Every finding on record at Okeechobee Health Care Facility

Based on record review, and interview, the facility failed to provide an estimate for cost of services per day to a resident receiving the Advanced Beneficiary Notice for Non-Coverage of services (ABN) for 2 of 3 sampled residents reviewed, Resident #66 and Resident #188. The findings included: Review of the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) reviewed provided information to beneficiaries so that they could decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility.1. Review of the Advanced Beneficiary Notice (ABN) for non-coverage of services that Resident #66 received and signed on 08/04/25 documented that Resident #66 checked option 3 that indicated he did not want the services that were checked off for physical therapy, occupational therapy or the daily skilled nursing care. The document had a sentence that said, an estimate that these services will cost you. The words cost in SNF, where a dollar amount should be per day/item or service did not give a dollar amount for those services.2. Review of the Advanced Beneficiary Notice (ABN) for non-coverage of services that Resident #188 received and signed on 05/25/25 documented that Resident #188 checked off option 3 that indicated he did not want the services that were checked off for daily skilled nursing care. The document had a sentence that said, an estimate that these services will cost you. The words cost in SNF, where a dollar amount should be per day/item or service, did not give a dollar amount for those services.An interview was conducted on 08/21/25 at 10:08 AM with the Business Office Manager (BOM) who was asked about Beneficiary Notices and ABNs. She stated that she does the NOMNC (Notice of Medicare non-coverage) and ABN Notices for Long-Term Care residents (LTC) who do not go home. She stated that Social Service does the NOMNC for the residents that discharge home or go to another facility. She stated she was new in this position and started in October 2024. She stated she was not educated correctly, the BOM prior to her had populated the words cost in SNF on all the ABN documents for all the residents that sign the ABN notice, and the cost was in the admission agreement. She stated we do not talk about cost, and If someone wants private therapy, we do have a form and the cost on a separate form for them to sign.

Based on observation, interview and record review, the facility failed to ensure appropriate care and services for 2 of 4 sampled residents, Residents #172 and #183, as evidenced by the failure to thoroughly assess left arm pain, bruising, and a decline in range of motion for Resident #172, and failure to obtain blood pressure values for Resident #183 who was receiving an antihypertensive medication with physician ordered parameters. The findings included: 1. During an initial interview on 08/18/25 at 10:51 AM, Resident #172 stated he had an appointment with an orthopedic doctor scheduled for 08/22/25 but that he was upset that it took so long for him to see a doctor about his left arm. Resident #172 stated that about three weeks ago after he removed the footrest off his wheelchair and placed it on the seat of his walker, his wrist flipped over (outward) hard and ever since, his left arm hurts and it has a big bruise above my elbow. Resident #172 was observed with a large red and purple bruise above his elbow and over the area of his left bicep muscle. When Resident #172 was asked if the footrest hit his arm where the bruise was, he stated the footrest did not hit his arm, and that the bruise came from within his body after the twisting motion of his arm/wrist when placing the footrest on his walker seat. Resident #172 stated that he still dresses himself, but it is painful and difficult. Resident #172 stated he told his nurse what happened, he was seen by the Medical Director, and the doctor ordered an x-ray of both shoulders, but that only showed arthritis. When Resident #172 was asked if he was able to move his left arm normally prior to the incident that happened 3 weeks ago, he reported yes. He stated it was just like my right arm and demonstrated full range of motion of his right arm up in the air without any complaints or expressions of pain. Resident #172 was unable to move his left arm the same as his right arm and grimaced in pain when attempting to bend his left elbow and lift his arm up off the armrest of the wheelchair. Resident.#172 stated he gets pain medication, but it does not help. Review of records revealed that Resident #172 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented R#172 had a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale indicating the resident was cognitively intact. Further review of the MDS dated [DATE], Section GG for functional abilities, revealed that R#172 had no impairment to his upper extremities, and that he required setup/supervision with dressing and toileting. Review of the Occupational Therapy (OT) Discharge summary dated [DATE] revealed Resident #172 was able to raise bilateral arms above his head and straight out from the shoulders. Review of Physical Therapy (PT) Evaluation dated 05/30/25 revealed Resident #172 did not have any complaints of pain to his upper extremities and that an assessment of his upper extremities was not part of the PT Evaluation. Review of a nursing progress note dated 07/30/25 at 10:44 AM revealed Resident #172 complained of pain to his bilateral shoulders and that the pain increased when lifting his arms or when picking up objects. Further review of the progress note dated 07/30/25 revealed Resident #172 had reported pain relief from PRN (as needed) pain medication, but the pain returned as soon as the medication wears off and that the Medical Director had written new orders to obtain an x-ray of bilateral shoulders. Review of a progress note dated 07/30/25 at 10:58 AM revealed that orders were received from the Medical Director to apply Voltaren External Gel 1% to left shoulder every shift. Further review of the progress note revealed Resident #172's family member was notified of the Voltaren gel order, and of the x-ray of Resident #172's shoulders that was to be done on 07/30/25. Review of an 'Orders Administration note' dated 07/30/25 at 6:35 PM, in part, documented that Tramadol HCL Tablet 50 MG was ordered to be given by mouth every 6 hours as needed for moderate to severe pain and that Resident #172 had complained of pain at a level 6, in which rest and repositioning were not effective, and that the as needed Tramadol was administered. Review of X-ray results of Resident #172 bilateral shoulders, that the doctor was notified of with a time stamp dated 08/01/25 at 4:00 PM, revealed in part that the findings were 'no soft tissue swelling or gas, no acute fracture dislocation, degenerative changes of glenohumeral and AC [Acromioclavicular] joint.' Review of a Medical Directors progress note dated 07/31/25 at 4:46 PM, in part, revealed that Resident #172 was seen by an Advanced Registered Nurse Practitioner (ARNP) under the direct supervision of the Medical Director and that Resident #172 presented with shoulder pain, a pattern of condition was persistent, symptoms were active, severity of condition was moderate, and that it occurs in constant course. Further review of the progress note dated 07/31/25 revealed that abduction (movement of a body part away from the midline of the body) was limited to both shoulders, right shoulder more than left shoulder and to refer Resident #172 to an orthopedic doctor. During an interview on 08/20/25 at 9:32 AM, Staff A, Licensed Practical Nurse (LPN), reported that Resident #172 reported to her on 07/30/25 that something happened to his left arm with the footrest of the wheelchair, but he did not say he gotten hurt and there was not a bruise. When Staff C was asked what the redness on his left arm is from, she reported it is from something he had, he has a history of shoulder pain. He was given a short-term dosage of steroids and pain medication. During an interview on 08/20/25 at 10:35 AM, Staff B, Physical Therapist Assistant (PTA), was asked if Resident #172 had told her of an incident with the wheelchair footrest. Staff B reported that Resident #172 told her that he hurt his left arm reaching for something and it has been hurting ever since. When the PTA was asked if the Registered Physical Therapist (RPT) was advised of Resident #172's complaint of pain and if the RPT reassessed the resident, the PTA stated the RPT did not reassess Resident #172, and she had advised the nurse and documented it in her note on 08/01/25. Staff B stated that Resident #172 has been complaining of left arm pain ever since and that prior to that day, he had not specified the pain to the left shoulder but instead he complained of pain all over and that the left upper extremity was a new complaint of pain. Staff B was asked if she had noticed any redness or bruising to Resident #172's left arm, to which she replied, Yes, near his biceps area and I had not noticed it before'. Staff B reported that she had asked Resident #172 if the bruising was new and he said he did not know. Review of Physical Therapy Treatment Encounter notes from 07/24/25 to 08/19/25 revealed that on 08/01/25, Resident #172 had verbalized 10/10 level of pain to his left shoulder that limits the following functional activities: pulling, pushing, dressing, forward reaching; What relieves pain? Prescribed medications, remaining still; what exacerbates pain? Reaching and raising his left arm off armrest of the wheelchair and that nursing was made aware of [the resident's] increased pain level to his left shoulder. Further review of Physical Therapy Encounter notes in part revealed that on 08/04/25 Resident #172 reported pain level 9/10 left shoulder with mobility and use. On 08/05/25, Resident #172 reported left shoulder pain 10/10 with inability to raise arm off armrest without assistance from right arm. Nursing is aware. On 08/06/25, Resident #172 reported left shoulder pain level 8/10 post 1 hour of taking prescribed medication for pain relief. Patient reports medication provides no relief. Physical Therapy notes from 08/08, 08/11,08/12, 08/13, 08/15, 08/18 and 08/19/25 had reported Resident #172's pain to left shoulder with varying degrees between levels 7-8/10. During an interview on 08/20/25 at 2:35 PM, when Staff C, Registered Nurse (RN) Team Leader, was asked about Resident #172's left arm pain, Staff C stated the resident had complained of left shoulder pain to his nurse, Staff A. Staff A responded by contacting the Medical Director and Resident #172's family member. When Staff C was asked if anyone knew what happened to cause his left shoulder pain, she responded the resident never specifically said what the pain came from. Staff C was advised that Resident #172 was able to specifically report how he hurt his left shoulder during an interview on 08/18/25 with the surveyor and Staff C agreed to talk to the resident with the surveyor. During an interview on 08/20/25 at 2:40 PM, Resident #172 stated to Staff C, (RN) Team Leader that his left arm hurts and nothing has been done about it in three weeks. The resident stated to Staff C that he hurt his left arm after taking the footplate off the wheelchair and it flipped his wrist over and ever since then he has had pain with certain movements like lifting up a cup with my left hand and bringing it to my mouth and that he could not scratch his head anymore without pain. The resident had facial expressions of grimacing while demonstrating the arm motions that are now hard for him to do and that cause pain. Staff C asked Resident #172 who he told, and replied, I told my nurse, [Staff A]', and then the Medical Director saw me, and I got an X-ray but that did not show anything. Resident #172 then showed Staff C the large red area on his left bicep region and the resident gave permission for surveyor to take a photo of the area. Resident #172 then reported that he thinks the bruise came from an injury inside his arm after the footrest flipped his left wrist over. Staff C, (RN) Team Leader, said to the resident, I am sorry, I really did not know anything about it. Review of records after staff interviews revealed new Physician orders for Resident #172 dated 08/21/25 to 'Monitor bruise to left upper extremity and to contact doctor for any changes, Acetaminophen Tablet 650 MG, Tylenol 8-hour Arthritis pain oral tablet extended release 650 MG, and Hydrocodone-Acetaminophen Tablet 5-325 MG.' 2. Review of the record revealed Resident #183 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, on a 0 to 15 scale, indicating the resident had severe cognitive impairment. Further review of the record revealed Resident #183 had sustained a fall on 07/02/25. A progress note dated 07/02/25 at 6:06 PM documented the resident fell as he was seen squatting near his door. The nurse practitioner was called and a new order for hydralazine, a medication for high blood pressure, was ordered once a day for a systolic blood pressure (SBP/the upper number) over 180. Review of the physician order dated 07/02/25 documented to give 10 milligrams (mg) of Hydralazine by mouth every 24 hours, as needed for a SBP [systolic blood pressure] over 180. Review of the corresponding Medication Administration Record (MAR) documented the medication was given once on 07/02/25 at 6:21 PM with no documented blood pressure noted on the MAR. Review of the Blood Pressure Summary in the electronic medical record had a blood pressure reading on 07/02/25 at 6:21 PM of 188/10, which was crossed out and documented by Staff E, Registered Nurse (RN) Team Leader as correction. The record lacked any corrected blood pressure. Further review of the Blood Pressure Summary lacked any documented blood pressure reading from 07/07/25 through 07/20/25, from 07/22/25 through 08/02/25, from 08/04/25 through 08/17/25, and on 08/19/25. During a side-by-side record review and interview on 08/20/25 at 3:30 PM, Staff E stated the crossed-out blood pressure from 07/02/25 was because of the diastolic (lower number of the blood pressure) reading documented as 10, which was an error. The RN agreed there should have been another documented blood pressure for that date. When asked about the lack of blood pressure readings when there was an order to provide the medication as per physician ordered parameters, the RN agreed with the findings. Further review of this order revealed it was discontinued on 08/03/25 by Staff F, Licensed Practical Nurse (LPN) Team Leader. During an interview on 08/20/25 at 3:52 PM, when asked why the Hydralazine order was discontinued, the LPN stated if it was a PRN (as needed) order, and they have a standing order to discontinue a PRN medication if it is not used in 30 days. When told the medication was as needed for high blood pressures, and the blood pressures were not being completed, the LPN stated, Oh, that's a problem.

Based on facility policy, record review, and interviews, the facility failed to provide care and services related to weight management for 1 of 6 sampled residents, by not notifying the physician of Resident #27's weight gain. The findings included: Review of the policy titled Weight Management issued 08/01/25 documented in part . It is the policy of the facility to provide care and services related to weight management in accordance to State and Federal regulation. Procedure 8. Dietitians will evaluate all weights. 9. All weights will be documented in the resident's electronic record. 10. The physician and the resident or resident representative will be notified by the residents' nurse/designee of any unexpected and/or unplanned weight changes. Record review revealed Resident #27 was readmitted to the facility on [DATE]. Review of the annual comprehensive assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) Score of 03 on a 0-15 scale, indicating severe cognitive impairment. Review of the medical history documented a diagnosis of Morbid Obesity, and Type 2 Diabetes Mellitus.Review of the recorded weights for Resident #27 revealed that she weighed 212 lbs (pounds) on 06/10/25, on 07/10/2025 she weighed 226 lbs, a 13lb weight gain in 4 weeks, and on 08/10/25, her weight was 228lbs. Review of the nutrition progress note, and assessment revealed the most recent documented nutritional assessment for Resident #27 was on 07/04/25. Review of a care plan dated 06/30/25 documented a focus on 07/04/25 by the Registered Dietitian (RD) indicating that Resident#27 was morbid obese and she wanted to lose weight, and a goal was to lose 4-8 lbs. per month.During an interview on 08/20/25 at 2:32 PM, with the RD, when asked if he had reviewed the recent weights for Resident #27, he opened the resident's record and reviewed the weights. The RD was asked if he was aware of the 13 lb weight gain from June to July, and the RD stated, Let me see if I did a nutritional assessment on her. I did an assessment on her on July 4, 2025. The RD was made aware that the increase in weight according to documentation occurred on July 10, 2025. When asked who checked the weights on the residents, he stated The Certified Nursing assistant assigned to the resident. When asked who inputs the weights into the computer, the RD stated, The Team Leader. When asked how he was made aware of a significant weight change he stated, I will get an alert sent to my phone when the weight is put into the system. When asked if he got an alert for this resident's weight increase, the RD looked in his phone and stated, Yes, I don't know what happened. When asked why Resident #27 wasn't reweighed to see if there was a possible discrepancy, the RD stated, I'm not sure. During an interview on 08/21/2025 at 9:30 AM, with Staff E, Registered Nurse (RN), Team Leader, she was asked if she input the weight for Resident #27 in the computer on 07/10/25, and stated, Yes. When asked if she realized that she had a 13lb weight increase in 4 weeks, she stated, But her last weight was 228lbs. When asked what was done about the weight increase on 07/10/25, she stated, I did notify the doctor yesterday. When asked what happened at the time you noticed that Resident #27 had the weight increase on 07/10/25, was the resident reweighed, Staff E, RN, Team Leader stated, The resident was reweighed, but it wasn't put into the computer.

Based on record review and interview, the facility failed to ensure adequate monitoring for behaviors for a resident receiving a psychotropic medication for 1 of 5 sampled residents reviewed, Resident #178. The findings included: Review of Resident #178 medical record revealed Resident #178 was admitted to the facility on 08/ 30/22 with a diagnosis to include Unspecified Dementia with Behavioral Disturbances, Bipolar Disorder, and Type II Diabetes. Review of the annual Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 which means her cognition is severely impaired. Review of the physician orders documented the resident is on Seroquel (Quetiapine Fumarate) 12.5 MG twice a day for unspecified Bipolar Disorder. It has a list of behaviors, and adverse side effects.Review of the care plan documented Resident #178 is on a psychotropic medication and is at risk for drug related side effects and the interventions included to monitor behavior and mood every shift and document date, monitor for adverse side effects of drugs (lethargy, dizziness, increase in confusion, gait disturbance) and monitor for behavior/mood changes.Review of the Medication Administration Record (MAR) documented the psychotropic medication Seroquel being given twice a day but there is no documentation that the nurses are monitoring and documenting the residents' behaviors, adverse side effects or outcome.An interview was conducted on 08/21/25 at 9:03 AM with Assistant Director Of Nursing (ADON) and she was asked where they would document the resident's behaviors. She pulled up this resident and saw the order to document the behaviors but acknowledged that there was no place to document them.An interview was conducted on 08/21/25 at 9:15 AM with Staff D, Licensed Practical Nurse (LPN), who was asked to review the resident's physician orders, her MAR, and review the Seroquel order. He was asked where they document behaviors for the use of Seroquel, who stated we would document in the progress note. He then went back to progress notes and tried to locate documentation for behaviors exhibited but Staff D could not find any documentation.

Based on observation, record review and interview, the facility failed to follow physician orders for 1of 5 sampled residents on thickened liquids as evidenced by not following the therapeutic diet order for Resident #46. The findings included:Record review revealed Resident #46 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 05 on a 0-15 scale indicating severe cognitive impairment. Further review of the quarterly assessment dated [DATE], revealed Resident #46 should be supervised during her meals. Review of the medical diagnosis for Resident #46 documented a history of Dysphagia (difficulty swallowing).Review of the care plan dated 07/04/25, documented Resident #46 had difficulty swallowing and required nectar thickened liquids and altered diet to promote safe swallowing with a goal that the resident will safely tolerate the restrictive diet without signs and symptoms of aspiration. The staff were to instruct the resident to take small bites/sips, swallow slowly, monitor for coughing and choking, and serve the diet ordered (regular texture with nectar thick liquids, no straws.During an observation on 08/19/25 at 11:14 AM, Resident #46 was observed with a carton of vanilla ensure with a straw inside of it, and a white large Styrofoam cup with a straw inside of it, sitting on the bedside table next to her bed. Photographic Evidence Obtained.Review of the physician order dated 08/15/25, documented Resident #46 had a diet order for a 'regular diet, mechanical soft texture, mildly thick nectar consistency liquids, magic cup with meals; fortified foods with meals; NO STRAWS due to aspiration (chocking) precautions.'During an observation on 08/20/25 at 9:47 AM, Resident #46 was observed with her breakfast tray sitting on the bedside table in front of her. On the tray, there was a carton of nectar thickened milk, with a straw inside of it and a large white styrofoam cup with a straw inside of it. Resident #46 was heard coughing. There were no staff present at the bedside.During an interview on 08/20/25 at 1:41 PM, when Staff F, Licensed Practical Nurse (LPN), Team Leader, was asked are you aware of the diet order for Resident #46, Staff F, LPN, Team Leader stated, I will have to look in the computer. She reviewed the order and stated, The diet is mechanical soft texture and nectar thickened liquids. Staff F was asked what else the order said and she stated, Are you talking about the part that says no straws? At that time Staff F was made aware that Resident #46 had been observed with a straw in her liquids over the past couple of days.

Based on facility policy, observation, record review, and interview, the facility failed to initiate Enhanced Barrier Precautions (EBP/prevent transmission of infection) for 1 of 2 sampled residents, Resident #187, who had an infected wound. The findings included:Review of the policy titled Enhanced Barrier Precautions revised on 08/01/25 documented in part, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission multidrug resistant organisms (MDRO). 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Record review revealed Resident #187 was admitted to the facility on [DATE]. Review of the annual comprehensive assessment dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 00, on a 0-15 scale, indicating severe cognitive impairment. Review of a physician order dated 08/18/25 instructed staff to administer Sulfamethoxazole-Trimethoprim Tablet 800-160 MG (Bactrim/antibiotic) 1 tablet by mouth every 12 hours for wound infection to left foot for ten days. Another physician order dated 08/09/25, indicated Resident #187 was treated with Cephalexin (antibiotic) Tablet 500 MG for wound infection in between the fourth and fifth toe for seven days. Further review of a physician order for Resident #187, dated 08/09/25 instructed staff to cleanse between pinkie toe and fourth digit with soap and water, apply bacitracin (antibiotic ointment) and dry dressing every shift, with no indication of location. Observation of wound care was conducted for Resident #187 on 08/20/25 at 11:00 AM with Staff G, Registered Nurse (RN), and the Educator at bedside. When Staff G was getting ready to remove the old dressing from the resident's left foot, the dressing was not in place. The dressing was found in the trash can in the resident's room. The Educator took the dressing out of the trash can and a small amount of serous (yellow) drainage was observed of the dressing. The wound was located in between the fourth and fifth left toe, appeared white, and a small opening was noted. During the observation of the wound care done on Resident #187, Staff G did not wear a grown. Staff G was asked if a wound culture (test for infection) was ordered for Resident #187 and she stated, Yes, I believe it was collected on Monday.During an interview on 08/20/25 at 11:31 AM, the Educator was asked when is a resident placed on EBP, who stated, If the resident has a wound infection or a history of an MDRO. When asked if the resident is kept on EBP even after infection has been treated and they are negative she stated, Yes. When asked if Resident #187 was supposed to be on EBP due to her infected wound and continuous treatment with antibiotics, the Educator stated, I'm not sure. I will have to find out. Review of the physician orders for Resident #187 did not indicate that EBP was initiated for the infected wound between her left fourth and fifth toe.

Based on observation, interview, record review, and policy review, the facility failed to ensure adequate kitchen staff to provide timely meal delivery as per schedule for 2 of 2 meals observed (lunch and dinner on 04/24/24), affecting 11 of 41 sampled residents (Residents #172, #85, #87, #129, #18, #157, #41, #96, #135, #53, and #193). This failure could potentially affected all 196 residents who consume food orally in the facility at the time of the survey. The census at the time of survey was 198 residents. The findings included: 1. Review of the policy, titled, Timely Meal Service and Mealtimes Frequency, (not dated), documented, in part, the following: Policy: Food will be delivered promptly at allotted times to ensure safe, palatable, and high-quality food is serviced at the proper temperature. Review of the Food Services Cart Delivery Schedule provided upon request documented the specific times each food cart was to leave the kitchen to be delivered to the specific unit. Each unit had two to five carts scheduled for delivery, at scattered times, for each meal. The main dining room and the Gardens dining room were open for lunch and dinner. Review of the schedule revealed the following general information and schedule for the A-unit, which was the Memory Care Unit being observed: a) Breakfast carts were to leave the kitchen starting at 6:56 AM, with the last cart at 8:10 AM. b) Breakfast carts for the A-Unit were scheduled to leave the kitchen at 7:00 AM, 7:24 AM, 7:46 AM, and 8:10 AM. The Gardens dining room was not open for breakfast. c) Lunch carts were to leave the kitchen starting at 11:20 AM, with the last cart at 12:40 PM. d) Lunch carts for the A-Unit were scheduled to leave the kitchen at 11:25 AM, 11:48 AM, 12:12 PM (Gardens dining room), 12:21 PM, and 12:40 PM. e) Dinner carts were to leave the kitchen starting at 4:55 PM, with the last cart at 6:15 PM. f) Dinner carts for the A Unit were scheduled to leave the kitchen at 5:00 PM, 5:22 PM, 5:46 PM (Gardens dining room), 5:55 PM, and 6:15 PM. During an interview on 04/23/24 at 11:44 AM, the spouse of Resident #172 stated the lunch trays arrive to the Gardens dining room between 1 and 2 PM. The spouse explained staff start assisting the residents into that dining room around 11:30 AM, and then they sit there for more than an hour. The spouse explained this was the memory care unit for the cognitively impaired residents. The spouse explained while waiting for the food residents get bored and anxious, or simply fall asleep, placing their heads down on the tables. The spouse stated by the time the food arrives, many residents are either no longer interested, or too sleepy to eat. An observation of the lunch meal for the A-Unit and Gardens dining room was made on 04/24/24 beginning at 11:37 AM with continuous observation until 1:15 PM. At 11:37 AM, eleven (11) residents were in the Gardens dining room awaiting lunch. Most of the residents had been served drinks. The first food cart was delivered to the unit at this time for residents who ate in their rooms. The following was also observed: g) At 11:54 AM, fourteen residents were noted in the Gardens dining room with two staff. h) At 12:18 PM, the second lunch cart was delivered to the A-Unit for residents in their rooms. This cart was scheduled to leave the kitchen at 11:48 AM. i) At 12:24 PM, fifteen (15) residents were in the dining room. The daughter of Resident #85 was noted sitting next to her mom, rubbing her arm, and soothing her mother, and talking with the residents at that table. There were 3 to 4 staff in the dining room, sometimes wandering in and out of the room. j) At 1:02 PM, the trays still had not arrived to the Gardens dining room. Resident #172 was sitting up in his wheelchair sleeping. Other random residents had been observed going in and out of the dining room or sleeping at the tables, one with her head down on the table. When asked about the dining room service times, the daughter of Resident #87 stated they were always running late, often not arriving until 1:20 PM or 1:30 PM. The daughter stated, It's hard on these residents because they either get restless or sleepy. j) At 1:04 PM, the third cart arrived to the A-Unit and food was provided to the residents in the Gardens dining room. The Gardens dining room trays were scheduled to leave the kitchen at 12:12 PM. k) At 1:11 PM, the fourth cart arrived to the A-Unit. It was scheduled for 12:21 PM. l) At 1:14 PM, the final tray was delivered. It was scheduled for 12:40 PM. An observation of the dinner meal for the A-Unit and Gardens dining room was made on 04/24/24 beginning at 5:11 PM, with continuous observation until 7:19 PM. The following was observed: m) At 5:11 PM, the first cart arrived for the residents in their rooms. It was scheduled to leave the kitchen at 5:00 PM. n) At 5:49 PM, the second food cart was delivered to the A-Unit. It was scheduled to leave the kitchen at 5:22 PM. An observation of the Gardens dining room revealed it was locked and dark. o) At 6:11 PM, Resident #129 approached the surveyor for the second time, asking for cookies or crackers. Staff had provided ice cream to the resident about 10 to 15 minutes earlier. Staff provided a sandwich to the resident and stated, (Name of Resident #129) your dinner will be here soon. p) At 6:24 PM, Resident #18 went to the nurses' station and asked for ice cream. Staff K, Certified Nursing Assistant (CNA), explained this resident's tray arrives on the last cart that usually arrives to the unit about 6:45 PM. q) At 6:34 PM, Staff K and J, both CNAs, explained when dinner does not arrive by 6:30 PM, they close the dining room because the residents get more agitated, and it runs into their rounds before shift change at 7 PM. Staff J stated it was difficult and frustrating, explaining when lunch was late, it runs into our rounding time as well. When asked if they knew why the meals were served late, Staff K stated it was usually because they don't have enough staff in the kitchen. During this observation, it was considerably louder on the unit, with residents in general, more anxious and noisier. r) At 6:39 PM, the third food cart arrived to the A Unit. It was scheduled to leave the kitchen at 5:46 PM. s) The fourth and fifth food carts were delivered at 6:43 PM and 6:45 PM. Another small cart was delivered at 6:52 PM. By 6:55 PM, most residents were eating, and the unit was considerably quieter. t) At 6:58 PM Staff T, CNA, delivered a meal to Resident #157, who was in bed. The resident was sound asleep as per the CNA. Staff T attempted to feed the resident, but at 7:15 PM reported she was kind of waking up, but pocketing her food, so she stopped feeding her as per the nurse's instruction. u) A final cart was delivered to the Unit at 7:02 PM. The cart lacked a tray for Resident #18, who was asking for her food. Resident #18 received her dinner at 7:19 PM. During an observation and interview on 04/25/24 at 9:40 AM, Staff L, CNA, who had just finished feeding Resident #157, stated she had one more resident to feed. When asked about the timing of the meals, Staff L volunteered that one morning recently they did not get the first breakfast tray until 8 AM. The food cart schedule documented the first food cart for the A-Unit was to leave the kitchen at 7:0-0 AM. Staff L stated the evening meal in the Gardens dining room doesn't arrive until 6:30 PM or after. The CNA explained they take the residents into the dining room about 5:15 PM to set them up, but when the dinner is late, the residents get antsy, ask why they are there, or fall asleep waiting. The CNA explained the late meals affect their ability to get their work done timely as they are waiting 45 minutes to an hour for meals, which cuts into their care time. During an interview on 04/25/24 at 10:07 AM, Staff C, Registered Nurse (RN)/Team Leader, explained when the second and later trays are late, it affects the residents who have not been provided a tray yet, as they seek out those that have trays already their food. The RN stated in general, when trays are late, they either get more anxious or they fall asleep, and then they may or may not eat well. On 04/25/24 at 10:47 AM, the Food Service Manager was noted providing a new meal schedule for the A-Unit, and was asked to provide the past 30 days of completed daily food service schedules that documented the scheduled times the food carts were to leave the kitchen and the time the food carts actually left the kitchen. Review of the schedules revealed multiple meals where food service carts were delivered 30 to 45 minutes or more later than scheduled. During an interview on 04/25/24 at 11:09 AM, when asked the reason for the trays being up to an hour late, the Food Service Manager stated, lack of staff. The Food Service Manager stated he has been a cook short, needs 4 or 5 more dietary aids, and wants a person dedicated to special orders and phone orders. The Food Service Manager stated, Its too much (for the current kitchen staff) for the number of residents and requests in this facility. During an interview on 04/25/24 at 1:27 PM, when asked about kitchen staffing and timing of the meal delivery, the Administrator and Consultant Dietician both agreed they needed more staff and were aware of the late meals. The managers volunteered they have had kitchen issues for the past year or more, either with a lack of staff or the need for stronger personnel in the kitchen. 33103 2. Review of the Food Services Cart Delivery Schedule provided the specific times each food cart was to leave the kitchen to be delivered to the specific unit. The residents below (Residents #41, #96 and #135) were on the C-Wing. The Breakfast cart was documented as 9C at 7:58 AM and lunch at 12:32 PM. 2a. Review of Resident #41 records revealed the resident was admitted to the facility 03/03/23 and has a BIMS (Brief Interview for mental Status) score of 15, indicating cognition is intact. During an interview on 04/22/24 at 11:51 AM Resident #41 stated, 'They don't serve us are meal at lunch until 2:00 PM and dinner at 8:00 PM'. Further observations conducted on 02/24/24 nothed the breakfast cart arriving on the C-unit at 8:40 AM and lunch cart at 1:30 PM. On 02/25/24, the breakfast arrived on the C-unit at 8:30 AM; and the lunch arrived on floor after 1:10 PM. 2b. Review of Resident #96 records revealed the resident was admitted on [DATE] and has a BIMS score of 15, indicating cognition is intact. An interview was conducted on 04/22/24 at 12:00 PM with Resident #96, who stated they usually don't get dinner until 8:00 PM. A secondary interview was completed on 02/24/24 at 2:40 PM with Resident #96 who was asked about how they know what is being served. She stated that they had it on channel 2 but that it has not been working since Christmas. She pulled up the TV (television) to show the surveyor, and stated that they use to have the phone number to the kitchen as well and the times to call the kitchen to put a special order in but it got to a point that they stopped answering the phone and it is no longer on the TV. When asked how they know what is on the menu for the day, she stated that unless you get out of bed and are in the hallway you don't know. She stated it is very frustrating. 2c. Review of Resident #135 record revealed the resident was admitted to the facility on [DATE] and has a BIMS score of 15, indicating cognition is intact. During an interview with Resident #135 on 04/22/24 at 11:27 AM, he stated we don't get breakfast until 9:00 AM. I think it's supposed to come round 7-8 AM, I have called the kitchen and complain. 39167 3. Clinical records review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis included: Malnutrition. The admission Minimum Data Set (MDS) assessment, reference date 03/19/24, recorded a BIMS score of 14, indicating Resident #53 was cognitively intact. The care plan dated 03/15/24 documented Resident #53 was at risk for malnutrition and dehydration due to malignant cancer of the large intestine. Intervention included to provide diet as ordered. On 04/22/24 at 12:56 PM, an interview process was started with Resident #53, who stated a concern with the facility's food, saying the food was always served late. 4. Clinical records review revealed Resident #193 was admitted to the facility on [DATE] with diagnoses including: Septicemia, Anemia, and Cirrhosis. The admission MDS assessment, reference date 02/03/24, recorded a BIMS score of 11, indicating Resident #193 was moderately cognitively impaired. The care plan dated 01/28/24 documented Resident #193 was at risk for malnutrition and dehydration due to Sepsis. Intervention included to provide diet as ordered. On 04/22/24 at 10:35 AM, an interview with Resident #193 revealed a concern with the facility's food department. He voiced the food was always being served late and cold. He further stated the facility did not provide enough food and provided wrong orders. Resident #193 divulged that he has reported his concern to the food department, they sat in his room and asked questions, he went over the day-by-day concerns with them, and he was still receiving the wrong food, and things he didn't order were put on his tray. He is not getting what he has ordered. On 04/25/24 at 1:27 PM, an interview was conducted with the Nursing Home Administrator and the Dietitian who were made aware of the food concerns of Resident #53 and Resident #193.

Based on observations, interviews and record reviews, the facility failed to provide foods prepared in a safe and sanitary manner in accordance with professional standards for food safety. The findings included: 1. During the initial kitchen tour, on 04/22/24 at 8:50 AM, accompanied by the Dietary Consultant and the Food Service Manager, the following observations were noted: a. Upon entering the kitchen and approaching the hand washing sink to perform hand hygiene, there was 'used ice' in the hand washing sink. Staff M, Dietary Aide, stated ice was used as a cooling medium for cold holding of cartons of milk in a bus tub and then dumped in the hand washing sink. b. There was an accumulation of food residue in the blades of produce slicers. c. There was an accumulation of food residue on the underside of the stand mixer d. The internal temperature of a 6-inch deep one third sized pan of gravy was 46 degrees Fahrenheit (F). The pan of gravy was in the process of cooling from the previous day's dinner meal, as reported by Staff N, Dietary Aide e. Upon entering the dish washing area from the hallway, it was noted that there was an apron lying over the basin and faucet of the hand washing sink. There was no soap at the hand washing sink for staff to perform hand hygiene. Staff N stated that she uses the hand sink in the main kitchen to perform hand hygiene and then comes over to the dish washing room. f. On a cart located just inside of the door to the dishwashing room, there were an employee's watch, a set of keys on a key chain, and a cellular phone on top of an open box of single use gloves. At the conclusion of the initial kitchen tour, the Consultant Dietitian and the Food Service Manager acknowledged findings and understanding of the concerns. 2. During a follow up visit to the kitchen, on 04/23/24 at 7:35 AM, while staff were plating the breakfast meal, Staff N was observed putting pellet plates on the pellet warmer, and placing on the plates on the trays for staff to put a plate of food on. It was noted that the pellet plates were cold to the touch. Upon further observation, the pellet warmer was found to be malfunctioning and flashing an error message and not warming the pellet plates. 3. During an observation of the unit pantries, on 04/24/24 at 8:20 AM, accompanied by the Food Service Manager, it was noted that there were no metal-stemmed probe style thermometers available for staff to ensure that foods are prepared and/or reheated to safe temperatures in the microwave ovens on the four units. At the conclusion of the observation, the Food Service Manager acknowledged the findings and understanding of the concern. 4. During the follow up tour of the kitchen, on 04/24/24 at 10:52AM, accompanied by the Consultant Dietitian and the Food Service Manager, the following observations were noted: a. There was a 6-inch deep 1/3 sized hotel pan of broccoli and cauliflower and a 6-inch deep 1/3 sized hotel pan of green beans that Staff O, Cook, was processing. When asked Staff O stated that the items were leftovers that were intended to be pureed, reheated and served at another meal service later in the week. b. The Consultant Dietitian was noted to be using disinfectant wipes with a 1-minute dwell time. After taking the temperature of the chicken, the Consultant Dietitian wiped the probe of the thermometer with the disinfectant wipe and immediately placed it into the next item without allowing for the one minute dwell time. c. Staff P, Dietary Aide, and Staff Q, Dietary Aide, were observed handling open foods while wearing a watch. d. A portion of the chicken that was being served to residents with orders for Regular diet with regular texture was 5 ounces, while a portion of the puree chicken for residents on a pureed diet was 2.5 ounces. At the conclusion of the follow up tour, the Consultant Dietitian and the Food Services Manager acknowledged the findings and understanding of the concerns.

Based on observation, interview, and policy review, the facility failed to ensure palatable food and food served at a proper temperature for 9 of 41 sampled residents, Residents #172, #25, #109, #193, #195, #96, #135, #182, and #17. The findings included: 1. Review of the policy, titled, Timely Meal Service and Mealtimes Frequency, (not dated), documented, in part: Policy: Food will be delivered promptly at allotted times to ensure safe, palatable, and high-quality food is serviced at the proper temperature. Review of the Food Preparation Guidelines, reviewed 09/22/23, documented, in part: Policy Explanation and Compliance Guidelines: . 3. Food and drink shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: a. Providing meals that are varied in color and texture. b. Using spices or herbs to season food in accordance with recipes. c. Serving hot foods/drinks hot and cold foods/drinks cold. d. Addressing resident complaints about foods/drinks. During an interview on 04/23/24 at 11:44 AM, the spouse of Resident #172, explained her husband resides in the memory care unit, and her main complaint is that the meals are late, and the food is cold. The spouse explained her husband eats finger foods and she tastes them first as she would not feed her husband something she would not eat herself. The spouse stated the other night the kitchen served steak fries that were ice cold. The wife stated she just pushed them aside. The spouse finally volunteered that at times the meat is tough, stating that she had seen staff and residents having difficulty cutting the meat at times. During a supplemental interview on 04/24/24 in the afternoon, the spouse of Resident #172 volunteered she was assisting her husband with a peanut butter and jelly sandwich and noted the strangest thing and I just don't understand. The spouse stated one side of the sandwich was toasted and the other side was not. An interview was conducted on 04/24/24 at 6:34 PM, with Staff K, Certified Nursing Assistant (CNA), who stated she had worked at the facility for years, volunteered the food quality and variety has declined since the change in ownership. The CNA stated the repetition of the meals had also increased. Staff J, CNA, stated she sometimes eats meals at the facility, and she always needs to add salt and pepper. During an interview on 04/25/24 at 9:40 AM, Staff L, CNA, who has worked at the facility for 5 years, stated the quality of food is not as good as before the change in ownership. A test tray was provided on 04/24/24 at 1:15 PM, on the second to last food cart. The side of chopped spinach lacked any type of seasoning. 39167 2. Clinical records review revealed Resident #25 was recently admitted to the facility on [DATE] with diagnosis that included: Malnutrition. The significant change Minimum Data Set assessment, reference date 02/19/24, recorded a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #25 was moderately cognitively impaired. The care plan completed on 02/07/24, documented Resident #25 was at risk for malnutrition and dehydration due to diuretic use and gastroesophageal reflux disease. Intervention included to provide diet as ordered. On 04/24/24 at 8:48 AM an interview was conducted with Resident #25, who stated that the food was terrible, 9 times out of 10 it was served cold. She divulged she personally had a run-in with the kitchen about their cooking. She stated she knows they have problems but that doesn't help us, we need to eat right, since the new company have taken over, the food has been terrible. They make it seems in the ticket like we're in big hotels ordering lunch, well we don't. 3. Clinical records review revealed Resident #109 was admitted to the facility on [DATE] with diagnosis that included: Hypertension (high blood pressure). The quarterly MDS assessment, reference date 03/19/24, recorded a BIMS score of 15, indicating Resident #109 was cognitively intact. The care plan completed 03/26/24 documented Resident #109 was at risk for malnutrition and dehydration due to dementia and depression. On 04/23/24 at 9:58 AM an interview was conducted with Resident #109, who revealed her concern about the facility's food. She voiced the facility always served the food cold. 4. Clinical records review revealed Resident #195 was admitted to the facility on [DATE] with diagnosis that included: malnutrition. The admission MDS, reference date 02/19/24, recorded a BIMS score of 13, indicating Resident #195 was cognitively intact. The care plan dated 02/13/24 documented Resident #195 was at risk for malnutrition and dehydration due to malignant breast cancer and gastroesophageal reflux disease. Intervention included to provide diet as ordered. On 04/22/24 at 1:05 PM, an interview was conducted with Resident #195, who voiced concern about the facility's food. She stated the food was terrible, the facility needs better food quality, the food was always served cold, and the plates were not hot. On 04/24/24 at 12:17 PM, a subsequent interview was conducted with Resident #195, who revealed, the food was always served late, the facility doesn't serve snacks between meals, she was diabetic, she cannot go without anything in between the meals. On 04/25/24 at 1:27 PM, an interview was conducted with the Nursing Home Administrator and the Dietitian, whostated they were made aware of the food concerns for Resident #25, Resident #109, and Resident #195. 33103 5. Review of Resident #96 records revealed the resident was admitted to the facility 04/14/23 and has a BIMS score of 15, indictaing cognition is intact. During an interview on 04/22/24 at 12:00 PM with Resident #96, she stated that 'the food is cold, and I have to have them reheat it. I usually don't get dinner until 8:00 PM'. 6. Review of Resident #135 records revealed the resident was admitted to the facility on [DATE] and has a BIMS score of 15, indicating cognition is intact. During an interview with Resident #135 on 04/22/24 at 11:27 AM, the resident stated the food is cold for all 3 meals. 7. Review of Resident #182 records revealed resident was admitted to the facility on [DATE] and has a BIMS score of 13, indicating cognition is intact. During an interview on 04/22/24 at 11:34 AM, Resident #182 stated that his food is cold for all 3 meals. He stated he goes to the dining room for lunch and it may be a bit warmer. He stated this has been going on for sometime, but can't give exact time frame. I told someone who was in dining room. 38893 8. Record review documented Resident #17 was admitted to the facility on [DATE]. According to the residents most recent full assessment, an annual MDS, dated [DATE], Resident #17 had a BIMS score of 15, indicating that the resident was cognitively intact. Resident #17's diet orders included: Regular diet, Regular texture, Regular/Thin consistency - 1:1 assist with meals. Double Portions For Breakfast - 09/20/22. During an interview with Resident #17, on 04/23/24 at 9:22 AM, when asked about the food served in the facility, Resident #17 replied, Breakfast is really good, but that's about it. It is nasty. You gotta be really hungry to eat it. I hardly ever eat lunch because it doesn't taste good. I am always telling them (referring to staff that assist with eating). 9. Record review documented Resident #38 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, Resident #38 had a BIMS score of 15, indicating intact cognition. Resident #38's diet orders included: Regular diet, Regular texture, Regular/Thin consistency - Extra sauce/gravy on side, distant supervision/periodically - 10/28/22. During an interview with Resident #38, on 04/22/24 at 10:41 AM, when asked about the food being served at the facility, Resident #38 replied, Terrible - You don't get what you order half of the time. The pasta is always undercooked. I fight with them all of the time. I fought with them yesterday. You never know what you get because the owners are so cheap, the quality of the food has gone way down and I always tell them that it is cold. 10 On 04/22/24 at 11:40 AM, lunch arrived to the 200-unit via a metal cart that was not insulated and had no additional heat source. One staff member immediately began removing trays from the cart and served them to the residents in their rooms. It was noted that the pellet plates used to keep food at proper temperatures was cold to the touch. 11. On 04/23/24 at 7:30 AM, during an observation of breakfast served to the residents in their rooms on the 200-unit, that the pellet plates used to keep foods at proper temperatures were cold to the touch. 12. During an observation in the kitchen, on 04/23/24 7:35 AM, Staff O was observed placing pellet plates on a pellet warmer and then placing them on a tray for staff to place plates of food on. The pellet plates were cold to the touch and the plates that the food was being plated on were lukewarm to the touch. Further observation revealed that the pellet warmer was not working and was showing an error message that was ignored by staff. When asked about the plates being lukewarm, Staff N, Dietary aide, replied, we keep it (referring to the plate warmer) at a low setting because the plates get too hot and burn staff.

Based on observation, interview, and record review, the facility failed to ensure timely and proper care and services for 3 of 30 sampled residents, as evidenced by: Nursing staff failed to ensure administration of the full dose of an anti-viral medication (Paxlovid) for Resident #10; failed to assess and treat edema for Resident #82; and failed to timely treat constipation for Resident #85. The findings included: 1. Review of the record revealed Resident #10 was admitted to the facility on [DATE], and resided in her current room in the memory care unit since 04/27/23. Review of a progress note dated 02/09/24 at 12:21 AM revealed the resident tested positive for the COVID-19 virus. Review of the audit reports for the pharmacy orders for Paxlovid revealed the following: a) A verbal order was entered on 02/09/24 at 12:13 PM, twelve hours after testing positive for the virus, and electronically signed by the physician on 02/10/24 at 7:35 AM, for the administration of Paxlovid twice daily for five days, and then discontinued on 02/10/24 at 1:20 AM. b) A second verbal order for Paxlovid twice daily for five days, was entered on 02/10/24 at 1:20 AM, electronically signed by the physician on 02/10/24 at 7:35 AM. An entry on this audit dated 02/10/24 at 7:48 AM documented the medication was on hold, Awaiting MD (physician) to sign off for pharmacy. Review of the February 2024 Medication Administration Record (MAR) and corresponding progress notes revealed the following: c) Paxlovid was not administered on 02/09/24 at 9 PM as ordered, with no rationale documented in the corresponding progress notes. d) A progress note on 02/10/24 at 6:07 AM documented Paxlovid was not available. e) Paxlovid was on hold from 02/10/24 at 9 PM through 02/12/24 at 9 AM. f) Paxlovid was not administered on 02/12/24 at 9 PM. The corresponding progress note documented, Unable to give at this time. g) Paxlovid was administered starting on 02/13/24 at 9 AM through 02/15/24 at 9 AM, indicating the resident received only 5 of the 10 scheduled doses. Corresponding progress notes lacked any rationale. During a side-by-side review of the record and interview on 04/25/24 at 10:19 AM, when asked about the failure to administer the full prescription of Paxlovid for Resident #10, Staff C, Registered Nurse (RN)/Team Leader, stated the first dose scheduled for 02/09/24 at 9 PM was more than likely not yet available. When shown the Paxlovid order audit that documented, Awaiting MD to sign off for pharmacy, Staff C identified and explained there was a medication-to-medication interaction documented on a Medication Reconciliation Form dated 02/09/24, and the pharmacy would not fill the prescription until the interaction form was signed off by the physician as OK to administer. Staff C was able to locate the Medication Reconciliation Form that was signed by the physician, but this form lacked the date the form was signed by the physician. When asked the process for these Medication Reconciliation Forms, Staff C explained the forms are sent to the facility from the pharmacy, staff place these forms in the physician's folder for signature, and staff would then return it to pharmacy. Staff C noted the form was initiated on 02/09/24, which was a Friday, and stated the physician probably did not sign it until his arrival to the facility on Monday 02/12/24, thus the reason Paxlovid was not started until 02/12/24. Staff C further stated staff did not extend the administration time to compensate for the late initiation of the medication, thus the Paxlovid dropped off the electronic MAR after the 9 AM dose on 02/15/24, agreeing Resident #10 only received 5 of the scheduled 10 doses. 2. Review of the record revealed Resident #82 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment documented the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale. This MDS documented the resident needed supervision to touching assistance for putting on footwear, and had diagnoses to include Coronary Artery Disease and Heart Failure. Review of weekly assessments from December 2023 and January 2024 revealed Resident #82 had 2+ pitting edema (swelling of the feet rated on a scale of 0 for none to 3 for severe). Weekly assessments in February and March 2024 lacked the edema. A physician progress note dated 03/13/24 lacked any edema. A current order dated 02/18/24 revealed staff were to assist the resident to her wheelchair at all mealtimes. An order dated 10/15/23 documented the resident was taking Bumex 1 milligram daily for Heart Failure, which contributes to edema. During an observation and interview on 04/22/24 at 1:34 PM, Resident #82 stated her only concern was her puffy feet. The resident had on a pair of slip-on shoes and her feet were noted swollen up out of the shoes, and appeared as moderate edema. A second observation on 04/23/24 at 10:29 AM revealed Resident #82 in her recliner with her feet elevated. The bilateral pedal edema remained. On 04/24/24 at 11:44 AM, Resident #82 was sitting up in her wheelchair getting ready to go to the dining room for lunch. The resident confirmed she had had the edema problem on and off for a long time. The resident stated she elevates her legs in the recliner, but spends the majority of the day up in her wheelchair, as she likes to go to activities and to the dining room for meals. The resident stated she had tried the stockings in the past, but they cut off the circulation. Resident #82 was wearing a different pair of shoes, but the edema remained. During an interview on 04/24/24 at 3:27 PM, Staff H, Licensed Practical Nurse (LPN) / Team Leader, stated the resident had been on Bumex for edema and that it was a chronic condition. During an interview on 04/24/24 at 3:45 PM, Staff G, LPN/MDS Coordinator, stated the edema management intervention and care plan was resolved on 03/01/24, as the edema had resolved at that time. During a supplemental interview on 04/24/24 at 3:54 PM, Staff H stated that no one had brought the resident's edema to her attention this week. Staff H stated Resident #82 was independent with dressing and would only call for assistance when she was in the bathroom, if she needed help with her clothing. During an interview on 04/24/24 at 3:57 PM, Staff I, LPN who had worked all day as the resident's direct care nurse, stated she had not noticed any edema that day as the resident had been out of her room most of the day. The LPN stated the resident gets herself dressed each day. During an interview on 04/24/24 at 4:13 PM, Staff S, Certified Nursing Assistant (CNA) who was the resident's direct care CNA all day, stated she helped the resident get dressed that morning and her feet looked normal. During an interview on 04/25/24 at 10:49 AM, Staff I, LPN, stated she assessed the resident's feet the previous evening, after surveyor questioning, and agreed Resident #82 had bilateral edema. The LPN stated she notified the ARNP (Advanced Registered Nurse Practitioner) the previous evening and received new orders for the edema. 3. Review of the record revealed Resident #85 was admitted to the facility on [DATE], and had resided on the memory care unit since admission. Review of the current MDS assessment dated [DATE] documented the resident was always incontinent of her bowel movements. An order dated 04/07/24 documented to administer 30 milliliters of Milk of Magnesia every 24 hours at bedtime as needed for constipation. Review of the Tasks section of the electronic medical record on 04/22/24, revealed the resident's last bowel movement was on 04/17/24 during the 7 AM to 3 PM shift. A progress note dated 04/22/24 at 8:03 AM documented, Alert Note: No BM in 48 hours. Will monitor for BM and give PRN (as needed) med (medication) if still no BM this morning. Review of the April 2024 MAR lacked any documented administration of the 'as needed' Milk of Magnesium medication for constipation since 04/17/24. During an interview on 04/23/24 at 2:59 PM, Staff F, CNA, stated she was told Resident #85 had had a BM the previous day. During an interview on 04/25/24 at 12:09 PM, Staff C, RN/Team Leader, stated their standing protocol is to provide Milk of Magnesia if a resident does not have a BM in 48 hours. Staff C was informed of the lack of BM for Resident #85 from 04/17/24 until 04/22/24 with no 'as needed' medication provided. Staff C agreed with the concern. 41837

Based on observation, interview, and record review, the facility failed to develop and incorporate an integrated care plan for the hospice services for 1 of 1 sampled resident reviewed for Hospice, Resident #506. The findings included: Review of the facility's Hospice-Nursing Facility Services Agreement dated 08/30/22 included in part under Agreements, the following: 2. Responsibilities of Facility (e) Coordination of Care - For Routine Care (i) Design of Hospice Plan of Care. In accordance with applicable federal and state laws and regulations, Facility shall coordinate with Hospice in developing a Hospice Plan of Care for each Hospice Patient that is consistent with the hospice philosophy and is responsive to the unique needs of each Hospice Patient and his or her expressed desire for hospice care. Hospice retains primary responsibility for determining each Hospice Patient Plan of Care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care. Facility shall ensure that Facility's care plan for each Hospice Patient reflects both the most recent Hospice Plan of Care and a description of the Facility Services furnished by Facility in accordance with its applicable regulations. Record review for Resident #506 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hypertensive Heart Disease with Heart Failure, and Essential (Primary) Hypertension. Review of the MDS for Resident #506 dated 10/12/23 revealed in Section O under hospice care was 'yes while a resident'. Review of the MDS for Resident #506 dated 01/12/23 revealed in Section O under hospice care was 'yes while a resident'. Review of the MDS for Resident #506 dated 04/13/23 revealed in Section C a BIMS score of 0 indicating severe cognitive impairment. Section O documented under hospice care, 'yes while a resident'. Review of the Care Plan for Resident #506 revealed there was no integrated plan of care for Hospice care including End of Life or Terminal Diagnosis. Review of the Hospice Binder for Resident #506 located at the nurse's station on A-Wing indicated the Hospice start of care (SOC) date was 07/14/23. The last documentation from any member of Hospice was dated on 10/23/23. Review of the hospice documentation for Resident #506 revealed no concerns. The resident was last seen by hospice nursing staff on 04/24/24. An interview was conducted on 04/25/24 at 12:15 PM with Staff A, Certified Nursing Assistant/CNA, who stated she has been working off and on at the facility since 2019. When asked if she was taking care of Resident #506, she said yes. When asked if the resident was on hospice services, she said she is not aware, but the resident may be, and she is just not aware. An interview was conducted on 04/25/24 at 12:20 PM with Staff B, Licensed Practical Nurse (LPN), who stated she has worked at the facility for just over a year and normally does not work on a cart [medication cart] but she is a weekend supervisor. When asked which residents she cared for today, she listed the room numbers (Resident #506 was included in her assignment). When asked if any of the residents she is assigned today are under Hospice services, she said no. An interview was conducted on 04/25/24 at 12:30 PM with Staff C Registered Nurse/RN Team Leader who stated she has been working at the facility for 5.5 to 6 years and in the team leader role for the past 2 months and she works on the A-Wing. When asked if there are any residents on A-Wing on hospice services, she said yes, Resident #506. When asked if they have any issues for Resident #506 what do they do, she said they contact hospice to obtain orders. When asked how often hospice staff visit Resident #506, she said nursing comes every 2 weeks she believes, and the aide comes a couple of times a week. When asked where the documentation for hospice is kept, she showed the surveyor a hospice binder for Resident #506 located at the A-Wing nursing station. She acknowledged there was no collaborated hospice documentation in the hospice binder since 10/23/23. She said the resident was recently transferred to A-Wing on 04/09/24 and maybe there was documentation on one of the other wings that the resident had been on. When asked about the care plan for the resident, she acknowledged there was no collaborated care plan for hospice, end of life or terminal diagnosis that included any delegation for hospice staff. An interview was conducted on 04/25/24 at 12:43 PM with Staff D, MDS Coordinator who stated he works on the A wing. When asked if Resident #506 is on hospice services, he said no. The MDS Coordinator acknowledged the MDS for Resident #506 dated 04/13/24 documented in Section O under 'hospice care -no while a resident'. The MDS Coordinator was then asked to check the payor source and acknowledged the payor source for Resident #506 was Hospice Medicaid. When asked if Resident #506 ever had a collaborated hospice care plan had, he said it would be an end of life or terminal diagnosis. The MDS Coordinator acknowledged there was no collaborated hospice, end of life or terminal diagnosis care plan. The MDS Coordinator stated the MDS Coordinator initiates and updates the care plan for residents as well as other staff such as nursing or social services. An interview was conducted on 04/25/24 at 12:50 PM with the Administrator who verified that Resident #506 was on hospice services and is the only resident in the facility on hospice services. When asked about the hospice documentation for Resident #506, the NHA stated hospice staff thought their office was emailing the hospice documents to the facility, the hospice staff brought over the documents withing 2 hours. An interview was conducted on 04/25/24 at 1:10 PM with the Director of Nursing (DON) who stated she has worked at the facility for [AGE] years. When asked if they have any residents who are on hospice services, she said they have 1 and it is Resident #506. The DON stated she has been on hospice pretty much since the day she was admitted to the facility. When asked if they have an issue with the hospice resident who do they would contact, she said they contact hospice. When asked how often hospice staff visit the resident, she said the nurse comes once a week and the aide comes a couple of times a week. When asked about the hospice's visits documentation, she said they have a hospice binder at the nursing station for the resident and it should be there, but the hospice does not always provide them with the documentation timely, they are inconsistent. The DON acknowledged they do not have a collaborated hospice care plan for this resident. On 04/25/24 at 3:20 PM, the Administrator provided recent hospice documentation that the hospice provider had just given to the facility. The Administrator also informed the surveyor that the MDS for Resident #506 was updated to reflect the resident was on hospice care. An interview was conducted on 04/25/24 at 3:25 PM with Staff E, MDS Coordinator who stated she has worked at the facility for [AGE] years. The MDS Coordinator stated they have 1 resident on hospice services, and she acknowledged there was no integrated plan of care for Hospice.

Based on observations and interviews, the facility failed to have nurse staffing information posted daily. The findings included: Upon entering the facility on 04/22/24 at 8:30 AM, it was noted that the nurse staffing information was not posted. On 04/22/24 at approximately 1:30 PM, all members of the survey team reported the nurse staffing information was not found during multiple tours of all units of the facility during the initial pool process. Upon returning to the facility on [DATE] at 6:45 AM, the nurse staffing information was not posted. On 04/23/24 at approximately 12:30 PM, all members of the survey team reported the nurse staffing information was not found during multiple tours of all units of the facility during the initial pool process. During an interview, on 04/24/24 at 2:45 PM with the Staffing Coordinator, when asked about the nurse staffing information being posted, the Staffing Coordinator replied, We haven't' been posting it for like a year. I don't have an explanation, I just thought that we weren't doing it anymore.

Based on observation, interview, and record review the facility failed to ensure an order was obtained to check for wander guard functioning and placement for 1 of 3 sampled residents reviewed (Resident #134); failed to ensure physician orders were followed regarding checking for wanderguard (a device designed to help protect memory care residents against elopement) functioning for 2 of 3 sampled residents reviewed for wanderguards (Residents #151 and #161); and failed to ensure a policy was in place for elopement and wanderguard maintenance. The findings included: 1. Review of Resident #134's record revealed the resident was admitted on [DATE] and diagnoses that included the following: Bipolar disorder, current episode manic with psychotic features; History of Urinary Tract Infection (UTI); Hypertension (HTN); Cognitive Communication Deficit; Adjustment Disorder with Anxiety; and Dementia with Behavioral Disturbance. Review of the resident's Minimum Data Set (MDS) last quarterly assessment completed on 11/01/22 revealed the resident had a Brief Interview for Mental Status (BIMS) of 03, which is consistent with severe impairment. The resident is ambulatory and required supervision and is not steady but can stabilize herself without assistance and the resident wears a wanderguard daily for wandering / exit seeking behaviors. Review of the resident's progress notes revealed the resident wandered in the secured unit frequently going in and out of other resident rooms, requiring frequent redirection. On 02/06/23 at 12:05 PM, an observation of Resident #134 revealed the resident was wearing a wanderguard on her ankle. The resident appeared confused and stated she was scared. On 02/07/23 at 3:19 PM, the resident was observed lying in her bed with her eyes closed. On 02/08/23 at approximately 10:30 AM, the resident was observed in activities. Record review for Resident #134 revealed an order, dated 09/20/22, for a wanderguard bracelet for safety related to wandering, every shift related to dementia with behavioral disturbance. The resident was care planned for wandering with no purpose, with an intervention to wear a wanderguard bracelet for safety related to wandering behaviors. Further review of the record did not reveal any monitoring of the resident's wanderguard for placement and functioning by the nursing staff. 2. Record review of Resident #151 revealed the resident was admitted on [DATE] and had diagnoses including, in part: Epilepsy; Dementia, Anxiety, Major Depressive Disorder, Tremor, Insomnia, Alzheimers Disease and Drug Induced Subacute Dyskinesia. Review of the MDS, dated [DATE], revealed the resident had a BIMS score of 0, consistent with severe impairment. The MDS revealed the resident was ambulatory and did not use any assistive devices and that a wanderguard was in use daily. Review of the resident's care plans revealed she was care planned for wandering and wearing a wanderguard. The resident was observed to be wandering the hall frequently during the survey. On 02/07/23 at 3:13 PM, the resident was noted to be participating in activities. On 02/08/23 at 12:20 PM, the resident was wandering the hallway and attempting to get into the medication cart while this surveyor and Staff B, Registered Nurse / RN, were conducting a medication storage observation. Review of Resident #151's physician orders revealed an order, dated 09/22/22, stating wanderguard bracelet for safety related to wandering behavior, day shift to check for placement and proper functioning. A subsequent review of the Treatment Administration Record (TAR), where phsysicain orders are documented, revealed documentation the order was carried out. In an interview on 02/08/23 at 12:20 PM with Staff B, RN, it was revealed this staff member checks wander guards about every thirty (30) days by taking the resident to the exit doors of the secured unit to make sure it alarms. A subsequent review of the February 2023 TAR for Resident #151 revealed Staff B documented checking for function and placement on February 2, 3, and 4, 2023, although she said she only checks them monthly. 3. Review of Resident #161's record revealed the resident was admitted on [DATE] with diagnoses including: Dementia with behavioral disturbance, Atrial Fibrillation, HTN with Heart Failure, and Major Depressive Disorder. Review of the progress notes revealed significant wandering on the unit. The physician orders revealed an order for a wander guard bracelet for safety related to wandering behavior. Every shift to check placement and proper functioning. Review of Resident #161's care plans revealed a care plan for behaviors of wandering with no purpose with interventions included staff to monitor placement / functioning and change once a year/as needed. Review of the MDS for Resident #161, dated 11/25/22, significant change assessment, revealed the resident has a BIMS score of 0, consistent with severe impairment, and uses a wander guard daily. The resident is ambulatory with assistive devices (walker) and uses a wheelchair. Review of the TAR revealed documentation of checking for placement and functioning on each shift. On 02/06/23 at 1:37 PM, an observation of Resident #161 revealed the resident was lying in bed with eyes open. Resident #161 was noted to have a wanderguard bracelet. On 02/08/23, a policy for elopement and wander guard monitoring was requested. On 02/09/23 at 8:30 AM, an interview with Staff C, Licensed Practical Nurse (LPN), revealed Staff C was not aware of how the wanderguards were checked, that when the residents show up to be checked they get checked but he was not sure how the wanderguards were checked. Staff C stated, maybe the Certified Nursing Assistants (CNA's) check them. Staff C stated he thought they changed the wanderguards every three months. The TAR revealed it was documented being checked by Staff C who verified he did not know how or what to check. On 02/09/23 at 8:37 AM, an interview with Staff D, Certified Nursing Assistant CNA, stated she personally checks the wanderguards for placement every day and functioning she checks weekly. She will either have the residents walk with her or she will wheel them by the double doors at the exit. Staff D stated there is also a place in the dining room that is very close to the doors and the wanderguard will alarm there as well. She stated she documents checking placement and functioning in her tasks once a week. On 02/09/23 at 11:25 AM, Staff E, LPN, was interviewed. She was asked if she knew how frequently the wanderguards are checked for functioning and placement. She stated when she worked on that unit some years ago, the residents wore wanderguards. She stated she does not remember how frequently they are supposed to be checked for functioning and placement. She stated she knew the residents were taken to the exit doors to be checked for functioning. 4. On 02/09/23 at 9:30 AM, an interview with the Director of Nursing (DON) revealed the facility does not have a policy related to elopement and monitoring wanderguards. The DON stated it is the nurse's responsibility to check for placement and functioning every shift as ordered. The DON stated the facility does not have a device to check the wanderguards, and the nurses must take them (the residents) up to the double exit door in the secured unit to check for functioning.

Based on policy review, observation, record review and interview, the facility failed to provide appropriate perineal care (the process of washing the genital and rectal area) to residents with history of urinary tract infection (UTI) for 1 of 1 sampled resident reviewed, Resident #77. The findings included: Policy review, titled, perineal care, revised 08/11/22, indicated, in part, it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the excess possible, and to prevent and assess for skin breakdown. Perineal care refers to care of the external genitalia and the anal area. Policy explanation and compliance guidelines included: gather supplies needed. a) Basin method: filled no more than 2/3 full of warm water. Wash clothes, towels, toilet paper, perineal cleanser, drape (if applicable), gloves and other relevant personal protective equipment. B) disposable cleaning cloth method: prepackaged bath product/cleaning cloths, towels, toilet paper (if applicable), drape (if applicable), gloves, and other relevant personal protective equipment. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. Cleanse buttocks and anus, front to back: vagina to anus in females. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus). Repeat on opposite side using separate section of washcloth or new disposable wipe with each stroke. 1. Record review revealed Resident #77 was admitted to the facility on [DATE] with diagnoses that included: Neurogenic Bladder and Non-Alzheimer's Dementia. The quarterly minimum data set (MDS) assessment, reference date 01/11/23, recorded a Brief Interview for Mental Status score (BIMS) of 11, indicating Resident #77 was moderately cognitively impaired. No behavior was recorded in this MDS. This MDS documented Resident #77 was always incontinent to bowel and bladder. Review of the physician order, dated 10/10/22, revealed an order for Hiprex (Methenamine Hippurate) - an antibiotic, to give 1 tablet by mouth one time a day for Prevention of Bacterial UTI (Urinary Tract Infection). The record revealed a care plan with revision date 10/19/22 that indicated Resident #77 was on antibiotic therapy to prevent urinary / bladder infections which places her at risk for adverse drug side effects. Review of progress note, dated 12/02/22 written at 1:45 PM, indicted the attending doctor was in on AM [morning] rounds, was notified about new onset of hematuria (blood in urine), and gave orders to start Resident (#77) on Keflex antibiotic for a UTI. A progress note, dated 12/03/22 written at 1:52 PM, indicated Resident #77 was on antibiotic Keflex 500 mg twice a day for 3 days for UTI. Another progress note, dated 01/02/23 written at 10:38 PM, indicated 'during a brief (overgarment) change, Resident (#77) was noted to have vaginal bleeding, briefs saturated with bright red blood. Resident (#77) stated she had some discomfort in pelvic region.' On 02/09/23 at 10:34 AM, perineal care observation was conducted with Staff A, Certified Nursing Assistant / CNA. Staff A retrieved wet wipes, removed a few wipes and placed them directly on the bed (without any protective barrier). The resident was noted with blackish diarrhea that went all the way up to the symphysis pubic area. Staff A wiped the top of the pubic area, groin, and buttock area, and did not separate the labia to clean it. Staff A removed her gloves and without conducting hand hygiene, she retrieved extra wipes from the wipes' container with her bare hands and placed more wipes directly on the bed. She then applied new gloves without conducting hand hygiene, and used the wipes from the bed to continue the care. At 10:40 AM Staff A voiced she was done with completing the perineal care. When inquired about separating Resident #77's labia to clean it, Staff A stated she did clean it. Resident #77's vagina was noted unclean, with feces present. Staff A put an adult brief on Resident #77 without properly cleaning the resident, even after the surveyor's pointed Resident #77 vagina was unclean. On 02/09/23 at 10:45 AM, an interview was conducted with the Director Of Nursing (DON). The surveyor explained how Staff A had conducted the perineal care. The DON revealed she would conduct a 1 on 1 perineal care competency with Staff A and have her review the 'perineal care' policy. At this time, the DON revealed she had reviewed the perineal care process many times with Staff A.

Based on observation, interview and record review, the facility failed to provide food that was prepared, stored and served in a manner to prevent the growth and spread of pathogens that cause foodborne illness. The findings included: 1. During the initial kitchen tour, on 03/10/20 at 9:53 AM, with Staff A, Kitchen Supervisor, and Staff B, Supervisor/Lead Cook, the following observations were made: a. The drain cover from the drain of the mechanical ware washing machine was dislodged from the floor. b. Bus tubs that were used for maintaining proportioned cartons of fluids, juices , milk, were noted to be wet-nesting on a shelf with cleaned and sanitized equipment in the mechanical ware washing area. c. The handle of the stand mixer was encrusted with food residues. d. Cleaned and sanitized 4 inch deep, full sized hotel pans were noted to be wet-nesting on a shelf in a processing/food preparation area. e. There was an accumulation of food residues on the blade of the manual table mounted can opener. f. The internal temperature of a 4 inch deep ¼ sized hotel pan of carrots that was in the process of cooling, according to staff, in the walk in cooler was 46 degrees Fahrenheit (F). It was noted that the container was tightly wrapped in plastic wrap. Staff were instructed to discard the carrots. g. There was an accumulation of ice on the ceiling of the walk in freezer over packages of foods. During the tour, the facility's Registered Dietician Consultant arrived and joined the tour. The Registered Dietician Consultant, Staff A and Staff B verbally acknowledged understanding of the concerns. All temperatures were taken using the facility's calibrated, metal stem probe-style thermometer. 2.During a follow up tour of the kitchen, on 03/12/20 at 11:42 AM, accompanied by the Registered Dietician Consultant and the Certified Dietary Manager, the following observations were made: a. An open cart containing cleaned and sanitized plates and bowls was stored partially underneath the hand washing sink, exposing the equipment to splash over from handwashing. b. The internal temperature of a 6 inch deep ¼ sized hotel pan of chicken noodle soup that was hot holding on the line was 125 degrees F. Staff were instructed to re-heat the soup to an internal temperature of 165 degrees F before being served. c. The temperature of salads cold holding in a reach in cooler was 45 degrees F. It was noted that during the process of assembling the resident's meal trays for lunch (the meal being observed), the reach in cooler was open until intervention in the form of this surveyor requesting the temperature of the salads be taken. Staff were instructed to take the salads from the reach in cooler and cool them. d. Staff C, Cook, was observed wearing a watch on his arm while handing a product and assembling lunch trays. Staff C was instructed to removed the watch, wash hands and don clean single use gloves and return to assembling the trays. The Registered Dietician Consultant and the Certified Dietary Manager acknowledged the findings and understanding of the conerns. All temperatures were taken using the facility's caliberated metal stem probe-style thermometer. 3. On 03/11/20 at 9:30 AM, a small personal refrigerator was observed next to the window bed in resident room [ROOM NUMBER]. The resident was present at the time and stated it was his. Observation of the refrigerator revealed there was no thermometer present. The refrigerator contained a partial loaf of bread, a package of celery sticks, several containers of yogurt and a partial jar of white cheese dip. The bottom area of the refrigerator was significantly soiled with light brown matter. On 03/12/20 at 2:11 PM, the refrigerator was observed with no changes to the contents. On 03/13/20 at 10:40 AM, the refrigerator was brought to the attention of the Unit Manager. She observed and acknowledged the condition of the refrigerator and lack of thermometer. She stated she thought the residents were responsible for their personal refrigerators. She made a telephone call, and then stated it was the staff's responsibility to monitor and clean the residents' personal refrigerators. (Photographic evidence obtained.)

Based on observation, interview, record review and policy review, the facility failed to ensure proper care and services for two of 2 sampled residents reviewed with a history of Urinary Tract Infections (UTIs), Residents #123 and #10. Two Certified Nursing Assistants (CNAs/Staff E and Staff F) failed to provide appropriate Foley (urinary drainage device) care to Resident #123. The facility failed to inform the physician of Resident #10's complaint of dysuria (pain with urination), in a timely manner. The findings included: 1. An observation on 03/11/20 at 8:56 AM revealed Resident #123 had a Foley catheter. The urine observed in the tubing of the catheter was cloudy. Upon arrival to the room of Resident #123 on 03/12/20 at 2:24 PM, Staff E, a CNA (certified nursing assistant) was preparing to provide personal care. The CNA used personal wipes throughout the process, wiping front to back multiple times. The CNA failed to wipe off or clean the Foley catheter during this process. The CNA placed a new brief on Resident #123, and found a pair of shorts for the resident. While threading the Foley tubing through the leg of the shorts, the CNA raised the Foley bag above the level of the resident's bladder and above the level of the bed, potentially allowing the urine to back flow into the bladder. During an interview after the observation, when asked why she did not clean the Foley tubing, the CNA stated, You made me nervous, but I can go do it now. The CNA was also informed of the concern related to raising the Foley bag above the level of the bladder, and stated Oh, I'm sorry. A second observation of personal care for Resident #123 was made on 03/13/20 at 9:54 AM, with Staff F, a CNA. Staff G, another CNA who assisted with positioning and cueing. Both CNAs washed their hands and gloved. Upon removal of the adult brief, soft stool was noted on the Foley tubing and on the front of the resident. Staff F cleaned Resident #123 using numerous wipes, but never separated the labia to ensure cleanliness. The CNAs assisted Resident #123 to her left side, and stool was noted on the wound dressing on the resident's sacrum. The CNA notified the nurse. After provision of wound care, Staff F told the resident she wanted to clean the front area again, to make sure I got everything. The CNA cleaned again on both sides, down the front without separating the labia, and again down the Foley catheter tubing. The CNA started putting the brief on, and the surveyor asked the resident if she could provide just a little guidance. Resident #123 encouraged the surveyor to do so, and the CNA was asked to separate the labia to ensure cleanliness. The CNAs finished donning the resident's brief and clothing. The Foley catheter strap was loose at the beginning of the observation, and was now completely apart. During an interview outside of the room, the CNAs were able to verbalize the rationale for cleaning thoroughly and use of the catheter strap. Staff G stated she would go fix the catheter strap. Review of the record revealed Resident #123 was admitted to the facility on [DATE], with the most current readmission on 01/30/20. Review of the current Significant Change Minimum Data Set (MDS) assessment dated [DATE], documented Resident #123 had a Brief Interview for Mental Status (BIMS) score of 11, on a scale of 0 to 15, indicating some cognitive impairment. This MDS also documented the use of the Foley catheter for a [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. An additional order documented to keep the catheter below the level of the bladder. laboratory results dated [DATE] documented Resident #123 had a UTI. Review of the care plan dated 01/31/10 documented Resident #123 required a catheter for urination which places her at risk for UTIs. The goal was to be free from signs and symptoms of UTI, which was not met as of 02/23/20. Interventions included the use of the leg strap and provision of catheter care. Review of the document Catheter Care Policy reviewed 07/17/19 documented the policy is to provide catheter care in an effort to reduce bladder and kidney infections. Care for females included to gently separate the labia to expose the urinary meatus, and to clean the catheter with a new moistened cloth. 2. During an interview on 03/10/20 at 3:51 PM, Resident #10 stated it [MEDICAL CONDITION] she urinates. The resident stated she had not yet told anyone, as it just started, and was asked to put on her call bell to inform the staff. A random CNA answered the call light, was told about the new complaint by Resident #10, and the CNA stated she would let the nurse know. Review of the record revealed Resident #10 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented Resident #10 had a BIMS score of 15, indicating the resident was cognitively intact. Review of the current care plan dated 09/04/18 at risk for increased incontinence/UTI, with updates as recent as 03/04/20, with a goal to remain free from signs and symptoms of a UTI, included the interventions to monitor for dysuria and report any abnormalities to the Nurse Practitioner (NP) or physician. During an interview on 03/13/20 at 12:50 PM, the Infection Control Coordinator explained Resident #10 was seen by the NP today related to the resident's complaint of burning, and explained the current antibiotic was discontinued in order to get another urinalysis next week. When asked if the NP or physician was notified of the dysuria earlier in the week, the Infection Control Coordinator stated she was unsure. During an 03/13/20 at 1:07 PM, Staff H, a Licensed Practical Nurse (LPN) confirmed she was told of the resident's complaint of dysuria Tuesday afternoon (03/10/20). When asked if she reported it to the physician at that time, the LPN stated she did not as it was late in the afternoon, and further stated that she informed the NP today. The LPN stated she may have passed on the information to the next shift via email. Review of her email information for the next shift on 02/10/20 lacked any report regarding Resident #10 . The LPN explained Resident #10 was already on an antibiotic but agreed she should have informed the physician of the resident's complaint.

Based on record review and interview, the facility failed to ensure the accuracy of the MDS (minimum data set) for 2 of 29 sampled residents reviewed related to antianxiety usage (Resident #46, #134). The findings included: 1. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) assessment reference date 12/24/19 revealed that under Section N for medications, sub-section B was coded incorrectly for antianxiety. The MDS was coded 0 in subsection B. Review of the Medication Administration Record, [REDACTED]. 2. Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) assessment reference date 02/17/20 revealed that under Section N for medications, sub-section B was coded incorrectly for antianxiety. The MDS was coded 0 in subsection B. Review of the Medication Administration Record, [REDACTED]. On 03/13/20 beginning at 2:11 PM, a side by side review of Resident #46 and Resident #134's records, and interview was held with the Director of Nursing. She acknowledged the findings.

Based on observation, interview, and record review, the facility failed to ensure adaptive equipment was available for 1 of 3 sampled residents reviewed with nutritional concerns (Resident #113). The findings included: An observation of Resident #113 was made on 03/11/20 at 5:25 PM through 5:48 PM in the main dining room. Resident #113 was eating slowly but independently, using regular utensils and drinking cups. The resident was having some difficulty using the utensils and drinking the fluids, having to grasp the items multiple times. A second observation was made on 03/12/20 at 12:31 PM. Resident #113 was again in the main dining room, but had double handled cups for drinking the fluids. The resident was using these cups effectively. The menu ticket documented the use of these cups. Review of the record revealed Resident #113 was admitted to the facility on [DATE], with the most current readmission on 04/25/18. Review of the Minimum Data Set (MDS) assessment for a significant change dated 02/02/20, documented Resident #113 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired. Further review of the record revealed an order dated 02/14/20 for the use of the 2 handled cups, with the current care plan with the same intervention. During an interview on 03/12/20 at 1:15 PM, the consultant Registered Dietician (RD) was made aware of observations of previous evening without the adaptive equipment, and agreed with the concern.

Based on record review and interview, the facility failed to document attending physician involvement in the care planning process for 5 of 5 sampled residents reviewed (Residents #10, #92, #112, #113, and #151). This was identified as a system documentation issue with the potential to affect all residents. The census at the time of entrance was 177. The findings included: 1. Review of the record revealed Resident #10 was admitted to the facility on [DATE]. Review of the most current documented Interdisciplinary (IDT) Care Plan Review, dated 12/05/19, lacked any documented involvement of the physician. 2. Review of the record revealed Resident #92 was admitted to the facility on [DATE]. The most recent Minimum Data Set (MDS) quarterly assessment was completed on 01/25/20. Review of the IDT MDS (minimum data set) Care Plan Review, dated 01/30/20, lacked any documented physician involvement. 3. Review of the record revealed Resident #112 was admitted to the facility on [DATE] with the most current quarterly MDS assessment completed on 02/02/20. Review of the IDT MDS Care Plan Review dated 02/07/20 lacked any documented physician involvement. During an interview on 03/12/20 at 11:13 AM, Staff D, an MDS Coordinator was asked about physician involvement in the care planning process. The nurse identified the physician's quarterly note dated 02/19/20, twelve days after the care plan review, which lacked any care planning involvement with the IDT. During the continued interview on 03/12/20 at 11:26 AM, Staff D stated when issues arise at the quarterly care plan meetings, the physician will be notified and involved and there should be a follow up note. The MDS coordinator was asked how the physician's involvement in the IDT quarterly care planning process is completed and documented, even when there are no issues or changes, and the MDS coordinator had no response. 4. Review of the record revealed Resident #113 was admitted to the facility on [DATE] with most current MDS assessment for a significant change completed on 02/02/20 for a decline in several Activities of Daily Living (ADLs). Review of the IDT MDS Care Plan Review dated 02/06/20 lacked documented physician involvement. 5. Review of the record revealed Resident #151 was admitted to the facility on [DATE] with the most current quarterly MDS assessment completed on 02/24/20. Review of the IDT MDS Care Plan Review dated 02/27/20 lacked any documented physician involvement. During an interview on 03/13/20 at approximately 3:00 PM, the Director of Nursing (DON) agreed with the lack of documented physician involvement in the care planning process. The DON stated they would continue to utilize the IDT MDS Care Plan Review forms with the addition of the physician.

Based on observation, staff interview and administrative record review, the facility failed to ensure that prepared medications were secure at all times and not out of the nurses' visual contact. The findings included: An observation of the medication administration for Resident # 57 with Staff A, Licensed Practical Nurse, was conducted on 01/30/19 beginning at 1:50 PM. The nurse prepared [MEDICATION NAME] 500 mg one tab and [MEDICATION NAME] 25 mg one tab. The nurse crushed all tablets and placed in a medicine cup. She later mixed the crushed medications with 10 cc of water and left the prepared medications on the overbed table at the resident's bedside, while she went to the other side of the room, into the bathroom to wash her hands. The medications were not in the nurse's direct visual field. An interview was conducted with Staff A following the observation at 2:32 PM. The nurse confirmed she left the medication on the table, out of her direct supervision, while she went into the bathroom to wash her hands.