Every finding on record at Nspire Healthcare Lauderhill

Based on observations, interviews and record reviews, the facility failed to follow the approved menu for lunch on 02/16/26. This had that potential to affect 99 of 99 residents that would have been served from the main menu; and failed to follow the approved recipe for lunch on 02/18/26. This has the potential to affect 75 of 75 residents with orders for regular texture diets. The findings included:1. During an observation of lunch served in the dining room, on 02/16/26 at 12:09 PM, it was noted that the menu that was posted outside of the Dining Room documented that the residents were to be served Barbecue Chicken and the approved menu also documented that residents were to be served Barbecued Chicken, During the observation, residents were served a piece of chicken thigh that did not have an appearance of being barbecued chicken. During an interview, on 12/16/26 at 12:20 PM, with the Food Service Director (FSD), when asked about the chicken served to the residents being Barbecued Chicken, the FSD stated that they did not have any barbecue sauce and that the kitchen prepared baked chicken as a substitute. When asked about notifying residents of the substitution, the FSD stated that the posted menu should have been changed the night before. 2. During an observation of lunch being served in the Dining Room, on 02/16/26 at 12:09 PM, the residents were served a single bone-in chicken thigh that appeared to be a small portion. During an interview, on 12/16/26 at 12:20 PM, when the surveyor requested the weight of the bone in chicken thighs, the FSD stated that the facility did not have a scale in the kitchen to ensure that the residents were served the proper portion sized of the chicken.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was observed during 2 of 2 visits conducted in the Main Kitchen. The findings included: 1. A tour of the kitchen was conducted on 02/16/26 at 8:52 AM and the following issues noted: a. Staff R, Cook, was observed with visible facial hair but no beard hair net. When asked why he had no beard net, he stated he is usually clean shaven and does not grow a beard. b. The dry storage area was observed with accumulated debris on the floor next to a reach in freezer. c. In the walk-in refrigerator, there were 22-8 ounce cartons of low-fat milk with an expiration date of 02/06/25. d. Cartons of low-fat milk were also noted on the tray line with expiration dates of 02/06/25 and 02/13/25. e. Two single servings of strawberry gelatin were found in the walk-in refrigerator with an expiration date of 02/10/26. f. The walk-in freezer was observed with an accumulation of ice on the pipes under the cooling unit. g. A box of commercially processed omelets placed on a shelf under the unit had accumulation of ice on top. h. Icicles were on the shelf under the cooling unit. i. The left corner entrance of the freezer floor was noted with a large amount of ice accumulation. j. There was accumulation of ice around the freezer door's jamb, frame, and the door itself. k. The ice from the top of the door jamb was melting and landing on the floor below and there was accumulation of ice on the floor below the door. l. In a large reach-in freezer, there was an unrecognizable yellow colored spillage on the bottom where 2 large tubs of ice cream were sitting and one of the tubs had an open tear. m. The ice machine was noted with orange-colored growth and condensation was dripping off that area into the ice. n. The ice scoop holder was placed on top of the ice machine where it could not dry properly and nesting water was observed. o. The can opener was observed with accumulation of food residue and debris. p. The concentration of quaternary ammonia used for sanitizer in a bucket located in a food assembly area was below the 200 parts per million required to sanitize food and nonfood contact surfaces. 2. During a second observation of the kitchen on 02/18/26 at 11:45 AM the lunch tray line was observed. Multi surface cleaning cloths were used to wipe the steam table, on the cook's side while he was plating food. The cloths were not placed in a sanitizing bucket after use. Staff R used the cloth to wipe the top of a plate where the food had dripped over the side. Staff R was alerted to the improper procedure by this surveyor, he acknowledged it, and proceeded to pass the plate to dietary staff who were placing them in a food cart. This surveyor had to stop Staff R who then re-plated the food properly and discarded the first plate. In an interview conducted on 02/18/25 at 5:07 PM with the Regional Certified Dietary Manager and the Registered Dietitian, the findings were reviewed.

Based on observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services in order to maintain a clean and sanitary environment in 10 of 58 rooms. The findings included: 1. Observation on the following dates and times revealed: On 02/16/26 at 11:35 AM, there was an accumulation of dust on the filters of the wall mounted air conditioning unit and portions of the wall were in need of being painted in room [ROOM NUMBER]. On 02/16/26 at 11:44 AM, the door frames at the entrance to rooms [ROOM NUMBERS] were in need of painting. On 02/16/26 at 1:02 PM, in room [ROOM NUMBER], the surface of the foot board of the window bed was worn and the surface of the overbed table was worn to a point that the particle board underneath was exposed. The paint on the wall between the sink and the commode was peeling. On 02/16/26 at 1:40 PM, there was an accumulation of dust on the filters of the wall mounted air conditioning unit in room [ROOM NUMBER]. On 02/16/26 at 2:59 PM, in room [ROOM NUMBER], it was noted that the door frame was in need of being painted, the wall at the head of the bed was damaged and in need of being painted, there was an accumulation of dust on the wall mounted air conditioning unit, and the windowsill above the air conditioner was damaged. On 02/17/26 at 8:30 AM, the sides of the door frame at the entrance to room [ROOM NUMBER] appeared to have had a bumper removed and was in need of being painted. On 02/17/26 at 10:43 AM, the linen on the window bed of room [ROOM NUMBER] was worn thin and had holes in it, there was an accumulation of dust on the wall mounted air conditioning unit, the foot board showed signs of wear, the surface of the overbed table was worn to a point that the particle board underneath was exposed and the wall at the head of the bed was in need of being painted. On 02/17/26 at 11:42 AM, there was an accumulation of dust on filter of the wall mounted air conditioning unit and the paint on the walls in the bathroom was peeling in room [ROOM NUMBER]. On 02/17/26 at 12:00 PM, there was an accumulation of dust on the wall mounted air conditioning unit and there were no filters in the unit of room [ROOM NUMBER]. On 02/17/26 at 1:40 PM, there was an accumulation of dust on the air conditioning filters in room [ROOM NUMBER]. During an environmental tour, on 02/19/26 at 2:47 PM, with the Director of Maintenance, the Director of Maintenance was made aware of the concerns and acknowledged the findings. 2. Record review for Resident #28 revealed the resident was readmitted to the facility on [DATE], with diagnoses that included: Dementia, Anxiety, Restlessness and Agitation, and Psychosis. Review of the Annual Minimum Data Set (MDS) for Resident #28 dated 11/24/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment also indicated that the resident was independent with ambulation and toilet transfer. During an observation on 02/16/26 at 11:43 AM, no toilet seat was noted in Resident #28's bathroom. The bathroom floor, on the left side of the toilet, was cracked and lifted. On 02/17/26 at 8:49 AM, there was no toilet seat observed in Resident #28's bathroom. The bathroom floor, on the left side of the toilet, was cracked and lifted. On 02/18/26 at 01:10 PM, no toilet seat was noted on Resident #28's toilet and the floor on the left side of the toilet was cracked and lifted. On 02/19/26 at approximately 9:30 AM, there was no toilet seat in Resident #28's bathroom and the bathroom floor on the left side of the toilet was cracked and lifted. Staff L, Restorative Certified Nursing Assistant (CNA) who has been employed by the facility since 2019, was present and acknowledged the toilet and floor issues. On 02/19/26 at 1:31 PM, an interview was conducted with Staff L who stated that Resident #28 was able to use his bathroom independently and does not have incontinence issues. She further stated that when maintenance concerns are identified, they are entered into the electronic maintenance system to alert the department. She had not alerted maintenance to the missing toilet seat or the damaged floor. On 02/19/26, a review of the Grievance Log for the last 6 months and current Maintenance Log did not reveal any complaint or work order request to replace the toilet seat in Resident #28's bathroom. During an interview conducted on 02/19/26 at 2:47 PM with the Director of the Maintenance Department, who was employed by the facility since 04/01/25, he stated how maintenance requests were handled. They were entered into an electronic system by staff which would alert him via a phone he was carrying. He would handle the request immediately or as soon as possible. He stated that it would have been on the Maintenance Log if it had been entered into the system. He acknowledged that it was not on the Log. The floor in the bathroom was shown to the Maintenance Director, and he stated that he was in the process of retiling bathroom floors on that wing and would fix it next.

Based on observations, interviews, and record review, the facility failed to initiate a care plan for wandering and behavioral problems for 2 of 2 sampled residents reviewed for a resident-to-resident altercation, Resident #90 and Resident #10; failed to initiate a care plan for respiratory condition and diagnosis of asthma for 1 of 2 sampled residents reviewed for respiratory condition, Resident #88; failed to develop and implement a care plan for the use of psychotropic medication for 1 or 5 sampled residents reviewed for unnecessary medication, Resident #71; and failed to follow fall interventions for 1 of 2 sampled residents reviewed for falls, Resident #1. The findings included: 1. Record review documented Resident #90 was admitted to the facility on [DATE] with diagnoses of Dementia, Anxiety disorder, and Depressive disorder. The Minimum Data Set (MDS) dated [DATE] revealed Resident #90 with memory problems and a cognitive status moderately impaired. Record review documented Resident #10 was admitted to the facility on [DATE] with diagnoses of hemiplegia, dysphagia, and Depressive disorder. The quarterly MDS dated [DATE] showed Resident #10 with a Brief Interview of Mental Status (BIMS) score of 14, indicating cognitive intactness. In an interview conducted on 02/16/26 at 10:00 PM with Resident #10, he stated that a few weeks ago, Resident #90 walked into his room, tried to grab his phone, and slapped him on the face. This happened a few weeks ago, but he could not remember the date or time. When asked whether he had told any staff member, he said he thought he had but could not remember who or when. Review of the facility's documentation dated 02/16/26 revealed Resident #90 walked into Resident #10's room, yelling and screaming, and when asked to leave the room, she hit Resident #10 on his right arm and left arm with no injuries. The Quarterly MDS dated [DATE] for Resident #90 revealed that under section E for behaviors, Resident #90 was marked for wandering 1 to 3 days. The Significant change MDS dated [DATE] revealed that under section E for behaviors, Resident #90 was marked for wandering 1 to 3 days The quarterly Elopement Evaluation dated 12/23/25 showed Resident #90 was at risk for elopement with a score of 1.0 (at risk). A review of the care plan did not show that any Wandering or Behavior problems were initiated for Resident #90 prior to the altercation on 02/16/2026. In an interview conducted on 02/18/26 at 10:50 AM with Staff A, Licensed Practical Nurse (LPN), she stated that she has been working at the facility for the last 2 years. Resident #90 usually walks around the facility, and she goes everywhere. Resident #90 sometimes enters residents' rooms and is redirected by staff as much as possible. Resident #90 is very affectionate and sometimes hugs and kisses various staff members. In an interview conducted on 02/18/26 at 11:00 AM with Staff B, Certified Nursing Assistant (CNA), it was stated that Staff B has worked at the facility for the last 3 years. She is familiar with Resident #90 and has worked with her in the past. Resident #90 walks up and down the hallways and sometimes goes into residents' rooms. She needs redirecting, and they do so when needed. According to Staff B, Resident #90 can be very affectionate and sometimes very aggressive. This has been her normal behavior since she has been here, and she may walk up to you and hit you for no reason. In an interview conducted on 02/18/26 at 11:35 AM with Staff C, LPN, she stated that she had been working at the facility for 2 months. Resident #90 has been observed walking up and down the hallways and entering patients' rooms. She is usually affectionate but stated that she walked up to her about a month ago and pushed her. In an interview conducted on 2/18/26 at 12:15 PM with Staff D, CNA has been working in the facility for the last 15 years. Resident #90 walks around the facility and wanders into other residents' rooms. She has mood swings and has seen her aggressiveness in the past. In an interview conducted on 02/1/26 at 12:20 PM Staff E, CNA, stated that she has been working in the facility for 13 years. She is familiar with Resident #90 and stated that she walks around the unit, walking into other residents' rooms. According to Resident #90, she has never seen her aggressiveness in the past. In an observation conducted on 02/18/2026, at 12:30 PM, Resident #90 was noted walking around the facility towards 300s hallway (which is not her hallway). Continued observation showed Staff at her side. 2. Record review documented Resident #88 was admitted to the facility on [DATE] with diagnoses that included Asthma, Chronic Obstructive Pulmonary Disease (COPD), Cognitive Communication Deficit, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. Review of the admission Minimum Data Set (MDS) assessment, dated 12/15/25, under Section C documented the Brief Interview for Mental Status (BIMS) score of 6, indicating severe impaired cognitive function. Review of physician orders dated 12/04/25 documented for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate), 2 puffs, inhale orally two times a day for Asthma. Review of the psychiatry consultation notes dated 01/22/26 revealed poor rating on insight, judgement, short term memory, and long-term memory, indicating Resident #88 needed staff interventions to manage his Asthma and COPD. Review of admission nursing skilled notes dated 12/04/25 at 9:48 PM documented Resident #88 had no signs of difficulty breathing; No shortness of breath noted; Right lung clear; Left lung clear; Humidification: No; No oxygen; Head of Bed elevated; Head elevated at 30 degrees; and No cough. Review of nursing care plan did not include goals, plans and interventions for the resident's diagnoses of Asthma and COPD, but had plans, goals and interventions for behavior monitoring related to mood disorder, anxiety, dementia and cognitive communication deficit. In an interview conducted with the Administrator on 02/17/26 at 4:00 PM, when asked who updates the nursing care plan, he responded that all staff including the Social Services Director, the Director of Nursing (DON), and the Regional Nurse Consultant review the residents' nursing care plans. In an interview conducted with Staff H, Registered Nurse (RN), on 02/18/25 at 8:55 AM, when asked if she is familiar with the nursing care plan's goals and interventions for Resident #88, responded, yes. When she was asked if she follows the nursing interventions, she did not respond. In an interview conducted with Staff N, Registered Nurse (RN) on 02/19/26 at 3:00 PM, when she was asked if she checks and updates the care plan for a resident with Asthma, Chronic Obstructive Pulmonary Disease and other respiratory conditions, responded that the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator are the ones responsible for updating the nursing care plans. 3. Record review revealed Resident #71 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an Admission/Medicare 5-day Minimum Data Set (MDS) with a reference date of 01/02/26, the resident was not assessed for cognition due to the resident was 'rarely/never understood'. Resident #7's diagnoses at the time of the assessment included: Chronic Obstructive Pulmonary Disease (COPD), Atrial fibrillation, Hypertension (HTN), Peripheral Vascular disease (PVD), Benign prostatic hyperplasia, Diabetes Mellitus (DM), Non-Alzheimer's dementia, and Psychotic disorder. Resident #71's Hospital transfer form documented diagnoses that included: Depression, Dementia, and Psychotic disorder with hallucination. Review of Resident #71's orders included: fluvoxaMINE Maleate Oral Tablet 50 MG (Fluvoxamine Maleate) - Give 1 tablet by mouth at bedtime for Depression – 12/29/25. Donepezil HCl Tablet 10 MG - Give 1 tablet by mouth one time a day for pain – 12/30/25. SEROquel Oral Tablet 25 MG (Quetiapine Fumarate) - Give 1 tablet by mouth two times a day related to PSYCHOTIC DISORDER WITH HALLUCINATIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION – 12/31/25. buPROPion HCl Oral Tablet 100 MG (Bupropion HCl) - Give 1 tablet by mouth in the morning related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE – 01/23/26. Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) - Give 750 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE – 01/22/26. Further review of the resident's records revealed there was no care plan for the use of psychotropic mediations. During an interview, on 02/19/26 at 12:36 PM with the Social Services Director, when asked about care planning for psychotropic medications, the Social Services Director replied, the MDS Coordinator does the care planning for psychotropic medications. We haven't had an MDS Coordinator for a couple of months – since November. While there is no MDS Coordinator, nursing would be initiating the care plan. During an interview, on 02/19/26 at 12:50 PM, the Director of Nurse (DON) acknowledged there was no care plan related to the use of the psychotropic medication. During an interview, on 02/19/26 at 12:56 PM with the Divisional MDS Coordinator, the Divisional MDS Coordinator stated the facility not had an MDS Coordinator since the middle to end of December 2025. 4. Review of the Fall Prevention Program policy dated 11/07/25 revealed the following: residents will receive care and services in accordance with their level of risk to minimize the likelihood of falls and staff were to ensure call lights were within reach of residents while in bed. Review of the Call Lights policy dated 11/07/25 revealed the following: staff will ensure the call light is within reach of resident and secured, as needed. Record review for Resident #1 revealed the resident was readmitted to the facility on [DATE]. The following diagnoses were included: Schizoaffective Disorder, Heart Failure, Diabetes, Anxiety, Schizophrenia, Difficulty Walking, and Disorders of Bone Density. Per fall risk evaluation dated 11/20/25 the resident was also identified with the predisposing disease of Vertigo. Review of the Quarterly Minimum Data Set (MDS) for Resident #1 dated 12/30/25, revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. The assessment also revealed that the resident was independent with ambulation and toileting. Review of the Care Plan for Resident #1 initiated on 01/08/21 with a focus on Falls included an approach that stated staff should be sure the resident's call light was within reach and to encourage the resident to use it. During an observation on 02/16/26 at 11:33 AM, Resident #1 was interviewed while she was in bed. The call light was noted on the floor wedged under her roommate's bed frame. When asked about the location of the call light, Resident #1 stated that she could pick it up off the floor and knew how to use it. On 02/17/26 at 8:50 AM, Resident #1 was observed in her room in bed. The call light was on the floor wedged under her roommate's bed frame. When asked, the resident denied placing the call light where it was noted. On 02/18/26 at 1:11 PM, Resident #1 was observed in bed. The call light was on the floor wedged under her roommate's bed frame. During an interview conducted on 02/19/26 at 9:40 AM, Staff Q, Certified Nursing Assistant (CNA), stated she had been employed by the facility for two months. She stated that when a resident is at risk of falls, the nurse would let her know and that usually one-on-one care is provided. She was unable to provide any other interventions related to risk of falls. She and this surveyor went to Resident #1's room and Staff Q was shown the call light on the floor under the roommate's bed. Staff Q acknowledged that it was on the floor under the roommate's bed. On 02/19/26 at 9:58 AM, Resident #1 was interviewed regarding the call light. She stated that if the light was on the floor, she would pick it up. The call light had been seen by Staff Q earlier and was pinned on the resident's bed. She was able to reach it and squeezed it on her own and stated that she knew she could call staff by using it.

Based on observation, interview, and record review, the facility failed to provide activities to meet the interests of and support the physical, mental, and psychosocial well-being of 1 of 2 sampled residents for activities (Resident #98). The findings included:Record review revealed Resident #98 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was dependent for activities of daily living and was receiving tube feedings. Review of Resident #98's physician orders revealed an order dated 11/04/25 indicating the resident was not to take anything by mouth (no food or drink). Observations conducted on Resident #98 on 02/16/26 at 10:00 AM, 02/17/26 at 10:00 AM and 2:00 PM, 02/18/26 at 10:00 AM and 2:00 PM, and 02/19/26 at 10:00 AM revealed the resident was noted in bed, with no music, TV, or any forms of entertainment or interactions. An interview was conducted with the Activities Director on 02/19/26 at 11:00 AM. The Activity Director stated Resident #98 was not on 1:1 (in room only) for activities. There has been discussion to make her 1:1 since her return from the hospital due to her receiving tube feedings for nutrition, but she was not currently on 1:1 activities. The Activity Director directed the surveyor to the Activity's Assistant responsible for Resident #98, and stated she maintains a book for resident's participation. An interview was conducted with the Activity's Assistant for Resident #98 on 02/19/26 at 11:05 AM with the Activity Director present. The Assistant provided a Daily Recreation Activity Program Documentation for Resident #98 for the month of February 2026. It was documented daily from 02/01/26 until 02/18/26, that Resident #98 observed cards/games, listened to music/singing, verbally socialized, observed TV/movies, and actively drank coffee. The Activity Director confirmed Resident #98 could not drink coffee, as she could not have anything by mouth, and that the resident had not attended activities.

Based on record review, interview, and observation, the facility failed to follow the professional standards of practice for oral inhalation medication administration for Resident #88, and for percutaneous endoscopic gastrostomy (PEG) tube medication administration for Resident #99; failed to obtain a dermatology consult in a timely manner for 1 of 1 sampled resident for skin conditions, Resident #93; and failed to coordinate resident care with hospice for 2 of 2 sampled residents reviewed for hospice services, Resident #7 and Resident #98. The findings included: 1. Review of the facility's document titled, Specific Medication Administration Procedures, dated 05/22, documented the following: The purpose is to allow for safe, accurate, and effective administration of medication using an oral inhaler (with or without a spacer/chamber) or nebulizer. Ask the resident to breathe out as deeply as possible (do not exhale into the inhaler) Hold breath for 10 seconds or as long as possible to allow medications to reach deeply into lungs. Slowly exhale through nose. If another puff of the same or different medication is required, wait at least 1-2 minutes between, then repeat the procedures above. Record review documented Resident #88 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), and Asthma. Review of admission Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview for Mental Status (BIMS), revealed a score of 6 indicating severe cognitive impairment. Review of physician orders dated 12/04/25 documented Albuterol Sulfate HFA, 108 (90 Base) MCG/ACT Aerosol, solution, 2 puffs, inhale orally every 6 hours as needed for wheezing. During a medication administration observation with Staff H, Registered Nurse (RN), on 02/18/25 at 8:45 AM, Staff H took a holder for the above medication, slid the medical dose container into the holder and brought it into the resident's room. Staff H sprayed one puff to resident's mouth, did not ask the resident to inhale, closed mouth, and keep the mouth closed for 1 to 2 minutes, then sprayed another puff into the resident's mouth. She did not ask the resident to rinse his mouth after but instead gave him the oral tablets to drink followed by water to drink. The resident swallowed the water after swallowing all the oral pills. Staff H did not monitor the resident's reactions after 2 puffs were administered but left the resident's room immediately. She did not take any vital signs. Staff H cleansed the oral inhalation holder by wiping it with a tissue paper, then put it in a plastic bag inside the medication cart. She did not go back to the resident's room to monitor reactions to the medications or take vital signs such as heart rate, respiratory rate, oxygen saturation and blood pressure, or perform a respiratory assessment by checking the resident's lung sounds. Staff H prepared the medications for the next resident. In an interview conducted with Staff N, RN on 02/19/26 at 3:00 PM, when she was asked how she administers oral inhalation nebulizer medication, she responded that she makes sure to take the residents vital signs, asks him to take deep breaths, administers one puff if vital signs are ok, asks resident to keep mouth closed for 1 to 5 minutes. She monitors the resident again. She stated she would wait to check for any reactions after the first oral puff, and if another puff is ordered, she would ask the resident to take another puff orally when there are no reactions. She would ask the resident to keep the mouth closed. She would also ask the resident to rinse his mouth and spit out the water rinse. She would wait another 5 minutes to check for resident's reactions, before exiting the resident's room. When all was done, she would document in Medication Administration Record. She added she would document vital signs and the resident's reactions to the oral inhalation treatment. 2. Review of a facility's policy titled, Medication Administration via Enteral Tube, revised on 11/07/25, documented that in accordance with facility procedure, enteral tube placement must be verified prior to administering any fluids (h). Record review documented Resident #99 was admitted to the facility on [DATE], with diagnoses that included Traumatic Subdural Hemorrhage Without Loss of Consciousness, Subsequent Encounter, and Dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], under Section C of the BIMS, revealed it was disabled by question C0100, indicating severe impaired mental cognition. Review of the physician order dated 02/21/25, documented Enhanced Barrier Precaution (EBP) related to Peg tube usage. Review of the physician order dated 03/04/25 documented to flush every 4 hours with 50 milliliter (ml) water before and after bolus feedings via PEG daily. During a medication administration observation on 02/18/25 at 9:45 AM with Staff H, RN, she stated she would provide medications to Resident #99. Staff H prepared all the medications, then entered the resident's room. Resident #99's door was observed to have a Center for Disease Control (CDC) poster for Enhanced Barrier Precautions (EBP). There were personal protective equipment (EBP) supplies hanging inside the pockets of a cloth hamper on the other side of the door. Staff H washed her hands and proceeded to administer oral medications via Resident #99's mouth. When the oral medications were swallowed by the resident, Staff H washed her hands again, donned gloves, but did not don on PPE gown. She stated she would administer the medications via PEG tube. She shook the Jevity container, then prepared the syringe. Staff raised the head of Resident #99's bed, lifted the resident's gown on the abdominal area, undid the Velcro on the abdominal binder, then with gloved hands, uncovered the end port of the PEG tube, inserted the tip of the syringe into the end port, then poured water into the barrel of the syringe for flush. This staff did not check for residual and did not listen to bowel sounds with a stethoscope. At 9:45 AM, the Jevity was slowly going in, so Staff H disconnected the tip of the syringe from the end port of the PEG tube. She stated that 'only 10 ml of Jevity went inside the PEG tube'. She removed her gloves and without hand sanitizing, donned another set of gloves, and decided to stop the PEG tube feeding. She did not Velcro the abdominal binder, but covered the resident's abdominal area with bed sheet, and discarded the Jevity container, the small plastic medication tray and the small cups for oral medications into the trash can. When Staff H completed the medication administration, she was asked why she did not check the PEG tube placement, and did not complete the PEG tube feeding. She did not respond. In an interview conducted with Staff N, RN, on 02/19/26 at 3:00 PM, when she was sked how she administers medications through PEG tube, she responded, she donned PPE gown and gloves, disinfects the end port, then checks for PEG tube placement by aspirating for stomach contents. She makes sure that the resident receives all the medications before she documents in MAR. 3. Record review revealed Resident #93 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required substantial / maximum assistance with activities of daily living (ADLs). Resident #93 was care planned for impairment to skin integrity related to chronic xerosis & poor safety awareness. Resident has a behavior of continuously scratching his extremities. An observation was conducted on 02/16/26 at 11:00 AM. Resident #93 was observed sitting up in a wheelchair being transported down the hallway. The resident was observed scratching his arms and legs. Resident #93 was observed in short paints with patchy sites with scratch marks on them. Review of Resident #93's orders revealed an order dated 02/08/25 for Ammonium Lactate External Lotion 12% to apply to both legs every shift for chronic xerosis; Report worsening to MD (physician) or NP (Nurse Practitioner). There was another order dated 01/29/26 for a dermatology consult. Review of Resident #93's progress notes dated 01/29/26 documented the resident was noted with generalized skin rash to body. The MD was made aware and new order received for the dermatology consult. Further review of Resident #93's records did not have any evidence dermatology was consulted for the resident. An interview was conducted with the Director of Nursing (DON) on 02/18/26 at 12:0 PM. The DON acknowledged the above. 4. Record review revealed Resident #7 was admitted to the facility on [DATE]. Resident #7 had orders dated 05/22/24 for hospice services. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, was dependent on activities of daily living, and was receiving hospice services. Resident #7 was care planned for a terminal prognosis and is under hospice services. Interventions on the care plan included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, and work with nursing staff to provide maximum comfort for the resident. Review of Resident #7's progress notes revealed a note dated 12/06/25 that documented the resident was noted with a hematoma to the right forehead and was unable to explain what happened; The MD and family were notified; and to Continue to monitor the resident. A review of a change in condition form dated 12/06/25 documented a cyst was found to Resident #7's forehead. MD was notified and orders were received. Further review of Resident #7's records did not reveal any orders, assessments, od documentation from the hospice MD or nurse concerning the above incident. 5. Record review revealed Resident #98 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was dependent for activities of daily living. The assessment documented the resident was receiving hospice services. Resident #98 was care planned for hospice services. Resident #98 had orders dated 01/07/26 for hospice related to Alzheimer's Disease. Review of Resident #98s progress notes revealed a note dated 01/16/26 that documented the resident was observed with edema and tightness in the right arm; Swelling noted upon assessment; and Hospice team notified and made aware of findings. There were no new orders at this time. Further review of Resident #98's record did not reveal any orders, assessment, or documentation of the condition of the resident's arm. An interview was conducted with the Director of Nursing on 02/19/26 at 11:00 AM. The DON stated there should be a hospice book/binder for residents on hospice in which hospice personnel communicate in. There was no hospice book was found for Resident #7 or Resident #98.

Based on observation, interviews and record review, the facility failed to provide protein supplements to aid with wound healing for 1 of 1 sampled resident reviewed for pressure ulcer, Resident #25.The findings included: In an observation conducted on 02/18/2026 at 8:40 AM, Resident #25 was in her room eating her breakfast meal. Closer observation showed that she ate about 70% of her meal.Record review revealed Resident #25 was readmitted to the facility on [DATE] with diagnoses of Dementia, type 2 Diabetes and unspecific protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #25 has Brief Interview of Mental Status (BIMS) score of 06 that indicated severe cognitive impairment. A review of the skin check progress note dated 01/12/2026 showed Resident #25 had a stage 2 pressure ulcer, partial thickness on the sacrum.A review of the skin check progress note dated 01/19/2026 showed Resident #25 had a stage 2 pressure ulcer, partial thickness on the sacrum.A review of the skin check progress note dated 01/26/2026 showed Resident #25 had a stage 2 pressure ulcer, partial thickness on the sacrum.A review of the skin check progress note dated 02/02/2026 showed Resident #25 had a stage 2 pressure ulcer, partial thickness on the sacrum.A review of the skin check progress note dated 02/09/2026 showed Resident #25 had a stage 2 pressure ulcer, partial thickness on the sacrum.The care plan initiated on 12/15/2025 showed Resident #25 has a history of actual pressure area and is at risk for further pressure areas and skin impairments due to decreased mobility and incontinence.A review of the Clinical Dietitian progress note dated 01/23/26 revealed to increase the liquid protein supplement and to continue to monitor and follow.A review of the Physician's order dated 01/23/2026 documented for pro source liquid protein 3 times a day. In an interview conducted on 02/17/2026 at 10:10 AM with the Director of Nursing (DON), she stated that once the wound care specialist identifies the wound as pressure wound, she would let her know and she would send the actual wound care report to the Clinical Dietitian and the Administrator immediately. Her expectation is that the Clinical Dietitian would review the wound report and recommend nutritional interventions to be in place such as vitamins, minerals and protein supplements.In an interview conducted on 02/17/2026 at 11:00 AM with facility's Clinical Dietitian, she stated that she comes to the facility once a week. Any residents who have pressure ulcers the DON would call her to let her know and she would also review the wound care report once a month. For residents with stage 2 wounds, she would look at what medications they may be on and order protein supplements, or nutritional supplements if needed.A review of the Medication Administration Record (MAR) for January 2026 and February 2026 showed that no protein supplements were provided to Resident #25 as ordered on 01/23/26.In an interview conducted on 02/18/2026 at 3:12 PM with the Clinical Dietitian, she was asked how she would verify that a resident is provided the nutritional supplements that are ordered. She stated that she would ask the nurse who is taking care of the resident if the resident is taking the nutritional supplements and the amount that is taken. In an interview conducted on 02/19/2026 at 9:45 AM with Staff P, Registered Nurse, when asked if Resident #25 was receiving protein supplements she said no. She proceeded to check in the electronic system and verified that the order was not in the MAR.

Based on observation, interviews, and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 sampled resident reviewed for social services, Resident #10. The findings included: Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Dysphagia, and Depressive Disorder. The quarterly MDS dated [DATE] showed Resident #10 with a Brief Interview of Mental Status (BIMS) score of 14, indicating cognitive intactness.In an interview conducted on 02/16/26 at 10:00 AM with Resident#10, he stated that he was supposed to see an Ear, Nose, and Throat (ENT) specialist months ago, but was told it might take months to see one. He further said he has been experiencing ringing in his ears for some time.A progress note dated 11/29/25 showed Resident #10 complained of ringing in the left ear and popping in the right ear. The Nurse Practitioner was made aware, and an order for an ENT consultation was given. Resident #10's wife was also made aware of the consultation.A review of the physician's order showed an ENT consultation order dated 11/29/25.A social service note dated 12/22/25, 3 weeks later, stated that Resident #10's face sheet and an order were sent to the in-house ENT specialist. It showed that the social worker would follow up on the date of the next visit to the facility.A social service progress note dated 01/05/26 revealed that the Power of Attorney (POA) and Resident #10 no longer wanted to proceed with the audiology consultation at this time.In an interview conducted on 02/17/26 at 12:35 PM with Staff A, Licensed Practical Nurse, she stated that once an order is placed in the system, they would either call the ENT office to make the appointment or forward the order to the facility's social services to make the appointment.In a phone interview conducted on 02/17/26 at 1:10 PM with Resident #10's spouse, she stated that she initially told the facility's social services that she did not want to proceed with the ENT appointment because she was under the impression that they had to pay for the visit out of their own pocket. The issue was cleared, and she came to the facility to speak with social services last month on February 2nd, 2026. She told the social worker she wanted to proceed with the appointment and was told that the in-house ENT had just left the facility, and that Resident #10 would be seen on the next visit.In an interview conducted on 02/17/26 at 1:32 PM with the facility's social services, she reported that the in-house ENT visits the facility every 6 months. When she gets an ENT consultation, she would try to call for the appointment as soon as she can. She would either use an in-house ENT service or call for an outside service. The nursing team would also let her know any ENT consultations ordered for the residents, typically on the same day or the next, during daily clinical meetings. According to social services, Resident #10 initially had an appointment with an outside ENT scheduled for 12/24/25. She contacted the ENT office to schedule the transfer for the appointment and was told that they do not have a stretcher for transportation and that they were unable to accommodate the resident. The social service called Resident #10's wife to inform her that they would use the in-house ENT and was told by the wife that they would not proceed with the appointment due to a payment issue. About two weeks after 01/05/26, the spouse came to the facility and stated she would proceed with the ENT appointment in the next few months. When asked, this social worker said that she documented the discussion with the spouse, and when asked if she had made another ENT appointment for Resident #10, she said no.

Based on observations, interviews and record reviews, the facility failed to ensure an antipsychotic order was active and physician had verified the order for 1 of 5 sampled residents reviewed for unnecessary medications, Resident #51. The findings included:Review of the facility's policy titled, Medication Orders, revised on 11/07/25, documented the following:Verbal orders should be received only by licensed nurses, or pharmacist, and confirmed in writing by the physician, on the next visit to the facility.The elements of the medication order included:Date and time the order is written.Duration or stop date.Diagnosis and indication for use.PRN (as needed) orders should also specify the condition for which they are being administered (e.g. as needed for sleep)Verbal orders-The nurses should document an order by telephone or in person on the physician's order sheet or input into electronic record as per facility policy, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical recordsRecords review documented Resident #51 was admitted to the facility on [DATE] with diagnoses that included Cognitive Communication Deficit, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the moist recent Minimum Data Set (MDS) assessment under Section C of the Bried Interview for Mental Status revealed a score of 6 indicating Resident #51 had severe cognitive impairment.Record review revealed Resident #51 had no diagnoses of schizophrenia or bipolar disorder. Preadmission Screening and Resident Review (PASSAR) Level I did not indicate any diagnoses for Schizophrenia or bipolar disorder. A PASSAR Level I on 11/25/25 revealed a diagnosis of Psychotic Disorder, Delirium and Altered Mental Status. Additional review documented that Resident #51 had no Schizophrenia or bipolar disorder but started taking [NAME] oral 40 milligram (mg), and [NAME] 20 mg, intramuscularly (IM), as needed every 12 hours, on 12/18/25. Review of nursing care plan with different dates documented Resident #51 had behavior problems as evidenced by the following:-Repeatedly attempting to stand or ambulate independently from wheelchair despite staff education on 11/03/2025.- Becoming combative when redirected or instructed not to engage in unsafe behaviors dated 11/03/25, 12/30/25, and 12/31/25.- Urinating on the floor dated 12/17/2025.- Wandering into other resident's room.-Eating from their trays dated 12/27/25, and 12/28/2025. Review of physician orders dated 12/18/25, documented an order for 'Geodon intramuscular solution reconstituted 20 milligrams (mg), (Ziprasidone Mesylate): Inject 20 mg intramuscularly every 12 hours as needed for agitation related to Psychotic Disorder with Hallucinations Due to Known Physiological Condition.'An additional physician order documented 'Geodon Oral Capsule 40 mg, (Ziprasidone HCl). Give 40 mg by mouth every 12 hours related to Psychotic Disorder with Hallucinations due to Known Physiological Condition.' Review of the progress notes dated 02/06/26 at 7:50 PM documented Geodon 20 mg was injected intramuscularly as needed for agitation related to Psychotic Disorder with Hallucinations Due to Known Physiological Condition. It also documented that the medication was administered to resident for agitation, who was threatening and spitting on people. The resident also used the medication Cart to hit people.Review of the nursing progress notes dated 02/07/26 at 9:00 AM documented that an intramuscular injection of [NAME] 20 mg, (prn), as needed was administered to Resident #51, but was ineffective. The notes documented that Resident #51 slept and rested for about 2 hours, but remained agitated, non-directable, displayed aggressive behavior, and threatened others. The resident had also destroyed most of the furniture in his room. Review of laboratory and diagnostic sections revealed no baseline electrocardiogram (EKG), and laboratory works were ordered before Resident #51 started the [NAME] prescription. In an interview conducted with the Pharmacist on 02/19/26 at 10:54 AM, when he was asked if he reviewed Resident #51's antipsychotic medication, responded yes. When he was asked why Resident #51 was not included in the list for unnecessary medications review from 12/26 until now, 02/26, he responded he would call the prescribing physician. He added that they discuss Resident #51's treatment during their monthly meeting. When he was asked why Resident #51 was taking antipsychotic even when he does not have bipolar disorder and Schizophrenia, he responded he would call the prescribing physician. In an interview conducted with Resident #51's psychiatric physician on 02/19/26 at 11:15 AM, he stated that Resident #51's [NAME] was prescribed for the diagnosis of Psychosis due to Encephalopathy. He added that the [NAME] oral and intramuscular administration started in 12/25 when he ordered it, but it was supposed to be administered and valid for only 14 days. He did not know that the resident was still taking the intramuscular injection of [NAME]. He is aware about the need to have a baseline diagnostic work up, but he based them on standards. He was also aware that the resident received about 120 mg per day in 12/25. In an interview conducted with the Director of Nursing (DON) on 02/19/26 at 11:30 AM, when she was asked if the staff who accepted the order for [NAME] may be interviewed, responded that the staff no longer works in the facility. When she was asked if they review orders for Resident #51, she responded, yes. In an interview conducted with the Social Services Director on 02/19/26 at 1:44 PM and at 2:43PM, when she was asked if Resident #51 had been recently seen by a Mental Health Professional, responded that a physician saw this resident on 11/25/25. She added that she looked at the care plan with the notes on aggression and the physician was notified. They performed a PASSAR on 11/25/25 but nothing was changed so it remained the same PASSAR Level I. When she was asked why PASSAR Level I was not updated with the progress notes documenting aggressive behavior, she stated that it was a mistake and a Level II PASSAR should have been initiated. She added that she would add Resident # 51 to the list for PASSAR updates. The Social Services Director added that she discusses any resident updates with the Director of Nursing (DON), the Minimum Data Set (MDS) Coordinator, and sometimes the whole team. They make sure that they talk about all residents with newly onset behavior changes, with any new assessments and interventions written during the psychiatry consultations. She added that all the psychiatry consultation notes are reviewed by Nursing. When she was asked if any Nurse reviewed the onset of aggression and the medication ordered by a physician on 12/08/25 for Resident #51, she responded she would review the chart again. This staff never came back after this interview. In an interview with Staff N, Registered Nurse (RN), on 02/19/26 at 2:24 PM, she stated that she is assigned to Resident #51 and had taken care of him several time before but never had any chance of injecting the [NAME] 20 mg intramuscularly. She provided the oral dose of [NAME]. She stated that she uses other techniques to decrease the resident's agitation. She explained that she tries to converse or talk to this resident in his native Creole language, and it seems to be effective. She knows that she is able to handle the resident. When Staff N was asked if the intramuscular (IM) injection is still a valid order since it was ordered back in 12/25, she responded, yes, it is still being given for periods of agitation. When she was asked if the nurses verified this order with the physician, she responded, yes, other nurses verified with the Medical Director and the psychologist who see this resident. In an interview conducted with Staff S, LPN, on 02/19/26 at 2:30 PM, when she was asked if she had provided the [NAME] intramuscular injection for Resident #51, she responded yes. When she was asked if she verified if the order is still active, she responded, it is still active because nurses still give it to Resident #51. When she was asked if she personally verified with the physician if the order is still active, she did not respond. When she was asked if she had given both the oral and the intramuscular [NAME], she stated she did not remember.

Based on observation and interview, the facility failed to discard refuse in a sanitary manner. This was observed during 2 of 2 refuse areas. The findings included:1. During a tour of the kitchen on 02/16/26 at 8:52 AM, Staff R, Cook, and this surveyor walked outside to the main dumpster area. Debris outside of the dumpster was observed around it which included gloves, paper, plastic, lids, a paint roller, and a paint can. Staff R stated he had just swept the area a few days before. In an interview conducted on 02/18/25 at 5:07 PM with the Regional Certified Dietary Manager and the Registered Dietitian, the findings were reviewed. 2. During an observation, on 02/17/26 at 2:18 PM, outside of the emergency exit at the end of the 400 unit, it was noted that there was a pile of pallets, discarded furniture and other unidentifiable refuse by the dumpster. During a second observation, on 02/10/26 at approximately 9:00 AM, it was noted that the piles of refuse and debris had increased from the previous observation. During the environmental tour, on 02/19/26 at 2:47 PM, with the Maintenance Director, when asked about the refuse being picked up, the Maintenance Director stated that he had a company that picked up specific types of refuse and a second company that comes every other week on opposite weeks to pick up additional types of debris. The Maintenance Director acknowledged the findings and stated that he would have the debris/refuse picked up more often to avoid piling up.

Based on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC's) standard precautions guidelines by failing to ensure residents' hands are sanitized, and or by failing to encourage residents to sanitize hands before eating, during lunch observations for Resident #83 and Resident #51; failed to follow CDC's guidelines on standard precautions by failing to disinfect the meal table before, and after glucometer testing, and before placing a lunch tray for Resident # 83; and failed to follow the CDC guidelines for Enhanced Barrier Precaution (EBP) during percutaneous endoscopic gastrostomy (PEG) tube medication administration for Resident #99. The findings included: Review of Center for Disease Control and Prevention (CDC) recommendations for Standard Precautions documented the following:Standard Precautions are used for all patient care.They're based on a risk assessment and make use of common-sense practices that protect healthcare providers from infection and prevent the spread of infection from patient to patient. The recommendation details to perform hand hygiene, and properly handle, clean and disinfect patient care equipment and instrument/devices.Clean and disinfect the environment appropriately. https://www.cdc.gov/infection-control/hcp/basics/standard-precautions.html Review of EBP signage card from CDC revealed the following: Everyone must clean hands, including before entering and leaving the room. Wear gloves and a gown for the following High-ContactResident Care Activities: Device care or use: central line, urinary catheter, feeding tube, tracheostomy https://www.cdc.gov/long-term-care- facilities/media/pdfs/enhanced-barrier-precautions- sign-P.pdf 1. Record review documented Resident #83 was admitted to the facility on [DATE] with diagnoses that included Conversion Disorder with Seizure or Convulsions, Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance of Mood, Mood Disturbance, Anxiety and Major Depressive Disorder. Review of recent Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview for Mental Status (BIMS), revealed a score of 06 indicating severe impaired cognition. Section N revealed yes responses that Resident #83 was receiving antidepressant, diuretic, hypoglycemic (including insulin), and anticonvulsant. Review of the nursing care plan revealed the resident has impaired cognitive function / dementia or impaired thought processes related to Dementia, and Impaired decision-making. During a blood sugar test on 02/16/26 at 11:55 AM with Staff F, Registered Nurse (RN), it was observed that Staff F entered Resident #83's room and placed the tray with glucometer, tissue paper, lancet, and glucometer strip on top of Resident #83's meal table without first disinfecting it.Staff F performed hand hygiene, then obtained the blood glucose level. Staff F performed hand hygiene again, and since she did not see a trash can inside the resident's bathroom, she tossed the paper towel, that she had used for drying her hands and turning off the faucet, on top of Resident # 83's meat table. When she saw that the surveyor was looking at the meal table, she took the used paper towels and left the resident's room without disinfecting the table. A few minutes later, Staff G, Certified Nursing Assistant (CNA) placed the meal tray on top of the table without first disinfecting it. Staff G did not encouraged Resident #83 to sanitize his hand before eating and touching the food inside the meal tray. When Staff G was asked why she did not encourage Resident #83 to sanitize hands before eating, she did not respond. When she was asked if she disinfected the meal table, she did not respond. 2. Record review documented Resident #51 was admitted to the facility on [DATE] with diagnoses that included Altered mental Status, Unspecified dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Cognitive Communication Deficit, and Encephalopathy. Review of admission MDS assessment dated [DATE], under Section C, revealed a BIMS score of 09, indicating moderate impaired cognitive function. Review of the nursing care plan revealed the resident has a behavior problem as evidenced by: urinating on the floor, (12/17/2025); wandering into other resident's room; and eating from their trays (12/27/25, and 12/28/2025). During a unit tour on 02/16/26 at 9:20 AM, Resident # 51 was not inside his room. During observation of the resident's bathroom, it revealed the toilet had not been flushed and was with toilet paper inside the bowl. There was no trash can inside the bathroom. There was also no trash can inside the resident's room. During lunch time, Staff I from the Rehabilitation Department placed the lunch tray on top of resident's meal table on 02/16/26 at 12:55 PM. Staff I did not sanitize the resident's hands. The resident had been observed going in and out of other residents' rooms that morning and before lunch, and was touching inside his underwear. Staff I, on 02/16/26 at 12:55 PM, did not sanitize the resident's hands, and left the room as soon as the resident started eating food from the lunch tray.When Staff I was asked if he sanitized the resident's hands before he let him eat, he responded, yes. When he was asked what he used in sanitizing the resident's hands, he responded that he obtained wet paper towel inside the bathroom. When he was asked to show where he tossed the paper towel after sanitizing the residents' hands, he responded, he tossed it in the trash can inside the resident's bathroom. When he was asked to show the surveyor the trash can, Staff I went inside the resident's bathroom but found no trash can. He went back to the resident's room and started looking for a trash can but found none as well. When he was asked again if he sanitized the resident's hands before letting him eat lunch, he did not respond. 3. Record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses that included Traumatic Subdural Hemorrhage without Loss of Consciousness, and Dysphagia. Review of MDS assessment dated [DATE], under Section C, revealed no BIMS score, as it was disabled by question C0100, indicating severe cognitive impairment. Review of nursing care plan dated 02/21/25 revealed staff were to use Enhanced Barrier Precaution (EBP) related to PEG tube [percutaneous endoscopic gastrostomy] usage. During a medication pass observation with Staff H, RN, on 02/18/26 at 9:28 AM, a CDC EBP poster was observed on Resident #99' s door. There was a blue cloth hamper with PPE gowns and supplies hanging at the back of Resident #99's door. Staff H stated she would administer medications via the PEG tube. Staff H performed hand hygiene, and donned PPE (personal protective equipment) gloves, but failed to don a PPE gown during the PEG tube medication administration. When Staff H was asked why she did not don on PPE gown, she responded, nerves.

Based on record reviews and interviews, the facility failed to complete in a timely manner, based on the resident's needs and included in the record, the resident's discharge needs and discharge plan for 1 of 2 sampled residents, Resident #1. The findings included: Record review of the provided document, titled, SS-160, Discharge Planning, with an effective date of 11/30/14, revealed that discharge planning begins the day of admission. Statement #2 revealed that discharge planning record will be completed within seven days after admission. Statement #6 revealed that within 24 to 48 hours, or the next day after discharge to home, a follow-up phone call, or if necessary, a home visit will be made to ascertain that community services / referrals are indeed being provided according to the discharge plan. Record review documented Resident #1 was admitted to the facility on [DATE] with diagnoses that included Sepsis following a Hospital Procedure, Acute Respiratory Failure, Alkalosis, and Osteomyelitis. The resident was discharged on 03/21/25. Review of the admission Minimum Data Set (MDS) assessment under Section C of the Brief Interview for Mental Status (BIMS) revealed Section C was disabled by question C600, indicating Resident #1 had signs and symptoms of delirium. Under Section N, it was revealed that Resident #1 was receiving anticoagulant, antibiotic, and opioid medications. Review of Nursing care plan, initiated on admission [DATE]) and updated with Intravenous use, did not include any focus, goals and interventions for Resident #1's discharge. Review of the Nursing progress notes dated 03/06/25 revealed an order for, Cefepime HCL intravenous solution, 1 GM (Gram)/50 ml (milliliter), use 2000 mg intravenously every 12 hours for bone and joint infection for 27 days. Review of the physician order revealed Resident #1 was to be discharged on 03/21/25 with an order for, Home Health services (Registered Nurse (RN)/ Physical Therapy (PT)/Occupational Therapy (OT)/ Home Health Aide (HHA), Durable Medical Equipment (DME) such as wheelchair, commode, and shower chair, home infusion of Intravenous (IV), and to follow up with Primary Care Physician (PCP). Review of the Nursing progress notes dated 03/21/25 at 9:48 AM revealed Resident #1 left the facility accompanied by the son and the transporter. Resident #1 had an intact and patent peripherally inserted central catheter (PICC) line to left arm. Review of the record did not reveal any follow-up call to Resident #1 and/or family by Social Services staff or other members of the the clinical care team, a day after discharge. Review of the Nursing progress notes dated 03/22/25 at 3:01 PM revealed a call was received from Resident #1's son stating the IV medications were not received at his house. Resident #1's son came to the facility and was told by the Physician Assistant (PA) that the IV scripts were faxed to pharmacy and a copy was given to Resident # 1's son. Further review of the progress notes revealed Resident #1's son came back to the facility again stating the pharmacy, where the order was faxed, was unable to provide the IV medications, so the PA informed the facility's Pharmacy to provide a 3-day supplies of IV antibiotics and to follow up with Resident #1's insurance. There was no documentation on 03/23/25 regarding follow up with Resident #1's insurance and a follow up from any facility staff regarding the IV antibiotics. Review of Nursing progress notes, dated 03/24/25, revealed Resident #1's son called the facility again stating the IV antibiotics were not received from the Pharmacy. An additional review of the Nursing progress notes dated 03/25/25 revealed the IV antibiotics were still not received by Resident #1. Review of the Social Services (SS) progress notes dated 03/27/25 revealed the SS staff contacted Resident #1's son for a follow up. Resident #1's son stated that the durable medical equipment (DME) was not received. The Social Worker (SW) contacted the DME company [name provided] to inquire about the delay. The DME company's representative stated that the company [name provided] did not send the clinical history for equipment. The SW contacted the company [name provided] to get documentation sent to the DME company and she had remained on the line for confirmation. The company's [name provided] representative faxed the clinical documents to the DME company. Resident #1's son was notified and was appreciative of the facility's assistance. An interview was conducted with Staff B, Licensed Practical Nurse (LPN), on 04/09/25 at 11:06 AM, who when asked if she had given the IV antibiotics to Resident #1, responded, 'yes'. When asked if she had given the discharge instructions to the resident's family regarding IV antibiotics, she responded, 'yes'. Staff B also stated it is the responsibility of the Social Worker to make sure the resident has IV antibiotics medications instructions with the pharmacy information. An interview was conducted with Staff C, Director of Social Services, on 04/09/25 at 11:19 AM, who stated that she did not confirm the pharmacy receipt of the IV antibiotic prescribed for the resident. She did not document the discharge instructions for the IV medications. She remembered that Resident #1's family had to call the facility on 03/24/25 and on 03/27/25 to make sure the medication was faxed to the pharmacy. When asked about the discharge process, Staff C responded that she usually calls the day after the resident leaves the facility for follow up. When asked why she did not follow-up call the day after Resident #1 was discharged from the facility, she did not respond.

Based on record reviews and interviews, the failed to facility to ensure Licensed Practical Nurses (LPNs) have the competencies and skill sets necessary to provde residents' needs of Intravenous (IV) antibiotics for 1 of 2 sampled residents, Resident #1, as evidenced by lack of required IV training and certificate. The findings included: Review of the professional key standard for Licensed Practical Nurses (LPNs) documented: LPNs must be certified in IV [intravenous] therapy and have completed 30 hours of post-graduation IV hydration training, including 4 hours dedicated to central line care. Record review revealed Resident #1 was admitted on [DATE] with diagnoses that included Sepsis following a Hospital Procedure, Acute Respiratory Failure, Alkalosis, and Osteomyelitis. Review of admission Minimum Data Set (MDS) assessment under Section C of the Brief Interview for Mental Status (BIMS) revealed that Section C was disabled by question C600, indicating Resident #1 had signs and symptoms of delirium. Section N revealed Resident #1 was receiving anticoagulant, antibiotic, and opioid medications. Review of the physician orders dated 03/17/25 revealed an order for: Cefepime HCL intravenous [IV] solution, 1 GM (Gram)/50 ml (milliliter), use 2000 mg intravenously every 12 hours for bone and joint infection for 27 days. Review of the Medication Administration Record (MAR) for 03/2025 revealed Staff B, Licensed Practical Nurse (LPN), administered the IV medication Cefepime on 03/17/25 and 03/20/25 at 12:00 PM. An additional review of 03/25 MAR revealed Staff B performed peripheral IV line flushing using 5 ml (milliter) Normal Saline every 12 hours, to maintain patency of IV access on 03/11/25, 03/12/25, 03/17/25 and 03/20/25 at 9:00 AM. An interview was conducted with Staff B on 04/09/25 at 11:06 AM, who when asked if she administered IV antibiotics to Resident #1, who stated, Yes, I hung IV antibiotics for her. She added IV medications and antibiotics can be administered by LPN alone without RN supervision at this facility. An interview was conducted with Staff E, Regional Registered Nurse (RN) Consultant, on 04/09/25 at 2:49 PM, who when asked if LPNs need IV certifications before administering IV medications, she responded, They do not need certifications. An additional interview was conducted with Staff B on 04/09/25 at 3:00 PM, who when asked if she has IV certification to hang IV antibiotics, she responded, No. An interview was conducted with Staff F, LPN, on 04/09/25 at 3:14 PM, who when asked if she performs IV flushing and administering IV medications, she responded, No, I am still working on getting my IV certification. An interview was conducted with the Director Of Nurses (DON) on 04/09/25 at 3:30 PM, who stated that LPNs who provide IV antibiotics administration and IV access line flushing have IV certifications. When asked to provide a copy of the IV certification of Staff B, LPN, she stated, she would provide it later because the Human Resource Staff already left for the day. She added it would be emailed to the surveyor. No IV certification of Staff B, LPN, was provided to this surveyor 2 days after the survey.

Based on observations, interviews, and record review, the facility failed to ensure that residents were treated in a dignified manner during dining for 8 of 21 sampled residents, Resident #8, Resident #19, Resident #29, Resident #76, Resident #90, Resident #5, Resident #26 and Resident #83; and failed to provide assistance with Activities of Daily Living (ADLs) regarding dining for 1 of 1 sampled resident reviewed for ADLs, Resident #73. The findings included: Record review revealed Resident #19's Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 07, indicating moderate to severe cognitive impairment. Record review revealed Resident #90's Quarterly MDS assessment dated [DATE] showed a BIMS of 03, indicating severe cognitive impairment. Record review revealed Resident #73's Quarterly MDS assessment dated [DATE] had a BIMS score of 03, indicating severe cognitive impairment. Record review revealed Resident #83's Quarterly MDS assessment dated [DATE] had a BIMS score of 03, indicating severe cognitive impairment. In an observation conducted on 09/09/24 in the main dining room from 12:10 PM to 12:30 PM, 21 residents were observed eating their lunch meals in the main dining room. Three (3) round tables were observed with the following: a. A table had two residents sitting for the lunch meal. Resident #8 was observed eating her lunch meal while Resident #19 was still waiting on their lunch meal. b. Three residents were sitting at a table for the lunch meal. Resident #29 and Resident #76 were eating their lunch meals, while the third, Resident #90, was still waiting on his lunch meal, observing the other two residents eating. c. Two residents sat at a table for the lunch meal. Resident #5 was eating his lunch meal while Resident #73 was waiting for her lunch meal. In an observation conducted on 09/09/24 at 12:40 PM, Resident #26 was eating her lunch tray in the room, and her roommate, Resident #83, did not get her lunch tray. The observation continued at 1:05 PM, 25 minutes later, and Resident #83 did not get her lunch tray. It was at 1:15 PM, 35 minutes later, that Resident #83 received her lunch tray. An interview was conducted on 09/11/24 at 2:50 PM with Staff A, Certified Nursing Assistant, (CNA), who stated she was educated on dignity during dining. She always knocks on the door before entering the room and ensures she sits down at an eye level while feeding residents. An interview was conducted on 09/11/24 at 3:00 PM with Staff E, Registered Nurse, who stated he was educated on treating residents dignifiedly during dining. When serving in the main dining room, they must ensure that one table at a time is served to all residents before moving on to the next table. 2. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses to inlcude Hyperlipemia, Alzheimer's Disease, a History of falling, and Muscle Weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Section GG of the MDS revealed Resident #73 needs substantial maximum assistance for eating. In an observation conducted on 09/09/24 at 9:35 AM, Resident #73 was noted in the room with the breakfast tray untouched. Closer observation revealed that Resident #73's roommate was already done eating her breakfast tray. In an interview conducted on 09/09/24 at 9:40 AM, Resident #73's family member stated she [Resident #73] needs assistance with her eating and someone to check in on her during mealtimes. She holds food and liquids in her mouth and, at times, forgets to swallow, [Resident #73] eats better when staff assisting her to eat, and she (familiy member) was worried [the residnet] was skinny and did not eat much. An observation conducted on 09/10/24 at 12:55 PM revealed Resident #73 eating her lunch meal with no staff in the room. A closer observation revealed that Resident #73's tray was 100% untouched. At 1:10 PM, 15 minutes later, the tray was still 100% untouched. The observation was continued at 1:25 PM, 30 minutes later, and no staff member in the room was assisting Resident #73 with her lunch tray. The lunch meal was about 5% consumed. An interview was conducted on 09/9/24 at 12:30 PM with Staff A, Certified Nursing Assistants (CNA), who stated that some days, Resident #73 eats about 40% of her meals, and some days, she needs assistance from staff. Staff A stated Resident #73's eating habits are not predictable. Review of the Care Plan initiated on 01/4/2023 showed Resident #73 has impaired cognition related to dementia. Resident #73 is at nutritional risk related to an altered diet and impaired cognition. An interview was conducted on 09/10/24 at 3:21 PM with the Staff MDS Coordinator, who stated she would look at the rehab report and the initial evaluation to determine what status to code residents under Section GG for eating. She stated she often spends time with the residents to get to know them and find out what they are able to do and what they can not do. After spending time with the residents, she gets to know them and what they can and cannot do. When asked by the surveyor what it means when a resident is coded in the MDS for 'substantial maximum assistance for eating,' she stated the following, the resident cannot finish the meal without someone assisting them. This means that they need lots of help during mealtimes, and they have maximum assistance from staff who would be right next to them to assist them at all times.

Based on review of policy and procedure, observation and interview, the facility failed to ensure the bathroom Emergency call light system was accessible and within easy reach of the residents and staff members for 7 of 53 residents observed (Resident #95, Resident #45, Resident #3, Resident #29, Resident #17, Resident #76 and Resident #23), in the secure, locked unit. The findings included: Review of the facility policy and procedure on 09/12/24 at 11:44 AM, titled, Call Bell System, provided by the Administrator effective date 11/30/14, documented, in part, in the Policy Statement: Resident must have, at all times, a system to notify staff when assistance is needed Procedure: .will be placed within reach of any resident . Record review revealed Resident # 95 was admitted to the facility on [DATE] with diagnoses that included Dementia, Diabetes Mellitus Type II, Hypertension and Depression. Resident #95 ambulates in and out of her bathroom throughout the day. She had a documented Brief Interview Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Record review revealed Resident # 45 was readmitted to the facility on [DATE] with diagnoses that included Autistic Disorder, Schizophrenia, Parkinsonism and Hypertension. The resident's BIMS score was not documented but it indicated moderate cognitive impairment. Record review revealed Resident #3 was readmitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Schizophrenia, Dementia, Parkinsonism and Generalized Anxiety Disorder. Resident #3 self-propels in his wheelchair in and out of his bathroom throughout the day. He had a BIMS score of 2 indicating severe cognitive impairment. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis affecting the right dominant side, Dementia, Diabetes Mellitus Type II, Major Depressive Disorder and Repeated falls. Resident #29 self-propels in her wheelchair in and out of her bathroom throughout the day. She had a BIMS score of 4, indicating severe cognitive impairment. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that included Heart Failure, Depression, Diabetes Mellitus Type II, Anxiety Disorder and Hypertension. She had a BIMS score of 4, indicating severe cognitive impairment. Record review revealed Resident #76 was readmitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis affecting right dominant side, Diabetes Mellitus Type II, Cerebral Infarction, Anemia and Unsteadiness on feet. Resident #76 self-propels in his wheelchair in and out of his bathroom throughout the day. He had a BIMS score of 14, indicating he was cognitively intact. Record review revealed Resident #23 was readmitted to the facility on [DATE] with diagnoses that included Dementia, Systolic Congestive Heart Failure, Depression, Epilepsy, Asthma, Parkinsonism, Altered mental status and Hypertension. Resident #23 self-propels in his wheelchair in and out of his bathroom throughout the day. He had BIMS score of 8, indicating moderate cognitive impairment. During an observational room tour conducted of the 100-hallway locked area unit, between the three (3) days of 09/09/24 through 09/11/24, the following four (4) resident rooms were observed to have their bathroom Emergency call lights not accessible and not within easy reach for the residents and facility staff's use. Photographic Evidence Obtained. a. On 09/09/24 at 10:53 AM, Resident #95's bathroom was observed to have the bathroom Emergency cord was noted to be tied around the bathroom bar. On 09/10/24 at 10:04 AM, Resident #95's bathroom was still observed to have the bathroom Emergency cord was noted to be tied around the bathroom bar. On 09/11/24 at 9:20 AM, Resident #95's bathroom was still observed to have the bathroom Emergency cord was noted to be tied around the bathroom bar. b. On 09/09/24 at 11:21 AM, Residents #45's and Residents #3's bathroom was observed to have no pull cord attached to the bathroom Emergency call system in the bathroom. On 09/10/24 at 10:08 AM, Residents #45 and #3's bathroom was still observed to have no pull cord attached to the Emergency call system in the Resident's bathroom. On 09/11/24 at 9:23 AM, Residents #45 and #3's bathroom was still observed to have no pull cord attached to the Emergency call system in the Resident's bathroom. c. On 09/09/24 at 11:48 AM, Residents #29 and #17's bathroom was observed to have the bathroom Emergency call light cord wrapped around the bathroom handrail. On 09/10/24 at 10:15 AM, Residents #29 and #17's bathroom was still observed to have the Emergency call light cord wrapped around the bathroom handrail. On 09/11/24 at 9:25 AM, Residents #29 and #17's bathroom was still observed to have the bathroom Emergency call light cord wrapped around the bathroom handrail. d. On 09/09/24 at 12:07 PM, Residents #76 and #23's bathroom Emergency bathroom cord was tied to the toilet faucet connection above the toilet x 1 on the first day of the survey. Following the observational room tour, an interview was conducted on 09/11/24 at 9:31 AM with the Maintenance Director, the Housekeeping Director, the Director of Nursing (DON), the Regional Nurse, the Regional Maintenance Director and the Administrator, regarding the residents' bathroom emergency call lights all being observed as inaccessible. Each acknowledged that the residents' bathroom call lights should be readily accessible for both the residents and staff use, in the event of an emergency. Three (3) of the four (4) residents bathroom's emergency call lights had not been made easily accessible and within reach, to both the residents and staff for those resident rooms, until after surveyor inquisition/intervention. On 09/12/24 at 11:36 AM, Residents #29 and 17's room was still observed, on a fourth (4th) observation, with the Administrator present, to have the bathroom emergency call light in the exact same position as it had been on three (3) previous days, wrapped around the bathroom handrail. The Administrator further recognized and acknowledged that on 09/11/24 at 10:31 AM, the facility should ensure that the bathrooms' emergency call lights should always be readily accessible and within reach for both resident and staff use, in the event of an emergency.

Based on observation, interview and record review, the facility failed to implement a care plan for Post Traumatic Stress Disorder (PTSD) and failed to implement a care plan for an anticoagulant for 1 of 24 sampled residents, Resident #88. The findings included: 1. Record review revealed Resident #88 was admitted to the facility post hospitalization on [DATE], with admitting diagnoses that included Unspecified Cirrhosis of Liver, Coronary Artery Disease, Non-Alzheimer's Dementia, and Post Traumatic Stress Disorder. Review of the admission Minimum Data Set (MDS) with an assessment reference date of 08/15/24, documented a Brief Interview for Mental Status (BIMS) score of 8 indicating the resident had moderate cognitive impairment. Section I of this MDS revealed the resident had Post Traumatic Stress Disorder (PTSD). Review of the record revealed there was no care plan that addressed PTSD. An interview was conducted with the MDS Coordinator on 09/10/24 at 3:10 PM, who was responsible for putting a care plan in place for PTSD. The MDS Coordinator stated this would be her job. She was asked why there was no care plan for PTSD for this resident and she stated she would put one in today. 41837 2. Record review for Resident #88 revealed the resident was admitted to the facility on [DATE] with diagnoses including in part: Essential (Primary) Hypertension and Unspecified Atrial Fibrillation. Review of the MDS assessment for Resident #88 dated 08/15/24 documented in Section C, a Brief Interview of Mental Status score of 8 indicating moderate cognitive impairment. In Section N, documented under Anticoagulant, is taking - yes. Review of the physician's orders for Resident #88 revealed an order dated 08/16/24 for Eliquis (Apixaban) 5mg, give 1 tablet by mouth two times a day for A-fib (Atrial Fibrillation). Review of the physician's orders for Resident #88 revealed an order dated 08/15/24 for Anticoagulant Medication - monitor for discolored urine, black tarry stools every shift. Review of the Care Plan for Resident #88 revealed no care plan for the anticoagulant or for risk of bleeding. An interview was conducted on 09/11/24 at 11:07 AM with the MDS Coordinator who stated she has been working at the facility for less than 1 year and started in October 2023. When asked if a resident is on an anticoagulant would the resident have a care plan related to anticoagulant for at risk for bleeding. She stated, of course they would have to have a care plan for risk of bleeding if they are on an anticoagulant. She said that is very important.

Based on interviews and record review, the facility failed to ensure residents received assistance with making eye appointment for 1 of 1 sampled resident reviewed for vision, Resident #89. The findings included: Record review revealed Resident #89 was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Dementia Unspecified Severity with Agitation, Altered Mental Status, Delirium Due to Known Physiological Condition, and Psychotic Disorder with Hallucinations Due to Known Physiological Condition. Review of the Minimum Data Set (MDS) for Resident #89 dated 05/22/24 documented in Section B under Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision was answered yes. Documentation in Section C revealed a Brief Interview of Mental Status score of 6 indicating severe cognitive impairment. A telephone interview was conducted on 09/10/24 at 10:22 AM with the family member of Resident #89 who stated she brought it to attention of staff that she would like the resident seen by eye doctor about 2 months ago because the resident had no eyeglasses. She had bought the resident a pair of over the counter reading glasses in the meantime. The family member stated the social worker told her they would have the eye doctor see the resident, but she has not heard of any appointment being set or of the resident having seen the eye doctor. An interview was conducted on 09/10/24 at 2:02 PM with the Social Service Director (SSD) who was asked if Resident #89 was seen by the eye doctor. She said she believes the resident was seen by the eye doctor, but they have not received the paperwork yet. An interview was conducted on 09/11/24 at 2:00 PM with the SSD who was asked about the documentation for the eye exam for Resident #89. The SSD stated the resident had not been seen by the eye doctor. The SSD stated she had spoken to Resident #89 and the resident had informed her that a family member had brought her some glasses. When brought to the SSD attention that the resident has severe cognitive impairment, the SSD said I know but I thought the glasses were lost and then they were found. The SSD acknowledged she did not arrange for Resident #89 to be seen by the eye doctor as requested by Resident #89's family member. The SSD further acknowledged she did not have any additional conversation with the family member regarding eyeglasses after she spoke to the resident.

Based on observations, interviews and record review, the facility failed to identify weight loss, and provide nutritional intervention in a timely manner for 2 of 5 sampled residents reviewed for nutrition, Resident #32 and Resident #7. The findings included: Review of the facility's policy, titled, Weighing the Resident, revised on 05/06/2022, showed the following: Record weight and alert nurse to any significant change. Notify the Physician of any significant weight change and consult the Dietitian. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses that inclluded Muscle wasting, History of falling, Dementia, Muscle weakness, and Anemia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 03 indicating severe cognitive impairement. In an observation conducted on 09/10/24 at 8:48 AM, Resident #32 received her breakfast tray. At 9:00 AM, the Director of Nursing (DON) came into the room and sat near Resident #32 to help her with the breakfast tray. At 9:03 AM, the DON left the room with the breakfast tray and said to the surveyor, She does not want to eat. I will bring her cereal from the kitchen. In an observation conducted on 09/11/24 at 8:45 AM, Resident #32 received her breakfast tray. At 9:00 AM, Resident #32 was observed eating on her own and only ate one bite of her bread and a few teaspoons of the cereal. Continued observation at 9:15 AM, which was 30 minutes later, revealed Resident #32 did not eat any more of the food on her breakfast plate from the earlier observation at 9:00 AM. Review of the physician's orders showed the following: give 120 milliliters (ml) of nutritional support three times a day, dated 08/30/24; give a house shake with lunch one time a day, dated 09/04/24; and give a regular texture diet, dated 03/04/24. Review of Resident #32's weight log showed the following weights: On 05/06/24, 130.8 pounds (#). On 06/03/24, 129.8 #. On 07/02/24, 125.4 #. On 08/06/24, 121.6 #. The weight loss over 2 months was 6.4% weight loss. The weight on 09/03/24 showed a weight loss of 8.9% in 3 months from 06/03/24 to 09/03/24. Review of the Certified Nursing Assistants, (CNAs), documentation of the amount of meals consumed revealed that from 08/13/24 to 08/30/24, Resident #32's daily intake (3 meals a day) was an average of 46%. Review of the Clinical Dietitian's progress note dated 08/30/24 showed the following: trending non-significant weight loss past 180 days. Resident #32 is eating between 25% and 50% of her meals. Suggest increasing nutritional supplements 120 ml to 3 times a week. This clinical note addressing the above weight loss was completed 24 days after the 6.4% weight loss was identified on 08/06/24, with a weight of 121.6 pounds. Review of the Clinical Dietitian's progress note dated 09/04/24 showed the following: significant weight loss in 90 days. Resident #32 is eating between 25% and 50% of her meals. An additional house shake (nutritional supplement) was added to the lunch meal for additional calories and protein. An interview was conducted on 09/11/24 at 10:06 AM with the facility's Clinical Dietitian, who started working in the company for about one year. She stated she comes into this facility one time a week as well. A significant weight loss is when a resident loses 5% in one month, 7.5% in 3 months, and 10% in 6 months. A severe weight loss will populate in the electronic system, letting her know if any residents have severe weight loss. She will try to follow up on the residents within 24 to 48 hours. She would address any trending weight loss as soon as she could, within 24 hours to 48 hours. Resident #32 weight loss trend was addressed about 24 days later. When asked by the surveyor why she addressed the weight loss 24 days later, she did not know. In an interview conducted on 09/12/24 at 1:00 PM, with the Director of Nursing, she was told of the findings. 50370 2. Record review revealed Resident #7 was admitted on [DATE] with the diagnoses that included Essential Primary Hypertension, Type 2 Diabetes, Hyperlipidemia, and Atherosclerotic Heart Disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], in Section C revealed a Brief Interview of Mental Status (BIMS) score of 03 indicating the resident had severe cognitive impairment. Section K of MDS revealed no complaints or difficulty or pain when swallowing. Additional data under Section K showed Resident #7 weighed 116 pounds (Lbs/#) on 08/05/24 indicating no weight loss of 5 % in the last month and no weight loss of 10% or more in the last 6 months. Review of the laboratory result dated 05/28/24 revealed Resident #7 had low total protein of 6.0 g/dl (gram per deciliter is the sum concentrations of all individual serum protein), indicating resident's level was on the bottom spectrum of the normal values of 6 g/dl to 8.3 g/dl.) and an albumin level of 3.0 gm/dl. (indicating below the normal range of 3.5 to 5.5 grams per deciliter which could indicate an underlying medical condition related to kidney, liver, and heart and could also indicate nutritional deficiencies). Review of records showed a nutrition care plan for altered nutrition and hydration, swallowing problems related to coughing or chocking during meals or swallowing medications. Care plan for potential pressure ulcer, impaired cognition related to dementia, complications of diabetes mellitus, previous CABG (Coronary Artery Bypass Graft) related to Hypertension and lifestyle choices were noted. Review of Assessment, titled, Nspire Daily Skilled Notes, dated 09/09/24, documented, in part, the following: ADL (Activities of Daily Living) status is assisted, Resident receives PT (Physical Therapy), and OT (Occupational Therapy), swallowing problems were not noted. Review of Task under Percentage of Meals eaten showed the following data for Resident 7: 0n 08/30/24, consumed 25% at breakfast, 50% at lunch and 75% at dinner. On 08/31/24, consumed 25% at breakfast, 74% at lunch 75% at dinner. On 09/01/24, consumed 0% for breakfast, 50% at lunch, and 75% at dinner. On 09/02/24, consumed 50% at breakfast, 75% at lunch, 100% at dinner. On 09/03/24, consumed 50% at breakfast, 50% at lunch, 25% at dinner. Review of weight records showed the following data: 114.2 pounds on 09/03/24, 117.2 pounds on 08/30/24; 116.2 pounds on 08/05/24; 119.4 pounds on 07/05/24; 120.8 pounds on 06/03/24; 125 pounds on 05/02/24, and 122.2 pounds on 04/03/24. This indicated a weight loss of 2.66 % in a month and 6.55 % weight loss in 6 months. Review of the physicians' order dated 11/03/22 showed that Resident #7 was to be provided with one carton (120 ml [milliliters]) of NSA (No Salt Added) House Shake, twice daily with lunch and dinner. On 02/05/24, the orders showed the resident was to receive a regular textured diet order. On 08/02/24, an order was documented to give Resident #7 snacks daily at HS (hour of sleep) one time at night. On 09/09/24, an order for a NSA supplement was added, increasing the supplement to three times a day. Review of the Registered Dietician (RD) notes, dated 06/03/24, showed the facility staff addressed Resident #7's moderate protein calorie malnutrition by documenting fluctuating appetite (mostly eating 25-50% of meals, and occasionally 75 0r 100 of meals). Review of the RD notes, dated 06/03/24, documented Resident #7 had 5.6 % weight loss in 5 months (126.4 Lbs weight on 02/05/24 to 120.8 Lbs on (06/03/24). Additional notes documented a 4.2 Lbs weight loss in one month (120.8 Lbs on 06/03/24 from 125.0 Lbs. on 05/02/24) with a BMI (Basal Metabolic Index ) of 19.5. Review of the RD notes, dated 06/03//24 documented the following interventions: to monitor laboratory (albumin, total protein, pre-albumin), weight and PO [oral] intake, to continue aggressive PCM (Protein Calorie Malnutrition) treatment with supplements, house shake one carton BID (two times a day) at lunch and dinner, NSA (No Salt Added) of 120 ML (milliliters), QID (4x a day). It added that staff assist with meals. In an interview with Resident #7 on 09/10/24 at 09:30 AM, she stated she sometimes does not like to eat, and only drinks tea in the morning. During lunch observation on 09/10/24 at 1:30 PM, Resident # 7's lunch tray remained untouched. There was no supplement noted on the meal table. There was no assistance from staff observed. Resident #7 returned her meal tray to the meal cart with staff observing. Staff did not ask if she wanted to have an alternate lunch. During an observation conducted on 09/11/24 at 9:26 AM, Resident #7 stated that she drank tea, but did not touch breakfast. The breakfast tray was delivered before 9:00 AM and remained untouched at 9:50 AM. No staff approached the resident to encourage her to eat or asked her if she wanted something else. In an interview with Staff I, Certified Nursing Assistant (CNA), on 09/11/24 at 9:30 AM, she stated that Resident #7 eats when the food is interesting. She stated that Resident #7 eats only 50% of her meal most of the time. When asked if she had seen Resident #7 drinking nutritional supplement during breakfast and lunch, she stated no. When asked if she assisted Resident #7 in eating, she answered no. She stated Resident #7 likes to drink tea but refuses food on the breakfast tray. When asked if she offered Resident #7 a different breakfast, she responded, no. She added that Resident #7 likes to eat her lunch. An interview was conducted with the Registered Dietician (RD) on 09/11/24 at 10:06 AM. She said that she was not concerned about Resident #7's weight loss because it was a weight loss trend and not a weight trigger for significant weight loss in the electronic system. When the surveyor reviewed with her the weight loss of Resident #7, which went down to 114.2 pounds on 09/03/24, from 117.2 pounds on 08/30/24, and 125 pounds on 05/12/24, she stated she knew about the weight loss trend, but it was not significant weight loss and considered it not important. When asked by the surveyor why she modified the nutritional supplement order to 3 times a day on 09/09/24, she stated that she increased the volume of the supplement because of Resident #7's weight loss trends. During an interview with the Director of Nursing (DON) on 09/12/24 at 2:00 PM, the above findings were reviewed.

Based on observations, interviews, and record review, the facility failed to follow the physicians' orders for tube feeding for 1 of 1 sampled resident reviewed for nutrition, Resident #69. The findings included: Record review revealed Resident #69 was readmitted to the facility on [DATE] with diagnoses that included Hemiplegia, History of falling, Muscle Weakness, and Chronic Kidney Disease. Review of the Physician's orders revealed the following: a. On 09/04/24, Enteral feeding continuous with Jevity 1.5 (tube feeding formulary type), at 75 milliliters (ml) an hour for 20 hours or until 1500ml has infused with off feeding time at 10:00 AM. b. On 09/10/24. Enteral feeding is continuous with Jevity 1.5 (tube feeding formulary type) at 75 milliliters (ml) an hour for 20 hours or until 1500ml has been infused. c. On 09/11/24. Enteral feeding two times a day for one day bolus feeding with Jevity 1.5 (237ml) times 2 for one day. Review of the weight log for Resident #69 showed the following: On 05/02/24, a weight of 121 pounds. On 06/03/24, a weight of 118.6 pounds. On 07/05/24, a weight of 113 pounds. On 08/07/24, a weight of 111 pounds. On 08/19/24, a weight of 110.8 pounds. On 09/03/24, a weight of 107 pounds. This showed a 9.8% weight loss in 3 months. In an observation conducted on 09/10/24 at 7:30 AM, Resident #69 was noted in bed with the tube feeding running at 75ml an hour, which started on 09/10/24 at 6:00 AM. The tube feeding was noted at the 1000ml mark out of a 1000ml capacity bottle. In an observation conducted on 09/10/24 at 10:15 AM, Resident #69 was noted in bed with the tube feeding running at 75ml an hour, which started on 09/10/24 at 6:00 AM. The tube feeding was noted at the 850ml mark out of a 1000ml capacity bottle. The tube feeding that started at 6:00 AM in the morning, running at 75ml an hour, should have been at the 700ml mark out of a 1000ml capacity bottle. In an observation conducted on 09/10/24 at 11:30 AM, Resident #69 was noted in bed with the tube feeding running at 75 ml an hour which started on 09/10/24 at 6:00 AM. The tube feeding was noted at the 750ml mark out of a 1000ml capacity bottle. The tube feeding that started at 6:00 AM in the morning running at 75ml an hour should have been at the 600ml mark out of 1000ml capacity bottle. In an observation conducted on 09/10/24 at 1:00 PM, Resident #69 was noted in bed with the tube feeding running at 75 ml an hour which started on 09/10/24 at 6 :00AM. The tube feeding was noted at the 600ml mark out of a 1000ml capacity bottle. The tube feeding that started at 6:00 AM in the morning running at 75ml an hour should have been at 475 ml mark out of 1000ml capacity bottle and not at the 600ml mark as observed. In an observation conducted on 09/11/24 at 12:47 PM, Resident #69 was noted in the room with the tube feeding running. The tube feeding was noted with Jevity 1.5 at 75ml an hour, which started on 09/11/24 at 6:45 AM. About six hours later, the tube feeding bottle was noted at the 900ml mark out of the 1000ml capacity bottle. Review of the Clinical Dietitian progress note dated 08/23/24 revealed the following: weight loss trigger with no enteral feeding intolerances reported per nursing. Feeding increases related to significant weight loss. Review of the Clinical Dietitian progress note dated 09/06/24 revealed that Resident #69 has been losing weight, and the Dietitian updated the orders to change to continuous feedings. Review of the care plan dated 04/19/24 showed that Resident #69 requires tube feeding and needs to see the doctor's orders for current tube feedings. Resident #69 will maintain adequate nutritional and hydration status. An interview was conducted on 09/11/24 at 1:32 PM with Staff C, Licensed Practical Nurse, who stated she provided Resident #69 with bolus tube feeding at 9:30 AM this morning and at 12:00 PM today. She further said that Resident #69 is tolerating her tube feeding well. An interview was conducted on 09/11/24 at 1:42 PM with the Registered Dietitian, who stated she was told by nursing there was a malfunctioning of the tube feeding pump for Resident #69, and an order was placed for bolus feeding to meet the additional feeding of her needs for the tube feeding that started this morning. She confirmed that the tube feeding observed on 09/10/24 at 10:15 AM should have been at the 700ml mark and not at the 850ml mark as observed. The Registered Dietitian stated that she changed the tube feeding order from bolus to continuous to ensure that Resident #69 received the estimated calories and protein needs. An interview was conducted on 09/11/24 at 2:00 PM with the Director of Nursing, who stated Resident #69 used to pull her tube feeding out, which may have caused some of the weight loss. When asked for any documentation regarding the tube feeding behaviors, she was not able to provide any further documentation.

Based on observation, interview, record and policy review, the facility failed to timely assess a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) and failed to provide psychosocial services to meet the need for PTSD diagnosis for 1 of 1 sampled resident reviewed for PTSD, Resident #88. The findings included: The facility's policy, titled, PTSD Procedure and Policy, effective 08/14/20 and revised 11/20/20, documented, in part, Upon admission, all residents will be screened for potential PTSD using a standardized tool, such as the PTSD Checklist for DSM-5 (PCL-5) and Residents identified with PTSD will be offered individualized care plans that include: trauma-informed therapy or counseling, medication management (if appropriate). Record review revealed Resident #88 was admitted to the facility post hospitalization on [DATE], with admitting diagnoses that included Unspecified Cirrhosis of Liver, Coronary Artery Disease, Non-Alzheimer's Dementia, and Post Traumatic Stress Disorder. Review of the Minimum Data Set (MDS) assessment documented the Brief Interview for Mental Status (BIMS) with a score of 8, indicating moderate cognitive impairment. Section I of this MDS revealed the resident had PTSD. An interview was conducted with the resident on 09/10/24 at 1:25 PM. He stated he was a veteran, has PTSD and was in the hospital with a flashback before he was admitted here. He stated sudden loud noises remind him of the war like a car backfiring or loud car noises. An interview was conducted with Staff F, Registered Nurse (RN), on 09/10/24 at 1:40 PM, who stated she was aware of the PTSD diagnosis but was unaware of the triggers. She stated that he never spoke about it. An interview was conducted with the Social Service director on 09/10/24 at 1:45 PM. She was asked what she would do with a resident admitted with PTSD. She stated she does not deal with PTSD and she thinks a nurse does. When asked who would do a care plan for PTSD, she stated that the surveyor should talk to the MDS person. An interview was conducted with the MDS Coordinator on 09/10/24 at 3:10 PM, who stated she had been working in this facility for 11 months. She was asked what was the process if a resident was admitted with a diagnosis of PTSD. She stated the resident would be followed by psychiatry. She was asked who would talk to the resident about why he had PTSD and what his triggers were. She stated she would rather the psychiatrist talk to him about that. The MDS coordinator was asked if the resident had been seen by a psychiatrist yet and she stated she would put him on the list to be seen. The surveyor asked why has the resident not been seen since he has been here for a month already and she did not know. She stated that it is her job to put a care plan in for PTSD. She was asked why there was no care plan for PTSD for this resident and she stated she would put one in today. The PTSD policy was received by the surveyor on 09/12/24 at 10:00 AM and reviewed. An interview was conducted with the Regional Nurse Consultant who stated they have no PTSD tool. If they did, the Social Service Director would do the assessment. She stated that no resident has been screened with the PTSD checklist because they are not using the tool at this time and will have to re-evaluate this policy. An interview was conducted with the Psychiatrist on 09/12/24 at 11:50 AM, who had completed the assessment of Resident #88 that morning (09/12/24). The Psychiatrist stated the resident is confused and he has a lot of brain problems and encephalopathy and his current ammonia level is normal. He is hearing voices and hearing soldiers marching and because he is hallucinating he started him on Seroquel. (Seroquel is an antipsychotic medication used for the treatment of schizophrenia, bipolar disorder and major depressive disorder.) He does not seem distressed by it. He will see him next week. He thinks someone admitted with PTSD should be seen by a psychiatrist but since no one made him aware of it, he is seeing him today.

Based on observations, interviews and record review, the facility failed to ensure that it is free of hazards in the environment by failing to ensure that the water temperature in resident's bathrooms, on the 300 and 400 units, was within safe guidelines and allowable maximum water temperatures to prevent possible burns. This hazardous environment exposed the facility's residents with conditions such as decreased skin sensitivity, reduced reaction time and decreased cognition or dementia to an increased risk [MEDICAL CONDITION] by scalding. Nineteen (19) of 45 sampled residents were reviewed for accident hazards (Resident #6, Resident #10, Resident #13, Resident #14, Resident #15, Resident #17, Resident #20, Resident #21, Resident #22, Resident #23, Resident #25, Resident #26, Resident #28, Resident #31, Resident #32, Resident #34, Resident #39, Resident #40 and Resident #295). It was determined the provider's non-compliance caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Administrator and the Director of Nursing were notified that Immediate Jeopardy existed on January 10, 2021 at 4:20 PM. It was determined the Immediate Jeopardy was removed on January 10, 2021. The scope and severity was lowered to an (E). The findings included: Review of the facility's policy titled, Water Management Program, revised on 01/20/20 showed the following: Daily temperature checks for hot water in resident care areas, kitchen and laundry areas. Routine preventive maintenance of all mixing valves used to provide proper hot water temperature used within the facility. Review of the facility's policy titled, Monitoring and Recording Facility Hot Water Temperature for Residents Rooms, Common Areas, and Shower Rooms, revised on 01/2020 showed the following: Hot water temperature will be checked daily within the facility by the maintenance and/or management staff and documented on the facility water temperature log. Temperatures must be taken prior to use or treatment given to a resident. If a temperature is above 110 degrees, Fahrenheit, apply cold water to achieve temperatures between 100-110 degrees Fahrenheit and the clinical staff will maintain these records. All temperature checks for hot water temperature must be done using a Dial Stem Thermometer. Infrared and digital thermometers are not to be used. Prior to monitoring hot water temperatures, all Dial Stem Thermometers must be calibrated. The preferred method to calibrate is the use of ice and water in a cup, by placing the thermometer into the ice water and adjusting the needle to 32 degrees Fahrenheit or 0 degrees Celsius. During an observation conducted on 01/10/21 at 9:49 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was hot to the touch. At 9:51 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 9:56 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 9:57 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was hot to the touch. At 9:59 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 10:02 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 10:04 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 10:06 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 10:08 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 10:10 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 10:12 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 10:14 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. At 10:16 AM, the surveyors entered the resident's restroom located in room [ROOM NUMBER] and pushed the hot water sink lever on the left side to test the temperature of the hot water. After waiting 15-20 seconds, the surveyors reached their hands under the running water to check the temperature of the water. Surveyors had to immediately pull their hands out of the water since it was too hot to the touch. In an interview with Resident#26 on 01/10/21 at 10:10 AM, she stated that there was an issue with the hot water temperatures about 1 month ago. She further stated that maintenance instructed her to turn on the cold water with the hot water to decrease the water temperature to a safer, more acceptable range. During record review, it was noted Resident #26 had a Brief Interview of Mental Status (BIMS) of 12 (which is a slight cognitive impairment). On 01/10/21 at 10:25 AM, the Maintenance Director was asked about the hot water temperatures in the resident's restrooms. The Maintenance Director was asked to participate in a second tour of the resident's restrooms and to check the water temperatures. He used the facility's digital metal stemmed thermometer to check the water temperatures in the residents' restroom, which was in conflict with the facility's policy & procedure (P&P). The Maintenance Director was then observed pulling a new thermometer out of a box. The Maintenance Director was asked to calibrate the facility's brand new thermometer. When asked if he knew how to calibrate the thermometer, he stated, No. During a second tour of the resident's restrooms accompanied by the Maintenance Director, the temperature of the water from each hand sink located in each resident's room was checked using the facility's calibrated thermometer and the following was noted: (1) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 131.5 degrees Fahrenheit (F). (2) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 129.2 degrees F. (3) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 132.3 degrees F. (4) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 130.3 degrees F. (5) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 129.2 degrees F. (6) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 124.3 degrees F. (7) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 131.2 degrees F. (8) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 124.5 degrees F. (9) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 128.3 degrees F. (10) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 129.4 degrees F. (11) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 124.2 degrees F. (12) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 127.8 degrees F. (13) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 131.0 degrees F. (14) The temperature of the bathroom hand sink of room # 400 was 131.0 degrees F. (15) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 127.2 degrees F. (16) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 128.5 degrees F. (17) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 128.1 degrees F. (18) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 124.2 degrees F. (19) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 124.9 degrees F. (20) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 122.8 degrees F. (21) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 124.2 degrees F. (22) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 131.2 degrees F. (23) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 129.4 degrees F. (24) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 130.5 degrees F. (25) The temperature of the bathroom hand sink of room [ROOM NUMBER] was 133.2 degrees F. Following the tour, the Maintenance Director stated that the water temperatures of the hand sink should be between 110-115 degrees F. He further acknowledged all findings and stated that the water temperatures were too hot in all resident rooms that were checked. During a subsequent interview on 01/10/21 at 12:09 PM, the Maintenance Director stated that he checked the temperature of the water in resident rooms once per month and that when needed, he would check the water temperature once per week. He further stated that the hot water was not brought to his attention by any staff members and that this was the first time that he was made aware of the unsafe hot water temperature levels. According to him, painters were in the water heater room on 01/09/21 and must have moved the dial (mixing valve) by mistake, increasing the water temperature. The Maintenance Director stated that the mixing valve was very sensitive. On 01/10/21 at 2:19 PM, the Maintenance Director adjusted the water temperatures in the resident rooms to a safe temperature level that ranged from (99 F - 101F). During an interview on 01/10/21 at 3:45 PM, the Maintenance Director stated that he was adjusting the mixing valve because some of the resident's restrooms had water temperatures that were too hot or too cold. He stated that the facility had a total of 6 water heaters (2 water heaters in the 300-400-unit, 2 water heaters in the 100-200-unit, and 2 water heaters in the kitchen and laundry areas). According to him, there was 1 mixing valve for every 2 water heaters, which pushes the hot water to all of the resident's restrooms. When asked how he checked the temperatures, he stated that he goes by how the water feels on his hands and will also check the temperature with his thermometer. The temperatures for the water in the laundry are noted on the temperature logs in the laundry room. He stated that he checks the shower temperatures and documents it on the bottom of the monthly log. The Director of Nurses provided a list of 18 residents who could ambulate (14 that could ambulate independently and 4 that could ambulate with an assistive device) and a summary of their Brief Interview of Mental Status (BIMS) score. Further record review showed the following: Resident #34 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #34 can ambulate independently. Resident #22 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #22 has a BIMS score of 05 which is moderate to severe cognitively impaired and can ambulate independently. Resident #25 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #25 can ambulate independently. Resident #6 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #6 can ambulate independently. Resident #10 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #10 can ambulate independently. Resident #32 (room [ROOM NUMBER]-W) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #32 with a BIMS score of 0 which is severely cognitively impaired. Resident #32 can ambulate independently. Resident #14 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #14 can ambulate independently. Resident #39 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #39 can ambulate independently. Resident #20 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #20 can ambulate independently. Resident #28 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #28 can ambulate independently. Resident #15 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #15 can ambulate independently. Resident #17 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #17 can ambulate independently. Resident #21 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #21 had a BIMS score of 0 which is severely cognitively impaired. Resident #21 can ambulate independently. Resident #31 (room [ROOM NUMBER]-W) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #31 can ambulate independently. Resident #23 (room [ROOM NUMBER]-W) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #23 can ambulate with an assistive device. Resident #23 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #295 (room [ROOM NUMBER]-W) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #295 with a BIMS score of 0 which is severely cognitively impaired. Resident #295 can ambulate with an assistive device. Resident #13 (room [ROOM NUMBER]-W) was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #13 had a BIMS score of 0 which is severely cognitively impaired. Resident #13 can ambulate with an assisting device. Resident #40 (room [ROOM NUMBER]-D) was admitted on [DATE] with a [DIAGNOSES REDACTED].#40 had a BIMS score of 08 which is moderate to severely cognitively impaired. Resident #40 can ambulate with an assisting device. Record review showed that Resident #34 was noted with an open dry scab to the right arm in the weekly skin observation dated 12/26/20. Resident #6 was noted with a skin tear to the left hand in the weekly skin observation dated 12/11/20. Resident #32 was observed with a potential for impaired skin integrity related to fragile skin as noted on the care plan dated 12/14/20. Resident #14 was noted at risk for alteration in skin integrity in the care plan dated 11/18/2020. Resident #39 is at risk of changes in skin integrity as noted in the care plan dated 10/23/20. Resident #20 is at risk for impairment to skin integrity related to fragile skin as noted in the care plan dated 11/18/20. Resident #28 at risk for skin impairment related to fragile skin as noted in the care plan dated 12/03/20. Resident #15 has a potential for pressure ulcer development related to disease process as noted on the care plan dated 01/08/21. Resident #295 has a surgical wound to the left hip as noted in the care plan dated 01/10/21. Resident #13 had a potential impairment to skin integrity as noted in the care plan dated 01/10/21. Resident #40 was noted with a lower back wound in the weekly wound observation dated 12/26/20. In an interview on 01/10/21 at 4:26 PM with the facility's Administrator, she stated that the Maintenance Director has been here for about 2 years. The Administrator expected the Maintenance Director to be responsible for checking the overall maintenance and safety of the facility, which included areas such as, hot water, locked doors, and electricity. When it came to hot water, the Administrator stated that she expected the Maintenance Director to conduct a routine weekly and monthly check of the hot water using a temperature log. According to her, the Maintenance Director should conduct weekly checks in different areas of the facility to identify where to check for the monthly log. She further stated that she had not seen the Maintenance Director's temperature logs. The Administrator reported that it was her responsibility to check the Maintenance Director's documentation and that she had not checked his documentation. The Administrator further stated that she had participated in 1 Quality Assurance Performance Improvement (QAPI) meeting since starting this new position. According to her, the hot water was not mentioned in the most recent QAPI meeting. The Administrator stated that the Maintenance Director was not at the facility full time and that he was only there 2-3 times per week as he went to different sister facilities. She stated that they hired a full time Maintenance Director who will be starting in 2 weeks. She also confirmed that painters were in the facility on 01/09/21. Review of the Monthly Water Temperature Log dated January 2021 showed that all resident rooms were checked for hot water temperatures which showed ranges from 110-111 degrees F. Further observation of the Monthly Water Temperature Log dated January 2021 instructed maintenance to check at least one room on a different wing daily, which was not completed. Review of the Monthly Water Temperature Log dated December 2020 showed that all resident rooms were checked for hot water temperatures which showed ranges from 110-111 degrees F. Further observation of the Monthly Water Temperature Log dated December 2020 instructed maintenance to check at least one room on a different wing daily, which was not completed. Review of the Monthly Water Temperature Log dated November 2020 showed that all resident rooms were checked for hot water temperatures which showed ranges from 110-111 degrees F. Further observation of the Monthly Water Temperature Log dated November 2020 instructed maintenance to check at least one room on a different wing daily, which was not completed. In an interview on 01/11/21 at 8:07 AM, the Maintenance Director stated that prior to the survey, the last maintenance check for hot water was done on 01/05/21 and that no temperatures were above 115 degrees F. He further stated that a plumbing company came for a visit on 01/10/21 and found that the problem was the mixing valve because it was fluctuating the water temperatures. The Maintenance Director also reported that the mixing valve was working fine prior to this incident and that it must have malfunctioned over the weekend or on 01/10/21. In his interview with the painter, he realized that the painter must have leaned on the mixing valve while painting the water room which could have caused the mixing valve to shift causing an increase in water temperatures. He further stated that another plumbing company would be at the facility in 1 hour to give a second opinion. During an observation conducted on 01/11/21 at 9:30 AM, Resident #26, who resided on the 300 wing was observed in her bathroom standing up in front of her wheelchair. Further observation showed Resident #26 washing her upper body and upper portions of her legs under running water at the bathroom hand sink. Resident #26 resided in one of the rooms identified as having a high water temperature. During an interview on 01/11/21 at 3:50 PM, Staff F, Registered Nurse, stated that she is very familiar with the residents in the 300 unit and that she has worked with them closely. According to her, Resident #25, Resident #6, Resident #32, and Resident #39 were able to ambulate independently and had the capability to open the lever of the hand sink in their rooms. She further stated that she has often seen Resident #25 using the hand sink in her room. During an interview on 01/11/21 at 3:52 PM, Staff G, Certified Nursing Assistant, stated that Resident #22 sometimes goes to the bathroom to urinate and she has seen her washing her hands at the hand sink in her room. Staff G stated that even though Resident #295 was to ask for assistance, Resident #295 would get up, go to the bathroom, and will wash her hands in the hand sink in her room. She further stated that Resident #40 was able to go to the bathroom without assistance and that she saw him going to the hand sink in his room and washing his hands. During an interview on 01/11/21 at 3:54 PM, Staff G, Certified Nursing Assistant, she stated Resident #15, Resident #23, Resident #17, Resident #13, Resident #21, and Resident #31 could physically transfer from the bed safely walk to the bathroom and operate the hand washing sink. During an interview on 01/11/21 at 3:56 PM, Staff H, Certified Nursing Assistant, stated that Resident #20 was incontinent at times and could use the sink. She further stated that Resident #20 would sometimes open the water on herself and let it run. Staff H stated that Resident #28 was incontinent at times and could use the sink. She further stated that Resident #28 used it to wash her hands and sometimes used it to wash her body. During an interview on 01/11/21 at 5:09 PM, Staff F, RN, was asked which residents would be able to tell if the water temperature is hot or cold. She stated that Resident #39 was confused and would not be able to tell the difference between hot or cold water. At 5:14 PM, Staff G, CNA, stated that Resident #15 and Resident #295 would not be able to tell the difference between hot or cold water. During an interview on 01/11/21 at 5:17 PM, Staff L, Floor Tech, stated that he painted the water heater room on 01/10/21 at 7:00 AM. He further stated, I think I might have touched the valve while painting. During an observation conducted on 01/12/21 at 9:52 AM, Resident #13, who resided on the 400 wing, was in the bathroom inside of her room. She was observed pulling up her adult pull-up briefs and then pulling up her pants independently. Continued observation revealed that Resident #13 got closer to the hand sink and only opened the hot water lever. She then put both of hands under the running water and rinsed her hands for about 10-15 seconds. She closed the hot water lever and pulled a piece of paper from the paper holder and dried her hands together. At 9:55 AM, she exited the bathroom pushing her rolling walker towards her bed and then sat in her bed. An interview was attempted, but Resident #13 did not speak English and responded in an unidentified language. Resident #13 resided in one of the rooms identified as having a high water temperature. During an interview conducted on 01/12/21 at 10:02 AM, Staff K, Occupational Therapist, stated that she had worked in the facility for the past [AGE] years. She stated that she assesses for [MEDICAL CONDITION] and asks residents to identify hot and cold-water temperatures using their fingers. According to her, most residents in the facility did not have a good sense of judgement of identifying hot or cold-water temperatures. When asked if there were any residents with a good sense of judgement, she stated that Resident #26 was cognitively aware and would be able to identify hot or cold water temperatures. Staff K stated that the sensation of hot and cold is not only affected by a medical [DIAGNOSES REDACTED]. She stated that a majority of residents in the facility had some form of dementia. Because of this, she stated that it was very important for staff to closely observe residents since they were not good historians for interviews. She stated, The staff has to be aware of water temperatures because the residents might not notice if their skin is getting too warm or blistering. During an interview on 01/12/21 at 1:38 PM, the Administrator/Risk Manager stated that she began working at the facility on 08/31/20. She further stated that she was responsible for assessing all risks for residents and staff, removing/minimizing the risks of someone getting injured, and putting systems/practices in place to prevent issues from re-occurring. When asked how she identified issues, she stated that she made rounds and had morning meetings where staff members were asked if they had any potential concerns/hazards. She further stated that issues were identified mostly by observations. The Administrator/Risk Manager stated that she relied on the Maintenance Director to check the water temperatures and acknowledged that it was her responsibility to supervise him. She stated that if she were to do things differently, she would have made a weekly routine to meet with the Maintenance Director to check the audit tools. When asked who the Maintenance Director reported water temperatures to, she stated that he did not report them to anyone. She further stated that she was aware that the Maintenance Director was taking temperatures on a regular basis, however, she was unsure how often he was doing it. She stated that she would have expected for him to check the temperatures more than once per month. When asked about reporting maintenance issues, she stated that staff members use the TELS (The Equipment Life System - a maintenance reporting system) or call her directly to report maintenance issues. According to her, no water issues were mentioned in any QAPI meetings in the past 3 months. When asked about education, she stated that staff members are continuously educated on how to report broken equipment. She reported that staff members may not report water issues if they are not specifically educated on it. During an interview on 01/12/21 at 1:53 PM, the DON stated that she has worked in this facility for 1 year and 1 month and participates in QAPI meetings once per month. According to her, hot water had not been mentioned in any QAPI meetings in the past 3-4 months and no staff members had mentioned any water issues to her directly. She stated that if staff members noticed any water issues, they would report it to her, and she would then report it to the Maintenance Director. She stated that the facility had a TELS system in Point-Click-Care (electronic charting system), however, it was not used often because maintenance was always available. During an interview on 01/12/21 at 2:56 PM, the Maintenance Director stated that he has worked in the facility for 3 years and comes to the facility 2-3 days per week. He stated that no one had mentioned the hot water temperatures to him. When asked about reporting maintenance issues, he stated that the facility had a TELS system for reporting maintenance issues where he would receive concerns directly to his phone. He further stated that staff members knew that the TELS system was used for communication with maintenance. He stated that staff members would also report maintenance issues to him directly when they saw him on the floors or that they would call or text him. He stated that no hot water temperatures had been reported in the TELS system or verbally to him in the past 3-4 months. When asked about the mixing valve, he stated that it was already defective and that when it got moved by the painter, the rubber was burned away. When asked about QAPI, he stated that he participated in QAPI meetings once per month and that water safety had not been mentioned in any QAPI meetings in the past 3 months. During a tour of the laundry area on 01/13/21 at 11:09 AM, the Housekeeping Supervisor was asked about handwashing and stated that they could not use the hand sink in the washing room because the water was too hot. She further stated that the issue was verbally reported about 1 month ago to the Maintenance Director. According to her, the Maintenance Director's resolution was to shut off the water to the hand sink and to deliver a new sink. She reported that a new sink was delivered on the week of 01/04/21 to be installed and that the hot water temperature was fixed earlier this week. The facility's Immediate Jeopardy Removal Plan was verified as completed and included: 1. The hot water valves were turned off in the 17 rooms affected at the time the water temperatures increased. The hot water tanks were flushed immediately after the valves were turned off. Completed 1/10/21. 2. The Plumbing company was called to assess, repair and/or exchange the defective part. Completed on 1/10/21. 3. The Plumbing company completed an onsite assessment and temporarily repaired the mixing valves. Completed on 1/10/21. 4. Order for a new mixing valve with a backup mixing valve, were placed by the plumbing company and a second vendor and scheduled for delivery on 1/12/21. 5. New mixing valve installation is scheduled for Tuesday 1/12/21. 6. Staff in facility at the time of the deficiency notification were notified of the deficiency and reeducated on the water temperature changes and reporting hot water temps completed on 1/10/21. 7. Remainder of staff will be reeducated on water temperature changes and reporting hot water temperatures, prior to the start of their scheduled shift. 8. Emergency AD HOC meeting was held to discuss the noncompliance, the immediate removal plan, findi

Based on observation, interview , and record review, the facility failed to ensure there was adequate supervision in place to prevent residents from falling for 2 of 2 residents sampled for accidents (#119 and #150). Resident #119 fell 9 times in the facility and sustained injuries and hospitalization s, including a trauma admission to an Intensive Care Unit (ICU) as a result. Resident #150 fell 5 times in the facility including 3 times in one day. There were no fall assessments completed for any of Resident #150's three falls that occured on the same day. The findings include: Review of the fall policy (issue date 12/2011) revealed "An evaluation of the patient is completed timely following a fall or change in patient condition that increases the patient's risk for falls." It also noted that "The care plan is revised as clinically indicated to met the patient's current needs." 1) Record review of Resident #119's demographic face sheet, the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the 6/11/14 MDS assessment revealed there was no falling incident coded. Record review of Resident #119's fall risk care plan revealed the resident was at risk for additional falls due to unsteady gait, syncope/vertigo, history of falls. The care plan was not revised as a result of a fall on 5/8/14. Record review of the progress notes revealed Resident #119 had a one-to-one private duty aide with her from 10 am to 10 pm daily when she was first admitted to the facility. The last time staff noted the private duty aide at the resident's bedside was on 12/10/13. On 12/13/13 Resident #119 sustained her first fall at the facility. She did not complain of pain and was able to move her extremities. Staff initiated neuro-checks and began to note that the resident required monitoring at regular intervals because she refused to stay in bed or in the wheelchair and was very unsteady on her feet. Resident #119 fell for the 2nd time on 12/17/13. She complained of pain and had eccymotic areas to the right side of her face. On 12/19/13, the facility had a care plan meeting with Resident #119's trust officer in which they discussed the recent falls. The trust officer verbalized considering a change of facility because he was uncertain if he should transfer her to a smaller facility where she would receive more one to one care. Resident #119's 3rd fall occurred on 1/26/14 after which she sustained a bruise under her left eye. The nurses' note did not specify the circumstances surrounding the fall (the resident went into another resident's room and was pushed by that resident and fell ). The resident's 4th fall happened on 3/3/14 and she was transferred to the hospital for a Computerized Tomogrophy (CT) scan. Resident #119 fell for the 5th time on 3/24/14 and was found on the floor near the bed with a cut to the back of her head. The doctor ordered her to be sent out to the hospital. A 3/25/14 note indicated the resident returned to the facility with a laceration to the back of her head which had 7 staples in it and had a small amount of serosanguiness drainage. On 5/3/14, there was no note regarding the circumstances surrounding the resident's 6th fall except to note that X-rays were taken of her wrist and shoulder and that the results were positive for fracture. She was sent to the hospital. 5/4/14 notes indicated Resident #119 returned to the facility with a [DIAGNOSES REDACTED]. Resident #119 fell for the 7th time on 5/8/14, this time in the dining room when she was noted on the floor near the dinner table. There was no noted injury. The 8th fall occurred on 8/15/14 in the dining room when an activity aide heard a bang and then saw the resident lying on the floor with the wheelchair flipped over on its back. She sustained no injuries. Resident #119's 9th and most recent fall was on 9/16/14 when she was found on the floor in the dining room bleeding from her nose and unconscious. She was sent out to the hospital via rescue. Record review of the fall assessments completed after Resident #119 fell revealed the falls occurred on 12/13/13, 12/17/13, 1/26/14, 3/3/14, 3/24/14, 5/3/14, 5/8/14, 8/15/14, and 9/16/14. The fall assessment dated [DATE] indicated the resident fell on [DATE] at 15:00. It noted the resident had a gait problem, was on antidepressants, and had the following diseases and/or conditions: 1) Cardiac disrhythmias, 2) Decline in functional status, 3) Incontinence, 4) Agitation, 5) Cognitive impairment, 6) Alzheimer's disease, 7) Other dementia, 8) Anxiety disorder, 9) Depression, 10) Vitamin D deficiency. It indicated the care plan was initiated/revised. According to the additional observations/comments on the assessment, the resident had Dementia with behaviors and was recently discharged from 1:1 personal attendant. Lexapro was increased to 10 mg every morning. Her Vitamin D levels were low so Vitamin D was added to her medication regimen. She had a fall in the hallway outside of her room and they updated the care plan to include assessing the resident's skin and reporting of any alterations. The fall assessment dated [DATE] indicated the resident fell on [DATE] at 2:00. It indicated the resident was on antipsychotics and antianxiety medications. The resident was noted as impulsive or with poor safety awareness, wandering, and muscle weakness. It indicated the resident was noted sitting on the floor next to the roommate's bed. The care plan was updated to include encouraging the use of hipsters. The fall assessment dated [DATE] indicated the resident fell on [DATE] at 22:05. It noted an additional disease/condition of anemia, syncope, and fatigue/weakness. It noted an environmental factor of proximity to an aggressive patient. The resident went into another resident's room and would not re-direct out of the room. The other resident pushed her out and she fell on to her left side and hit the door causing swelling and eccymotic area to the left chin and peri-orbital areas. It noted an order for [REDACTED]. The fall assessment dated [DATE] indicated the resident fell on [DATE] at 18:00. It noted she had impaired balance during transitions. On this date, the resident stood from her wheelchair and ambulated away from it. She fell before staff could get to her. At times she refuses to stay seated in her chair and can be difficult to redirect. She can get aggressive when staff tries to redirect her. Staff will continue to redirect her to the chair and offer activities as needed. They will also encourage the use of non skid socks. The fall assessment dated 3/25/14 indicated the resident fell on [DATE] at 21:50. It noted she was found on the floor in her room and was unable to say what happened. She was discharged from therapy with a wheelchair and she rarely uses it. She refuses to sit when redirected. She gets belligerent when redirected. Will continue to encourage and redirect as needed. The fall assessment dated [DATE] indicated the resident fell on [DATE] at 6:00. It noted she was now on diuretics. She was assisted with morning care and was left in bed by the aide. The aide was walking by the room and saw the resident on the floor and reported it to the nurse. The resident complained of pain to the right wrist. Orders were given for an x-ray. The care plan was updated to include a scoop mattress. The fall assessment dated [DATE] indicated the resident fell on [DATE] at 18:00. It noted she had difficulty maintaining a standing position. The resident was transferred to the dining room and assisted with tray set up by the staff. A short while later, she was noted on the floor away from the table. The resident has a history of attempting to exit the wheelchair unassisted and is frequently redirected by staff. The facility changed the resident's dining seating assignment to provide closer supervision during meals. There were no injuries noted. The fall assessment dated [DATE] indicated the resident fell on [DATE] at 14:30. The resident was sitting in the activities room with staff supervision when she pushed back on her wheelchair and flipped it backwards. She fell from the chair onto her left side but sustained no injuries. Neuro checks were initiated and the Medical Doctor (MD) notified. The care pan was updated with an intervention to include anti tippers on the wheelchair to minimize the risk of flipping backwards. The fall assessment dated [DATE] indicated the resident fell on [DATE] at 17:45. The resident was in the dining room during dinner when she was noted laying on the floor face down and bleeding from her nose. She was transferred to the hospital for further evaluation due to a period of unconsciousness. She was re-admitted on [DATE] with and order for PT/OT evaluation and treatment to improve her ADL functional ability. Record review of a hospital emergency department report revealed it indicated the resident arrived at the hospital on [DATE] and was given a CT scan of the brain without contrast due to a fall with head injury. Record review of a x-ray report dated 5/3/14 indicated the resident underwent [REDACTED]. She underwent a 3 view right wrist x-ray which showed a mildly displaced acute transverse fracture of the distal radius with minimal angulation and mildly displaced subacute fracture of the styloid process of the ulna. Record review of a hospital history and physical noted an admission date of [DATE] and indicated the resident was transferred from the nursing home status [REDACTED]. The emergency room physician upgraded her to trauma after finding intracranial hemorrhaging and subarachnoid hemorrhaging and admitted her into the ICU. Record review of treatment sheets from March 2014 through August 2014 revealed there were 74 instances in which staff did not initial for Resident #119's fall precautions. Observation of the resident on 9/25 at 4:32 pm revealed she was in the activity room in her wheelchair. She stood up out of the chair and was approached by activities staff who asked her to sit down. She complied but continued to motion with her hands. The Director of Nursing (DON) then took her out of the room and wheeled her off the unit and out the facility's front door. The DON sat on a bench across from the resident and began speaking with her. Interview with the Resident Assessment Coordinator on 9/25 at 4:53 pm revealed she said a resident that has had a fall should have the care plan updated after each subsequent fall. However she said that they try to determine a root cause for the fall and if there are additional interventions to be put in place. She said that sometimes they are doing all that they can. She was not aware whether or not the resident's fall care plan was updated after each fall because she has only been in her position for three months. She referenced the care plan and confirmed there was no update to the care plan after the 5/8/14 fall. She further confirmed at 11:18 am on 9/26/14 that the 6/11/14 MDS assessment was not accurate relating to falls. Interview with the North Wing Unit Manager on 9/25/14 at 5:07 pm revealed staff can be right next to the resident but the resident will try to get up out of her wheelchair. She doesn't tell staff what she wants or give anyone a reason why she is getting up. She has only been here since June and the resident has only had two falls since then. Interview with the activities director on 9/26 at 8:36 am revealed she was unsure whether the resident had ever fallen in the activities room. She reported her last fall was in the main dining room. She said they always have supervision in the activities room during activities. She is always on the floor and doesn't stay in her office. She said there are usually one or two staff members in the activity room and she stays in the "behavior" room. She has three full time employees plus two part time employees. Interview with the DON on 9/26/14 at 9:21 am revealed the resident's 1st fall was 12/13/13 at 3:00 pm. The resident was noted sitting on the floor in the 300 hallway. There was no injury. It was unwitnessed. Staff A, LPN wrote a statement that the Certified Nursing Assistant (CNA) reported to her that she found the resident sitting in the hallway while she was doing rounds. There was no statement from the CNA. The 2nd fall was on 12/17/13 at 2:00 am. The resident was found sitting on the floor next to her roommate's bed with a small scratch on her cheek. She complained of pain to her right leg. Staff B, the LPN provided a statement and said the resident was found sitting on the floor next to her roommate's bed at 2:00 am. The 3rd fall was 1/26/14 at 10:05 pm. The resident went into another resident's room and could not be re-directed out of the room. The other resident pushed her and she fell down and hit her face. The DON stated the incident/accident log which noted the resident rolled out of bed was a mistake because that was not what happened. The resident got facial X-rays as a result of this incident and there were no fractures. The 4th fall was 3/3/14 at 6:00 pm. The resident was ambulating along the 300 hallway and suddenly lost her balance and fell to the floor. The nurse who witnessed this could not get to her before she fell . Staff C was the LPN that witnessed it. There was no information given regarding the proximity of the nurse to the resident when she witnessed the fall. The 5th fall was on 3/24/14 at 7:50 pm. The resident was noted sitting on the floor in room 309 with a cut to the back of her head. The resident did not reside in room 309, she was in room 308. The CNA , staff D gave a witness statement. She said she heard the resident screaming, she rushed to room 309 and found her sitting on the floor near the bed. The resident was sent out to the hospital. The 6th fall occurred on 5/3/14 at 6:00 am. The resident was found sitting on the floor near the door to her bedroom. She stated she fell off the bed. According to staff E, CNA, the resident was found sitting upright near the door to her bedroom during morning rounds. The resident told her she fell out of her bed. The resident complained of pain to her right wrist. Staff F, LPN also gave a statement that the resident was noted in bed asleep without any agitation before the fall occurred. An X-ray determined the resident had a fracture of the wrist. She was sent out to the hospital and came back with a soft cast. The 7th fall was on 5/8/14 at 6:00 pm. The resident was found sitting on the floor in the main dining room. Staff G, CNA indicated in a statement that she walked into the dining room and noticed the resident sitting on the floor. Her wheelchair was locked and slightly pushed away from the table she was seated at prior to being on the floor. Staff H, CNA indicated in a statement that she was in the main dining room assisting residents with dinner. She was sitting at table 14 and assisting another resident with her meal. Another staff member came in and stated that the resident was son the floor. She immediately turned around and saw the resident on the floor. She did not hear any noise when the resident fell and she did not see the resident fall. She did not call for help. Staff I, CNA, indicated in a statement that as she entered the dining room, the resident was noted lying on the floor. She immediately asked another staff member to call the nurse. The DON did not know which staff member she asked to call the nurse. There was no injury. The 8th fall was on 8/15/14 2:30 pm. Staff J, Activity Aide indicated in a statement that while she was setting up and activity in the dining room, she heard a bang, turned around and saw the resident lying on the floor on her left side with the wheelchair flipped over. The 9th fall occurred on 9/16/14 at 5:30 pm. Staff K, CNA indicated in a statement that she was in the hallway going to the Coral Way dining room when she heard a sound in the main dining room. She heard someone say "Call the Nurse." She called the nurse and when they got to the scene they found the resident lying face down on the floor next to a table. Staff I, CNA, indicated in a statement that she was in the dining room positioning another female resident, facing the window, when she heard another female resident screaming. She looked around to see what happened and she saw the resident lying face down of the floor next to another resident's table. Staff B, LPN indicated in a statement that around 5:45 pm she heard the staff K call for her to come to the dining room because there was an emergency. She went immediately and saw the resident's lying face down on the floor next to another resident's table with blood coming from her nose. There was no water on the floor and the resident's wheelchair was locked at the table she was sitting at. She was last seen in the dining room sitting in her wheelchair at 5:40 pm prior to the fall. The resident went out to the hospital as a result. At the hospital they noted intracranial hemorrhaging and subarachnoid hemorrhaging. She was admitted into the Intensive Care Unit unit. The DON said the resident had a private duty aide when she first came to the facility. The decision to have a private duty aide is up to the family. She confirmed that the 6/11/14 MDS was not accurate relating to falls since the last assessment. She explained they look at each fall and assess each fall individually. For instance, when Resident #119 fell out of bed, they gave her a scoop mattress to make it more difficult to get out of bed. When she tipped the wheelchair, they added anti-tippers to the wheelchair. Each fall is assessed to try to figure out why the resident fell to see what they can do to try to decrease the risk to fall again. In regards to the vagueness of some of the staff statements, she said that is an ongoing issue. Some staff doesn't want to say anything and fear they will get in trouble if they provide more details. She said sometimes things happen so fast that you cannot prevent a resident from falling. She said it is an ongoing assessment to see what they can to to prevent a fall. She said they do offer 1:1 assistance and sometimes they provide it to the resident. For instance yesterday she was taken outside because she kept trying to stand up. Sometimes they have an activity aide sit next to her in activities. Sometimes they walk her in the hallways. She said that they will have to look at this resident deeper because she doesn't want the resident to fall anymore. They will have to share the responsibility with the family and the guardian and get them involved. She acknowledged the multiple instances of missing staff initials regarding Resident #119's fall precautions on the treatment sheets. 2) Record review of Resident #150's demographic information located on her progress notes revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the accident/incident log revealed Resident #150 fell 5 times. She fell 3 times on 9/14/14, once on 9/17/14, and once on 9/18/14. She sustained no injuries the first four falls, but was found with a skin tear to her right elbow. According to a 9/14/14 9:09 am progress note, the resident was seated in the wheelchair near the nursing station. The nurse walked away from the cart to tend to another resident and when she returned, the resident was on the floor. Another progress note dated 9/14/14 at 7:43 pm indicated the Supervisor was notified during dinner that the resident was on the floor in activities. Resident #150 was on the floor on her right side with a minimal amount of blood on the floor and on the back of her head. There was no progress note regarding the 9/14/14 dining room fall which occurred in between the hallway fall and the activities fall. A 9/17/14 progress note indicated the resident's son found her on the floor mat. A 9/18/14 progress note indicated that at 7:05 am, the resident's was observed on the floor in a sitting position in the doorway. She had a small skin tear to her right elbow. Review of the fall assessments completed after the resident's falls revealed there was no assessment completed after the resident 9/14/14 falls. A fall assessment date 9/19/14 indicated the resident fell on [DATE] at 8:20. She was admitted to the hospital at risk for falls. She was placed in a low bed with a scoop mattress and mats were on the floor. She was found on the floor next to her bed soon after staff left the room. She will be given hipsters and she will be evaluated by therapy for gait and transfer training. A fall assessment dated [DATE] indicated the resident fell on [DATE] at 7:05. It noted she had difficulty maintaining a standing position and had impaired balance during transitions. She was on antipsychotic and antidepressant medications. She had the following diseases and/or conditions; 1) Decline in functional status, 2) Incontinence, 3) Chronic or acute condition resulting in instability, 4) Agitation, 5) Impulsivity or poor safety awareness, 6) Cognitive impairment, 7) Alzheimer's disease, 8) Depression, 9) Infection. The comments indicated the resident's was at risk for falls with injuries. She had a history of [REDACTED]. She also received psychoactive medications. She was restless at times. She had a scoop mattress and mats on the floor next to the low bed. She wore hipsters. Staff would escort her to supervised activities. She will be assisted into a reclining Geri chair at this time. Therapy evaluated the resident and she gets PT and OT. Will have psych consult for medication review. Interview with the South Wing nurse manager on 9/25/14 at 4:42 pm revealed the resident had falls while at the facility but she was not present on the days that the resident fell . She had a few falls. She had one on the 3-11 shift. The resident had a low bed, floor mats, hipsters. She reported that nursing staff completes a fall assessment after each fall. She reported that if the resident falls in the facility and is transferred out of the facility, that record is closed so there would not be a fall assessment. The care plan would be updated when the resident came back to the facility. The care plan should be updated after each fall. Interview with the Activities Director on 9/26 at 8:35 revealed she was not present when the resident fell in the activities room. She is not sure how many staff were present. Interview with the DON on 9/26/14 at 8:45 am revealed the 1st fall was on 9/14/14 at 8:00 am. The resident got out of her wheelchair lost her balance and fell on her back in the hallway. According to the Program Director, the resident was in her wheelchair by the nursing station. She passed the resident and went into the nursing station. When she turned around, the resident was standing at the medication cart holding the Medication Administration Record. Before she could reach the resident's, the resident lost her balance and fell . There were no injuries. Neuro checks were initiated (they are initiated for all unwitnessed falls). The next fall was that same morning at 8:41 am. Staff took the resident to the dining room. The resident got out of her wheelchair and fell on to the floor in the main dining room before staff could get to her. According to the North Wing Nurse Manager, a CNA brought the resident into the main dining room. The resident did not have an assigned seat. While staff checked around for a seat for the resident, the Nurse Manager went back to feeding the residents she was taking care of. She was feeding two residents at the same time. She said this is common and staff could be cuing one while feeding the other. While the nurse manager fed the two residents, the resident stood up and fell . There was no injury. Staff continued neuro-checks from the previous fall. The resident's next fall was 9/14/14 at 6:00 pm. She was found in the activities room on her right side with a small amount of blood on the back of her head. According to the North Wing Nurse Manager, she was coming up the hallway heading to the North Wing. She was on her way to her office. She turned and looked and saw the resident lying on the floor in the activities room. The resident's wheelchair was by the table and locked. The resident was at the other end of the table on the floor. According to the DON there was no statement taken from staff S, who had directed staff to place the resident at the table. The resident's next fall was on 9/17/14 at 8:20 pm. The resident was found sitting on the mat by her bed with no new injury. The resident's son is the one who found the resident on the floor. According to CNA staff T, at 8:10 she went on break. Before she left she changed the resident and left her in the low bed with mats at each side of the bed. According to the DON, the resident did not have any more falls. The resident came to the facility on [DATE] and the care plan was initiated that day. She said staff is expected to complete a fall assessment after each fall. She confirmed that there were only two fall assessments. She said the South Wing Unit Manager did not do a fall assessment when she came to work on Monday the 15th because the resident's chart was closed and they cannot document in a closed chart. She confirmed the weekend manager did not complete fall assessments after the resident fell on [DATE].