessment form with input from the IDT, the Unit Manager stated that she was not aware of any. When told the resident had had the inhaler since admission, the Unit Manager stated she was not aware of that either. During a supplementary interview on [DATE] at 10:28 AM, Resident #104 confirmed he had the inhaler since he arrived to the facility and that he had used it a couple of times. The resident again stated, It is not right that they took it from me overnight. 2) Record review for Residet #7 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Malignant Neoplasm of Larynx, Malignant Neoplasm of Anterior Surface of Epiglottis, Paralysis of Vocal Cords and Larynx, and Tracheostomy Status. Review of the Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #7 included in part the following: An order dated [DATE] for Budesonide Inhalation Suspension 0.5mg via trach three times a day for cold, upper congestion. The order was discontinued on [DATE]. An order dated [DATE] for Budesonide Suspension 0.5mg/2ml give 2ml inhale orally every 12 hours for shortness of breath unsupervised self-administration. An order dated [DATE] for resident to perform self-laryngectomy care and nebulizer self-administration medication; returned demonstration noted and resident education form uploaded. Report abnormalities to provider when applicable. (There was no order for self-administration of medication prior to [DATE]). There was no Self-Administration of Medications evaluation/assessment completed for Resident #7 until [DATE]. Review of the Care Plan for Resident #7 dated [DATE] with a focus on the resident has Laryngectomy tube he does his own Laryngectomy care and refuses to let staff do treatment of trach. The goal was for the resident to have no signs/symptoms of infection through the review date. The interventions included in part the following: Ensure that trach ties are secured at all times. May self-administer nebulizer treatments as ordered. Monitor/document respiratory rate, depth and quality. Check and document every shift as ordered. Suction as necessary. On [DATE] at 12:14 PM an observation was made of Resident #7 sitting on the edge of the bed with the tracheostomy in place. There were two vials of Budesonide Suspension 0.5mg/2ml sitting on his windowsill and an open bottle of Hydrogen Peroxide 3% sitting on top of his air conditioning unit. During an interview conducted on [DATE] at 12:14 PM with Resident #7, who was able to communicate by writing on a pad of paper with pen, when he was asked who provides the Budesonide breathing treatments, he said he does. He has done it for years. When asked if he was ever told the medications need to be locked at all times, he said he used to lock them in his nightstand but lost the key quite some time ago and so he just uses the windowsill and the top of the air conditioning unit. During an interview conducted on [DATE] at 10:00 AM with Staff K Licensed Practical Nurse who was asked who provides Resident #7 with the Budesonide, she said it is not due to be given on her shift it would be the nurses on the shift when it is due. When asked if residents can administer medications themselves, she said only if they have been assessed to do so. When asked if the medications need to be secured at all times, she said yes. During an interview conducted on [DATE] at 10:15 AM with H Registered Nurse Unit Manager who was asked about Resident #7 self-administering medications, she said he would need to be assessed, and the meds would need to be secured at all times. She acknowledged the Budesonide and the Hydrogen Peroxide were unsecured at the bedside. Review of the policy Resident rights – Self Administration of Meds – Clinically Appropriate issued 06/2020, documented in part, Procedure: . 2. When a resident requests to self-administer medication(s), it is the responsibility of the interdisciplinary team (IDT) to determine that it is safe before the resident exercises that right.

Based on observations, interviews, and record reviews, the facility failed to provide nail care for 1 of 2 sampled residents (Resident #21), who was reviewed for nail care.The findings included: Record review revealed Resident #21 was admitted to the facility on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease, Muscle Weakness, Other Lack of Coordination, and Arthritis. A Significant Change assessment dated [DATE], documented Resident #21's Brief Interview for Mental Status (BIMS) score was 14. This indicated that he was cognitively intact. Resident #21's care plan last revised on 12/06/25 documented that he had an ADL (Activities of Daily Living) self-care performance deficit related to Chronic Obstructive Pulmonary Disease, Arthritis, and Muscle Weakness. A documented intervention, since 07/19/24, was for staff to trim and clean his nails on bath day and as necessary. An observation on 04/06/2026 at 12:32 PM revealed that Resident #21's fingernails were long. They were approximately one half of an inch past his fingertips. An interview with Resident #21 was conducted on 04/06/26 at 12:35 PM. When asked if he liked his fingernails this long, Resident #21 said I don't have anybody to clean them. I don't like them so long. A second observation of Resident #21's fingernails on 04/07/2026 at 2:12 PM revealed his fingernails were long. Light brown to medium brown colored sediment was under his fingernails. Both hands had long fingernails that were approximately one half of an inch past fingertips. An interview was conducted with Staff M on 04/07/2026 at 4:35 PM. When asked to observe and describe the condition of Resident #21's fingernails, Staff M said that they were too long, and they needed to be cut. Staff M explained that Resident #21 liked his nails short.

Based on observation, interview, and record review, the facility failed to effectively communicate and document communication with medical professionals for 1 of 5 sampled residents observed during the medication administration observation. Resident #126 had low blood pressure readings on two consecutive days and Staff E, Registered Nurse (RN) made independent decisions as to which blood pressure medications to hold and then later provide. The facility also failed to ensure accurate skin assessments for 1 of 14 new admissions as evidenced by the failure to include a skin impairment to the right leg of Resident #126.The findings included:1) Review of the policy Medication Administration and Documentation - General not dated, documented in part, Policy: Medication Administration and Documentation shall occur in a timely and accurate manner. 2. Medications are to be administered within a two-hour time frame (i.e. one hour before or after the medication order time. Responsibility: The licensed nurse: . 18. Documents administration of medication on the MAR (Medication Administration Record) or eMAR (electronic) immediately following administration. Documents any medications not administered (i.e. refused, etc.) and documents reason. 22. Documents all held or refused medications on MAR or eMAR. Uses prudent professional judgement by informing Physician in a timely manner when medications held, refused, or otherwise unavailable for administration.During a medication administration observation for Resident #126 on 04/08/26 beginning at 9:36 AM, Staff E, RN stated she had taken the resident's blood pressure earlier and it was 115/60 and that she was going to re-check it prior to the administration of her morning medications. Upon re-check the resident's blood pressure was 109/54. The RN told Resident #126, I will hold on to the BP (blood pressure) meds (medications) as your BP is in the good range Staff E stated she would hold the spironolactone (a blood pressure and diuretic, a pill to rid excess fluid through urination) and amlodipine (a blood pressure pill). Staff E returned to the medication cart and wasted the two blood pressure medications and stated, usually if it's below 110 (the upper reading of the blood pressure) we hold the medication.During medication reconciliation after the observation, the record revealed the same nurse had held only the amlodipine on 04/07/26 for a blood pressure reading of 98/63.During an interview on 04/08/26 at 11:13 AM, when asked if she was made aware the blood pressure medications were held on 04/07/26 for Resident #126, Staff F, Nurse Practitioner (NP) stated she was told yesterday that her blood pressure was under 110 and that she held her BP meds. When asked if she was told today, the NP stated, not yet, but we are rounding. When asked if she had been told which blood pressure medications were held yesterday, the NP stated she was not.During a supplemental interview on 04/08/26 at about 11:20 AM, when asked again the process for when a medication was held, Staff E, RN stated it would depend upon the parameters, but generally if the blood pressure was below 110 she would hold it to divert an emergency of extremely low blood pressures. The RN then stated she would wait two hours, re-take the blood pressure and give the medication if the blood pressure had increased above the 110 reading. When asked if she would document all of her interventions, the RN stated she should. When asked why she held both the amlodipine and spironolactone earlier that day, but only the amlodipine yesterday, the RN stated because the BP went up and she had given the amlodipine. When asked if she documented that follow-up administration of the amlodipine, the RN stated, Maybe not because if I'm in a hurry I may have forgotten. Review of the record lacked the documented administration of the amlodipine on 04/07/26. When asked if she was allowed to decide which medications to hold, the RN stated, No that is why I talk with the doctor. When told the NP was not aware which medication was held or that she only held one of the blood pressure pills, the RN stated, Oh.During a follow-up interview on 04/08/26 at approximately 11:39 AM, Staff F, NP stated she was unaware Staff E, RN, went back and gave the amlodipine on 04/07/26.During a follow-up interview on 04/08/26 at 1:08 PM, when asked again about her reason to hold both meds that same day, but only one medication the previous day, the RN stated because Resident #126 was already on another diuretic, Lasix, and yesterday after holding just the amlodipine she voided excessively. 2) Review of the record revealed Resident #126 was admitted to the facility on [DATE]. Review of the skin assessment dated [DATE] in the admission Evaluation, the assessment lacked any documented issues. Review of a second skin assessment dated [DATE] documented bilateral upper extremity bruising, a right foot wound, bilateral lower extremity discoloration, and bruising to the resident's jaw. This entry lacked any documented dressing or open area to the resident's right leg. Review of the skin assessment dated [DATE] documented bruising but lacked any skin issue to the resident's right leg. A skin assessment dated [DATE] lacked any documented skin issues.Review of the physician orders and progress notes lacked any documentation related to a skin issue to the resident's right leg.During an interview and observation on 04/06/26 at 8:06 AM, Resident #126 was lying in bed on top of the covers. A boarder dressing dated 3/30 was noted to the resident's right leg just below her knee. Photographic evidence obtained. When asked about the dressing to her leg, the resident was unsure what had happened.On 04/08/26 at 9:36 AM when asked about the dressing on her right leg, Resident #126 stated it had been removed by staff but was unable to recall when or by whom.During an interview on 04/09/26 at 10:09 AM, when asked about completion of the skin assessment at admission, Staff B, Unit Manager, stated the nurse should utilize the skin/wound section in admission Evaluation. The Unit Manager reviewed the skin assessments and agreed with the findings, confirming the skin assessment dated [DATE] was completed by the wound care nurse and lacked any documentation related to the right leg.

Based on observations, interviews, and record reviews, the facility failed to identify and treat hand contractures for 1 of 2 sampled residents, Resident #94, reviewed for range of motion. The findings included: Record review revealed Resident #94 was admitted to the facility on [DATE]. Her diagnoses included Gout, Glycoprotein Disorders, Rheumatoid Arthritis, Polyneuropathy, Arthritis and Dementia, Without Behavioral Disturbance. A quarterly assessment dated [DATE] revealed that Resident #94 had memory problems, and she required assistance with feeding. Her care plan for chronic pain related to Neuropathy and Arthritis, last revised on 06/18/24, included an intervention for physical activity to strengthen and improve mobility. It also included an intervention for staff to observe and report decreased functional abilities and decreased range of motion.An observation on 04/07/2026 at 11:00 AM revealed that both of Resident #94's hands were in her lap under a folded blanket. Staff N, her CNA (Certified Nursing Assistant), removed the blanket. Both of Resident #94's hands were contracted. Her fingers curled towards the palms of her hands. An interview was conducted with Staff N on 04/07/26 at approximately 11:00 AM. When asked if Resident #94 could open her hands to straighten the fingers, Staff N explained that Resident #94 did not open her hands. She said that Resident #94 kept her fingers curled in (like closed hands). Record review revealed no orders for a hand appliance to decrease the risk of further contracture. Medical physician's notes reviewed showed no mention of hand contractures. An interview with the Director of Rehabilitation on 04/09/2026 at approximately10:00 AM revealed that Resident #94 had no treatments for splinting or orthotic care for her hands. She said that the therapy department did not provide therapy for Resident #94's hand contractures. The Director of Rehabilitation confirmed that the benefits of treating hand contractures included possible prevention of pain and/or prevention of the contractures from worsening.

Based on record review and interview the facility failed to ensure offering and provision of the pneumococcal vaccine for 1 of 5 sampled residents, Resident #48.The findings included:Review of the record revealed Resident #48 was admitted to the facility 04/20/23. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact.Review of the electronic medical record under the immunization tab revealed documentation Resident #48 had refused the pneumococcal vaccine on 06/28/23. The record lacked any further documentation related to that vaccine.During a side-by-side record review and interview on 04/08/26 at 3:17 PM, when asked how often the pneumococcal vaccine was offered to residents, the Infection Preventionist (IP) stated upon admission and annually when they are obtaining consents for the flu vaccine. The IP was unable to find any evidence of a current consent for or declination of the pneumococcal vaccine for Resident #48.During an interview on 04/09/26 at 11:56 AM, when asked if she were offered the pneumonia vaccine would she want it, the resident stated, I think so. When asked if she knew what the vaccine was for, she stated she wasn't sure. When told the vaccine was to help prevent pneumonia the resident stated, I've had that before. When asked again if she would want the vaccine if it were offered to her, Resident #48 stated she would. When asked if she had been offered the pneumonia vaccine the resident stated she had not.During an interview on 04/09/26 at 11:59 AM, when asked about the cognition of Resident #48, Staff D, Registered Nurse (RN) stated she can be a little confused at times, but she is alert and oriented and can make her needs known.During an interview on 04/09/26 at 9:30 AM, when asked why the pneumococcal vaccine was missed for Resident #48 this past season, the Assistant Director of Nursing (ADON) stated they have no idea how she was missed.

Based on observations, interviews and record review, the facility failed to follow the approved menu for lunch on 11/06/24, and failed to notify the residents of the change in the menu. The findings included: 1. The approved menu for the lunch being served on 11/06/24 documented that residents were to be served 'Golden Fried Chicken'. The approved recipe for the 'Golden Fried Chicken' (no reference date) provided instructions that were documented as: Procedures: 1. For Frying: Fry at 350 degrees Fahrenheit (F) for 10-12 minutes, or until done. 2. For baking: place pieces in a single layer on a parchment paper lined sheet pan sprayed with pan release. Heat at 350 degrees F for 20-25 minutes or until done. 3. Serve 3 oz (ounces) portion. 4. CCP (Critical Control Point): [NAME] to a minimum internal temper of 165 degrees F. Notes: 3. Note: fry in batches; overcrowding the chicken will lower the oil's heat, leading to greasy chicken. 4. Note: Product is fully cooked. Do not overheat. During the follow up kitchen tour, on 11/06/24 at 11:30 AM, accompanied by the Dietary Manager and the Registered Dietitian (RD), it was noted that the chicken being plated and served to the residents was chicken wings that did not have an appearance of being 'Golden Fried Chicken', as the wings had no breading and did not have a 'Golden' color. Furthermore, the kitchen did not have the means to fry the chicken as instructed due to not having a fryolator or deep fryer for cooking. When the Dietary Manager was asked about the chicken wings not being Golden Fried Chicken, the Dietary Manager stated, the chicken was pan fried. The Dietary Manager further stated that the supplier was out of the fried chicken that would have been prepared for the meal. During an interview with Staff B, Dietary Aide, when asked about the preparing the 'Golden Fried Chicken' Staff B described the chicken as being chicken breasts that come breaded and commercially processed/cooked and that the kitchen only had to reheat to the appropriate temperature prior to hot holding and serving. 2. The approved menu that was posted on the units for the residents documented that the facility would be serving Golden Fried Chicken for lunch on 11/06/24. During the follow up kitchen tour, on 11/06/24 at 11:30 AM, accompanied by the Dietary Manager and the RD, it was observed that the facility was serving chicken wings that did not appear to be fried as there was no breading on the chicken wings and they did not have a color or appearance of being fried. During an interview with the Dietary Manager, when asked about the facility serving the chicken wings instead of the 'Golden Fried Chicken', the Dietary Manager stated that the supplier did not have the commercially processed fried chicken breasts that were supposed to be served according to the approved menu. When asked about the timing of the delivery of the chicken, the Dietary Manager stated that the delivery that did not include the chicken was on Monday (11/04/24). The Dietary Manager acknowledged that the menu displayed for the residents should have been changed and the residents should have been notified of the change. 3. The approved menu documented that the residents were to be served 4 ounces (oz) of fried chicken for the lunch meal on 11/06/24. During the Follow up kitchen tour, on 11/06/24 at 11:30 AM, accompanied by the Dietary Manager and the RD, while observing the meal being plated, Staff B was observed placing 3 bone-in chicken wings on the plates and then completing the meal with starch and vegetables. At the request of this Surveyor, Staff B placed 3 of the chicken wings that represented one serving on the facility's calibrated kitchen scale. It was noted that the chicken wings appeared to be equal parts bone (not edible) and chicken. The chicken weighed 4.5 oz. Staff B continued plating the meal and use a scoop to place a portion of mechanically altered chicken on plate. At the request of this Surveyor, Staff B placed a scoop of the mechanically altered chicken that represented one serving on the facility's calibrated kitchen scale. The portion of the mechanically altered chicken was 4.2 oz and did not contain bones in the portion. The Dietary Manager acknowledged that the residents were not being served the appropriate amount of chicken due to not having considered that the chicken being served contained bones for the regular menu, and instructed the kitchen staff to retrieve the regular meals that had already been placed in a cart so that an additional bone-in chicken wing could be added to the meals.

Based on observations, interviews and record reviews, the facility failed to provide meals prepared, served and stored in a sanitary manner in accordance with standards for food safety. The findings included: 1. During the initial kitchen tour, on 11/04/24 at 8:43 AM, accompanied by the Dietary Manager, Staff A, Dietary Aide, was observed handling open foods and working with food equipment without wearing any kind of restraint over his beard. The Dietary Manager instructed Staff A to put on an appropriate hair restraint. 2. During the follow up kitchen tour, on 11/06/24 at 11:30 AM, accompanied by the Dietary Manager and the Registered Dietitian, the internal temperature of cut melons on fruit plates was 51 degrees Fahrenheit (F) and the internal temperature of deli sandwiches (sliced ham) was 49 degrees F. It was noted that the fruit plates and the sandwiches were kept on a speed rack that was located directly next to the hot holding area at an ambient temperature with no additional cooling mediums to ensure that the foods are maintained at a safe temperature. The Dietary Manager acknowledged that the foods were not at the appropriate temperature and instructed staff to place the speed rack in the walk in cooler until proper temperature were reached. During an interview with the Dietary Manager, when asked about the process for preparing and cooling the fruit plates and deli sandwiches, the Dietary Manager stated that the items were prepared in the morning at ambient temperature in the processing area and then the whole rack is placed in the reach in cooler, and removed from the cooler just as the staff were prepared to begin plating the lunch meal. 3. The facility's policy, titled, 'Food Brought in the Facility by Family or Visitor', with a reference date of March 2020, documented: Policy: It is the right of the residents of this facility to have food brought in by family or other visitors. The food will be handled in a way to ensure the safety of the residents. Procedure: All food items that are already prepared by the family or visitor brought in will be labeled with name and dated. a. The facility will refrigerate label and dated prepared items in the nourishment refrigerator. During a tour of the unit pantry at the 100-200 unit nurse's station, accompanied by the Dietary Manager, there was a carton of eggs in a plastic grocery bag in the reach in refrigerator. It was noted that there was no label on the bag or the carton to designate which resident the eggs were for and when the eggs were placed in the refrigerator.

Based on interviews and record reviews, the facility failed to provide showers per resident's preferences and according to the shower schedule for 1 of 2 sampled residents reviewed for choices, (Resident #309). The findings included: Record review for Resident #309 revealed that the resident was admitted to the facility on [DATE] and moved to her current room on 10/11/24. According to the resident's most recent complete assessment, a Medicare 5-Day Minimum Data Set (MDS), dated [DATE], Resident #309 had a Brief Interview for Mental Status score of 14, indicating that the resident was 'cognitively intact'. The assessment documented that Resident #309 required 'substantial/maximal assistance' for bed transferring from the bed, and 'partial/moderate assistance' for bed mobility. Resident #309's diagnoses at the time of the assessment included: Hypertension, UTI (Urinary Tract Infection) (last 30 days), DM (Diabetes Mellitus), Hyponatremia, Hyperlipidemia, Malnutrition, Anxiety disorder, Depression, Polyneuropathy, Immunodeficiency, Muscle weakness, Dysphagia, Abnormalities of gait and mobility, Need for assistance with personal care, Constipation, Adjustment disorder with mixed anxiety and depressed mood, Muscle wasting and atrophy, necrotic bilateral lower legs (heels) and that the resident was at risk for pressure development with none present upon admission. Resident #309's orders dated 11/05/24 included: Resident prefers to shower Tuesday, Thursday and Saturday 1500PM-2300PM; Bed bath PRN (as needed) - every evening shift every Tuesday, Thursday, and Saturday. Resident #309's care plan for Activities of Daily Living (ADLs), initiated on 08/19/24 and most recently revised on 08/28/24, documented, Resident has an ADL self-care performance deficit related to Diabetes Mellitus, Urinary Tract Infection, history of Deep Vein Thrombosis, Hypertension, Hyperlipidemia, history of Cerebrovascular Incident, Neuropathy, history of Anxiety, Depression, Right lower extremity Cellulitis, Muscle Spasms, muscle weakness. The goal of the care plan was documented as, Resident will improve current level of function in ADLs through the review date. Date Initiated: 08/19/2024 Revision on: 09/05/2024 Target Date: 09/12/2024 Interventions to the care plan included: o showers as scheduled Date Initiated: 08/19/2024. o BED MOBILITY: The resident requires partial/moderate assistance by 1 staff to turn and reposition in bed frequently and as necessary. Date Initiated: 08/19/2024. o TRANSFER: The resident requires substantial/maximal assistance by 1 staff to move between surfaces frequently and as necessary. Date initiated: 08/28/24. During an interview, on 11/05/24 at 9:19 AM with Resident #309 and the resident's daughter, when asked about being provided with showers, Resident #309 stated that she had not been showered since being admitted to the facility. The resident's daughter stated that the resident had only been showered on two occasions since being admitted to the facility. Record review of an ADL task worksheet for the previous 30 days, documented that Resident received showers on 5 occasions and was provided bed baths multiple times. Further review of the resident's electronic health record revealed no documentation of Resident #309 refusing ADL care and showers. During an interview, on 11/06/24 at 4:43 PM with Staff C, CNA, when asked about providing showers to Resident #309, Staff C replied, I only work 2-3 days a week on 3 PM to 11 PM shift. She never refuses, if they refuse, I would let the supervisor know and document in the POC (Plan of Care). During an interview, on 11/06/24 at 4:46 PM, with Staff D, RN (Registered Nurse) Supervisor, when asked about ensuring that residents are provided showers per preferences and according to schedule, Staff D replied, I know when I am working, the CNA gives me the paper and I sign off on them and they go to the Unit Manager (UM). During an interview, on 11/06/24 at 4:52, with Staff E, LPN (Licensed Practical Nurse) /UM, when asked about ensuring that residents are provided showers per preferences and according to schedule Staff E replied, the shower sheets reflect what is in the electronic health record. I talk to them every day (referring to Resident #309 and the resident's family member) and they have not said anything to me about showers being an issue.

Based on observation, interview, and record review, the facility failed to speak in a dignified manner during care, activities, and meals for 4 of 4 sampled residents (Resident #36, #86, #8, and #83), reviewed for dignity The findings included: 1) Record review revealed Resident #36 was admitted to the facility 06/26/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. The MDS, section D, for Mood documented she sometimes felt lonely or isolated from those around her. Review of the Care Plan dated 10/15/24, documented Resident #36 had diagnoses of Major Depressive Disorder, Anxiety Disorder, and Schizoaffective Disorder. During an interview on 11/04/24 at 12:59 PM, when asked if she was being treated with dignity and respect, Resident #36 voiced that sometimes the Certified Nursing Assistants (CNAs) spoke another language in front of her. The Resident stated, Their feelings come out through their language spoken; I feel like they are talking about me. She explained sometimes she would go out to the nurses' desk to ask for something, and staff ignored her. When asked how that made her feel, the resident stated she didn't feel like she had done anything wrong and felt disrespected. When asked if she had told anyone about these interactions with staff, she stated she hadn't told anyone because she was afraid staff would be mad at her. During a follow up interview on 11/07/24 at 10:45 AM, when asked how her care had been since the last interview, Resident #36 stated There are only certain individuals who are not treating me nice; I wish nurses would ask me how I'm feeling more often. The resident voiced desire to address concerns with staff and thanked the surveyor for helping. During an interview on 11/07/24 at 10:56 AM, when Resident #36's concerns were brought up, the Social Services Director stated she was not aware of the situation. She agreed the resident was not treated in a dignified manner and should not fear retaliation from staff. 2) Record review revealed Resident #86 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #86 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the Care Plan dated 09/24/24, documented Resident #86 diagnoses include Major Depressive Disorder, Anxiety Disorder, dependence on Renal Dialysis, abnormalities of gait and mobility, and severe protein-calorie Malnutrition. During an interview on 11/05/24 at 8:35 AM, Resident #86 was observed to be visibly upset. When asked if staff treat her with dignity and respect, the resident replied, No they don't ever really respect me or treat me with dignity. When asked to provide an example, the resident stated One time I got back from dialysis and asked for my food, the (CNA) said it was too late to eat but offered me a peanut butter and jelly sandwich but I declined the sandwich. The resident stated the (CNA)'s response was Oh well then go walk and get it yourself. The resident replied to the (CNA) You know I can't walk. The (CNA) replied, Well then I guess you can't eat. When asked how that made the resident feel, she stated she felt disrespected. When asked if she had told anyone about the situation, she stated I don't tell them because they still have to take care of me and I don't want them to be meaner to me after. During an interview on 11/05/24 at 9:06 AM, when asked if he was aware of Resident #86's concerns, the Administrator was not aware of the concerns and agreed the resident had not been treated in a dignified manner and should not fear retaliation. During a follow up interview with Resident #86 on 11/07/24 at 10:40 AM, she thanked the surveyor for helping address her concerns. The resident stated, Thank you for helping me out the other day and reporting it for me, I just didn't want to get anyone in trouble. 25404 3) Record review revealed Resident #8 was admitted to the facility on [DATE], with readmission on 04/18/24, and resided on the secured memory care unit. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 5, on a 0 to 15 scale, indicating the resident was cognitively impaired, but exhibited clear speech. This MDS also documented Resident #8 had impaired vision secondary to glaucoma. Review of the current care plan initiated on 12/28/23 documented Resident #8 had potential impaired visual function related to glaucoma. A care plan initiated on 05/26/23 documented Resident #8 required set up assistance with the meal tray to eat. During an observation on 11/04/24 at 11:51 AM, 18 residents were in the main dining room awaiting lunch. Resident #8 was sitting at a long table with other residents, and loudly asked, Are we gonna eat? Staff responded yes and that the food was coming. The tray cart arrived at 12:22 PM, and a meal was provided to the resident sitting next to Resident #8, and she stated, I smell the food and again asked if she was going to eat. Staff did not provide food to Resident #8 until 12:38 PM, and never addressed her after her table mate received a meal. During a subsequent observation on 11/05/24 at 9:59 AM, Resident #8 was in the main dining room, which was also the activity room, and yelled out, Are we gonna eat? Staff F, Unit Manager responded, We just had breakfast about an hour and half ago and walked away. No staff asked if she was hungry and or if she wanted something to eat. 4) Review of the record revealed Resident #83 was admitted to the facility on [DATE], and currently resided on the secured memory care unit. Review of the current MDS assessment dated [DATE], documented the resident had not completed a BIMS evaluation as he was rarely understood. The most recent fall risk assessment dated [DATE] indicated the resident was at high risk for falls with a score of 23. Review of the care plan initiated on 08/22/23 documented Resident #83 exhibited a communication impairment due to Alzheimer's dementia, and staff were to gently approach the resident in an open, friendly, and relaxed manner. A care plan initiated on 08/16/24, documented the resident was at risk for falls related to muscle weakness, incontinence, poor safety awareness, and medication use. This care plan instructed staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening, and improved mobility. During an observation on 11/06/24 at 9:30 AM, Resident #83 was in the activity room and attempted to stand up from his wheelchair. Staff G, Certified Nursing Assistant (CNA) approached the resident, and spoke with him, telling him to be calm, as she was gently pushing on the resident's left shoulder. The CNA did not allow the resident to stand up from the wheelchair. At 9:34 AM Resident #83 again attempted to stand up from his wheelchair, and the same CNA did not allow the resident to stand all the way up and immediately encouraged him to sit back down. The Unit Manager went over to the resident and stated, [First name of resident], sit down on your butt please. Stay down . promise? At 9:42 AM, Resident #83 attempted to stand up again. Staff G, CNA, immediately stated, [First name of resident] sit down and gently pushed him back in the chair and stated, Sit back and relax. At 9:44 AM, Resident #83 again attempted to get up. Staff I, CNA, had just entered the common area, and went over to help Resident #83 stand for a few minutes. Resident #83 sat back down on his own, and did not try to stand back up. During an interview on 11/06/24 at 9:21 AM, Staff I, CNA stated Resident #83 could walk, and that she and Staff J, CNA, would often work together and they both allow him to walk from his bed to the bathroom, or down the hall with assistance. During an observation on 11/06/24 at 3:12 PM, Resident #83 was in his wheelchair near the nurse's station and stood up unattended. Staff H, Licensed Practical Nurse (LPN), went to him and immediately tried to get him to sit down, and the resident resisted. The resident stood for a few moments and was trying to walk. When asked if he could walk down the hall with assist, the LPN stated, Yes, but that is when he falls. After the surveyor questioned, the LPN walked with Resident #83 back to the activity room and sat back down in his wheelchair. The resident settled down and sat at the table.

Based on observations, interviews and record reviews, the facility failed to provide housekeeping and maintenance services as a means to provide a clean, safe, and home like environment on 3 of 4 units, in the Shower room and the outside patio. The findings included: During a tour of the facility, conducted on 11/04/24 from 9:00 AM to 4:00 PM, the following was observed: On the 200 unit: In room [ROOM NUMBER], the wall behind the head of the B (window) bed was damaged. In room [ROOM NUMBER], the wall to the left of the hand sink in the shared restroom was damaged and the wall to the resident's right side of the bed (A bed) was damaged. On the 300 unit: In room [ROOM NUMBER], the seat of the wheelchair for the resident in the D bed (closest to the door and on the right) was worn and there were multiple black marks on the floor. In room [ROOM NUMBER], the laminate surfaces of the over bed tables were damaged to a point where the particle board underneath was exposed. In room [ROOM NUMBER], the over bed table for the B bed was damaged to a point where the table leaned and was not sturdy. In room [ROOM NUMBER], there was a strong urine odor noted during all four days of the survey by several members of the survey team. On the 400 unit: Outside of room [ROOM NUMBER], a ceiling tile by the air conditioning vent was stained in a manner indicative of the tile being wet at some point. In room [ROOM NUMBER], the arms on both of the residents' wheelchairs were damaged to a point where the foam padding underneath was exposed and there was no remote for the television for the B bed. In room [ROOM NUMBER], the privacy curtain between the beds was stained and the wall by the closet was damaged. In room [ROOM NUMBER], the overbed tables were damaged to a point where the particle board underneath was exposed; the remote control for the television of the B bed was damaged; and there was a red light on the wall mounted air conditioning unit that indicated the filter needed to be cleaned or changed. In the shower room on the 100 unit, the baseboard and wall inside of the entrance to the room was damaged; the kick plate on the back side of the entry door was damaged; and there was a black mold like residue on the walls and in the grout of the shower stall. During the environmental tour, on 11/07/24 at 1:35 PM, the Maintenance Director and the Housekeeping/Laundry Supervisor acknowledged understanding of the concerns. The Maintenance Director stated, We are in the process of replacing the tiles. We have extra tiles, we are focusing on the tiles that need to be replaced and then we are going to overhaul room by room. The Administrator stated, we are waiting for regional to assist with the planning and the manpower to plan on re-doing the floors and the doors. The company that took over started managing the facility with a CHOW (Change of Ownership) in January 2024. We started ordering the new ones (referring to the over bed tables) and the issue that we had was that some of them were coming out of the box like that and we switched to the plastic ones. We are getting 20-30 per month and replacing the old ones. The Administrator and the Director of Maintenance were not able to provide a time frame for the repairs and replacement of the over bed tables when asked.

Based on interview and record review, the facility failed to ensure the participation of the resident in the development of the resident's care plan and ongoing participation in resident care planning meetings for 1 of 2 sampled residents reviewed for Care Planning (Resident #34). The findings included: On 11/04/24 at 9:14 AM during the initial resident interview with Resident #34, he stated that he was very upset at being unable to leave the facility. I want to get out of here. I am here against my will. As far as I know, I am still responsible for my own health care decisions, but no one lets me make decisions about my health care. I do not have a power of attorney or a health care surrogate. I have never been invited to any care plan meetings. All decisions are made by my sister, and I don't want anything to do with her. A review of Resident #34's Minimum Data Set (MDS) assessment showed that Resident #34 was assessed to have a Brief Interview Mental Status score of 13 out of a possible 15 (mildly impaired). There was no documentation in his electronic record which showed he had an assigned power of attorney or named anyone in his family as a health care surrogate or legal representative. There was also no documentation which showed that he was mentally incapacitated to make his own health care decisions. All the care plan meetings reviewed showed that Resident #34's sister had been invited to the care plan meetings, and she had attended, but there was no evidence that Resident #34 had been invited or attended any of the meetings other than his initial meeting at the time of admission. Record review revealed on 08/20/2024 at 1:13 PM MDS / Care Plan Note: care plan meeting held with [sister] reviewed care plan no care concerns noted. 04/02/2024 14:01 MDS/Care Plan Note: care plan meeting held with sister via phone would like resident to have double portions for breakfast in am, no other care concerns noted. 03/21/2024 13:04 - Social Services Note: Writer spoke with [resident's] sister that if [resident] has to be transferred to an ALF, she is requesting a facility in Okeechobee . 01/17/2024 13:59 - Social Services Note: CP [care plan] meeting held on 1/9/24 with IDT (Interdisciplinary Team), Pt's (patient) sister [name] and Brother in Law [name] as POC [plan of care] continues as reviewed. Pt is alert and oriented, with confusion however is able to communicate his needs effectively .They are requesting LTC for Pt (patient) . 01/12/2024 10:16 - MDS/Care Plan Note: Care plan meeting held with IDT and [Sister and Brother-in-Law]. Reviewed medications, weight, diet, meal intake, ADL's, Therapy, Code status, D/C (discharge) plan. Stated she would like to get POA (power of attorney) papers completed and will meet with notary and then give POA papers to SS (social services). Stated [resident] will not be able to return home, he was a Hoarder and will not be able to return to home he was living in. Continue with current plan of care. 12/22/2023 12:30 - Social Services Note: 48 hr CP meeting held with IDT team, sister, Niece and Pt at bedside as POC continues as reviewed. Pt is alert with confusion although is able to communicate his needs. Mood is stable with no behaviors evident. Family is very supportive and are requesting LTC (Long Term Care).No DPOA (Designated Power of Attorney) or AD (Advanced Directives) are on file, therefore Pt is a Full Code. On 11/07/24 at 11:51 AM, the Social Services Director was interviewed and asked to assist in locating any documentation as to why Resident #34 was not in attendance at this care plan meeting. On 11/07/24 at approximately 1:00 PM, the Social Services Director reported that she was unable to determine why the resident was not being invited or attending his care plan meetings. She also stated that she could not locate any documentation in the resident's record that the resident was unable to make his own health care decisions. On 11/07/24 at 2:29 PM, the MDS Coordinator stated, I have only been working for 2.5 weeks. She acknowledged that she could not find any documentation that Resident #34 was provided with an invitation to his care plan meetings. She stated, The Receptionist will mail out the letters to the family members, and the Activities Department hands out the letters to the residents. On 11/07/24 at 2:42 PM, the Activities Assistant stated that all the care plan meeting letters that are to be handed out to the residents are put in her mailbox, and she passes them out. She stated that she had no documentation to show that an invitation was provided to Resident #34. On 11/07/24 at 2:44 PM Resident #34 was again asked if he was provided with a letter of invitation to his care plan meetings, he adamantly stated, I have never been invited to a care plan meeting. If they gave me something, I wouldn't be able to read it anyways; I am illiterate. On 11/07/24 at 2:59 PM, the Social Worker was interviewed about Resident #34 being illiterate. She stated, He asks for the Chronicle every morning, and he was able to read the paper that I just now provided to him. I don't know why he would claim to be illiterate On 11/07/24 at approximately 4:00 PM, the Administrator was informed of the concern regarding Resident #34 not being involved with his care plan and lack of any documentation showing resident was invited and encouraged to attend his care plan meeting. It was also discussed with the Administrator that since the resident had no documentation showing he had appointed anyone to be his POA, Health Care Surrogate or Representative, it may not be appropriate for the resident's sister and brother-in-law to be invited to participate in his care plan meetings unless he gives his consent.

Based on observation, interview, and record review, the facility failed to provide assistance with grooming, including hair washing and nail care to 3 of 5 sampled residents, who were dependent upon staff for care (Resident #28, #40, and #44). The findings included: 1) Review of the record revealed Resident #28 was admitted to the facility on [DATE] and resided in the secured memory care unit. Review of Minimum Data Set (MDS) assessment dated [DATE] lacked a Brief Interview for Mental Status (BIMS) score as the resident was rarely understood. This MDS documented the resident needed partial to substantial assistance from staff for Activities of Daily Living (ADLs). Review of a care plan initiated 03/18/23 documented Resident #28 had a communication problem and impaired ability to make self understood and another initiated on 06/07/23 that she needed the assistance of staff for all ADLs. Review of the Certified Nursing Assistant (CNA) tasks indicated the resident had only had one shower in the past month. Observations on 11/04/24 at 12:16 PM, 11/05/24 at 9:58 AM, and on 11/06/24 at 9:49 AM all revealed the resident's hair needed to be washed as it appeared flat and greasy. During an interview on 11/07/24 at 11:40 AM, when asked about showers and hair washing for Resident #28, Staff J, CNA, stated that most of the time the resident was already up out of bed when she arrived to work. When asked if that was a reason to not provide a shower, the CNA did not answer. When asked if she had provided a shower to Resident #28, or washed her hair this week, the CNA stated, I think Monday. 2) Review of the record revealed Resident #40 was admitted to the facility on [DATE] and resided in the secured memory care unit. Review of Minimum Data Set (MDS) assessment dated [DATE] lacked a Brief Interview for Mental Status (BIMS) score, as the resident was rarely understood. This MDS documented the resident needed substantial assistance from staff for showering and bathing. Review of care plans initiated on 09/18/21 documented Resident #40 was severely cognitively impaired for daily decision making and needed the assistance of one staff for all ADLs. Observations on 11/04/24 at 12:11 PM, 11/05/24 at 9:39 AM. and 11/06/24 at 9:38 AM revealed the resident's hair needed to be washed. During the first two observations the resident's hair was hanging loose and appeared flat and greasy. The resident had her hair pulled back in a ponytail on the third observation and it remained greasy looking. 3) Review of the record revealed Resident #44 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 4, on a 0 to 15 scale, indicating severe cognitive impairment. An MDS assessment dated [DATE] documented a BIMS score of 7, and the resident indicated the provision of a bath and shower were very important. Although a care plan initiated on 04/07/24 indicated the resident refused showers and ADL at times, review of progress notes and CNA documentation lacked any documented refusal of care in the past 30 days. Observations on 11/04/24 at 11:20 AM and on 11/05/24 at 2:10 PM revealed Resident #44's hair needed to be washed as it appeared greasy. During a supplemental observation and interview on 11/07/24 at 11:48 AM, when asked if she felt as if Resident #44 was receiving proper care and services, the Power of Attorney (POA) stated, No look at that hair. It looks like it hasn't been washed in weeks. And these fingernails are way too long. [Name of Resident #44] would always keep her nails short and clean. Observation of the resident's fingernails revealed they were all very long. When asked if she had spoken to staff about her concerns, the POA stated she had just last week, to include the Social Services Director (SSD). During an interview on 11/07/24 at 11:58 AM, when asked if she was able to trim fingernails, Staff G, assigned CNA, stated she could but had not done so for Resident #44. During an observation and interview on 11/07/24 at 12:08 PM, Staff H, Licensed Practical Nurse (LPN) agreed the resident had excessively long fingernails and greasy hair. The LPN stated she was unaware the aides where not doing the ADLs and just hadn't noticed. The LPN agreed she should have noticed the needed care. On 11/07/24 at 12:18 PM, the SSD stated she did not recall any conversation with the POA of Resident #44.

Based on observation, record review, interview, and policy review, facility staff failed to assess lung sounds and vital signs pre and post nebulizer treatments for 3 of 3 sampled residents reviewed for nebulizer treatments (Residents #42, 95 and #63). The findings included: 1) Review of the policy titled, Respiratory Care and Oxygen Administration revised 10/2022 documented, in part, 12. Evaluation of respiratory status and breath sound and response to treatment should be documented in the clinical record. Review of the record revealed Resident #42 was ordered a nebulizer treatment, Ipratropium-Albuterol, every four hours for lung congestion. This order dated 11/05/24 specifically instructed to assess and document the resident's lung sound, pulse and respiration rates, and oxygen saturation level pre and post treatment. During an observation on 11/06/24 beginning at 4:18 PM, Staff N, Licensed Practical Nurse (LPN), obtained the nebulizer treatment for Resident #42 from the medication cart, placed the medication into the nebulizer mask, and started the treatment. The LPN checked the resident's oxygen saturation level and pulse rate, then looked at the resident for a moment and stated, No cough so breathing is clear. At 4:32 PM the LPN stated the treatment was complete and assessed the resident's oxygen saturation level and pulse rate again and left the room. The LPN confirmed she had completed the treatment. When asked if she would normally assess lung sounds with a stethoscope, the LPN stated she would. When asked why she did not do so for Resident #42, Staff N stated, If she is not coughing, she is clear. If she is coughing, I would listen. I used nursing judgement. She was clear. 2) Record review revealed Resident #95 was ordered the nebulizer treatment of Acetylcysteine Solution 10% for secretions, twice daily for three weeks, as of 10/23/24. A second nebulizer treatment initiated on 09/26/24 for Ipratropium-Albuterol was to be administered via nebulizer four times daily. Both orders specified to assess and document lung sounds, pulse and respiratory rates, and oxygen saturation levels, pre and post treatments. The second nebulizer treatment lacked any place to document the assessments. During an observation on 11/06/24 beginning at 12:44 PM, Staff K, LPN, gathered the Ipratropium Albuterol nebulizer to administer to Resident #95. The LPN put the medication into the nebulizer, hooked up the tubing to the resident's tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs), and began the treatment. The LPN stood at the bedside during the entire treatment, but did not perform any type of assessment or do any vitals. During an interview on 11/07/24 at 10:23 AM, when asked the assessment process when administering a nebulizer treatment, Staff K stated she took the resident's vitals prior to the treatment. When asked if there was any other type of assessment that needed to be done, the LPN was unsure. The LPN was unaware of the need to complete additional vitals after the treatment or to assess the lung sound pre or post treatment. 51137 3) Review of the policy titled, Standards and Guidelines: SG Respiratory Care and Oxygen Administration issued 3/2020 and revised 10/2022 documented, Guidelines: . 12. Evaluation of respiratory status and breath sounds and response to treatment should be documented in the clinical record, especially if treatment is provided as needed for an exacerbation or acute onset of a respiratory condition. Record review revealed Resident #63 was admitted to the facility 10/19/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS section I Active Diagnoses documented he had respiratory failure. Review of the Care Plan dated 10/19/2024 documented, Resident #63 has congestive heart failure and will have clear lung sounds, heart rate, and rhythm within normal limits through review date. This same care plan revealed interventions such as check breath sounds and monitor/document for labored breathing, monitor/document for the use of accessory muscles while breathing, and vital signs as ordered/PRN (as need.) During a medication administration observation on 11/06/24 at 04:20 PM, Staff L, Licensed Practical Nurse (LPN), administered a nebulizer treatment to Resident #63 without performing a pre-administration or post administration assessment. When asked how she knew if the medication was working for the Resident, Staff L states I could check his vitals and his breathing. When asked how she would do that and why she had not done that, Staff L stated she would check his pulse oxygenation, but she forgot. Staff L did not mention she would auscultate (listening with intent to examine) for lung sounds.

Based on observation, record review, and interview, the facility failed to ensure pain management for 1 of 5 sampled residents, as evidenced by the failure to administer a lidocaine patch, as per physician order for Resident #99. The findings included: Review of the record revealed Resident #99 had an order initiated on 10/31/24 for a lidocaine 5% patch, to be applied to the lower back daily at 9 AM and removed daily at 9 PM. A medication pass observation was made for Resident #99 on 11/06/24 at 8:57 AM, with Staff K, Licensed Practical Nurse (LPN). The LPN obtained a lidocaine 5% patch from the medication cart, took a piece of paper tape and applied to the outside of the patch, and wrote the date on the piece of tape, using a thick black marker. The LPN entered the resident's room, and upon pulling up the back of the resident's shirt, a lidocaine patch with the initials of Staff K and the date of 11/04/24 was noted on the resident's lower back. The LPN confirmed that was the patch she had placed on the resident's back on Monday 11/04/24, and that she did not work on Tuesday 11/05/24. The LPN also confirmed the order was for the patch to be placed on the resident's back every morning and removed every night. Further review of the November 2024 Medication Administration Record (MAR) revealed Staff K documented the placement of the patch on Monday 11/04/24. This MAR documented another nurse removed the patch on 11/04/24 at 9 PM, while a second nurse applied and removed a patch on 11/05/24. This obviously did not happen as the patch observed on Wednesday 11/06/24 was dated Monday 11/04/24. The Director of Nursing was made aware of observation on 11/06/24 during the morning, and agreed with the concern.