Every finding on record at Ormond Rehabilitation and Nursing Center

Based on interview and record review, the facility failed to ensure a refund was issued to the resident or resident representative within 30 days from the resident's date of discharge from the facility for 1 resident sampled for refunds, Resident #2.The findings include: Review of Resident #2's records revealed the resident was admitted to the facility on [DATE] and discharged from the facility on [DATE]. On [DATE] at 9:45 am, a phone interview was conducted with Resident #2's brother who stated he had not received a refund after Resident #2 expired on [DATE]. He explained that he had called the facility several times but never got a return call. During an interview on [DATE] at 1:22 pm, the Business Office Manager (BOM) was asked to explain the refund process following a discharge. She stated that refunds are issued within 30 days of discharge. When asked how she determines refund amounts, she stated she has a packet that she uses for everyone. She fills out the needed information to determine the amount to be refunded, then she sends this to the regional office for review. The regional office will complete the request and issue a check for the refund amount, and it is sent to the resident/family. When asked if there were any pending refunds, she stated there were no current refunds pending, the last two had their checks issued and are now complete.When the BOM was asked about the refund for Resident #2 who expired on [DATE]. She stated she was working on it. She stated that she sent her paperwork to the regional office which showed an amount of over $1,100.00 due the brother. The regional office reviewed the request, and it was determined that the resident responsibility was greater than was being paid, after reconciling the money in the account there would have been around $6.00 for a refund. (Photographic evidence obtained)When asked if she had been in contact with the brother of Resident #2 who paid the resident's responsibility every month, she did not answer. When asked if it was their policy to speak with family, she stated it was. When asked if she had any written communication sent to the brother, she could not produce any emails or letters. She also stated she had not spoken to him on the phone.Review of the facility's policy and procedure titled, Resident Refund Policy dated February 2011 read, Any funds on deposit with the Facility shall be refunded and the resident trust savings account must be closed and refunded when a resident leaves the Facility or expires. This must be done within 30 days of the discharge date (or sooner, according to State requirements). This process is to be handled by the Business Office Manager ( BOM).

Based on interviews, record review, and facility policy review, the facility failed to ensure a peripherally intravenous (IV) used for the administration of intravenous fluids was removed in accordance with professional standards following the discontinuation of the IV for one (Resident #1) of three residents reviewed for intravenous care. Resident #1 was discharged home with the peripheral IV remaining in her arm.The finding include:On 4/2/26 at 9:30 AM, a phone interview was conducted with Resident #1's daughter. When asked about her mother's discharge from the facility, she stated, It was concerning that the facility would send her mother home with an IV, and thankfully she was ok from it.Review of Resident #1's medical record revealed an admission date of 1/23/26, and discharge date of 2/13/26. The resident's medical diagnoses included essential hypertension, unspecified atrial fibrillation, and supraventricular tachycardia, unspecified.Review of the physician's order dated 1/31/26 revealed, Ok for peripheral IV placement for fluids. A second physician's order revealed, Sodium Chloride Intravenous Solution 0.9 %, Use 1 liter intravenously one time only for low blood pressure for 1 Day 0.9% NS @ 75/hr. x 1 liter with end date of 2/1/26. Review of Resident #1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January and February 2026 revealed no orders for IV care or flush.Review of the nursing assessment for Resident #1 dated 2/12/26, noted no IV's, no skin conditions, or areas of concern. A review of the resident's care plan revealed no mention of IV care.Review of a nursing note dated 2/16/26, indicated the resident's daughter called and said the IV was not taken out.During an interview with Registered Nurse (RN) A on 4/2/26 at 10:00 AM, she was asked about current residents with peripherally inserted central catheter (PICC line)/IV therapy. Specifically, how she would care for it and then document the care she provided. She stated, We have standing orders for dressing changes, flushes. They are documented on the MAR and TAR. When asked about documenting observations of IV site on her skin assessment, she stated she did not, and that she would check for skin breakdown or redness, not IV site condition.During an interview with the Director of Nursing (DON) on 4/2/26 at 12:25 PM, she was asked about IV care by the facility. She stated the facility has an outside company that would start any IV that is ordered. The nursing staff (RNs) would be responsible for the ongoing care of the IV as well as documentation. She stated all care of the IV should be documented in the progress notes. When the IV is discontinued, this would be documented as well in the progress notes. When asked about skin checks, she stated if the IV was present it should be documented there as well.On 4/2/26 at 1:09 PM, a phone interview was conducted with RN B, who completed the IV therapy for Resident #1. When asked if she had discontinued the resident's IV after therapy was completed, she stated, I honestly don't remember. When asked how she would maintain an IV, she stated she would ask the practitioner for orders. She further stated they should have flush orders. When asked if she documented the discontinuation of an IV, she stated she would if I remember to.A review of the facility's policy titled Intravenous (IV) Therapy (Peripheral), dated 11/2025, indicated the following: Purpose: To provide a manner for the safe initiation, maintenance, and discontinuation of peripheral IV therapy in residents. section 8. Discontinuation of IV: Document removal. (Photographic evidence obtained)

Based on the kitchen food service observations, staff interviews, and a review of facility records and policies and procedures, the facility failed to maintain dietary equipment in safe and sanitary condition to prevent the outbreak of foodborne illness, with the potential to affect any resident who consumed ice from the facility's kitchen, by failing to maintain and clean the ice machine to prevent contamination/biological growth. Food safety and sanitation are important in health care settings serving nursing home residents. Kitchen equipment shall be maintained and kept free of waterborne microorganisms to avoid a potential source of pathogen exposure.The findings include: During a follow up visit to the kitchen on 08/26/2025 at 11:20 AM, the ice machine located outside the kitchen's main door's ice diverter was covered with a slimy, pink substance. The 2025 ice machine cleaning log hanging on the side of the ice machine documented cleaning on 08/24/2025. (Photographic evidence obtained) During this follow up visit, the Regional Food Service Director verified with his personal cell phone a document showing that the ice machine was cleaned by Maintenance on 07/31/2025. He stated the ice machine would be shut down, all ice removed and cleaned today. (Photographic evidence obtained). On 08/27/2025 at 8:29 AM, Dietary Aide A was asked who was responsible for cleaning the ice machine and how often. She replied, At one time we were told it was Maintenance, then they said it was Dietary. We were told last that it was Maintenance's responsibility. Dietary is currently cleaning the outside, and inside edges around the open area of the door one time per week. On 08/27/2025 at 8:42 AM, [NAME] B was asked who was responsible for cleaning the ice machine and how often. She replied, As far as I know it's Maintenance; I don't know their cleaning schedule. Dietary does not clean it at all. On 08/27/2025 at 9:03 AM, the Certified Dietary Manager was asked who was responsible for cleaning the ice machine and how often. She replied, The kitchen staff. It's an ongoing issue with Dietary and Maintenance. We wipe down the outside and run the scoop through the dish machine every week. On 08/27/2025 at 9:49 AM, the Maintenance Director was asked who was responsible for cleaning the ice machine and how often. He replied, Dietary and Maintenance. Maintenance cleans the ice machine quarterly. The top and bottom of the ice machine including the fan, condenser, the tray and diverter area is cleaned. A review of the facility's Work History Report, Direct Supply TELS (electronic maintenance program) indicated:Task Description: Ice machines/ice bins: Verify ice machine and ice cart scoops and scoop bins are cleaned and sanitized; marked done on-time by the Maintenance Director on 7/21/2025. A review of the facility's policy and procedure titled Ice Machines and Ice Storage Chest (revised 01/2012), revealed:Policy Statement: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice . 3. Our facility has established procedures for cleaning and disinfecting ice machines and storage chests which adhere to the manufacturer's instructions. The infection Preventionist (or designee) maintains a copy of these procedures. A review of the facility's policy and procedure titled Ice Machine and Ice Storage Chests (revised 8/27/2025), revealed:Policy: Ice machine and ice storage chest/containers must be maintained in a safe and sanitary condition . 3. The ice machine will be cleaned monthly per manufacturers' recommendation and as needed by Maintenance. 4. The Dietitian will check the ice machine for cleanliness monthly during facility visits and will report need for additional cleaning to the Administrator. (Copies obtained)

Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure treatment and care were provided in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #28) of 27 residents in the survey sample whose care plans were reviewed. Resident #28, with a Brief Interview for Mental Status (BIMS) score indicating intact cognition, stated he was not receiving his medications as ordered, and a review of his medical record for August 2025 revealed that on numerous dates, five medications were not signed off by nursing as having been administered. Failure to administer medications as ordered by the physician has the potential to cause a negative outcome to the resident's physical, mental, or psychosocial health and well-being. The findings include: On 08/24/2025 at 1:33 PM, Resident #28 stated he believed some of his medications were missed. He stated they were sometimes late or not provided at all. Resident #28 could not identify a particular medication that was late or missed. A review of the resident's active physician's orders revealed:Ferrous Sulfate oral tablet 325 (65 Fe (iron) mg, give 1 tablet by mouth in the morning for anemia (08/07/2025)Plavix oral tablet 75 mg (Clopidogrel Bisulfate), give 1 tablet by mouth at bedtime for antiplatelet (06/13/2025)Vitamin C oral tablet (Ascorbic Acid), give 500 mg by mouth in the morning for iron absorption (08/07/2025)Risperidone oral tablet 2 mg, give 1 tablet by mouth every morning and at bedtime for schizophrenia (06/13/2025)Amlactin Daily External Lotion 12% (Lactic Acid (Ammonium Lactate), apply to bilateral (both) feet topically every morning and at bedtime for dry skin. Wash feet with soap and water before applying lotion (07/20/2025) A review of Resident #28's August 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed missing documentation used to verify that the following medications were administered:Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia was missing signatures on 8/10/2025 and 8/13/2025 verifying that the medication was administered.Plavix oral tablet 75 mg for antiplatelet was missing a signature on 8/9/2025 verifying that the medication was administered.Vitamin C oral tablet (Ascorbic Acid) for iron absorption was missing signatures on 8/10/2025 and 8/13/2025 verifying that the medication was administered.Risperidone Oral Tablet 2 mg for schizophrenia was missing a signature on 8/9/2025 verifying that the medication was administered.Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate) was missing signatures on 8/9/2025 and 8/12/2025 verifying that the medication was administered. (Copy obtained) Further review of the medical record revealed that Resident #28 was admitted to the facility on [DATE]. Primary diagnoses included, but were not limited to, Parkinson's disease without dyskinesia, anemia, dementia in other diseases classified elsewhere with other behavioral disturbance; schizoaffective disorder - bipolar type, persistent mood disorder; dementia with psychotic disturbance. A review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed that the resident was receiving antipsychotic and antiplatelet medications. He had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. A review of the resident's Care Plan, dated 07/01/2025, revealed impaired cognitive function/or impaired thought processes related to dementia; at risk for adverse reaction related to Doxycycline, Seroquel allergies; use of psychotropic medications related to schizophrenia; antiplatelet therapy related to history of cerebral infarction; Parkinson's disease, anemia, dementia, and risk for alteration in skin integrity related to Parkinson's disease, wasting syndrome and malnutrition. Interventions included administration of medications as ordered by the physician. Monitor/document for side effects and effectiveness; monitor weight/weight changes; administer medications as ordered by the physician; monitor for side effects and effectiveness every shift; provide and serve supplements as ordered: see current orders; and keep skin clean and dry, use lotion on dry skin. (Copies obtained) On 08/27/2025 at 10:20 AM, Certified Nursing Assistant (CNA) G was asked if the resident had complained about not receiving his medications at all or receiving his medications late. CNA G replied, no. On 08/27/2025 at 10:29 AM, Licensed Practical Nurse (LPN) H was asked if the resident complained about not receiving his medications at all or receiving his medications late. LPN H replied, No, I give it to him on time. LPN H was asked about the following medications that were missing the documentation to verify that they were administered: Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia missing signatures on 8/10/2025 and 8/13/2025. She replied, I'm not sure what happened. It was 5:00 AM medication in the morning. I was not at the facility. Plavix oral tablet 75 mg for antiplatelet, missing a signature on 8/9/2025. She replied, That's night shift. Vitamin C oral tablet (Ascorbic Acid) for iron absorption, missing signatures on 8/10/2025 and 8/13/2025. She replied, That's an AM medication. I'm not sure. Risperidone oral tablet 2 mg for schizophrenia, missing a signature on 8/9/2025. She replied, Night shift. Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate), missing signatures on 8/9/2025 and 8/12/2025 to verify that the medication was administered. She replied, Night shift. On 08/27/2025 at 11:52 AM, the Assistant Director of Nursing (ADON) was asked to verify that the following medications, missing signatures on the MAR to verify administration, were provided: Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia, missing signatures on 8/10/2025 and 8/13/2025; Plavix oral tablet 75 mg for antiplatelet, missing a signature on 8/9/2025; Vitamin C oral tablet (Ascorbic Acid) for iron absorption, missing signatures on 8/10/2025 and 8/13/2025; Risperidone oral tablet 2 mg for schizophrenia, missing a signature on 8/9/2025; and Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate), missing signatures on 8/9/2025 and 8/12/2025. She confirmed that these medications were not documented as having been administered on the dates noted above. A review of the facility's policy and procedure titled Administration of Drugs (dated 04/2022), revealed:Policy: Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. Policy Interpretation and Implementation . 2. Drugs must be administered in accordance with the written orders of the attending physician. 3. All current drugs and dosage schedules must be recorded on the resident's Electronic Medication Administration Record (eMAR). 4. Topical drugs used in treatments should be recorded on the resident's treatment record . 9. The nurse administering the drug must record such information on the resident's eMAR before administering the next resident's drug. 10. The nurse administering the drugs must electronically sign the resident's eMAR . 12. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse should give the appropriate chart code inside the eMAR that states the reason for not administering that particular drug. 13. The nurse should enter an explanatory note in the progress notes for the eMAR when drugs are withheld, refused, or given other than at scheduled times. The physician should be notified of drugs that are withheld and/or repeated refusal of drugs. (Copy obtained)

Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure residents' medical records were complete and accurately documented, in accordance with accepted professional standards and practices, for one (Resident #28) of a total survey sample of 27 residents whose records were reviewed. Resident #28, with a Brief Interview for Mental Status (BIMS) score indicating intact cognition, stated he was not receiving his medications as ordered, and a review of his medical record for August 2025 revealed that on numerous dates, five medications were not signed off by nursing as having been administered. The resident's record must reflect the care and services provided to the resident.The findings include: On 08/24/2025 at 1:33 PM, Resident #28 stated he believed some of his medications were missed. He stated they were sometimes late or not provided at all. Resident #28 could not identify a particular medication that was late or missed. A review of the resident's active physician's orders revealed:Ferrous Sulfate oral tablet 325 (65 Fe (iron) mg, give 1 tablet by mouth in the morning for anemia (08/07/2025)Plavix oral tablet 75 mg (Clopidogrel Bisulfate), give 1 tablet by mouth at bedtime for antiplatelet (06/13/2025)Vitamin C oral tablet (Ascorbic Acid), give 500 mg by mouth in the morning for iron absorption (08/07/2025)Risperidone oral tablet 2 mg, give 1 tablet by mouth every morning and at bedtime for schizophrenia (06/13/2025)Amlactin Daily External Lotion 12% (Lactic Acid (Ammonium Lactate), apply to bilateral (both) feet topically every morning and at bedtime for dry skin. Wash feet with soap and water before applying lotion (07/20/2025) A review of Resident #28's August 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed missing documentation used to verify that the following medications were administered:Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia was missing signatures on 8/10/2025 and 8/13/2025 verifying that the medication was administered.Plavix oral tablet 75 mg for antiplatelet was missing a signature on 8/9/2025 verifying that the medication was administered.Vitamin C oral tablet (Ascorbic Acid) for iron absorption was missing signatures on 8/10/2025 and 8/13/2025 verifying that the medication was administered.Risperidone Oral Tablet 2 mg for schizophrenia was missing a signature on 8/9/2025 verifying that the medication was administered.Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate) was missing signatures on 8/9/2025 and 8/12/2025 verifying that the medication was administered. (Copy obtained) A review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed that the resident was receiving antipsychotic and antiplatelet medications. He had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. On 08/27/2025 at 10:29 AM, Licensed Practical Nurse (LPN) H was asked if the resident complained about not receiving his medications at all or receiving his medications late. LPN H replied, No, I give it to him on time. LPN H was asked about the following medications that were missing the documentation to verify that they were administered: Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia missing signatures on 8/10/2025 and 8/13/2025. She replied, I'm not sure what happened. It was 5:00 AM medication in the morning. I was not at the facility. Plavix oral tablet 75 mg for antiplatelet, missing a signature on 8/9/2025. She replied, That's night shift. Vitamin C oral tablet (Ascorbic Acid) for iron absorption, missing signatures on 8/10/2025 and 8/13/2025. She replied, That's an AM medication. I'm not sure. Risperidone oral tablet 2 mg for schizophrenia, missing a signature on 8/9/2025. She replied, Night shift. Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate), missing signatures on 8/9/2025 and 8/12/2025 to verify that the medication was administered. She replied, Night shift. On 08/27/2025 at 11:52 AM, the Assistant Director of Nursing (ADON) was asked to verify that the following medications, missing signatures on the MAR to verify administration, were provided: Ferrous Sulfate oral tablet 325 (65 Fe) mg for anemia, missing signatures on 8/10/2025 and 8/13/2025; Plavix oral tablet 75 mg for antiplatelet, missing a signature on 8/9/2025; Vitamin C oral tablet (Ascorbic Acid) for iron absorption, missing signatures on 8/10/2025 and 8/13/2025; Risperidone oral tablet 2 mg for schizophrenia, missing a signature on 8/9/2025; and Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate), missing signatures on 8/9/2025 and 8/12/2025. She confirmed that these medications were not documented as having been administered on the dates noted above. A review of the facility's policy and procedure titled Administration of Drugs (dated 04/2022), revealed:3. All current drugs and dosage schedules must be recorded on the resident's Electronic Medication Administration Record (eMAR). 4. Topical drugs used in treatments should be recorded on the resident's treatment record . 9. The nurse administering the drug must record such information on the resident's eMAR before administering the next resident's drug. 10. The nurse administering the drugs must electronically sign the resident's eMAR . 12. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse should give the appropriate chart code inside the eMAR that states the reason for not administering that particular drug. 13. The nurse should enter an explanatory note in the progress notes for the eMAR when drugs are withheld, refused, or given other than at scheduled times. The physician should be notified of drugs that are withheld and/or repeated refusal of drugs. (Copy obtained)

Based on observations, record review, interviews, and a review of the facility's policy and procedure for Falls and other facility documentation, the facility failed to implement a comprehensive person-centered care plan for one (Resident #10) of 27 residents whose care plans were reviewed for falls. Fall mats were ordered for Resident #10 but were not in place, which could result in fall injuries. The findings include: On 8/24/25 at 11:30 a.m., Resident #10 was observed lying in a high bed with an air mattress and 1/4 side rails. The resident was asked if he had fallen and he replied yes. He reported several falls and having gone to the hospital after one fall. He could not remember the date, only that the fall was recent. On 8/25/25 at 9:30 a.m., the facility's matrix was reviewed. The matrix revealed that the resident had fallen with a major injury. On 8/25/25 at 2:30 p.m., Resident #10 was observed lying in bed. No fall mats were at bedside. His room and bathroom were checked, but there were no fall mats in his room. He reported that he did not need the mats when he was asked about them. The bed was in high position. A record review revealed that the resident had episodes of confusion. On 8/26/25 at 9:00 a.m., Resident #10 was observed lying in bed watching TV and eating his breakfast. Fall mats were not observed at bedside. His bed was in high position. On 8/27/25 at 9:30 a.m., the resident was observed in bed with his eyes closed. The bed was in high position, and no fall mats were observed. On 8/27/25 at 11:00 a.m., Resident #10 was observed in bed watching TV. The bed was in high position, and no fall mats were observed. A review of Resident #10's medical record revealed that he had a re-entry on 7/18/25 with an initial admission on [DATE]. His diagnoses included osteomyelitis of the ankle and foot, chronic obstructive pulmonary disease (COPD), mild protein calorie malnutrition, and anemia. The five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a prior fall and that the resident needed substantial, maximum assistance with toileting, partial, moderate assistance with bed mobility, and for transfers, he required substantial maximal assistance. Resident #10 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 possible points, indicating moderate cognitive impairment. A review of the Care Plan dated 7/10/25 revealed that the resident was at risk for falls and had a history of falls. Interventions included that the bed be in low position (initiated 7/23/25) and fall mats (two) beside the bed (initiated 7/11/25). (Copy obtained) The medical record documented a fall on 7/11/25 with a small abrasion under the left knee where the resident slid out of his wheelchair, and on 7/16/25, he was found lying prone on the side of the bed. Resident #10 hit his head and suffered skin tears to his right elbow and was transferred to the hospital. An interview was conducted with Registered Nurse (RN) E on 8/27/25 at 11:00 a.m. who said she had worked in the facility for two years. She reported that the resident had a fall and was sent to the hospital last month. He returned to the facility. When she was asked what interventions were used for fall prevention, she reviewed the resident's care plan and reported that he had a low bed and fall mats at bedside. RN E was accompanied to Resident #10's room. After entering the room, RN E confirmed that the resident had no fall mats, and his bed was not low. She started lowering the bed and told the resident she was going to get him some fall mats. An interview was conducted on 8/27/25 at 11:32 a.m. with the Assistant Director of Nursing (ADON). She reported that the resident had a fall on 7/11/25 where he slid out of his wheelchair trying to reach the call light. The Unit Manager arrived and reported that the resident suffered a small abrasion under his left knee and a Dycem cushion to the wheelchair was implemented on 7/16/25. The Unit Manager/Licensed Practical Nurse (LPN) also reported that two fall mats at bedside were added to the care plan on 7/11/25. The ADON reported that on 7/16/25 the resident was transported to the hospital due to oa change in condition. He had fallen and stated his head hurt. He had slid out of bed. The fall risk evaluation revealed a high risk for falls (12) on 7/18/25. The Unit Manager confirmed that there were no fall mats at bedside. She went to get some. She stated the resident had fall mats, but his room was deep cleaned, and the mats were removed. The Unit Manager confirmed that there had been no fall mats in room since 8/24/25. A review of the facility's policy and procedure titled Falls (dated April 2022) revealed: It is the policy of this center to determine fall risk, provide interventions to prevent/reduce falls, and update interventions as needed to prevent and/or reduce falls and injury. 1.Fall risk screen within 24 hours of admission, quarterly and PRN (as needed). 2.Care plan in place for fall reduction. 3.Update the plan of care. (Copy obtained) A review of the facility's Performance Improvement Plans (PIPs) revealed that Falls was one of seven PIPs in in place for this facility. It had a start date of 8/25/25, one day after the survey began on 8/24/25. The Falls PIP was implemented due to notification of family, no timely interventions and documentation. Resident #10 did have a Fall care plan documented but did not have his fall mats or low bed implemented. The concern was not following the care plan.

Based on resident record review, interviews, and review of the facility's transfer/discharge policy, the facility failed to ensure required documentation was completed prior to transfer/discharge for 1 (Resident #1) of 3 residents reviewed for transfer/discharge, from a total sample of 7 residents. The findings include:Clinical record review indicated that Resident #1 was admitted to the facility on [DATE], re- entry on 9/7/22 and discharged on 7/31/25. His diagnoses included aftercare following joint replacement, type 2 diabetes mellitus, dementia without behavior, metabolic encephalopathy, anxiety disorder, need assistance with personal care, heart failure and neurogenic arthritis.Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/19/25, indicated that the resident had a Brief Interview for Mental status score of 11 out of 15 possible points, indicating moderate cognitive impairment. Review of the physician's orders dated 7/31/25 for Resident #1 revealed he was discharged to Blue Palms Health and Rehab of Daytona. Review of the care plan with a close date of 8/5/25 revealed that resident had impaired cognitive function/dementia or impaired thought process. Intervention included to communicate with the resident/family/caregiver regarding resident capabilities and needs. Discuss concerns about confusion disease process, nursing home placement with resident/family/caregivers. The care plan also indicated that the resident wished to remain in the facility for long term care, intervention included, to discuss feeling and concerns with impending discharge and monitor for and address episodes of anxiety, fear or distress. Review of the Discharge summary dated [DATE] noted the reason for discharge as transfer to skilled nursing facility. The Discharge MDS with ARD of 7/31/25 revealed that the type of discharge was planned. During interview with the administrator on 8/18/25 at 1:45 pm, she stated that Resident #1 was discharged to another skilled nursing facility with a memory care unit after an elopement incident on 6/28/25. When asked about the discharge planning and notification she stated that the discharge was an emergency due to safety concerns. She stated she consulted the ombudsman's office and was notified that they could proceed with the discharge. When asked if the resident responsible party was notified, she stated that the resident did not have a responsible party. She stated that the responsible party had passed away a year ago. The administrator was asked for information of the ombudsman's notification, which she mentioned that the discussion was verbal, and she did not have any paperwork. She was asked to notify the ombudsman that she spoke with to contact surveyor. During a follow up interview with the Administrator was conducted on 8/19/25 at 12:00 pm, she confirmed that the Agency of Health Care Administration (AHCA) transfer - discharge forms were not completed. She added that she could not get ahold of the ombudsman. In an interview with the Director of Social Services (SSD) on 8/19/25 at 12:56 pm, she stated that she had been working in the facility for 4 months. She stated that she was involved with the discharge planning. She explained that discharge planning starts on admission, and the plan may change depending on the resident's progress. She stated that she is notified of the residents plans during the Patient-Driven Payment Model (PDPM) meeting, quarterly assessment and care planning. She was involved with Resident #1 discharge and that the discharge notification came from the administrator. When asked if Resident #1 was provided prior notification for discharge, she stated that the Administrator told her that she had communicated with the ombudsman about it. Therefore, she proceeded to secure placement and resident was moved out. During a phone interview with the Ombudsman on 8/19/25 at 2:30 pm, she confirmed that their office does not make any discharge recommendation, and they were not consulted of any discharge from the facility. She also stated that the facility had not sent any Transfer/Discharge notices since January 2025. Review of the facility's Transfer/Discharge Policy Dated April 2022 revealed that the Center provide a resident/resident representative with thirty days written notice of impending discharge.Policy Interpretation and Implementation: Except as specified below, a resident/his or her representative will be given a thirty (30)-day advance notice of an impending transferor discharge from the Center: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the Center.b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the Center;c. The safety of individuals in the Center is endangered; d. The health of individuals in the Center would otherwise be endangered;e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the Center.f. An immediate transfer or discharge is required by the resident's urgent medical needs. g. The resident is transferred for other than medical reasons.h. The resident has not resided in the Center for thirty (30) days; and/[NAME]. The Center ceases to operate.The resident/representative will be provided with the following information:a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge.c. The location to which the resident is being transferred or discharged .d. The name, address, and telephone number of the state long-term care Ombudsman. e. The name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmental disabled individuals (as applies); and f. The name address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 2 observations conducted in the central kitchen. The findings included: Review of the facility's policy, titled, Sanitation, dated November 2017, revealed the following: All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. All utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair and shall be free from breaks, corrosion, open seams, cracks, and chipped areas. Kitchen waste not disposed of by mechanical means shall be kept in clean, leak-proof, nonabsorbent, tightly closed containers and disposed of daily. 1. In a tour of the central kitchen on 05/20/24 at 8:55 AM, accompanied by the facility's Food Service Director (FSD), the following were noted: a. The floor around the kitchen and behind the stove area was noted dirty with pieces of scattered debris. b. Opened cardboard boxes were noted on the floor near the three-compartment sinks. c. Two (2) round skillets were coated with a grease-like film with a black/brown coloring. d. A large round dumpster located near the food production area, with exposed garbage and no lid. e. Used dirty paper napkins sitting on top of the plate warmers. f. Three (3) of the three hood lights were not working under the hood. g. Three (3) of the nine (9) fluorescent lights were missing bulbs and were noted to be broken and chipped. h. Two (2) exposed air vents were noted to have black / brown matter around the rims with no lids. i. A round silver bowl was noted sitting on top of a delivery cart with canned peaches. Closer observation showed a round scoop sitting on top of the canned peaches. j. The Food Service Director was using a Hydrion Chlorine meter (testing the chlorine concentration) to take the reading on a red bucket that was sitting on top of the kitchen counter. The reading showed a range of 0 out of 500 maximum level. In this observation, the Food Service Director stated that this was not the correct Hydraulic meter that was used to test the chlorine levels and proceeded to look for another Hydrion strip meter. In this observation, Staff D, Dietary Aide, said that the cloth in the red bucket had no cleaning solution but only soap and water. She was in the process of replacing the soap water in the red bucket with the appropriate cleaning solution. k. A dirty fryer basket was noted sitting on dirty cardboard behind the kitchen stove area. l. The walk-in refrigerator had a plastic bag of green bean salad that was not dated. m. The walk-in refrigerator had a plastic bag of raw carrots that was not dated or labeled. n. The walk-in refrigerator had three (3) unidentified food items inside a dish bowl that needed to be labeled and dated. o. The walk-in refrigerator had a box of frozen meat patties that were not sealed and opened to the air. p. The walk-in freezer had three large bags of unidentified frozen food items that needed to be labeled or dated. q. The floor around the dry storage area was noted to be dirty with pieces of scattered debris. r. A dirty, used rag was sitting on the kitchen counter, not in a red bucket with cleaning solution. s. Used, dirty brown paper towels were noted underneath the stove area behind a metal bar. 2. A second visit and observation to the main kitchen was conducted on 05/22/24 at 11:30 AM. The following were noted: Using a facility digital thermometer, the Corporate Food Service Manager took the temperature of a cold cottage cheese and ham salad. The ham salad had an internal temperature of 46 degrees Fahrenheit (F) and not the recommended 40 degrees Fahrenheit and below. Using a facility digital thermometer, the Corporate Food Service Manager took the temperature of another cold cottage cheese and ham salad. The ham had an internal temperature of 48.8 degrees Fahrenheit, not the recommended 40 degrees Fahrenheit and below. In this observation, the Corporate Food Service Manager stated that the cold ham and cottage cheese salads were recently taken out of the walk-in refrigerator for the tray line. In an interview conducted on 05/23/24 at 3:30 PM with the facility's Administrator, she was informed of the findings.

Based on observations, interviews, and record review, the facility failed to dispose of refuse in a sanitary manner for two of two observations conducted in the main dumpster area. The findings included: Review of the policy, titled, Garage and Rubbish Disposal, dated April 2022, revealed the following: All garbage and rubbish containing food waste shall be kept in containers. All containers shall be provided with tight-fitting lids or covers, and such containers must be kept covered when stored or not in continuous use. Each container must be thoroughly cleaned at least daily on the inside and outside so as not to contaminate food, equipment, utensils, or food preparation areas. Garbage and rubbish containing food wastes shall be stored to be inaccessible to vermin. Storage areas shall be always kept clean and shall not constitute a nuisance. All garbage and rubbish shall be disposed of daily. Outside dumpsters provided by garbage pick-up services must be kept closed and free of litter around the dumpster area. 1. In an observation conducted on 05/20/24 at 8:50 AM in the main dumpster area, the following were noted: a. A large roll-off dumpster was noted with debris, cardboard boxes, soda boxes, furniture, a mattress, and unidentified garbage. The dumpster had no lid and was only secured on three sides. Photograph Evidence Obtained. b. A large, open patio area located near the backdoor to the kitchen was observed with used utensils, food wraps, and debris. c. Four (4) gray round dumpsters were noted with dirty standing water, unidentified trash, and garbage bags. Closer observation showed insects flying over the dumpsters, and a foul odor came from all four dumpsters. Photographic Evidence Obtained. 2. In an observation conducted on 05/20/24 at 3:10 PM in the main dumpster area, the following were noted: d. A large roll off dumpster noted with debris, cardboard boxes, soda boxes, furniture, mattress, and unidentified garbage. The large roll off dumpster had no lid and was only secured on 3 sides. Photograph Evidence Obtained. e. A large, open patio area located near the backdoor to the kitchen was observed with used utensils, food wraps, and debris. f. Four (4) gray round dumpsters were noted with dirty standing water, unidentified trash, and garbage bags. Closer observation showed insects flying over the dumpsters with a foul noticeable odor coming from all 4 dumpsters. Photographic Evidence Obtained. In an interview conducted on 05/20/24 at 3:20 PM with the facility's Maintenance Director, he said he oversees the daily cleaning of the dumpster area. He further said that he did not see the large, open patio area near the backdoor to the kitchen with all the utensils, food wraps, and debris. In an interview conducted on 05/23/24 at 3:30 PM with the Administrator, she was informed of the findings.

Based on observations, interviews, and record review, the facility failed to provide the correct diet order per the physician's orders for one (1) of 5 sampled residents, Resident #200, reviewed for nutrition. The findings included: Record review documented Resident #200 was admitted on [DATE] with diagnoses of protein-calorie malnutrition, Dysphagia, and type 2 Diabetes. The documented Brief Interview of Mental Status (BIMS) score dated 05/17/24 revealed a score of 11, indicating mild to moderate cognitive impairment. In an observation conducted on 05/20/24 at 12:00 PM, Resident #200 was in his room with the lunch meal. The meal ticket on the lunch tray revealed the following: a mechanically ground diet with mechanically ground roasted red potatoes and mechanically ground lemon chicken. The lunch meal on the plate showed mechanically ground chicken and pieces of red potatoes that were about 2 inches long, not mechanically ground. In this observation, Resident #200 stated that he has a poor appetite and only ate about 15% of his lunch meal. In an observation conducted on 05/21/24 at 11:44 AM, Resident #200 was eating his lunch meal. The meal ticket was noted with a mechanically ground diet, with spaghetti noodles and a mechanically ground broccoli floret. The meal tray was observed with pieces of broccoli florets that were chopped and not grounded, about 1 inch in size. Review of the active order summary report dated 05/15/24 revealed a diet order for consistent carbohydrates, chopped texture regular diet; and on 05/22/24, and order for a diet order for consistent carbohydrates, pureed texture. The care plan dated 05/15/24 showed that Resident #200 has the potential for nutritional problems and to provide diet as ordered. In an interview with the Director of Nursing (DON) on 05/22/24 at 12:48 PM, she stated when an order is written for a diet, it is filled out by the nursing staff on a meal slip and then taken into the central kitchen. It is later added to meal tracker that is printed on the meal tickets for the specific resident. When asked as to why the printed meal tickets observed this week for Resident #200 were different than the diet order in the electronic system, she did not know. In an interview conducted on 05/22/24 at 1:20 PM with the facility's Food Service Director (FSD), he stated there are two types of mechanical diets. One is mechanically chopped, and the other type is mechanically ground. When asked about the mechanical ground diet, he stated that the vegetables will be minced like garlic, with a minced texture. The chef will put the veggies on the cutting board and cut the veggies until they are minced size. The FSD stated the nurses would write the diet order on a slip to give to him, and he would input the diet order into the meal tracker, which is what produces the meal ticket. The meal tracker has two options for mechanically altered diets from which he can choose. In an interview conducted on 05/22/24 at 1:46 PM with the facility's Speech Language Pathologist (SLP), she stated that Resident #200 was admitted to the facility on a mechanical chopped diet consistency. He was eating about 25% of his meals and needed help loading up the utensils with food items to eat. According to the SLP, the resident only ate about 5-6 bites of his food and stated that he was not hungry. When she tried giving him a yogurt, he said that he liked the consistency and texture of the yogurt. When she tried trials of a purred diet, the resident was able to independently feed himself and consume much more of the food on his own. Resident #200 liked the purred texture and asked the SLP to downgrade the diet to a puree texture. When asked about the two types of mechanical diets, the SLP was unaware that two types of options could be placed in the electronic system. In an interview conducted on 05/23/24 at 3:45 PM with the facility's Administrator, she was told of the findings and the importance of providing the correct diet order for Resident #200.

Based on observations, interviews, and record review, the facility failed to maintain a safe, sanitary, and homelike environment for two (one across from room [ROOM NUMBER] and the other across from room [ROOM NUMBER]) of two shower rooms and 5 of 38 resident rooms, affecting Residents #12, #146, #248, #247, and #197. The findings include: On 05/20/24 at 9:45 AM, an observation was made in Resident #12's room of the wall behind the bed with peeling paint, and the light fixture on the wall behind the head of the bed with one of three light bulbs not working. On 05/20/24 at 10:00 AM, an observation was made in Resident #146's room of walls and baseboards with peeling paint, and the light fixture on the wall behind the head of the bed with two of three light bulbs not working. On 05/20/24 at 10:16 AM an observation was made in Resident #248's room of the wall behind the head of the bed with mismatched paint, and the light fixture on wall behind the head of the bed with one of three light bulbs not working. On 05/20/24 at 1:30 PM, an observation was made in Resident #247's room of the light fixture on wall behind the head of the bed with one of three light bulbs not working. On 05/20/24 at 9:56 AM, an observation was made in Resident #197's room of the floor around and behind the resident's bed with debris and disposable food packaging. On 05/21/24 at 10:20 AM, an observation was made in the shower room (central bath) located across from room [ROOM NUMBER]. The shower had loose tiles on the floor below the shower head, and there was black biological growth on the shower floor between the tiles and where the tiles met the wall in the shower. On 05/21/24 at 10:25 AM, an observation was made in the shower room (central bath) located across from room [ROOM NUMBER]. The shower room had an overwhelming odor of urine; there was a hair brush in the sink; a used brief in a plastic bag on the floor next to the sink; and personal belongings and towels in a plastic bag on the shower floor. Black biological growth was observed on the tile on the shower floor, between the floor tiles, and along the wall/floor. The fluorescent light fixture between the shower and the toilet was not working, and the lock to the shower room/central bath did not lock. During an interview with Resident #197 on 05/20/24 at 9:56 AM, she stated she was admitted to the facility a few weeks ago. She said she told staff multiple times about the dirt and debris around the room and behind the bed, but nothing had been done thus far. During an interview with the Director of Housekeeping (DOH) on 05/21/24 at 10:30 AM, he stated he had worked at the facility for five years. He acknowledged that the shower room smelled of urine and had dirty items on the floor and in the sink. He also acknowledged that the flourescent light fixture was not working and that he would contact maintenance to repair the light and look at the door lock. During an interview with the DOH and with the Director of Maintenance (DOM) on 05/23/24 at 9:20 AM while doing an environmental facility tour, the DOM stated he had worked at the facility a little over a year. He stated they were ordering light bulbs that had a lower wattage, so they were not so bright if the resident did not like the lights to be so bright. The DOH and DOM said they were working together on repairing walls and painting as residents were discharged from their rooms. The DOH said they would work with nursing to ensure that when residents got out of bed, they could move the beds away from the wall to clean behind the bed. The DOM said they made room rounds daily to ensure equipment and the environment was maintained. The DOH and DOM stated they were working on getting the shower floors cleaned. A review of the facility's policy titled Environmental Services (dated 08/2022) revealed in part: 1. The facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 2. The facility will provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible. 3. The facility will provide: a. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. d. Adequate and comfortable lighting levels in all areas.

Based on observation, interviews, policy and record review, the facility failed to obtain a physician order for Occupational Therapy (OT) prior to commencing OT for 1 of 1 sampled resident reviewed for rehabilitation (Rehab) services, Resident #146. The findings included: The policy of the facility, titled, Physician's Therapy Orders, dated April 2022 documented, Therapy services must be ordered by a licensed physician / licensed nurse practitioner. All therapy services provided to the resident must be ordered in writing by the resident's physician / nurse practitioner. Record review documented Resident #146 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Type 2 Diabetes, and Hypertension. On the Resident Interview & Staff assessment dated [DATE], it was documented the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. The resident expressed at this time that she thought she should be getting more therapy. On 05/20/24 at 11:17 AM, during the initial pool process, Resident #146 was interviewed. Review of Resident #146's order for therapy revealed an order for skilled PT (physical therapy) intervention 5x week x 4 weeks which was dated 05/17/24. There was no physician order for OT. On 05/22/24 at 1:53 PM, an interview was conducted with Staff E, Occupational Therapist and Director of Therapy. Resident #146's therapy was discussed, and the surveyor asked if Resident #146 was receiving any OT. Staff E stated that the resident started OT on 05/16/24 and has had 4 days of OT so far on 05/16/24, 05/18/24, 05/20/24 and 05/21/24. The surveyor asked where the order was for OT and Staff E reviewed the orders and stated she would have to put in a late entry clarification order because there was no order. On 05/23/24 at 10:00 AM, the physician orders were reviewed for Resident #146. The order for OT was put in on 05/22/24, effective 05/16/24 for OT evaluation and treatment.

Based on observation, interviews, policy and record review, the facility failed to provide showers per resident preference for 1 of 3 residents sampled for shower choices (Resident #146). The findings included: On 05/20/24 at 11:17 AM, Resident #146 was interviewed. She stated she was not given a choice of the number of showers she could receive. She was told that her shower days were Wednesdays and Saturdays on the 3-11 shift. She was not given a preference of whether she wanted a morning or evening shower, or if she wanted to have a shower more than twice a week. She said she would like more showers but was not given that option. A review of Resident #146's medical record revealed that she was admitted to the facility on [DATE] with diagnoses including congestive heart failure, Type 2 diabetes, and hypertension. Her Brief Interview for Mental Status (BIMS) score was 15 out of 15 possible points on the Resident Interview & Staff Assessment, dated 05/16/24. This indicated the resident was cognitively intact. A review of bathing preferences in the task section of the electronic health record (EHR), revealed that the resident was given one shower on 05/18/24. On 05/23/24 at 2:00 PM, during an interview with the Director of Nursing, she was asked if there was any other documentation that would show that the resident had received showers, and she replied that all documentation was electronic and the certified nursing assistants (CNAs) charted showers in the task section of the EHR. A review of the facility's policy titled Activities of Daily Living (ADLS)/Maintain Abilities (dated 8/2022), revealed: Residents have the right to choose their schedules, consistent with their interests, assessments, and care plans. This includes, but is not limited to, choices about the schedules that are important to the resident, such as waking, eating, bathing, and going to bed at night.

Based on interviews and record reviews the facility failed to identify and evaluate residents who smoke for 2 out of 55 residents who were identified for smoking (Residents #7 and #28). The findings included: Review of the facility's policy titled Free of Accident Hazards/Supervision/Devices dated 08/2022 included in part: It is the policy of this facility to ensure it provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes Identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s), and monitoring for effectiveness and modifying interventions when necessary. Review of the facility's policy titled: Smoke Free Facility Policy with no date included in part: The facility shall establish and maintain a smoke-free environment, inclusive of all tobacco products and electronic cigarettes (E-Cigarettes). Procedure: 1. A non-smoking policy shall be enforced for all staff and residents. 4. Upon admission, the resident's smoking history will be taken and the facility smoking policy shall be explained to the resident. If needed, a resident centered care plan is to be put in place by the interdisciplinary team. 1. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Synovitis and Tenosynovitis and Generalized Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #7 dated 03/18/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. Record review for Resident #7 revealed no Nursing Admission/Readmission for the resident. Review of the Admission/Readmission Summary for Resident #7 dated 12/08/23 included: Has recently quit smoking in the past 0-6 months. Review of the Smoking Evaluation for Resident #7 dated 05/22/24 is documented in Section AA, Is resident a smoker - yes. Review of the Care Plan for Resident #7 dated 05/22/24 with a focus on the resident smokes when signed out off of the property. The goal was for the resident to continue to be a safe smoker throughout next review date. The interventions included: Encourage good oral hygiene. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Resident educated on properly storing smoking materials. Smoking evaluation completed as needed. During an interview conducted on 05/22/24 at 1:50 PM with Resident #7 who was asked if he smokes, he said yes, he signs himself out and goes to the facility next door. When asked what he smokes, he said cigarettes. When asked where are the cigarettes and lighter kept, he said they are hidden in his closet. When asked if the closet was locked, he said no. When asked how long he has been smoking at the facility, he said he has been for months. 2. Record review for Resident #28 was admitted to facility on 12/29/23 with diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Major Depressive Disorder, and Tobacco Use. Review of the MDS for Resident #28 dated 04/04/24 revealed in Section C BIMS 15 indicating a cognitive response. Review of the Nursing Admission/Readmission for Resident #28 dated 12/29/23 documented under Section Smoke/Smoking Eval: Is resident a smoker - no. Review of the Smoking Evaluation for Resident #28 dated 5/22/24 is documented in Section AA, Is resident a smoker - yes. Review of the care plan for Resident #28 dated 05/22/24 with a focus on the resident smokes while off of property. The goal was for resident to remain a safe smoker while off of property through the next review date. The interventions included: Complete smoking evaluation as needed. Educate resident regarding smoking risks and hazards and about smoking cessation aids that are available. Encourage good oral hygiene. Resident educated on proper storage of smoking materials. On 05/20/24 at 9:18 AM during the facility entrance conference with the Administrator, when asked if they have any residents who smoke, she stated this is a non-smoking facility. During an interview conducted on 05/22/24 at 1:20 PM with Resident #28 who was asked if he smokes, the resident said yes, but he signs himself out to smoke on the property for the Assisted Living Facility next door. When asked what he smokes, he said cigarettes, it helps calm his nerves. When asked how long he has been smoking at the facility, he said since he has been here it helps calm his nerves. When asked where the cigarettes are kept, he refused to answer. When asked if he had a lighter for the cigarettes, he said I don't want to talk to you, if you have any questions, you can talk to my lawyer. During an interview conducted on 05/22/24 at 1:40 PM with the Administrator, who was asked if they have any residents who smoke, she said yes, 2, they sign themselves out of the facility and go to the Assisted Living Facility's property next door to smoke. She added they are both alert and oriented and all that. The Administrator said we are a smoke free facility, so residents are not allowed to smoke on our property. The Administrator said she sees the residents smoking on the other property but has no idea who holds their cigarettes or lighters. During an interview conducted on 05/22/24 at 1:57 PM with the Director of Nursing (DON) who stated they are a non-smoking facility they have 1 resident who admits to smoking but they have never seen cigarettes or lighter on the resident or in the resident's room. They have another resident they suspect smokes, because the resident sometimes smells like cigarettes, but the resident denies he smokes. The DON said they are a non-smoking facility, and residents have the right to sign themselves out of the facility to smoke off the property. When asked about who keeps the cigarettes and lighters, she said they do not keep the items. When asked if residents were evaluated for safe smoking, she said no, because they are a non-smoking facility. During an interview conducted on 05/22/24 at 2:20 PM with the Administrator who stated the smoking policy in the Admission Packet was incorrect and provided the new smoking policy.

Based on interviews and record reviews, the facility failed to 1) Implement a smoking care plan for two (Residents #7 and #28) of 22 sampled residents, and 2) Implement an Enhanced Barrier Precaution (EBP) care plan for one (Resident #247) of 22 sampled residents. The findings include: 1. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Synovitis and Tenosynovitis and Generalized Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #7 dated 03/18/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. Review of the Smoking Evaluation for Resident #7 dated 05/22/24 documented in Section AA, Is resident a smoker - yes. Review of the Care Plan for Resident #7 dated 05/22/24 with a focus on the resident smokes when signed out off of the property. The goal was for the resident to continue to be a safe smoker throughout next review date. The interventions included: Encourage good oral hygiene. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Resident educated on properly storing smoking materials. Smoking evaluation completed as needed. During an interview conducted on 05/22/24 at 1:50 PM with Resident #7 who was asked if he smokes, he said yes, he signs himself out and goes to the facility next door. When asked what he smokes, he said cigarettes. When asked where are the cigarettes and lighter kept, he said they are hidden in his closet. When asked is the closet was locked, he said no. When asked how long he has been smoking at the facility, he said it was for months. 2. Record review for Resident #28 revealed the resident was admitted to facility on 12/29/23 with diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Major Depressive Disorder, and Tobacco Use. Review of the MDS for Resident #28 dated 04/04/24 revealed in Section C a BIMS score of 15 indicating a cognitive response. Review of the Smoking Evaluation for Resident #28 dated 5/22/24 documented in Section AA, Is resident a smoker - yes. Review of the care plan for Resident #28 dated 05/22/24 with a focus on the resident smokes while off of property. The goal was for resident to remain a safe smoker while off of property through the next review date. The interventions included: Complete smoking evaluation as needed. Educate resident regarding smoking risks and hazards and about smoking cessation aids that are available. Encourage good oral hygiene. Resident educated on proper storage of smoking materials. On 05/20/24 at 9:18 AM during the facility entrance conference with the Administrator, when asked if they have any residents who smoke, she stated this is a non-smoking facility. During an interview conducted on 05/22/24 at 1:20 PM with Resident #28 who was asked if he smokes, the resident said yes, but he signs himself out of the facility to smoke on the property next door. When asked what he smokes, he said cigarettes, it helps calm his nerves. When asked how long he has been smoking, he said since before he came here. When asked where the cigarettes and lighter are kept, he refused to answer and stated, I don't want to talk to you, if you have any more questions, you can talk to my lawyer. During an interview conducted on 05/22/24 at 1:40 PM with the Administrator, who was asked if they have any residents who smoke, she said yes, 2, they sign themselves out of the facility and go to the Assisted Living Facility's property next door to smoke. She added they are both alert and oriented and all that. The Administrator said we are a smoke free facility, so residents are not allowed to smoke on our property. The Administrator said she sees the residents smoking on the other property but has no idea who holds their cigarettes or lighters. During an interview conducted on 05/22/24 at 1:57 PM with the Director of Nursing (DON) who stated they are a non-smoking facility they have 1 resident who admits to smoking but they have never seen cigarettes or lighter on the resident or in the resident's room. They have another resident they suspect smokes, because the resident sometimes smells like cigarettes, but the resident denies he smokes. The DON said they are a non-smoking facility, and residents have the right to sign themselves out of the facility to smoke off the property. When asked about who keeps the cigarettes and lighters, she said they do not keep the items. When asked if residents were evaluated for safe smoking, she said no, because they are a non-smoking facility. During an interview conducted on 05/22/24 at 2:20 PM with the Administrator who stated the smoking policy in the Admission Packet was incorrect and provided the new smoking policy. 3. Record review for Resident #247 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Sepsis and Abscess of Liver. Review of the MDS for Resident #247 dated 05/02/24 revealed in Section C a BIMS score of 12 indicating moderate cognitive impairment. Review of the Care Plan for Resident #247 dated 4/29/24 with a focus on the resident is on ABT (Antibiotic) IV (Intravenous) Medications related to infection via PICC (Peripherally Inserted Central Catheter) line to LUE (Left upper extremity). The goal was for the resident to not have any complications related to IV Therapy through the review date. The intervention included EBP when providing care per facility protocol was created/added to the care plan on 05/20/24. Review of the Care Plan for Resident #247 dated 05/02/24 with a focus on the resident has liver abscess infection w/ drain in place. The goal was for the resident to be free from s/sx of liver complications, including infection, abnormal or unexplained bleeding, malnutrition, anemia, cognitive decline, or mental status changes by review date. The intervention included EBP when providing care per facility protocol created/added to the care plan on 5/20/224. Review of the Care Plan for Resident #247 dated 05/09/24 with a focus on the resident has actual impairment to skin integrity to coccyx. The goal was for the resident to be free from injury through the review date. The interventions included: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Group 2 mattress for wound healing on coccyx. Roho cushion to wheelchair. Ensure cushion in place when resident using wheelchair. There was no intervention for EBP when providing care per facility protocol. Review of the facility's policy titled Care Plan - Comprehensive dated January 2023 included in part: A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychological needs shall be developed for each resident. An Interdisciplinary Team in coordination with the resident, his/her family or representative develops and maintains a Comprehensive Care Plan for each resident. The Comprehensive Care Plan has been designed to: Incorporate identified problem areas, incorporate risk factors associated with identified problems. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident assessment or within twenty-one (21) days after the resident's admission, whichever occurs first. Care plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly.

Based on interviews and record reviews the facility failed to identify a pressure ulcer on admission for 1 of 1 residents sampled for pressure ulcers (Resident #247). The findings included: Review of the facility's policy titled: Pressure Injury Protocol dated 02/17/18 included the following in part: All residents will be assessed for their risk of developing pressure injury using a standardized and approved assessment tool upon admission and periodically throughout their stay. Residents with an existing pressure injury and those with a history of pressure injury fall into the category of High Risk for development of further pressure injuries. An appropriate interdisciplinary plan of care will be developed within 72 hours of admission to reduce the risk of pressure injury and aid in the prevention of new pressure injuries. Record review for Resident #247 revealed the resident was admitted to the facility on [DATE] with diagnoses included: Other Gram-Negative Sepsis and Abscess of Liver. Review of the Minimum Data Set for Resident #247 dated 05/02/24 revealed in Section C a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment. Documented in Section M was the following: Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device? The answer documented to this question was no. Is this resident at risk of developing pressure ulcers/injuries? The answer documented to this question was yes. Does this resident have one or more unhealed pressure ulcers/injuries? The answer documented to this question was no. Review of the Physician's Orders for Resident #247 revealed an order dated 05/07/24 for Wound care Consult two times a day for Evaluation and Treatment of Coccyx area. Review of the Physician's Order for Resident #247 revealed an order dated 05/09/24 to cleanse coccyx with NS (Normal Saline) and pat dry. Apply honey, collagen, and calcium alginate. Cover with dry dressing, one time a day for wound care. Review of NSG (Nursing) Admission/Readmission for Resident #247 dated 04/27/24 under Skin Alterations Present pressure ulcers was not documented. Review of the Admission/readmission summary for Resident #247 dated 04/27/24 documented Skin alterations noted on admission/readmission (if present):Abdomen - Surgical Incision: Width - Stage Unstageable, Left knee (front) - Other (specify): scab: Right knee (front), Other (specify): scab. The Acute Visit authored by the Nurse Practitioner for Resident #247 dated 05/07/24 documented resident was seen, 05/07/2024, per nurse request for a possible stage II pressure injury on his coccyx area. Noted stage II pressure injury on coccyx area. Skin pink and warm to the touch. Assessment and Plan: Pressure ulcer of coccyx , unstageable *: Zinc Oxide External Ointment 10% - Applied topically to coccyx two times a day. Advised patient to lay on his side to relieve pressure. The Weekly Skin Integrity review for Resident #247 dated 05/02/24 documented under current skin condition included: Left knee (front)-scab/ redness. Right knee (front)- redness Right iliac crest (front)-drain Left antecubital-iv site Right buttock-red/dry The Weekly Skin Integrity review for resident #247 dated 05/09/24 documented under current skin condition: Sacrum-open area Review of the Care Plan for Resident # 247 with an initiated date of 4/27/24 with a focus on the resident has potential/actual impairment to skin integrity was revised on 05/09/24 to the resident has potential/actual impairment to skin integrity to coccyx. The goal was for the resident to be free from injury through the review date. The interventions included: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Group 2 mattress for wound healing on coccyx. Roho cushion to wheelchair. Ensure cushion in place when resident using wheelchair. There was no intervention for EBP when providing care per facility protocol. During an interview conducted on 05/22/24 at 2:00 PM with the Director of Nursing (DON) who was asked if the facility had any residents with acquired pressure ulcers, she said no. When asked about Resident #247, the DON said the resident was admitted with several wounds. The DON acknowledged there was no documentation of a coccyx or sacral wound on admission. The DON also acknowledged the documentation for the coccyx pressure ulcer was identified after the resident was admitted to the facility.

Based on observation, interviews, record review and policy review, the facility failed to provide an anchor for catheter tubing for 1 of 1 resident observed for catheter care (Resident #25). The findings included: The policy of the facility titled Catheter Care, Urinary dated April 2022 revealed Key Procedural Points .Check to see that the catheter remains secured with a leg strap, if applicable, to reduce friction and movement at the insertion site. and Steps in the procedure Secure catheter utilizing a leg band, if applicable. Resident #25 was admitted to the facility on [DATE] with diagnoses that included Unspecified fracture of second thoracic vertebra, Hypertension, and Neuromuscular dysfunction of the bladder. Her Brief Interview for Mental Status (BIMS) score was 15 on the quarterly Minimum Data Set with an assessment reference date of 03/29/24. This indicated the resident was cognitively intact. A review of the physician's orders for catheter care for Resident #25 revealed an order for Urinary Catheter: Change Catheter Anchor and urine bag every night shift every Sun for urine catheter. On 05/23/24 at 1:40 PM Foley catheter care was observed on Resident #25 with Staff H, a certified nursing assistant (CNA). Staff H cleansed the perineal area around the tubing on the Foley catheter and cleansed the tubing with soap and water. She dried the tubing with a towel. During the observation of catheter care, there was no anchor for the tubing either before the care was done or after. An interview was conducted with Staff H immediately after catheter care was completed asking if she had an anchor for the catheter. Staff H stated that she did not have an anchor.

Based on observations, interviews, and record reviews, the facility failed to identify a significant weight loss and provide nutritional interventions in a timely manner for 2 of 5 residents reviewed for nutrition (Resident #10 and Resident #199). The findings included: A review of the facility ' s policy titled Weighing and Weight at-risk protocol dated April 2022, showed the following: Complete all weights with re-weights on the following parameters: 0-175 pounds-variances of 4 pounds for loss or gain. Nursing and Dietitian to review weights for significant weight loss and at-risk weight loss and determining variances with re-weights as noted above. Interventions in place: notify the Dietitian of newly identified significant weight loss, review the needs for fortified foods, diet liberalization, frequent foods that the Resident likes, and frequent meals or snacks. It further showed that intakes should be reviewed at a minimum weekly, and the narrative documentation should include areas identified and measures put in place to show interventions. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses of Dysphagia, Sepsis, and Muscle Weakness. The Order Summary Report revealed the following orders: health shake three times a day, dated 04/21/24 (seven days after Resident #10 ' s admission); night snack at bedtime, dated 05/02/24; and a diet order for a mechanically chopped diet with nectar thick consistency, dated 04/14/24. A review of Resident #10 ' s weights showed the following: a weight of 118 pounds on 04/14/24, a weight of 102 pounds on 04/18/24, a weight of 98.1 pounds on 05/02/24, a weight of 99.4 pounds on 05/09/24 and a weight of 101 pounds on 05/16/24. This showed a 13.5% severe weight loss from 04/14/24 to 04/18.24 and a severe 16.86% weight loss from 04/14/24 to 05/02/24. In an observation conducted on 05/22/24 at 8:59 AM, Resident #10 finished her breakfast meal. She ate some of her French toast but did not touch any of her ham, hot cereal, or house shake. In an observation conducted on 05/22/24 at 12:00 PM, the lunch tray was brought into Resident #10 ' s room and was set up for her. The tray was filled with ground turkey, mashed sweet potato, and ground vegetables. At 12:17 PM, the Resident ate 20% of her lunch meal but did not drink any of her house shakes. The Initial Nutrition Evaluation dated 04/18/24 showed the following: Resident #10 ' s admission weight was noted at 118 pounds which matched the hospital admission weight that was recorded on admission. Resident #10 ' s Usual Body Weight was noted at 125 pounds, and her meal intake was noted between 26% to 75% of her meals. No other nutritional assessment or notes were completed after 04/18/24 addressing the severe weight loss for Resident #10. The Certified Nursing Assistants' documentation of meal intake revealed that from 04/14/24 to 05/21/24, Resident #10 consumed 100 meals between 40.6% and 64%. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #10 has a Brief Interview of Mental Status (BIMS) score of 05, which is severely cognitively impaired. The Care Plan, which was initiated on 04/29/24, showed that Resident #10 was at risk for dehydration, suboptimal intake, and malnutrition. A registered dietitian will evaluate and make recommendations as needed. In an interview conducted on 05/21/24 at 3:45 PM with the facility ' s Registered Dietitian, she stated that 5% weight loss in less than a month is considered severe. There is a Weight Exception log that she runs to identify any weight changes with gains or losses that are triggered in the parameters that are in the electronic system. She runs the report once a week and will follow up to address the weight loss and reassess the nutritional needs. When asked if she noticed the severe weight loss that Resident #10 had from 04/14/24 to 04/18/24, she said no. When asked if she knew that Resident #10 had a significant weight loss, she said, I do not see it in my notes. She further said it was not on her list for residents with severe weight loss who needed to be seen. 2. A record review showed that Resident #199 was admitted to the facility on [DATE] with diagnoses of severe protein-calorie malnutrition, muscle weakness, and respiratory failure. In an observation conducted on 05/20/24 at 12:03 PM, the staff brought the lunch tray into Resident #199's room. The observation continued at 12:15 PM, which showed that Resident #199 did not eat anything on his lunch tray. In this observation, Resident #199 said, I am in pain and have nausea. In an observation conducted on 05/20/24 at 12:35 PM, Resident #199 did not touch any food on his lunch tray. During this observation, Resident #199 asked the Surveyor if they could take his lunch tray out of the room. In an observation conducted on 05/21/24 at 8:50 AM, Resident #199 was noted in his room with a breakfast tray of only 10% consumed. In this observation, Resident #199 was asked how his appetite was, and he said, I have no appetite. He further stated that his stomach was hurting and he was not feeling well. When asked by Surveyor if he knew his current body weight, he said that the last time they took his weight was in the hospital. Resident #199 stated that his weight used to be 170 pounds. A review of the weight log showed the following weights recorded: 161 pounds on 05/04/25 and 149.8 pounds on 05/07/24. This shows a 6.9% severe weight loss from 05/04/24 to 05/07/24. The Initial Nutrition assessment dated [DATE] revealed Resident #199's Usual Body Range of 175 pounds. Resident #199 meets the criteria for malnutrition diagnosis and muscle wasting. It further showed that Resident #199 eats between 51% to 100% of meals and that his son brings Ensure, a Nutritional Supplement. Further review did not show any additional nutritional assessment or notes addressing the severe weight loss from 05/04/24 to 05/07/24 and poor intake of meals. A review of the Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 15, which is cognitively intact. The nutrition care plan dated 05/05/24 revealed that Resident #199 will maintain adequate nutritional status by not having significant weight loss and consuming at least 50% of meals daily through the review date. In an interview conducted on 05/23/24 at 9:50 AM with Staff C, Certified Nursing Assistant, she stated that Resident #199 has not been eating very well this week and has only consumed between 0-25% of his meals. She further said that she told the Nurse about Resident #199's poor meal intake. In an interview conducted on 05/23/24 at 11:53 AM with the facility's Registered Dietitian, she stated that there is an overall clinical dashboard that will show the list of Residents with poor intake of meals and the percentage intake of meals. This dashboard is linked to the CNA's documentation of the daily intake of meals. She will then follow up with the residents and get more information regarding any medication changes, speak to the residents, refer to her first initial nutritional assessment, and provide the necessary dietary interventions. When asked if she knew that Resident #199 was not eating well, she said no and stated, He did not show up on the clinical dashboard for her to see She then said, It is still not showing up on my dashboard today.

Based on observations, interviews, and record review, the facility failed to ensure that each Resident received care and services for the provision of hemodialysis consistent with professional standards of practice for two of the two residents reviewed for Dialysis (Resident #196 and Resident #201). The findings included: A review of the facility policy titled Dialysis dated 04/2022 revealed that A communication process must be established between the nursing home and the dialysis facility to be used 24 hours a day. The care of the Resident receiving dialysis services must reflect ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff. The communication process should include how the communication will occur, who is responsible for communicating, and where the communication and responses will be documented in the medical record. 1. Resident #196 was admitted to the facility on [DATE] with a diagnosis of end-stage renal disease and dependence on renal dialysis. A review of orders showed the following: Sevelamer tablet 800 milligrams to be given every morning and at bedtime with meals dated 05/03/24. Dialysis every Monday, Wednesday, and Friday, which was dated 05/06/24. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #196 had a Brief Interview of Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment. In an interview conducted on 05/20/2024 at 3:30 PM with Resident #196's wife, she stated that he was not back from the dialysis center and that he was picked up at 9:00 AM this morning. She is concerned that the medication Sevelamer is not given with the meals as needed and that this morning, the nurse tried to give Resident #196 his dosage of Sevelamer on his way out to the transportation car outside the facility. She further said that she has complained about the medication not being given with the meals, but nothing has been done about it. The care plan initiated on 05/06/24 included communicating with the dialysis center regarding medication, diet, and lab results and coordinating residents' care with the dialysis center. A review of the dialysis binder located in the nurse's station did not show any dialysis communication sheets between the facility and the dialysis center for Resident #196 since his admission to the facility on [DATE]. In an interview conducted on 05/21/24 at 11:50 AM with Staff B, Licensed Practical Nurse, she stated that the communication sheets are usually in the dialysis binder located in the unit. When asked why the dialysis communication sheets were missing for Resident #196, she said that she needed to know. She further stated they are sent with the Resident when he goes to dialysis treatments. The dialysis center always needs to remember to send the dialysis sheets back with the Resident and that she must call the dialysis center to request the forms. When asked by Surveyor if she had any of the communication sheets for Resident #196 for the last few weeks, she said no. In a phone interview conducted on 05/23/24 at 12:12 PM, the facility's Pharmacist stated that the medication Sevelamer helps control the level of phosphate in patients on dialysis. It is better absorbed with meals, so it is preferred to be given with meals. 2. A chart review revealed that Resident #201 was admitted to the facility on [DATE] with diagnoses of end-stage renal disease and dependence on renal dialysis. A review of the Physician's orders showed an order for Sevelamer 800 milligrams to give two tablets with meals, which was dated 05/17/24. In an interview conducted on 05/21/24 at 9:00 AM with Resident #201, he stated that he only started dialysis for the first time about two weeks ago, and yesterday was the first time he went to an outpatient dialysis center from the facility. He further said that he only came back to the facility around 8:30 PM last night and that his dinner plate was waiting for him in his room when he came back from dialysis. When asked by the Surveyor if the medication (Sevelamer) was given with his dinner, he did not know. The care plan dated 05/20/24 revealed the following: communicate with the dialysis center regarding medication, diet, and lab results and coordinate the resident's care with the dialysis center. A review of the dialysis communication binder located in the nurse's station, did not see any communication sheet for Resident #201. Review of the Medication Administration Record for the month of May 2024 showed that the scheduled medication for Sevelamer was given on 05/20/24 at 8:00 AM and 12:00 PM but was not given at 5:00 PM because Resident #201 was outside the facility at dialysis. Further review revealed that the medication order for Humalog (insulin) 100 units was not given at 5:00 PM as scheduled because Resident #201 was at dialysis. In an interview with the Director of Nursing on 05/22/24 at 10:40 AM, she stated that Sevelamer is to be given with meals. When an order is given with meals, they must hold the medication and schedule it around dialysis times. On admission, the medicines need to be reviewed by the nursing team and addressed immediately by calling the doctor for further direction on working with the scheduled dialysis times. She also expected the nurse to call the doctor and ask them what to do if they needed to administer medication, but the resident was not in the facility. In an interview conducted on 05/23/24 at 4:00 PM, with the facility's Administrator, she was informed of the findings.

Based on observations, interviews, and record reviews, the facility failed to treat residents in a dignified manner while providing care and services for 3 of 22 sampled residents (Residents #15, #38, and #247). The findings include: 1. A review of Resident #15's medical record revealed that the resident was originally admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia. A review of the resident's Minimum Data Set (MDS) assessment, dated 03/15/24, revealed in Section C a Brief Interview for Mental Status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. On 05/20/24 at 9:29 AM, an observation was made of Licensed Practical Nurse (LPN) J administering medications in the hallway to Resident #15, who was located next to the medication cart outside of room [ROOM NUMBER]. During an interview with LPN J on 05/23/24 at 11:30 AM, she stated she had worked at the facility for three years. When asked if medications were administered to the residents in the hallway, she said, You're not supposed to administer meds in the hallway. 2. A review of Resident #38's medical record revealed that the resident was admitted to the facility on [DATE] with a diagnosis of displaced fracture of lateral end of left clavicle subsequent encounter for fracture with routine healing. A review of the resident's MDS assessment, dated 05/07/23, revealed in Section C a BIMS score of 10/15, indicating moderate cognitive impairment. On 05/20/24 at 9:43 AM, an observation was made of RN M administering medications in the hallway to Resident #38, who was located next to the medication cart outside of room [ROOM NUMBER]. 3. A review of Resident #247's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including sepsis and abscess of liver. A review of the resident's MDS assessment, dated 05/02/24, revealed in Section C a BIMS score of 12/15, indicating moderate cognitive impairment. On 05/20/24 at 2:25 PM, an observation was made of RN I gathering supplies outside of Resident #247's room. She went into the room. RN I was observed changing the dressing on Resident # 247's abdomen. She removed the old dressing, cleaned around the entry site of the abdominal drain, applied gauze, placed four pieces of paper tape around the gauze, applied a fifth piece of paper tape over the dressing and said, Now I will sign and date it. RN I then proceeded to write on the dressing located on the resident with a marker to sign and date the abdominal dressing. During an interview with RN I on 05/23/24 at 12:05 PM, she stated she had worked at the facility almost one year. When asked how the nurses were expected sign and date a dressing, she said, You should sign and date a piece of tape and then apply it to the resident after the wound care is completed. When asked if medications were ever administered in the hallway, she said, No, we do not do that. The medications are given in the resident's room. A review of the facility's policy titled Dignity (dated 08/22/22) revealed in part: Treat each resident with respect and dignity with regards to the following: Personal Care During medication and treatment opportunities