Every finding on record at Palm Beach Nursing Center

Based on observations, interviews and record reviews, the facility failed to prepare, store and serve food in a sanitary manner in accordance with standards for food safety professionals. The findings included:1. During the initial kitchen tour, on 01/05/26 at 9:07 AM, accompanied by the Certified Dietary Manager (CDM), the following were noted:a. The hand washing sink was not secured to the wall.b. There was an accumulation of residue on the exterior of the mechanical dishwashing machine.c. Cleaned and sanitized trays were wet nesting on the shelf in the dishwashing area.d. Staff F, Dietary Aide, was observed handling dirty and potentially contaminated wares with gloved hands. Staff F then proceeded to handle cleaned and sanitized wares as they came out of the machine with same gloved hands. The surveyor intervened and the Dietary Aide was instructed to remove the gloves and perform hand hygiene.e. The painted surface of the interior of the door of the ice machine was chipped.f. There was an accumulation of residue and debris on the shelf under the hot holding unit.g. There was an accumulation of debris behind the plate warmer.h. The surface of the wall behind the cooking equipment was damaged and peeling.i. The wall and frame around the window between the walk in cooler and the processing area was chipped and damaged.j. There was an accumulation of rust on an air conditioning vent over the processing area.k. There was an accumulation of ice from the cooling unit in the walk-in freezer. At the conclusion of the tour, the CDM acknowledged understanding of the concerns. 2. During a follow up visit to the kitchen, on 01/06/25 at 12:02 PM, a full sized six-inch-deep hotel pan containing bags of frozen mixed vegetables was observed on top of the convection oven. When asked about the observation, Staff G stated that the vegetables were frozen and were being thawed. The CDM acknowledged that placing foods at ambient room temperature was not a safe method for thawing food.

Based on observations, interviews and record reviews, the facility failed to provide housekeeping and maintenance services in a manner to provide a clean and sanitary environment in 20 of 62 rooms and in the common areas of the facility. The findings included:During an environmental tour of the facility conducted on 01/08/26 at 10:53 AM, with the Maintenance Director and the Maintenance Assistant, both from a sister facility, the following was observed: room [ROOM NUMBER] - the floor tiles were separating from the floor throughout the room. room [ROOM NUMBER] - the hand-washing sink in the restroom did not work, the floor tiles were not secure to the floor throughout the room, the ceiling was stained indicative of being wet at some point in time. room [ROOM NUMBER] - a portion of the wall in the bathroom where a dispenser was removed was not painted. room [ROOM NUMBER]- the hand-washing sink in the restroom did not work. room [ROOM NUMBER] - the wall behind the head of the door and window beds were damaged and in need of being painted, the bottom of the room entry door was chipped. room [ROOM NUMBER] - a portion of the wall in the bathroom where a dispenser was removed was not painted. room [ROOM NUMBER] - the wall behind the head of the head of the door bed was damaged and in need of being painted. room [ROOM NUMBER] - the rubber around the exterior of the over bed table for the door bed was missing exposing the particle board underneath. room [ROOM NUMBER] - the wall behind the head of the door bed was damaged and in need of being painted. room [ROOM NUMBER] - the wall behind the head of the window bed was in need of being painted. room [ROOM NUMBER] - the wall to the left of the door bed was damaged and in need of being painted and there were rub marks above the area that was in need of being painted. room [ROOM NUMBER] - The wall in the bathroom opposite the entrance was damaged an in need of being painted, the surface of the dresser was chipped on the bottom. room [ROOM NUMBER] - the exterior of the room door facing the corridor was chipped in several places. room [ROOM NUMBER] - the wall under the toilet paper dispenser was damaged and in need of being painted. room [ROOM NUMBER] - the inside of the restroom door was chipped, the covering on the wall was coming off of the wall at the left of the door in the bathroom, the ceiling throughout the room was stained in several places. room [ROOM NUMBER] - There was an accumulation of dust and a mold-like substance inside of the vent of the wall mounted air conditioning unit, there was an odor of mold noted in the room, the wall in the bathroom below the hand-washing sink counter and the toilet paper dispenser was damaged and in need of being painted. room [ROOM NUMBER] - a face plate that was installed behind the door was cracked creating a hole in the wall, an area of the ceiling/wall juncture was stained and separating indicative of being wet, there was an accumulation of debris inside of the wall mounted air conditioning unit. room [ROOM NUMBER] - the rubber around the edge of the over bed table of the window bed was missing exposing the particle board underneath. room [ROOM NUMBER] - the face plate over an outlet for cable was not secured to the wall leaving a hole in the wall. room [ROOM NUMBER] - the rubber around the edge of the over bed table of the door bed was missing exposing the particle board underneath, the ceiling tiles in the bathroom were stained indicative of being wet at some point, there was an accumulation of dust on the vent over the commode, there was a gouge in the wall at the baseboard to the resident's left side of the commode.room [ROOM NUMBER] - 1 of the 3 light bulbs was burnt out and another of the 3 light bulbs over the resident's bed and the toilet was not working properly. During an interview on 01/06/26 at 8:27 AM, Resident #59, with a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact, the resident stated she had to reach into the tank of the commode and pull the chain attached to the plunger to flush the toilet for about the last week. There was a ceiling tile that was stained, indicative of being wet at some point at the second-floor nurse's station. In the Acuities/Dining Room on the second floor, there were ceiling tiles that were stained indicative of being wet at some point and the wall at the right of the entrance was damaged and in need of being painted. The handrails throughout the second floor were separating in a manner that residents would be susceptible to skin tears. The exterior of the door to the Medical Records storage room was chipped. The door of the Shower room on the second floor was chipped. During this environmental tour of the facility, on 01/08/26 at 10:53 AM, with the Maintenance Director and the Maintenance Assistant, both from a sister facility, the Maintenance Director acknowledged the findings. The Maintenance Director confirmed that the facility had not had any maintenance staff, including a Director since the beginning of December 2025 and a Maintenance staff since the end of December 2025.

Based on observations, interviews, and record review, the facility failed to address equipment repair of a malfunctioning bed in a timely manner for 1 of 22 sampled residents, failed to maintain a call light within reach for 1 of 22 sampled residents, and failed to maintain residents' items in an accessible manner for 1 of 22 sampled residents, Resident #3, Resident #46, and Resident #131. The findings included: 1. Record review revealed that Resident #3 was admitted on [DATE] with diagnoses to include: Acute Osteomyelitis, Diabetes, Hypertension, Hyperlipidemia, Chronic Kidney Disease, Chronic Embolism and Thrombosis, of Lower Extremity, and Non-Pressure Chronic Ulcers. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident had intact cognition. Review of Physician's Order dated 09/02/25 documented, Low Airloss mattress every shift for Check function q [every] shift. During an interview with Resident #3 on 01/06/26 at approximately 10:00 AM, it was observed that the resident was laying on an air mattress. He stated that the mattress did not have enough air and it tilted. It was observed that the resident was laying towards the left side of the bed. Resident #3 stated that he had reported it to a nurse during the middle of September 2025 and the Maintenance Department had come in to check it. The resident thought it was the frame of the bed, but the Maintenance Department told him it was the mattress and since it was a rental, they would contact the company and have them come and look at it. Resident #3 stated no one ever returned to repair the bed. Observation revealed a sticker at the foot of the bed which revealed the company information that included where the bed was rented from, a phone number and dates of '08/18/2023' and 'Reinspect Due Date of 08/17/2023'. Photographic Evidence Obtained. On 01/07/26 at 10:05 AM, an interview with the Interim Maintenance Director was conducted regarding the issues with Resident #3's bed. The Bed Rental Policy Contract, The Rental Agreement, and any invoices or maintenance paperwork were requested. The paperwork later provided by the facility was the delivery invoice dated 08/18/2023. Photographic Evidence Obtained. The Director checked the bed, returned and stated the resident preferred to lay on the left side of the bed because the over the bed table was on the right side where the resident kept his computer. He further stated that because the resident laid on the left side and is a large man, it caused the bed to deflate on that side. The Director also stated that he checked the mattress and it was even. On 01/07/26 at 11:47 AM, Resident #3 was revisited to discuss what the Director of Maintenance has stated about the bed. The resident insisted that the bed was not even and that he purposely had tried to lay on the other side of the bed and it still had leaned or tilted. On 01/07/26 at 3:34 PM, an interview with a supervisor from the company who had provided the air mattress and bed frame was conducted. The facility had provided the paperwork from when the bed was delivered on 08/18/23. The sticker on the bed was dated 8-18-23 and Reinspect Due Date 8-17-23. The supervisor confirmed that the year for the reinspection was incorrect and that it was recommended to reinspect the bed annually to keep it in good working order. She also explained that their equipment was rent-to-own and the facility had already most likely paid off the bed. Paperwork showing maintenance or reinspection of the bed was requested and the supervisor stated she would research it and send it to the Administrator. On 01/08/26 at 10:33 AM, Resident #3 was observed in a new bed. The resident stated that the bed was better inflated and now even. Observation revealed the resident laying in the center of the bed. On 01/08/26 at 2:48 PM, the supervisor of the bed rental company called and stated that Resident #3's bed was paid off after 188 days of rental and no requests for service were ever placed. She explained that maintenance of equipment was not automatic and had to be called in. 2. Record review revealed Resident #46 was admitted on [DATE] with diagnoses to include: Encephalopathy, Chronic Obstructive Pulmonary Disease, Depression, Congestive Heart Failure, Hypertension, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. Review of the Quarterly MDS assessment dated [DATE] documented a BIMS score of 09, indicating Resident #46 had moderate cognitive impairment. The MDS also indicated the resident was visually impaired. Further record review revealed a care plan with an approach initiated on 03/29/25 that documented, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an interview with Resident #46 on 01/05/26 at 11:41 AM, the resident was noted resting in bed. The resident's call light was not within his reach and hung over the wall call light panel. During the interview the resident requested to be repositioned. The surveyor activated the call light for the resident at 11:45 AM. Staff E, Certified Nursing Assistant (CNA), responded to the call light at 11:47 AM, repositioned the resident, turned off the call light, and left it hanging on the wall call light panel. On 01/05/26 at 3:38 PM, Resident #46 was observed in bed, and the call light was noted still hanging on the wall call light panel. Photographic Evidence Obtained. On 01/05/26 at 3:41 PM, Staff D, Registered Nurse (RN), was interviewed at the Nurse's Station and stated that Resident #46 was alert enough to use the call light. Staff D and the surveyor walked to the resident's room and the call light was observed still hanging on the wall call light panel. Staff D noted it was not within the resident's reach. 3. Review of the record revealed Resident #131 was initially admitted to the facility 10/28/25 and re-entered on 11/13/25 with a primary diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. Review of the current MDS assessment dated [DATE] documented Resident #131 had a BIMS score of 06, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This same MDS documented that Resident #131 had an impairment on one side of his upper extremities. Review of Resident #131's care plan revised 12/03/25 documented, The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t HTN, [related to Hypertension] Hemiparesis with Left sided weakness, Speech delays. muscle weakness. Review of the grievance log for 11/11/25 documented there had been a grievance for Resident #131 due to the staff not being attentive. During an interview on 01/05/26 at 1:40 PM, with the Resident 113's representative, she, when asked how the care was, stated the care was not good here and she couldn't wait to get him out. She said the resident had a stroke which had affected the mobility and function of the left side of his body and left him cognitively impaired. She voiced every time she came in to visit him all his belongings such as the call light and bedside table were on his affected side (left.) She expressed it was very frustrating because she had talked to the Director Of Nursing (DON) many times and it was addressed in the moment but as soon as she left, things were back to how they were before. She stated she always had to come in and check on him after work since she works close by. An observation was made of the call bell hanging on the left side by the resident's bed. During an observation on 01/06/26 at 1:45 PM, the call light and positioning remote were seen hanging from the left side of Resident #131's bed. During an interview on 01/07/26 at 2:07 PM, the Assistant Director of Nursing (ADON) was made aware of the concerns that Resident #131's representative had and she agreed that his belonging should be placed on his dominant side and stated she would talk to staff to address it. On 01/08/26 at 8:16 AM, the surveyor received a phone call from Resident #131's representative who stated she had visited Resident #131 yesterday (01/07/26) and repeated that his belongings and the bedside table were on his left side. She also mentioned that the resident's door was closed as his roommate's family were visiting. When she entered the room after knocking very loudly, she observed Resident #131 leaning towards his right side. She stated she was very upset to see that as he could have fallen and no one could watch him with the door closed.

Based on observations, interviews, and record review, the facility failed to assess residents accurately and in a timely manner for a change in status for 1 of 1 sampled resident, Resident #5. The findings included:Record review revealed Resident #5 was last readmitted on [DATE] with diagnoses to include: Chronic Obstructive Pulmonary Disease, Emphysema, Muscle Wasting and Atrophy, Anxiety, and Dementia. Review of the resident's most recent Minimum Data Set (MDS) assessment, a Significant Change, dated 11/10/25, revealed the Brief Interview of Mental Status (BIMS) score was 13, on a scale of 0 to 15, indicating Resident #5 had intact cognition. The MDS also indicated the resident was receiving Hospice services. Further review of the resident's record revealed a physician's order documenting the resident was admitted to Hospice on 11/03/25 and a Do Not Resuscitate (DNR) form was signed on 11/04/25 by the resident. Photographic Evidence Obtained. Record review revealed a quarterly Social Services assessment, identified as a late entry, Created 12/17/2025, and Effective 11/26/2025, that did not indicate the resident was under Hospice services, and indicated that the Resident was to remain a Full Code. Photographic Evidence Obtained. On 01/07/26 at approximately 1:00 PM, an interview was conducted with the Regional MDS Nurse Coordinator. She stated that there had been no MDS Coordinator for the last two weeks and she was filling in. During the interview, she stated that the Social Worker's assessments must be completed by the Resident's Assessment Reference Date (ARD). On 01/07/26 at 1:48 PM, the Social Services Director who had been employed by the facility for two and a half years, was interviewed. She stated that she is informed of upcoming MDS's and Significant Changes, during the daily Clinicals Meeting. She stated that Social Services assessments were completed before each ARD date. Resident #5 had an assessment with an ARD date of 11/10/25 and the Social Services assessment was created on 12/17/25 which was over a month later. The discrepancies found in the assessment were discussed with the Social Services Director who could not provide an explanation and stated that she would discuss the issue with her Assistant who had completed the assessment. On 01/07/26 at 3:46 PM, an interview was conducted with the Social Services Director's Assistant, who had been employed by the facility for approximately 10 months. When asked about the discrepancies found in Resident #5's assessment, he stated that they were all mistakes. No further explanation was provided.

Based on observation, interview and record review, the facility failed to timely administer PRN (as needed) pain medication to a resident with voiced pain for 1 of 1 sampled resident, reviewed for pain management, Resident #139.The findings included:Review of the facility's policy titled, Policy and Procedure: Clinical- Medication Administration. Purpose: To administer medications as per provider's orders and in accordance with regulatory guidelines and practice standards. Administration Time: Medication are to be administered within 1 hour of the scheduled administration time, unless the resident is on a liberalized med administration program.Review of the record revealed Resident #139 was initially admitted to the facility 11/18/25 and re-entered 12/09/25 with a primary diagnosis of Displaced Fracture of Olecranon Process without Intraarticular Extension of the Left Ulna (Fracture of Left Elbow). Other diagnoses included multiple fractures of her neck and back area. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #139 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact.Review of Resident #139's care plan revised 12/16/25 documented Focus: [Resident #139] is at risk for pain related to status post fall at home with left elbow fracture, T6/10/12 & L 1/2 compression fractures. Goal: [Resident #139] will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions / Tasks: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Monitor / document for probable cause of each pain episode. Remove / limit causes where possible; Monitor / record / report to Nurse resident complaints of pain or requests for pain treatment; Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx [signs and symptoms] or c/o [complaint of] pain or discomfort.Review of Resident #139's active orders revealed a PRN (as needed) order for Oxycodone-Acetaminophen Oral Tablet 10-325 MG, Give 1 tablet by mouth every 4 hours as needed for pain.Review of the Resident #139's January's MAR/TAR (Medication Administration Record / Treatment Administration Record) for Oxycodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth every 4 hours as needed for pain documents as follows:On 01/01/26 at 9:10 AM for a pain level of 9; 1:34PM for a pain level of 8; 6:10 PM for a pain level of 8.On 01/02/26 at 3:00 AM for a pain level of 7; 10:03 AM for a pain level of 6; 2:44 PM for a pain level of 6; 8:54 pm for a pain level of 8.On 01/03/26 at 3:47AM for pain level of 7; 10:12 AM for a pain level of 7; 3:44PM for a pain level of 7; 8:05 PM for pain level of 6.On 01/04/26 at 5:10AM for a pain level of 7; 10:49 AM for a pain level 5; 3:43 PM for a pain level 5.On 01/05/26 at 2:40 AM for a pain level of 7; 9:11AM for a pain level of 7; 2:28 P for a pain level of 7; 6:30 PM for a pain level of 7; 10:35 PM for a pain level of 6.On 01/06/26 at 4:10 AM for pain level of 6; 8:19 AM for a pain level of 6; 1:22 PM for a pain level 7; 5:57 PM for a pain level of 6.On 01/07/26 at 12:30 AM for a pain level of 8; 7:40 AM for a pain level of 6; 12:46 PM for a pain level of 7.During an interview on 01/05/26 at 11:52 AM, Resident #139 was observed wearing a left arm sling and her arm was wrapped with an elastic bandage. When asked how her care was Resident #139 stated she had been in and out of the facility and hospital since November due to falling into a drained pool where she broke her left arm. She stated, I don't know if they are busy and forget or get sidetracked, but I have to wait a really long to get my pain medication especially during the night. Resident #139 stated she would feel throbbing pain on her arm sometimes. She stated, When I ask for my pain medication they say they don't have the keys yet or that it's too early especially during shift change. It has gotten to the point where I've had to start tracking times on my own. I will write down the time they gave it to me and add ten minutes to give them time to document it, and I've noticed long lapses of time. Resident #139 stated the times she misses her as needed dose ranges from a couple of hours up to 12 hours at a time. Resident #139 showed the surveyor her recorded times along with a picture of an x-ray to show the severity of her broken arm. She stated, I really am in pain, I don't want to get anyone in trouble, but I am in pain. During an interview on 01/07/26 at 2:07 PM, a side-by-side chart review was conducted with the ADON (Assistant Director of Nursing) where January's MAR/TAR was reviewed for PRN administration of Oxycodone-Acetaminophen. The ADON identified the lapses of administration with the surveyor and agreed it should have been administered timely if Resident #139 was voicing pain. During a follow up interview on 01/7/26 at 2:40 PM, Resident #139 stated it was mostly night shift who didn't provide her with her pain medication timely and stated the past night she overheard her night shift nurse complaining that all her residents were on pain medication. Resident #139 stated it wasn't her issue if all the residents were on pain medications, but it also made her feel better that she wasn't the only one asking for it. During an interview on 01/08/26 at 11:15 AM, Resident #139 stated although she was going home tomorrow, she was happy her night was good and finally got her pain medication on time. She stated she didn't want other residents going through what she went through and thanked the surveyor for the help.

Based on observations, interviews, and record review, the facility failed to accurately document the narcotic medication dispended, administered or disposed of for 3 of 4 sampled residents reviewed for Narcotic Medication Storage, Residents #25, #33 and #58. The findings included: Review of the facility's policy titled, Clinical-Narcotic Count/Disposal, dated 12/08/25, included the following: Procedure: 5. When a schedule II medication is administered, the licensed nurse will complete an entry on the count sheet indicating the date and time of administration, amount administered, amount remaining and signature. 6. If a dose of schedule II narcotics is removed from the container but refused by the resident or not given for any reason, it will be destroyed in the presence of 2nd licensed nurses. This disposal will be documented on the count sheet. 1. Medication storage review was conducted on 01/08/26 at 12:05 PM, of the North Cart on the second floor with another nurse surveyor present. Two residents were selected for review of narcotics. Staff B, Registered Nurse (RN), was asked to show the Oxycodone 5-325mg tablet that was prescribed for Resident #25. She removed the medication from the locked narcotic box and there were 13 pills in the packet. The controlled medication utilization record for Resident # 25 revealed that there were 13 Oxycodone 5-325mg tablets remaining. During a side-by-side comparison of the narcotic sheet and the electronic medication administration record (MAR), there were no electronic entries for the medication signed out on 01/08/26 at 02:30 AM and 01/04/26 at 12:29 PM. Staff B, RN and Director Of Nursing (DON) were present and agreed that there were no entries made on the electronic record for these two removals. 2. On the same medication storage review conducted on 01/08/26 at 12:05 PM, of the North Cart on the second floor, Staff B, RN was asked to show the Oxycodone 10mg tablet that was prescribed for Resident #33. She removed the medication from the locked narcotic box and there were 4 pills remaining in the packet. The controlled medication utilization record for Resident #33 revealed that there were 4 Oxycodone 10 mg tablets remaining. During a side-by-side comparison of the narcotic sheet and the electronic MAR, the orders on the pill pack stated that the medication can be administered every 8 hours as needed but the MAR stated that the medication can be administered three times per day, AD LIB. The time stamp for the MAR was requested to compare with the entries made on the narcotic sheet. A review of the administration timestamp in the MAR was conducted with a side-by-side review with the Unit Manager (UM) on the first floor. The dose that was administered on 01/07/26 at 9:36 PM (2136 hours) was given 6 hours after the dose administered on 01/07/26 at 15:27 PM instead of after 8 hours. 3. A second medication storage review was conducted on 01/08/26 at 12:41 PM, of the South Cart on the first floor, with another nurse surveyor present. One resident was selected for review of narcotics. Staff C, Registered Nurse (RN) was asked to show the Tramadol HCL 50 mg tablet that was prescribed for Resident #58. She removed the medication from the locked narcotic box and there were 19 pills in the packet. The controlled medication utilization record for Resident # 58 revealed that there were 19 Tramadol HCL 50 mg tablets remaining. During a side-by-side review of the narcotic sheet, line 5 of the document was incomplete. It did not have a date or time entered. There was documentation in the column amount given as one. There were 2 initials in the initial if error column. The DON who was present during the review and agreed that the entry on line five did not include a date or time. The DON was unable to confirm if the signatures on the bottom of the sheet for Narcotic Waste/Spillage were correlated to the initials on line five with the missing date and time. Both surveyors listened while Staff D, RN, was called via speaker phone from the DON's office on 01/08/26 at 1:19 PM regarding the narcotic documentation for Resident #58. Staff D stated that when he noticed that the pill was open, he did not want to put tape on the back, so it was wasted with another nurse working that day. Staff D did not remember who co-signed the waste. The DON called Staff L, RN, on 01/08/26 at 1:45PM. Both surveyors listened via speaker phone. Staff L, RN stated, the pill was loose, whenever that happens, we waste it. When asked if she remembered when this took place, she said no.

Based on observation, interview and record review, the facility failed to appropriately label and store drugs in accordance with currently accepted professional principles for 1 of 3 sampled residents for medication administration observation, Resident #16. The findings included: Review of the policy, titled, 5.0 Medication Storage, documented, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL Department of Health guidelines. Procedure. C. Medications will be stored in the original, labeled containers received from pharmacy.Review of the record revealed Resident #16 was initially admitted to the facility 03/22/21 and had a re-entry date of 10/19/22 with the primary diagnosis of Parkinsonism. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment.Review of Resident #16's care plan dated 12/08/25 documented, Resident #16 is on anticonvulsant medication due to DM [Diabetes Mellitus] Neuropathic Pain. Administer anticonvulsant medications as ordered by physician.Review of the current orders documented, Gabapentin Oral Capsule Give 100 mg orally three times a day - 1 capsule by mouth three times daily for diabetes mellitus neuropathy pain, dated 05/17/25.A medication administration observation was conducted for Resident #16 on 01/07/26 at 9:34 AM with Staff A, RN (Registered Nurse), where Staff A was observed dispensing the resident's morning medications. Upon the medications being dispensed, Staff A stated she was dispensing Gabapentin 100 mg and proceeded to pop one capsule into the medication cup. Staff A then handed the surveyor the medication card, the medication card read as followed, Gabapentin Cap 100 mg; 3 Caps (300MG) by mouth twice daily for neuropathy. There was no resident name noted on the medication card and it appeared to have been ripped off. Photographic Evidence Obtained.A reconciliation count was made where Staff A was asked to count the total amount of pills she had in her medication cup; Staff A stated her total number of pills was 9 and the surveyors count was 11 per the medication card's doses. Staff A was asked to review the Gabapentin medication card, upon her review Staff A stated oh it should be 3 capsules and popped 2 extra pills into her medication cup. When asked how she knew the medication card belonged to Resident #16 if there was no Resident name on it, she looked at the medication card and then went through additional medication cards she had for Resident #16 where a second medication package was also found to read Gabapentin Cap 100 mg; 3 Caps (300MG) by mouth twice daily for neuropathy. This medication pack was also missing the Resident name on it. Upon further review, Staff A looked at her orders for Resident #16 which stated, Gabapentin Oral Capsule give 100 mg orally three times a day - 1 capsule by mouth. Staff A realized these medication cards did not belong to Resident #16 and stated she was going to take the medication cards to back order. When asked why she was using medication cards with no resident label, Staff A was not able to answer. She agreed the importance of reading the medication cards prior to dispensing medication and stated she would send it back to pharmacy.On 01/07/26 at 10:15 AM, during a side-by-side review of the medication administration findings, the Director of Nursing (DON) agreed with the findings and stated the medication cards would be sent back to pharmacy to be labeled appropriately.

Based on observations, interviews and record reviews, the facility failed to follow the approved recipe for the desserts that were served for lunch on 01/06/26 and 01/07/26. The findings included: 1. Review of the approved menu documented the residents were to be served a Cinnamon [NAME] Sugar Blondie for dessert for lunch on 01/06/26. During an observation of the lunch meal, on 01/06/26 beginning at 11:37 AM, it was noted that many of the residents, including Residents #3, #120, #122, and #163, were served what appeared to be a serving of chocolate pudding. The residents' tray tickets that accompanied the meal documented that they were to be served 'Vanilla Pudding Parfait'. The approved recipe for 'Fortified Pudding Parfait' documented: Garnish with whipped topping; and may use any flavor of pudding. During an interview, on 01/06/26 at approximately 12:30 PM, with the Certified Dietary Manager (CDM) when asked about the dessert, the CDM stated the pudding was for residents with orders for fortified foods. During the interview, the CDM acknowledged that the pudding that was served was not the correct 'Vanilla Pudding Parfait' as it was not vanilla and did not have any garnish. 2. Review of the approved menu for the lunch meal on 01/07/25 documented that the residents were to be served 'Marble Cake with [NAME] Frosting'. The approved recipe for the 'Marble Cake with [NAME] Frosting included the following instructions: 1. Combine chocolate cake mix and water. 2. Combine white cake mix and water. 3. Pour both cake batters into greased and floured half sheet pans. Gently mix batters together to make large swirls in the batter. 4. Bake in the oven at 350 degrees. 5. Spread frosting evenly on cooled cake. During the follow up kitchen tour, on 01/07/26 at 11:16 AM, it was noted that the kitchen staff had prepared what appeared to be a yellow cake with a dollop of white frosting and a swirl of chocolate syrup on top. When the CDM was asked about the marble cake, the CDM voiced the details of the recipe for the marble cake and acknowledged that the cake that was prepared and being served was not a marble cake. The CDM acknowledged that the yellow cake that was being served and the marble cake that was supposed to be served had entirely different flavors. 3. Record review revealed Resident #3 was admitted on [DATE] with diagnoses that included: Acute Osteomyelitis, Diabetes, Hypertension, Hyperlipidemia, Chronic Kidney Disease, Chronic Embolism and Thrombosis, of Lower Extremity, and Non-Pressure Chronic Ulcers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, on a scale of 0 to 15, indicating intact cognition. Review of the physician orders documented Resident #3 had a Diet Order dated 08/21/25 for CCD (Controlled Carbohydrate Diet) NAS (No Added Salt) diet, Regular texture, Regular/Thin Liquids consistency. During an interview with Resident #3 on 01/06/26 at approximately 10:00 AM, the resident stated the Dietary Staff were not following what was on the meal tickets. On 01/06/26 at 12:08 PM, during a meal observation in Resident #3's room, it was observed that the resident's tray ticket specified Vanilla Pudding Parfait. The resident had Chocolate Pudding. Photographic Evidence Obtained.

Based on observations, interviews, and record review, the facility failed to provide food that avoids allergens for 1 of 6 sampled residents, Residents #103, and the facility failed to provide food according to residents' preferences for 1 of 6 sampled residents, Residents #3. The findings included: 1. Record review revealed Resident #103 was readmitted on [DATE] with diagnoses to include: Cerebral Infarction, Cerebral Atherosclerosis, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Seizures, Depression, Hypertension, and Hypothyroidism. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 02, on a scale of 0 to 15, indicating Resident #103 had severe cognitive impairment. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 06/12/23 indicated under allergies, Gluten. Photographic Evidence Obtained. As per the Diet History and Food Preference document dated 10/17/25, under Food Allergies/Intolerances, it documented, GLUTEN no bread. Photographic Evidence Obtained. On 01/05/26 at 11:57 AM, during a dining room observation, it was noted that Resident #103's tray ticket had in large, bold Allergies: flour. The lunch tray was observed with Chicken Pot Pie. An attempt was made to interview the resident regarding the allergy, but the resident was unable to respond appropriately due to her poor cognition. Photographic Evidence Obtained. On 01/06/26 at 12:12 PM, Resident #103's lunch tray was observed with Egg Noodles and Ground Swedish Meatballs. She had consumed all the meatballs. Photographic Evidence Obtained. On 01/06/25 at 12:48 PM, the Certified Dietary Manager (CDM) provided the ingredients for the Meatballs and Noodles. Both contained flour. Photographic Evidence Obtained. The CDM stated that he did not have any Gluten Free items. The Pot Pie Filling recipe was also provided, and it contained flour. Photographic Evidence Obtained. On 01/06/26 at approximately 1:00 PM, an interview was conducted with the Registered Dietitian (RD) regarding Resident #103's allergy to gluten. The RD stated the resident's representative had provided dietary preferences since the resident was unable to and the resident did not get bread on meal trays. On 01/06/26 at 1:06 PM, a phone call was placed to Resident #103's representative who stated that he had never asked for the resident to be on a Gluten Free Diet. On 01/07/26 at 11:53 AM, Resident #103's lunch tray was observed with an Open-Faced Sandwich on Bread and Marble Cake for dessert. The Tray Ticket no longer indicated the resident was allergic to flour. Photographic Evidence Obtained. On 01/08/26 at 11:42 AM, an Advanced Practice Registered Nurse (APRN) progress note with an effective date of 01/07/26 was observed with, Patient stated has been taken Gluten without reaction. Allergy resolved per patient. Photographic Evidence Obtained. On 01/08/26 at 11:45 AM, a RD note, effective 01/06/26, documented, RD did discuss with Nursing attaining an allergy test, as feasible to ensure [resident] has No true allergy for her overall health and avoiding any negative reactions to food provided to her. will monitor and review per policy. Photographic Evidence Obtained. On 01/08/2026 at 04:20 PM the RD was interviewed over the phone. The RD stated that she had not removed the allergy from the meal tickets and that Nursing had removed it. The RD stated that she had spoken with the Director of Nursing (DON) about the allergy. The RD called back a few minutes later and stated that she had again spoken with the DON who stated that Resident #103's APRN had been contacted and had advised to remove the allergy. On 01/08/26 at 5:12 PM, an interview was conducted with the Director of Nursing (DON) who was made aware of the progress note written by the APRN stating that the resident reported not having an allergy to gluten. When reminded that Resident #103's last BIMS score was 02, the DON made no comment. 2. Record review revealed Resident #3 was admitted on [DATE] with diagnoses to include: Acute Osteomyelitis, Diabetes, Hypertension, Hyperlipidemia, Chronic Kidney Disease, Chronic Embolism and Thrombosis, of Lower Extremity, and Non-Pressure Chronic Ulcers. Review of the quarterly MDS assessment dated [DATE], documented a BIMS score of 14, on a scale of 0 to 15, indicating Resident #3 had intact cognition. Review of Resident #3's physician diet order dated 08/21/25, CCD (Controlled Carbohydrate Diet) NAS (No Added Salt) diet, Regular texture, Regular/Thin Liquids consistency. During an interview with Resident #3 on 01/06/26 at approximately 10:00 AM, the resident stated that the Dietary Staff were not following what was on the meal tickets. On 01/06/26 at 12:08 PM, during a meal observation in Resident #3's room, it was observed that the resident's lunch tray ticket specified Vanilla Pudding Parfait and Lemon Butter Baked Fish Fillet. The resident had Swedish Meat Balls and Chocolate Pudding. The resident stated that he did not care for the meatballs and declined asking for another food item. Photographic evidence was obtained.

Based on record reviews and interviews the facility failed to coordinate the care ordered by the podiatrist for 1 of 3 sampled residents (Resident #2). The findings included:Review of the record revealed that Resident #2 was admitted to the facility on [DATE]. Review of the diagnosis revealed a documented history of Type 2 diabetes with left foot ulcer, chronic osteomyelitis (infection in bone), and right below the knee amputation. During an interview with Resident #2's daughter on 10/28/25 at 1:45 PM, she stated that she was concerned because her father is healing from an amputation of his left toes. She stated that she scheduled a follow up appointment for the resident to be seen be the podiatrist on 10/27/25 and he missed the appointment, because the nurse forgot to make arrangements for transportation. The resident's daughter stated I am concerned about the delay in care. My father was supposed to have surgical debridement done but the facility failed to do what was needed for medical clearance. During an interview with the Administrator on 10/28/25 at 1:20 PM, the podiatry visit notes for Resident #2 were requested. She stated, They should be uploaded on the resident's record. She was made aware that no podiatry notes were found on the resident's chart.During an interview on 10/28/25 at 3:32 PM, the administrator stated that she had to call the podiatrist office to get copies of the visit notes, because they could not locate them. She provided copies of the visit notes for 09/22/25 to 10/17/25.Review of the podiatry visit note dated 10/03/25, documented a plan that new dressing orders were given and Resident #2 was to follow up in 2 weeks.Review of the physician orders for Resident #2 did not reveal any updated wound care orders as of 10/03/25. Review of the podiatry visit note dated 10/17/25, revealed documentation by the podiatrist that stated suspect pseudomonas infection of the left foot wound and further surgical debridement is warranted at this time, a script for medical clearance and cephalexin. The plan was for Resident #2 to have surgical debridement within the next 7-14 days pending medical clearance.During an interview on 10/28/25 at 4:30 PM, the first floor Unit Manager was asked to view the progress note for 10/03/25. When asked were orders sent with visit note, she looked in the resident's record and stated I don't know. The only wound care order for Resident #2 is from 09/18/25. She was asked to view the visit note dated 10/17/25 and was asked if she knew where the script for medical clearance and the cephalexin was that was given with the visit note, shed stated, I wasn't aware of this. The Unit Manger was asked what the process was when the resident had a doctor's appointment and returned with paperwork, she stated Either me or the nurse will review the paperwork and input any orders. When asked what if the resident returns from a doctor's appointment without any paperwork what would you do, she stated I would call the doctor's office to follow up.During an interview with the ADON (Assistant Director of Nursing), when asked what the process is when a resident has a doctor's appointment and returns with paperwork, she stated, The nurse should review the paperwork and put in any orders given. When asked what if the resident returns without paperwork, she stated the nurse should call the doctor's office to make sure no new orders were given.

Based on observations, interviews, and staffing calculations, the facility failed to ensure sufficient staffing as evidenced by identified care issues during this survey, voiced concerns from Residents #73, #31, #74, #63, #45, #221, and #104, documented low-weekend staffing, and concerns voiced in Resident Council. The findings included: 1) During this recertification survey, the following issues, potentially related to the lack of staff, were identified and noted: a) Failure to ensure timely and proper incontinence care for Residents #47 and #66, failed to ensure shower and shampooing hair for Resident #74, and failed to ensure nail care for Resident #8. (Refer to F677 and F690). b) Failure to ensure timely and appropriate respiratory care for Residents #78, #51, #31, and #82. (Refer to F695). c) Failure to ensure palatable and hot food as voiced by Residents #82, #89, #93, and #77. (Refer to F804). d) On 06/24/24 at 11:57 AM it was noted the Second Floor Unit Manager was working as the direct care nurse for the 2N unit. When asked why she was working the floor as a direct care nurse, the Unit Manager stated, We had a call out. You know it happens. e) Upon arrival to the 2N unit on 06/27/24 at 9:33 AM, the staffing was posted on the white board and documented Staff U, Licensed Practical Nurse (LPN) was the assigned direct care nurse. Upon arrival to the 2N medication cart, the First Floor Unit Manager was at the cart, appeared rushed preparing medications for the residents, with the Second Floor Unit Manager at her side. When asked about the lack of the assigned direct care LPN, the Second Floor Unit Manager stated they had a call-off a little earlier. 2) During this recertificaiton survey, the following voiced concerns related to staffing were noted: a) During an interview on 06/25/24 at 11:32 AM, when asked if staff were responsive to his needs, Resident #73 stated, The evening and night CNAs (Certified Nursing Assistants) don't respond. They are sleeping. Resident #73 stated his call light is on the floor more often than within his reach, even though he asks them to tie it onto his bed rail. The resident explained he often has to yell out for help or get his roommate to push the call light. The resident stated he was so aggravated at times he, Feels like throwing things (to get attention, but he doesn't). When asked why he usually calls for help, the resident stated it was to get changed (referring to incontinent care). Resident #73 stated the average wait time for care on the evening and night shift is an hour, and if it's close to shift change it is a longer wait. When asked how the staff respond, the resident stated staff come in and turn the call light off at times, but most of the time they don't even show up. The resident voiced the staffing was worse on the weekends. When asked if he had voiced his concerns to anyone, Resident #73 stated he spoke with management a while ago. Review of the record revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, on a scale of 0 to 15, indicating the resident was cognitively intact. b) During an interview on 06/24/24 at 10:33 AM, Resident #31 stated he often has to wait an hour for staff to assist him with repositioning. The resident's BIMS score was 14, indicating he was cognitively intact. c) During an interview on 06/25/24 at 11:43 AM, Resident #74 stated he has been left in his chair for up to five hours because there is not enough staff. The resident also stated sometimes incontinent care is provided at 1 PM, and then he is not provided incontinent care again until 9 PM. Resident #74 stated there is not enough staff to help reposition him either. Resident #74 had a BIMS score of 13, indicating he is cognitively intact. d) During an interview on 06/24/24 at 1:05 PM, Resident #63 stated his only complaint is that the 11 PM to 7 AM staff are not attentive. The resident stated he has to yell and scream, they just won't come, and he feels the staff are sleeping at night. When asked what assistance he required during the night, Resident #63 explained that he has a sacral pressure ulcer and although he can't lie on his sides for a long period of time, he would like to get off of his back at times. He further stated if staff do put him on his side, they won't come back to put him back on his back when he calls. Resident #63 had a BIMS score of 15, indicating he was cognitively intact. e) During an interview on 06/24/24 at 10:58 AM, Resident #45 stated when she does number 2 (defecate) in the morning, sometimes she doesn't get changed until the afternoon. Resident #45 was admitted to the facility on [DATE] and stated that had happened three times. The resident voiced there's not enough staff. Although the resident's BIMS score was an 08, indicating she had some cognitive issues, she was able to be interviewed. f) During an interview on 06/24/24 at 11:30 AM, Resident #221 stated, I don't think there is enough staff. During the night I have to wait a long time to get someone to answer my call for help. Sometimes they don't come. Resident #221 was a new admission, was alert and oriented, and able to be interviewed. g) During an interview on 06/24/24 at 10:46 AM, Resident #104 voiced concern about a lack of staff. The resident explained she has waited two hours for staff to answer her call light and change her (provide incontinence care). Resident #104 had a BIMS score of 14, indicating she was cognitively intact. During this interview, her roommate stated the night CNAs do not answer the call light timely. The roommate stated they were short staffed on Saturday 06/22/24, and Resident #104 had to wait two hours for incontinence care. 3) Review of the staffing calculations for the second quarter of 2024 (starting on 03/31/24) to present, revealed the facility consistently utilized 10 CNAs over a 24-hour period on the weekends, with only 9 CNAs noted on Saturday 05/18/24. The number of CNAs during the week for this same time frame was 11 to 13 CNAs in a 24-hour period. During an interview on 06/28/24 at 4:31 PM, when asked if they had enough staff, the Staffing Coordinator stated they are pretty well staffed except for Sundays. When asked about the weekends in general, the Staffing Coordinator agreed they should staff the same on the weekends as they do during the week. When told their staffing numbers are consistently lower on the weekends, the Staffing Coordinator agreed. 32078 4) On 06/27/24 at 3:00 PM, a special Resident Council meeting was held to discuss concerns voiced by many of the residents during the initial interview process. The following 4 residents in attendance for this meeting were all alert and oriented and regularly attended the monthly resident council meetings: Resident #88, who has a BIMS (Brief Interview of Mental Status) of 13 out of 15 (cognitively intact); Resident #84, who has a BIMS of 14 out of 15; Resident #14; who has a BIMS of 15 out of 15; and Resident #15, who has a BIMS of 13 out of 15. Resident #54, who has a BIMS of 15 and had never attended a Resident Council meeting before, attended for approximately 5 minutes in the beginning. Each of these 5 residents confirmed that staff response to call lights is very bad at night and on weekends. Resident #15 stated, Staff will come in and tell you they are coming back, but they never do. Residents #88, #84, #54, and #14 all stated that during the nights and on weekends, it often takes a couple hours to get help, and sometimes staff will never come at all. The 4 regular Resident Council attendees confirmed that incontinent care is not done in a timely manner, especially at night. Resident #14 stated: I have had to stay in wet briefs all night because I couldn't get staff to answer the call light. I would hear them laughing and talking outside my room, but as soon as I turn on my call light, they all seem to disappear. These 4 Resident Council Attendees also stated that the food is consistently served cold. They each stated they have complained to the Dietary Department about the food being served cold. Resident #14 stated, Even though there has been a small improvement lately, it hasn't been a consistent improvement. The 4 resident Council attendees ( Residents #88, #84, #15, and #14) confirmed that food trays will often sit in the carts for a long time before staff pass them out to the residents. Also, each of the Residents Council attendees stated there are many times the food is not served according to the resident's preferences.

Based on observation, interview and record review, the facility failed to ensure right to privacy for Resident's person and records affecting Resident #9, #116, and #77, related to privacy curtains, loudly speaking residents's diagnosis, walking into resident rooms without permission and leaving residents naked. The findings included: 1) Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including: cancer, and bipolar disorder. The quarterly minimum data (MDS) assessment, reference date 03/27/24, recorded a Brief Interview for Mental Status score (BIMS) of 15, indicated the resident was cognitively intact. On 06/24/24 at 11:13 AM, an interview process was started with Resident #9.Tthe resident was observed to be alert and oriented. He explained that privacy is huge for him; sometimes when staff are providing activity of daily living care, to included bed bath, the staff don't close the curtain all the way, while his body was exposed while lying in the bed; sometimes people come into the room without knocking and/or asking for permission, while he is receiving care, and sometimes when they knock on the door, they give him no time to respond, the staff just walk right in. He stated, The staff need to be respectful about his privacy, and the staff need to knock on the door and ask for permission before entering his room. He further explained due to the lack of privacy it has become stressful to him when a Certified Nursing Assistance (CNA) say they're ready to provide care to him. He said his stress level goes up because he kept thinking who's probably going to walk into the room without knocking and/or asked for permission. He divulged, when his roommate visitors come in, he had told the facility he doesn't want visitors in his room, while he was receiving care, because the curtain does not close all the way the visitors would be able to see his exposed body, but the facility told him this was not a private room. On 06/24/24 at 11:54 AM, while the interview process was being conducted with Resident #9, the surveyor was standing in front of the closed room door, that suddenly, Staff Q, a CNA opened the door, she almost hitting the surveyor with the door. The surveyor then yelled, don't hit me with the door please! and quickly moved away. Staff Q did not knock on the door, or asked for permission to come, she walked right into the room to bring the lunch tray to Resident #9's roommate. During that time Resident #9 looked at the surveyor while stating proof. On 06/27/24 at 12:25 PM, the resident's roommate had 2 family members visiting. At 12:27 PM, the family had left the room, and during that time staff A, CNA, came to the room to tell Resident #9 that she was ready to provide care to him. The resident was noted stressed out and he was shaking. He then refused the care. He stated, he doesn't want to receive care right now, because he is stressing out, he doesn't know if the roommate family are going to return to the room and see his body while lying in the bed. The resident said the curtains did not pull all the way. During that time, observation was made of his curtain and the roommate curtain. When asked, Staff A pulled his curtain and the roommate curtain closed. Both curtains had a huge gap, they were not able to close all the way. Staff A then said, maintenance said he was going to fix it, she has reported to maintenance. Subsequently, Staff A made a statement in the presence of Resident #9. She said he was refusing care, that's his choice and his right. At that moment, an interview was held with Staff A. The surveyor asked her why the resident refused care. She stated, I don't know. The surveyor asked her what she thought about the curtain. She confirmed they were not able to close all the way, and the roommate's visitors would be able to see his body if they were to come back in the room. During that time the resident's roommate returned to the room to say goodbye to him. On 06/27/24 at 12:52 PM, the resident was in the process of receiving care and the curtains were not replaced, they were still short with a huge gap. 2) On 06/25/24 at 9:37 AM while the surveyor was standing in the hallway, there were two nurses standing in the hallway as well. Staff B, Registered Nurse (RN) was heard telling Staff C, (the North and South unit manager) that she was looking for the HIV medication for a resident. She stated the resident's room number loud enough that the surveyor was able to hear it. During that time there was one housekeeper staff standing immediately next to them, and all the residents' doors in the unit were open with the potential for them to hear about a resident's diagnosis. At 9:39 AM, an interview was held with Staff C who acknowledged the nurse had spoken loudly while in the hallway and repeated a resident diagnosis. 3) On 06/25/24 at 10:13 AM, while interviewing a resident in her room, the door was closed. The Human Resources staff knocked on the door, he didn't wait for permission to enter the room, and he then commenced to walk in the room. Once he saw the surveyor standing there, he apologized and left. On 06/28/24 at 10:22 AM, an interview was held with the Social Service Director (SSD) and the Director of Nursing (DON). They were made aware of the privacy concerns. 25404 4) Review of the record revealed Resident #77 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 13, on a 0 to 15 scale, indicating he was cognitively intact. Resident #77 resided in a room with the bed at the window. On 06/24/24 at 10:24 AM, Staff S, Certified Nursing Assistant (CNA), looked out of the opened door of Resident #77, with his gloves on and the curtain pulled around the bed at the door, and stated he was taking care of someone. Within a minute or two, the CNA left the room. Upon entering the room while the CNA was gone, after gaining permission, Resident #77 was observed lying on top of the bed totally naked, with the bed covers at the foot of the bed and out of reach. The curtain was not drawn around the bed. The surveyor excused herself and went back out into the hallway, just outside of the room. Within a minute or two, Staff S returned to the room with a bag of clean linens. During an interview on 06/24/24 at 11:39 AM, when asked about the lack of privacy, Resident #77 stated staff sometimes pull the curtain for privacy, but sometimes do not. Resident #77 stated he had gotten used to it, and just shrugged his shoulders.

Based on policy review, record review, observation, and interview, the facility failed to ensure oxygen care and services for 4 of 5 sampled residents (Residents #78, #51, #31, and #82). The findings included: Review of the policy Nursing - Oxygen Administration effective 04/01/22 documented, General Guidelines: . 5. All disposable equipment labeled with the resident's name, the date it was opened or provided, and should be changed a minimum of every 7 days. 1) Review of the record revealed Resident #78 was admitted to the facility on [DATE] and moved to his current room on 05/14/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident was on continuous oxygen. This MDS documented the resident was totally dependent upon staff for all activities of daily living (ADLs) and had functional limitation in range of motion to all extremities. During an observation on 06/24/24 at 11:14 AM, Resident #78 was lying in bed with the oxygen concentrator running at 3 liters per minute. The concentrator was visibly dirty with black debris, tan colored splattering of what looked like tube feeding formula, and faded white streaks. The filter on the back of the oxygen concentrator was gray to white in color, appeared dusty instead of clean and black or dark. The nasal cannula was noted just under the resident's right eye. During a supplemental observation on 06/26/24 at 9:13 AM, the oxygen equipment remained in the same condition. During an interview on 06/28/24 at 9:58 AM, the Maintenance Director stated his department was not responsible for the oxygen concentrators or oxygen filters. During an interview on 06/28/24 at 10:11 AM, the Housekeeping Manager stated the housekeepers were responsible for cleaning the resident equipment in the rooms, such as oxygen concentrators, but was unsure who was responsible for the oxygen filters. During the environmental tour on 06/28/24 at 10:45 AM with managerial staff, the Administrator stated that the maintenance department was responsible for changing the oxygen filters. 39167 2) Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included cancer of the larynx. Review of the admission Minimum Data Set (MDS), assessment reference date 05/25/24, recorded a brief interview for mental status (BIMS) score of 15, which indicated Resident #51 was cognitively intact. This MDS recorded no mood or behavior concern. Review of physician order, dated 05/20/24, documented Ambu bag at bedside. (Ambu bag is a device known as a bag valve mask, which is used to provide respiratory support to patients). On 06/26/24 at 3:23 PM, Resident #51 was noted with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck). An interview was held with Resident #51, and the resident was asked about the ambu bag which was supposed to be at bedside. The resident signaled I don't know. With his permission, the surveyor looked for the Ambu bag in the drawers and closet. It was not there. At approximately 3:28 PM, the surveyor called the Director of Nursing (DON) to the room and inquired about the Ambu bag which was supposed to be at bedside, per the physician order. The DON searched for the ambu bag in the same locations that the surveyor had searched, and she was not able to find the ambu bag, either. Subsequently, the DON asked Staff C, the North and South Unit Manager, for the ambu bag. Staff C left and went to the other side of the unit and obtained a bag with trach care items, including an ambu bag. When asked where these items were found, Staff C said she kept them in the trach room. 50370 3) Resident # 31 was admitted to the facility on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Chronic Respiratory Failure with Hypoxia (Low Oxygen Tissue Level), Shortness of Breath (SOB) when lying flat. Record review of Minimum Data Set (MDS) dated [DATE] revealed Resident # 31 scored 14 under Section C of the Brief Interview for Mental Status (BIMS) indicating good cognitive function. Review of Physician Order written on 06/03/24 and activated on 06/09/24 showed to Change nebulizer tubing/mouthpiece every Sunday during night shift. Another order for oxygen equipment showed to change tubing every Sunday night, and to provide oxygen inhalation (via nasal cannula at 3 Liters per minute {@3 L}. Review of Care Plan showed this resident has altered respiratory status/difficulty breathing related to Chronic Obstructive Pulmonary Disease (COPD), emphysema, chronic respiratory failure, Shortness of Breath (SOB) when lying flat. The goal of this care plan is for staff to make sure resident have minimal risk of complications related to Shortness of Breath (SOB) though the review date. The interventions include monitoring for the effectiveness and side effects of oxygen therapy with changing and dating nebulizer mask and tubing as ordered, monitoring for signs and symptoms (s/sx ) of respiratory distress, and reporting to Medical Doctor (MD) PRN (pro re nata or as needed) these respiratory distress signs and symptoms. During observation and interview on 06/24/24 at 10:33 AM, this resident was observed with oxygen tubing and nasal cannula wrapped around the left wrist. Resident # 31 stated, I am uncomfortable. The humidifying solution canister and the oxygen tubing had a written date of 06/09. During observation and interview on 06/25/24 at 10 :20 AM, Resident #31 was sitting on his bed with nasal cannula and tubing wrapped around his left wrist. He stated, I can control when to put them inside my nose. He added the insides of his nose were getting dried. Upon closer observation, the oxygen level was between 3 and 4 Liters per minute and the humidifier was on. The green top of humidifying canister had the date of 06/09 written in black ink. In another observation on 06/25/2024 at 11:00 AM, Staff M saw the resident without nasal cannula on both nares indicating he was not receiving the oxygen therapy, This Staff did not say anything to the resident or inform a Nurse that this resident was not receiving oxygen therapy. She left the room without a word. During observation on 06/26/2024 at 12:55 PM, this resident's oxygen canister (humidifier) and tubing still have the same date of 06/09. Resident made a productive cough, and his nasal cannulas and tubing were wrapped around wrist. Suddenly Staff L, a RN, came in (she did not knock on the door). She looked at the resident but did not say anything to him (or reminded resident to put the nasal cannula back on the nares). She went in and then out. This Surveyor waited to make sure she had informed a Nurse regarding this resident not wearing nasal cannula on both nares. After 5 minutes, no Staff came back inside the room. During observation and interview on 06/26/24 2:18 PM with Staff L, an RN, when asked if she had noticed resident was not receiving oxygen therapy because the nasal cannula and tubing were wrapped on his left arm, she stated she just made a quick glance if resident was eating lunch. She stated she did not check anything else. After this conversation, this Staff did not go back to the resident's room to check the oxygen therapy but continued sitting at the front desk. Review of progress notes dated on 06/27/2024 at 00:15 revealed Resident # 31 was restless in bed and had a chief complaint of Shortness of breath presenting an O2 sat (oxygen saturation {the amount of hemoglobin bound to oxygen in your blood}) of 93% (Normal oxygen saturation is 95 % to 100%) on room air. He called 911 and was re- hospitalized . 4) Resident #82 was admitted on [DATE] with the diagnoses of Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), and Chronic Respiratory Failure with Hypoxia and Heart Failure. He was hospitalized on [DATE] with a complaint of Left Flank Pain and a diagnosis of Major Sepsis. He was readmitted to the facility on [DATE] with the diagnoses of Sepsis unspecified Organism, non -ST Elevation Myocardial Infarction, Acute Posthemorrhagic Anemia, Acute Respiratory Failure with Hypoxia. The resident's quarterly Minimum Data Set (MDS) performed on 06/05/2024 revealed a score of 15 on Brief Interview for Mental Status (BIMS) located on Section C indicating good cognitive function. Section O assessment on 06/13/2024 revealed Continuous Oxygen therapy. Further review of plan showed to monitor oxygen saturation and respiratory status, to use oxygen pro re nata (prn or as needed) to maintain oxygen saturation greater than 92 percent (O2 sat >92%), to continue Nebulized treatment, to continue medications, and to get out of bed (OOB) with assistance. The following orders activated on 05/10/24 included to change oxygen tubing and humidifier every Sunday night shift.; to provide oxygen at 3 Liters per Nasal Cannula (L per NC) every shift; to change Nebulizer Tubing and Mask every Sunday during night shift and to date, initial, and place in dated bag; to encourage this resident to use Incentive Spirometry for 3 sets of 10 breathes for 15 minutes; to record volume with best effort and good technique two times a day related to chronic obstructive pulmonary disease, unspecified. Record review of Care Plans based on the diagnoses of COPD, Chronic Respiratory Failure with Hypoxia, Shortness of Breath (SOB) when lying flat and the resident's oxygen usage, this resident will display optimal breathing patterns daily through review date. The facility Staff must do the following: Change oxygen tubing and humidifier as ordered and PRN (pro re nata or as needed); Give aerosol or bronchodilators as ordered. The Staff must also monitor/document any side effects and effectiveness of treatment, ensure the head of bed is elevated or resident is out of bed upright in a chair during episodes of difficulty breathing, monitor for difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond endurance, monitor for signs and symptoms ( s/sx) of acute respiratory insufficiency such as Anxiety, Confusion, Restlessness, Shortness of Breath (SOB) at rest, Cyanosis, Somnolence. During initial observation and interview on 06/24/24 11:22 AM, this Resident's oxygen tubing had a paper tag dated 6/12/24. In an interview, resident said Staff did not change his Oxygen tubing yesterday since he requires longer tubing to go to the bathroom. The Staff said the facility did not have a longer oxygen tubing for him. During observation and interview on 06/24/2024 at 1:22 PM, this resident said he is always on 3 Liters of oxygen per minute. This surveyor observed the oxygen humidifying canister (humidifier is usually a container of a distilled water given concurrently with oxygen therapy to provide moisture to the inhaled air thus preventing nasal mucosa dryness) dated 06/16/2024. The long oxygen clear tubing was dated 06/12/24 (tag wrapped around the tubing). During observation on 06/25/24 at 12:30 PM, Resident # 82 was sitting in bed with the same clear oxygen tubing (dated 06/12/24). He added that Staff did not change his oxygen tubing. It was supposed to be changed last Sunday (06/23/2024). The same canister (humidifier) was dated 06/16/2024. On 06/27/24 at 12:27 PM, during observation this Surveyor noticed the oxygen tubing is connected directly to the oxygen concentrator (the canister of humidifier was missing; observed during the first days of survey), delivering 3 Liters per minute (L/min). There was a new green colored tubing connected to a clear nasal cannula tubing with tape tag dated 06/23/24. Resident # 82 stated they just changed the tubing but did not provide a new humidifier (green top plastic cannister was gone). (The order states to change humidifier every Sunday night).

Based on record review and interviews, the facility failed to ensure timely, accurate, and complete PreAdmission Screening and Resident Record Review (PASSARs) for 3 of 4 sampled residents reviewed for PASARR's (Residents #64, #78, and #94). The findings included: 1) Resident #64 was admitted to the facility on [DATE] with diagnoses including Psychosis and Dementia. No completed Level 1 PASSAR was found in Resident 64's electronic record. On 06/26/24 at 1:54 PM, a request was made to the Social Services Director for a copy of the PASSAR for Resident #64, since one could not be located in the Resident's electronic record. On 06/27/24 at 11:30 AM, the Social Services Director brought a copy of the PASSAR that had been completed by her on 06/27/24. No previous copy of Resident #64's PASSAR was provided. 2) Resident #78 was admitted on [DATE] and readmitted on [DATE] with diagnoses including Parkinsonism and Psychosis. A review of Resident #78's Level I PASSAR, completed on 06/22/23, was not completed in its entirety. There was missing information regarding: Present Location of Individual Being Evaluated Representative's Name, Address, Telephone Number Medicaid Identification Number or Other Health Insurance Name and Number Section I.A had no checkmarks indicating a mental illness or suspected mental illness, even though there is a documented history of Psychosis. Section II.1, II.2a, and II.3b all had checkmarks indicating yes there were situations that would warrant a Level II PASSAR. Section IV, which indicates whether the Resident may or may not be admitted to a nursing facility was left black. Under the signature of the person completing the form, the box asking for information regarding what agencies received a copy of the PASSAR is left blank. No Level II PASSAR was found in Resident #78's electronic record. On 06/26/24 at 1:54 PM, the Social Services Director (SSD) was informed that Resident #78's Level I PASSAR was incomplete and indicated a Level II PASSAR may be required; however, no Level II PASSAR could not be found in the resident's electronic record. On 06/27/24 at 11:31 AM, the Social Services Director stated, The Psychiatrist was in visiting and reviewed the Level I PASSAR and stated that the previous PASSAR completed by the hospital was not accurate, as the information was not reflective of the resident's behavior/diagnoses while residing in the facility. A new PASSAR is being completed to accurately reflect the resident's condition. On 06/27/24 at 12:14 PM, the Social Services Director brought a newly completed Level I PASAR for Resident #78, dated 06/27/24. 3) Resident #93 was admitted on [DATE] with diagnoses including Unspecified Psychosis, Anxiety, Depression, and Dementia. A Level I PASSAR was completed on 05/22/24. Several sections of the PASSAR form were left blank: Social Security Number Present Location of Individual Being Evaluated Representative's Name, Address, Telephone Number Medicaid Identification Number or Other Health Insurance Name and Number No check marks were present in Section A (MI or suspected MI) even though resident does have diagnoses of mental illness (Psychosis, Anxiety Disorder) No check marks were present under SERVICES. There was no indication as to Finding based on (check all that apply): No answer was checked to Question #4: Has the individual exhibited actions or behaviors that may make them a danger to themselves or others? Section IV does not have a check mark in response to the statement Individual may be admitted to an NF (check one of the following: Under the signature of the person completing the form, the box asking for information regarding what agencies received a copy of the PASSAR is left blank. On 06/26/24 01:54 PM, the Social Service Director was informed that the PASSAR for this resident was not complete. She stated, The PASSARs we have been getting from the hospital are almost always not filled out entirely. Sometimes, we get a form with just the resident's first name and nothing else on the form. I try to catch them, but I miss some. On 06/27/24 at 11:40 AM, a fully completed Level I PASSAR was provided by the Social Services Director, dated 06/27/24.

Based on policy review, observation, record review, and interview, the facility failed to respond to a voiced complaint for 1 of 1 sampled resident. Resident #38 voiced a concern about her roommate to staff with no further action or response taken. The findings included: Review of the policy Social Services - Grievance Process revised 02/21/23 documented in part, Purpose: It is the policy of this facility to support the resident's right to voice grievances without discrimination or reprisal. Definitions: 1. Grievance is defined as a concern that cannot be resolved to the satisfaction of the person making the objection at the bedside or immediately. Grievances are formal written or verbal complaints . General Guidelines: 1. the Facility Grievance Coordinator is the Director of Social Services . 4. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Coordinator. Procedure: 1. The facility shall implement a process whereby when there is a grievance, it should be: a. Documented on the facility Grievance Report. b. Routed to the Grievance Coordinator or their designee, if not available. 5. When a grievance is received orally and the resident does not choose to complete a written report, then the staff member receiving the grievance shall complete the report and forward it to the Grievance Coordinator/Director of Social Services. Review of the record revealed Resident #38 was admitted to the facility on [DATE] and moved into her current room on 12/20/23. Her roommate, Resident #40, moved into that same room on 05/14/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #38 had a Brief Interview for Mental Status score of 9, on a 0 to 15 scale, indicating some cognitive impairment. This MDS also indicated it was very important for Resident #38 to choose her clothes, take care of personal belongings, choose between a bath and a shower, choose her bedtime, and have privacy on the phone, indicating she could voice her preferences. Resident #38 was also receiving medications for insomnia, depression, and anxiety. On 06/24/24 in the morning, while observing residents on the second floor, Resident #40 was observed self-propelling throughout the unit. Resident #40 was observed at times yelling out and or crying, with staff needing to redirect and or console, and at other times the resident was calm. On 06/24/24 at about 3:15 PM, Resident #40 was observed in her room, sitting in her wheelchair, constantly moving back and forth in her chair, holding the facility phone that was in her room. Resident #40 was screaming at the phone, and suddenly forcefully threw the phone to the floor. Resident #38, the roommate, and the surveyor both jumped from the startling loud noise. There were black marks all over the floor on the side of the room belonging to Resident #40, showing her agitation as she had wheeled back and forth, turning about (Photographic Evidence Obtained). Resident #38 was visibly upset and stated, This has been going on for a month . 24/7 . she throws her phone and other things day and night . I can't take it. She needs help. It's been a month. After speaking with the resident for a while, she changed the subject and wanted some ice cream. When told the surveyor could not get her anything, but she could use the call bell and ask the staff for some ice cream, Resident #38 pushed the call bell. On 06/24/24 at 3:24 PM, the Social Services Assistant (SSA) answered the call bell, and Resident #40 became visibly agitated again. The SSA asked if he could help Resident #38 who stated, She (referring to Resident #40) is driving me crazy . it's 24/7 . I can't take it. The SSA listened and just stated, OK. Review of the record lacked any documented evidence of this interaction or any follow-up by the Social Services Director (SSD). During an interview on 06/28/24 at 12:12 PM, when asked if there had been any follow-up regarding the interaction observed on 06/24/24, the SSA stated he would get the SSD. On 06/28/24 at 12:33 PM, the SSD stated she was not made aware of any concerns between Resident #38 and Resident #40. When told of the observation and interaction with the SSA, the SSD stated she had not been made aware.

Based on observation and interviews, the facility failed to ensure a clean, comfortable and homelike environment for residents on 3 of 4 units. The findings included: During the initial tour of the facility which began on 06/24/24 at 9:30 AM, the following concerns were observed by the survey team: 1) room [ROOM NUMBER] - The foot of Bed A has a chunk of wood missing from the right side of the footboard, leaving jagged edges. Photographic Evidence Obtained. 2) room [ROOM NUMBER] - The top border of the vertical blinds covering the resident's window was off and positioned upright on the floor in the corner of the room. Photographic Evidence Obtained. 3) room [ROOM NUMBER] - The privacy curtain separating Bed A from Bed B had a large, brown stain on bottom, right section of the curtain; and the pole holding tube feeding bottle had residue smeared on the display screen. Photographic Evidence Obtained. 4) room [ROOM NUMBER] - The air-conditioning vent had dust build up in the top and side vents. A small roach was seen crawling into one of the vents. Photographic Evidence Obtained. 5) room [ROOM NUMBER] - Wall behind Bed B in disrepair. A bowl containing unknown substance with small insects (or seeds??) on top it and the table. Metal parts on the floor at the top of the resident's bed; and Tube Feeding pole and tube feeding machine with brown dripping down the pole and onto the machine. There was also brown residue on the floor near the Tube Feeding pole. The top of the oxygen concentrator contained brown drippings and dust. The brown substance was still observed on 06/28/24 during the tour with Housekeeping and the Administrator. Photographic Evidence Obtained. 6) room [ROOM NUMBER] - Bed A does not have a bedside nightstand/dresser. A plastic bin is being used as the nightstand for Bed A. Photographic Evidence Obtained. 7) room [ROOM NUMBER] - Strong urine odor permeating the room which was also noted on 06/25/24, 06/27/24, and 06/28/24. Per the Unit Manager, the resident in Bed B is known to urinate on the floor. On 06/28/24 at 9:58 AM, an interview was conducted with the Maintenance Director, who stated he had recently been hired for this position. He stated, Resident furniture comes through central supply. The nurse or aides would report missing items so they can be ordered through central supply. The CNA's and nursing staff are to let us know if repairs are needed through messages or work orders. We work off a work order system called Secura and keep a maintenance log of all the work completed. On 06/28/24 at 10:11 AM, an interview was conducted with the Housekeeping Manager, who stated he had only been in this position for 2.5 months. He stated he had not been made aware of the urine odor in room [ROOM NUMBER]. Staff should have notified me if there was still a urine odor in a resident's room after being cleaned. If it is urine-soaked mattress, maintenance is responsible for replacing the mattress. It is my understanding that the CNAs are responsible for cleaning the IV poles and Oxygen Machines during Turn-over, but housekeeping should clean them during their cleaning of the room. We have specific rooms scheduled for deep cleaning twice a month. On 06/28/24 at 10:45 AM, an environmental tour was completed with the Housekeeping Manager and the Administrator. Environmental concerns were discussed with both. She made a note of the missing nightstand in room [ROOM NUMBER], and both she and Housekeeping confirmed they were unaware that a plastic bin was being used instead of a regular nightstand for Bed A. When entering room [ROOM NUMBER], the Housekeeping Manager confirmed the presence of strong urine odor. He stated that it would be addressed by the Housekeeping Department. During the tour, the stained privacy curtain in room [ROOM NUMBER] could not be verified, as the resident was receiving care during this time. On 06/28/24 at 11:32 AM, the Housekeeping Manager confirmed the presence of the stained privacy curtain in room [ROOM NUMBER]. He stated staff were, at this time, replacing the stained curtain with a clean curtain.

Based on record review and interview, the facility failed to follow physician orders related to blood pressure parameters and failed to obtain blood pressure and heart rate vital signs for 2 of 5 sampled residents reviewed for medication usage (Residents #40 and #73), and failed to ensure the provision of medications for 1 of 1 sampled resident who voiced complaints (Resident #82). The findings included: 1) Review of the record revealed Resident #40 was admitted to the facility on [DATE]. Review of the current orders revealed Midodrine (a medication for low blood pressure) was ordered as of 12/23/23, to be given three times daily. This order documented nursing staff were to hold the medication is the resident's systolic blood pressure (the upper number) was above 130. Review of the current Medication Administration Record (MAR) for June 2024 documented the following: a) On 06/18/24 at 2200 (10 PM) the resident's blood pressure was 131/76, and the medication administered. b) On 06/22/24 at 1400 (2 PM) the resident's blood pressure was 138/79, and the medication was administered. c) On 06/23/24 at 2200 (10 PM) the resident's blood pressure was 108/65, and the medication was held. Review of the previous MAR for May 2024 documented the following: d) On 05/21/24 at 0600 (6 AM) the resident's blood pressure was 135/69, and the medication was administered. e) On 05/30/24 at 0600 the resident's blood pressure was 198/55, and the medication was administered. During a side-by-side review of the record on 06/28/24 at 12:25 PM, the second floor Unit Manager was shown the findings and concerns. The Unit Manager stated she would look into it and inform the surveyor of any additional information. As of the Exit Conference, no additional information was provided. 2) Review of the record revealed Resident #73 was admitted to the facility on [DATE]. Review of the current orders revealed as of 02/21/24 staff were to obtain the resident's BP (blood pressure) and pulse twice daily, at 8:00 AM and 8:00 PM. Review of the June 2024 MAR documented a checkmark twice daily, indicating the blood pressure and pulse were being done twice daily. The MAR lacked any documented values for the blood pressure or pulse. Review of the vital sign section of the record revealed a blood pressure reading was documented daily at 8:00 AM. The record lacked the evening blood pressure. Further review of the vital signs revealed the pulse was documented only thirteen of 127 ordered times, since the initiation of the order through 06/27/24. The only days that had a documented pulse were 02/21/24, 03/01/24, 04/04/24, 04/05/24, 04/07/24, 04/12/24, 04/19/24, 05/03/24, 05/10/24, 05/24/24, 05/31/24, 06/07/24, and 06/14/24. During a side-by-side review of the record, on 06/28/24 at 12:13 PM, the second floor Unit Manager was made aware of the findings and concerns. The Unit Manager explained the normal process would be for the staff to document the vital sign readings in the MAR. The Unit Manager stated she would look into it and inform the surveyor of any additional information. As of the Exit Conference, no additional information was provided. 50370 3) Resident #82 was admitted on [DATE] with diagnoses of Heart Failure and Chronic Obstructive Pulmonary Disease (COPD). He was hospitalized on [DATE] with the complaint of Left Flank Pain and a diagnosis of Major Sepsis. He was readmitted to the facility on [DATE]. Record review of quarterly Minimum Data Set (MDS) performed on 06/05/2024 revealed a score of 15, Brief Interview for Mental Status (BIMS) indicating good cognitive function. A medication order initiated on 05/10/2024 and activated on 05/11/2024 of Bumetanide 1mg (milligram) one tablet by mouth one time a day related to Heart Failure (a diuretic that treats fluid retention by reducing swelling or edema). During observation and interview on 06/28/2024 at 09:13 AM, Resident was observed sitting on the right-side of the bed. He had nasal cannula prongs on both nasal openings with a clear tubing dated 06/23/24 connected to long green tubing attached to Oxygen concentrator at 3 L/m (Liters per minute). (There was no visible canister of solution or Humidifier attached to the oxygen tubing). This Resident complained he is having a hard time talking and breathing. He added he has not received his water pill for the past 5 days. When asked why, he stated Nurses do not give it to me, and I do not know why. In an interview and observation with Staff J, an LPN on 06/28/2024 at 09:20 AM, she stated from previous experience that Staff usually call the Pharmacy if there is a missing medication. She will check if the resident is not getting his water pill. She showed this Surveyor the resident has been receiving the medication according to the Electronic Medication Administration Record. In an interview on 06/28/2024 at 10:11 AM, the resident stressed that he did not receive his water pill which was scheduled this morning. The Nurse gave his other scheduled medications but not his water pill. He is almost crying when he said it and added I am very stressed. The medication makes me breathe easier and I continually have a hard time breathing. He also showed this Surveyor his urinal confirming that his urine output is half of what he usually eliminated because the water pill has not been administered to him. He also pointed to his right upper thigh stating, My right thigh is getting more swollen everyday. Record review of the electronic Medication Administration Record on 06/28/2024 at 10:20 AM, revealed there were check marks and Nurses' initials indicating the medications were administered. On 06/23/2024 a check mark with nurse's initials of MLB7 was documented. On 06/24/2024, 06/25/2024, and 06/27/2024 check marks with the Nurse's initials of ssl were documented, and a check mark with Nurse's initials of BS were documented on 06/26/2024. In another interview with Staff J, an LPN on 06/28/2024 at 1:38 PM, she stated she spoke to the Pharmacist who told her that the Bumetanide medication will be delivered later tonight. She then called the resident's physician, who prescribed Lasix (a diuretic that helps reduce sodium and fluid retention in the body). She was made aware by this resident that he had not received the prescribed water pill for the past few days. She gave the one-time prescribed Lasix medication to this resident today. In an interview on 06/28/2024 at 02:40 PM, Resident #82 stated the Nurse gave him a medication, but it was not the same. He needed something for his heart failure and the Nurse did not explain to him what the substitute medication was for. In an interview with the Director of Nursing (DON) on 06/28/2024 at 2:36 PM, she stated the medication is usually stored in the Medication Storage Cart. She asked this Surveyor to accompany her upstairs to show the Medication Storage Cart where the resident's medication is usually kept. She tried her keys on the Medication Cart Middle located in front of the Nurses' Station on the second floor, but they did not work. The DON came back at 2:50 PM unlocked and opened Medication Cart Middle with the new set of keys and started searching for the missing medication, but did not find the missing medication. She then stated The resident's Bumetanide (Diuretic) medication is not here.

Based on record review, observation, interview and policy review, the Facility failed to timely provide the prescribed eyeglasses for 1 of 2 residents sampled for vision (Resident #35). The Findings included: Resident # 35 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Chronic Atrial Fibrillation, Shortness of Breath, Type 2 Diabetes. She had undergone Cataract Surgery on 05/10/2023. Record review on 05/07/2024 of the Minimum Data Set (MDS), Section C revealed this resident received a score of 13 indicating good cognitive function on the Brief Interview for Mental Status (BIMS). Section B showed adequate vison. Additional vision assessment showed resident's ability to see adequate light with glasses or other visual appliances. Corrective lenses (contacts, glasses, or magnifying glass) were used in completing this vision assessment. During an interview on 06/25/2024 at 10:00 AM, the resident stated she is unable to read because the facility did not give her the prescribed eyeglasses. She had been waiting for the eyeglasses since last year after cataract surgery. In an interview with the Social Services Director on 06/24/2024, she stated the facility tried to track the location of the medically prescribed eyeglasses. When asked about the tracking documentation, she was unable to respond. In an interview with the resident on 06/25/2024 at 09:33 AM, she complained that her eyeglasses were sent to the facility by the Eye Company and got lost. She received this information from the Social Services Director. This resident told the Surveyor that she had not been reading since May 2023. She had been waiting for a very long time and she could not get a verifiable response from the facility staff. In an interview with the Director of Social Services on 06/25/2024 at 10:11 AM, she stated Resident # 35 had been seen by an eye doctor last year. The Administrator joined the interview, and she added that the eye doctor's office sent the glasses to this facility last year, but the resident did not receive them. The DON tried calling the doctor back but did not get any response. The facility decided to refer this resident to another eye doctor. This new eye doctor recommended a pair of reading glasses, with 2.5 Diopter (Dpt). This facility provided those to this resident, but the resident gave it back because it did not help her with reading. The Director of Social Services stated that an eye doctor would be seeing this resident on Thursday 06/27/2024, adding that accurate and prescribed eyeglasses are going to be provided to this resident. In an interview with another RN, Staff E on 06/26/2024 at 2:00 PM, she stated the resident did tell her about missing glasses. In an interview with this resident on 06/26/2024 at 2:10 PM, she still has problems with reading and is waiting for her eyeglasses. In an interview with Staff D, an LPN on 06/27/2024 at 9:05 AM, she stated the resident had been complaining about her eye and eyeglasses. She knew about the missing eyeglasses since last month and she never informed the resident's physician. In an interview with a visiting Optician on 06/27/2024 at 1:45 PM, he stated he verified the surgeon recommended prescription eyeglasses after surgery last year. He verified all the information from his phone and added that the eyeglasses were prescribed and ordered from his company. He added the company has a systematic procedure which keeps track of the eyeglasses ordered from them. He was sure they sent the eyeglasses to the facility. He does not understand how a resident failed to receive the prescribed eyeglasses. In another interview with the Director of Social Services on 06/27/2024 at 2:50 PM, she said it takes a month or longer for the ordered eyeglasses to arrive at the facility after ordering them. When asked why this resident's eyeglasses are still not received when they were ordered back in January 2024, she didn't have a response. The facility waited until January 2024 to provide resident the substitute eyeglasses for the prescribed lost eyeglasses post -surgery in 2023. Since January 2024, the facility had not been able to provide prescribed eyeglasses Resident #35 needs to read. In an interview with the Eye Doctor from the eye company on 06/27/2024 at 3:41 PM, he stated he was not made aware by the facility that the prescribed eyeglasses were not received by this resident. In another interview with this resident on 06/28/2024 at 08:57 AM, she stated she cannot see with the glasses she received from the Eye Doctor yesterday. She was told before eye dilatation that when the given eye medication wears off, she would be able to see again with the glasses they left for her, but she cannot see. In another interview with the Director of Social Services on 06/28/2024 at 10:18 AM, she stated she will get the policy and procedures for eyeglasses today. In an interview with Social Services Assistant on 06/28/2024 at 12:30 PM, this Surveyor reminded him to submit the grievance for the lost eyeglasses. This Surveyor wanted to get documentation that the facility tried to track this resident's eyeglasses from the eye company. In an interview with Social Services Director on 06/28/2024 at 1:01 PM, she stated she is still getting information regarding tracking of Resident #35' s glasses. The facility waited until January 2024 to provide the substitute for prescribed glasses ordered by eye doctor post-surgery in October 2023, additionally the facility gave substitute eyeglasses instead of the prescribed glasses. In another interview with Resident # 35 on 06/28/2024 2:54 PM, this resident said that the facility is sending her outside to be eye tested again. She was very upset because she does not know when she can read and see better again. Record Review of a document titled Policy, Procedures and Information: Policy Nursing-Visually Impaired Resident with an effective date of 04/01/2024, showed only definitions of visual devices, the process when residents lose visual devices, interactions with visually impaired residents and interventions to help prevent accidents for the visually impaired residents. There is no written process on how the Facility tracks eyeglasses not delivered or received from the prescribing source. Record review on 06/26/2024 at 3:06 PM showed no Progress notes pertaining to this resident complaining about missing eyeglasses. Until after inquiry with the Director of Social Services, an updated progress notes were electronically written on 06/26/2024 by Social Services Director at 08:55 AM, stating she had contacted the office who was responsible for resident's surgery last year regarding this resident's eyeglasses. There were no notes explaining the result of Resident # 35's eyeglasses inquiries from the office. The facility's Social Services Director did not provide any documentation regarding the lost prescribed eyeglasses.

Based on policy review, record review, observation, and interview, the facility failed to ensure proper incontinence care for 1 of 4 sampled residents reviewed with a history of Urinary Tract Infections (UTIs) (Resident #66). The findings included: Review of the policy Nursing - Perineal Care (care provided to a resident after an incontinent episode) revised 02/21/23 documented, Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure . For a female resident: e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Review of the record revealed Resident #66 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent upon staff for toileting and was always incontinent of bowel and bladder. Review of the physician orders and laboratory results revealed Resident #66 had a UTI as of 07/05/23 with organisms of E. Coli (Escherichia [NAME], normal intestinal flora, that is not found in urine), indicating poor incontinence care. The record also revealed three additional orders for urinalysis on 12/24/23, 05/26/24, and 06/16/24, related to signs and symptoms of a UTI, that were not completed (Refer to F770 for details). An order dated 06/25/24 documented the use of an antifungal and steroid cream to the sacrum. Review of the latest skin evaluation completed on 06/27/24 documented a rash to the sacrum with orders in place. This assessment lacked any redness to the perineal area. Review of the current care plans initiated on 04/30/23 confirmed the bowel and bladder incontinence and the resident's need for total assistance with incontinence care. During an interview on 06/24/24 at 2:50 PM, the son of Resident #66 volunteered, Mom gets lots of UTIs here. She did not get them at home. An observation of incontinence care for Resident #66 was made on 06/27/24 at 11:24 AM with Staff T, Certified Nursing Assistant (CNA). Upon removal of the resident's adult brief and during personal care to the resident's front side, the skin was noted to be red, and the resident was grimacing as if uncomfortable. The CNA did not notice the resident's grimacing. The CNA provided appropriate care to the resident's front area, then assisted the resident to her side. Staff T then cleaned the resident's back side by wiping from the buttock toward the front with each cleansing swipe and rinse. Resident #66 continued to grimace. When asked by the surveyor if that hurt, the resident stated, Yes, that hurts. The CNA acknowledged and provided care more gently. A diffuse red rash was noted on the resident's upper buttock and lower back. During an interview after the provision of care, when asked the appropriate direction for cleansing of the resident during incontinence care, Staff T stated, Front to back. When asked why she cleaned the back side of Resident #66 from back to front, the CNA responded, I did? and had no further reasoning. During an interview with the Second Floor Unit Manager on 06/27/24 in the afternoon, she was unaware of the resident's redness and grimacing observed during the incontinence care earlier that day.

Based on observation, interview and record review, the facility failed to ensure activity of daily living (ADL) care for 3 of 7 sampled residents related to incontinence for Resident #45, hair shampoo and incontinence care for Resident #74, and nail care for Resident #8. The findings included: 1) Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses that included: Cerebral Vascular Accident (CVA), one-sided weakness (Hemiplegia) and depression. The quarterly Minimum Data Set (MDS), assessment, reference date 04/19/24, recorded a brief interview for mental status (BIMS) score of 08, which indicated Resident #45 was moderately cognitively impaired. This MDS recorded the following mood: Feeling down, depressed, or hopeless. Trouble falling or staying asleep or sleeping too much. Feeling tired or having little energy. Poor appetite or overeating. No behavior concern was recorded. The MDS also recorded Resident #45 required supervision or touching assistance with toileting hygiene. She required set up or clean up assistance with Personal hygiene. The care plan, review/revision date 05/09/24, indicated Resident #45 had an ADL self-care performance deficit related to status post CVA with right sided weakness. Also, Resident #45 had potential for impairment to skin integrity related to decreased mobility and bowel/bladder incontinence. The goal was Resident #45 will maintain or develop clean and intact skin by the review date. Interventions included: provide incontinence care as needed. The skin assessment dated [DATE] and 06/26/24 revealed Resident #45 had redness in the sacral and perineal area. On 06/24/24 at 10:58 AM, an interview process was started with Resident #45. She was noted alert and oriented, but slow to respond. During the interview, she stated when she does number 2 (defecate), in the morning, sometimes she doesn't get changed until the afternoon. She said this has happened three times already. On 06/26/24 at 9:00 AM, the surveyor went to check on Resident #45. When asked how she was doing, she said, I am sitting in feces. At 9:01 AM, Resident #45 put the call light on to alert the staff regarding her needing assistance with changing her adult brief. At 9:03 AM the human resources (HR) staff answered the call light. He informed Resident #45 that he was going to seek assistance for her. At approximately 9:05 AM, HR informed the attending nurse, Staff R, a license practical nurse (LPN), that Resident #45 needed to be changed, and he was going to look for the assigned certified nursing assistant (CNA). At 9:18 AM, no one attended to Resident #45 to change her soiled adult brief. At 9:19 AM, the surveyor observed Staff A, a CNA walking in the hallway. When the CNA was asked what assignment she had, the CNA responded with the room numbers that she was assigned, which included Resident #45's room. When asked what she was getting ready to do, the CNA said she was going to assist another resident first, then she would assist Resident #45. At 9:22 AM, Staff R was heard asking for the attending CNA (Staff A) to go assist Resident #45. At 9:29 AM, Staff R saw the attending CNA (Staff A) walking in the hallway and asked her to go and change Resident #45. The CNA said she was going to do Resident #45 next, after she was done with the other resident. At 9:34 AM, Staff A finally went and performed care to Resident #45. At 9:47 AM, while Resident #45 was receiving care, this surveyor observed Resident #45 with extreme redness to her groin and gluteal area. On 06/27/24 at 11:26 AM, a subsequent interview was held with Resident #45. When the resident was asked about the redness to her groin and gluteal area, she stated, That's because I sits in a soiled adult brief for too long, that's what doing it. On 06/28/24 at 11:04 AM, an inquiry was made regarding the resident's severe redness of her skin. The Director of Nursing (DON) voiced that the resident had contact dermatitis. The DON and Social Services Director (SSD) were made aware of Resident #45's voiced complaint of staff not cleaning her timely when she soils her adult brief. 50370 2) Resident #74 was admitted on [DATE] with diagnoses of dorsalgia (spine pain), difficulty in walking, muscle weakness, atrial fibrillation, age related nuclear cataract, essential primary hypertension. This resident had a history of falling in August 2023. A record review of the Minimum Data Set (MDS) dated [DATE], revealed Brief Interview for Mental Status (BIMS) score of 13 in Section C indicating good cognitive function, while Section O showed passive range of motion score of 7 compared to active range of motion score of 0 (zero). Further record review of the modified triggered areas of the MDS revealed Activities of Daily Living (ADL) assistance for movement is needed related to resident's dependent status in the ability to roll from lying on back to left and right side. Pressure ulcer and injury were modified triggered areas due to frequent urinary and bowel incontinence. It also showed that Resident #74 needed substantial/maximal assistance in toileting. During observation and interview on 06/24/2024 at 11:38 AM, the resident stated he wanted his hair shampooed because his hair had not been shampooed for 6 months. He added his scalp itches. When asked how often he shampooed his hair when he was living at home, this resident stated everyday. Resident # 74 added, I really like my hair to be shampooed, but he knew it would be hard to make this simple request from Staff because they are busy. He added that Staff sometimes changed him at 1 PM and the next change or perineal care would be at 9 PM. This resident is still wearing his gown and has not changed into regular clothes. His hair is not combed. His face did not look like it was cleaned after breakfast. During observation on 06/25/24 at 09:31 AM, the resident was deeply asleep. In an interview with the resident and his roommate on 06/25/2024 at 1:30 PM, they both verified that this resident gets perineal care, and changes in positioning at 05:30 AM, with the next perineal care after lunch between 2:00 PM to 3:00PM. Resident #74 stated he sits in a wet brief for hours at times. The resident was still wearing his gown with left over food on his neck areas. His fingernails have brownish material underneath. His hair uncombed, had brownish lower teeth, distribution of whitish hair on jaw, above nose, and facial areas. When asked if staff attended to him, or give him personal grooming assistance, he stated Maybe after 2:00 PM. When asked about hair shampooing, he said he stopped asking staff because he knew the answer. They are busy and do not have time. In an interview with a CNA, Staff K on 06/28/204 at 10:02 AM, when this Surveyor asked about shampooing hair logs, she stated the facility does not have one. When asked if she had shampooed Resident # 74's hair, she stated no. When asked how residents would get their hair shampooed, she stated they must ask. In an interview with a CNA, Staff N on 06/28 2024 at 10:30 AM, when asked if she could provide hair shampooing to this resident, she stated that Resident # 74 is not one of her assigned residents. 25404 3) Review of the record revealed Resident #8 was admitted to the facility on [DATE] and moved to his current room on 03/28/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, on a 0 to 15 scale, indicating cognitive impairment. This MDS also documented the resident needed from partial to moderate assistance for personal hygiene tasks. Review of the current care plan initiated on 01/17/24, and revised on 02/01/24, revealed Resident #8 had an ADL (activities of daily living) self-care performance deficit related to late effects of a stroke affecting his right side. This care plan instructed staff to provide up to moderate assistance of one person for personal hygiene and grooming. During an observation on 06/24/24 at 2:32 PM, Resident #8 was sitting in his wheelchair, pleasantly answering questions. An observation of the resident's fingernails revealed they were trimmed, but black debris was noted under most of his nails on both hands. When asked if staff help him clean his nails, Resident #8 stated, No. A short beard was also noted. When asked if he likes his beard, the resident stated, No, I'd like it cut off. When asked if he could do it himself, he stated, Not anymore. I used to. When asked if staff offer to shave him, he stated they do not. An observation on 06/26/24 at 8:59 AM revealed Resident #8 had been shaved, but his fingernails remained dirty. During an observation on Friday 06/28/24 at 11:26 AM, Resident #8 had just gotten up into his wheelchair. As per his roommate, who was alert and oriented, the resident prefers to get up between 10 AM and noon. Staff N, Certified Nursing Assistant (CNA), was in the room and stated she had just finished providing morning care and put lotion on the resident's hands. Resident #8 was rubbing his hands back and forth and fresh lotion was noted. Three fingernails on each hand remained with black noted under each nail. When asked the process for keeping fingernails clean, the CNA explained they clean the nails as needed, with a wooden stick that is flat on the end. When asked if she does it routinely for the residents, Staff N stated. When I work I do it. When shown the resident's fingernails, the CNA agreed they needed to be cleaned. When asked why she had not done so, the CNA stated she had no reason. Review of staff assignments for the week revealed Staff N, CNA, had worked that same assignment on Tuesday 06/25/24, Wednesday 06/26/24, and Thursday 06/27/24.

Based on interview and record review, the facility failed to provide care for a resident with a surgical wound and to follow physician's orders for wound dressing changes and pedal pulse checks, resulting in the need for urgent surgical debridement and subsequent skin grafts. This affected 1 of 3 sampled residents reviewed for surgical wounds (Resident #1). The findings included: During an interview on 08/27/20 at 9:50 AM, a family member of Resident #1 stated that Resident #1 had been admitted to the facility on [DATE]. Resident #1 had undergone vascular bypass surgery on his right leg and needed surgical wound care and physical therapy. The family member stated that Resident #1 had a follow up appointment on 06/04/20 with the vascular surgeon and at that time, the surgical incision was intact and look good (photographic evidence provided). The family member stated that Resident #1 had a second follow up appointment with the vascular surgeon on 06/11/20. The family member stated that at this visit, the surgical incision had dehiscence (a partial or total separation of previously approximated wound edges) and the underling tissue was black and necrotic. Necrotic tissue is dead or devitalized tissue (photographic evidence obtained). The vascular surgeon informed the family member that the tissue cannot be salvaged and must be removed urgently. The family member stated that Resident #1 had to have a surgical debridement (the removal of dead necrotic or infected skin tissue) on 06/12/20 and lost a portion of his calf muscle and has subsequently had to have multiple skin grafts to cover the wound. The family member stated that she could not believe the staff at the facility had not communicated anything to the family about Resident #1's wound or called the vascular surgeons office. The family member stated that the wound was to have a dressing change every day and that she spoke to the nurses every other day on the phone to see how Resident #1 was doing and no one ever mentioned anything about the wound. Clinical record review revealed that Resident #1 had been admitted to the facility on [DATE]. Resident #1's admitting [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a type of [MEDICAL CONDITION] that causes your bone marrow to make too many red blood cells, excess cells thicken your blood slowing its flow, which may cause serious problems, such as blood clots. Resident #1 is documented as having mild cognitive impairment. Resident #1 had been hosptalized on [DATE] with an occlusion of his right superficial femoral artery and underwent bypass from below the knee popliteal to peroneal artery. Resident #1 had a surgical incision from his right groin to his knee (upper), and a second incision from his right knee to his ankle (lower). Resident #1 had a physician's orders dated 05/27/20: Head to toe skin checks weekly on Monday day shifts. Resident #1 had a physician's orders dated 05/27/20: Monitor surgical site to right lower extremities for signs and symptoms of infection every shift. Resident #1 had a physician's orders dated 05/28/20: Right leg upper/lower extremities coat incision and staples with [MEDICATION NAME] then cover with 4x4 gauze and wrap with ace wrap daily until follow up with surgeon. Day shift. Resident #1 had a physician's orders dated 06/08/20: Right leg upper/lower extremities coat incision and staples with [MEDICATION NAME] then cover with 4x4 gauze and wrap with ace wrap daily until follow up with surgeon. Day shift. Review of Resident #1's hospital discharge paper worked scanned into the facility record dated 05/27/20 revealed , the Discharge Plan from the vascular surgeon, follow up doppler ultrasound, check pedal pulses every 4 hours, and right leg upper/lower extremities coat incision and staples with [MEDICATION NAME] then cover with 4x4 gauze and wrap with ace wrap daily. The resident was not on antibiotics. Review of Resident #1's History and Physical dated 06/01/20 revealed that Staff D, a Nurse Practitioner, documented that Resident #1's Treatment Plan was to follow the vascular surgeon's recommendations to check pedal pulse every shift. Further review of the record revealed that Resident #1's Treatment Plan was updated on 06/03/20, 06/06/20, 06/08/20 and 06/10/20, and all updated plans documented to check pedal pulses every shift. The resident had no documented fever while at the facility. The resident's care plan included only a baseline care plan for Wound care as ordered. Further review of Resident #1's record revealed that there was no order for Resident #1 to have his pedal pulses checked. There was no evidence the nurses checked the pedal pulse every 4 hours as documented on the discharge plan by the vascular surgeon. Review of Resident #1's Treatment Administration Record (TAR) revealed no gaps in documentation for the monitoring of the surgical site for signs and symptoms of infection. The TAR revealed no gaps in documentation for the right leg upper/lower extremities coat incision and staples with [MEDICATION NAME] then cover with 4x4 gauze and wrap with ace wrap daily until follow up with surgeon. Review of Resident #1's hospital record revealed an admission assessment dated [DATE] documenting right lower extremity wound necrosis and dehiscence. Surgical debridement of necrotic tissue and eschar, decreased sensation at digits, wound vac, receiving [MEDICATION NAME], and a wound culture gram positive cocci. Review of the facility provided policy on 08/27/20, Physician Orders at a glance, last revised on 11/06/19; Physician/Medical Practitioners orders given via telephone or verbal: The Nurse receiving the order is responsible for complete order documentation. During an interview on 08/27/20 at 1:00 PM Staff A, a Registered Nurse and the Wound Care Nurse, stated that she had assessed and treated Resident #1's on 06/08/20. Review of Staff A's Observation Note of 06/08/20 revealed 'Resident was in bed resting comfortably, denied any pain prior to treatment. Dressing change to right lower medial leg has 28 staples intact with small opening within staples 1.5 cm x 0.5cm x 0.5cm, edges redness, peri-wound with large purple bruising, moderate amount of sero-sanguineous drainage with no warmth or odor noted. Coated with [MEDICATION NAME] covered with dry dressing secured with kerlix/ace wrap. No pain noted. Seen by Nurse Practitioner today and will follow up with Surgeon on 6/11/2020.' Staff A stated that during the time period Resident #1 was in the facility, she was not working exclusively as the wound care nurse, and she had been assigned to work in the facilities COVID Unit. Staff A stated that she was doing weekly wound assessments, but the Unit Nurses were completing the ordered treatments. A side by side review of Resident #1's TAR for 06/08/20 revealed that Staff A had not documented on the TAR that she had done the ordered treatment. The TAR on 06/08/20 for the ordered 'right leg upper/lower extremities coat incision and staples with [MEDICATION NAME] then cover with 4x4 gauze and wrap with ace wrap daily' was signed off by Staff B, a registered nurse. Staff A stated that Staff B was the resident's unit nurse on 06/08/20. Staff A was asked why the unit nurse would sign off on a treatment that she (Staff B) had completed. Staff A stated that the unit nurses often sign off on the TAR for wound care. Staff A was asked about Resident #1 having his pedal pulses assessed every shift. Staff A stated that Resident #1 should have had his pedal pules checked. Staff A stated that the Nurse Practitioners and Physicians are to communicate with the Unit nurses regarding their orders, and the nurses put the orders in the computer. During an interview at 2:30 PM on 08/27/20, Staff C, a registered nurse, was asked to review Resident #1's TAR for 06/09/20 and 06/11/20. Staff C stated that she had been assigned to Resident #1 and had signed off on the TAR for the ordered 'Right leg upper/lower extremities coat incision and staples with [MEDICATION NAME] then cover with 4x4 gauze and wrap with ace wrap daily'. Staff C stated that she did not recall any issues with Resident #1's surgical incision on 06/09/20. Staff C stated that on 06/11/20, she did sign off for the treatment but did not change the dressing on 06/11/20 because the resident had gone to a follow up appointment at the vascular surgeon and when he returned he had a fresh dressing on his leg. Staff C was asked about Resident #1 having his pedal pulses checked. Staff C stated that she recalled Resident #1 had a doppler of his right leg done on 06/02/20 but was unaware of the results. Staff C stated that she was not aware that the resident was to have his pedal pulse checked every shift. In a side by side review of Resident #1's 06/01/20 History and Physical, and review of treatment plan, Staff C stated that checking the pedal pulses should have been an order. Staff C stated that the Nurse Practitioners communicate to the unit staff what they want for orders. Staff C did not recall any Nurse Practitioners communicating to her regarding Resident #1 needing pedal pulses checked. During an interview at 8:20 AM on 08/28/20 Staff D, a Nurse Practitioner, stated that he could not recall the last time he has seen Resident #1's surgical wound. Staff D stated that he relied on the nurses to keep him informed if there were concerns about a resident. Staff D stated that he had received a request from Staff A regarding Resident #1's surgical incision on 06/08/20. Staff D stated that when he assessed the resident (06/08/20), the dressing was intact, and he did feel a pedal pulse. Staff D stated that he always discusses and reviews residents' condition and plans with the nurses. When asked if he had ordered Resident #1 to have his pedal pulses checked every shift, Staff D stated absolutely and that was something he reviewed with the nurses every time he saw the resident. Staff D stated that he currently does not enter orders into the facility's Electronic Medical Record (EMR), the facility staff enter orders. Staff D stated that of course a resident that had just had vascular surgery would have to have his pedal pulses checked. Staff D could not recall what Unit nurses he had reviewed Resident #1's care with. During an interview at 6:30 PM on 08/28/20, Staff B, a Registered Nurse, stated that she had been assigned to Resident #1 on 06/08/20 and 06/10/20. Staff B reviewed the TAR for 06/08/10 and stated that she had signed off on Resident #1's ordered 'right leg upper/lower extremities coat incision and staples with [MEDICATION NAME] then cover with 4x4 gauze and wrap with ace wrap daily', but she had not actually done the treatment but the wound care nurse, Staff A, had done it. Staff B stated that when the wound care nurse does the dressing change, the unit nurse usually sign off on the TAR. Staff B stated that she documented that the dressing was clean and intact on 06/08/20, not that she had done it. Staff B was asked to review the TAR for 06/10/20. Staff B stated that it is the same as 06/08/20, I documented that the dressing was clean and intact because the wound care nurse would have done it. Staff B was asked if she had communicated with the wound care nurse about Resident #1's wound on 06/10/20. Staff B stated that she could not recall. Staff B was asked if she had any direct observation of Resident #1's lower right surgical incision on 06/08/20 or 06/10/20, Staff B stated that she was not sure, I don't think I did, I was assuming the dressing had been changed. Staff B was asked about Resident #1 having his pedal pulses checked. Staff B stated that she was not aware that the resident was to have his pedal pulse checked every shift. In review of Resident #1's 06/01/20 History and Physical and review of Treatment Plan, Staff B stated that checking the pedal pulses should have been an order. Staff B stated that the Nurse Practitioners communicate to the unit staff and a staff nurse puts the orders in the EMR. Staff B did not recall any Nurse Practitioners communicating to her regarding Resident #1 needing pedal pulses checked. Further review of the clinical record revealed no evidence or documentation of wound or dressing assessment when the resident returned from the surgeon's visit on 06/11/20 to when the resident was discharged to the hospital on the morning of 06/12/20 for surgical intervention. Review of the staffing assignments for 06/08 through 06/11/20 revealed the wound care nurse was either not working these days or not on the unit the resident was on but was an assigned unit nurse on another unit of the facility. The staff nurses had assumed the wound care nurse had completed the dressing changes for the resident. During an interview at 4:30 PM on 08/27/20, the Administrator stated that currently the Nurse Practitioners are not entering orders into the EMR, the facility staff are entering the orders. The Administrator stated that there is planned training for the Nurse Practitioners and the Doctors to enter their orders into the EMR.