Every finding on record at Nspire Healthcare Miami Lakes

Based on observations, interviews and record review facility failed to ensure a safe environment on two (100 and 300 wings) out of four wings as evidenced by unattended housekeeping carts containing hazardous chemicals left unlocked by housekeeping staff. There were four housekeeping carts in the facility at the time of survey The findings included:Observational tour on 03/09/2026 at 11:15 AM of the 100-wing revealed Staff D, Housekeeping walking away from the housekeeping cart leaving it unlocked and going down the hall. When staff returned, the surveyor notified Staff D of the identified concern and was asked to view the contents of the cart. It was revealed that the cart contained hazardous chemicals. (photo)On 03/09/2026 at 11:30 AM, the Housekeeping Director was interviewed and revealed all housekeeping carts are to be locked when unattended for the safety of residents.On 03/09/2026 at 11:35 AM, an inspectional tour conducted with the Housekeeping Director of all housekeeping carts in the facility revealed; the 300- wing housekeeping cart was unlocked and the latch was broken.On 03/09/2026 at 2:11 PM Staff D, Housekeeping was interviewed (translated by another surveyor) revealed the cart should be kept locked for the safety of the residents and stated: I am aware I left the housekeeping cart unlocked.On 03/09/2026 at 2:14 PM Staff E, Housekeeping (translated by another surveyor) revealed the cart should be locked because there are liquids inside that can harm the residents, but the latch had broken this morning.A follow up interview on 03/12/2026 at 9:33 AM with Staff E, Housekeeping revealed the latch on the housekeeping cart had broken again.Record review of facility's policy and procedure titled Care, Cleaning and Storage of Equipment dated 6/1/2025 revealed Policy: It is the policy of this facility for environmental services cleaning carts to be cared for, cleaned and properly stored to ensure safety and infection prevention.

Based on observations, interviews and record review the facility failed to ensure that one (Resident #109) out of two sampled residents with skin conditions and contracture received treatment and care in accordance with professional standards of practice as evidenced by a dressing on Resident#109's right lower leg that had not been changed in three days despite a physician order for dressing change every other day and no splint device in place on the residents contracted right hand. There were 116 residents residing in the facility at the time of survey. The findings included:Observation on 03/09/2026 at 10:39 AM revealed Resident #109 in bed receiving oxygen at two liters per minute via nasal canula. The resident's contracted right hand had no splint device in place, and a dressing dated 3/6 was noted on the resident's right lower leg. (photo)On 03/09/2026 at 2:37 PM Resident #109 was observed in bed with no hand splint device in place on the right hand and dressing dated 3/6 noted on the resident's right lower leg.Record review of a demographic sheet revealed Resident #109 was re-admitted on [DATE] with diagnosis that included: Hemiplegia and hemiparesis affecting right dominant side, Type 2 Diabetes, and Morbid obesity.Record review of an annual minimum data set (MDS) reference dated 1/15/2026 revealed Resdient#109 had a Brief Interview of Mental Status (BIMS) score of 7 indicated moderate cognitive impairment and had no ulcers, wounds or skin problems.Record review of a care plan initiated on 08/23/2023 revealed Resident #109 had potential/actual impairment to skin integrity related to fragile skin and history of gastrostomy tube with interventions that included: Keep skin clean and dry, use lotion on dry skin, and monitor/document location.Record review of a physician's order sheet revealed Resident #109 had an order dated 1/23/26 for Xeroform Petroleum Patch 2 (Bismuth Tribromo phenate-Petrolatum), apply to right lower leg topically every day shift every other day for open area floor nurse clean open area to right lower leg with normal saline pat dry apply xeroform then cover with abdominal pad and kerlix.On 03/09/2026 at 2:40 PM Staff B, Registered Nurse (RN) was asked about the frequency of Resident #109's wound dressing changes Staff B, RN revealed the dressing is scheduled to be changed every other day by the floor nurse. Staff B, RN was then made aware of identified concern.On 03/09/2026 at 2:50 PM, the Director of Nursing (DON) stated: The dressing for [Resident#109] should have been changed on Sunday.On 03/11/2026 at 7:53 AM Resident #109 was observed in bed with no hand splint device in place on the contracted right hand. (photo)On 03/11/2026 at 11:10 AM Resident #109 was observed in bed receiving breathing treatment. There was no hand splint device in place. The Assistant Director of Nursing was present at bedside.Record review of a care plan initiated on 08/23/2023 revealed Resident #109 had potential/actual impairment to skin integrity related to fragile skin and history of gastrostomy tube with interventions that included: right hand splint device to be used.Record review of an interdisciplinary therapy screen dated 2/26/26 revealed Resident #109 was screened for right hand contracture and would benefit from splint, OT (Occupational Therapy) evaluation upon delivery of splint.On 03/11/2026 at 11:14 AM Staff B, Registered nurse (RN) stated: Due to [Resident#109's] history of cerebral infarction the right hand is weak. A splinting device is not ordered.On 03/11/2026 at 11:17 AM, Staff B, RN and the surveyor conducted an observation and interview with Resident #109; it was noted that the resident was unable to open the right hand.On 03/11/2026 at 2:23 PM, the Physical Therapy Director presented paperwork indicating on 2/26/2026 Resident # 109 was evaluated and a splint device was recommended for right hand contracture. The Physical Therapy Director revealed the splint had not arrived yet.Record review of facility's policy and procedure titled Provision of Quality Care dated 06/01/2025 revealed Policy: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices.Policy Explanation and Compliance Guidelines:Each resident will be provided with care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews and record review the facility failed to ensure one (Resident #109) out of two sampled residents with contractures and one (Resident # 8) out of two sampled residents receiving dialysis received treatment and care in accordance with the comprehensive person-centered care plan as evidenced by: 1)Resident #109 who has a right-hand contracture had no splint device in place. 2) The facility's staff did not administer a phosphorus binding agent in accordance with Resident #109's dialysis care plan. There were 116 residents residing in the facility at the time of survey. The findings include: Resident #109Observation on 03/09/2026 at 10:39 AM revealed Resident #109 in bed with right hand noted contracted and had no splint device in place.On 03/11/2026 at 7:53 AM Resident #109 was observed in bed with no hand splint device in place on the contracted right hand. (photo)On 03/11/2026 at 11:10 AM Resident #109 was observed in bed receiving breathing treatment. There was no hand splint device in place. The Assistant Director of Nursing was present at bedside.Record review of a demographic sheet revealed Resident #109 was re-admitted on [DATE] with diagnosis that included: Hemiplegia and hemiparesis affecting right dominant side.Record review of Resident #109's Annual Minimum Data Set (MDS) reference dated 1/15/2026 revealed Resident #109 had a Brief Interview of Mental Status (BIMS) score of seven out of fifteen indicating moderate cognitive impairment.Record review of a care plan initiated on 08/23/2023 revealed Resident #109 had potential/actual impairment to skin integrity related to fragile skin and history of gastrostomy tube with interventions that included: right hand splint device to be used.Record review of a care plan initiated on 08/23/2023 revealed Resident #109 had an Activities of Daily Living (ADLs) self-care performance deficit with interventions that included: right hand splint device to be used. Record review of a care plan initiated on 08/23/2023 revealed Resident #109 was at risk for pain with interventions that included: right hand splint device to be used. Record review of a quarterly minimum data set (MDS) reference dated 1/15/2026 indicated Resident #109 has moderate cognitive impairment, independent for eating, and received dialysis.Record review of an interdisciplinary therapy screen dated 2/26/26 revealed Resident #109 was screened for right hand contracture and would benefit from splint, OT (Occupational Therapy) evaluation upon delivery of splint. Interview on 03/11/2026 at 11:09 AM Staff F, Certified Nursing Assistant (CNA) revealed: [Resident #109's] right hand is weak and I clean it and do range of motion exercises at times. On 03/11/2026 at 11:14 AM Staff B, Registered nurse (RN) stated: Due to [Resident#109's] history of cerebral infarction the right hand is weak. A splinting device is not ordered.On 03/11/2026 at 11:17 AM, Staff B, RN and the surveyor conducted an observation and interview with Resident #109; it was noted that the resident was unable to open the right hand.An interview with the Director of Nursing (DON) on 03/11/2026 at 1:25 PM revealed staff are to follow the care plan.On 03/11/2026 at 2:23 PM, the Physical Therapy Director presented paperwork indicating on 2/26/2026 Resident # 109 was evaluated and a splint device was recommended for right hand contracture. The Physical Therapy Director revealed the splint had not arrived yet. Resident # 8On 03/11/2026 at 7:09 AM Resident #8 was observed consuming breakfast.Record review of a demographic sheet revealed Resident #8 was admitted on [DATE] with diagnosis that included but not limited to: End Stage Renal Disease.Record review of a physician's order sheet revealed Resident #8 had an order dated 8/13/25 for Calcium Acetate Oral Tablet 667 milligrams (mg) (Phosphate Binder) Give two tablets by mouth before meals for Hyperphosphatemia.Record review of a care plan initiated on 03/28/2023 and revised on: 04/15/2025 revealed Resident #8 had renal failure related to End stage renal disease with interventions that included but not limited to: Give medications as ordered by physician. On 03/11/2026 at 7:10 AM Staff C, Registered Nurse (RN) stated: No medications were given before dialysis. Observation on 03/11/2026 at 11:30 AM Resident # 8 was seated in room consuming lunch independently. On 03/11/2026 at 11:35 AM Staff B, RN was asked if the medication ordered to be given before meals was administered and Staff RN stated, Not yet. I didn't want to give on an empty stomach. Record review of the Electronic Medication Administration Record revealed the medication Calcium Acetate was signed as given on 3/11/26 at 11:38 AM (during lunch).Further review of the Electronic Medication Administration Record revealed administration signatures on 3/10/26 at 8:01 AM, 1:25 PM, and 6:28 PM and 3/9/26 at 1:28 PM, 3:59 PM. Record review of the facility's mealtimes revealed breakfast is served at 7:40 AM, lunch at 11:45 AM, and dinner at 4:45 PM on the facility's 100 wing.On 03/11/2026 at 3:25 PM an interview with the Consultant Pharmacist revealed giving Calcium Acetate at inconsistent times could affect the efficacy of it. It can be given before or after meals depending on what the prescriber wants.On 03/11/2026 at 4:07 PM an interview with the Dialysis RN stated: A resident with a diagnosis of End Stage Renal Disease experience high Phosphorus levels and low Calcium levels. The calcium acetate is given to lower the phosphorus levels which can also affect the calcium levels. I have explained to the staff the importance of administering the calcium acetate immediately after dialysis before lunch to provide enough time between the next ordered dose. During an interview on 03/11/2026 at 4:10 PM, the Director of Nursing revealed nurses should follow the physician's orders and may administer medications an hour before or after the scheduled time. If a physician orders medication to be given before meals, it should be given it as ordered. Record review of facility's policy and procedure titled Comprehensive Care Plans dated 06/01/2025 reviewed/ revised: 11/14/2025 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observations, interviews and record review the facility failed to ensure that one (Resident #100) out of two sampled residents with an indwelling urinary catheter, tubing was properly positioned as evidenced by: observation of Resident #100's indwelling urinary tubing coiled and kinked preventing urine from flowing freely and increasing the risk for catheter-associated urinary tract infections and other serious medical issues. There were eight residents with indwelling urinary catheters residing in the facility at the time of surveyThe findings included:On 03/09/2026 at 9:55 AM Resident #100 was observed in bed with no apparent distress; the indwelling urinary tubing was kinked preventing the free flow of urine (photo).On 03/09/2026 at 9:59 AM Staff B, Registered Nurse (RN) was made aware of the identified concern and stated, The urinary tubing should allow for the free flow of urine to prevent back flow that can cause infection.Record review of a demographic sheet revealed Resident#100 was re-admitted on [DATE] with diagnosis that included: UTI, Neuromuscular dysfunction of bladder, and retention of urine.Record review of a significant change in status minimum data set (MDS) reference dated 1/20/2026 revealed Resident #100 had moderate cognitive impairment and had an indwelling catheter.Record review of a care plan initiated on 11/10/2023 revealed Resident #100 had indwelling catheter related to retention of urine and neurogenic.Record review of a physician's order sheet revealed Resident #100 had an order dated 2/10/2026 to maintain indwelling catheter.for urinary retention and Neurogenic bladder and change as needed for obstruction or blockage.Record review of the facility's antibiotic stewardship documentation for December 2025 revealed Resident #100 started an antibiotic by mouth for UTI on 12/11/25.During an interview on 03/09/2026 at 2:51 PM the Director of Nursing (DON) revealed that indwelling urinary catheter tubing should be positioned straight, not kinking to prevent any obstruction of urine that could cause urinary tract infection (UTI).On 03/09/2026 3:40 PM the Infection control preventionist revealed staff are to ensure the indwelling urinary tubing is straight to prevent any return of urine to bladder that can cause a UTI.Record review of facility's policy and procedure titled Urinary Tract Infection (UTI) Prevention and Management Including Indwelling Urinary Catheters Effective Date: 11/3/2025 Review Date: 1/2/2026 revealed Policy: Nspire Healthcare Miami Lakes is committed to preventing urinary tract infections (UTs) through evidence-based infection prevention practices, appropriate catheter management, early identification of symptoms, and timely clinical intervention. The facility will implement measures to minimize the use of indwelling urinary catheters and ensure that when catheters are clinically necessary, they are managed according to accepted standards of care to reduce the risk of catheter-associated urinary tract infections (CAUTIs). Catheter Maintenance To reduce infection risk: Avoid kinks or obstruction in tubing.

Based on observations, interviews and record review the facility failed to follow infection control protocol for one (Resident #34) out of seven sampled residents as evidenced by: an observation of a toothbrush in a shared bathroom belonging to Resident #34. There were 116 residents residing in the facility at the time of survey. The findings included:On 03/19/2026 at 10:06 AM Resident #34 was observed in bed no apparent distress, and a toothbrush was observed in the bathroom (photo). On 03/09/2026 at 11:22 AM Staff G, Certified Nursing Assistant (CNA) was made aware of the identified concern and stated, The toothbrush belongs to [Resident # 34]. Further revealed toothbrushes are stored in a plastic bag and kept in the drawer.Record review of a demographic sheet revealed Resident # 34 was re-admitted on [DATE] with diagnosis that included: Cerebral infarction. Record review of a quarterly minimum data set (MDS) reference dated 12/5/2025 revealed Resident #34 had a Brief Interview of Mental Status (BIMS) score of 3, indicated severe cognitive impairment and required set up or clean up assistance for oral hygiene. Record review of a care plan initiated on 10/06/2023 revealed Resident # 34 had an Activities of daily living (ADL) self-care performance deficit related to discharge from hospital on [DATE] with interventions that included: Personal hygiene/ Oral hygiene care: The resident requires to maximize independence. On 03/09/2026 at 3:31 PM the Director of Nursing (DON) was interviewed and stated, Every personal item, including toothbrushes are to be stored in a plastic bag in the drawer for infection control purposes. On 03/10/2026 at 11:40 AM an interview with the Infection Preventionist revealed toothbrushes are stored in plastic bags for infection control purposes. Record review of facility's policy and procedure titled Infection Control undated revealed Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observations, interviews and record review facility failed to ensure that residents' information was kept confidential on one (Unit one,100-wing med cart) out of four med carts and on one out of 2 units as evidenced by: 1) Open unattended computer screen on the 100-wing med cart. 2) Document with residents' medical information posted on the bulletin board in front of Unit 1. There were 116 residents residing in the facility at the time of survey. The findings included: Observation on 03/09/2026 at 10:28 AM revealed the unattended 100 Wing medication cart computer screen open with residents' information visible.On 03/09/2026 at 10:30 AM Staff B, Registered Nurse (RN) stated: I am supposed to either close the computer or put the screen to sleep when I am away from the cart for privacy for the residents.During an interview on 03/09/2026 at 2:49 PM the Director of nursing (DON) stated: Nurses are to close the laptop completely or lock the screen when away room cart to protect residents' information. Observation on 03/09/2026 at 12:08 PM revealed a posting with residents' medical information on the billboard in front of the 100/200-Wing nursing station (photo).On 03/09/2026 at 12:10 PM the DON was made aware and stated: It should not be posted because it has residents' medical information.Record review of the facility's policy titled HIPAA Security Measures dated 06/01/2023 revealed Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and /or records that are in electronic format

Based on observations, record review and interview the facility failed to ensure food was prepared under sanitary conditions as evidenced by failure to 1) maintain equipment in the kitchen in a clean sanitary manner, 2) the Unit 2 Pantry Freezer did not contain a thermometer and 3) the Unit 1 Pantry microwave in a clean sanitary manner. This has the potential to affect one hundred and fourteen out of one hundred and fifteen residents who eat orally residing in the facility at the time of the survey. The findings include: Record review of the facility's policy titled Nourishment Storage-Pantry (effective date 12/2023) documented: Policy-Resident Nourishments are stored properly to maintain food safety; Procedure-1) An accurate thermometer is maintained inside of the refrigerator and freezer. 1) Observation of the initial kitchen tour on 8/26/24 at 7:59 AM with the Certified Dietary Manager, Senior Food Service Director revealed brown like stains on the inside and outside of the convection oven doors. Photographic evidence submitted. On 8/26/24 at 8:00 AM, interview with the Certified Dietary Manager, Senior Food Service Director. He stated, We do a weekly clean of the oven. He confirmed the brown like stains on the inside and outside of the convection oven doors. 2) Observation of the Unit 2 Pantry Refrigerator on 8/27/24 at 11:35 AM revealed resident's food items were in the freezer with the resident's name, resident's room number and date that the food item was placed in the freezer. No thermometer was noted in the freezer. Observation and interview of the Unit 2 Pantry Refrigerator and Freezer with the Director of Nursing (DON) on 8/27/24 at 11:36 AM. She confirmed that the thermometer was not in the freezer. She called the Certified Dietary Manager, Senior Food Service Director on the cell phone to place one there. 3) Observation of the Unit 1 Pantry Refrigerator on 8/27/24 at 11:38 AM revealed the microwave used to warm up resident's foods was not clean, had brown, dried substances and contained brown-like rust stains in the microwave. Photographic evidence submitted. Observation and interview of the Unit 1 Pantry Microwave with the DON on 8/27/24 at 11:40 AM. She confirmed brown, dried substances and brown-like rust stains were in the microwave.

Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct identified quality deficiency in the problem areas related to repeated deficient practice for F641 Accuracy of Assessments. The facility was cited for F641 in 2023. This repeated deficient practice has the potential to affect any of the 115 residents residing in the facility at the time of the survey. The findings included: Review of the facility policy and procedure titled Quality Assurance Performance Improvement Program (QAPI) revision date 10/24/22 states: The center and organization have a comprehensive, data driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Procedures: Identifying quality deficiencies and Corrective Action: The center will review department system data. If a quality deficiency is identified, the committee will oversee the development of corrective actions The center may choose the method of corrective action i.e. Plan, Do, Study, Act or Performance Improvement Project. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 06/2024,07/2024, and 08/2024 documented the facility had a QAA Committee meetings monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Control Preventionist/Risk Manager, Dietary Manager, Clinical Dietician, Director of Housekeeping, Director of Maintenance, Director of therapy, Director of Human resources, Director of admissions, Director of Business office, Director of Social Services, Director of Activities, MDS (Minimum Data Set) Coordinator, and Discharge Planner. Interview on 08/29/24 at2:20 PM with the Administrator/QA, Stated, the QAA Committee meets every month on the last Thursday of the month, the last meeting was held in the month of 08//2024. The committee consists of the Medical Director, Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist and all interdisciplinary team members. The purpose of QAPI is to identify any potential issues or any concerns where we will need additional education to be provided to the staff. QAPI is an ongoing program, a working tool, where multiple members get together to come up with solutions for problems and issues. We review previous agendas, see what is completed, what needs to be continued, what is resolved and address any new identified issues. We have Clinical meetings daily at 9am in the morning, we review issues from the prior day, we involve family of residents in planning of care and have the patient present if they are alert and oriented.

Based on observations, record review and interview facility failed to accurately code a Minimum Data Set (MDS) for one resident (Resident #34) out of nine sampled residents, as evidenced by hearing aids not included in Section B of the Medicare 5-day MDS with reference date of 7/8/24 despite Resident #34 using hearing aids on a daily basis. The findings included: On 8/26/24 at 9:05 AM Resident #34 signaled to surveyor her inability to hear and to come closer. Hearing aids observed on nightstand. On 8/28/24 at 1:20 PM Resident #34 was seated in a wheelchair near bed. Hearing aids in place. Family at bedside. Record review of demographic sheet for Resident #34 revealed an admitted [DATE] with Diagnosis that included: Dementia. Record review of a Medicare 5-day Minimum Data Set (MDS) with reference date of 7/8/24 for Resident#34 Section B revealed Hearing- Adequate, Hearing Aid- No, Ability to Understand others: understands. Record review of a Care Plan initiated on 6/10/24 revealed Resident #34 had an Activities of Daily Living (ADL) self-care performance deficit related to hearing difficulty with a goal of will improve current level of function in ADLs through next review. The interventions included: Encourage resident to participate in fullest extent possible with each interaction. Record review of a physician's order sheet revealed an order dated 6/11/24 for diagnosis: Hearing Difficulty. On 8/29/24 at 9:15 AM The Social Services Director reported ; the Medicare 5-day MDS dated [DATE] Section B for Resident #34 is incorrectly coded and Section B should have be coded to included hearing aids. Record review of Policies and Procedures: Subject: MDS Effective Date: 11/30/2014 Revision Date: 9/25/2017 Policy: The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses, and preferences using the federal and/or state required RAI. Procedure: Specified sections of the RAI process are completed by the center designated Interdisciplinary Team Members. Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy.

Based on observation, interview and record review, the facility failed to ensure a 1) convection oven, food steamer and gas range stove used to prepare food for residents were in good repair and clean and 2) the Unit 1 Pantry microwave was clean. This has the potential to affect one hundred and fourteen out of one hundred and fifteen residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled Maintenance (effective date 11/2014) documented: Policy-The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair; Procedure-The Director of Environmental Services will follow all policies regarding routine periodic maintenance and all employees will report physical plant areas or equipment in need of repair or service to their supervisor. 1) Observation of the initial kitchen tour on 8/26/24 at 7:59 AM with the Certified Dietary Manager, Senior Food Service Director revealed brown like stains on the inside and outside of the convection oven doors. Photographic evidence submitted. On 8/26/24 at 8:00 AM, interview with the Certified Dietary Manager, Senior Food Service Director. He stated, We do a weekly clean of the oven. He confirmed the brown like stains on the inside and outside of the convection oven doors. Observation of the initial kitchen tour with the Certified Dietary Manager, Senior Food Service Director on 8/26/24 at 8:02 AM revealed the food steamer was not working. Interview with Staff A, [NAME] on 8/26/24 at 8:03 AM. She stated, The steamer does not work and it keeps shutting off. Observation of the initial kitchen tour with the Certified Dietary Manager, Senior Food Service Director on 8/26/24 at 8:05 AM revealed only one side of the gas range stove was working. Interview with the Staff A, [NAME] on 8/26/24 at 8:06 AM. She stated, Only one side of the range is working. 2) Observation of the Unit 1 Pantry Refrigerator on 8/27/24 at 11:38 AM revealed the microwave used to warm up resident's foods was not clean, had brown, dried substances and contained brown-like rust stains in the microwave. Photographic evidence submitted. Observation and interview of the Unit 1 Pantry Microwave with the DON on 8/27/24 at 11:40 AM. She confirmed brown, dried substances and brown-like rust stains were in the microwave.

Based on observations, record review and interview the facility failed to implement precautions to prevent catheter related injuries for two residents (Resident # 352 and Resident # 21) out of the three residents with indwelling catheters residing in the facility. As evidenced by Resident # 352 and Resident #21 indwelling catheter tubing were each observed touching the floor; and failed to ensure one out of one resident (Resident #252) with a prescribed order for skin tear treatment was implemented timely. Resident # 352 On 08/28/24 at 9:37 AM Resident #352 was observed seated in her wheelchair propelling along the hallway outside he room, the indwelling urinary catheter tubing was on touching the floor self-propelling wheelchair. (Photo evidence) Review of Resident #352's Admission Record indicated an admitted d 08/08/2024. Clinical Diagnoses include but not limited to: Acute kidney failure, Retention of urine, Hydronephrosis with urethral stricture not elsewhere classified. Review of Resident #352's admission orders indicated monitor indwelling catheters per shift; Leg strap anchor to indwelling catheter in place q ( every) shift may change indwelling catheter monthly and as needed for blockage or leakage. Review of Resident # 352's Care Plan Initiated 8/9/2024 documented the resident has indwelling catheter with [catheter size] balloon, for urinary retention . the resident will remain free from catheter related trauma through review date. Leg strap to anchor indwelling catheter. Check tubing for kinks each shift. Review of the Initial Assessment Minimum Data Set (MDS) dated [DATE] revealed Resident #352 coded for indwelling catheter use. On 08/28/24 at 9: 42 AM Resident #352 stated; I am doing much better, they changed my [catheter brand] yesterday and I am going home tomorrow. The catheter bag was noted dated 08/2/24. On 08/29/24 at 10:15 AM Staff I Registered Nurse (RN) revealed the resident has an indwelling urinary catheter due to urinary retention. The resident will be discharged tomorrow to home, she was in the facility for therapy. Staff I, RN was shown the photograph with Resident # 352 seated in the wheelchair and the catheter tubing on the floor; Staff I acknowledged the concern and stated: That it is an infection control problem. It was changed yesterday. But I am going to change it During a follow up observation with staff I, in the resident's restroom the nurse acknowledged the date on the catheter was 08/27/24 not 08/28/24; Staff I, RN reported she made a mistake. 51356 Resident #21 On 08/26/24 at 09:01 AM Resident #21 was observed sitting in her wheelchair at the left side of her bed. The indwelling catheter tubing was observed on the floor.(Photo evidence) On 08/28/24 at 12:00 PM Resident #21 was observed sitting in her wheelchair on the right side of her bed eating lunch. The indwelling catheter tubing was observed on the floor. Record review of the resident's admission records revealed, Resident # 21 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The resident's clinical diagnoses include but not limited to: Retention of urine, unspecified, Acute Kidney failure and Diabetes Mellitus. Review of the orders for August 2024 include order dated 8/11/24 - Cranberry Oral Tablet (Cranberry (Vaccinium macrocarpon)) Give 1 tablet by mouth one time a day for UTI (urinary tract infection), order dated 8/26/24 - May change indwelling catheter monthly and as needed for blockage or leakage as needed and every day shift starting on the 25th and ending on the 25th every month, order dated 8/23/24 - Enhanced barrier precautions due to [] indwelling catheter every shift, order dated 8/6/24 - Maintain [] catheter with [size] on balloon for Urinary Retention and change PRN (as needed) for obstruction, order dated 8/13/24 F/U follow up) with Urology (catheter (dx) diagnosis: urinary retention) Review of the Admission Minimum Data Set (MDS) Modification of admitted d 8/16/24, indicated in Section C for Cognitive Patterns, BIMS (Brief Interview of Mental Status) documented a score of 13 out 15 indicating the resident is gave an intact cognitive response. Section GG - Functional Abilities: Functional Limitation in Range of Motion: upper and lower extremities - No impairment. Mobility Devices: Wheelchair? - Yes; Self Care: Eating - supervision or touching assistance. H - Bladder and Bowel: Indwelling catheter? - Yes Review of the Resident # 21 Care Plans revealed an initiated date of 8/14/2024 and revision dated 8/26/2024 indicated- Focus: This resident has a Urinary Tract infection related to (r/t) abnormal urinalysis Culture and Sensitivity. Goals: The residents urinary tract infection will resolve without complications by the review date. Interventions: encourage adequate fluid intake, enhance barrier precaution r/t intravenous Antibiotics. Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. Focus: This resident has Indwelling Catheter with [ size] for Urinary Retention Goals: The resident will be/remain free from catheter-related trauma through review date. Intervention: Position catheter bag and tubing below the level of the bladder and away from entrance room door, enhance barrier precaution r/t catheter. Interview on 8/28/24 at 12:36 PM Staff C, RN (Registered Nurse) revealed the catheter should not be touching the floor. She reported the resident transfers herself from bed to chair. I do rounds to check and to make sure the indwelling tubing is in the correct position. I also educate the resident about infection control. On 08/28/24 at 02:43 PM, Staff D, Certified Nursing Assistant stated: I assist the resident transferring from bed to chair and from chair to bed. This resident does not transfer alone. 45019 Resident #252 Review of Resident #252's wound care note dated 06/14/2024 documented skin tear left ankle, Primary dressing-Mupirocin ointment, Secondary dressing: dry protective dressing, Dressing frequency: daily Review of Resident #252's weekly skin assessment note documented 6/14/24-left ankle (outer)-skin tear, treatment in place. Review of Resident #252 Treatment Administration Record (TAR) revealed there was no documentation for treatment to the resident's left ankle skin tear starting 06/14/2, treatment for the resident's left ankle skin tear started 06/21/24. Review of the medical records for Resident #252 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Seizures, Dementia, Gastrostomy status and Altered mental status. Resident # was discharged on [DATE] to the hospital. Review of the Physician's Orders Sheet for May-June 2024 revealed Resident #252 had orders that included but not limited to: 6/21/24-Mupirocin external ointment 2% -apply to left ankle topically every day shift for wound care, clean left ankle with normal saline, pat dry, apply Mupirocin and cover with dry dressing daily. Record review of Resident #252 's Discharge Return anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 2, on a 0-15 scale indicating the resident is cognitively impaired. Section GG for Functional Status documented the resident required maximal assistance for Activities of Daily living. Section M for Skin Conditions documented no pressure ulcers or deep tissue injuries. Review of Resident #252 Care Plans Reference Dates 4/25/24 and 6/21/24 documented: The resident has potential/actual impairment to skin integrity related to fragile skin. Focus-the resident will maintain or develop clean and intact skin by the next review date. Interventions-encourage good nutrition and hydration to promote healthy skin, keep skin clean and dry, use lotion on dry skin, skin treatment to left ankle as ordered. Interview on 08/29/24 at 12:47 PM the Director of Nursing (DON) stated the resident did not have a foot fungus, the skin tear to the left ankle was discovered on 06/20/24. On 06/20/24 treatment to the left ankle skin tear was started with Mupirocin ointment daily, Surveyor and the DON viewed the skin assessment sheet dated 06/14/24, the weekly skin assessment indicated the resident had a skin tear to the left ankle and treatment was in place, DON stated the treatment administration record does not have any orders for treatment for a skin tear starting on 6/14/24, treatment for the resident's skin tear started on 06/20/24. The DON acknowledged there was a wound care order prescribed by the resident's physician on 06/14/24 for treatment for the left ankle skin tear for the resident that was not implemented. Interview on 08/29/24 at 01:34 PM the Registered Nurse Wound Care (Staff B) stated: I have been doing wound care here at the facility for almost two (2) years, I started seeing this resident on 6/20/24 for treatment to the skin tear on her left ankle, prior to 06/20/24 the floor nurses treated the resident's skin. I am not aware if there was a prior order for treatment for the skin tear to the left ankle. The orders for treatment are prescribed by the resident's physician. Review of the facility policy and procedure titled Clinical Guideline Skin and Wound dated 04/01/2017 states: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Process: License nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. License nurses to document the presence of skin impairment/new skin impairment when observed and weekly until resolved.

Based on observations, interview and record review facility failed to implement care plans for two residents ( Resident #302 and Resident #252) out of nine sampled as evidenced by splinting device not applied for Resident#302 and no skin treatment done for Resident#252. The findings included: 1) On 8/26/24 at 10:08 AM Resident #302 was observed seated in the upright position in bed. Resident #302's left arm appeared weak and left hand appeared contracted. A splinting device was observed on a wheelchair next to Resident #302's bed. On 8/28/24 at 1:29 PM Resident #302 was seated in a wheelchair next to bed. A splinting device observed in a plastic bag on nightstand. Record review of demographic sheet for Resident #302 revealed an admitted [DATE] with diagnosis that included: Muscle Weakness. Record review of physician orders sheet revealed an order dated 8/23/24 directions: Left resting hand splint for positioning and electrical stimulation application to left upper extremity (LUE) to facilitate volitional movements. Record review of Electronic Health record for Resident #302 revealed an Admission Minimum Data Set (MDS) with reference date of 8/29/24 was in progress. Record review of a Care Plan for Resident #302 initiated on 8/29/24 revealed Risk for pain and discomfort related to Cerebrovascular Accident, Left side Hemiplegia, use left hand resting splint with a goal of will not have an interruption in normal activities due to pain through review date. The interventions included: Use resting left hand splint for position and Neuromuscular electrical stimulation (NMES) application to LUE to facilitate volitional movements. On 8/28/24 at 12:50 PM Staff E, Certified Nursing Assistant (CNA) stated, Every morning after hygiene care I offer to apply the splinting device for [Resident #302] and [Resident #302] allows me to do it. Today was the first day [Resident #302] refused for me to apply the splint and wanted therapy to do it. When [Resident #302] refuses I inform nurse. Today I haven't let the nurse yet. I did not notice it was removed Tuesday or Monday. On 08/28/24 at 1:15 PM The Occupational Therapist stated, I wrote the order for a splinting device to prevent contracture of the left hand of [Resident#302]. It should be applied when she is sitting upright. Therapy is responsible for applying the splint daily. There is no time frame because it is for a trial basis. When asked how staff know when to apply or when to remove there was no answer. On 08/28/24 at 1:23 PM Staff C, Registered Nurse (RN) stated: I was not aware that [Resident #302] was removing her splinting device. I am not clear on the frequency of applying the splint. On 08/28/24 at 1:25 PM Staff F, Occupational Therapy Assistant stated, There is no specific time frame for the splinting device. It is a trail to determine if Resident#302 will have movement. I will apply the splint during therapy. On 8/29/24 at 8:28 AM Resident #302 stated, Sometimes the splint hurts my neck because my arm is heavy. I do not have any issue with allowing staff to apply the device. I do not refuse for staff to apply the splint. On 8/29/24 at 9:31 AM The Director of Nursing stated, When a resident is admitted from the hospital with others for splinting devices we follow the orders. If therapy wants to implement splinting devices for a trail there is no schedule. When it is a trial basis therapy is responsible to apply the device. Therapy is responsible to communicate with nursing during the clinical meetings that are held every day about interventions needed for the residents. Record review of Progress notes for Resident #302 revealed no documentation about Resident #302 refusing the application of splinting device or removing device after it was applied. Record review of Policy Subject: Plans of Care Effective Date: 11/30/2014 Revision Date: 9/25/2017 Policy: An individualized person-centered plan of care will be established by the Interdisciplinary team (IDT) with the resident and /or resident representative(s) to the extent practicable and uploaded in accordance with state and federal regulatory requirements. plan of care is to be maintained as part of the final medical record. Procedure: Develop and implement an individualized Person-Centered Comprehensive plan of care by the Interdisciplinary team that includes but is not limited to- the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines determined by the residents' needs or as requested by the resident, and , to the extent practicable, the participation of the resident and the resident's representative(s) within seven (7) days after the completion of the comprehensive assessment (MDS). 45019 2) Review of Resident #252 Care Plans Reference Dates 4/25/24 and 6/21/24 documented: The resident has potential/actual impairment to skin integrity related to fragile skin. Focus-the resident will maintain or develop clean and intact skin by the next review date. Interventions-encourage good nutrition and hydration to promote healthy skin, keep skin clean and dry, use lotion on dry skin, skin treatment to left ankle as ordered. Review of Resident #252's wound care note dated 06/14/2024 documented skin tear left ankle, Primary dressing-Mupirocin ointment, Secondary dressing: dry protective dressing, Dressing frequency: daily Review of Resident #252's weekly skin assessment note documented 6/14/24-left ankle (outer)-skin tear, treatment in place. Review of Resident #252 Treatment Administration Record (TAR) revealed there was no documentation for treatment to the resident's left ankle skin tear starting 06/14/2, treatment for the resident's left ankle skin tear started 06/21/24. Review of the medical records for Resident #252 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Seizures, Dementia, Gastrostomy status, Dysphagia, Altered mental status, Adult failure to thrive, Presence of Cardiac Implants and Grafts and Hemiplegia and Hemiparesis. Resident # was discharged on [DATE] to the hospital. Review of the Physician's Orders Sheet for May-June 2024 revealed Resident #252 had orders that included but not limited to: 6/21/24-Mupirocin external ointment 2% -apply to left ankle topically every day shift for wound care, clean left ankle with normal saline, pat dry, apply Mupirocin and cover with dry dressing daily. Record review of Resident #252 's Discharge Return anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 2, on a 0-15 scale indicating the resident is cognitively impaired. Section GG for Functional Status documented the resident required maximal assistance for Activities of Daily living. Section M for Skin Conditions documented no pressure ulcers or deep tissue injuries. Interview on 08/29/24 at 12:47 the PM Director of Nursing (DON) stated the resident did not have a foot fungus, the skin tear to the left ankle was discovered on 06/20/24. On 06/20/24 treatment to the left ankle skin tear was started with Mupirocin ointment daily, Surveyor and DON viewed the skin assessment sheet dated 06/14/24, the weekly skin assessment stated the resident had a skin tear to the left ankle and treatment was in place, the DON stated the treatment administration record does not have any orders for treatment for a skin tear starting on 6/14/24, treatment for the resident's skin tear started on 06/20/24. The DON acknowledged there was a wound care order prescribed by the resident's physician on 06/14/24 for treatment for the left ankle skin tear for the resident that was not implemented. Interview on 08/29/24 at 01:34 PM Registered Nurse Wound Care (Staff B) stated: I have been doing wound care here at the facility for almost two (2) years, I started seeing this resident on 6/20/24 for treatment to the skin tear on her left ankle, prior to 06/20/24 the floor nurses treated the resident's skin. I am not aware if there was a prior order for treatment for the skin tear to the left ankle. The orders for treatment are prescribed by the resident's physician.

Based on observations, record review and interviews facility failed to provide dignity for one resident (#87) out twelve residents who are assisted with meals as evidenced by an observation of staff standing while assisting Resident#87 with a meal. There were 119 residents residing in the facility at the time of survey. The Findings Included: On 8/26/24 at 8:35 AM Resident#87 was seated in the upright position in bed. Staff H, Registered Nurse (RN) was standing while assisting Resident#87 with breakfast. On 8/26/24 08:40 AM Staff H, RN stated, It is the protocol of this facility to set up the resident in the upright position and be at eye level for meals. I'm not sure if I can stand while assisting residents with meals. Also stated I have not received any in-services regarding this. Lastly stated I started in July of 2023. Record review of demographic sheet for Resident#87 revealed an admitted [DATE] with diagnosis that included Dementia. Record review of Quarterly Minimum Data Set (MDS) with reference date of 7/24/24 Section C (Cognitive Status) revealed a Brief Interview of Mental Status (BIMS) score of 3 indicated severe cognitive impairment, section GG (functional status) revealed set up clean up assistance for eating, and section K (Swallowing) revealed no or unknown significant weight gain/ loss in last month or 6 months and Resident#87 was receiving a therapeutic diet. Record review of physician orders sheet revealed an order dated 1/17/24 directions: No added salt diet and regular texture. Record review of Care Plan initiated on 1/17/24 and started on 5/24/24 revealed Resident#87 had potential nutritional problem related to fair appetite and intake at meals, receiving therapeutic diet with the goal of will experience no significant weight change through review date. The interventions included provide, serve diet as ordered. Monitor intake and record each meal. On 8/29/24 at 2:05 PM The Director of Nursing (DON) stated, Staff are to be seated next to the resident while assisting them to eat and staff are aware of this protocol. Record review of The Policies and Procedures Subject: Feeding Residents requiring Assistance Effective Date: 11/30/2018 Revision Date: 9/19/23 Policy: Nursing personnel will provide assistance with feeding when a resident is unable to do do independently. Procedure: Position resident comfortably, transfer to straight back chair if appropriate.

Based on Record Review and Interview, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F584 Safe/Clean/Comfortable/Homelike Environment and F641 Accuracy of Assessment. This practice has the potential to increase the risk of negative outcomes for all residents in the facility. There was a census of 107 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit 02/20/2022, Safe/Clean/Comfortable/Homelike Environment was cited related to the facility failed to maintain room temperatures within an acceptable range of 71 to 81-degrees Fahrenheit for three residents' rooms and facility failed to accurately code the Minimum Data Set(MDS) for one out of twenty three sampled residents, as evidenced by not documenting active diagnosis of Diabetes Mellitus and medication on the admission MDS. During an interview on 04/27/2023 at 02:43 PM, the Nursing Home Administrator revealed that the Quality Assessment and Assurance Committee (QAA) meets the last Thursday of every month. The administrator stated that the QAA Committee is comprised of the following members: Director of Nursing Services, Administrator, Business Office Manager, Registered Dietitian, Environmental Director, Maintenance Director, Social Services Director, Discharge Coordinator, Director of Rehab, Minimum Data Set (MDS) Coordinator, Unit Manager, and Medical Director. Nursing Home Administrator stated, we are working on 4 Performance Improvement Plans (PIP) on Nutrition, Return to hospital, Remodeling, and Minimum Data Set, we are working on room and bathroom remodeling, we have already completed a PIP in regard to chairs as during COVID we were wiping them too much and they were damaged, we also completed a PIP in regard to wheelchair. She continued and stated, for homelike environment, we have placed furniture as a concern, I have showed one of the other surveyors that we recently bought 5 beds, the order was placed 4/24/23 and they are already here at the facility, as I mentioned before we had issues with damage done in our physical furniture as we were sanitizing them during COVID, and because of this we bought 60 regular chairs for the resident rooms, 100 wheelchairs, multiple air-conditioning units, and the dryers for the laundry. We try to do things every month based on a budget. Also, we try to monitor the rooms through the Guardian Angel Program and if they find anything they can report it to us. We have also been painting and retouching walls, and this is done every day. Regarding Accuracy of Assessment she stated, there was a computer breach at the end of November 2022, at the time we did not have an email to communicate with the Agency for Healthcare Administration (AHCA), we did not have access to the system not even Point Click Care (PCC). For this issue, we did an action plan, we communicated to AHCA that our system was breached, we did not have a system at all, we had to do the manual orders, if there were new admission, we got the reconciliation from the hospital, all the documentation was done on paper. We had issues with transmission, omission, and miscoding on the MDS. For example, on the Minimum Data Set we will code for falls and check yes but then the system would not accept it, the system was transmitting blank information, we had to get a second random set of people at the corporate office that had a special access as the information was not arriving to Center for Medicare & Medicaid Services (CMS), we had some of our consultants doing the MDS outside of the facility. We implemented the PIP, and we identified the problems we had, it took about 4 weeks. Corporate did not know who hijacked the system, and they did a PIP explaining what was happening, they were working day, night, and people who hijacked the system did not make it to PCC. Review of Policies and Procedures with Subject Quality Assurance Performance Improvement Program (QAPI) and Effective Date 11/30/2014 revealed, Policy: The Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Program Design and Scope 1. The center's QAPI program is an on-going comprehensive review of care and services provided to residents. Including but not limited to: a. Environmental Services b. Medical Records 2. Review of activities may include but not be limited to: a. Environment of care/safety b. Staff orientation, in-service and competence Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but it not limited to: a) Implementation b) Ensure corrective actions are implemented to address identified problems in systems. c) Evaluates the effectiveness of actions. 3. The program is a coordinated effort among departments and services within the organization that involves leadership working with input from Center staff, residents, and families. Feedback: the center will obtain feedback to assist in identifying problems and areas of opportunity. Feedback may be obtained including but not limited to the following sources: a) Direct care staff b) Other staff members c) Residents d) Resident representatives Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance. 4. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to: a. Direct observation tools b. Audit tools c. Quality measures d. MDS data Systematic Analysis and Action: The center will ensure systems and actions are in place to improve performance. 5. The center will develop corrective actions based on the information gathered and review effectiveness of the actions. 6. The center will review and develop corrective actions on medical Errors and adverse Events.

Based on observations, interview and record review, the facility failed to provide a safe, clean, homelike environment in one out of two nursing units for one (Resident #218 residing in room [ROOM NUMBER]-D). The facility had 107 residents at the time of the survey. The findings included: Observation and interview with Resident #218 on 04/24/2023 at 10:26AM revealed she is alert and oriented x3, and she voiced out discomfort with her mattress and nobody has resolved the problem. Resident #218 stated the mattress is bad. Observation revealed the bed's headboard is broken; it has a hole that allows you see the wall through the headboard. Observation of Resident #218 on 04/26/2023 at 12:05pm revealed resident sitting in her wheelchair inside her room, she stated she was good and was in a good mood trying to do exercises on her own. When Resident #218 was asked about her bed, she re-stated nobody took care of the bed though she and her sister has complained to everyone (she does not identify any staff by name or position, but she stated she has told them her mattress is not comfortable and nobody changed it). Asked about the bed's headboard she looked at it and said she knew it was like that, meaning it was broken, but she did not elaborate further on it. (See photographic evidence) Record review of Resident #218's face sheet revealed the date of admission on 04/13/2023. Diagnoses included but were not limited to Unspecified Symptoms and signs involving nervous system, Other cerebral infarction, Unspecified symptoms, and signs involving the genitourinary system, Type 2 Diabetes Mellitus, Unspecified Atrial Fibrillation, Unspecified Osteoarthritis, unspecified site. Record review of Resident #218's Minimum Data Set (MDS) Admission assessment dated [DATE] revealed a score of 13 in the Brief Interview for Mental Status (BIMS) meaning the resident is cognitively intact. Record review of Resident #218's Care Plan dated 04/19/2023 revealed the resident wishes to return home. Goals and Interventions in place. Record review of Resident #218's Progress Notes dated from admission until 04/25/2023 revealed no documentation on the resident complaining about anything. During an interview with the acting Maintenance Director on 04/27/2023 at 09:15 am revealed he comes here on Mondays, and he is familiar with this facility because he worked here previously as the Maintenance Director. He is now working with another facility from the same company, and he is familiar with the process of reporting anything that needs to be fixed. The acting Maintenance Director stated this facility keeps a workbook in the nursing stations where everyone (staff) will document any need for maintenance or repair in the rooms or the common areas. When asked if Resident #218 reported a problem with the bed mattress and how is the process to change a mattress, he stated it will be the same process. The acting Maintenance Director stated any staff who knows about the problem will log it in the book, and the maintenance person that is working full time here will check the book daily, and they will take care of any report. The acting Maintenance Director stated sometimes they change the mattress and residents keep asking them for the mattress to be changed because they do not realize they did it already. When asked if he was aware of Resident #218's request to change the mattress, he said he did not know anything about it. He stated sometimes residents told the staff (Certified Nursing Assistants -CNAs) and they forget to tell Maintenance or to put it in the book. Observation on 04/27/2023 at 10:40 am revealed Resident #218 was not in her room and was said to be in therapy. Observation conducted with the acting Maintenance Director revealed the bed was changed. There was a bed with a headboard in good condition and observed no concerns. Observation revealed the new mattress looks in good condition. Interview with the Social Services Assistant on 04/27/2023 at 10:42 am revealed she did not receive any grievance or request from Resident #218 to have her mattress changed. Interview with Staff B, Registered Nurse (RN) on 04/27/2023 at 10:45 am revealed she did not see the headboard of Resident #218's bed was in disrepair. When asked if she entered the resident's room to take care of resident, Staff B stated she does but she did not notice anything out of the ordinary in the room. Staff B stated Resident #218 did not tell her she was uncomfortable with this mattress. Interview with Staff C, RN, and Unit Manager on 04/27/23 at 10:50 am revealed she and Resident #218's CNA changed her bed about 10 minutes ago. When asked why she changed Resident #218's bed, Staff C stated they did it because Resident #218 told her CNA she did not like the mattress, she told the CNA it was in bad condition like sinking in the middle. Staff C stated Resident #218 complained about the mattress but not the bed. When asked Staff C what she observed on Resident #218's bed, she stated the bed was working properly there was no problem with the bed, and stated they changed the bed from the room across from Resident #218's room that was empty. When surveyor asked Staff C's opinion about the Resident #218 original bed, she stated she observed there was something on the headboard on the right side, something cracked on the wood. When the surveyor asked if she believes it was ok for a resident to have that bed in the bedroom, Staff C stated, no that is not ok. Staff C acknowledged she did not report to Maintenance after seeing Resident #218's bed headboard condition. Staff C stated any staff going inside the room is supposed to observe and report any situation where residents' rooms and furniture needs to be repaired and they will put in the book for maintenance to do it, but so far nobody has reported. Staff C stated she is aware it is not good to have this furniture in the room, they should have been reported and replaced. Interview with Staff D, Maintenance on 04/27/2023 at 01:55 am stated he went to Resident #218's room to check when the acting Maintenance Director told him about the problem with the bed's headboard, and they had just changed it. Staff D stated there was no work order in the book, he went to take care of the bed's headboard after the acting Maintenance Director told him, but the bed was changed already. Interview with the acting Maintenance Director on 04/27/2023 at 11:00 am revealed the staff from nursing who is entering in the rooms all the time are supposed to report about any repairs or replacements that need to be done in the residents' rooms, but nobody reported or wrote in the book. Interview with the Nursing Home Administrator (NHA) on 04/27/2023 at 11:35 am revealed she did not have any grievance on behalf of Resident #218. Today they filed a grievance on behalf of this resident because another CNA who is not assigned to the resident overheard when Resident #218 was telling the surveyor about the mattress, and she was informed, and they filed a grievance. The NHA stated they took care of that, they filed a grievance, and they changed the bed from another room, which was done by the Unit Manager (Staff C) and another staff, and it was resolved. The NHA stated they tried to resolve the concerns right away to prevent further complaints. Asked her opinion about the condition of the broken headboard of Resident #18's bed, the NHA stated she believes it is just the headboard not the bed, the bed was working well, but the headboard should have been reported and replaced. The NHA stated this facility was inherited from another company recently, and they are trying to fix anything they find, they are doing good with costumer service, and they are trying to fix everything they need. The NHA stated she believes they do the best for residents in the facility, but when there is a mistake, she will accept and fix the problem. The NHA stated they do have a Performance Improvement Plan (PIP) open for Maintenance, but it is for bathroom and rooms' remodeling. The CNA only reported she overheard the surveyor and resident talking about the mattress, but she did not report anything about the bed condition. The NHA disagreed with the fact of considering Resident #218's bed headboard condition not meeting the home environment condition as they are required. The NHA stated she believes a home environment is together with everything around, she believes its not just the bed or furniture condition but the care, the staff who provide the care and about the satisfaction with what they receive. But the NHA stated she considers it should have been reported to maintenance, they have spare headboards in the facility, and it would have been taken care of by Maintenance staff as they did it. The NHA stated the facility only has one person doing work in the Maintenance Department. They are looking for the right candidates, but they have not found the right person with experience to do the job. They are hiring a Maintenance Director. Record review of the Workbook dated 04/2023 revealed no work order related to changing Resident #218's mattress. There is no work order to replace or repair the resident's bed headboard. Record review of Policy and Procedures on Maintenance dated 11/30/2014 revealed: Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Procedure: The Director of Environmental Services will follow all policies regarding routine periodic maintenance. The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. All employees will report physical plant areas or equipment in need of repair or service to their supervisor. All items needing maintenance assistance will be reported to maintenance using the Maintenance using the Maintenance Repair Request form (attachment A). The form will be completed and placed in a designated area on the nursing unit or in the maintenance office. Environmental Services personnel will check for completed forms through the day. Record review of the Complaint/ Grievance report dated 04/27/2023 revealed grievance a filed on behalf of resident #218 with concerns stated mattress. Assistant Director of Nurses (ADON) went and interviewed the resident and she said she was not comfortable with the mattress. The bed and mattress were changed immediately. Interview with Staff E, CNA on 04/27/2023 at 01:55 pm revealed she did not see the headboard on the bed was broken, she stated she is aware she must report anything that needs repair to maintenance staff, but she did not see it. When asked if she provides assistance to this resident daily, she said she does but she did not see it. Staff E stated it was today after Resident #218 stated she wanted her mattress to be changed, she and Staff C, the Unit Manager changed her bed to another room that was empty. Staff E stated, the original bed assigned to Resident #218 was working well, and she did not see anything bad on the headboard. A further interview with the NHA on 04/27/2023 at 02:30 pm revealed the request to change the mattress is something that should not be managed as a grievance. The NHA stated they did it today because the CNA overheard the resident complaining about it to surveyor, but that request should have been addressed as a work order for Maintenance. The NHA stated if staff did not put it in the book, it means they should re-train staff to identify the need of a work order. Grievance is for complaints voiced out by residents that have not been resolved immediately. Policies and Procedures on Grievances dated 11/30/2014 revealed no concerns. Policy: Prior to or upon admission, the resident's designated person will be informed of the right to file and the procedure for filing a complaint. Procedure: Reporting: If the resident or residents designated person, feel or believe that the residents rights have been or are being violated by staff or another resident or in any other way, the resident and/or residents designated person shall make his/her complaint known to the Administrator.

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (Resident # 114) out of 24 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section A, subsection A2100 for Discharge Status for Resident #114. There were 107 residents residing in the facility at the time of the survey. The findings included: Review of the medical records for Resident #114 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Unspecified Atrial Fibrillation and Problems related to Care Provider Dependency. Resident #114 was discharged on [DATE]. Review of the Physician's Orders Sheet for April 2023 revealed Resident #114 had orders that included but were not limited to: 4/6/2023-Discharge home per family request, home health services-Registered Nurse, Physical therapy, Occupational therapy, Home Health Aide evaluation and treatment. Transportation provided by insurance. Record review of Resident #114's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section A for Identification Information in subsection A 2100 for Discharge Status documented that the resident was discharged to an Acute Hospital. Record review of Resident #114 's Care Plans dated 03/24/2023 revealed: Resident wishes to return to home. Interventions included: Encourage the resident to discuss feelings and concerns with impending discharge, establish a pre-discharge plan with the resident/family/caregivers, evaluate progress and revise the plan as needed. Review of the Social service's progress notes for Resident #114 documented on 04/06/2023 at 16:19 Members transportation just arrived for resident to return to home. Review of the Discharge planning progress notes for Resident #114 on 04/04/2023 at 18:21 documented family requested that the resident be discharged from the facility on 04/06/2023. Patient will be discharged home, address provided, family notified, transportation will be provided by insurance. Interview on 04/27/23 at 08:10 AM Director of Nursing (DON) stated this resident was discharged home on 4/6/2023, requested the DON review the Discharge MDS section A, subsection- A2100, the DON acknowledged Section A2100 documented discharge to acute hospital. Interview on 04/27/23 at 09:34 AM Minimum Data set (MDS) Coordinator (Staff A) when asked about the coding error in section A, subsection A2100 of the resident's MDS, stated the error was corrected and retransmitted to Center for Medicare and Medicaid Services (CMS) today. We are currently randomly picking 10 resident's MDS weekly and checking for accuracy, we have a Performance Improvement plan (PIP) in place, the Performance improvement plan was started last year December (12/2022) when the facility was hacked. Reviewed MDS PIP with MDS coordinator and explained to the MDS coordinator the PIP presented states: area being reviewed -Timeliness of MDS assessments, the PIP does not address MDS inaccurate coding/errors. Copy of PIP received. Review of the facility policy and procedures titled, Minimum Data Set effective date 11/30/2014 states: The center conducts initial and periodic standardized, comprehensive, and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses, and preferences using the federal Resident Assessment Instrument (RAI). Procedures step 3-Each person completing a section or portion of a section of the MDS signs the attestation statement indicating its accuracy.

Based on observation, interview and record review, the facility failed to treat 1 (Resident #71) out of 23 sampled residents in a dignified manner. Two staff members were observed standing while feeding resident #71. The findings included: On 02/07/22 at 10:07 AM, Resident #71 was observed in bed, with oxygen on at 2 liters per minute via nasal cannula. The resident did not respond when spoken too. During observation of Resident #71 on 02/07/22 at 12:53 PM, Resident # 71 was observed to be in bed and was being fed lunch, by Staff H, a Registered Nurse. Staff H was observed to be standing up while feeding Resident #71. The resident was wearing oxygen via nasal cannula and the food was getting on the residents nasal cannula during the feeding. During observation of Resident #71 on 02/08/22 at 9:07 AM, Resident #71 was observed in bed and her breakfast tray was on the bedside table. At 9:14AM on 02/08/22, Staff I, a Resident Assistant was observed standing up while trying to feed Resident #71. Staff I reported the resident would not take anything to eat or drink. During an interview on 02/10/22 at 10:10AM, Staff E, the Registered Nurse Unit Manager was asked, who trained the staff to feed residents, Staff E reported that the training was done by the Director of Nurses (DON) and the Dietitian. The policy and procedure was requested for feeding residents. On 02/10/22 at 10:10 AM the DON brought a copy of the staff competency list for Eating Support. The Eating Support competency form was not dated, but it included a section for the staff name, job title, date, reason for the competency (annual, new hire or other). The instructions were to complete with each Certified Nursing Assistant (C N A). Items #12 on the competency criteria included, Never make the resident feel that the meal must be hurried but that the procedure is pleasant. Give him/her your complete attention. Sit so you are at the same level as the resident. The DON was informed two staff members were observed standing while feeding Resident #71. During medical record record review it was noted, Resident #71 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents diet order was for a Consistent Carbohydrate and Heart Healthy (CHO), No Added Salt, pureed diet.

Based on observation, interview the facility failed to maintain room temperatures within an acceptable range of 71 to 81-degrees Fahrenheit for three residents' rooms (room #101, room # 102, and room # 112) observed during the survey, potentially having an adverse effect on three Residents (Resident #40, Resident #60, and Resident # 35 ) out of 23 residents sampled during the survey. Room temperatures set out of range have the potential to affect all 88 residents in the facility at the time of this survey. Room 101. Observation on 02/07/2022 at 10:24 AM revealed, Resident # 40 was in her bed. The resident was awake in her bed and not interview-able. The room felt cold. Room observations revealed the wall air-conditioning unit was set at 60 degrees Fahrenheit. Continued observation on 02/07/2022 at 11:11 AM showed Resident #40 continued lying in bed. The room remained cold. The wall air-conditioning unit remained set at 60 degrees Fahrenheit. (Photograph taken) Room 102 Observation on 02/07/2022 at 10:26 AM revealed, Residents #60 was in her bed. The resident was awake in her bed, and was not interviewable. Room observations revealed the wall air-condition unit was set at 66 degrees Fahrenheit. (Photograph taken) Room 112 Observations on 02/07/2022 at approximately 10:30 AM and at 11:44 AM revealed, Resident #35 laid asleep in her bed. She appeared to be shaking under a thin white blanket. The room felt cold. Room observations revealed the wall air-condition unit was set at 67 degrees Fahrenheit. Observation on 02/08/2022 at 10:10 AM revealed, Resident #35 in her bed, awake. Resident #35 was not interviewable. The window air condition unit was set at 65 degrees Fahrenheit. (Photograph taken) Observation and Interview on 2/09/2022 at 2:30 PM with the Housekeeping and Maintenance Director revealed, the Maintenance Director reported that air temperatures is monitored frequently by all staff throughout the facility. He measured temperatures at the nurse's station with the use of an infrared thermometer. Upon discussion of the above mentioned observations, the Maintenance Director explained that the room temperatures should remain at approximately 72 degrees.

Based on observations, records reviewed and interviews, the facility failed to 1.) Implement care planned intervention to properly assess and document any [CONDITION(S)] (swelling caused due to excess fluid accumulation in the body tissues) for one resident (Resident #16) out of two residents triggered for concerns with [CONDITION(S)] during the survey. The facility overlooked the resident's [CONDITION(S)] on her right lower extremity, therefore failed to document and to communicate the issue to the physician. 2) Failed to develop an individualized mobility care plan reflecting approaches used for one resident (Resident #78) out of 2 residents reviewed for mobility devices. There were 88 residents residing in the facility at the time of the survey. The findings included: Observation on 02/07/2022 at 11:58 AM revealed, Resident #16 sitting in her wheelchair propelling herself back to her room returning from activities and both legs appeared swollen. No leg rest/ lifts were observed on her wheelchair. Review of the medical Face Sheet revealed that Resident # 16 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plans for Resident # 16 revealed care plan dated 01/11/2022 revised on 01/11/2022; Focus: The Resident has hypertension. Goal: The resident will remain free of complications related to hypertension through review date. Interventions/Tasks included but not limited to monitor for and document any [CONDITION(S)]. Notify MD (Medical Doctor). Observation and interview on 02/08/2022 at 09:46 AM revealed Resident #16 was on her way to activity. Resident #16 reported she participated in activities every day and loves to stay active and her only concern was the pain in her legs. Both legs appeared swollen and no leg rest or lifts was noted on her wheelchair. Observation on 02/09/2022 at approximately 9:45 AM Resident #16 was noted propelling herself to activity room and her legs continued to appear swollen. There were no lifts noted on her wheelchair. Observation on 02/09/2022 at 10:41 AM revealed, Resident #16 remained in the activity room. Both feet were noted placed directly on the floor. No lifts noted on her wheelchair. Continued observation at 11:58 AM showed Resident #16 legs remained swollen while she propelled herself from activity back to her room. Observation and interview with Resident #16 and the survey team's nurse on 03/05/2022 at 12:20 PM revealed, Resident #16 was in her room, sitting in her wheelchair with her feet flat on the floor. Resident #16 agreed to an interview and observation. Upon observation, the survey team's nurse agreed that Resident # 16's legs appeared swollen and [CONDITION(S)] appeared present on Resident # 16's right lower extremity. On 02/10/2022 at 6:25 AM during an interview, Staff J a Registered Nurse (RN) acknowledged that Resident # 16 had swollen legs and that the resident sometimes reported pain or discomfort in her legs. Staff J,RN explained the possible reasons for the swelling included Resident #16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff J, RN explained that for said conditions, keeping legs elevated while in wheelchair is recommended and the nurses ensured that the legs remain elevated. Staff J added that he could report the resident's [CONDITION(S)] to their doctor. During the interview, Staff J agreed to review clinical record. Review of nurses' notes for Resident #16 from January 1, 2022, through February 9, 2022, showed daily skilled notes that indicated the resident was assessed for [CONDITION(S)] daily. The skilled notes documented; [CONDITION(S)] not present. Staff J, RN agreed to observe Resident #16 at the time. Observation and interview on 2/10/2022 at approximately 7:05 AM revealed, Resident #16 was awake in her bed and agreed to the observation by Staff J, RN. The resident reported she always had problems with her legs, but it was much better. Still swollen, but not as bad lately. Staff J, RN washed his hands, put on gloves, and proceeded to check the resident for [CONDITION(S)]. Staff J, RN explained that the assessment consists of gently pressing the area and observing for deepening and stretching of the skin. Staff J, RN reported she has [CONDITION(S)] on her right lower extremities (deepening of skin noted). Staff J, RN later agreed that the nurses' notes were wrong to document [CONDITION(S)] not present and he will report it to the oncoming nurse, to follow up. 2) On 02/07/22 at 9:56 AM Resident #78 was observed lying in bed, awake but confused, asking/calling out for husband in Spanish. Oxygen was on at 2 liters per minute (LPM), the nasal cannula for the oxygen was over the resident's ears but not in nostrils. Resident #78's indwelling catheter tubing was noted with cloudy amber urine. On 02/09/22 08:54 AM Resident was observed in bed, alert but confused, the indwelling catheter was in privacy bag attached to the bed and the tubing was noted with cloudy amber urine. Record review revealed that Resident #78 was readmitted to the facility most recently on 01/20/2022. Her medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Occupational Therapy (OT)- Patient to be seen for skilled OT 5 times per week. Review of Resident # 78's care plan with review date of 01/31/2022 indicated- Focus: Resident has an ADL (Activities of Daily Living ) self- care performance deficit related to impaired mobility, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .Goal: The resident will improve current level of function through the review date. Interventions: Assist with ADLs and toileting needs. Monitor, document, report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self-care. PT/OT evaluation and treatment as per MD (Medical Doctor) orders. Record review of the Omnibus Budget Reconciliation (OBRA) Admission MDS dated [DATE] revealed in Section C for Cognitive Patterns a Brief Interview of Mental Status (BIMS) summary score of 5 out of 15 indicating Resident # 78 is cognitively impaired. Section G for activities of daily living (ADL) documented that for bed mobility Resident #78 requires assistance of one person with ADLs to physically assist and total dependence for personal hygiene and toileting. Section G0300 Balance during transitions and walking A. Moving from seated to standing position- activity did not occur; B. Walking- activity did not occur; C. Turning around- activity did not occur; D. Moving on and off toilet- activity did not occur; E. Surface to surface transfer- Not steady, only able to stabilize with staff assistance. G0600 Mobility devices indicated wheelchair. Section O for special services documented that Resident # 78 received PT/OT and noted therapy start date of 01/22/2022. On 02/09/2022 at 12:04 PM, during record review and interview with the MDS coordinator the care plan and MDS documentation for Resident #78 were reviewed. It was revealed that the care plan did not include interventions indicating current use of a mechanical lift for Resident #78. The Occupational Therapist who was also present reported that PT/OT department did order the need for use of a mechanical lift on the change of condition report and 24 hour report. Record review and interview on 02/09/22 at 12:25 PM with the Occupational Therapist reveled documented in the PT/OT progress notes for the Resident #78 starting 01/23/2022 up to 02/08/2022 and the 24 hour change of condition report dating 01/06/2022 reflecting Resident #78 required total assistance for transfers using mechanical lift. On 02/10/22 at 09:09 AM the Registered Nurse Unit Manager was notified about the care plan not having the information related to the mechanical lift.

Based on observations, interviews and record review, facility failed to accurately code the document the Minimum Data set for one ( Resident #78 ) out of twenty three sampled residents. as evidenced by not documenting active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: On 02/07/22 at 9:56 AM Resident #78 was observed lying in bed , awake but confused, asking/ calling out for husband in Spanish. Oxygen was on at 2 liters per minute (LPM), the nasal cannula for the oxygen was over the resident's ears but not in nostrils. Record review of Resident # 78's clinical records revealed that Resident #78 was readmitted to the facility most recently on 01/20/2022. Resident # 78 medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical records documented the resident is full code. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 78's care plan with review date of 01/31/2022 indicated Focus: The resident has Diabetes Mellitus. Goal: The resident will have no complications related to diabetes through the review date. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor, document, report as needed any sign or symptoms of [CONDITION(S)] and [CONDITION(S)]. Record review of the Omnibus Budget Reconciliation (OBRA) Admission MDS dated [DATE] revealed in Section C for Cognitive Patterns a Brief Interview of Mental Status (BIMS) summary score of 5 out of 15 indicating Resident # 78 is cognitively impaired. Section G for activities of daily living (ADL) documented that for bed mobility Resident #78 requires assistance of one person with ADLs to physically assist and total dependence for personal hygiene and toileting. Review of the MDS Section I for Active Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section J for Health Conditions item J1400 for condition or chronic disease that may result in a life expectancy of less than 6 months documented no. Section N for medications was not documented to indicate the resident's current medications.

Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents resulting in serious body injury and multiple fractures for 1 (Resident #1) and in minor injuries for 1 (Resident #2) out of 3 residents reviewed during the survey. The findings included: 1. Record review of the facility's Incident Log for (MONTH) (YEAR) revealed, an incident for Resident #1 on 7/16/18 for an injury with laceration, the resident was found on the floor and the resident was admitted to the hospital. The clinical record included a physician's orders [REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], Section C for cognitive status had the resident coded as 03 on the Brief Interview for Mental Status (BIMS) indicating the resident had cognitive impairment Section E for Behaviors, had the resident coded for rejection of care or wandering. Section G for Functional Status, had the resident coded as 3: Extensive Assistance for bed mobility, transfer and toileting, and 8: for Activity did not occur for walking in room. Section I for Active [DIAGNOSES REDACTED]. Section J for Health Conditions had, the Resident coded for pain assessment should be conducted for presence of pain. The resident was also coded for fall history, fractures related to falls in the last 6 months prior to admission. The residents care plans included: A care plan dated 6/19/18 for at risk for falls due to unsteady gait status [REDACTED]. The goal was to minimize risk for falls. The interventions/task included: administer medication, bed in low position, encourage to transfer and change positions slowly, evaluated medications of patient demonstrates changes in mental status, ADL function, appetite, neurological status; have commonly used articles within easy reach; low bed; provide assist to transfer and ambulate; refer to therapy plan of treatment; reinforce need to call for assistance. Record review of the facility's Clinical Guideline for Fall Management indicated: Resident are evaluated for fall risk. Patient centered interventions are initiated to decrease fall risk and potential for injury. A fall is defined as unintentional change in position coming to rest on the ground, floor or other lower level but not as result of an overwhelming external force. Record review of the nurses progress notes dated 6/19/18 revealed, resident #1 was admitted from the hospital with [DIAGNOSES REDACTED]., staff provided needed care, safety maintained, and vital signs were included. Nursing progress notes dated 6/18/18, 6/20/18, 6/22/18, 6/26/18, 7/2/18, 7/4/18, and 7/9/18 indicated safety measures were in place, and call light was within reach. Nursing progress notes dated 6/21/18, 6/23/18, 6/30/18, and 7/7/18 indicated the resident had a low bed, the call light was within reach, and safety measures were in place. Nursing progress notes dated 6/29/18 indicated the resident was in the wheelchair with the wheels locked, at the nurses station for close monitoring. Nursing progress notes dated 7/11/18 indicated Resident #1 was sitting at the nurses station for close supervision to prevent falls. Nursing progress notes dated 7/15/2018 at 12:20 AM documented the resident was received in bed sleeping, transfer to the wheel chair, awake and alert, no pain verbalized during shift, safety measures in place, bed in low position, and call light within easy reach. Nursing progress notes dated 7/16/2018 at 11:04 AM noted: Patient transferred back to bed, awake and verbally responsive, noted on floor by staff, call placed to (Medical Doctor) MD, order to transfer patient to Hospital for CT scan of head status [REDACTED]. Nursing progress note dated 7/16/2018 at 12:10 PM documented, Resident transferred to the hospital. Nursing progress note dated 7/16/2018 at 22:05 documented, called hospital emergency room ( ER) and spoke to nurse and patient will be admitted with [DIAGNOSES REDACTED]. Review of the facility's incident report dated 7/16/18 revealed, the type of fall was without injury or minor injury in the patient's room. The description included: Patient found laying on the floor in front of wheelchair next to bed, unable to state to staff what happened due to history of Alzheimer's Dementia. Medical Doctor (MD) notified on 7/16/18 at 10:40 AM. The incident report section titled, Center Action: Patient Care documented: Patient noted with open area to forehead, skin tear to the back of right hand, and skin to left lower lateral leg cleanse with normal saline and steri strips applied as ordered. Orders given to transfer to hospital for a CT of the head. Patient taken to hospital on [DATE] at 12:10 PM by ambulance. The residents family member was notified. During an interview on 12/17/18 at 2:44 PM with Staff D, a Registered Nurse (RN), it was reported, the resident had a fall in the morning while she was in the conference room. She reported, the resident went to the hospital, and she had a fracture. During an interview on 12/17/18 at 3:15 PM with Staff B, a Certified Nursing Assistant (CNA), it was reported, she remembered Resident #1 was on fall precautions. She reported, she was with another patient and Staff A, a Licensed Practical Nurse (LPN) told her the resident fell . She reported, the resident was already gone to the hospital when she came to the residents room. During an interview on 12/17/18 at 3:39 PM with Staff A, an LPN, it was reported, the resident was laying down in front of the wheelchair around 10:00 AM. She reported, the resident had a cut on the forehead and was bleeding, but there were no injuries to her nose or mouth. She reported, the resident was sent to hospital right away. She reported, the Resident was on fall precautions. Record review of the facility investigation revealed staff statements of incident investigation included: Staff E, a Physical Therapy Assistant (PTA) statement indicated she saw the Resident on 7/16/18 from 8:25 AM to 9:25 AM. A cognition deficit and required total assistance for all functional mobility tasks; when the session finished, the CNA was inside room. Staff A, a Licensed Practical Nurse (LPN) statement indicated she was called to the resident's room by staff passing by, and found the resident laying on floor in front of wheelchair next to the bed, the patient was unable to tell what happened due to a history of Alzheimer's, there was an open area noted to the forehead, skin tear to right back of hand and to left lower lateral leg, orders also given to transfer to hospital for CT of head, patient medicated for pain. Staff B, a Certified Nursing Assistant (CNA) statement indicated at 8:00 AM she went to the room to clean the patient, after being cleaned she left her in bed, at 9:00 AM she came back into the room changed patient brief, finished getting her dressed and put her into the wheelchair and help patient with breakfast. By 9:50 AM she was done with patient, left her in the wheelchair for therapy and went to do other patient care. A statement from Staff C, an LPN indicated, she was at the nurses station when a staff member told her the nurse wanted help in the 200 hallway, she found the nurse in room [ROOM NUMBER] next to the patient on the floor, placed a call to the MD who answered and gave orders to send resident to the hospital for a CT scan of the head, called hospital ER and gave report. Record review of the facility's investigation results als revealed: the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. History of dementia, Alzheimer's, Osteopenia. The facility's timeline of the 7/16/18 incident documented: Approximately 7:20-8:00 AM Patient asleep in bed. Approximately 8:20 AM-9:00 AM staff attempted to feed patient breakfast. She refused most. Approximately 9:30-10:10 AM care provided by assigned CNA and patient was place in chair in the room by bedside. Approximately 10:30 AM patient was found lying on floor next to bed in front of wheel chair. Patient was sent out for CT scan of brain secondary to incident. Record review of resident #1's hospital record revealed an admission date of [DATE]: The emergency room [DIAGNOSES REDACTED]. The chief complaint indicated per the ambulance service, the patient fell out of bed hitting head, found on floor. The history of the present illness indicated, resident presented to ER with chief complaint of [MEDICAL CONDITION]. Context indicated, the resident was found by facility staff on the floor and believed to have fallen attempting to get out of bed. The physical exam included: Head with horizontal laceration in mid forehead, skin tears on left lower extremity and right wrist, and diminished skin turgor. The CT of the Cervical spine indicated acute non-displaced [MEDICAL CONDITION] posterior arch of cervical 1. The CT of the facial bones indicated acute comminuted fracture of right nasal bone. The CT of the brain indicated, a 4 mm acute subdural hematoma along the anterior falx and [MEDICAL CONDITION]. The Emergency Department (ED) Course indicated, Resident #1 became more alert to verbal and tactile stimulation; findings of the subdural, cervical spine and nasal fracture; and the resident was going to be transferred to a trauma center due to the suspected acute bleeding in the brain. There was a transfer form dated 7/16/18, to hospital for [DIAGNOSES REDACTED]. The ambulance service form dated 7/16/18 indicated: Chief complaint / Reason for admission: Fall, CT of head around 10 AM. Vital signs 120/60, pulse 76, respirations 18, O2 sat 97%. During an interview on 12/18/18 at 11:16 AM with the facility's Director of Nurses (DON) it was reported, the resident had wide history of falls and she was admitted with fractures due to falls in the Assisted Living Facility (ALF) she was living in before being admitted to the facility. She reported, the resident was in unit 1, in a room located near the nurses station. She reported, the resident had a [DIAGNOSES REDACTED]. She reported, when the resident fell , she had a laceration on the forehead. She reported, the resident went to the hospital and she had a head injury with a subdural hematoma. Interview on 12/18/18 at 3:16 PM with the Risk Manager / Administrator. She reported, the Resident was in her room on 7/16/18 from 8:20 A.M. to 9:00 AM when staff attempted to feed her breakfast. From 9:30 to 10:10 AM care was provided by the CNA. From 10:10 A.M. to 10:20 A.M., the Resident was observed on the floor in front of the wheelchair. She reported, the Resident was sent to the hospital. She mentioned preventive measures to prevent the resident from falling. 2. Record review of the facility's Incident's Log for (MONTH) (YEAR) revealed, Resident #2 was listed as having a fall on 12/4/18. The facility's List of Residents with fall risks included Resident #2. The facility's Face Sheet indicated Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The residents MDS dated [DATE], Section C for Cognitive Patterns, had the resident coded as 03 on the BIMS, indicating the resident had cognitive impairment. Section E for Behaviors, had the resident coded for rejection of care or wandering. Section G for Functional Status, had the resident coded as 3: Extensive Assistance for bed mobility, and transfer as a 4: Total dependence for toileting, and 8: Activity did not occur for walk in the room. Section I Active [DIAGNOSES REDACTED]. Section J for Health Conditions had Resident coded for pain assessment should be conducted for no for presence of pain. Resident was also coded for fall history prior to admission, fractures related to falls in last 6 months prior to admission. There was a care plan for: High risk for falls related to anxiety, decreased mobility, history of falls, unable to communicate need and recent fall; had actual fall with minor injury; cognitive deficit; anxiety; ADL self-care performance deficit; dependent on staff for meeting emotional, intellectual, physical and social needs. The residents fall risk assessment dated [DATE] for Resident #2 revealed, a score of 75: High risk. Record review of nurses progress notes included, an admission entry dated 11/24/18 indicating, the resident was admitted from the hospital with [DIAGNOSES REDACTED]. Resident incontinent of bladder and bowel, bruises in several areas, baseline plan discussed with patient's son, patient oriented to call light, bed placed in lowest position, safety measures in place, and call light within reach. Nursing progress notes dated 12/4/18 at 9:00 AM revealed, MD made aware of fall and resident transferred to hospital for head CT. The CNA flow sheets included, a fall risk, hydration/fluids offered, personal hygiene and toileting every shift. The facility's Incident Report dated 12/6/18 for Resident #2 documented: Patient found by CNA while making rounds on the floor trying to get up by himself. Alert moving all extremities. Skin tear to right upper extremity and laceration to right side of the forehead. The description of event indicated: Unwitnessed fall to floor. There was a portable X-ray result dated 12/4/18 for the skull, right elbow and left femur with negative results. During an interview on 12/17/18 at 1:39 PM with Staff F, a RN. She reported, the resident fell in the morning, and he was found on the floor in the residents room. During interview on 12/17/18 at 5:29 PM with the Administrator / Risk Manager. She reported, Resident #2 was found on the floor by the CNA. She reported, the resident had a skin tear to the right upper extremities and laceration to the right side of the forehead. She reported, fall preventions were in place as per the care plan. During an interview on 12/18/18 at 11:08 AM with the DON, she reported the MD gave an order to send the resident to the hospital for a Head CT since he hit his head and was on an anticoagulant. She reported, the CT scan results were negative and the resident returned to the facility the same day. She reported, the resident had a [MEDICAL CONDITION], right arm skin tear, and he had X-rays done on the left arm in facility before going to the hospital and they were negative.

Based on record review and interview the facility failed to accurately assess a resident for risk of falls for 1 (Resident #1) out of 3 sampled residents for falls. This resident had an actual fall and sustained a fracture to his ribs. This practice will place residents at risk for further falls, fractures, and even death. Review of resident #1's hospital records revealed he was hosptalized on [DATE] to 10/01/13, at an acute care facility, prior to admission to this facility. The resident was assessed to have poor safety awareness, impaired attention/concentration, fall precautions; and was admitted secondary to weakness. According to hospital admission notes, dated 09/27/13, the resident fell at home. Record review for Resident #1 of the facility's Admission Fall assessment revealed it was a part of the Patient Admission Screen. Section J. Fall Risk revealed the area checked was urinary/fecal incontinence; history of falls not marked. Record review of the Minimum Data Set (MDS) for Resident #1 revealed; Admission assessment; Assessment review date: 10/09/13; Section J1700. A) Did the resident have a fall any time in the last month prior to admission/entry or reentry: no response entered; B) Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry: no response entered; Fall History on Admission: No; Section V revealed Falls care area was care planned due to resident with balance problems, on antidepressant and on antianxiety medications. Record review of the Minimum Data Set (MDS) for Resident #1 revealed; Admission assessment; Assessment review date: 10/16/13; Section J1700. A) Did the resident have a fall any time in the last month prior to admission/entry or reentry: no response entered; B) Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry: no response entered; Section V revealed Falls care area was care planned due to resident with balance problems, on antidepressant and on antianxiety medications. Record review revealed Resident #1 had sustained a fall in the facility, in the hallway on 10/10/13. Record review of resident #1's clinical chart revealed the resident was admitted to the facility on [DATE] his [DIAGNOSES REDACTED]. muscle weakness, difficulty in walking, Alzheimer ' s disease, anxiety, [MEDICAL CONDITIONS], debility, and altered mental status. Record review of a form titled: Situation Background Assessment Recommendation (SBAR); for Resident #1 revealed; the date and time of event: 10/10/13 at 11:30am. Describe event: patient sitting in front of nurse's station stood up and attempted to step over the foot rest of the wheel chair (w/c); patient assisted back to the w/c by the nurse and patient ' s assigned doctor. Positive Range of Motion (ROM) noted to upper and lower extremity; Physician notified (MD present at time of the incident); suggested to monitor vitals, observe, and ordered an x-ray. Review of x-ray results revealed it was dated 10/10/13. Clinical history: pain; Impression: acute fractures of the left posterior lateral sixth, seventh and eighth ribs. Interview with Assistant Director of Nursing (ADON) on 11/12/13 at 2:14pm; she reported their system does not give them a final score to be able to determine who is at high risk for falls, therefore everybody is initially put at the same level. Interview with Minimum Data Set (MDS) coordinator on 11/12/13 at 3:40pm revealed they place everyone at risk. Because they don't directly interact with the residents, nursing is supposed to communicate with us who is at a higher risk.

Based on record review and interview the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Resident #1) out of 3 sampled residents for falls. This resident had an actual fall and sustained a fracture to his ribs, in 3 locations. This practice will place residents at risk for further falls, fractures, and even death. Record review revealed Resident #1 had a fall in the facility in the hallway on 10/10/13. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for Resident #1 of the facility's Admission Fall assessment revealed it was a part of the Patient Admission Screen. Section J. Fall Risk revealed the area checked was urinary/fecal incontinence; history of falls not marked. Record review of a form titled: Situation Background Assessment Recommendation (SBAR); for Resident #1 revealed; the date and time of event: 10/10/13 at 11:30am. Describe event: patient sitting in front of nurse's station stood up and attempted to step over the foot rest of the wheel chair (w/c); patient assisted back to the w/c by the nurse and patient 's assigned doctor. Positive Range of Motion (ROM) noted to upper and lower extremity; Physician notified (MD present at time of the incident); suggested to monitor vitals, observe, and ordered an x-ray. Review of x-ray results revealed it was dated 10/10/13. Clinical history: pain; Impression: acute fractures of the left posterior lateral sixth, seventh and eighth ribs. Record review of the care plan(s) for Resident#1 revealed the resident was care planned for 1) cognitive deficit as evidenced by moderate decision making/short-long term memory loss; 2) falls care plan initiated on 10/03/13 revealed; focus: at risk for further falls due to unsteady gait, Altered Mental Status (AMS), Alzheimer ' s disease, dementia, restlessness, poor safety awareness; Interventions: 10/03/13 Bed in low position; have commonly used articles within easy reach; reinforce need to call for assistance; reinforce wheelchair safety as needed such as locking brakes; therapy evaluation and treatment per orders. The falls care plan was revised on 10/11/13; the only intervention added to the care plan was "Re-educate to call for assistance." Further review of nurses notes revealed the resident was placed near the nursing station for close monitoring on a regular basis due to having poor safety awareness and being confused, below are some of the nurse's notes for Resident #1: 10/02/13 at 12:11 Admission note: pt educated on call light use and safety. Pt verbalized understanding but noted to be making attempts to get up without call light use and without requesting assistance. Pt at nursing station for supervision; 10/04/13 at 15:02 pt assisted into chair and placed near nursing station for a closer evaluation; 10/05/13 at 14:02 pt had several attempts to get out of w/c without assistance; 10/07/13 at 14:20 pt noted attempting to get out of w/c several times. Placed near nursing station for a closer evaluation; 10/07/13 at 21:45 pt admitted to the facility and is noted to be confused and has poor safety awareness. Safety is maintained with bed in low position and call light placed within easy reach and pt was educated on use and informed to call for help when needed, pt is placed at the nurse's station for closer monitoring. He is seen on multiple occasions to be attempting to get from the bed to the chair and is standing up when at the nurse's station and had to be redirected on multiple occasions not to do so. 10/08/13 at 11:07 pt sitting in w/c by nursing station. Pt noted to get up and attempted to walk, pt redirected not to do that; 10/08/13 pt anxious trying to get out of w/c several times, pt put by nursing station for closed monitor; 10/10/13 at 9:46 pt sitting in front of nurse's station for close observation; 10/10/13 at 20:09 sitting up close to the nursing station for close supervision; 10/11/13 at 1:14 received resident sitting on w/c at station; 10/11/13 at 14:36 pt sitting on w/c by nursing station for close supervision because pt attempted to get up form w/c to walk without assistance; 10/14/13 at 12:05 Quality of Life Nurses notes on 10/14/13 revealed the resident continues to be closely monitored for fall. He has poor safety awareness, frequently attempts to get up from chair and bed. He is redirected/reoriented throughout the shifts and needs and is given constant supervision. Safety measures include low bed, floor mat, involved in activities and kept in areas of increased supervision especially during periods of restlessness. Call light kept within easy reach at all times and he is able to use and is reminded to use light; 10/14/13 pt sitting up in w/c by nursing station at this time; 11/17/13 at 11:37 pt sitting in w/c by nursing station when received; 10/17/13 at 20:30 sitting up in w/c close to the nursing station. Taken to this room for dinner. Resident was noted with legs off the bed and trying to get out of bed without assistance, assisted back to bed but refused to stay in bed, assisted up in wheelchair place close to nursing station for close supervision; 10/18/13 at 15:11 Care Plan Progress Note: resident discussed in care plan meeting. He has a short and long term memory deficit and moderately impaired in decision making; 10/18/13 at 16:50 resident very anxious, repeatedly getting up from w/c, pt also tries to get out of bed without assistance, refused to stay in bed, assisted up in w/c place close to the nursing station for close supervision; 10/18/13 at 20:00 sitting quietly by the nurses station; 10/19/12 at 11:46 pt sitting in w/c at nursing station for close supervision, because pt noted attempted to get up in w/c so many times without assistance, pt redirected, smiling and continues to do that; 10/19/13 at 22:52 pt kept at nursing station for safety and supervision; 10/20/13 at 23:13 sitting at nurses station. Observation continues; 10/21/13 at 21:09 sitting up in w/c close to the nursing station when received. Physical Therapy evaluation and plan of treatment dated 10/03/13, for Resident #1 revealed [DIAGNOSES REDACTED]. Precautions: Fall, safety and decreased cognition. Occupational Therapy evaluation and plan of treatment dated 10/03/13 revealed [DIAGNOSES REDACTED]. Precautions: Confusion and Fall risk. Interview the desk nurse present at the time of the fall on 11/12/13 at 3:55pm, revealed the resident was sitting in front of the nurses station, she turned to answer the phone and heard the physician say " hey sit down," when she turned she saw the resident already on the floor on his side on top of the wheelchair leg; she and the doctor went over to the resident; the doctor was talking to him and asked him if he was ok, the resident complained of pain so the doctor ordered an x-ray. The resident was placed in bed in his room, his nurse and the doctor assessed him. Most of the time the resident was by the nurses station because he always wanted to get up from his wheelchair. Interview with the (Assistant Director of Nursing) ADON on 11/12/13 at 12:43pm revealed that resident #1 is alert and forgetful with episodes of confusion and agitation. He was placed at the nurse's station for closer observation, he got up from the chair and slid to the floor attempting to step over the foot rest of the wheelchair and fell on the floor. His doctor was in the facility; he assessed him and ordered x-ray to left ribs. The x-ray showed acute fracture of left posterial lateral 6th,7th, and 8th ribs. Interview with ADON on 11/12/13 at 2:14pm; she reported their system does not give them a final score to be able to determine who is at high risk for falls, therefore everybody is initially put at the same level. The ADON reported that it is the facility practice not to use bed or chair alarms. She presented the surveyor with a typed document sent by corporate with the heading: Implement: Elimination of alarms. The document states: Although alarms have been part of clinical trials demonstrating the efficacy of multi-component fall prevention interventions, the evidence to support the individual contribution of alarms to fall reduction is not evident. Alarms are merely signaling devices and will not prevent a fall. For these reasons, bed or chair alarms and sensor pads are no longer endorsed as an intervention to prevent falls. Effective with this revised release of the Fall Practice Guide, the ordering of any alarms or alarm type products require the approval of the Director, Clinical Services for the Center. Interdisciplinary teams are encouraged to evaluate each individual patient 's risk factor and put in place interventions that are specific to that patient. Interview with Minimum Data Set (MDS) coordinator on 11/12/13 at 3:40pm revealed they place everyone at risk. Because they don't directly interact with the residents, nursing is supposed to communicate with us who is at a higher risk.

Based on observation, interview, and record review the facility failed to adequately assess and monitor the development of a pressure ulcer in one Resident #1; and 2) ensure the resident received wound care treatment that promote healing and prevent infection in one Resident #3 out of 3 sampled residents The findings include: 1) Clinical record review reveals that Resident #1 was admitted to the facility: on 2/3/2012. His [DIAGNOSES REDACTED]. He has a past medical history of [REDACTED]. Review of Minimum Data Set (MDS) for Resident #1: Clinical record review reveals that Resident #1 was admitted to the facility: on 2/3/2012. His [DIAGNOSES REDACTED]. He has a past medical history of [REDACTED]. Review of wound care notes reveals the following: 3/10/12: 2 small open areas less than 0.5cm; pink scar tissue; no drainage; 3/18/12: Length=2.2 centimeters; width=2.0 centimeters; depth=0; pale tissue with scant serosanguineous drainage and surrounding tissue with discoloration; 3/25/12: length=5.0 centimeters; width=3.5 centimeters; depth=0; description: dark pink/red tissue; drainage: scant serosanguineous;and surrounding tissue with discoloration; 4/1/12: length=5.0 centimeters; width=3.5 centimeters; depth=0.1; description: dark pink/red tissue; drainage: scant serosangineous and surrounding tissue with discoloration; ; 4/8/2012: length=7.5 centimeters; width=2.5 centimeters; depth=0.4 centimeters; description: dark pink/red tissue; drainage: scant serosangineous and surrounding tissue with discoloration; ; 4/15/12: length=7.5 centimeters; width=2.5; depth=0.3 centimeters; description: pale pink and yellow tissue; drainage: none and surrounding tissue with discoloration; ; 4/18/12: length=7.0 centimeters; width=2.0 centimeters 0.3 depth; description: pink=50%; red=50%; drainage: serous, clear normal appearance. The length, width and depth increased. Review of the "Skin Alteration Record" dated 3/10/2012 has the type as a sacrum abrasion There was no staging of the wound only that it was an abrasion The type, measurements, description, drainage, skin surrounding and pain were documented weekly. However, the sacral wound was still documented as a sacral abrasion . Review of the "Skin Alteration Record" dated 4/1/2012 to 4/18/2012, there is no type of alteration nor staging of the wound documented, only the measurements, description, drainage, skin surrounding and pain were documented weekly. Review of Minimum Data Set (MDS) The Initial admission assessment MDS dated [DATE] ; Section M - Skin conditions: Does this resident have one or more unhealed pressure ulcer(s) at stage I or higher? the response " No. " There was no MDS initiated for a significant change for Resident #1. Interview with the MDS coordinator on 7/11/2012 at 2:09pm; she confirms that she coded the last MDS on Resident #1. She confirms that a significant change can be completed if there is a change in one major area for a resident. When asked if a significant change was necessary for Resident #1; she reports that one should have been done when the wound became a stage III. Review of the wound care notes reveals that Resident #1 ' s sacral ulcer fit the clinical definition of Stage 3 by 3/25/2012. Review of the care plan for Resident #1 for alteration in skin as evidenced by an open area to the sacral area; did not identify this as a stage 3 pressure ulcer. 2) During an Observation of wound care treatment on 7/11/2012 at 11:03am revealed wound care treatment by the facility ' s wound care nurse for Resident #3. Supplies gathered using aseptic technique. Resident #3 was observed on an air mattress with bed bumpers bilaterally on each side of the bed. A percutaneous endoscopic gastrostomy tube (PEG) was observed to the abdomen, which was temporarily discontinued for wound care treatment. The nurse removed a dressing, which was partially soiled with a yellow to brownish color. After discarding the soiled dressing, he changed gloves and began wound care treatment again, without washing his hands. The wound bed was observed to be pink with no drainage. The nurse cleaned the wound with normal saline. He was observed to changed gloves, but did now wash his hands. The nurse then applied the physician ordered ointment to the wound bed; covered the wound and secured the dressing with tape. The nurse was then observed to place all the soiled items in a red bag, left the resident ' s room without washing his hands. The nurse then brought the items to the appropriate room to discard and had at this point washed his hands. Interview with the Director of Nursing (DON) on 7/11/2012 at 1:58pm; she confirms that it is the facility ' s policy for nurses to perform multiple incidences of hand washing throughout wound care treatments. Review of the facility ' s policy titled, dressing change: nonsterile and sterile, reveals: the following procedure for wound treatment: verify physician's order [REDACTED].; cleanse wound per physician's order [REDACTED].