Every finding on record at Miami Shores Nursing and Rehab Center

Based on observation record review and interviews, the facility failed to meet infection control standards of practice for Resident #5 during hygiene care. This is evidenced by Staff A not performing hand hygiene, changing gloves or changing washcloths during hygiene care for Resident #5. There were 91 residents residing at the facility at the time of the survey. The findings included: On 06/24/25 at 01:13 PM, Staff A was observed not performing hand hygiene prior to the procedure. Upon the surveyor's entry into the room, the Certified Nursing Assistant (CNA) was already wearing a gown, mask, and gloves. The resident is on enhanced barrier precautions and has a Percutaneous Endoscopic Gastrostomy (PEG) tube; the PEG tube machine was noted to be turned off. The CNA removed the resident's soiled clothing, leaving the resident uncovered while filling the basin with water. Soap was added directly to the water. The CNA did not remove gloves or perform hand hygiene at any point during the procedure. The resident's face was washed using soapy water, and the same washcloth was used to cleanse the remainder of the body. After drying the resident, the CNA turned her to wash and dry her back, then applied a clean brief and gown. Following the procedure, the CNA emptied the basin, removed the gown, gloves, and mask, and discarded them in the trash. Review of the medical records for Resident #5 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Dysphagia, unspecified. Review of the Physician's Orders Sheet on 04/04/2024 revealed that Resident #5 had an order for Enhanced Barrier Precautions for peg tube use, every shift. Record review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Score of 00, on a 0-15 scale indicating the resident is cognitively impaired. Section GG for Functional Abilities documented the resident is dependent on eating, toileting, showering, sit to lying, upper and lower body dressing. Section K for Nutrition documented no or unknown loss or gain of 5% or more in the last month or loss or gain of 10% or more in the last 6 months. Record review of Resident #5's Care Plans revealed the resident requires enhanced barrier precaution related to tube feeding. Interventions include- Educate resident, responsible party or caregivers regarding enhanced barrier precaution. Follow infection control guidelines as indicated. Maintain enhanced barrier precaution as indicated during dressing, bathing/showering, transferring. providing hygiene, changing linens, changing briefs or assisting with toileting, device care or IV access line care, urinary catheter care, feeding tube care, tracheostomy/ventilator care, ostomy care, or during wound care. Record review of Resident #5's Care Plans revealed the resident has an activities of daily living (ADL) self-care performance deficit related to (r/t) diagnosis (Dx) diabetes mellitus (DM) , osteoarthritis, hyperlipidemia, dementia and gastroesophageal reflux disease (GERD). Interventions include - Apply left hand roll when out of bed for support and comfort. Apply Wedge Foam Cushion to high back WC, for positioning and comfort as tolerated. Enhanced Barrier Precautions for peg tube use. Interview on 06/24/25 at 03:30 PM with Director of Nursing (DON) stated Enhanced Barrier Precautions apply to residents with certain medical conditions, including those with PEG tubes, foley catheters, dialysis access, wounds, or surgical sites with staples. These residents require a physician's order for enhanced precautions, which must be acknowledged and signed off on every shift. Clear signage is posted outside the resident's room to guide staff on when and how to properly don and doff personal protective equipment (PPE). Non-compliance with these protocols has led to employee terminations in the past, reflecting the facility's commitment to strict adherence. Education on enhanced barrier precautions is provided weekly by the staff educator, with additional one-on-one training conducted as needed during real-time observations. During bed baths, gloves should be changed after cleaning and drying the resident to prevent cross-contamination. A separate washcloth should be used for the resident's face and replaced immediately if it becomes soiled. Interview on 06/24/25 at 11:43 AM with Staff F, LPN stated a patient is on enhanced barrier precaution if they have a peg tube, foley catheter or wound. Before entering the patient room, I must make sure I wear a gown, gloves and mask before providing care. I receive education monthly or when there is a new hiring, by the infection preventionist. Interview on 06/24/25 at 12:00 PM with Staff G, LPN stated a patient is on enhanced barrier precaution if they have a peg tube, wound or any open area. Before entering the patient room, I must wash my hands, put on my gown, gloves and mask before providing care. I receive education every day, by the infection preventionist. Interview on 06/24/25 at 04:00 PM with Staff H, CNA stated the residents on Enhanced Barrier Precautions usually have wounds, bedsores, Foley catheters, or PEG tubes. Before I give care, I knock on the door, introduce myself, and make sure I identify the resident. If there's a sign on the door, I get my supplies and put on a yellow gown, gloves, and a mask. I get training on how to properly wear PPE every other week from the staff educator. When I give a bed bath, I change my gloves during the process, use a different washcloth for the face and armpits, and make sure to cover the resident's top half while I wash the lower body. Review of the facility policy and procedure January 2018 regarding Bed Bath of Resident states During the Bed Bath: Cover patient with bath blanket and remove top bed linen (keep patient covered at all times). Remove gown while maintaining dignity. Begin bath in the following order, using a clean part of the washcloth for each 1. Eyes - Wipe from inner to outer canthus, no soap. 2. Face, neck, and ears 3. Arms and hands - Support joints; include fingernails. 4. Chest and abdomen - Keep female patients covered as much as possible. 5. Legs and feet - Clean toes and heels well. 6. Back and buttocks 7. Perineal area - Use clean gloves; cleanse front to back. Review of the facility policy and procedure August 2014 regarding hand washing/hand hygiene states all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single-use disposable gloves should be used: Before aseptic procedures; When anticipating contact with blood or body fluids; When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.

Based on observations, interviews, and record reviews, the facility failed to properly store controlled substances on three out of four sampled medication carts as evidenced by unreconciled medication monitoring/control record sheets. The facility had four medication carts. The findings included: On 6/24/2025 at 1:32 PM a medication administration observation was completed with Staff A, Registered Nurse (RN) on the west wing medication cart #1; Staff A, RN verified the physician's order, removed the controlled substance from a bingo card placed it in a medication cup; after administering the controlled substance, Staff A, RN returned to the medication cart and signed in the medication monitoring/ control record sheet to indicate the controlled substance was given. Interview on 6/24/2025 at 1:37 PM, the surveyor asked Staff A, RN about the protocol for documenting removal of a controlled substance. Staff A, RN replied, I sign the narcotic log after the resident takes the medication because if the resident refuses, I can't sign that I have given it. The surveyor asked Staff A, RN, to explain the purpose of the narcotic log and what is indicated when a substance is given or removed from bingo card and if the log needs to be accurate at all times. Staff A, RN revealed, the narcotic log indicates the substance was removed and yes the narcotic log need to be accurate at all times. On 6/24/2025 at 1:51 PM a medication storage check was completed with Staff B, Licensed Practical Nurse (LPN) on the east medication cart #1. At that time the controlled substance log was observed signed and dated with no time. Upon further review, the electronic administration record (EMAR) was observed unsigned for the controlled substance. (photo evidence) Interview on 6/24/2025 at 1:55 PM, Staff B, Licensed Practical Nurse (LPN) revealed the protocol for signing the narcotic log, Staff B, LPN stated: I administered the medication at 1:19 PM and forgot to sign. I am supposed to sign at the time I remove the medication from the bingo card. On 6/24/2025 at 1:58 PM, a medication storage check was completed on the east side medication cart #2 with Staff C, LPN, the Medication Monitoring / Control Record was observed signed, no date written, time written but the EMAR was observed signed at 8:40 AM. At 2:00 PM a second Medication Monitoring / Control Record was observed signed, no date written, no time written, amount written, amount written, amount written, amount correct, and the EMAR was signed for that medication at 9:40 AM. (photo evidence) On 6/24/2025 at 2:01 PM, during the continued medication storage check with Staff C, LPN a Bingo card of controlled substances was observed with a broken seal and tape reinforcing it. (photo evidence) Interview on 6/24/2025 at 2:01 PM, Staff C, LPN revealed: I didn't have my pen so I couldn't sign the sheet. Sometimes when the pharmacy sends the medication and the bingo card needs to be reinforced so the pill doesn't fall out. Someone placed a tape to help. The correct procedure is to call the pharmacy to resend the medication. On 6/24/2025 at 3:30 PM, the Director of Nursing stated: Nurses are to verify the physicians' order, verify in the narcotic book, pop out the narcotic, sign his or her name with time date amount at the time it is taken out of the bingo card. The narcotic should always be reconciled and signed out. If there is any tear or abnormality in the bingo card it should be sent back to pharmacy. Record review of a Policy titled 4.0 Schedule II Controlled Substance Medication (undated) revealed POLICY: This policy is to ensure adherence to state and federal laws relating to the dispensing of Schedule II controlled substance medications. In a non-emergency situation, Schedule Il controlled medications will NOT be dispensed without a written. or electronic prescription. In an emergency and when allowed by federal and state regulations and in compliance with the required documented follow-up procedure, Specialty RX, Inc. pharmacies WILL dispense Schedule Il controlled medications upon an oral authorization but to a 72-hour supply. To dispense Schedule III-V controlled medications, an oral, written, or electronic prescription is required. A pharmacist may not dispense more than a 30-day supply of a controlled substance listed in Schedule Ill upon an oral prescription issued in this state. H. Dispensing of Controlled Dangerous Substance 5. When a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials

Based on observations, record review and interviews the facility's Quality Assessment and Assurance (QAA)/QAPI) committee failed at demonstrating an effective plan of action to correct identified quality deficiency in problem areas as evidence by repeated deficient practice for F 880-Infection Prevention and Control and F 761- Label/Store Drugs and Biologicals. There were 91 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during a recertification conducted on March 23, 2025 through March 26, 2025, F880- Infection Prevention & Control was cited due to the facility's failure to implement infection control procedures related to trash and food observations on the floor inside The Resident's pantry room on the East side nursing station, indwelling catheter tube touching floor, staff not wearing proper personal protective equipment (PPE) and improper hand hygiene during wound care. F761- Label/Store Drugs and Biologicals was cited related to an unattended unlocked medication cart on the west side nursing station and medication and glucometer and lancets left at a resident's bedside. Review of the facility's policy and procedure titled Quality Assurance & Performance Improvement (QAPI) Plan QAPI Goals/Purpose Statement - Our purpose is to provide excellent quality resident/patient care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good resident/patient outcomes and perceptions of patient care. Our nursing home has a Performance Improvement Program which systematically monitors, analyzes and improves its performance to improve resident/patient outcomes. It recognizes that the value in healthcare is the appropriate balance between good measures, excellent care and services and cost. Scope - Our center's full range of services included in our QAPI program are post-acute care and long-term care. The QAPI committee will consist of representation from Minimum Data Set (MDS), nursing, social services, dietary, housekeeping & laundry, maintenance, medical records, activities and Risk Management/Staff education. Therapy, music therapy, human resources, resource development, business office and therapy departments will be asked for input or sit on a performance improvement project sub- committee as requested. Interview on 06/24/2025 at 3:20 PM the Administrator revealed, the QAPI (Quality Assurance and Performance Improvement) team consists of the Director of Nursing (DON), department heads, the administrator, wound care nurse, dietary staff, and the medical director. Meetings are held monthly, with the next meeting scheduled for this Thursday. The purpose of the QAPI meetings is to review quality assurance initiatives and performance improvement efforts, particularly focusing on previous citations and audit outcomes. The team evaluates post-survey findings and identifies deficiencies. Supervisors create audit forms to help track and monitor compliance. Current areas of focus include addressing previous deficiencies, improving infection control practices, ensuring privacy, preventing unattended medications, and enhancing documentation practices.

Based on observation, record review and interviews, the facility failed to follow their infection control protocol in the East side soiled utility room and with Resident's #2 and #57. This is evidenced by trash and food observations on the floor inside the resident's pantry room on the East side nursing station, Resident #2 indwelling catheter tube touching floor, staff not wearing proper personal protective equipment (PPE) when entering droplet precaution rooms during meal tray distribution and Improper hand hygiene during wound care. There were 96 residents residing at the facility at the time of the survey. The findings included: 1) On 03/23/25 at 07:51 AM, Staff were observed not wearing PPE while entering a contact/droplet resident room while distributing breakfast trays. 2) On 03/25/25 at 11:02 AM, observation of Wound Care. The Wound Care Nurse gathered supplies that consist of kerlix, normal saline, collagen, tape, 4 x 4 gauze, scissors, red bag and chuck pads. The Wound Care Nurse locked the computer and cart, knocked on the residents' door, provided privacy, washed hands, applied gown and double gloves. The old dressing dated 03/23/25. The Wound Care Nurse removed the old dressing and one pair of gloves. The Wound Care Nurse sanitized the gloves and applied a new pair of gloves. The Wound Care Nurse cleaned the wound, removed one pair of gloves and applied another pair of gloves. The Wound Care Nurse placed collagen power and 4 x 4 gauze on the wound, wrapped the kerlix and dated the tape on the wound. The Wound Care Nurse removed the gloves, gown, washed hands, throwed the red bag in biohazardous bin in the biohazard room, washed hands and signed off on treatment record. Review of the medical records for Resident #57 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Unspecified open wound, right lower leg, initial encounter. Review of the Physician's Orders Sheet on 03/24/2025 revealed that Resident #57 had an order for Collagen-Antimicrobial External Sheet (Collagen-Antimicrobial) Apply to Left lateral leg topically every day shift every other day for Surgical Wound Cleanse left lateral leg with normal saline, pat dry, apply Ag collagen sheet cover with 4x4 and wrap with kerlix every other day and as needed until resolved and Apply to Left lateral leg topically as needed for Surgical Wound Cleanse left lateral leg with normal saline, pat dry, apply Ag collagen sheet cover with 4x4 and wrap with kerlix every other day and as needed until resolved. Review of the Physician's Orders Sheet on 03/11/2025 revealed that Resident #57 had an order to Offload bilateral heels with pillows while in bed as tolerated, every shift. Review of the Physician's Orders Sheet on 02/20/2025 revealed that Resident #57 had an order for a Geriatric air mattress in place to promote wound healing and as preventative measures. Check for proper functioning every shift. Review of the Physician's Orders Sheet on 01/06/2025 revealed that Resident #57 had an order to Turn and reposition every (q) 2 hours (hrs) and as needed, every shift. Record review of Resident #57's Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Score of 15, on a 0-15 scale indicating the resident is cognitively intact. Section GG for Functional Abilities documented the resident is dependent on toileting, showering, upper and lower body dressing. Section H for Bowel and Bladder documented Resident #57 is always incontinent. Section J for Health Conditions documented no falls since admission. Section K for Nutrition documented no or unknown loss or gain of 5% or more in the last month or loss or gain of 10% or more in the last 6 months. Section M for Skin Conditions documented diabetic foot ulcers and pressure injury device for bed. Record review of Resident #57's Care Plans revealed the resident has a diabetic ulcer of the right lateral lower leg and is at risk for complication. Interventions include- Geriatric air mattress in place to promote wound healing and as preventative measures. Check for proper functioning every shift. Monitor Blood Sugar Levels. Monitor pressure areas for color, sensation, temperature. Interview on 03/25/25 at 11:23 AM with the Wound Care Nurse it was stated she has been the wound care nurse at this facility since 2022. The measurements for the wound on 3/13/25 were 6.2x4.7x0.2 cm and it is improving but the resident is non-compliant and refuses treatment or medications. The Resident has diabetes that slow down wound healing process. She has supplements like multivitamin for hair, skin and nails. The Resident is on enhanced barrier precautions for the open wound. The Resident has pain management and receives Percocet and Tylenol around the clock. The Resident has orders for an air mattress for offloading, pillow offloading, turn and reposition every 2 hours, bunny boots and weekly skin checks by nurses. The protocol for the new resident would be doing a skin integrity assessment form. She would fill out the form with the residents' information, do a head-to-toe assessment, document and if they have a wound, she would asses the wounds and call whichever doctor is responsible. I would ask the doctor what to order for the patient, insert the orders and make a note. There is a log for residents with wounds on admission and initial treatment. The Wound Care Nurse states she would put an order for an air mattress if required and call the family to explain what was found. The podiatrist comes every Thursday. The podiatrist sees patients with wounds from the knee down and the wound doctor see patients hip and up. The wound doctor comes on Tuesday's. The Wound Care Nurse states she rounds with the doctors. The surveyor asked the Wound Care Nurse why she used doubled gloves during the care and she stated it is within the protocol and she has doubled gloved during wound care observations in the past with the Agency for Healthcare Administration (AHCA) and they have been okay with it. 3) Interview on 03/26/25 at 12:54 PM with Staff H, Registered Nurse (RN) stated before entering the room, I fully apply PPE before going inside. Gown, gloves and mask. I received education about infection control and handwashing by Staff T, RN. The staff test for covid almost every day and a staff nurse does it. The residents stay isolated. Interview on 03/26/25 at 12:30 PM with Staff I, Licensed Practical Nurse (LPN) stated, I have been a nurse at the facility for [AGE] years. Before entering a residents room, the staff should put on PPE which consist of gloves, gown and mask. As a nurse, I would only test residents if they have signs or symptoms of covid. After the resident is positive, they should have 3 negative tests to be taken off isolation. I have received education about handwashing and infection control by a supervisor or Staff T, RN. Interview on 03/26/25 at 02:20 PM with Staff J, LPN it was stated before entering a residents room that is covid positive, I would put on my PPE. I received education on handwashing and infection control almost everyday by Staff T, RN. The supervisors test the residents to see if they are still are positive and they stay in isolation. Interview on 03/26/25 at 01:58 PM with DON it was stated I have been the DON at the facility for 2 months. Staff should perform hand hygiene when they encounter residents rooms, handling soiled linen or handling and passing out trays. Staff receive education monthly, have surveillance and on spot teaching by Staff T, RN. Staff should not double glove when giving care to residents. Staff should throw away gloves and wash hands. Interview on 03/26/25 at 01:09 PM with Staff E, Certified Nursing Assistant (CNA) stated I have been a CNA at the facility for one year. If a resident is covid positive I would put on mask, gown and gloves before entering the room. I have received education on infection control and hand washing, last year by Staff T, RN. I would wash my hands before feeding resident's, giving care, after taking out garbage, laundry and before passing food trays. Interview on 03/26/25 at 01:15 PM with Staff F, CNA stated I have been a CNA at the facility for [AGE] years. If a resident is covid positive I would wear a gown, glove, hat and mask before entering the room. I have received education on infection control and hand washing, yesterday by Staff T, RN. Interview on 03/26/25 at 01:24 PM with Staff G, CNA stated she has been a CNA at facility for [AGE] years. If the resident was covid positive, I would clean my hands, knock, apply gown, gloves, mask and shield for droplet precautions. My last education on infection control and handwashing was given a month ago by Staff T, RN. Review of the facility policy and procedure August 2014 regarding hand washing/hand hygiene states all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single-use disposable gloves should be used: Before aseptic procedures; When anticipating contact with blood or body fluids; When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 48906 4) On 3/23/25 at 7:01 AM an observation was made of trash and food on the floor inside the East side nursing station resident's pantry room (see photo). The Surveyor notified Staff L, Licensed Practical Nurse (LPN) and Staff L stated, The Resident's pantry room is used to store residents' food and residents who are capable are allowed to get ice and use the microwave. The surveyor asked why there was trash and food on floor and Staff L, LPN replied, I don't know, I cleaned it when I came on shift. Housekeeping cleans the room in the morning. On 3/23/25 at 8:43 AM the Environmental Services Director was interviewed about how and when the pantries are cleaned and stated, I clean the residents' pantry Monday thru Friday. Another Housekeeping staff cleans the resident pantry on weekends at 5:00am. There are two resident pantries. That staff member called to let me know she would be late and at that time it was the Porter's responsibility to clean the Pantry. On 3/23/25 at 8:54 AM Staff Q, Housekeeping staff stated, I normally come in at 5:30 am and clean the pantry. Today I came in at 8:00am and I cleaned it at 8:00am. On 3/23/25 at 9:08 AM Staff R, Environmental Services (porter) was interviewed and stated, I started work at 5:30am. When I come in I take out the trash Soiled Utility room and then checked the pantry and all the shower rooms. I did not clean the Resident pantry yet when you saw it because I was still taking out the trash from around the building. 5) On 3/23/25 at 7:10 AM The East side Soiled utility room was toured with Staff L, LPN. Staff L, LPN observed entering the room by inputting a code on a keypad. No concerns were observed inside the Soiled Utility room. When the surveyor walked away, Staff L, LPN was overheard telling another staff member that the door doesn't lock. At that time, the Surveyor returned to Soiled Utility room with Staff R, Environmental Services (porter) and Staff L, LPN and both staff revealed the Soiled Utility Room door was not able to locked. On 3/23/25 at 7:58 AM the Maintenance Director revealed the lock was fixed and noted in the maintenance logbook. 6) On 3/23/25 at 7:56 AM a mask and supplement carton was observed in the East Side shower room photo obtained). 7) On 3/23/25 at 10:20 AM There was an observation of two room doors with Droplet Precaution signs posted ajar. The signs included instructions that the door is to be closed at all times (photo obtained). The surveyor observed Staff O, Certified Nursing Assistant (CNA) in the hallway. The surveyor asked if it is within their protocol to leave doors open when residents are under Droplet precautions and Staff O, CNA replied, Sometimes the residents ask to leave the door open. I do not know why the doors were left open, but I will close them. Staff O, CNA closed both doors. 8) On 03/24/25 at 7:38 AM Resident#2 was observed in bed with oxygen in progress at 2 Liters per minute via a nasal cannula, no apparent distress was noted. The urinary catheter tubing was observed touching the floor (photo obtained). 03/24/25 07:42 AM Staff N, Licensed Practical Nurse (LPN) stated, I did a double and when I rounded this morning, and I checked on Resident#2. At that time the indwelling catheter tubing was not touching the floor. It appears the reason it was touching the floor was because someone lowered the bed too low. I round every two hours and as needed to make sure the proper interventions are in place. I communicate with the Certified Nursing Assistant (CNA) about required interventions for catheter care and I will reinforce. 03/24/25 at 7:53 AM Staff P, CNA stated, I am the CNA taking care of Resident#2 today. I have received in-services catheter care and the nurse speaks to me about catheter care. I empty the collection bag and record the amount. I don't allow the collection bag to touch the floor. I also make sure it is anchored to the bed. I made rounds this morning and the tubing was not touching the ground and I did not lower the bed. The bed should not be too low because the tubing or bag might touch the ground for infection control purposes. On 03/24/25 at 8:10 AM the Nursing educator advised the surveyor that the Indwelling urinary catheter system was changed. On 3/23/25 at 10:24 AM the Director of Nursing (DON) was interviewed about infection control concerns and stated, I have given several in-services about Enhanced Barrier Precaution (EBP) multiple times. The sign says when to use the Personal Protective Equipment (PPE). On 3/26/25 at 11:44 AM the DON revealed the nursing educator does frequent rounds on the floors and observes staff performing hygiene care and does on the spot teachings. We have 14 residents under Droplet Precautions for either Covid or exposure to Covid. Staff are required to don a gown, mask, gloves, a face shield is optional. The residents on Droplet Precaution doors should be closed. Some residents don't like having the door closed and request to leave it open. It is not recommended to leave the door open but we try to honor residents' rights and if that can't be done we find alternative means and it is care planned. We in-serviced all staff about Covid outbreak, hand hygiene, donning PPE, early signs and symptoms of Covid on 3/14/25. Staff are to monitor residents' catheters to make sure the urine is draining properly and catheter tubing is not kinked, or touching the floor. The Soiled Utility room door should be kept locked to prevent any infection. Record review of a POLICY/PROCEDURE: SUBJECT: Infection Prevention and Control and Surveillance Program DATE: January, 2020 INTENT: It is the policy of the facility to ensure that the Infection Control Program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations, and national guidelines. PROCEDURE: 1. The facility will establish and maintain an infection prevention and control program under which it: a. Prevents, identifies, reports investigate, and controls the spread of infections and communicable disease in the facility; An additional record review revealed a Policy titled SUBJECT: Standard and Transmission-based Precautions. DATE: (no date) INTENT: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with State and Federal Regulations, and national guidelines. PROCEDURE: Transmission-based Precautions 1. Transmission-based precautions include airborne, contact, and droplet precautions. Residents requiring airborne precautions will be transferred to a hospital or other health care facility with airborne precaution capability. Residents that require contact and or droplet precautions may remain at this facility. a. Staff are to put on a mask upon room entry and removed upon room exit of resident placed on droplet precautions. 12. a. Staff are to put on gowns and gloves upon room entry and remove gowns and gloves upon exit of resident room. Further record review revealed a policy titled Enhanced Barrier precautions revealed date written: March 2024 POLICY: Enhanced Barrier Precautions (EBP) will be in place for residents as set forth by CMS guidance pertaining to Multidrug-Resistant Organisms (MDRO's) in Memorandum Ref: QSO-24-08-NH March 20, 2024. Residents will be evaluated on admission for the need for EBP.

Based on observations, interviews and record review, the facility failed to provide supervision to prevent safety hazards for one resident (#2) out of 32 sampled residents as evidenced by an observation of an electrical cord plugged into an outlet suspended in the air in such a way that caused a tripping hazard in the room of Resident#2. There were 96 residents residing in the facility at the time of the survey. The findings included: On 03/23/25 at 9:44 AM an observation was made of an electrical cord for the air mattress wrapped around the side table, extending and suspended in the air, which caused a tripping hazard in the room of Resident #2. Staff H, Registered Nurse (RN) was present in the room at the time of the observation and was notified by the surveyor of the potential tripping hazard. Staff H, RN readjusted the plug behind the bed. On 03/25/25 at 12:18 PM the Nursing Home Administrator (NHA) was made aware by the surveyor about the tripping hazard observation and stated, Electrical cords should be behind the bed and plugged into the wall unit to avoid a tripping hazard. On 03/25/25 at 3:00 PM the NHA informed the surveyor that all plugs are now zip tied to the bed frame to prevent any tripping hazard. The NHA showed the surveyor a picture that revealed the electrical cord was zip tied around the bed frame. Record review of a demographic sheet for Resident #2 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses that included: Acute Respiratory Failure with Hypoxia and Covid-19. Record review of a significant change in status Minimum data set (MDS) reference dated 2/24/25 revealed Resident#2 had a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, no potential indicators of Psychosis, was dependent on staff for Chair/bed-to-chair transfer and no falls since Admission/Entry or Reentry or Prior Assessment. Record review of a Care Plan initiated on 09/25/2023 and revised on 09/25/2023 revealed Resident#2 was at risk for falls related to Monoplegia of right dominant side, muscle weakness and had interventions that included: Follow facility fall protocol. Record review of physician order sheet revealed an order dated 3/23/25 for Low air loss mattress in place as preventative measures and to promote wound healing. Check for proper functioning every shift. Record review of the policy (undated) titled, Miami [NAME] Nursing and Rehabilitation Safety and Supervision of Residents: revealed a Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation. Facility-Oriented Approach to Safety 4. Employees shall be trained and in serviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Electrical Safety.

Based on observation, record review and interviews, the facility failed to ensure residents' medical records are accurate in accordance with accepted professional standards and practices for one (Resident #33) out of one resident sampled, as evidenced by a Nurses' Progress Note for Resident#33 documented the resident was COVID 19 positive and the resident was COVID 19 negative. These practices has the potential to affect any of the residents residing in the facility. The findings included: Record review of the Charting and Documentation Policy and Procedure revised 03/2024 documented: Policy Statement-All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record; Policy Interpretation and Implementation-1) All observations, medications administered, services performed must be documented in the resident's clinical record; 2) Entries may only be recorded in the resident's clinical record by licensed personnel (Registered Nurse, Licensed Practical Nurse, Physician, Therapists). Review of the Charting Errors and/or Omissions Policy and Procedure revised 03/2024 documented: Policy Statement-Accurate medical records shall be maintained by this facility; Policy Interpretation and Implementation-1) If an error is made while recording the data in the medical record, Staff member will be added to the medical record as an error. Review of the Demographic Face Sheet for Resident #33 documented the resident was admitted on [DATE] with diagnoses that included but not limited to chronic obstructive pulmonary disease, diabetes mellitus, hypertension, acute kidney failure, protein-calorie malnutrition and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #33 documented the resident's Brief Interview of Mental Status (BIMS) Summary Score was 00, indicating severe cognitive impairment and required dependent assistance for ADLs (activities daily living). Review of the Nurses' Progress Notes for Resident #33 dated 3/24/2025 at 06:48 documented: Resident remaining in droplet/contact precaution for COVID 19 positive results using z pack in this moment asymptomatic with positive improvement. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for March 2025 documented the resident was not receiving antibiotics or a Z pack (Azithromycin). On 3/26/25 at 8:04 AM during an interview and record review, with the Director of Nursing (DON) it was stated, He does not have COVID. He does not receive any antibiotics such as Z pack. The progress note is inaccurate. On 3/26/25 at 9:59 AM during an interview with Staff B, Licensed Practical Nurse (LPN) revealed that the resident is not COVID positive.

Based on observations, interviews and record reviews, the facility failed to provide privacy for residents' information on two out of four computer screens on the East side nursing station as evidenced by an observation of an unlocked, unattended computer screen with resident information easily accessible/visible on the east side medication cart #1 and at the East side nursing station. There were 96 residents residing in the facility at the time of the survey. The findings included: 1.On 03/23/25 at 7:39 AM, an observation was made of an unlocked, unattended computer screen on the East side medication cart #1 (photo obtained ). On 03/23/25 at 7:41 AM Staff H, Registered Nurse (RN) returned to the medication cart and was asked by the surveyor the protocol for keeping residents' information private on computer screens and replied, I am supposed to lock the screen before I walk away. I was worried about getting the supervisor for you, so I forgot to lock the screen. 2. On 03/23/25 at 8:08, an observation was made of an unlocked, unattended computer screen at the East side nursing station with resident information visible (photo obtained). On 03/23/25 at 8:09 AM Staff M, Licensed Practical Nurse (LPN) was notified by the surveyor about the observation and immediately locked the computer and locked the screen and stated another staff member left it open. Record review of an undated Policy revealed SUBJECT: Patient Privacy DIVISION: Administration DOS Risk Management Services Director DATE: 6/2020 Patient Privacy Policy for Nursing Homes Purpose: The purpose of this policy is to ensure the protection of patient privacy and confidentiality in accordance with applicable laws, including the Health Insurance Portability and Accountability Act (HIPAA) and state-specific regulations. The policy aims to safeguard personal, medical, and financial information of residents in the nursing home, promoting trust, dignity, and respect. Scope: This policy applies to all employees, contractors, volunteers, and other personnel working in the nursing home, including those who handle patient records, communicate with patients, and interact with their families. Definitions: 1.Patient Information: All personally identifiable information (PII) and protected health information (PHI) about residents, including medical, financial, and personal details. 1. Confidentiality: The duty to protect patient information from unauthorized disclosure, access, or use. 2. Protected Health Information (PHI): Any information related to a patient's health condition, treatment, or payment that can be used to identify the patient. 4. Electronic Health Records (EHR): Digital version of a patient's medical history, including their treatment plans, medications, and appointments. Policy Statement 1. Confidentiality and Privacy: a. All patient information must be treated as confidential. Unauthorized access, use, or disclosure of patient information is prohibited. b. Patient information, whether written, electronic, or verbal, should only be disclosed to individuals who have a legitimate need to know, in compliance with legal and regulatory requirements.2. Access to Patient Information: a. Only authorized personnel who require patient information to perform their duties may access PHI. b. Patient information should be stored securely, and access to records must be restricted to those with proper authorization. 4. Electronic and Paper Records: a. Electronic records must be stored in password-protected systems with encryption to prevent unauthorized access. b. Paper records containing PHI should be securely stored in locked areas, and any physical documents that are disposed of should be shredded.

Based on observations, record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I was completed accurately prior to admission for three Residents (#50, #83, #60) out of three residents reviewed for PASARR. There were 96 residents residing in the facility at the time of the survey. The findings Included: Record review of the Pre-Admission Screening and Resident Review (PASARR) Policy and Procedure dated 2016 documented: Policy Intent-It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review; Procedure-1) A facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program as stated under Federal Regulations. 1) Observation of Resident #50 on 3/25/25 at 11:07 AM revealed the resident sitting up in bed with the television on. Record review of the Demographic Face Sheet for Resident #50 documented the resident was admitted on [DATE] with diagnoses of diabetes mellitus, hypertension, anxiety disorder, schizophrenia, atrial fibrillation, congestive heart failure and atherosclerosis heart disease. The resident was readmitted to the facility on [DATE]. Review of the PASARR for Resident #50 revealed the PASARR Level I was done on 1/21/25 with no diagnoses of Anxiety Disorder and Schizophrenia checked on the form with documented history. The form documented no PASARR Level II was required. PASARR Level I was completed by a Social Worker at the hospital on 1/21/25. Review of the Minimum Data Set (MDS) 5 Day Assessment for Resident #50 dated 1/28/25 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 00 out of 15 indicating severe cognitive impairment, resident is currently not considered by the state level II PASRR process to have a SMI (Severe Mental Illness) or ID (Intellectual Disability) or a related condition and the resident required substantial/maximal to dependent assistance for ADLs (Activities Daily Living). On 3/26/25 at 7:30 AM, interview with the Admissions Director. She stated, We update the PASARR, when they come here, if it is incorrect. On 3/26/25 at 8:07 AM, interview and record review with the Director of Nursing (DON). She stated, The PASSR was incorrect and should have included the diagnoses for Anxiety Disorder and Schizophrenia. 2) Observation of Resident #83 on 3/25/25 at 11:12 AM revealed the resident sitting up in bed, asleep with a catheter, tube feeding machine off and with the television on. Record review of the Demographic Face Sheet for Resident #83 documented the resident was admitted on [DATE] with diagnoses of acute respiratory failure, dementia, shortness of breath, insomnia, alzheimer's disease, hypertension, depression, mood affective disorder and psychosis. Review of the PASARR for Resident #83 revealed the PASARR Level I was done on 12/19/24 with no diagnoses of Psychosis, Depression, and Mood Affective Disorder checked on the form documented history and medications. The form documented no PASSAR Level II was required. PASARR Level I was completed by a Registered Nurse Worker at the hospital on 12/19/24. Review of the Minimum Data Set (MDS) Significant Change Assessment for Resident #83 dated 3/06/25 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 00 out of 15 indicating severe cognitive impairment, resident is currently not considered by the state level II PASARR process to have a SMI or ID or a related condition and the resident required partial/moderate to dependent assistance for ADLs (Activities Daily Living). Review of the Physician's Order Sheet (POS) for February 2025 and March 2025 for Resident #83 documented the resident received Quetiapine Fumarate Oral Tablet 25 MG (milligrams) Give 1 tablet via PEG-Tube at bedtime for psychosis and Escitalopram Oxalate Oral Tablet 10 MG Give 1 tablet via PEG-Tube in the morning for psychosis. Review of the Care Plans for Resident #83, written 12/19/24 documented the resident received antipsychotic medications. On 3/25/25 at 7:54 AM, interview with the Social Services Assistant. She stated, The Admissions Office checks the PASARRs. On 3/26/25 at 8:08 AM, interview and record review with Director of Nursing (DON). She stated, The PASARR was incorrect and should have included the diagnoses for Psychosis, Depression and Mood Affective Disorder. 48906 3) On 03/23/25 at 10:57 AM while sitting in the dining area, the surveyor overheard yelling in the hallway. The surveyor observed Resdient #60 standing in the doorway yelling. Multiple staff members were observed speaking to Resident#60 in a calm manner however Resident #60 continued to yell. Minutes later, Resident #60 agreed to sit in a chair in the doorway of the room. Record review of a demographic sheet for Resdient #60 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses that included: Depression, Psychotic Disorder with Delusions due to Known Psychological condition, schizoaffective disorder. Record review of an Annual Minimum Data Set reference dated 3/19/25 revealed A1500. Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? - No. Section I revealed Schizophrenia, Depression (other than bipolar), Section N-Antidepressant and Section O- E. Psychological Therapy, E1. Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days- 0. Record review of Care Plan initiated on 12/04/2024 and revised on 12/19/2024 revealed Resident #60 was noted with physically aggressive behaviors, had a goal to demonstrate effective coping skills through the review date. (Target Date: 03/16/2025) and interventions included: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later and Psychiatric/Psychogeriatric consult as indicated. Record review of a physician's order sheet revealed orders dated 2/7/24 to monitor for side effects r/t (related to) psychotropic med use and 7/10/24 to Trazodone Hydrochloride Oral Tablet 50 milligrams directions: Give 1 tablet by mouth at bedtime related to Depression. Record review of a PASARR Level 1 dated 6/2/23 revealed Section I: PASARR Screen Decision- Making A. MI or suspected MI (check all that apply): no diagnosis was checked. The surveyor requested the most recent PASARR from the Director of Nursing (DON). The Nursing Home Administrator presented the surveyor with a PASARR for Resident #60, dated 3/22/22, Section I: PASARR Screen Decision- Making A. MI or suspected MI (check all that apply): no diagnosis was checked. Interview with the Nursing Supervisor stated, Resident #60 was seen by Psychiatry yesterday and I will complete a new PASARR. The Nursing Supervisor presented a PASRR for Resident#60, dated 3/25/25 to Surveyor which revealed: Section I: PASRR Screen Decision- Making A. MI or suspected MI (check all that apply): Anxiety, Depressive disorder was checked. On 3/26/25 the DON presented the Surveyor with a Progress note written by the Psychiatrist dated 3/25/25. The progress note revealed a diagnosis that included: Schizophrenia. On 3/26/25, the Director of Admission and the Director of Nursing were interviewed about the PASRR process. The Director of Admissions stated, Upon admission I work with the Social workers in the hospitals prior to admission, to gather the clinicals and a completed PASARR. Sometimes the PASARRs are incomplete, and the diagnoses don't reflect the current medications the residents are taking. In this instance, I refer to the DON. The PASARR is used to make sure the resident is in the right setting due to any cognitive impairment or mental illness. If the resident is transferred to the hospital and returns in less than 30 days it is not required to update the PASARR. When Resident #60 was admitted there was no medication for depression and that is why no diagnoses were checked. On 3/26/25 the DON stated, When residents are admitted I review the medications and the history to make sure it is correctly reflected on the PASARR. We review the PASARRs monthly and/or when there is a change in behavior. PASARRs are also discussed in the morning meeting and the social worker is made aware and any new changes are care planned. We also get a psychiatric or psychologist consult for the resident. The PASARR for Resident #60 should have been updated at the time the antidepressant was prescribed to reflect all current mental illness diagnoses. The Psychiatrist evaluated Resident #60 yesterday (3/25/25) due to Resident #60 exhibiting increased anxiety and prescribed a new medication. Resident #60 is typically quiet, requires redirection and that is effective. Record review of a Policy and Procedure titled, Subject: Pre-Admission Screening and Resident Review (PASARR) Program revealed: DATE: 2016 INTENT: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations. DEFINITIONS: For purposes of this Policy: 1. An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b) (1). 2. An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in S483.102(b) (3) or is a person with a related condition as described in 435.1010 of this chapter. S483.20(k)(4) A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. PROCEDURE: 1. A facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program as stated under Federal Regulations to the maximum extent practicable to avoid duplicative testing and effort. Coordination 1. Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. 2. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status 2. The facility will not admit, on or after January 1, 1989, any new residents with: A. Mental disorder, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to: i. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and ii. If the individual requires such level of services, whether the individual requires specialized services; or B. Intellectual disability, as unless the State intellectual disability or developmental disability authority has determined prior to admission: i. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and ii. If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. 3. Exceptions. For purposes of this requirement include: 1. The preadmission screening program under paragraph(k)(1) of the regulation need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. 2. The State may choose not to apply the preadmission screening program under paragraph (k)(1) of the regulation to the admission to a nursing facility of an individual: Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, Who requires nursing facility services for the condition for which the individual received care in the hospital, and iii. Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. 4. Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If the facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.

Based on observation, interviews, and record review, the facility failed to develop and implement comprehensive care plans for Residents #43, #74 and #291 as evidenced by no comprehensive care plan with interventions for floor mats for one resident (#291), no implementation of a fall care plan for one resident (#74) out of 6 residents who use floor mats and no care plan for a neck brace for one (#43) out of two residents who require neck braces. There were 96 residents residing in the facility at the time of the survey. The findings included: 1. On 3/23/25 at 7:54 AM Resident#291 was observed in bed with one floor mat on the resident's right side, a call light was in reach. Another observation on 03/25/25 08:53 AM revealed bilateral floor mats were in place for Resident #291. Record review of a demographic sheet for Resident #291 revealed an admitted [DATE] with diagnoses that included: Syncope and Collapse, Muscle Wasting and Atrophy. Record review of an admission Minimum data set (MDS) reference dated 3/8/25 revealed Resident #291 had a Brief Interview of Mental Status (BIMS) score of 9, indicated moderate cognitive impairment and required supervision or touching assistance for rolling left and right and partial/moderate assistance for Sit to stand, transfer and walking 10 feet. Record review of a Care Plan initiated on 03/23/2025 and revised on 03/23/2025 revealed Resident #291 was at risk for falls and had no interventions pertaining to floor mats. Record review of Resident #291's current physician order sheet revealed no current orders for floor mats. On 3/25/25 at 11:45 AM, Staff H, Registered Nurse (RN) was interviewed about how many floor mats are required for Resdient #291 and stated, I was the nurse on Sunday and there was only one floor mat present on the Resident #291's left side because the resident usually gets out on that side of the bed. On 3/25/25 at 1:58 PM The MDS Coordinator stated, The floor mats had not been care planned until today for Resident #291. 2. On 03/23/25 at 9:53 AM Resident#74 was observed in bed, no distress, appears confused, bed low, call light in reach, one floor mat on the right side of resident. Staff N, LPN was asked how many floor mats are to be present and replied, I will check and get back to you. Record review of a demographic sheet for Resident#74 revealed an admitted [DATE] with diagnoses that included: Muscle wasting and Atrophy right upper arm, Right and Left Lower Leg, and Difficulty in walking. Record review of a Quarterly Minimum data set (MDS) reference dated 1/28/25 revealed Resident#74 had a Brief Interview of Mental Status (BIMS) of score 00, indicated severe cognitive impairment, uses walker and wheelchair, required partial/moderate assistance for walking and transfer. Record review of a care plan initiated on 02/01/2025 and revised on 02/01/2025 revealed Resident#74 was at risk for falls and had interventions that included: Provide bilateral floor mats for falls precautions and safety. Record review of a physician order sheet for Resident#74 revealed no orders for floor mats. Interview on 3/25/25 at 11:02 AM Staff N, Licensed Practical Nurse (LPN) stated, I am the nurse assigned to R#74 today. This resident is under fall precautions. One intervention is the floor mat on the right side of the resident because this is the side he usually tries to get up from the bed. I have observed this resident sitting on the right side of the bed. He can walk short distances with assistance and uses a wheelchair. The floor mat is used for safety precautions. This resident is to have one floor mat. On 3/25/25 at 1:34 PM the MDS Coordinator nurse presented the surveyor with a revised care plan for at risk of falls with a revised intervention dated 3/25/25: Provide right floor mats for falls precautions and safety. On 3/25/25 at 1:58 PM the MDS Coordinator stated, I am in charge of completing and updating care plans in conjunction with the nursing staff. The Restorative nurse communicates with me for residents who require floor mats for fall precaution. R#74's care plan was revised today (3/25/25) to reflect an intervention from bilateral floor mats to one floor mat on the right side. This intervention started over the weekend. On 3/26/25 at 8:24 AM the Restorative/ wound care nurse stated, Upon admission if a resident has a history of fall we put them in a fall program that includes close monitoring for 30 days, a low bed, and floor mat. The amount of floor mats are determined by the side the resident is observed trying to get out the bed without assistance. Sometimes it can be both sides. Resident #74 and #291 are not able to walk independently. We don't need a physician's order to implement floor mats. The floor mats are care planned. The floor mats were implemented for Resident #291 on the weekend due to observations by staff of Resident #291 trying to get out of bed. I told staff to place one floor mat on the side of the window. I informed MDS on Tuesday, 3/25/25. On 3/26/25 at 11:44am the Director of Nursing (DON) was interviewed by the surveyor about care planning concerns for floor mats. The DON stated there is a 24 hour report in the electronic health record where staff can check the updated status of residents. No order is required for floor mats but should be care planned. There is also a binder kept at the nursing stations that contain residents' who require floor mats. The Restorative nurse updates that binder. Record review of a Policy titled Comprehensive Care Plans DATE: 2010 REVISED: 12/2016, 3/2020 revealed DEPARTMENT: Nursing INTENT: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Every resident will have an Interdisciplinary Care Plan, with the Interim Interdisciplinary Care Plan initiated within 24 hours of admission. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. There will be ongoing documentation of the nursing process related to resident needs from admission to discharge. The interdisciplinary plan of care will be developed through collaborative efforts of the Interdisciplinary Team and other health care professionals. It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care. The resident and/or family member will be involved in the care planning. The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate. Developing the Care Plan: 1. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: b. Any services that would otherwise be required per regulation but are not provided due to the resident's exercise of rights, including the right to refuse treatment. Updating Care Plans: 1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. 3. The Care Plan will be updated and/or revised for the following reasons: d. A change in planned interventions; 51537 3) In an observation conducted on 03/23/2025 at 06:51 AM revealed, resident #43 lying in bed and stated that she was feeling tired. There were no visible signs of distress or discomfort at the time of observation. Her environment appeared to be calm, and no immediate concerns were noted. Observation of resident # 43 on 03/24/2025 at 09:11 AM. The resident was observed lying in bed the head of the bed was raised, and the resident stated she was tired. Observation of resident # 43 on 03/24/2025 at 01:14 PM. The resident was lying in bed, speaking very disoriented. Record review revealed Resident # 43 was originally admitted to the facility on [DATE]. Resident #43 diagnoses included Parkinson's disease without dyskinesia, without mention of fluctuations. Review of the physician's orders dated 8/20/2024 11:00pm Revision: 11/18/2024 revealed the resident must Keep C-collar in place at all times. Remove during care and inspect skin call MD if any abnormalities every shift. Record review of Resident # 43 Admission Minimum Data Set (MDS) Section C Cognitive Pattern in the Brief Interview for Mental Status (BIMS) documented 00 out of 15. Section G for functional status indicated the resident needs Supervisor/Touching Assistance for activities of daily living (ADL). The facility did not have a care plan for the use of the C-collar. Interview with Staff K, Registered Nurse (RN) on 03/25/25 at 9:14 AM revealed upon record review that the C-collar was to always kept in place, at this moment she proceeded to have the surveyor speak to restorative services for further information. Interview with the Physical Therapy Assistant (PTA) on 03/25/25 at 09:38AM revealed the resident is not doing therapy at this time, she revealed the resident is in a restorative program doing exercise and the surveyor needed to speak with someone from restorative. Interview with Staff G, Restorative Certified Nursing Assistant (CNA) on 03/25/25 at 10:05 AM revealed the resident was supposed to wear the C-collar constantly, but that normally she doesn't like to sleep in it, or wear it in the dining room, she also mentioned they continue to educate her of the importance of her wearing the C-collar. When the surveyor asked where the C-collar is now, the restorative aide revealed it is in the laundry, she stated the sponge is wet at the moment, but they will finish drying it and would place it back on the resident. Interview with DON on 03/26/25 at 02:14 PM revealed about the frequency of staff monitoring resident # 43, the DON responded that every 2 hours, the DON also mentioned the resident had been participating in a fall prevention program. Furthermore, she stated that in November 2024 Resident # 43 had a CT (Computed Tomography) scan for further evaluation, and the results were sent to the neurologist for reevaluation of the removal of the C-collar and no new order were received. Record review of the facility's policy and procedure to follow physicians order. Effective date 2005/Revised 2021 under Policy: The purpose is to ensure that residents receive care and services in timely a manner when orders are given by their Physicians. Policy 1. Physician orders will be followed as prescribed. If not followed, reason will be documented in Residents medical records.

Based on observations, interviews and record review, the facility failed to provide appropriate treatment and services for catheter care for one (Resident #2) out of one resident who has a suprapubic catheter as evidenced by observations of the urinary catheter tubing being kinked, and touching the floor. There were 96 residents residing in the facility at the time of the survey. The findings included: On 03/23/25 at 9:35 AM Resident #2 was observed in bed with oxygen in progress at 2Liters per minute via a nasal cannula and no apparent distress was noted. A urinary catheter tubing was observed kinking in a circle and the urine was not properly draining (photo obtained). Staff H, Registered Nurse (RN) was present in the room and was notified by the surveyor about the kinking of the tubing. Staff H, RN then straightened out the tubing to allow free flow of urine. Staff H, RN was asked by the surveyor the correct way to position the tubing and Staff H stated, I round every morning and check the catheter tubing. This morning, I found the night nurse was working with the indwelling catheter, so I didn't notice it was kinked. On 03/24/25 at 7:38 AM Resident #2 was observed in bed with oxygen in progress at 2 Liters per minute via a nasal cannula, no apparent distress was noted. The urinary catheter tubing was observed touching the floor (photo obtained). On 03/24/25 07:42 AM Staff N, Licensed Practical Nurse (LPN) stated, I did a double and when I rounded this morning, and I checked on Resident #2. At that time the indwelling catheter tubing was not touching the floor. It appears the reason it was touching the floor was because someone lowered the bed too low. I round every two hours and as needed to make sure the proper interventions are in place. I communicate with the Certified Nursing Assistant (CNA) about required interventions for catheter care and I will reinforce. On 03/24/25 at 7:53 AM Staff P, CNA stated, I am the CNA taking care of Resident #2 today. I have received in-services on catheter care and the nurse speaks to me about catheter care. I empty the collection bag and record the amount. I don't allow the collection bag to touch the floor. I also make sure it is anchored to the bed. I made rounds this morning and the tubing was not touching the ground and I did not lower the bed. The bed should not be too low because the tubing or bag might touch the ground for infection control purposes. On 03/24/25 at 8:10 AM the Nursing educator advised the surveyor that the Indwelling urinary catheter system was changed. Record review of a demographic sheet for Resident#2 revealed an admitted [DATE] and a readmitted [DATE] with a diagnosis that included Reflex Neuropathic Bladder. Record review of a significant change in status Minimum data set (MDS) reference dated 2/24/25 revealed Resident#2 had a Brief Interview of Mental Status (BIMS) score of 12, indicated moderate cognitive impairment, was dependent on staff for personal hygiene care, had indwelling catheter, and Neurogenic bladder, Obstructive uropathy. Record review of a Care Plan initiated on 11/01/2024 and revised on 03/07/2025 revealed Resident #2 had a suprapubic catheter related to obstructive uropathy and is at risk for complication with goals that included: be free of any s/s of infection through review date and interventions that included: Check tubing for kinks each shifts, Check catheter bag for any leakage and change as needed. Record review of the physician order sheet revealed an order dated 3/23/25 for 3/19/25-Foley catheter care every shift and as needed, Change Foley bag weekly every night shift every Sunday Change Foley catheter (16)FR every night shift every 1 month(s) starting on the last day of month for 1 day(s). On 03/25/25 01:58 PM Staff N, LPN was asked if this resident#2 has a suprapubic catheter? and Staff N replied, No. On 3/25/25 at 2:15 PM Staff S, Nursing supervisor approached the surveyor and revealed Resdient #2 had a suprapubic catheter. On 03/26/25 at 8:48 AM Staff N, LPN was reinterviewed and stated, Resident #2 has a suprapubic catheter. I thought it was an indwelling urinary (urethral) catheter because that is what this resident had before he went out to the hospital. I didn't know it was changed to a suprapubic catheter. I usually only empty the collection bag. After I spoke to you, I completed a skin check and realized there was a suprapubic catheter in place. On 03/26/25 at 11:44 AM the Director of Nursing (DON) was made aware of the catheter concerns and asked about procedures and protocols when providing catheter care and stated, Staff are to monitor the catheter to make sure the urine is draining properly, catheter tubing is not kinked or touching the floor. Also stated, The physician orders pertaining to catheter care for Resident #2 should have included suprapubic instead of Foley and they were updated on 3/25/25. Record review of a Policy titled, Urinary Catheter Care written: 4/01/2009 revision date: 9/14/2012, 01/12/2014 revealed: POLICY/PROCEDURE: The purpose of this procedure is to prevent infection of the resident's urinary tract. STEPS: 10. Secure catheter and check drainage tubing and bag to ensure that the catheter is draining properly.

Based on observations, interviews and record reviews, the facility failed to properly store medications as evidenced by an observation of a box of expired Rapid Antigen (Covid-19) test kits in one medication storage room and an unlocked cart (cart #1) on the west wing unit, and an unattended medication at the bedside for resident #2. The Findings included: 1) Accompanied by Staff S, an observation of the [NAME] Wing medication storage room was conducted on 03/23/2025 at 09:50 AM. The observation revealed a box with multiple expired Covid-19 test kits inside the bottom cabinet. Each Covid-19 test kit was observed with an expiration date of 01/30/2024. Staff S, Registered Nurse (RN) supervisor confirmed the expiration date and removed a box of multiple expired Covid-19 test kits. On 03/26/2025 at 02:58 PM, Staff S stated: The nursing supervisors are the ones in charge of monitoring and checking the medication storage room each shift. The supervisor from each shift is responsible of checking the crash cart, med room, and the pantry. When we find something or medication expired, we package it and return to pharmacy. If there is a medication that is expired in the med cart, we remove it right away and place it in the return bin for the DON (Director of Nurses) to waste it with the pharmacy. We are also supposed to place a sign on the box when it is expired, stating it cannot be used. To my understanding, a nurse cannot use a covid test without checking the expiration date first. We usually always have in-services regarding how long we are supposed to use, for example, the lancets, eye drops, solution for Accu-Check, covid tests, over the counter meds and where to look for the expiration date. Prior to administering medication, we are always supposed to check the expiration. We also have to label the Accu-Chek solution with the date it was opened and the date of expiration. On 03/26/2025 at 03:10 PM the Director of Nursing (DON) stated: The nursing supervisor and DON checks the medication storage rooms daily. If there are any supplies that are expired, we discard immediately. The expired covid test that you found, can still be used because there is an extended expiration date. It is stated in the FDA (Food and Drug Administration) website. The OHC ( Healthcare) Antigen self-tests were the ones that were expired. 48906 2) On 03/23/25 at 7:21 AM the surveyor was walking in the hallway, and an observation was made of the an unlocked medication cart (cart #1) on the [NAME] side nursing station. Staff U, Registered Nurse (RN) approached the medication cart and was asked by the surveyor about the protocol for medication storage. Staff U, RN replied, The medication cart should be locked when I walk away from it, but I forgot because I was moving quickly to assist residents. 3) On 03/23/25 at 9:35 AM the Surveyor entered the room of Resident #2. Staff H, RN was observed attempting to flush a feeding tube for Resient#2 to administer medication. Staff H was unable to flush the tube and told the surveyor that she would leave the room to retrieve an item to assist with the procedure. Staff H, RN exited the room. There was a cup of crushed medication mixed in water on the side table and a glucometer with a lancet on the side of the sink (photo obtained). On 03/23/25 at 10:33 AM Staff H, RN returned and was asked by the surveyor about the protocol for leaving medications. Staff H replied, I left the medication and glucometer with the lancet in the room because you (surveyor) were present. The proper protocol is to take the medications and materials with me. On 03/26/25 11:44 AM the DON and Nursing Home Administrator were informed of the observation and stated, The nurse didn't know she could not leave medications unattended. Record review of a Policy and Procedure titled, Medication Storage dated 2001 MED-PASS, Inc. (Revised April 2007) revealed a Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and policy review, the facility failed to assure cardboard boxes were properly disposed and contained on the facility grounds. Cardboard boxes were scattered on the ground outside the kitchen back door. The findings included: Record review of the Food-Related Garbage and Rubbish Disposal Policy and Procedure revised 4/2024 documented: Policy Statement-Food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters; Policy Interpretation and Implementation-4) Food storage boxes/containers will be disposed of by the end of each shift into the outside dumpsters. Observation of the outside of the facility at the kitchen back door with the Dietary Aide A on 3/23/25 at 7:01 AM. There were multiple cardboard boxes on the ground and not contained in the garbage bin. Photographic evidence submitted. On 3/23/25 at 7:03 AM, interview with Staff A, Dietary Aide. She stated, Someone is supposed to break down the cardboard boxes and take them to the garbage container. They should not be on the ground. On 3/23/25 at 8:27 AM, interview with the Dietary Director. He revealed that the carboard boxes were removed from the ground outside of the kitchen back door and should not have been on the ground.

Based on interview and record review, the facility failed to demonstrate effective plans of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F880 Infection Prevention & Control, as evidenced by the infection control protocol was not followed on the east side soiled utility room and failed to follow infection control protocol for one Resident # 57, as evidenced by a failure to implement hand hygiene. There were 96 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated October 19, 2023, F880 Infection Prevention & Control was cited related to the fact that the facility failed to implement infection control procedures for three (Residents 89, 347, 348) out of 28 sampled residents. Interview with the Director of Nursing (DON) on 03/26/25 at 03:44 PM. She stated that the Quality Assurance and Performance Improvement (QAPI) meetings are held each month. She stated that QAPI committee members are Medical Director, Administrator, Director of Nursing, Social Services, Business Office Manager, Dietary, MDS (Minimum Data Set), and Wound Care. She stated that they have daily meetings, and monthly recap meetings. They started reviewing the last meeting and focusing on the deficiencies the facility had in the last survey. She stated the way they monitor Quality Assurance is to continuously communicate with the different departments and make sure we track the corrective actions implemented. They also provide in-service education and regular performance review. She said staff addresses any concerns to their supervisor. Residents with weight issue get weighed weekly, if residents are not eating they have a team put a plan into place. When asked about staffing, she revealed they met the state requirements and they have increased supervision 7:00am-7:00pm. Record review of Quality Assurance/Quality Assurance Performance Improvement QAPI/QAA Goals/Purpose Statement: Our purpose is to provide excellent quality resident/patient care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good resident/patient outcomes and perceptions of patient care. [ .] has a Performance Improvement Program which systematically monitors, analyses and improves its performance to improve resident/ patient outcomes. It recognizes that the value in healthcare is the appropriate balance between good measures, excellent care and services and cost. We will monitor our operations for compliance with federal and state regulations.

Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for resident rooms. The findings included: Room# 37-D - On 10/16/23 at 10:10 AM, the night table was in bad shape, and had sharp edges. Room#31-D - On 10/16/23 at 09:17 AM, the sink was cracked and in disrepair. Room#32-D - On 10/16/23 at 09:30 AM, the sink was cracked and in disrepair. Room#34-D - On 10/16/23 at 09:39 AM, the night table was in bad shape, and had sharp edges. Room# 35D - On 10/16/23 at 09:55 AM, the night table in bad shape, sharp edges. On 10/19/23 at 10:01 AM the Maintenance Director was interviewed and stated, every day we do the tour in the rooms, and make sure that everything is working in perfect condition. He reported, they worked in the [NAME] area of the facility two years ago and finished like two years ago. The facility does not have inventory or stock because there is no space to keep stock in the facility, they order as they go. They can order two at a time, and they have been working on changes since the change of administration. 47124 room [ROOM NUMBER] - On 10/16/23 at 08:26 AM, the sink had cracked lines around the water stopper. room [ROOM NUMBER] - On 10/17/23 at 08:43 AM, the sink had cracked lines and orange discoloration around the water stopper. room [ROOM NUMBER] - On 10/16/23 at 08:33 AM, the sink had cracked lines around the water stopper. The counter had chipped paint. The third drawer down was not able to be pulled out and was stuck. On 10/17/23 at 08:33 AM, the third drawer was not able to be pulled out and was stuck. On 10/17/23 at 08:52 AM, The Maintenance Director approached the Surveyor stating the drawer was fixed. On 10/18/23 at 09:04 AM, the third drawer can be pulled out smoothly. On 10/19/23 at 08:28 AM, the third drawer down was movable. room [ROOM NUMBER] - On 10/16/23 at 08:41 AM, the sink had cracked lines around the water stopper. The counter had chipped paint. room [ROOM NUMBER] - On 10/16/23 at 09:20 AM, The sink was painted white. The sink had cracked lines into the white paint around the water stopper. On 10/19/23 at 10:02 AM, in an interview with the Maintenance Director. the Maintenance Director reported, The sinks in multiple rooms have cracks in them. What are the facility's plans to repair them?' The Maintenance Director stated, It's part of what we do every day. We paint and fix things every day. We worked on the west area of the facility two years ago. The administration changed since then. We replaced the sinks two years ago. I don't know how the sink was damaged. The plan is to work on the east side step by step. We cannot order but 2 sinks at a time due to space. In the review of the facility's policies and policies titled, Maintenance Service. Revised December 2009. The Policy Statement states Maintenance service shall be provided to all areas of the building, grounds, and equipment. In the section titled, Policy Interpretation and Implementation. 2. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards. F. Establishing priorities in providing repair service.

Based on observation, interview and records review, the facility failed to ensure one resident (Resident # 59) was free from the use of physical restraints, as evidenced by the facility's staff inhibiting the resident's ability to get out of his bed by placing four wheelchairs on each side of his bed, out of one resident investigated for restraints. This facility practice had the potential to have a negative impact on the health and safety of all 90 residents residing in the facility at the time of the survey. The findings included: During an observation of resident # 59 on 10/16/2023 at 09:25 AM, the resident was observed to be sleeping and four wheelchairs were observed around the bed. There were two wheelchairs by the right side and two wheelchairs by the left side of the bed. (Photographic evidence). On 10/16/2023 at 09:45 AM, Resident 59 was lying on his bed, awake. It was observed that the resident was dressed. Resident #59 was observed with four wheelchairs around the bed, there were two wheelchairs by the right side and two wheelchairs by the left side of the bed. Record review of the clinical records for Resident # 59 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE] and transferred to the hospital on 10/17/2023 due to malfunction of tube feeding. Clinical diagnoses included, but were not limited to, Unspecified Atrial Fibrillation; Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity; Aneurysm of the Ascending Aorta, without Rupture; Unspecified Dementia, Unspecified Severity, Without Behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Unspecified Mood (Affective) Disorder; Encounter for Attention to Gastronomy; Unspecified Severe Protein-Calorie Malnutrition; Noninfective Gastroenteritis and colitis, Unspecified. Record review of the physican orders dated 10/09/2023 revealed, Fall/Aspiration/Decubitus precautions, every shift. Record review of Admission Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns revealed the resident's Brief Interview for Mental Status (BIMS) summary score was 00 out of 15, indicating severe cognitive impairment. Review of Section E, Behavior revealed the resident had no potential indicators for Psychosis, physical behavioral symptoms were not exhibited. Review of Section P, Restraints and Alarms revealed the resident had no restraints. Record review of Falls Care Plan initiated on 08/31/2023 and the next review date 01/14/2024 revealed the resident was at risk for falls related to Osteoarthritis, Muscle weakness. Goal: The resident will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light was within reach and encouraged the resident to use it for assistance as needed. The resident needs a prompt response to all requests for assistance. Follow facility fall protocol. Interview with Staff A, Licensed Practical Nurse (LPN) on 10/16/23 at 09:45 AM revealed, she stated that she doesn't know why the chairs were by the resident bed. She stated that maybe staff want to know which one is good for the resident. Interview with Staff B, Certified Nursing Assistant (CNA) on 10/16/23 at 09:48 AM revealed, she stated the resident is at risk of falling, so the wheelchairs would protect him from getting out of the bed. She stated, when she got here in the morning the wheelchairs were there. She stated, she provided care for the resident and dressed him to get out of the bed. She stated, she is waiting for another CNA to help her to transfer the resident to the wheelchair. Interview with Director of Nursing/Risk Manager on 10/19/23 10:08 AM revealed, she stated resident # 59 is ambulatory with his wheelchair. She stated, the resident as alert and oriented to person and very confused. She stated, the resident was admitted in August 2023, he came without tube feeding and he lost weight, and the physician decided to place a tube feeding. She stated, she had no words to explain the incident with the wheelchairs because we trained all nursing staff not to use any restraints on residents. She stated, there were many interventions to prevent a resident from falls such as floor mats, bed in the lowest position. She stated, the nursing staff will have in-service education for abuse/neglect/restraints immediately. The CNA and the nurse had a teachable moment. Review of the facility's Policy and Procedures for Use of Restraints revised in April 2017 revealed, Policy: Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation. 1-Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.

Based on observation, interview, and record review, the facility failed to have the daily nurse staffing schedule posted prior to the beginning of shifts on two out of two nurses' stations. This practice had the potential to affect all 90 residents residing in those units and the public who visited the facility at the time of the survey. The findings included: During observation on the East nursing station on 10/16/2023 at 08:17 AM, it was noted that the staffing information posting board had no assignment written down on the board. On 10/16/2023 at 08:17 AM, Staff F, Licensed Practical Nurse (LPN), stated We don't have a schedule here. We keep the schedule at the other nursing station. During observation on the [NAME] nursing station on 10/16/2023 at 08:18 AM, it was noted that the staffing information posting board had no assignments written down on the board. On 10/16/23 at 08:19 AM, Staff E, Registered Nurse(RN), stated, The secretary called off today. I'm going to write the assignment down right now. On 10/16/23 at 08:21 AM, Staff F stated, Oh, I didn't know we had the schedule here. During an interview with the Staffing Coordinator on 10/19/23 at 11:02 AM regarding the staffing schedule, the Staffing Coordinator stated, I make the schedule in the afternoon before I leave and give it to the charge nurse for the next day schedule. They have to write it down on the board. On 10/19/2023 at 01:20 PM, the Assistant Director of Nursing (ADON) stated, the secretary is responsible for writing the schedule on the board in the morning at the start of the shift. The schedule is written by the staffing coordinator on the paper, then the secretary is supposed transfer the information to the board. The ADON then stated, What happened Monday is that the secretary called off because she has a death in the family. Review of the facility's policy and procedures titled, Posting Direct Care Daily Staffing Numbers that was revised in July 2016 revealed: Policy Statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy interpretation and implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and Licensed Vocational Nurse (LVNs) and the number of unlicensed nursing personnel Certified Nursing Assistant (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADLs), performing gastrointestinal feeds, giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notify physicians of changes of conditions. 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift.

Based on observation, record review and interview, the facility failed to implement infection control procedures for three (Residents #89, #347, #348) out of 28 sampled residents. As evidenced by Transmission Based Precaution (TBP) signage was not posted on Resident #347's door and oxygen therapy equipment not stored sanitarily for Resident's #89 and #348. This had the potential to affect 90 residents residing in the facility at the time of the survey. The Findings Included: 1. On 10/16/23 at 08:22 AM, observed Resident #89 in bed asleep, bed was in the lowest position, bilateral floor mats present, high back wheelchair in room, Continuous Positive Airway Pressure (CPAP) machine tubing and mask on the floor besides the resident's bed (Photo available). On 10/17/23 at 10:26 AM, Resident #89 observed in bed asleep, bed in lowest position, bilateral floor mats present, Continuous Positive Airway Pressure (CPAP) machine with tubing and mask exposed on bedside table (Photo available). On 10/18/23 at 08:50 AM, Resident #89 observed in bed asleep, bilateral floor mats present, bed in the lowest position, bedside table clean and clear. Review of the medical records for Resident #89 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Cerebral Infarction, Unspecified. Review of the Physician's Orders Sheet for October 2023 revealed, Resident #89 had orders that included but were not limited to: Oxygen (O2) at 2 liters /minute (LPM) as needed for shortness of breath or 02 saturation below 92%. Record review of Resident #89 's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score was unable to be determined. Section GG for Functional Status documented extensive assistance for bed mobility and transfer, total dependence for toilet use and limited assistance for eating. Interview on 10/17/23 at 09:42 AM, Licensed Practical Nurse (Staff C) from east wing stated, Resident #89 has a Continuous Positive Airway Pressure (CPAP) machine, It is his personal machine that he came with on admission, the family is supposed to be picking up the machine. I am not sure if he has used the machine, CPAP machines are usually used on the 3-11 PM shift, and I work on the 7-3 PM shift. On 10/19/23 at 08:21 AM during interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed, Resident #89 is on hospice, on admission his daughter brought the Continuous Positive Airway Pressure (CPAP) machine, she stated he was not really using it at home, we spoke to the hospice Doctor (MD) about the resident probably needing the CPAP machine. The MD stated to monitor the resident and he did not give any orders for the CPAP machine, we spoke to the resident's daughter and she stated that she will be in the facility to pick up the machine, the resident has never used the CPAP machine. Any resident's medical equipment if used it needs to be cleaned and disinfected and stored properly when not in use. The CPAP machine if used would be stored in a Ziploc bag with a date, and if not being used would be stored in its packaging and kept in a safe place for the resident. 2. On 10/16/23 at 08:34 AM, observed Resident #347's room door with Personal Protective Equipment (PPE) available hanging on the door, there was no signage observed on the use of PPE and what type of Transmission Based Precaution (TBP) the resident was on. (Photo available). On 10/16/23 at 8:40AM, Certified Nursing Assistant (Staff D) was present in hallway, when asked why the resident was on precautions, Staff D stated I believe the resident has a wound infection. On 10/17/23 at 8:48PM, Resident #347 was not in the room, the medical records revealed resident was discharged to the hospital on 10/16/23 at 8 PM. Review of the medical records for Resident #347 revealed, the resident was admitted to the facility on [DATE], last readmission was on 10/06/23. Clinical diagnoses included but were not limited to: Extended Spectrum Beta Lactamase (ESBL) resistance, Pressure Ulcer of unspecified heel, unstageable and Cellulitis of left lower limb. Resident #347 was discharged on [DATE]. Review of the Physician's Orders Sheet for October 2023 revealed Resident #347 had orders that included but not limited to: 10/9/23- Meropenem Intravenous Solution Reconstituted one (1) Gram (GM) Use 1 gram intravenously three times a day related to Extended Spectrum Beta Lactamase (ESBL) Resistance for 10 Days. Record review of Resident #347 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented the Brief Interview for Mental Status Score was unable to be determined. Interview on 10/17/23 at 9:53 AM Licensed Practical Nurse, Staff C, East Wing stated Resident #347 was transferred to the hospital on 10/16/23, the resident was on TBP for Extended Spectrum Beta Lactamase (ESBL) resistance. Staff C stated when a resident is placed on Transmission Based Precautions (TBP), the nursing supervisor and the Infection Control person make sure the resident has all the PPE and signage needed. The information about residents on TBP is communicated to the floor staff from the 24 hours report, verbally and the shift report. If a resident upon admission is on TBP, the assigned nurse, certified nursing assistants and housekeeping is informed by admissions and the supervisors. On 10/19/23 at 08:27 AM, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) stated Resident #347 was on contact precautions for an infection to the left heel ESBL positive, he came back from the hospital on readmission with the infection, when a resident is admitted on TBP, we call housekeeping to supply the PPE equipment box, get all the needed supplies from central supplies, get the signage, the ADON makes sure that all the equipment and signage is in the location where they are supposed to be. The nursing supervisor informs the nurse about the residents TBP status, the nurse informs the Certified Nursing Assistants (CNAs), also housekeeping and dietary staff are informed of the resident's TBP status. The central supply clerk checks the PPE supplies during the morning rounds daily and replenish what is running low, the nursing supervisor does daily rounds in the afternoon to make sure all PPE supplies are in place. Moving forward we are going to conduct an in-service with all the nursing staff about doing daily rounds and reporting any missing signage or PPE equipment/supplies for residents on TBP. There is an order in the system for this resident that states: Contact Isolation precautions, left heel wound ESBL positive. 3. On 10/16/23 at 08:29 AM, Resident #348 was observed in bed asleep, Oxygen (02) not running, the Nasal cannula (N/C) was hanging from the lower bed rail (Photo available), and the N/C tubing bag dated 10/16/23 was attached to the 02 concentrator. On 10/16/23 at 11:18 AM, Resident #348 was observed in bed awake. The surveyor attempted to interview the resident, but resident refused. On 10/17/23 at 10:23 AM, Resident #348 was observed in bed awake, he stated he is doing okay today, there was no oxygen concentrator or tubing observed in the resident's room. On 10/18/23 at 08:57 AM, Resident #348 was observed in bed receiving AM care, no distress was noted, and the oxygen concentrator was not in the room. Review of the medical records for Resident #348 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease (COPD). Review of the Physician's Orders Sheet for October 2023 revealed, Resident #348 had orders that included but were not limited to: Oxygen (O2) at 2 liters /minute (LPM)via nasal cannula (N/C) as needed (PRN) for (oxygen saturation) sp02 <92%. Record review of Resident # 348's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 15, on a 0-15 scale indicating the resident is cognitively intact. Section GG for Functional Ability and Goals documented supervision for eating, maximal assistance for all other Activities of Daily Living (ADLS). Interview on 10/17/23 at 09:55 AM with Licensed Practical Nurse, Staff C, from the East Wing stated when we make our rounds, we check to make sure the residents call lights are in reach, if a resident is receiving oxygen (02), an 02 sign needs to be on the door, if a resident is receiving breathing treatments we check how often, precautions and protocols, when 02 is not in use in the resident's rooms we store the 02 tubing in a Ziploc bag that is dated, the 02 tubing and supplies are changed weekly. On 10/19/23 at 08:14 AM during an interview with the Director of Nursing (DON) it was reported, when the 02 tubing is in use we put the date on the tubing, the tubing is changed weekly and when the 02 concentrator is not in used, it is placed in storage. We will be reeducating our nursing staff to pay attention during their rounds on the oxygen tube storage when the oxygen is not in use and making sure infection control standards are being followed regarding the 02-tubing storage. Review of the facility's policy and procedures titled, Infection Control/Cleaning and Disinfection dated January 2020 states: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Review of the undated facility's policy and procedures titled, Standard and Transmission Based Precautions states: Step #7-To designate a room for Transmission Based Precautions, a sign will be placed (Facility note where it will be, what it looks like, if color coded, etc.) Staff will be notified of the type of transmission-based precautions a resident is placed on and the reason. Staff are notified (Note how and when staff are notified, describe if staff are notified at staff huddle, shift change, or regular meeting).

Based on record reviews, observations and interviews the facility failed to follow tube feeding orders for 2 out of 5 sampled residents reviewed for tube feeding (Resident #72 and Resident #288). The findings included: Review of the facility's policy titled Tube (Enteral) Fed Residents with a revision date of 2019 included the following: The Dietitian/Diet Technician assesses the adequacy of the tube feeding and recommends changes as indicated. Nursing Services is responsible for the administration of the tube feeding. 1)Record review of Resident #72's clinical records revealed the resident was admitted to the facility on [DATE] with the most recent readmitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #72 had a Brief Interview for Mental Status of 0, which indicated that she had severe cognitive impact. Review of Section G of the MDS dated [DATE] documented that Resident #72 had a bed mobility self-performance of total dependence with support of one person, transfer self-support of total dependence with support of two persons, dressing self-performance of total dependence with support of one person, eating self-performance of total dependence with support of one person, toilet use self-performance of total dependence with support of one person, personal hygiene with self-performance of total dependence with support of one person. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #72's Care Plan dated 04/21/22 with a focus on problem of resident is at risk for complications of tube feeding i.e., aspiration, infection intolerance to feeding, and fluid overload/deficit. Goal was for resident to tolerate tube feeding without signs/symptoms (s/s) of complications and have stable weights thru next review date (NRD). Interventions included: Keep height of bed (HOB) on moderate high back rest. Tube feeding formula per Medical Doctor (MD) order. May hold feeding during shower care. Review of handwritten documentation in Nurse's Notes did not reveal any issues with the tube feeding for Resident #72. On 11/02/22 at 8:25 AM an observation was made of Resident # 72 resting in bed. Upon closer observation the resident had an unopened, bag of [MEDICATION(S)] 1.5 (formulary type) that was at the 1,500 milliliter (ml) mark out of a 1,500 ml capacity bag. The tube feeding was not infusing. On 11/02/22 at 10:10 AM an observation was made of Resident #72 lying in bed and singing. A closer observation revealed a tube feeding bag with [MEDICATION(S)] 1.5 (formulary type) that was started on 11/02/22 (no time was indicated). Closer observation revealed the tube feeding was at the 1,500 milliliter (ml) mark out of a 1,500 ml capacity bag. The tube feeding was at 60 milliliters per hour via an electric pump. On 11/02/22 at 11:05 AM an observation was made of Resident #72 resting in bed and watching television. A closer observation revealed the tube feeding was at the 1,450-milliliter mark out of a 1,500 milliliter capacity bag. The tube feeding was infusing via pump at 60 milliliters per hour via an electric pump. On 11/02/22 at 2:00 PM an observation was made of Resident #72 resting in bed and watching television. A closer observation revealed the tube feeding was at the 1,300 milliliter mark out of a 1,500 milliliter bag. The tube feeding was infusing at 60 milliliters per hour via an electric pump. The tube feeding according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The bag should have had the remaining tube feeding at the 1200 mark out of a 1500 ml capacity bag. 2)Record review for Resident #288 revealed that the resident was admitted to the facility on [DATE] with the most recent readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #288 had a Brief Interview for Mental Status of 0, which indicated that she had severe cognitive impairment. Review of Section G of the MDS dated [DATE] documented that Resident #288 had a bed mobility, transfer, dressing, eating, toilet use, and personal hygiene all had a self-performance of total dependence with support of one person. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #288's Care Plan dated 09/23/22 with a focus on problem of resident is at risk for complications of tube feeding i.e., aspiration, infection intolerance to feeding, and fluid overload/deficit. Goal was for resident to tolerate tube feeding without signs/symptoms (s/s) of complications and have stable weights thru next review date (NRD). Interventions included: Keep height of bed (HOB) on moderate high back rest. Tube feeding formula per Medical Doctor (MD) order. May hold feeding during shower care. Review of handwritten documentation in Nurse's Notes did not reveal any issues with the tube feeding for Resident #288. On 11/02/22 at 8:30 AM an observation was made of Resident #288 lying in bed with eyes closed. Upon closer observation revealed the resident had [MEDICATION(S)] 1.5 (type of tube feeding) that was started on 11/02/22 at 6:30 AM, it was infusing at 65 milliliters (ml) per hour via a feeding pump, with a volume of 1500 milliliters (mls) in a 1,500 milliliter (ml) bag. On 11/02/22 at 10:00 AM an observation was made of Resident #288 lying in bed with eyes closed. A closer observation revealed the resident had a tube feeding bag that was started on 11/02/22 at 6:30 AM. The tube feeding was at the 1,400 milliliter (ml) mark out of a 1,500-milliliter capacity bag. The tube feeding was infusing at 65 milliliters (ml) per hour via an electric pump. On 11/02/22 at 11:15 AM an observation was made of Resident #288 lying in bed with eyes closed. A closer observation revealed the resident had tube feeding that was started on 11/02/22 at 6:30 AM and was at the 1,350 milliliter (ml) mark out of a 1,500-milliliter capacity bag. The tube feeding was infusing at 65 milliliters (ml) per hour via an electric pump On 11/02/22 at 2:05 PM an observation was made of Resident #288 lying in bed with eyes closed. A closer observation revealed the resident had tube feeding that was started on 11/02/22 at 6:30 AM and was at the 1,300 milliliter (ml) mark out of a 1,500-milliliter capacity bag. The tube feeding was infusing at 65 milliliters (ml) per hour via an electric pump The tube feeding according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The bag should have had the remaining tube feeding at the 1,142.5 mark out of a 1,500 ml capacity bag. During an interview conducted on 11/03/22 at 9:05 AM with Staff H, Licensed Practical Nurse (LPN)when asked about tube feedings, she stated that the nurse is responsible for the tube feeding administration. Most times the tube feedings are hung and started at 6:00 AM and many of the resident's tube feedings are turned off from 10:00 AM to 2:00 PM for activities of daily care (ADLs) to be performed. During an interview conducted on 11/04/22 at 8:30 AM with the DON she stated that the nurse is responsible to monitor and document the tube feeding for residents. Any exceptions for the tube feeding from the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation in the progress notes should show how much tube feeding has been infused in their shift. The nurses also sign on the medication administration record MAR) as well. If the nurse just documented on the MAR, that would indicate that the feeding was infusing as ordered. During an interview conducted on 11/04/22 at 11:10 AM with Registered Dietician, when asked how does she know that the residents receiving tube feeding are they getting the full amount daily, she replied that she makes daily rounds and verifies that the tube feeding pump is running at correct rate and verifies that the hang time on the tube feeding bag and the amount left in the bag match the amount that should have been infused. She also stated that based on the residents' weights she will adjust the tube feeding accordingly.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, homelike environment for 4 out of 26 sampled residents (Residents #75, #54, #74, #288 and #11). The findings included: On 11/01/22 at 10:20 AM an observation was made of the light on the wall above the head of Resident #288's bed that had a pull cord of approximately 4 inches long (Photographic Evidence Obtained). On 11/01/22 at 10:30 AM an observation was made of the light on the wall behind the head of Resident #75's bed only had a pull cord that was approximately 3 inches long (Photographic Evidence Obtained). On 11/01/22 at 10:35 AM an observation was made of Resident #74's over bed table with the laminate peeling (Photographic Evidence Obtained). On 11/01/22 at 11:15 AM an observation was made in Resident #54's room of the wall mounted telephone next to her bed had no receiver (Photographic Evidence Obtained), On 11/01/22 at 10:55 AM an observation was made in Resident #11's room of a light bulb burnt out over the sink, and the vanity drawers on the right side of the sink do not close completely (Photographic Evidence Obtained). On 11/02/22 at 8:15 AM an observation was made of Resident #54's telephone mounted to the wall had no receiver. On 11/02/22 at 8:27 AM an observation was made of the light on the wall behind the head of Resident #75's bed only had a pull cord that was approximately 3 inches long (Photographic Evidence Obtained). On 11/01/22 at 10:25 AM an observation was made of a wooden handrail on the wall that was missing part of the wood on the bottom exposing splinters and a metal screw (Photographic Evidence Obtained). The location of the damaged handrail is on the north wall across from the across from a storage room near the West exit. On 11/03/22 at 8:45 AM an observation was made of a broken mirror located on the wall next to room number 25. Review of the facility's policy titled Environmental Services dated 03/01/10, included the following: The resident has a right to a safe, clean, comfortable, and homelike environment. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Facility will provide adequate and comfortable lighting levels in all areas. A tour of the facility was conducted on 11/04/22 at 9:20 AM with the Administrator and Staff F, Maintenance Assistant, the Administrator took notes of the items of concern and translated for Staff F, Maintenance Assistant (whose first language is Spanish). Staff F, Maintenance Assistant showed surveyor the Maintenance Log located at each nursing station, he explained that areas of concern by staff/residents are entered onto a repair requisition sheet that is kept in the Maintenance Log. Staff F, Maintenance Assistant said he reviews the Maintenance Logs daily on weekdays. He stated that the only staff that enter items of concern onto a repair requisition sheet are staff that work on the 11:00 PM -7:00 AM shift and weekend staff. For all other times a concern is identified by staff, they verbally inform the maintenance staff directly. During an interview conducted on 11/04/22 at 9:40 AM with the Administrator, he stated that they were and are using a Gang Tackling System for identifying and completing maintenance concerns. He stated they have not had a Director of Maintenance for about 4-6 weeks, and it is possible that all concerns may not have been documented since the Director of Maintenance left. They have plans to implement an electronic system (TELS) in the next year.

Based on observation, interview, and record review, the facility failed to assist during dining for 1 of 1 resident reviewed for Activities of Daily Living (ADLs), Resident #22. The findings included: In an observation conducted on 11/01/22 at 1:00 PM, the lunch tray was brought into Resident #22's room. Closer observation showed a tray with NAS (No Added Salt) diet mechanical soft consistency. The lunch plate was noted with meat lasagna, collard greens, and tropical fruits. Staff brought the tray into the room and walked out. Continued observation at 1:25 PM showed that Resident #22 only ate 10% of her lunch tray. In an observation conducted on 11/01/22 at 5:15 PM, the dinner tray was brought into Resident #22's room by Staff A, Certified Nursing Assistance (CNA). She set up the tray by the bedside and walked out of the room. Continued observation showed a dinner plate with an egg salad sandwich, potato salad, vegetable soup, and milk. At 5:32 PM, Resident #22 ate only 10% of her dinner meal. In an observation conducted on 11/02/22 at 7:34 AM, the breakfast tray was brought into Resident #22's room, and Staff walked out. Continued observation showed a breakfast tray with the following: Super cereal, pancakes, eggs, milk, coffee, juice, and fruits. At 7:55 AM, Resident #22 ate only 10% of her breakfast meal. No staff was observed in the room during this entire observation. A chart review showed that Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] showed that Resident #22 had a Brief Interview of Mental Status (BIMS) score of 01 out of 15 meaning the resident has severe cognitive impairment. Section G for eating showed that Resident #22 needs total assistance with one person assist for eating. A progress note dated 09/22/22 by the facility's clinical dietitian showed that Resident #22 weight was noted at 160 pounds on 09/19/22. It further showed that Resident #22 needs maximum assistance and encouragement with her meals. Another progress note dated 10/15/22 showed that Resident #22 lost 2 pounds and is now at 158 pounds. It further revealed that Resident #22 requires some assistance with her meals and needs to be encouraged at times. In an interview conducted on 11/02/22 at 2:53 PM with Staff C, Minimum Data Set (MDS) Coordinator stated that she based Section G on eating after speaking to the nursing staff, CNAs, Social Worker, and any staff members who interact with Resident #22. She also stated that the state of the residents might change, and she is only assessing their status for a specific time frame. In an interview conducted on 11/03/22 at 10:40 AM, Staff D, Certified Nursing Assistant (CNA), stated that Resident #22 needs assistance with her meals. She further stated that she needs encouragement with her meals and did that today for the morning meal. In an observation conducted on 11/03/22 at 11:10 AM with Staff E, a Certified Nursing Assistance, she was asked by Surveyor to take the weight on Resident #22. Staff E used the mechanical lift to take the weight of Resident #22, which showed a weight of 153.1 pounds. This showed a weight loss from 158 pounds from 10/13/22 to 11/03/22 at 153.1 pounds in about two and 1/2 weeks which is a 3.1% weight loss. In an interview conducted on 11/03/22 at 4:00 PM, the facility's Administrator was informed of the findings. Review of the facility's policy Activities of Daily Living (ADLs) dated 2005 showed that ADLs are both essential and routine aspects of self-care. This facility's policy encourages residents to maintain their highest practical level of functioning and prevent a decline in ADLs.

Based on interviews, observations and record review, the facility failed to provide activities of choice that met the resident's psychosocial needs for one resident, resident #59 (R#59), out of eight residents reviewed for activity choices. The facility failed to assist the resident in communicating with family and failed to meet the resident's need for spiritual/religious services outside of the facility. This facility practice had a negative impact on R#59's mental and psychosocial well being resulting in psychosocial harm. This has the potential to have a negative impact on all residents in the facility that require assistance with outside services. Findings Included: Observation and interview on [DATE] at 12:46 PM revealed resident #59 was in bed wearing a nightgown, the room appeared dark. The resident reported that he felt like he was in prison and that he could not go anywhere. Resident #59 began to cry as he explained that staff had informed him that he could not use the phone because he could not afford to pay. The resident kept crying as he expressed that he could not talk to his sister anymore because he did not have any money to pay for the phone call. Observation and interview on [DATE] at 1:05 PM revealed, resident #59 remained in his bed wearing his nightgown, the room remained dark. Staff F, a Certified Nursing Assistant (C N A), offered him lunch and/or the opportunity to attend the activity in the activity room, the resident refused and asked to be alone. The CNA reported, the resident did not want anything. The resident stated, he should have died a long time ago. The CNA explained, He is like that sometimes. Record review of the Comprehensive Minimum Data Set (MDS) for resident #59 with an assessment reference date of [DATE] revealed, the resident had a score of 14 on the Brief Interview for Mental Status (BIMS), which indicated the resident was able to verbalize his needs and was not cognitively impaired. A review of the social services progress note dated [DATE] noted R#59 was alert and oriented. Record review revealed, Resident #59 had a personal funds account handled by the facility and a balance of $453.18. Interview on [DATE] at 9:50 AM with Resident #59 revealed, Resident #59 again repeated that his concern was that he did not have any money and could not speak to his sister. He explained, the Social Services Assistant took his Social Security Card and his ID (identification), but staff had given him Zero Dollars the resident explained, he could not remember the name of the staff that told him he could not afford to call his sister anymore but it was months since he last spoke to his sister. (The resident appeared sad, and teary eyes). During the interview, Resident #59 reported, the activities offered in the East room were only for their religion. The resident explained that he was a Jehovah Witness since 1979 and that he informed staff that his religion was important to him. Resident #59 communicated his need to go to out to meetings on Mondays from 7:,[DATE]:30 PM and on Saturdays from 4:00 PM to 6:00 PM. He told the Activities Director or the Social Services Assistant (or both) that he wanted to go to a Kingdom Hall located not far from the facility. Staff told him he was going to have to wait and explained to him When somebody comes, that's when you will be able to go. The resident added, he felt bad about not being able to attend his religious services. The resident stated, I feel very bad, very bad, because we are called to be saved, I am a son of Jehovah. The resident also explained, he was not going to keep reminding staff about his need because it was not his place to do so. Interview with the Activities Director on [DATE] at 11:00 AM revealed, as the Activities Director, her duties included conducting quarterly and annual assessments in an effort to understand each resident's activity needs and preferences. The Activities Director explained, an individualized activities program was important, and without it the resident might get depressed. In addition, the Activities Director explained, being away from home might be difficult enough. During the interview, the Activities Director confirmed, the resident #59 was not participating in the activities, lately and that she had not attempted to coordinate outside religious services for R#59. She explained, she knew R#59 was a Jehovah Witness but did not know going to Kingdom Hall was important to him, the resident never told her. According to the Activities Director, the only thing the resident seemed to care about was talking on the phone with his family or friend. The Activities Director reported, the resident used to be on the phone a lot, and the only thing he wanted was to be able to use it and communicate with his family or friend. The resident had a cell phone his family provided, but it was more than a month since she last saw him using the phone. The Activities Director did not know what happened to the cell phone but remembered at some point a long time ago, at least two months she helped the resident by going to the store and paying for his phone. The Activity Director indicated that she used the facility's money. Record review of the Initial Activities Assessment for R#59 dated [DATE] noted, Resident is alert and oriented times three, he needs escort to Activities for Social Interaction he enjoys . Reading the Bible, going to Kingdom. A review of the Activity's Annual Assessments dated [DATE], as well as quarterly assessments dated [DATE] and [DATE], also noted activity interests that included Reading the Bible, going to Kingdom Hall. During a later interview, the Activities Director was unable to explain the reason for the discrepancy between her verbal report and the written activity assessments. The Activity Director again denied awareness that the resident was interested in going to the kingdom; her response was I don't know, maybe I wrote it wrong. During an interview on [DATE] at approximately 11:30 AM with the Activities Director and resident #59, the resident explained to the Activities Director his nephew took his cell phone. The resident also reported, facility staff told him he did not have the money to call his sister. R#59 again sobbed as he explained, he did not want to bother anybody anymore and he just wanted to go home . he also explained he was very smart and the best in math when he was younger, nobody was faster than him the resident kept crying, and took at least five minutes to redirect himself. Interview on [DATE] at 1:30 PM with the Social Services Assistant revealed, the Assistant said that she did not know the resident wanted to talk to his sister. She expressed that she could understand why someone might have told him that he would have to pay to make the phone call he was trying to speak to her every day; and its long distance you know . The Social Services Assistant explained, in the past, she assisted the resident by setting him up in her office so that he could talk to his sister. She also explained, it had been a long time since that happened but the resident never expressed any concerns. Interview on [DATE] at 3:12 PM with Staff L, a Certified Nurse Assistant (CNA) revealed, staff L was familiar with R#59 and cared for him almost every day. The CNA reported, the resident had a cell phone that his nephew took and had a non-working cell phone in his drawer. The CNA also reported, the resident used to talk to his sister a lot, but it has been a while since he last spoke to her. The CNA stated, the resident sometimes cried. She had seen him cry within the last three weeks, he cried while he was watching TV. The CNA tried re-directing the resident by talking to him about God, that usually worked. During an interview on [DATE] at 5:55 PM, with resident #59, he smiled as he happily reported, he had just finished speaking with sister. Within minutes, at the nurses' station, nurses on the unit, including staff D, a Registered Nurse Unit Supervisor and the Director of Nursing (DON) reported, the residents' sister called all the time and they transferred the call, and he spoke to her all the time. The charge nurse expressed, she could not understand why the resident would say that he was not speaking with her. Interview on [DATE] at 6:46 PM with R#59's sister revealed, the resident's sister was calling the facility almost every day, attempting to get a hold of her brother but was unsuccessful. The sister reported, she did not know what was going on, every time she called, she was either placed on hold, hung up on, or transferred to a line that would ring and no one would answer. The sister added, she lives in New York but was really close to her brother and she wanted to talk to him every day. In addition, the sister reported, I don't know what is going on with him, he is not under control, I don't even know because his nephew is not stable. I sent my brother a cell phone so I can talk to him every day. Now, I do not know what happened to the cell phone, but I was calling the facility almost every day. Sometimes I was so worried, I started wondering if he died , you know . I am the only one he has; I was the only one there when his legs were amputated. I do not want to die before him because I am the only one he has. I love my brother, I cried every day because I did not know what happened with him, before today it has been two months since I talked to him, they put me through to him today. I tried multiple times, I tried every day, at least every other day, sometimes the phone would ring and there was no answer, then one time this girl that speaks Creole, like us told me she would locate him and call me back, but she never did. I'm dying to see my brother, but I'm afraid if I fly down to Florida I would get sick, my son and nephew tell me I would get depressed . Record review of the nurses notes for R#59 dated [DATE] 1:00 PM revealed, Resident in bed, CNA reported the resident reported he wants to die resident was asked if he had a plan, the resident stated, I don't have any plans. Close observation maintained. Call placed to MD. Further review of the nurses notes at 2:00 PM revealed, Psych in facility resident was seen, no new orders given. Record review of the Psychiatric Evaluation Form dated [DATE] revealed, chief complaint, leave me alone, I did not say that. Note: Resident seen, Mood is fairly stable denies suicidal thoughts or plan, however staff reports recent mention of such. He states they misinterpreted his words. Record review of the Psychiatric Evaluation Form dated [DATE] revealed, chief complaint, stable. Note: Resident seen, Mood is fairly stable. Record review of the Psychiatric Evaluation Form dated [DATE] revealed, chief complaint, stable. Note: Resident seen, Mood is fairly stable, no evidence of [MEDICAL CONDITION] or behavioral issues. During an interview on [DATE] at 11:07 AM, staff D, The charge nurse supervisor, reported she could not speak for the resident's sister, but does not understand why she wouldn't ask for a supervisor or a manager if she had someone she was desperately trying to get a hold of.

Based on observation, interview and record review, the facility failed to demonstrate a system for ensuring the residents' activities program was monitored and re-evaluated for continued effectiveness for 2 of 8 residents (Residents #59 and #87) reviewed for activities planning. Finding included: 1) Observation and interview on [DATE] at 12:46 PM revealed resident #59 was in bed wearing a nightgown, the room appeared dark. The resident reported that he felt like he was in prison and that he could not go anywhere. Resident #59 began to cry as he explained that staff had informed him that he could not use the phone because he could not afford to pay. The resident kept crying as he expressed that he could not talk to his sister anymore because he did not have any money to pay for the phone call. Observation and interview on [DATE] at 1:05 PM revealed, resident #59 remained in his bed wearing his nightgown, the room remained dark. Staff F, a Certified Nursing Assistant (C N A), offered him lunch and/or the opportunity to attend the activity in the activity room, the resident refused and asked to be alone. The CNA reported, the resident did not want anything. The resident stated, he should have died a long time ago. The CNA explained, He is like that sometimes. Record review of the Comprehensive Minimum Data Set (MDS) for resident #59 with an assessment reference date of [DATE] revealed, the resident had a score of 14 on the Brief Interview for Mental Status (BIMS), which indicated the resident was able to verbalize his needs and was not cognitively impaired. A review of the social services progress note dated [DATE] noted R#59 was alert and oriented. Record review revealed, Resident #59 had a personal funds account handled by the facility and a balance of $453.18. Interview on [DATE] at 9:50 AM with Resident #59 revealed, Resident #59 again repeated that his concern was that he did not have any money and could not speak to his sister. He explained, the Social Services Assistant took his Social Security Card and his ID (identification), but staff had given him Zero Dollars the resident explained, he could not remember the name of the staff that told him he could not afford to call his sister anymore but it was months since he last spoke to his sister. (The resident appeared sad, and teary eyes). During the interview, Resident #59 reported, the activities offered in the East room were only for their religion. The resident explained that he was a Jehovah Witness since 1979 and that he informed staff that his religion was important to him. Resident #59 communicated his need to go to out to meetings on Mondays from 7:,[DATE]:30 PM and on Saturdays from 4:00 PM to 6:00 PM. He told the Activities Director or the Social Services Assistant (or both) that he wanted to go to a Kingdom Hall located not far from the facility. Staff told him he was going to have to wait and explained to him When somebody comes, that's when you will be able to go. The resident added, he felt bad about not being able to attend his religious services. The resident stated, I feel very bad, very bad, because we are called to be saved, I am a son of Jehovah. The resident also explained, he was not going to keep reminding staff about his need because it was not his place to do so. Interview with the Activities Director on [DATE] at 11:00 AM revealed, as the Activities Director, her duties included conducting quarterly and annual assessments in an effort to understand each resident's activity needs and preferences. The Activities Director explained, an individualized activities program was important, and without it the resident might get depressed. In addition, the Activities Director explained, being away from home might be difficult enough. During the interview, the Activities Director confirmed, the resident #59 was not participating in the activities, lately and that she had not attempted to coordinate outside religious services for R#59. She explained, she knew R#59 was a Jehovah Witness but did not know going to Kingdom Hall was important to him, the resident never told her. According to the Activities Director, the only thing the resident seemed to care about was talking on the phone with his family or friend. The Activities Director reported, the resident used to be on the phone a lot, and the only thing he wanted was to be able to use it and communicate with his family or friend. The resident had a cell phone his family provided, but it was more than a month since she last saw him using the phone. The Activities Director did not know what happened to the cell phone but remembered at some point a long time ago, at least two months she helped the resident by going to the store and paying for his phone. The Activity Director indicated that she used the facility's money. Record review of the Initial Activities Assessment for R#59 dated [DATE] noted, Resident is alert and oriented times three, he needs escort to Activities for Social Interaction he enjoys . Reading the Bible, going to Kingdom. A review of the Activity's Annual Assessments dated [DATE], as well as quarterly assessments dated [DATE] and [DATE], also noted activity interests that included Reading the Bible, going to Kingdom Hall. During a later interview, the Activities Director was unable to explain the reason for the discrepancy between her verbal report and the written activity assessments. The Activity Director again denied awareness that the resident was interested in going to the kingdom; her response was I don't know, maybe I wrote it wrong. During an interview on [DATE] at approximately 11:30 AM with the Activities Director and resident #59, the resident explained to the Activities Director his nephew took his cell phone. The resident also reported, facility staff told him he did not have the money to call his sister. R#59 again sobbed as he explained, he did not want to bother anybody anymore and he just wanted to go home . he also explained he was very smart and the best in math when he was younger, nobody was faster than him the resident kept crying, and took at least five minutes to redirect himself. Interview on [DATE] at 1:30 PM with the Social Services Assistant revealed, the Assistant said that she did not know the resident wanted to talk to his sister. She expressed that she could understand why someone might have told him that he would have to pay to make the phone call he was trying to speak to her every day; and its long distance you know . The Social Services Assistant explained, in the past, she assisted the resident by setting him up in her office so that he could talk to his sister. She also explained, it had been a long time since that happened but the resident never expressed any concerns. Interview on [DATE] at 3:12 PM with Staff L, a Certified Nurse Assistant (CNA) revealed, staff L was familiar with R#59 and cared for him almost every day. The CNA reported, the resident had a cell phone that his nephew took and had a non-working cell phone in his drawer. The CNA also reported, the resident used to talk to his sister a lot, but it has been a while since he last spoke to her. The CNA stated, the resident sometimes cried. She had seen him cry within the last three weeks, he cried while he was watching TV. The CNA tried re-directing the resident by talking to him about God, that usually worked. During an interview on [DATE] at 5:55 PM, with resident #59, he smiled as he happily reported, he had just finished speaking with sister. Within minutes, at the nurses' station, nurses on the unit, including staff D, a Registered Nurse Unit Supervisor and the Director of Nursing (DON) reported, the residents' sister called all the time and they transferred the call, and he spoke to her all the time. The charge nurse expressed, she could not understand why the resident would say that he was not speaking with her. Interview on [DATE] at 6:46 PM with R#59's sister revealed, the resident's sister was calling the facility almost every day, attempting to get a hold of her brother but was unsuccessful. The sister reported, she did not know what was going on, every time she called, she was either placed on hold, hung up on, or transferred to a line that would ring and no one would answer. The sister added, she lives in New York but was really close to her brother and she wanted to talk to him every day. In addition, the sister reported, I don't know what is going on with him, he is not under control, I don't even know because his nephew is not stable. I sent my brother a cell phone so I can talk to him every day. Now, I do not know what happened to the cell phone, but I was calling the facility almost every day. Sometimes I was so worried, I started wondering if he died , you know . I am the only one he has; I was the only one there when his legs were amputated. I do not want to die before him because I am the only one he has. I love my brother, I cried every day because I did not know what happened with him, before today it has been two months since I talked to him, they put me through to him today. I tried multiple times, I tried every day, at least every other day, sometimes the phone would ring and there was no answer, then one time this girl that speaks Creole, like us told me she would locate him and call me back, but she never did. I'm dying to see my brother, but I'm afraid if I fly down to Florida I would get sick, my son and nephew tell me I would get depressed . Record review of the nurses notes for R#59 dated [DATE] 1:00 PM revealed, Resident in bed, CNA reported the resident reported he wants to die resident was asked if he had a plan, the resident stated, I don't have any plans. Close observation maintained. Call placed to MD. Further review of the nurses notes at 2:00 PM revealed, Psych in facility resident was seen, no new orders given. Record review of the Psychiatric Evaluation Form dated [DATE] revealed, chief complaint, leave me alone, I did not say that. Note: Resident seen, Mood is fairly stable denies suicidal thoughts or plan, however staff reports recent mention of such. He states they misinterpreted his words. Record review of the Psychiatric Evaluation Form dated [DATE] revealed, chief complaint, stable. Note: Resident seen, Mood is fairly stable. Record review of the Psychiatric Evaluation Form dated [DATE] revealed, chief complaint, stable. Note: Resident seen, Mood is fairly stable, no evidence of [MEDICAL CONDITION] or behavioral issues. During an interview on [DATE] at 11:07 AM, staff D, The charge nurse supervisor, reported she could not speak for the resident's sister, but does not understand why she wouldn't ask for a supervisor or a manager if she had someone she was desperately trying to get a hold of. 2) Review of Resident #87's clinical record beginning on [DATE] revealed Resident #87's most recent admission to the facility was on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #87's Admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #87 was rarely/never understood and therefore a Brief Interview for Mental Status could not be conducted. Resident #87 was indicated as moderately impaired for daily decision making. Under Section F Preferences for Customary Routine and Activities, the following questions were indicated as 1. Very Important: How important is it to you to listen to music you like?, How important is it to you to be around animals such as pets?, How important is it to you to keep up with the news?, How important is it to you to do things with groups of people?, How important is it to you to do your favorite activities?, How important is it to you to go outside to get fresh air when the weather is good?, and How important is it to you to participate in religious services or practices?. The question of How important is it to you to have books, newspapers, and magazines to read? was indicated as 2. Somewhat important. Resident #87 was documented as the person providing the information. Review of Resident #87's Quarterly MDS dated [DATE] showed Resident #87 continued to be rarely/never understand and therefore a Brief Interview for Mental Status could not be conducted. Resident #87 was indicated as moderately impaired for daily decision making. Review of Resident #87's Quarterly Social Services assessment dated [DATE] showed Resident #87 does not have the presence of pain that impacts her socialization. Review of Resident #87's Initial Activities Assessment completed on [DATE] showed Resident #87's mental status as alert and oriented to self, to staff members by face, and to family/friends. She was described as moderately social and was not marked for cognitive impairment. Her perception of placement was indicated as has little awareness and activity limitations indicated enjoys watching TV, gospel music, and church. Her mobility was indicated as using a wheelchair, her vision was indicated as good, her hearing was indicated as good, her communication was indicated as understands, and under Other was written is able to make self understood. Under Interests Resident #87 was indicated for music, religious/spiritual, social entertainment, special events, movies/TV/VCR, and current events. Present Needs indicated orientation and socialization. Assessment indicated: Resident is alert to person, she need escort to activities for social interactions. She enjoys watching TV, music, church, and gospel music. Review of Resident #87's Quarterly Activities Assessment completed on [DATE] showed Resident #87's mental status as alert and oriented to self and to family/friends. She was described as needs assist to activities and clear speech. Under Activity Interests she was indicated as has to be escorted to activities for social interaction, there she enjoys watching TV, gospel music, and church. Under Sociability, she was indicated as often joins group activities, seldom plays games with others, seldom starts conversation with others, seldom responds to conversation, and seldom establishes own agenda. Under Psychosocial, Resident #87 was indicated as Resident remains interviewable and describes self as: moderately social. She was not marked for cognitive impairment. Under Mood/Behavior During Activities, Resident #87 was described as cooperative, quiet, and passive. Under Are there any interests resident would like to pursue which are not offered? she was indicated as N/A. Under Hobbies/Favorites, she was indicated for watches TV, music, and church. Under Care Planning, she was indicated for continue with a goal of: will continue to invite and escort resident to daily activities, give hands on assistance. Review of Resident #87's Activities Notes in her clinical record showed Activities Staff wrote a note once a month on a day referred to as Gang Tackling. During Gang Tackling, all applicable departments focus on one particular resident to include an in-depth chart review and charting and to offer special attention to include a special meal of choice and specialized activities. Review of Resident #87's Gang Tackling Activities notes showed: -[DATE] (Resident #87) was readmitted on [DATE] from (hospital), she was greeted and welcomed back to the facility and hospitality basket was given. She is alert and oriented to person. She needs escort to activities for social interaction. Reviewed her activity/leisure it remains the same. She enjoys watching TV, gospel music, and church. She has family support. Activity staff will continue to offer escort to activities, give hands on assistance. -[DATE] Volunteer visit (Resident #87) in her room, they administered prayer service. She loves the church. She was happy. -[DATE] Resident was invited and escorted to beauty salon to get a hairstyle. She was very happy. -[DATE] Resident was invited and escorted to beauty salon to get a hairstyle. She was very happy. Review of Resident #87's current Comprehensive Care Plans showed: -[DATE]. Problems: Resident has little involvement in group activities per his/her own choice which can be attributed to his/her is alert to person, she need escort to activities for social interactions, she enjoys watching TV, movie, church gospel music. Goals/Objectives: Resident will be provided with in room visitation per resident's request for socialization, cognitive maintenance, interventions thru NRD (next review date). Interventions: 1. Provide socialization as requested by resident; 2. Provide books, magazines and newspapers per resident's request for cognitive stimulation; 3. Provide sensory stimulation as tolerated by resident; 4. Continue to encourage resident to participate in small group activities at least once a month; 5. Keep activity calendar posted within view and inform resident of the activity of the day and encourage him/her to attend; 6. Offer escort to activities; 7. Give hands on assistance (reviewed [DATE]) -[DATE]. Problem: Self care deficit as evidenced by: requires assist with Activities of Daily Living, transfer, and mobility. Also, Resident prefer to put her head down while sitting in the wheelchair. Goals included: (Resident #87) will be able to sit up with her head up during meal and activity times. Interventions included: 13. Staff will continue to encourage resident to sit up with her head up as much as she will allow. (reviewed [DATE]) Review of previous Activities Care Plans showed: -[DATE]. Problems: Resident has little involvement in group activities per his/her own choice which can be attributed to his/her is alert to person and confused, she needs escort to activities for social interactions, she enjoys watching TV, church, music, outdoor patio. She has family support. Goals/Objectives: Resident will be provided with in room visitation per resident's request for socialization, cognitive maintenance, interventions thru NRD (next review date). Interventions: 1. Provide socialization as requested by resident; 2. Provide books, magazines and newspapers per resident's request for cognitive stimulation; 3. Provide sensory stimulation as tolerated by resident; 4. Continue to encourage resident to participate in small group activities at least once a month; 5. Keep activity calendar posted within view and inform resident of the activity of the day and encourage him/her to attend; 6. Offer escort to activities; 7. Give hands on assistance (reviewed [DATE] and [DATE]-will continue) -[DATE]. Problems: Resident has little involvement in group activities per his/her own choice which can be attributed to his/her is alert and oriented to person and confused, she has potential for social isolation. She needs escort to activities for social interactions, she enjoys watching TV, church, music, outdoor. She has family support. Goals/Objectives: Resident will be provided with in room visitation per resident's request for socialization, cognitive maintenance, interventions thru NRD (next review date). Interventions: 1. Provide socialization as requested by resident; 2. Provide books, magazines and newspapers per resident's request for cognitive stimulation; 3. Provide sensory stimulation as tolerated by resident; 4. Continue to encourage resident to participate in small group activities at least once a month; 5. Keep activity calendar posted within view and inform resident of the activity of the day and encourage him/her to attend; 6. Offer escort to activities; 7. Give hands on assistance (reviewed [DATE] will continue, [DATE] will continue, [DATE] will continue, [DATE] will continue. see new care plan on [DATE]) Observations of Resident #87 showed: -On [DATE] at 10:28 AM Resident #87 was in bed with eyes closed. She did not verbally respond. -On [DATE] at 02:39 PM Resident #87 in her wheelchair next to her bed. She was dressed and awake. She did not verbally respond. She was not observed in activities today. -On [DATE] at 09:05 AM Resident #87 was observed in very low bed with her head under her covers. She was heard singing to herself. -On [DATE] at 08:03 AM Resident #87 was observed in bed under her covers. -On [DATE] at 10:51 AM Resident #87 was observed in an activity. In the activity, 16 residents and 2 activity staff were observed tossing balloons. A music video was playing in the background. Resident #87 was observed in her wheelchair in the middle of the room with her head down to the side. After asking staff about Resident #87, Resident #87 was given a small, yellow inflated ball and a small, yellow, flexible plastic ring. Resident #87 showed no interest and initially did not want to accept the items. When staff walked away Resident #87 put the items on the nearby table and put her head down again. -On [DATE] at 01:59 PM Resident #87 was observed in her room. A religious activity was in progress across the hallway in the activity/dining room. - On [DATE] at 02:02 PM, Resident #87 was escorted to the religious activity. She was observed with her head down and did not appear to actively attend to the activity. -On [DATE] at 09:35 AM Resident #87 was observed in her wheelchair in the small activity/dining area with music videos on. Her head was up and she appeared to be attending to the TV. A few other residents were in the activity/dining room finishing breakfast. An Activities Staff member was setting up the room for activities. The Activities Staff member attempted to engage Resident #87 by asking her if she was happy. Resident #87 did not answer so the Activities Staff member made additional attempts at initiating conversation. Resident #87 began laughing and singing to herself. -On [DATE] at 12:57 PM Resident #87 was observed being escorted out of her room in her wheelchair by a Certified Nursing Assistant. -On [DATE] at 01:27 PM Resident #87 was observed in her wheelchair in the small activity/dining room. There were approximately 16 residents and 1 staff. A TV show was playing on the TV at the front of the room. Resident #87 was observed fidgeting with her blanket, not attending to TV. She was heard making some vocalizations to herself. An interview was conducted with Resident #87's Family Member on [DATE] at 12:42 PM. Resident #87's Family Member stated she has seen the Activities Calendar posted but has not seen the programs run when visiting. She stated to her knowledge Resident #87 does not attend activities but she would like to see Resident #87 attend activities. Resident #87's Family Member stated when she visits she finds Resident #87 sitting in her room isolated and talking to herself. Resident #87's Family Member stated she has spoken to the Director of Activities about her concerns but she has not seen any changes. An interview was conducted on [DATE] at 01:58 PM with the Director of Activities regarding the process for determining the social/activity/leisure needs of each resident, how the effectiveness of the activities program is monitored, and when resident preferences are re-assessed to ensure needs are being met, including for Resident #87. The Director of Activities stated residents are assessed upon admission for activities preferences. If they cannot communicate then family members are interviewed. An activities care plan is established. Care Plans are reviewed quarterly and would then be updated if needed. She stated the Activities Department does not keep a log of activities attended by residents but every month during Gang Tackling she reviews the resident's chart and writes a monthly note about the activities attended. When asked how she knows if the activities provided are meeting the needs of each resident per their assessments and care plans, she stated she makes daily rounds to talk to residents and she observes them in activities. She checks what the residents do and when she sees a resident is sleeping or not attentive she will talk to them or give them a ball. Activities are chosen based on resident needs and since many residents are very religious she offers many religious groups. Every month the facility offers special events such as for Valentine's Day, St. Patrick's Day, and Mother's Day. The facility also has family dinners and she brings in entertainment once a month. Volunteers also spend time with residents. Regarding Resident #87, the Director of Activities stated Resident #87 likes gospel music and the church. She is always laughing. She likes gospel music, TV, and church. She always goes to group activities. Resident #87 goes everyday to activity. She likes the church. When you talk to Resident #87 she will laugh. She is provided beauty salon and manicures in her room. When not getting a manicure she goes to church, fresh air on the patio, and movies. If she does not want something she pushes it away. The sensory stimulation she receives is the soft ball placed in her hand or she is given a hand massage with lotion. The Director of Activities stated Resident #87's Family Member has called her and said she likes to see her mom in activity. The Director of Activities also stated that Resident #87's Family Member likes to see Resident #87 with her hair and nails done so when she knows Resident #87's Family Member is coming she does Resident #87's nails. A final observation of Resident #87 was made on [DATE] at 02:48 PM. Resident #87 was observed in her wheelchair in the small activity/dining room. She was sitting against the back wall, on the periphery of the room partially in the room and partially in the hallway. Staff were playing the Cupid Shuffle loudly and various staff, including Activities staff and other staff passing by, were dancing to the music and attempting to engage residents around them. Some residents were observed to be engaged in the activity and appeared to enjoy the activity. Resident #87 was observed with her head down to her right side with her eyes closed. When asked if Resident #87 was enjoying the activity, the Director of Activities walked over to Resident #87 and rubbed her arm. Resident #87 jumped slightly, appearing to have been startled. The Director of Activities attempted to engage Resident #87 by clapping to the music then asked Resident #87 if she was enjoying the music. Resident #87 loudly, clearly, and with emphasis said No! The Director of Activities offered to take Resident #87 back to her room and proceeded to assist her.