Every finding on record at Palm Garden of Vero Beach

Based on record review and interview, the facility failed to ensure provision of their admission Agreement, that included a written notice of resident rights along with services, for 1 of 3 sampled residents, Resident #2.The findings included:Review of the record revealed Resident #2 was admitted to the facility on [DATE] after a hospital stay. Review of the resident documents lacked any signed admission Agreement.During a side-by-side review of the record and interview on 04/30/26 at 11:17 AM, when asked the process for obtaining a signed admission Agreement with resident rights for a newly admitted resident, the Director of Guest Services stated she would talk with the resident to determine if they were able to understand and sign the agreement, checking their cognition and or checking with social services for a Brief Interview for Mental Status (BIMS) score if needed. The Director of Guest Services further stated if the resident was cognitively intact, she would go over the admission Agreement and obtain a signature, and if not cognitively intact she would reach out to the Power of Attorney (POA) or spouse or other family member as applicable. When asked the time frame to complete the admission Agreement, the Director of Guest Services explained that she works part-time at the facility three times weekly, but stated, about 72 hours, depending on if the family was available. The Director further stated the admission Agreement could be done via eSign (electronic signatures) with an email address. Upon review of a blank admission Agreement, the prices for services not covered were not filled in on the form. The Director of Guest Services explained when she populates the form with the date, the prices and or cost of services would automatically populate.During this continued interview, the Director of Guest Services was asked to locate and provide the signed admission Agreement for Resident #2. The Director of Guest Services looked in the electronic medical record (EMR) and stated there was none. When asked what happened, the Director of Guest Services stated she did not know but did recall at the time of Resident #2's admission, she was the only person in Guest Services, and she did take a vacation during that time. When asked about the written notice of costs for services not covered for Resident #2 when her benefits ended, the Director of Guest Services stated the resident or representative would have had a conversation with the Business Office Manager (BOM) and or Social Services Director (SSD) when her insurance benefits ended.During an interview on 04/30/26 at 11:48 AM, when asked how the resident was informed in writing of the room rates when their insurance benefits ended, both the BOM and SSD agreed the information was in the admission Agreement. When asked if either had provided Resident #2 or the representative with the costs not covered, both stated they had talked with the resident and daughter daily and informed them of the costs, but that it was verbal conversations with no documentation.

Based on record review and interview, the facility failed to ensure timely and appropriate care and services for 4 of 5 sampled residents as evidenced by the failure to ensure a timely orthopedic follow up appointment for Resident #2, and failure to thoroughly monitor and assess for a change in condition for Residents #4, #6, and #9, all who were transferred to the hospital with shortness of breath.The findings included:1) Review of the record revealed Resident #2 was admitted to the facility on [DATE] after a hospital stay for an orthopedic procedure. Review of the hospital discharge instructions included the need for a follow-up appointment with the resident's orthopedic surgeon in two weeks, with the instructions to call for an appointment.Review of the record revealed an order dated 01/02/26, seventeen days after admission to the facility, for a follow up appointment with the orthopedic surgeon. An orthopedic progress note revealed the resident was seen in the surgeon's office on 01/12/26, four weeks after the procedure. The record lacked any documented reason for the delay.During an interview on 04/30/26 at 11:01 AM, the Independence [NAME] Clerk voiced difficulty in scheduling appointments with the orthopedic surgeon of Resident #2. The [NAME] Clerk reviewed the calendar for Resident #2 and found the appointment scheduled for 01/12/26 at 9:40 AM. When asked about the 2-week time frame, the [NAME] Clerk stated if the doctor was booked up, they would ask for a verbal order for the wound care nurse to discontinue staples, if needed. When asked if there was any documentation as to why the appointment was delayed for Resident #2, the [NAME] Clerk stated no, and agreed with the findings.2) During an interview on 04/29/26 at 2:17 PM, when asked the process when one of her nurse's identified a change in condition in a resident, the Seaway Clinical Services Coordinator (Nurse Supervisor) stated the nurse should do a head to toe assessment with a full set of vital signs, document it on the Change in Condition form, and notify both the physician and family. When asked specifically about the vital signs, the Clinical Services Coordinator explained they utilize a vital sign machine that will document the vitals taken directly into the electronic medical record (EMR) when they are completed. The Clinical Service Coordinator confirmed the vitals should include blood pressure, pulse, respirations, and oxygen saturation, was made aware of the following, and agreed with the findings.a) Review of the record revealed Resident #4 was admitted on [DATE] with a subsequent hospitalization on 03/12/26. Review of the Change in Condition form dated 03/12/26 at 11:22 PM documented the resident's change was shortness of breath that started that same night. This form documented the blood pressure, pulse, and temperature from 1:52 PM on 03/12/26, ten hours earlier than the actual event.b) Review of the record revealed Resident #6 was admitted to the facility on [DATE] with a subsequent hospitalization on 04/12/26. Review of the Change in Condition form dated 04/12/26 at 9:27 PM documented the resident's change was shortness of breath that started that same night. This form documented the blood pressure and oxygen saturation from 7:15 AM on 04/12/26, the resident's temperature from 5:49 PM that day.c) Review of the record revealed Resident #9 was admitted on [DATE] with a subsequent hospitalization on 03/29/26. Review of the Change in Condition form dated 03/29/26 at 2:16 AM documented the resident's change was shortness of breath that started that same morning. This form documented the resident's pulse from 03/28/26 at 10:04 PM.

Based on observation, review of administrative records and interview, the facility failed to ensure that the facility's vents, other equipment, and areas were maintained, as evidenced by the appearance of multiple air vents having Black colored substances or rust-like staining on them; several ceiling tile and surfaces surrounding the vents having notable water staining around them; and sink cabinets with an offensive odor, black colored and water staining in them.The findings included:A tour of the facility was conducted on 09/17/25 beginning at 10:00 AM revealed multiple air vents with black colored substances or rust-like staining on them and several ceiling tile and surfaces surrounding the vents had notable water stains around them throughout the therapy area and on the Reflection Hallway.In the general therapy area, there was an air vent upon entry into the therapy area, as follows: 2 of three front vents outside the door; and 1 of 2 back vents in the therapy gym had noted black colored substance visible on them. In the general therapy room, there was a hand washing sink and below the sink was a cabinet. Upon opening the cabinet, there was an immediate noticeable offensive musty, moldy smell emitting from the cabinet. Further observation of the cabinet noted black colored substances in the bottom of the cabinet and water stains and cobwebs on the inside bottom side of the cabinet. The restroom in the therapy area also had an air vent with a black colored substance on it. In the Occupational Therapy side of the therapy area, there were several vents in this area which had black colored substances on them. In the Speech Therapy office, the air vent and around the sprinkler head, there was noted water stains on the ceiling and dark colored substances on them. In the Physical Therapy charting room, there was a vent with black colored substance on it.In the Rehabilitation (Rehab) Director's office, the air vent had rust-like staining on it. In the entrance to the Reflection Hallway, there was a large water staining on the ceiling. At the Reflection Nursing Station, the vent was noted to have rust-like spots on it.(Picture evidence available) A random interview with a resident receiving therapy was conducted on 09/17/25 at approximately 1:50 PM. The resident voluntarily said that she noticed that the vents needed to be cleaned. An interview was conducted with one of the therapy staff, Staff A, on 09/17/25 in the morning, revealed that the staff has experienced multiple respiratory illnesses in the last few months and was informed that it was from environmental issues. The staff also expressed that the air quality in the therapy room smells musty and moldy at times, especially when the air conditioner has been off. The staff expressed that the therapy gym air vents have black colored substances on them as well as in some of the smaller rooms in the therapy area. The staff was unaware if any testing for mold had been done but expressed that he/she has been experiencing respiratory issues lately. An interview with another therapy staff, Staff B, on 09/17/25 in the afternoon, expressed they have experienced respiratory illness in the last few months and have noticed the discoloration of the air vents in the therapy area. The staff expressed that they are wearing mask more now. An interview was conducted with the Rehab Director on 09/17/25 at 10:15 AM, who stated that he had noticed the black colored substances around the vents and that he reported this in the electronic system designated for maintenance. He stated they came that same day. He denied being aware of any staff experiencing respiratory issues. An interview was conducted on 09/17/25 at 10:50 AM with the Maintenance Director, who stated the facility is in the process of having a new roof put on and stated there is debris and dust coming down. He denied having testing done on the black colored substances visualized on the air vents. He stated that housekeeping will dust the vents, but the maintenance staff need to take down the vents and clean on the inside. He stated the facility conducts routine vent checks. The surveyor requested copies of the checks. Review of the Monthly AC [Air Conditioner] Vent Cleaning & Dusting Checklist documented the weekly checks. The Checklist noted instructions which is included:*Clean and dust all vents listed below once each week.*Initial in the correct box for each week ending date.*Report damaged, loose, or excessively dirty vents to Maintenance Supervisor. Review of the Monthly vent checklist sheets documented the facility has checked that the weekly checks were completed. Review of the September checks revealed that the staff documented that they have performed the weekly checks for week 1 and week 2 and noted the areas completed included Nursing Stations, Therapy Gym, and Hallway/Common Area Vents.Interview with the Maintenance Director on 09/17/25 in the afternoon, revealed the checks are done on Wednesdays, thus the check for week 2 would have been completed on 9/12/25. However, the surveyor conducted an observation on 09/17/25 and noted the above disparities, 5 days after the facility allegedly conducted the checks and had cleaned the vents. An interview was conducted on 09/17/25 at 11:25 AM with the Reflections Unit Manager, who expressed that there was a leak on the 100-wing, it was reported, and maintenance fixed the leak the same day. It should be noted that the above noted large water damage on the ceiling is from the Reflection Hallway. Review of the maintenance log revealed the following:A 05/16/25 - Work Order # 16784, which documented the PT gym under sink looks like termite pellets and mold. The maintenance staff documented that this was completed on 05/17/25 at 9:11 AM. There is no notation of what was found or done. It should be noted that during the surveyor's tour on 09/17/25, the above noted condition of the cabinet beneath the sink remained the same.A 06/23/25 work order # 17144, which documented, please paint the areas around our duct areas in the gym? Black spots/Stains. Both therapy gyms.' The work order documented a close-out date on 06/23/25 at 1:30 PM. It should be noted that the during the tour on 09/17/25, the conditions remained.

Based on observation, record review, and interview, the facility failed to ensure timely and appropriate quality of care for 3 of 11 sampled residents reviewed for medications and wounds, as evidenced by the failure to timely obtain and administer eye drops and antibiotics for Resident #24, failure to treat a wound per physician order for Resident#102, and failure to obtain a physician order for wound care prior to treatment for Resident #517. The findings included: 1. Record review revealed Resident #24 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 15, on a 0 to 15 scaled, indicating the resident was cognitively intact. During an interview on 04/21/25 Resident #24 stated she missed a dose of antibiotics and had trouble getting her eye drops upon admission to the facility. Review of physician orders revealed the following: a) As of 03/18/25, the resident was ordered the eye drop Lumigan at bedtime for glaucoma. b) As of 03/18/25, the resident was ordered the eye drop Pilocarpine four times daily for glaucoma. c) As of 03/21/25, the resident was ordered the eye drop Dorzolamide twice daily for glaucoma. d) As of 03/18/25, the resident was ordered the antibiotic Ceftriaxone 2 grams intravenously (IV) daily for Osteomyelitis. Review of the March 2025 Medication Administration Record (MAR) revealed the following: a) The Lumigan eye drop was not administered until 03/20/25 as staff were awaiting delivery, thus missing two doses. During an interview on 04/24/25 at 11:23 AM, the Unit Manager stated the eye drop was delivered to the facility on [DATE] and that she did not know why it was not administered timely. b) The Pilocarpine eye drop was not administered until 03/20/25 as staff were awaiting delivery, thus missing five doses. The Unit Manager stated this eye drop was also delivered to the facility on [DATE] and that she did not know why it was not administered timely. c) The Dorzolamide eye drop was documented as administered as of 03/20/25 in the morning, related to awaiting delivery, which would indicate the resident missed three doses. But during the continued interview, the Unit Manager stated the Dorzolamide was not delivered to the facility until 03/23/25. d) The Ceftriaxone IV antibiotic was administered as ordered on 03/19/25, but was not administered on 03/20/25, as the medication was on order. The Unit Manager confirmed this antibiotic was available in their emergency stock and should have been administered. Review of the April 2025 MAR revealed the following: e) The Dorzolamide eye drops were not administered on 04/13/25 and 04/14/25, as evidenced by a blank in the MAR, with no explanation provided. f) The IV Ceftriaxone was not provided on 04/11/25, as it was on order. During the continued interview, the Unit Manager confirmed the IV antibiotic had been available in the emergency supply. 52248 2. Record review revealed Resident #102 was admitted to the facility on [DATE]. Review of current Minimum Data Sheet (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status score of 15, on a 0-15 scale indicating no cognitive impairment. An observation on 04/21/25 at 11:45 AM revealed Resident #102 sitting in the wheelchair and on his right lateral lower leg, he had a skin tear, that was uncovered, with bloody drainage leaking on his sock and on a gauze dressing dated 04/21/25, which was below the skin tear. Review of the physician's order, dated 10/03/24, instructed the staff to cleanse self-inflicted skin areas to the right lateral lower leg with normal saline (salt solution), pat dry, apply xeroform (vaseline gauze), gauze pad and wrap with kerlix (bulky gauze dressing) on every night shift. An observation on 04/22/25 at 10:35 AM, revealed Resident #102 was observed sitting in the wheelchair in the room. There was a skin tear to right lateral leg, that was uncovered, with dry bloody drainage to the area. There was a gauze dressing, that was not dated, below the skin tear. An observation on 04/23/25 at 12:11 PM revealed Resident #102 sitting in the wheelchair with his lunch tray in front of him. There was a gauze dressing dated 04/23/25 to Resident #102's right lower leg, and a skin tear with bloody drainage was observed above the gauze dressing. During an interview on 04/23/25 at 12:19 PM, when asked if the skin tear, that was without a dressing, was the wound that had the ordered treatment or if is was a different wound underneath the dressing, Staff F, Licensed Practical Nurse (LPN), stated, I'm not sure, but I know he scratches his legs. I will change the dressing and look, because his leg does need attention. An observation on 04/23/25 at 3:23 PM revealed Staff F removed the dressing from Resident #102's right lower leg. Staff F removed a rolled gauze dressing, gauze pad, and xeroform. The area on the right lateral lower leg that was covered, was slightly red and the skin was intact. Staff F stated, The resident is saying that the gauze is itchy on his skin and that's why he is scratching his leg. I am not going to cover the area that I uncovered. I will just apply lotion to the area, but I will cover the other area with a bordered gauze after I clean it up. During an interview on 04/23/25 at 3:42 PM, when asked did you perform wound care on Resident# 102, the Wound Care Nurse stated, No, the nurses do. The wound care nurse briefly walked away, returned and stated, Resident #102 said the rolled gauze is itching him. I will put a call out to the ARNP (Advanced Registered Nurse Practitioner) for a new order to apply bordered gauze. He often has an issue with scratching. Review of an order dated 04/23/25, instructed staff to cleanse area to right lateral leg with normal saline, pat dry, apply xeroform and cover with bordered gauze dressing. An observation on 04/24/25 at 9:51 AM revealed Resident #102 sitting in the wheelchair with his right leg elevated. There was rolled gauze on his right leg secured with tape and dated 04/24/25. When asked if the nurse just did wound care to his right leg, Resident #102 stated, Yes. During an interview on 04/24/25 at 10:16 AM, when asked, are you the nurse who performed the wound care on Resident #102, Staff E, LPN, stated Yes, this morning. The wound was bleeding, because he scratches. When asked, did you remove the same type of dressing from Resident #102's right leg that you reapplied Staff E stated, Yes. 52179 3. Record review for Resident #517 revealed the resident was admitted to the facility on [DATE] with a diagnosis that included right ankle fracture requiring surgical repair. Review of the Hospital History and Physical dated 04/13/25 documented, in part, that Resident #517 landed on knees and left elbow .with severe pain in his right ankle. Review of the admission MDS assessment, which was in progress, documented Resident #517 had a BIMS score of 15, indicating the resident was cognitively intact. Review of the Admission Skin assessment dated [DATE] documented a skin tear to the left elbow. Review of the Skin Observation documentation on the Certified Nursing Assistant (CNA) task list from 04/18/25 at 2:01 PM revealed Resident #517 had a scratch and skin tear. Review of the physician's orders did not include an order for the left elbow dressing for the resident. During an observation conducted on 04/22/25 at 10:00 AM, the resident was sitting in a wheelchair, awake and alert and oriented. It was noted that the left elbow was covered with a dry and intact dressing dated 4/18. During an observation conducted on 04/23/25 at 12:17 PM, Resident #517 was sitting in room, awake, alert and oriented. The resident had a new dry and intact dressing on his left elbow dated 4/23 7a/7p. When the resident was asked what happened to his elbow, he stated that happened when I fell two weeks ago. It's nothing really. When asked who applied the dressing to his left elbow, the resident replied, someone here and they put something on it but the resident was unable to provide a name of the caregiver. During an interview on 04/23/25 at 3:30 PM, Staff D, LPN, stated she did not have to perform any dressing changes today for any of her assigned residents. She stated, it was all already done today. An interview conducted on 04/23/25 at 3:38 PM with the Wound Care Nurse (WCN) who stated that she did not do wound care for Resident #517. The WCN stated the nurses do wound care dressing on Monday's, Wednesday's and Friday's. During a side-by-side review of the record and interview on 04/23/25 at 4:00 PM with the Seaway Unit Manager (UM), she confirmed the lack of a physician order for left elbow wound care dressing changes. The UM reviewed the skin assessment documentation on 04/21/25 which identified a left elbow tear and agreed that there should be an order.

Based on observations, interviews, and record reviews, the facility failed to physicians' order were followed to avoid wearing socks to allow the wound to air dry; failed to provide guidance and education regarding the risk of using socks in the affected area; and failed to follow infection control practices, as evidenced by using items placed on the floor, for 1 of 5 sampled residents reviewed for wound care and management, Resident #100. The findings included: Clinical record review revealed Resident #100 was admitted to the facility on [DATE] and again on 02/25/25, with diagnoses that included Hypertension. The admission Minimum Data Set (MDS) assessment, referenced on 02/04/25, recorded a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #100 was moderately cognitively impaired. This MDS indicated no mood, or behavior concerns and documented the resident was dependent on assistance for lower body dressing and putting on or taking off footwear. Review of the care plan, revised on 02/04/25, noted Resident #100 had a pressure injury on the left heel. Interventions on the care plan included floating the heels while in bed as tolerated by the resident and treatments as ordered. Review of Certified Nursing Assistants (CNA) tasks revealed no sock on the left foot. An additional review of the clinical record indicated a physician order dated 04/08/25 to apply Betadine to the left heel every Tuesday, Thursday, and Friday, allowing it to air dry for wound care management. The order specifically stated, no sock to left foot; float heels. Review of the doctor's wound care evaluation dated 04/22/25 included the following recommendations: off-load wounds and float heels in bed. Additionally, place a heel elevator or 2-3 pillows behind the knees (posterior to the popliteal fossa) to elevate the heels from making contact with the bed surface. On 04/22/25 at 10:33 AM, an observation was conducted on Resident #100. She was found lying in bed with her heels positioned directly on the bed, not offloading. Her heel-protector boots were on the floor beneath the bed, and she stated, My heels hurt. On 04/23/25, at 11:56 AM, Resident #100 was observed sitting at the edge of her bed, wearing socks and placing her feet directly on the floor, not offloading them. She was talking to her visitor, who was beside her, labeling new socks that had been brought in. Two heel-protector boots were on the floor next to the bed. On 04/23/25 at noon, Staff A, Wound Care Nurse (WCN), conducted care for the left heel wound, applying Betadine to the open area. Staff A assessed the resident for pain, and the resident expressed that her heels hurt. After the wound care, Staff A asked if Resident #100 wanted to wear the new socks her friend had brought in. The resident responded, Yes. Staff A then applied the socks to the resident's feet and retrieved the heel protector boots from the floor, putting them on the resident's feet. This practice did not follow the physician's order to allow the wound to air dry. Staff A also failed to provide guidance or education regarding the risks of wearing socks in the affected area and the importance of allowing the wound to air dry. At 12:14 PM, the surveyor overheard the visitor telling Resident #100, The socks are not good for the bad foot; you should take them off. At 12:32 PM, another observation was conducted, and Resident #100 was still wearing the socks and the boots. On 04/23/25 at 12:20 PM, Staff C, the assigned CNA, was interviewed. She stated that when she came in, she observed Resident #100 wearing socks and commented, Maybe the previous shift put them on. On 04/23/25 at 1:13 PM, Resident #100 was sitting in bed, still wearing socks and the heel-protector boots. On 04/23/25 at 2:02 PM, an interview with Staff A (WCN) revealed that when asked why she put socks on the resident's feet after the wound care, she stated the resident preferred to have them on. When the surveyor pointed out that the physician's order specifically indicated no sock on the left foot, Staff A agreed upon seeing the order and acknowledged the wound care doctor preferred the socks not to be applied. The surveyor then asked why she had not provided guidance or education to the resident about the risks of wearing socks. Staff A agreed that she should have done so. After the surveyor's intervention, Staff A spoke to the resident, stating, Remember how the socks stick to the wound. The doctor does not want them on. The resident complied and allowed the nurse to remove the socks.

Based on observation, interview, and record review, the facility failed to ensure appropriate care and services for 2 of 3 sampled residents, Residents #162 and #11, who had indwelling catheters and a history of Urinary Tract Infections (UTIs). The findings included: 1. Review of the record revealed Resident #162 was admitted to the facility on [DATE]. Review of the current physicians' orders documented the resident had an indwelling catheter and staff were to flush the catheter as needed. Review of the current care plan initiated on 03/31/25 documented the resident was at risk for complications related to the use of an indwelling catheter. Interventions included to anchor the catheter and to irrigate it as ordered. Review of a urinalysis report revealed urine was collected on 03/31/25 for the test. The results of a positive UTI were reported to the facility on [DATE] with the completed culture on 04/03/25 indicating appropriate antibiotics to use. The urinalysis was not reviewed until 04/06/25 at which time an antibiotic was ordered. An observation on 04/22/25 at 11:26 AM revealed the indwelling catheter bag hanging on the bedside. Cloudy urine was noted in the tubing. During a subsequent observation on 04/23/25 at 9:15 AM, catheter care was observed with Staff G and Staff H, both Certified Nursing Assistants (CNA). Observation of the catheter tubing revealed continued cloudy urine. Photographic Evidence Obtained. During the care, a catheter anchor was noted on the resident's thigh, but the tubing was not secure. When staff turned the resident onto her right side, with the catheter bag on her left side, the tubing was pulled tightly. After the care, when asked the use of the anchor, Staff H stated it was to keep the tubing from pulling. Staff G attempted to hook the catheter into the anchor at the junction, in order to secure it, but Staff H told Staff G that was not correct, and put it back as it was, leaving the catheter loose and freely moving. During an observation on 04/23/25 at 3:43 PM, Staff I, Licensed Practical Nurse (LPN), was unaware of how to utilize the anchor, but agreed the catheter tubing was not secured. When asked if she had assessed the indwelling catheter that day, the LPN stated she had and the urine was cloudy that morning, and agreed it still was. When asked what she should do if the urine was cloudy, the LPN stated she should notify the physician but had not done so. During an interview on 04/24/25 at 9:58 AM, when asked what she would expect a nurse to do if a resident's indwelling catheter had cloudy urine, the Unit Manager stated the nurse should try to flush the catheter, encourage fluids, and call the physician if it persists. The Unit Manager stated she did receive an order for a urinalysis after the surveyor had asked the nurse about the cloudy urine the previous afternoon. When asked the process for reviewing the results, the Unit Manager stated the labs are uploaded by the lab into their electronic medical record and the lab will call the facility with any critical results. The Unit Manager explained that both the nurses and physician or nurse practitioner are responsible for reviewing the labs. During a side-by-side review of the record, the Unit Manager was made aware of the urinalysis of 03/31/25 and delay of antibiotic. The Unit Manager had no reason for the delay. 39167 2. Clinical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses that included non-Alzheimer's Dementia. The quarterly Minimum Data Set (MDS) assessment reference date was 02/23/25, documented a Brief Interview for Mental Status (BIMS) score of 06, indicating Resident #11 was severely cognitively impaired. This MDS did not record any mood or behavior concerns. It was documented that she was dependent and required assistance with toileting hygiene, personal hygiene, and toilet transfers. and was frequently incontinent of urine, indicating a loss of bladder control. The records included a care plan added to the revised plan dated 02/23/25. This care plan documented Resident #11 had incontinence related to impaired mobility, with her incontinent status potentially varying due to her diagnosis of dementia. It also noted that she was frequently incontinent of urine and had the potential for complications secondary to the UTI. On 04/10/25, a urine sample was collected, and the urinalysis results showed a positive urinary tract infection (UTI), which was reported to the facility by the lab on the same day. Further recollection of urine was suggested. On 04/15/25, the facility was able to straight catheterize the resident after several attempts due to her resistance. The results from this urine collection were reported on 04/18/25, confirming the presence of a UTI. On 04/19/25, a physician order for the antibiotic, Macrobid 100 mg to be taken orally twice a day for seven days, was initiated. On 04/24/25 at 11:03 AM, perineal care was initiated by Staff B, Certified Nursing Assistant (CNA). Staff B placed a large towel in the bathroom sink, allowed the water to run until the towel was saturated, and then applied soap. After retrieving the wet towel and squeezing some water out, she approached the resident and brusquely instructed her to open her legs. She then poured water from the towel onto the resident's private area and used wet wipes to clean the groin area and the top of the pubic bone, but did not provide care to the external genital structures. Staff B repeated the process, squeezing more water from the towel onto the pubic area and cleaning it with wet wipes. She then instructed the resident to turn, which the resident did without resistance. Staff B squeezed water from the towel onto the resident's buttocks and wiped them with the wet towel, then used wet wipes for additional cleaning. Without drying the perineal area, she applied protective zinc oxide cream to the buttocks and groin area, then put on a new adult incontinent brief and secured it. The care was completed at 11:09 AM, and Staff B stated, She was done. Later, at 11:56 AM on 04/24/25, the Director of Nursing (DON) and the Infection Control Preventionist were interviewed regarding how the care was provided to resident #11. The surveyor demonstrated the process Staff B had used during the care. The DON and the Infection Control Preventionist agreed that the process was improperly executed.

Based on record review and interview, the facility failed to ensure they followed physicians' orders that were recommended by the pharmacy, as evidenced by not discontinuing orders for Resident #48. The findings included: Record review revealed Resident #48 was admitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status score of 15, on a 0-15 scale indicating no cognitive impairment. A pharmacy consultation report dated 11/23/24 recommended that Lactobacillus (medication to promote growth of good bacteria in the gut) and Pyridoxine (a vitamin that is important for normal brain functioning) be discontinued. On 11/27/24, the physician accepted the pharmacy recommendation by signing the consultation. Photographic Evidence Obtained. Review of the current active orders for Resident #48 revealed the resident was still ordered to take lactobacillus and pyridoxine. Review of April 2025's Medication Administration Record (MAR) for Resident #48 revealed staff had also administered the lactobacillus and pyridoxine to Resident #48 on 04/23/25. Further review of the physician orders and MARs from 11/2024 through 04/2025 revealed the supplements had not been discontinued. During an interview on 04/23/25 at 4:10 PM, when asked who was responsible for making changes to the resident's orders after the doctor accepts or declines the pharmacy recommendation, the DON stated, the Unit Manager.

Based on policy review, observation, interview, and record review, the facility failed to implement effective infection control practices by failing to promptly initiate Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP); and failed to provide appropriate education or ensure competency following facility-acquired urinary tract infections (UTIs) for 4 of 9 sampled residents who should have been on EBP and TBP, involving Residents #129, #80, #31, and #6. The findings included: The policy, titled, Enhanced Barrier Precautions, with implemented date of 08/16/22, documented it is the policy of this facility to implement enhanced barrier precautions [EBP] for the prevention of transmission of multidrug-resistant organisms (MDROs). Enhanced barrier precautions refer to the use of gown and gloves for the use during high-contact resident care activities for residents known to be colonized or infected with MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The policy documented clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. An order for enhanced barrier precautions will be obtained for residents with of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Examples of targeted and epidemiologically important MDROs include but are not limited to: Enterobacterales, pseudomonas, Acinetobacter baumannii, candida auris, methicillin-resistant staphylococcus (MRSA), ESBL-producing Enterobacterales, Vancomycin-resistant enterococci (VRE), drug-resistant streptococcus pneumoniae. The policy, titled, transmission-based precautions, dated September 2019, documented transmission-based precautions are used when the route of transmission is not completely interrupted using standard precautions alone and the pathogen may have multiple routes of transmission. Transmission based precautions [TBP] are divided into: contact precautions, droplet precautions and airborne precautions. Contact precautions: wear PPE [Personnel Protective Equipment], gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment. See nurse sign posting will be on resident rooms alerting health care workers, resident and visitors that they must see the nurse before entering room. The reverse side of the sign will note the type of precaution, method of acceptable hand disinfection and PPE to be utilized. 1. Review of the clinical record revealed Resident #80 was admitted to the facility on [DATE] with a diagnosis that included Cirrhosis. The records indicated that on 04/15/25, a urine sample was collected for urinalysis, culture, and sensitivity (C&S) testing. The results were reported to the facility on [DATE], indicating the presence of extended-spectrum beta-lactamase (ESBL). On 04/19/25, the resident was prescribed 1 gram of Ertapenem (antibiotic/ATB) to be administered intramuscularly in the afternoon for 7 days to treat symptomatic bacteremia. The TBP initiation was noted to have been delayed by 4 days. Additionally, a physician's order for contact precautions related to the ESBL was documented on 04/22/25. The care plan, also dated 04/22/25, stated that Resident #80 was experiencing symptomatic bacteremia. 2. Review of the clinical record revealed Resident #31 was admitted to the facility on [DATE] with a diagnosis that included End-Stage Renal Disease (ESRD). Documentation indicated that on 04/18/25, a urine sample was collected for urinalysis, culture, and sensitivity testing. The results, reported to the facility on [DATE], showed the presence of extended-spectrum beta-lactamase (ESBL). The initiation of transmission-based precautions (TBP) was delayed by one day. Additionally, a physician's order for contact precautions related to the ESBL was documented on 04/21/25. The care plan, dated 04/22/25, noted that Resident #31 had a urinary tract infection (UTI) with ESBL and received antibiotics. 3. Review of the clinical record revealed Resident #6 was admitted to the facility on [DATE], with a diagnosis that included Neurogenic Bladder. On 04/16/25, a urine sample was collected for urinalysis, culture, and sensitivity testing. The results, reported to the facility on [DATE], revealed the presence of extended-spectrum beta-lactamase (ESBL). On the same day, the resident was prescribed 1 gram of Ertapenem {ATB] to be administered intramuscularly at bedtime for 7 days to treat a urinary tract infection. However, initiating enhanced barrier precautions (EBP) was delayed by 2 days. Additionally, a physician's order for EBP related to the Foley catheter and ESBL was documented on 04/22/2025. 4. The Infection by Unit Report from April 1 to April 30, 2025, documented seven UTIs, that included four confirmed as facility-acquired infections for Residents #129, #80, #31, and #6. On 04/24/25 at 12:07 PM, an interview was conducted with the Infection Control Preventionist (ICP) and the Director of Nursing (DON). When asked about the Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) that should have been implemented for Residents #129, # 80, 31, and #6, the ICP acknowledged that these precautions were initiated late. The ICP indicated that the nurses did not begin these precautions. She revealed the facility had identified the issue on Monday, April 21, 2025, which coincided with the arrival of the survey team at the facility. The ICP stated the facility had been experiencing increasing facility-acquired UTIs. The surveyor inquired about the actions taken in response and whether education or competency assessments had been provided to the Certified Nursing Assistants. The surveyor requested documented evidence of such education or competency training. The ICP stated she walks around and speaks with the staff regarding infection control, reminding them to maintain good perineal care and practice proper hand hygiene while emphasizing caution. Notably, the ICP pointed out that she typically does not require staff to sign in-service documentation, indicating a lack of documented competency assessments or in-service training related to UTIs. 38212 5. Record review revealed Resident #129 was admitted to the facility on [DATE] with Diagnosis that included, in part: Chronic Obstructive Pulmonary Disease (COPD), unspecified injury at C3 cervical spinal cord, atrial fibrillation (AFib), chronic pain syndrome, dependence on wheelchair and urinary tract infections (UTIs). On 04/17/25, the facility received a urine analysis results for Resident #129. The urine results indicated the resident had ESBL (Extended Spectrum Beta Lactamases) in their urine. The diagnosis of ESBL makes bacterial infections harder to treat with antibiotics. ESBL producing bacteria can spread from person to person. It can be contacted by simply touching an infected person or touching soiled objects that have not been cleaned thoroughly. By review of the facility policy, a resident who has the diagnosis of ESBL should be on contact precautions. When a resident has any type of precautions in the facility, a sign is to be posted on the door of the resident's room to indicate which type of precautions are to be followed. On 04/21/25 at 9:00 AM, a tour was conducted of the facility. Resident #129's door was observed, and the door did not have any posting for contact precautions. During an interview, on 04/21/25 at 11:02 AM, the Infection Preventionist stated that she had not completed rounds from the previous weekend to determine additional precautions for residents.

Based on interviews and record review, the facility failed to act to ensure prompt and effective resolution of grievances voiced by the members of the Resident Council regarding food and staffing concerns during Resident Council Meetings. The findings included: The facility's Grievance Policy and Procedure ([DATE]) states, The center recognizes the resident/legal representative/family has the right to voice grievances and recommendations for changes through an orderly and timely process free from discrimination and/or reprisal. They have a right to expect the center will make prompt efforts to resolve grievances and, upon request, have the right to obtain written decision regarding the grievance. Procedure: 1. A concern is defined as any formal expression of interest regarding the well-being of a resident. 4. The center will designate a Grievance Official with whom the grievance can be filed and will post his or her name, business address (mailing and email) and business number . 5. The Grievance Official is the Social Service Director/designee of the center. 7. The Grievance Official Center will oversee the grievance process, receiving and tracking grievances through their conclusions through investigating, document and follow-up on all formal concerns and grievances registered by any resident/legal representative/family/concerned party. a. All written grievances decisions will include the date the grievance was received, a summary statement of resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, grievance results that warrant any corrective action taken or to be taken by the center and the date the written decision was issued. b. The resident/legal representative/family/concerned party can expect that the center will review any grievance within 3-5 business days of receipt/notification of the concern. c. The resident/legal representative/family/concerned party can request a written decision regarding their grievances. d. The Grievance Official/designee will track grievances, including resolutions on the Grievance Log. This log will be taken monthly to the center's Quality Assurance Performance Improvement (QAPI) meeting. 21. Group grievances generated in Resident Council meeting will be reviewed by the Grievance Official and determination will be made on a case by case basis whether to initiate and follow the grievance process described in this policy. a. All Resident Council group grievances will be copied and logged on the monthly Grievance Log. b. The Grievance Official will assist Life Enrichment in resolving group grievances. A review of the Resident Council Minutes for the past 6 months revealed the following concerns voiced by the group during the meeting: July 2023 - Call lights not being answered; Beds not being made; menus not matching what is being posted on meal ticket and television; same meals being served. Follow up to concern regarding beds not being made, Nursing department wrote: Are addressing. Please provide the day and name of CNA. Follow up to concern regarding call lights not being answered, Nursing department wrote: Call lights are being audited regularly and addressed. Please provide day and shift as able. No proof of the audits of call lights provided in documentation. In-service was provided to dietary staff on 07/10/23 regarding customer service, food preferences and substitutions. August 2023 - Beds are not being made on weekends. Follow-up to concern regarding beds not being made, Nursing department wrote: I will pass this along to the weekend supervisor Day and also to the weekend MOD's (Managers on Duty) so education can be provided. September 2023 - Beds not being made still unresolved. Resident #24 wife stated there are not enough salads and fresh fruits provided; she also stated her husband sat in wet clothing for hours. All Resident members state they are not getting their scheduled showers. CNAs coming in and turning off call light and leaving, refusing to see or help with resident issues. Follow-up to concern regarding showers and beds being made, Nursing department wrote: please have all the residents stating that they are not receiving showers, also any that state that their beds are not being made because many are. Resident #24 to have grievance completed. Follow-up to concern about answering call lights, Nursing department wrote: Please have all resident that state this provide the names and dates of the CNAs when this occurs. Follow up to food concerns: Food Committee Meetings to be held on First Monday of each month going forward starting in October 2023. Follow-up to concern regarding not making beds on weekends, an in-service was conducted with supervisory nursing staff to monitor and check rooms on weekends. October 2023 - CNAs are arguing at the beginning shifts about their assignments instead of starting care, and nursing stations are not answering phones. Follow-up to concern regarding CNAs arguing over assignments, Nursing department wrote: Team members are adjusting to a new assignment [???] but care will always be provided as requested. I will encourage team members to discuss in a quieted manner. Follow up to concern regarding Nurse's station are not answering calls, Nursing department writes: Can we be more specific as to times. The desk has staff up until 5. After 5 P I will try to get staff to be more attentive since they are doing a lot of care. November 2023 - 3-11 shift is on their phone in room with ear buds. Nurse's give meds while resident is on the toilet. Trash is not being picked up by CNAs. Resident #24's wife states residents are not getting salad and fruits on their tray. Foods are over cooked' some food items are missing from trays. Follow up to concern regarding nurse's giving residents their medications while on the toilet, Nursing department writes: I will continue to educate nurses on dignity and passing medications. Nurses will be educated on where to not pass medications. Follow-up to concern about 3-11 shift on phone with ear buds in rooms, Nursing department writes: Please attempt to name who the CNA are. They are educated regularly on not wearing ear buds while in the center. Follow-up to CNAs not removing trash from residents' rooms, Nursing department writes: Each newly hired CNA and Nurse attends orientation and is educated in Patient Care. Follow-up to residents not getting salad and fruit on their tray and missing menu items on tray, Dietary department writes: will conduct tray audit for 2 weeks. Audit regarding tray accuracy is documented for 1 day (11/08/23). In-service down for dietary staff on 11/08/23 regarding knowing the different kinds of special utensils, cross contamination, Infection Control, Diet Texture, Resident Rights. There is nothing in the training regarding tray accuracy or foods being overcooked. December 2023 - Resident not receiving food that was ordered, food is cold when received, small portions, late food arrivals, running out of foods. CNAs still not taking out trash. Resident #101 wants to know why she never receives a response when she files a grievance. The afternoon shift, 3 PM-11 PM) are screaming and yelling during shift. Follow-up to Resident #101 not receiving a response to her grievances, Nursing department writes, Followed up with grievance form and follow up waiting on response. On 01/05/24, Social Services reviewed the Grievance dated 11/06/23. Confirmed agreement with resolution. Face sheet was updated with appropriate information. Grievance Form completed for grievance voiced regarding 3-11 shift screaming and yelling. Follow up waiting on response. No follow up for grievance regarding trash pick up in rooms. On 12/28/23 an in-service with housekeeping was held regarding putting bags in trash cans. Follow up to food concerns voiced during meeting, Dietary writes, Will keep up with the temperature check on food and make sure enough food is available. January 2024 - Overcooked vegetables and mashed potatoes, late meals. Grievance Form filled out regarding overcooked vegetables and given to Social Services/Nursing Dept. On 01/10/24 at 2:30 PM, a meeting was held with 5 alert and oriented, active members of the Resident Council (Residents #137, #124, #101, and #131), including the Resident Council President (Resident #29). All members were asked if the facility listens to their concerns and actively tries to resolve grievances voiced by the council's attendees. Each of the 5 members stated that the on-going issues are: 1) Residents are not getting showers on their scheduled shower days. All resident council attendees were asked if they have ever refused showers, and they stated that they do not and have not refused showers. The only time they would refuse a shower is if it was medically necessary. 2) CNAs and Nurses not answering call lights. Resident #137 stated, You can't find the aides to get assistance when you need it. Resident #124 stated, They are understaffed. Three aides called out this past weekend, and it puts an overload on others. Resident #131 confirmed, It never happens that supervisors come in to cover the aides that call out. Resident #101 stated, The staff don't do their job. They are always telling us, 'It's not my job.' I ran out of pull up and asked all day long for someone to bring me some, and they never brought them. Resident #101 confirmed, Staff during the 3-11 and 11-7 shift will fight with each other for about an hour about how many people they have to care for, and they are always speaking in a foreign language to each other in front of us. 3) Food concerns. Resident #101 stated, I have spoken to the cook directly and told him that they are overcooking the vegetables and the mashed potatoes are runny. Everything is cold when we get it and they put too much salt on the food for my taste. When asked if the facility provides feedback to the Resident Council on how the concerns voiced by the Council are being resolved, each of these members in attendance stated that the facility will tell them that they are looking into it, or working on it, but nothing seems to get resolved because it continues to be a problem.

Based on observation, interview, and record review, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 6 of 49 sampled residents, related to dental status, falls with major injury, anticoagulant use, discharge, and range of motion (Resident #31, #137, #89, #3, #170, and #129). The findings included: 1) During an interview on 01/08/24 at 4:38 PM, Resident #31 voiced concerns about his lack of dentures that fit. The resident was not wearing his dentures at the time and further stated the set that was provided to him by the on-site dentist never fit, so he has never worn them. Review of the record revealed Resident #31 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] documented the resident 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 the Annual MDS dated [DATE] documented No to the question, No natural teeth or tooth fragments/edentulous (no teeth). Review of the dental consults revealed Resident #31 received new dentures on 10/05/22, indicating he would have been edentulous as of that date. During an interview on 01/11/24 at 4:32 PM, Staff P, MDS Specialist, stated if Resident #31 was wearing the dentures, then the answer to that MDS question would be No. When told he had the dentures adjusted, was still not happy, and does not wear the dentures, the MDS Specialist agreed to the inaccurate MDS. 32078 2) Resident #137 was admitted on [DATE] with diagnoses which included Polyosteoarthritis, pain in right knee, Gout, muscle-wasting and atrophy, Restless Leg Syndrome, Neuropathy, pain in right leg, and repeated Falls. The Minimum Data Set (MDS) dated [DATE] documents that Resident #137 had a fall with major injury. Progress notes were reviewed from the date of previous MDS on 07/18/23 to most current MDS on 10/18/23, but there was no documentation of a fall with major injury during this time. On 01/11/24 at 3:33 PM, an interview was conducted with Staff A (MDS Specialist). She stated, I see a Fall on 09/07/23. I actually see 2 falls, but none of these falls were with major injury. 3) Resident #89 was admitted on [DATE] with diagnoses which included Dementia, Anxiety, Depression, Manic Depression, Seizure Disorder, and COPD. The Quarterly MDS completed on 10/27/23 documents use of Anticoagulant for Resident #89, but record review of the October 2023 Medication Administration Record showed no anticoagulant medication was provided to Resident #89 at this time. On 01/11/24 at 3:39 PM, Staff A (MDS Specialist) confirmed that Resident #89 was coded as taking an Anticoagulant; however, this resident was not taking anticoagulant during the assessment period in October. 4) Resident #3 was admitted to the facility on [DATE] with diagnoses which included Coronary Artery Disease, Hypertension, Diabetes Mellitus II, Hyperlipidemia, Cardiovascular Accident, Dementia, and Seizure Disorder. The Quarterly MDS completed on 12/11/23 documents use of Anticoagulant for Resident #3, but record review of the December 2023 Medication Administration Record showed no anticoagulant medication was provided to Resident #3 at this time. There was an order for Plavix, an anti-platelet medication. On 01/11/24 at 3:46 PM, Staff A (MDS Specialist) confirmed Resident #3's MDS was coded for anticoagulant use, but resident was not taking an anticoagulant at this time. Plavix, an anti-platelet, was coded as an anticoagulant. 38212 5) Resident #170 was admitted to the facility on [DATE] and was discharged on [DATE]. The resident was admitted following a fall from his scooter. The resident's record was reviewed. The MDS assessment for the discharge on 10/13/23 documented the resident was discharged to a short-term general hospital. In further review of the record, it was revealed the resident was discharged to his home. On 01/10/24 at 12:54 PM Staff A, an MDS Specialist was interviewed concerning the status of Resident #170's discharge. She stated the discharge MDS assessment was coded incorrectly, and the resident had been discharged to his home. 39167 6) Record review revealed that Resident #129 was admitted to the facility on [DATE] with diagnosis included aphasia (difficulty speaking). The admission Minimum Data Set (MDS) assessment, reference date 10/26/23, recorded a BIMS score of 00, which indicated Resident #129 was severely cognitively impaired. This MDS recorded Resident #129 had no functional limitation in range of motion of upper extremity, included: shoulder, elbow, wrist, and hand. On 01/08/24 at 10:13 AM and 01/11/24 at 10:48 AM Resident #129 was noted with left hand contracture. On 01/11/24 at 1:04 PM an interview was held with Staff A (MDS specialist), she was made aware of the MDS inaccuracy relating to hand contracture. Staff A reviewed Resident #129's record and agreed with the finding. She was advised to go and make observation on Resident #129. Staff A and two other MDS coordinators immediately went to visit Resident #129. At 1:18 PM Staff A voiced they went to assessed Resident #129 and noted that she had left hand contracture, Staff A voiced that she will modify the MDS.

Based on observation, interview, and record review, the facility failed to ensure provision of Activities of Daily Living (ADL) care, to include nail care and incontinence care, for 7 of 9 sampled residents (Resident #89, #100, #111, #114, #24, #34, and #83). The findings included: 1) Review of the record revealed Resident #89 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating he failed to answer any question correctly and was severely cognitively impaired. This MDS also documented Resident #89 was dependent upon staff for personal hygiene. An observation on 01/08/24 at 12:38 PM revealed Resident #89 had very long and thick fingernails, extending about a half an inch beyond the end of the finger. Review of the current care plan initiated on 08/09/23 documented Resident #89 scratches his arms and staff were to provide nail care. Review of the dermatology consults dated 11/10/23 and 12/01/23 both documented Resident #89 had chronic nail dystrophy (a ridging of the fingernail), usually caused by trauma, that once traumatized was easier to become infected with fungus and harder to cure. These consult reports documented to keep the nails clean, dry, trimmed, and to have nursing staff trim the resident's nails as needed. During an interview on 01/11/24 at 3:58 PM, when asked who was responsible for the resident's nail care, Staff N, Licensed Practical Nurse (LPN), stated the Certified Nursing Assistants (CNAs) unless the resident was diabetic or there was a special issue. When told the fingernails of Resident #89 were excessively long and thick, and that the dermatologist had recommended the nursing staff trim the resident's fingernails, the LPN was unaware. During a second observation at this time, the LPN agreed the nails were too long. The fingernails of both hands were excessively long, with some nails to the resident's right hand bending upward and outward, and excessively thick. 2) Review of the record revealed Resident #100 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] documented Resident #100 had a BIMS score of 99, indicating severe cognitive impairment. This MDS documented the resident was dependent on staff for hygiene. Review of the current care plan initiated on 11/15/19 and revised on 09/28/23 documented Resident #100 had an ADL self-care deficit related to decreased awareness of ADL needs, and impaired function and mobility. Interventions included to provide assistance as needed. An observation on 01/08/24 at 10:55 AM revealed Resident #100 in bed and a strong odor of a bowel movement noted. The fitted sheet was coming off the top of the bed, the resident's gown was off, and she was partially covered with a top sheet. On 01/08/24 at 11:36 AM, Resident #100 remained in bed in the same condition, with brown smears noted on the sheets. When greeted and spoken to, Resident #100 stated, I still don't have any clothes on. On 01/08/24 at 11:45 AM, the Administrator In Training (AIT) was noted in the resident's room for a second time since the original observation, as she had answered the call light for the roommate of Resident #100. On 01/08/24 at 12:27 PM, two CNAs went into the room to provided care. On 01/08/24 at 12:38 PM, Resident #100 was noted up in her wheelchair and the bed was stripped. Staff S, CNA, stated, . oh my . hard day . everyone needs a full bed change. When asked to clarify, Staff S stated she had not gotten to this resident because she had too many resident. The CNA stated she had to get up the alert and oriented residents first, or they would complain. The CNA then stated, And those that don't speak get left until I have time. During an interview on 01/10/24 at 11:54 AM, upon entering the room of Resident #100 with the AIT, she stated she recalled helping the roommate find her jacket on Monday morning (01/08/24). The AIT denied recalling any odors, and stated if she would have noted any care needs she would have found a CNA to provide assistance. During an interview on 01/10/24 at 4:43 PM, Staff H, LPN, was unaware Resident #100 was left in a soiled brief for one and a half hours on that Monday. 3) Review of the record revealed Resident #111 was admitted to the facility on [DATE]. Review of the Quarterly MDS dated [DATE] documented Resident #111 had a BIMS score of 15, on a 0 to 15 scale, indicating she was cognitively intact. This MDS documented the resident was dependent upon staff for toileting. Three of five mornings during the survey, on 01/08/24, 01/10/24, and 01/11/24, a strong urine odor was noted in the room of Resident #111. During an interview on 01/12/24 at 10:12 AM, when asked her normal routine for care, including incontinence care, Resident #111 stated the night staff change her brief at about 5 AM each morning. Resident #111 further stated at about 11 AM, staff will change her brief and get her up into her wheelchair. The resident stated it takes one person to clean her up and two persons with the Hoyer lift to transfer her into her chair. Resident #111 stated then staff will put her back to bed between 7 PM and 8 PM, changing her brief again at that time. When asked if they check or change her between 11 AM and 7 or 8 PM, Resident #111 stated they did not. The resident, a retired nurse, then explained she was concerned about potential breakdown because when they put her to bed, she is wet all the way through to her outerwear. When asked if she has requested to get cleaned up in between 11 AM and 7 or 8 PM, Resident #111 stated if they put her back to bed to clean her up, staff won't put her back in the wheelchair, and so she elects to stay up wet, only because she does not want to go back to bed that early. Resident #111 stated the only time she will request to get cleaned up is when she has a bowel movement. When specifically asked if staff offer to check her and or change her between the hours of 11 AM and 7 or 8 PM, Resident #111 stated they do not. The resident stated she is usually covered with a blanket over her legs and waist. Further review of the record revealed Resident #111 did have a history of a pressure injury. The concern was discussed with the Director of Nursing (DON) on 01/12/24 at 11:47 AM. The DON agreed with the concern and stated Resident #111 would not complain about anything. 4) Review of the record revealed Resident #114 was admitted to the facility on [DATE]. Review of the Significant Change MDS dated [DATE] documented the resident had a BIMS score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS documented the resident was dependent upon staff for all ADL care. Review of the weekly skin assessments for November 2023 through 01/10/24 documented a persistent rash to the resident's groin, abdominal folds, under the breasts, and under the arms. Physician orders revealed Nystatin powder, an anti-fungal medication, had been in use since at least 12/04/23. Note that prevention of fungal rashes includes maintaining the skin clean and dry. Upon entering the resident's room on 01/08/24 at 12:10 PM, a strong urine odor was noted. When asked how she was doing, Resident #114 stated she could use some help, and she pulled up her gown and showed the surveyor a bright red fungal type rash under her breasts and in the folds of her lower abdomen. When told it looks like there was cream or powder under her breast, Resident #114 stated, but they don't put it on daily. The white residue under the resident's breast appeared clotted up as if it had been there for some time. When asked about them keeping her private area clean, Resident #114 stated she really needed to be changed (referring to her adult brief), as she hadn't had her diaper changed since last night. When asked if staff provide her a full bath, the resident stated she hasn't had one for several days. When asked how often she would like a bath, she stated 2 or 3 times a week would be nice. Resident #114 denied refusing care. During a subsequent interview and observation on 01/10/24 at 9:11 AM, Resident #114 was sitting on the edge of the bed and stated she wanted to get back into bed. When asked about her rash, Resident #114 showed the surveyor the bright red rash under her right breast and stated, It really burns . I have to tuck my nightgown there. During a follow-up interview at 10:31 AM, Resident #114 was back in bed, but stated she has not been cleaned up or had a brief change yet that day. Further review of the nurse's progress notes from 09/01/23 to 01/10/24 revealed several refusals of bathing or showering, but the record lacked any documentation of educating the resident on the need for good hygiene or bathing to keep clean and dry, to prevent fungal rashes. During an interview on 01/10/24 at 4:35 PM, Staff N, LPN, stated Resident #114 was very difficult to convince to get cleaned up or even showered. The LPN stated she had tried to convince the resident, but the record lacked any documented evidence. 32078 5) Resident #24 was admitted to the facility on [DATE] with diagnoses which included Dementia, Malignant Melanoma, Hypertension, Anemia, Edema, Anxiety, Diabetes, Presence of vascular implants and grafts, Syncope and collapse, Benign Prostatic Hyperpiesia, muscle wasting and atrophy, abnormalities of gait and mobility, abnormal posture. Resident #24's Quarterly assessment dated [DATE], documents Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident requires extensive assistance with Activities of Daily Living (ADLs), and is frequently incontinent of bowel and bladder. Resident #24's Care Plan completed on 10/12/23 documents that the resident has an ADL Self-Care and/or mobility deficit and needs assistance with ADL's. He is at risk of developing complications associated with decreased ADL self-performance related to: Disease process/condition, Weakness. Resident can decline care at time. Staff to provide assistance/supervision as needed. On 01/08/24 at 10:45 AM, Resident #24's family member was in the resident's room visiting. The family member stated concerns that he has observed while visiting Resident #24. She stated that the CNAs are not changing the resident timely, and that staff are not toileting the resident when the resident asks to be toileted. She stated that one instance occurred when the resident was asking to be taken to the toilet because he had to have a bowel movement. The family member put on the call light, but staff did not come. The family member said she had to help him to the toilet, and when the resident was finished, the family member could not get the CNA to assist the resident with getting cleaned up and transferred off the toilet. The family member stated, Staff tend to disappear and you can't find them .There are some CNAs that don't want to do anything, and others that are overwhelmed and can't get to everyone. Resident's family member stated that she had wanted to take the resident down to activities at 10:30 AM, but staff had not come in to get the resident dressed and out of bed in time to attend the activities. On 01/10/24 at 11:40 AM, Resident #24's family member provided a list of notes regarding concerns with resident's care. The notes documented concerns with long waits for toileting and incontinence care, sometimes as long as 6-10 hours. family member stated that the hospice nurse reported to her that there were signs of redness on his bottom last week. The facility's Weekly Skin Check dated 01/05/24 documents, skin intact. family member stated, I had issues with them not giving [Resident #24] a shower when he was supposed to get it, but now that he is on Hospice, the Hospice aide gives him his showers, so they are getting done. The Grievance Log was reviewed, and Resident 24's family member had filed a grievance on 11/17/23 regarding resident care. The grievance was noted to have been resolved on 11/20/23. 6) Resident # 34 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Hypertension, History of falling, Osteoarthritis, Depression. Resident #34's Quarterly MDS dated [DATE] documents resident has a BIMS of 10, and she is dependent for toileting. Resident needs supervision or touching assistance for showers, upper body dressing, lower body dressing, and personal hygiene. Resident #34's Care Plan completed on 12/27/23 documents that Resident has an ADL self-care and/or mobility deficit. Resident needs assistance with all ADL's. Resident #34 is at risk of developing complications associated with decreased ADL self-performance related to Cognitive impairment, Disease process/condition and generalized Weakness. Interventions are to provide assistance/supervision as needed. Resident #34 is also at risk for alteration in skin integrity related to decreased mobility. Staff are to observe for signs and symptoms of alteration in skin and report; Skin check as per facility protocol. Skin Rash to buttocks and sacrum related to rash was observed and documented. On 01/08/24 at 11:25 AM, during an interview with Resident #34's son, he stated, The CNAs do not come around and provide assistance. My mother has not had her clothes changed since Friday (01/05/24), and she is not getting her showers. I spoke with the Administrator about this. However, a Review of Grievance/Complaint log for January 2024 does not contain a grievance from Resident #34's son regarding his care concerns. A review of Resident #34's shower task sheets shows documentation that Resident's shower days are Wednesday and Saturday from 3 PM - 11 PM. It is documented that the Resident received a sponge bath on 12/20/23 and 12/27/23. It is documented that resident refused shower/bath on 12/13/23, 12/16/23, 12/23/23, and 12/30/23. It is documented that the Resident did receive a shower on 01/03/23, 01/06/23 and 01/10/24. It is noted that if Resident #34 received a shower on 01/06/24, she would have had to have been put back into her dirty clothes after her shower, since Resident's son observed this resident's clothes not being changed since 01/05/23. A review of Resident 34's Progress Notes contain the following: 12/14/23 - Resident refused bath, resident reapproached and offered shower and stated, 'Do not touch me.' MD and POA made aware. 12/18/23 - resident refused shower. Resident reapproached and offered shower. Resident stated, 'I go in bathroom every day and run water in sink and wash myself in sink.' I encouraged her to take a shower and she says she will see. Weekly Skin Check completed on 12/21/23 and documents, Skin intact. 12/29/23 - resident approached this nurse saying she was bleeding and I looked at area and it is a large area of redness and rash in groin area, inner thighs, abdominal folds, and under bi lateral breast. Dr and DON notified. Weekly Skin Check completed on 12/29/23 and documents, Skin intact. This is the same day that nurse observed resident with large area of redness and rash in groin area, inner thighs, abdominal folds and under both breast. 01/01/24 - Resident reapproached and offered an shower today but resident stated I clean myself up . in sink and don't need a shower. On 01/12/24 at 9:40 AM, Staff R (CNA) stated, I just spoke with the Resident and she will get her shower before lunch. She has never refused me when it is time for her showers. 7) Resident #83 was admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation, Coronary Artery Disease, Congestive Heart Failure, Hypertension, and Dementia. Resident #83's Annual MDS Annual dated 11/20/23, documents resident has a BIMS of 99 (severely cognitively impaired) and requires substantial/maximal assistance with ADLs. The Care Plan completed on 11/29/23 documents Resident #83 has ADL self-care and/or mobility deficits and needs assistance with ADL's. Resident is at risk of developing complications associated with decreased ADL self-performance related to: Cognitive impairment, Tremor. On 01/08/24 at 11:10 AM, Resident #83 is observed with dirty nails on each hand. On 01/09/24 at 9:15 AM, Resident's nails were observed with dark substance under the nails. On 01/10/24 at 09:35 AM, Resident #83's son stated, My main concerns is that they are not keeping up on the day to day personal hygiene tasks for my dad (i.e. shaving, fingernails). I have spoken to staff previously, and I just spoke with the Administrator this morning to inform her of my concerns. On 01/10/24 at 9:40 AM, observation of resident's nails showed they were still not clean and resident had not been shaved. On 01/10/24 at 9:45 AM, Resident's son was seen speaking with the Clinical Care Coordinator on Unit C. On 01/11/24 at 4:02 PM, Resident #83 was seen sitting in wheelchair at nurse's station. Resident's nails were cut and clean, and the Resident had been shaved. At this time, a staff member was seen wheeling a cart around checking resident's nails. 01/12/24 10:08 AM Resident is dressed and in wheelchair sitting across from nurse's station. Resident has been shaved and nails are clean. A review of the Grievance/Compliance Log for January 2024 was reviewed on 01/10/24, and a grievance was filed by Resident #83's son on 01/10/24 regarding environment and patient care. No resolution date was recorded. The CNA Task sheets were reviewed for shaving. There was no data recorded prior to 01/11/24. It was documented that the resident was shaved on 01/11/24. Tasks reviewed for showers over the past 30 days show that a shower or bed bath was provided on 4 of the 30 days (showers on 12/29/23, 01/02/24, 01/05/24 and bed bath on 01/09/24).

Based on observation, interview, and record review, the facility failed to timely identify a change in condition and provide timely care and services for 2 of 4 sampled residents reviewed for respiratory care (Residents #5 and #44); failed to identify a change in skin condition and provide treatment for 1 of 2 sampled residents (Resident #34); and failed to properly monitor weights for 1 of 1 sampled resident reviewed with congestive heart failure (Resident #84). The findings included: 1) Residents #5 and #44 were a married couple residing in the same resident room. Resident #5 was independently ambulatory, and would assist his wife with her meals, or other small tasks. Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, on a 0 to 15 scale, indicating some cognitive impairment. This same MDS documented Resident #5 was independent for all ADLs including ambulation. Review of the record revealed Resident #44 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] documented the resident had a BIMS score of 14. This same MDS documented Resident #44 was dependent upon staff for all ADLs except eating, which was completed independently. On 01/10/24 at 12:14 PM, the daughter of Residents #5 and #44 went to the Independence Unit nurse's station, visibly upset, and asked Staff H, Licensed Practical Nurse (LPN) and direct care nurse for the day, what they were doing about her father's cough. The LPN stated she was unaware of his cough, but had heard Resident #44, his wife, coughing and they had just completed a chest x-ray, ordered cough medication, and would follow-up when they received results. The daughter stated she had spoken with the nurse on Monday about her father's cough, further stating, My daddy is 92. Monday was the first time I've ever seen him in bed during the day, and he's back in bed today. You all better work on that cough and check him out. He can't afford to get that COVID. During an interview on 01/10/24 at 12:49 PM, the daughter confirmed she had spoken with the Unit Coordinator on Monday, and stated she thought she was a nurse. The daughter confirmed she told the Unit Coordinator on Monday that her father was coughing and that he was in bed, which was a change for him. The daughter stated that now her mother was really coughing. The daughter stated her father was more with it than her mother, and her father would usually get up and help her mother with her food. During an interview on 01/10/24 at 12:52 PM, the Unit Coordinator confirmed the daughter of Residents #5 and #44 spoke with her on Monday regarding her father's cough and change in condition. The Unit Coordinator stated she reported the information to the residents' nurse, Staff J, Registered Nurse (RN), who worked on Monday and was not scheduled back to the facility until Friday. A Respiratory Panel was ordered on 01/10/24 at 4:45 PM for both Resident #5 and #44, nearly four hours after the daughter's voiced concerns. On 01/10/24 at 5:08 PM, Staff H, LPN, was noted with multiple respiratory swabs. The LPN explained she was going to do COVID and influenza (flu) tests on both Resident #5 and #44. On 01/11/24 at 9:40 AM, when asked about the results of the respiratory swabs for Residents #5 and #44, Staff M, LPN and direct care nurse for the day, stated both residents were started on cough medication, and the respiratory swabs were picked up that morning. During an interview on 01/11/24 at 10:04 AM, the Nurse Practitioner for Residents #5 and #44 stated she was not told about the cough for Resident #5 on Monday, further stating she had seen him on that morning and he didn't have a cough. The Nurse Practitioner was made aware the daughter was there on Monday afternoon and reported the cough and change in condition at that time. The Nurse Practitioner stated she was not made aware of the changes on Monday. During an interview on 01/12/24 at 1:07 PM, when asked if she was aware of Resident #5's cough on Monday, Staff J, RN and direct care nurse for the day, stated she did not hear him cough on Monday. When asked if she was told by the Unit Coordinator of the cough and change in condition of staying in bed, reported by the daughter on Monday, Staff J stated she did not recall. When asked the result of the nasal swabs done on Wednesday, Staff J, RN stated, The COVID was negative. When asked about the influenza results, Staff J, RN stated they were negative as well. Upon review of the laboratory results for both Resident #5 and #44, the Influenza A tests were noted to be positive for both residents. During an interview on 01/12/24 at 1:15 PM, the Independence Unit Manager reviewed and confirmed the Influenza A positive results for both Resident #5 and #44. The laboratory results documented the results were reported on 01/12/24 at 8:29 AM. The Unit Manager stated the laboratory did not phone the facility to report the positive results, and further pointed out that laboratory results usually documented who at the facility they spoke with, but these results lacked any documentation as to whom they spoke. 32078 2) Resident # 34 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Hypertension, History of falling, Osteoarthritis, Depression. Resident #34's Quarterly MDS dated [DATE] documents resident has a BIMS of 10, and she is dependent for toileting. Resident needs supervision or touching assistance for showers, upper body dressing, lower body dressing, and personal hygiene. Resident #34's Care Plan completed on 12/27/23 documents that Resident has an ADL self-care and/or mobility deficit. Resident needs assistance with all ADL's. Resident #34 is at risk of developing complications associated with decreased ADL self-performance related to Cognitive impairment, Disease process/condition and generalized Weakness. Interventions are to provide assistance/supervision as needed. Resident #34 is also at risk for alteration in skin integrity related to decreased mobility. Staff are to observe for signs and symptoms of alteration in skin and report; Skin check as per facility protocol. Skin Rash to buttocks and sacrum related to rash was observed and documented. On 01/08/24 at 11:25 AM, during an interview with Resident #34's son, he stated, The CNAs do not come around and provide assistance. My mother has not had her clothes changed since Friday (01/05/24), and she is not getting her showers. I spoke with the Administrator about this. A review of Resident #34's shower task sheets shows documentation that Resident's shower days are Wednesday and Saturday from 3 PM - 11 PM. It is documented that the Resident received a sponge bath on 12/20/23 and 12/27/23. It is documented that resident refused shower/bath on 12/13/23, 12/16/23, 12/23/23, and 12/30/23. It is documented that the Resident did receive a shower on 01/03/23, 01/06/23 and 01/10/24. It is noted that if Resident #34 received a shower on 01/06/24, she would have had to have been put back into her dirty clothes after her shower, since Resident's son observed this resident's clothes not being changed since 01/05/23. A review of Resident 34's Progress Notes and Weekly Skin Checks contain the following: Weekly Skin Check completed on 12/21/23 and documents, Skin intact. 12/29/23 - resident approached this nurse saying she was bleeding and I looked at area and it is a large area of redness and rash in groin area, inner thighs, abdominal folds, and under bi lateral breast. Dr and DON notified. Weekly Skin Check completed on 12/29/23 documents, Skin intact. This last weekly skin check was completed on the same day that the nurse observed resident with large area of redness and rash in groin area, inner thighs, abdominal folds and under both breasts. A review of physician orders was conducted. An order was found for Zinc Oxide 20% Ointment to be applied to buttocks and sacrum every shift for Rash. To be applied with Nystatin Powder (Active 09/20/2023). There was no order found for any skin treatment(s) to be done for the rash found on 12/29/23 located under breast, groin area, inner thighs, or abdominal folds. 39167 3) Record review revealed that Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: congestive heart failure (CHF), cardiorespiratory conditions, and respiratory failure. The quarterly MDS assessment dated [DATE] (which was in Progress), recorded a BIMS score of 15, indicated Resident #84 was cognitively intact. This MDS recorded no mood/behavior issues. Additional review of Resident #84's records evidenced a physician order dated 11/29/23 for daily weights in the morning for CHF, and to notify the provider if Resident (#84) gains 2 pounds or more in 1 day. Review of the comprehensive care plan dated 10/06/23, indicated Resident #84 had potential for altered nutrition related to potential for weight fluctuations due to edema, disease process, and CHF. Interventions included: Fluid Restriction as ordered with potential for weight fluctuation, and weigh per protocol. Review of daily weights dated from 12/25/23 through 01/08/24 indicated that weights were not monitored as ordered in the morning. The weights that were recorded were in the afternoons and evenings with some weights recorded in the mornings. The weights were as follows: 01/08/2024 18:11 (6:11 PM) 187.2 Lbs, 01/07/2024 14:43 (2:43 PM) 187.0 Lbs, 01/06/2024 15:26 (3:26 PM) 187.0 Lbs, 01/05/2024 18:08 (6:08 PM)188.0 Lbs, 1/2/2024 17:25 (5:25 PM) 188.0 Lbs, 1/1/2024 16:29 (4:29 PM)188.2 Lbs, 12/31/2023 13:24 (1:24 PM) 201.0 Lbs, 12/27/2023 19:55 (7:55 PM) 198.0 Lbs, 12/26/2023 18:28 (6:28 PM) 198.0 Lbs, and 12/25/2023 20:42 (8:42 PM) 198.0 Lbs. On 01/11/24 at 1:23 PM an interview was held with Resident #84; an inquiry was made about the times he gets weighed. He voiced that he gets weight anytime in the day morning, afternoon and evening, he added there's not a particular time the staff weighed him. During that time the resident was made aware that his order specifically indicated to weigh him in the morning, he then stated well, they haven't been doing that, he reiterated that there's not a particular time the staff weighed him. On 01/11/24 at 1:27 PM a side-by-side review of Resident #84's record and interview were conducted with the Reflection unit Manager, she was made aware of the concern relating to the weight times, she was also made aware that Resident #84 have confirmed the staff haven't been weighing him consistently in the morning. During that time the Reflection unit manager was offered to go talk to the resident with the surveyor. At 1:31 PM the Reflection unit manager went to talk to Resident #84. He confirmed that the staff have not been weighing him consistently in the morning only. He stated that the staff have weighed him at any time during the day (mornings, afternoons and evenings) whenever they feel like it. During that time the resident was made aware due to his diagnosis of CHF, the order was for him to be weighed in the morning. The resident said he doesn't mind getting weigh in the morning, as he usually gets up early at around 6:30 AM.

Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure care and services to meet the needs of showers for 3 (#112, #114 and #375) of 10 sampled residents reviewed for choices; to provide ADL care (nail and incontinence) for 7 (#24, #34, #83 #89, #100, #111 and #114) of 9 sampled residents; to follow dietary recommendations for and orders for obtaining weights for 1 (#95) of 8 sampled residents; Interviews from random residents, families, and staff voiced concerns about a lack of staff; and Interviews from Resident Council Members during Resident Council Meeting and review of Resident Council Minutes. The findings included: 1) Residents #112, #114 and #375 voiced concerns with a lack of staff and indicated they were not being provided baths and showers as per facility scheduling or per their request. (Refer to F561 for details). 2) Residents #24, #34, #83, #89, #100, #111, #114 concerns for nails and incontinence (Refer to F677 for details). 3) Resident #84 had a diagnosis of Congestive Heart Failure and weights were not monitored as ordered (Refer F684 for details). 4) Resident #95 had significant weight loss and staff failed to ensure re-weight and weekly weights as per Dietitians recommendation. (Refer to F692 for details). 5) The following residents, family members and staff interviews were obtained by the survey team included voiced concerns of sufficient staff: During an interview on 01/08/24 at 9:24 AM, Resident # 9 voiced the facility is short of staff most of the time, she is the last one on their list and sometimes they don't get to her at all, and she does not receive care. Sometimes she waited 1 hour for staff. She has waited a long time for staff to change her when she had bowel movement. During an interview 01/08/24 9:42 AM Resident #149 stated call lights are answered in 2 hours on average. During an interview on 01/08/24 at 10:00 AM Resident #124 stated there is a tremendous amount of staff turnover. You hardly have a nurse or CNA for 2 days before another one is assigned. The staff don't get a chance to know you or know what your needs are. It is frustrating. Some staff are good, and others are not. Sometimes I cannot get the assistance that I need because no one shows up to help me. During an interview 01/08/24 10:02 AM Resident #167 stated it takes an hour for anyone to come. She stated now I get up in my wheelchair to go to the bathroom. She stated, I started to get up in my wheelchair last week and this was motivated by the fact that no one would come and change her. During an interview on 01/08/24 at 10:08 AM Resident # 51 complained about lack of staffing, she revealed on 5 occasions the staff had left her in the bathroom sitting on the toilet for 45 minutes, she called them they just don't come. During an interview on 01/08/24 at 10:42 AM with Resident #155, she complained of lack of staffing, she voiced the aides don't do what they should do, weekends are terrible, nobody does their work during the weekend. During an interview on 01/08/24 at 10:45 AM Residents #24's family member was in the room visiting and provided information regarding concerns she has observed while visiting. She stated there are staffing concerns which result in the resident not getting his showers as scheduled, changed, and getting out of bed to attend activities. During an interview with Resident #131 on 01/08/24 at 10:53 AM. The resident complained of insufficient staffing, it takes them an hour to get help to take her to the bathroom. During an interview on 01/08/24 at 10:56 AM with Resident #375, he stated the problem is how the facility is run. The CNAs are running themselves ragged. They just don't have enough help. During an interview on 01/08/24 at 11:00 AM Resident #101 stated I am supposed to get 2 showers a week in the morning, but they changed them to the afternoon. I prefer to have them in the mornings, but they told me that I have to have them in the afternoons. I would love to have a shower more than 2 times a week, but I was told that I can only have 2. Sometimes I don't even get that. During an interview on 01/08/24 at 11:04 AM Resident #112 she stated sometimes when I call, they don't come at all. They are understaffed. Resident stated she waited a long time in the bathroom for them and helped her back to bed. During an interview on 01/08/24 at 11:04 AM Resident # 66 stated day shift CNA staffing has been bad especially the past three months. He stated he can push the call bell and will have to wait 40 to 45 minutes. He calls for himself (water or pain meds) and calls for his roommate Resident #134 who can't speak for himself. Resident #134 likes to get up by 10 AM so he can attend activities in the common area. Lunch runs late . lunch last week didn't come until 1:45 PM. Dinner was as late as 6:30 PM used to be about 5:00 PM to 5:15 PM. On Saturday 01/06/24, Resident #66 set up his stuff for a shower and shave; never got it. CNA stated she had 15 others to care for and did not have time. Sunday, he didn't see his CNA; he and his roommate got dressed themselves, but they didn't get to go to church yesterday; Father had to come in to give them communion. Last week his significant other called and asked them to tell Resident # 66 she would be 1.5 hours late. He never got the message. During a family interview for Resident #34 on 01/08/24 at 11:25 AM. Resident's daughter stated the CNAs do not come around and provide assistance. My mother has not had her clothes changed since Friday (3 days), and she is not getting her showers. During an interview 01/08/24 11:41 AM Resident #76 stated sometimes he waits an hour for anyone to answer his call bell. He stated they will walk right by the door when the light is going off and never stop to inquire about the reason. During an interview 01/08/24 12:35 PM with Resident #23 she stated she does not feel there are enough staff to meet her needs. She stated some aides are really good but then there are times that some aids or not. She could not be specific on dates, times, shifts. During an interview on 01/08/24 at 1:01 PM Resident #373 stated There is not enough staff of CNA'S. Yesterday my CNA was ragged. During an interview on 01/08/24 3:33 PM Resident # 122 stated it can take a while to get help; I can wait up to an hour and a half to get water. Yesterday he called three times before anyone brought him some water. Stated he drinks a lot of water. During an interview on 01/09/24 at 07:38 AM Resident #108 stated they are shorthanded all the time, and this doesn't change for the shifts. When I press the call light they will come into the room and look at what needs to be done and leave and not come back. His colostomy bag must be emptied, and sometimes it takes an hour to get resolved. During a family interview on 01/09/24 at 08:08 AM. The daughter-in-law of Resident #372 was very concerned with the lack of staff. She stated the CNA's have too many residents assigned. During an interview 01/09/24 08:26 AM Resident #41 stated they are short staff, I am in a diaper and have sat in soiled diaper for over 2 hrs. During an interview on 01/09/24 at 9:01 AM with Resident # 61, she voiced the only concern she has was regarding staffing. The facility doesn't have enough CNAs to take care of the residents, sometimes she sits in urine for half an hour. Also, she sits in stool for a while, she takes lactulose for liver problem which causes her to have loose stool. Last week she sat in the stool for 40 mins. She called the staff and notified them of her having a bowel movement, they've told her they sent the attending CNA to another area, so she sat in the stool, it causes her buttocks to irritate, which she has never had that issue before, so staffing is a big problem. 6) On 01/10/24 at 2:30 PM, a meeting was held with 5 alert and oriented, active members of the Resident Council (Residents #137, #124, #101, and #131), including the Resident Council President (Resident #29). All Resident Council members stated they are not getting showers on their scheduled shower days. All resident council attendees were asked if they have ever refused showers, and they stated that they do not and have not refused showers. The only time they would refuse a shower is if it was medically necessary. All resident Council Members stated that CNAs and Nurses are not answering call lights, especially on 3 PM -11 PM and 11 PM - 7 AM shifts. Resident #137 stated, You can't find the aides to get assistance when you need it. Resident #124 stated, They are understaffed. Three aides called out this past weekend, and it puts an overload on others. Resident #131 confirmed, It never happens that supervisors come in to cover the aides that call out. All of the attending Resident Council members stated that staff on the 3 PM - 11 PM shift will waste an hour arguing about their assignments instead of caring for residents. 7) Staff interviews During an interview on 01/09/24 at 2:50 PM Staff B, an LPN (Licensed Practical Nurse) was interviewed. She was asked about staffing and if she ever felt they needed more staff. She stated, we have enough nurses, however we need a lot more CNA's. During an interview on 01/09/24 at 2:56 PM Staff C, a CNA (Certified Nursing Assistant) was asked about staffing. She stated the least number of residents that she takes care of is 13 but mostly she has 15 residents. She stated they need more CNA's. On 01/09/24 at 3:10 PM Staff D, a CNA was interviewed. She stated sometimes she cannot complete her work in the hours she is given to complete the work. She stated some people get a bed bath and some get showers whichever she has time to complete. She stated she does what she can to get everyone clean. During an interview on 01/10/24 at 07:46 AM conducted with Staff F, a CNA, she stated they are short staffed with CNA's. She stated she takes her time and can get everything done by the allotted time. She stated she concentrates on one resident at a time and must ignore any calls because this is the only way she can get anything done. She stated they need more help. ON 01/11/24 at 8:55 AM Staff E, a CNA, was interviewed. She stated the facility could use more CNA'S to get the work completed. On 01/10/23 at approximately 10:00 AM the DON was asked how many residents needed 2 persons or greater to assist them with any ADL (Assistance of Daily Living) care. Later in the morning the DON produced a census sheet and the DON had calculated 91 residents out of 179 residents need 2 people or greater to assist them with their ADL's. 01/10/24 11:07 AM an interview was conducted with the Staffing Coordinator. She was asked about the process for staffing the units. She stated on the long-term units she usually likes to staff 11-13 residents for each CNA (Certified Nursing Assistant) On the short-term units, she schedules 9-11 residents for each CNA. She stated on the 300 unit she schedules 3 Nurses and goes by census for CNA's. On the 200 unit she stated she scheduled 2 nurses and 4 CNA's. She stated this unit has potential for 42 residents. Right now, they have 34-35 residents. On the 100 unit which is long term, she stated she schedules 2 nurses and 5 CNA's. She was asked about RN's. She stated the nurses work 12-hour shifts and there is always an RN on each of those shifts. She was asked what they do for call outs. She stated the 3-11 supervisor will take an assignment if they need a nurse. She stated the CNA's work 8-hour shifts. She stated if they have a callout the CNA's will do a double or stay over. She stated she calls the CNA's if someone calls off. She said she tries to make deals with them or pretty much anything to get them to work if needed. On 01/12/24 at 11:00 AM the staffing coordinator was interviewed again. She stated that sometimes nurses do CNA duties when the CNA's call out. She stated they do offer the CNA's bonuses (monetary) to do extra shifts, she stated they do have an agency however they have not used it in a long time.

Based on observation, record review, interviews, and test tray the facility failed to ensure palatable food as per voiced concerns from Resident #23, #140, #155, #95, #31, #70, #114, #76, #124, #131, #167, #374, #108, #29, #326, #98, #149, & #373. The findings included: During a recertification survey, 18 residents complained about the food to 5 surveyors. The following are the residents' interviews. 1. Review of Resident #23's MDS (Minimum Data Set), documents a BIMS (Brief Interview for Mental Status) of 15, which means her cognition is intact, stated to the Surveyor on 01/08/24 at 12:42 PM, the food does not match what is on the menu, the food is lukewarm. 2. Review of Resident #140's MDS, documents a BIMS of 13, which means his cognition is intact, stated on 01/08/24 at 10:04 AM, they serve breakfast late, he likes to eat at about 8:00 AM, the food cart usually comes to the floor at about 8 AM, but the food usually takes longer to get to him. 3. Review of Resident #155's MDS, documents a BIMS of 15, stated on 01/08/24 at 10:42 AM, the kitchen is a disaster, she voiced she does not get anything that she orders. 4. Review of Resident #95's MDS, documents a BIMS of 11, stated on 01/08/24 09:56 AM, the food is 'terrible' . stated texture is weird and it is tasteless. On 01/08/24 01:10 PM upon entering Resident #95 room, Resident #95 stated this fish is awful: it's hard as a rock. When asked if she could eat it, the resident stated No! I tried to nibble around the edges but couldn't eat it. The Resident took the piece of fish out and tried to break it in half, and it was noted to not bend and was obviously firm and nearly snapped in half. Fish and tater tots appear white and tan in color. Bun is not toasted. The yellow cheese had not melted, she put some tartar sauce on it, hoping it would help, but it did not help. 5. Review of Resident #31's MDS, documents a BIMS of 15, on 01/08/24 at 04:22 PM, stated it's 'terrible' . They used to have a pile of snacks at night; now only have like four bags of chips for 80 people. Today's fish was hard as a rock. He was observed going into the dining room and knocking the piece of fish against the metal cart and it made loud knocking sound/hard. Stated the whole fish was like that. It was like the last time they had fish. Portions are small. Half cup of fruit is ordered, and they give him half of a half cup sized bowl, a piece of pie is very small. 6. Review of Resident #70's MDS, documents a BIMS of 7, her cognition is severely impaired, stated on 01/08/24 at 10:15 AM The food really is not very good here. 7. Review of Resident #114's MDS, documents a BIMS of 13, stated on 01/08/24 at 12:10 PM the food stinks . it tastes terrible. On 01/10/24 at 09:55 AM, a resident was asked about her menu choices and stated she has never filled out the menu, no one explained it to her how it works. The Surveyor explained how it works. Call light pushed, nurse came in to assist her with filling out menu. 8. Review of Resident #76's MDS, documents a BIMS of 13, stated on 01/08/24 at 3:35 PM, the pasta is undercooked, pork chops are hard as a rock, don't get condiments like milk or sugar. Sometimes don't get all the utensils. On 01/08/24 03:42 PM threw lunch away it was hard to eat 9. Review of Resident #124's MDS, documents a BIMS 15, stated on 01/08/24 at 10:00 AM, the food does not look or taste appetizing. 10. Review of Resident #131's MDS, documents a BIMS of 12, cognition is intact stated on 01/08/24 at 10:53 AM, the food is lousy, the facility serves pasta too often, she's diabetic. The soup is spicy. 11. Review of Resident #167, documents a BIMS of 15, stated on 01/08/24 at 09:55 AM, I do not get what I request, everything is cold, they give me things not on the list. On 01/08/24 at 3:24 PM, a resident stated she received the wrong lunch, the administrator in training went to kitchen, and brought chicken on a plate. Everything was cold and even the plate was cold and had to be reheated. In the past 7 days brought wrong diet 3 times, everything was dry. On 01/09/24 9:24 AM, a resident stated she received the wrong food last night for dinner. She told them she wanted an alternative dinner, and they brought the regular diet. She stated they told her they were out of the alternative choice. 12. Review of Resident #374's MDS, documents a BIMS of 15, stated on 01/08/24 at 10:31 AM, I am on a no salt diet. Everything is very salty, not getting right diet. 13. Review of Resident #108's MDS, documents a BIMS of 15, stated on 01/09/24 at 07:48 AM, all they give me every day is sausage and French toast. I have asked for other stuff. A lady came in and we discussed preferences. I told her I wanted a sunny side up egg and home fries. Never have seen it. Everything is overcooked. What's on the menu is what you get. 14. Review of Resident #29's MDS, documents a BIMS of 15, stated on 01/09/24 at 8:45 AM, the food is not so good, it's very repetitive, not cooked well, it's just not good. 15. Review of Resident #326's MDS, documents a BIMS of 15, stated on 01/09/24 at 08:15 AM, I sat down with 3 different people. I can't eat the food they have; I have a bad stomach and they said they would take care of it. It's not that I won't eat it, it's that I can't. 16. Review of Resident #98's MDS, documents a BIMS of 14, stated on 01/08/24 at 12:18 PM, the food is cold, and everything is salty. On 01/09/24 at 9:48 AM, the resident stated her French toast was cold. 17. Review of Resident #149's MDS, documents a BIMS of 15, stated on 01/08/24 at 09:36 AM, the food is cold. On 01/09/23 at 9:34 AM, the resident stated she did not receive a dinner tray last night, someone went to the kitchen for a tray, and they brought her a burnt grilled cheese sandwich and some stuffing, she did not get a drink, salad, or dessert, she sent it back. 18. Review of Resident #373's MDS, documents a BIMS of 99, means the resident did not complete the interview, stated on 01/08/24 at 12:58 PM, the food is always cold. On 01/08/24 at 3:32 PM, she stated she couldn't eat the fish sandwich, it was hard as a rock and cold. Observations were made of food tray still at bedside and was uneaten. The fish was very hard and unable to cut with a knife. On 01/10/24 at 12:50 PM, Surveyor requested a test tray from the food line in the kitchen. The surveyors' thermometer was calibrated by the dietitian to 32 degrees at 12:50 PM. The food line began dishing the food out to the residents on the 300 hallways. At 12:56 PM the CDM stated the next tray is for the test tray. Staff Q, Dietary Aide was observed on 01/10/24 at 12:56 PM taking a lid from the middle of the hot warmer machine. The Surveyor advised her to stop and said, shouldn't you be taking from the top like you did all the other ones? The Dietary Aide stated, the one from the top is cold. She then went and grabbed the one from the top, and they labeled it a test tray. The food cart was then taken to the floor, but they forgot to place the test tray on cart and carried the tray to the food cart to proceed to floor. Arrived on floor at 12:56 PM with last tray off cart at 1:06 PM. CDM carried tray for surveyor back to the conference room and tray tested at 1:10 PM. The entree tested 108 degrees and the soup 102 degrees, the Surveyor that tested the soup stated it was Lukewarm. The entree was tested by two other surveyors and found that the Swedish meatballs were mushy and lukewarm. A review of the Resident Council minutes documented multiple grievances completed by the residents in resident council. This included on 12/07/23 there were complaints on not receiving correct order, cold food, small portions, late arrivals, running out of food and incorrect menu items. The desired outcome is doing Test tray audits, Tray line audits, and temperature checks and making sure there is enough food. A review of an email document that the facility provided to the surveyor documents on 10/23 residents requested menu changes. New Regional to implement review at resident council meeting to take effect 02/01/24. In December complaint of cold food with desired outcome for food to be at acceptable temperatures. A document showing tray line temperatures document room number but not which bed, the diet they are on and a temperature for the entree, vegetable, and starch. The document is not being followed. The date range of tray temperatures being done were on for the following weeks. 11/06/10-11/10/23; 11/13/23-11/17/23; 11/20/23-11/24/23; 12/11/23-12/15/23. During an interview on 01/10/24 at 7:30 AM with the Certified Dietary Manager (CDM), he stated the residents will get a daily menu on their breakfast trays every morning, they circle what they want on the menu and get it back to us, there is not a time limit, they give the menu back to anyone who will bring it back to us. He was asked if there were a lot of food complaints and he said we do get them. He was not in the facility on Monday but was asked if he had any concerns about food. He showed me a grievance from Monday from Resident #31 complaining the fish was dry. The CDM stated that the chef baked the fish, and it was supposed to be fried. The chef baked it too long. He stated that he is re-educating on following the cooking logs. During a secondary interview on 01/11/24 at 9:40 AM with the CDM, he stated when a resident complains that the food is not hot enough, we tell them to try to come to the main dining room since it comes directly from the kitchen, there is no delay on serving. We try to keep the steam tables above 160 degrees. We will put it back in the oven if it shows less than 150 degrees. That is one of the reasons why it gets overcooked. We are aware of people's complaints and work on them. Most residents complain of overcooking, but if it's a mechanical soft diet it has to be well done, because it has to be soft. We have talked to corporate about working on a new menu. When people complain, I try to resolve it immediately. Sometimes I am not aware of the concerns of Resident Council Meeting but then stated I go to the resident council meeting monthly. I don't wait until the council meeting to resolve concerns. We are currently short a chef and either I or the supervisor will jump in and cook. We have been short a chef since COVID 2020. We are short two aides. It doesn't matter which shift we are short because I will move staff around on different shifts. The Dietitian works Monday, Wednesday, Friday. She helps with food preferences, annuals, admissions, high risk resident, renal patients. On 01/11/24 at 9:30 AM, the Administrator stated that they have been aware of food concerns and have been working on it since December. She stated that the Dietitian is in the kitchen doing the temperature and checking food trays. They did not have any concern with the food until December, before that it was concerns with the menu. During an interview on 01/12/24 at 1:15 PM, with the Dietitian she was asked about doing food temps and checking trays. She stated she doesn't know anything about doing that, she goes around to the units once a month and randomly picks 1 room to test tray and temp. She has been doing this for a long time, this has nothing to do with resident concerns. During an interview on 01/12/24 at 1:20 PM with the CDM, he was asked if he checks food temps. He said yes. The surveyor asked what he did. He stated that he randomly picks 5 residents from each hallway. During an interview on 01/12/24 at 2:00 PM with the Assistant Executive, we started the process in the kitchen in October. I went into the kitchen weekly and monitored the CDM. We started this when we got complaints from Resident Council. I have been working with CDM getting the carts out and the dining room. I did test tray and went to the floor and talked to residents. Has documents in an email for 11/06/23, 11/22/23, 12/06/23, 12/07/23, and 12/08/23.

Based on record review and interview, the facility failed to ensure a resident was treated in dignified manner related to failure to provide assistance as requested, for 1 of 3 residents reviewed for dignity (Resident #152). The findings included: Record review revealed that Resident #152 was admitted to the facility on [DATE] with diagnosis that included depression. The quarterly Minimum Data Set (MDS) assessment, reference date 09/30/23, recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated Resident #152 was cognitively intact. This MDS recorded no mood/behavior issue. This MDS recorded that Resident #152 required supervision with activity of daily living care which included Locomotion on/off unit. On 01/08/24 at 10:23 AM, an interview was conducted with Resident #152. He stated, Last night (01/07/24) I was thirsty, and I had no water to drink. He went up to the nursing station (the Reflection nursing unit) and encountered 2 certified nursing assistant (CNAs). He requested water, and they completely ignored him; they didn't say a word to him. He never received water from them. He finally went to the other end of the building (at the Independent unit) to ask the staff for water. On 01/11/24 at 11:57 AM, an interview was held with the Reflection unit Manager. She was made aware of Resident #152's voiced concern.

Based on observation, interview, record review, and policy review, the facility failed provide adaptive rails to assist with bed mobility for 2 of 5 sampled residents (Resident #97 and #111). The facility also failed to ensure the accommodation of need for viewing of the TV for 1 of 1 sampled resident, Resident #97, who needed to turn on her right side to prevent and then subsequently assist with offloading to heal pressure injuries. The findings included: Review of the policy Side rails/Adaptive Rails Guideline revised January 2023 documented, Protocols: 1. Adaptive rails are used to assist with mobility and transfer of guests/residents. 1) Review of the record revealed Resident #97 was admitted to the facility on [DATE]. Resident #97 had a diagnosis of MS (Multiple Sclerosis), which had affected her lower extremities. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status Score (BIMS) of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented Resident #97 had impairment to one lower extremity and was dependent upon staff for Activities of Daily Living (ADLs). During a wound care observation on 01/10/24 at 11:01 AM, Resident #97 was noted with three pressure injuries, that were acquired while at the facility, one on her coccyx, one on her left hip, and one on her left lateral foot. As per the wound care nurse, Resident #97 prefered to lie on her left side. During an interview on 01/10/24 at 2:39 PM, Resident #97 explained the reason she prefers her left side was because when she was positioned on her right side she was looking directly at the wall and could not see her TV. Observation of the bed placement confirmed the resident's statement, and revealed enough space to turn the bed. When asked if staff had suggested or tried to turn the bed while she turned on her right side, so that she could enjoy her TV and also be able to offload her left side, the resident stated they had not. Resident #97 further stated, I want my side rail back. When asked what happened, the resident explained she was out of her room one day and upon return the rails were gone. Observation revealed a small adaptive rail on the resident's left side (as noted with her lying on her back), but lacked any rail on her right side. Resident #97 stated she used the rails to help her when being adjusted in the bed. The resident demonstrated how she could reach over to her right side, but there was nothing to grab. When asked if she had requested her side rail back, Resident #97 stated during care she had vocalized she wanted the rail back, and had done so quite persistently. Further review of the record revealed an Adaptive Rail Review dated 11/28/23 that documented, Medical reason for rail remains appropriate for Resident #97. 2) Review of the record revealed Resident #111 was admitted to the facility on [DATE]. Review of the Quarterly MDS dated [DATE] documented the resident had a BIMS score of 15, with no impairment of her upper extremities, but was dependent upon staff for ADL care and needed substantial assistance for turning in bed. During an interview on 01/12/24 at 10:12 AM, Resident #111 stated she had two good side rails before, but a couple of months ago they took away the one on this side (pointing to the right side of her bed). The resident stated she used it because staff always turn her to her right side when they clean her up. When asked if they told her why they took it away, the resident stated they said, The State said the rails were not safe so we can't have them. When asked how it made her feel when staff turn her without that side rail there, Resident #111 explained it was difficult for her as she had to hold on to the mattress when they turn her, demonstrating how it is difficult for her to grab it. Resident #111 stated she had not vocalized her desire for the side rail, as she didn't want to make trouble, but stated she was not given a choice at the time they took the second rail. The resident again stated she needed something to hang on to when staff turn her on her right side. During an interview on 01/12/24 at 11:01 AM the Director of Nursing (DON) stated the company decided the side rails needed to come off of all beds due to safety. The DON further explained if a resident needed one, the risk management team would do an evaluation. The DON stated that every resident was made aware of the corporate decision at the time of the change in 2023. The DON confirmed a resident could have a second adaptive rail if able to use safely. Further review of the record revealed an Adaptive Rail Review dated 11/29/23 that documented, Medical reason for rail remains appropriate for Resident #111.

Based on interview and record review, the facility failed to ensure showers as per resident choices and schedule for 3 (# 112, #114, and # 375) of 10 sampled residents reviewed for choices. The findings included: 1) Resident #375 was admitted to the facility on [DATE] with diagnosis in part to include: Cerebral infarction, Hemiplegia, heart failure, atherosclerotic heart disease without angina, flaccid hemiplegia affecting left dominant side, difficulty in walking and muscle wasting. On 12/29/23 Resident #375 was assessed and had a BIMS (Brief Interview for Mental Status) of 13. The score indicates the resident is cognitively intact. On 01/08/24 at 10:52 AM Resident #375's POA (Power of Attorney) and significant partner was interviewed. She stated the resident was at physical therapy and she was his caregiver and would answer any questions. The POA was asked about showers for the resident. She stated the resident had only received a shower once since his admission on 12/22/23. The documentation for Resident #375's showers was reviewed. The resident is scheduled to have showers on Monday and Thursday on the 3:00 PM - 11:00 PM shift. According to the schedule the resident should have had a shower on 12/26/23, 12/28/23, 01/01/24, 01/04/24 and 01/08/24. Documentation reviewed and indicated the resident was unavailable for showers on 12/28/23, 01/04/24 and on 01/08/24. On 01/10/24 at 11:00 AM an interview was conducted with the POA for Resident #375. Documentation was reviewed and she stated he has never refused or been unavailable for a shower. She stated she and the resident have begged the nurses and the CNA's (Certified Nursing Assistant) for the resident to have a shower. She stated she had gone to the nurse's station and had requested a shower for Resident #375. On 01/11/24 (Thursday) at 8:19 AM Resident was on the phone and face timing the POA. The resident and the POA were asked about the shower schedule and if any had been offered. They stated the resident was supposed to have one scheduled this afternoon. The plan of care was reviewed for Resident #375. The plan of care for ADL's (Assistance of Daily Living) documents the resident needs assistance with his daily living care. One of the interventions of the ADL plan of care documents the bathing preference of shower or bed bath. On 01/12/24 at approximately 1:00 PM the DON (Director of Nursing) was interviewed concerning the showers. He stated they have a correction plan being conducted concerning showers and when the resident refuses, they will document a note in the chart. Documentation was located in the chart for Resident # 375. Documented on 01/05/24, the note states the resident refused bath or was not available. Resident stated he was up early for physical therapy and was too tired to take a shower. No other documentation was found in the chart for any refusal or reason resident was unavailable for showers. 2) Resident # 112 was admitted to the facility on [DATE] with diagnosis to include in part: Unspecified fracture of upper end of right humorous, subsequent encounter for fracture with routine healing, Pain in right shoulder, atrial fibrillation, hypertension and generalized anxiety disorder. The resident was evaluated on 11/15/23 and was found to have a BIMS score of 14, which indicates the resident is cognitively intact. On 01/08/24 at 11:05 AM an interview was conducted with Resident #112. She was asked about receiving showers. The resident stated she has received 2-3 this month and would like more. The shower schedule and documentation for 30 days were reviewed for Resident #112. The resident is to receive showers on Tuesdays and Fridays on the 3:00 PM- 11:00 PM shift. The resident was to receive showers on 12/12/23, 12/15/23,12/19/23, 12/23/23. 12/26/23, 12/29/23, 01/02/24 and 01/05/24. On 12/12/23, 12/15/23 12/19/23 and 12/29/23, documentation revealed the resident was unavailable for a shower. Documentation for refusal of showers was reviewed. Refusal of showers was documented on 12/22/23 and 12/26/23. No documentation was found in the chart indicating the resident refused a shower on 12/22/23 and 12/26/23. During the 30-day time period, one note was found for refusal of a shower. The note was documented on 01/04/24 and documents the resident refusing a shower. No notes found in the documentation for why resident was documented as unavailable for showers. On 01/10/24 at 8:05 AM Resident #112 was interviewed. She stated she had a shower last night. She stated she is always available for a shower. The plan of care was reviewed for Resident #112. The plan of care for ADL's (Assistance of Daily Living) documents the resident needs assistance with her daily living care. One of the interventions of the ADL plan of care documents the bathing preference of shower or bed bath. On 01/11/24 at 2:47 PM the Nurse Manager for the 300 unit was interviewed. Review of the residents and the shower schedules were reviewed with the nurse manager. She stated she was unaware of the situation, and she would check into the shower situation. 25404 3) Review of the record revealed Resident #114 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented the resident had a BIMS score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented it was very important for her to choose between a bath and a shower, and she was dependent upon staff for showering. During an interview on 01/08/24 at 12:10 PM, Resident #114 voiced concerns related to being cared for timely. When asked specifically about the provision of showers, the resident stated she could not remember the last time she had a shower. When asked how often she would like a shower, Resident #114 stated a couple of times a week. Review of the Tasks section of the electronic medical record revealed the resident was scheduled for a shower on Monday, Wednesday, and Friday, during the 7 AM to 3 PM shift. Review of documentation for the last 30 days, from 12/09/23 through 01/08/24, revealed a shower was provided only on Wednesday 12/13/23 and Monday 12/25/23. The documentation by the CNAs lacked any refusal of showers. Review of corresponding nursing progress notes document the resident's refusal of showers just once, on 01/04/24, during that same time period. During an interview on 01/10/24 at 4:35 PM, Staff N, Licensed Practical Nurse (LPN), stated Resident #114 can be difficult to convince to get cleaned up or showered, but confirmed if a scheduled shower is refused by a resident, there should be documentation in the record.

Based upon observations, interviews and record review the facility failed to provide housekeeping and maintenance services necessary to provide a clean, comfortable and home like environment for 8 out 111 resident rooms and for 2 of 2 community shower rooms, in the 100 and 300 hallways. Additionally, there were 2 hallways out of 3, the 100 and the 300 hallways, where insufficient linens and towels were noted. The findings included: On 01/09/24 at 10:00 AM and again at 10:15 AM observations made by the survey team revealed linen carts in the 100-unit and 300-unit hallways were sparsely filled. On 01/11/24 at 4:00 PM, during the environmental tour conducted with the DON and Administrator present, the linen carts in the 300-unit hallway were observed to be nearly empty of linens and towels. This included 2 large 5 shelf rolling carts and 1 small 3 shelf rolling cart. The facility was unable to provide a schedule or other documentation to support the claim of regular reloading times for linens and towels. On 01/11/24 at 4:00 PM, a facility tour was conducted with the DON and Administrator present. During the tour the following environmental concerns were identified: room [ROOM NUMBER], the floors in the room were not swept. room [ROOM NUMBER], the toilet had intermittent flushing and clogging issues as per Resident #23. room [ROOM NUMBER], the door sticks when closed and is difficult to open. room [ROOM NUMBER], the privacy curtains were worn and stained. room [ROOM NUMBER], the privacy curtains were worn and stained, the bathroom floor and counter were dirty. room [ROOM NUMBER], the wall clock was not keeping time correctly. room [ROOM NUMBER], the privacy curtains were stained. room [ROOM NUMBER] had a broken wall plug cover on wall at the headboard and stained privacy curtains. The community shower in the 300-unit hallway had cracked and stained ceramic tiles on the floor and walls. The grout lines had black matter. The toilet was dirty. The shower chairs/beds were marked with a rust-colored stain on the PVC pipe frame. The Hoyer lift stored in the shower room has rust-colored stains on the base. There were rust-colored streaks along the bottom of the wall to the right of the door as one entered. The shower/privacy curtains were stained and worn. The community shower in the 100-unit hallway had cracked and stained ceramic tiles on the floor and walls. The grout lines had black matter. The toilet was dirty. The shower/privacy curtains were stained and worn. The shower had a commode with a bucket. The bucket had brownish standing water in it. There were rust-colored streaks along the bottom of the wall to the right of the door as one entered. The shower/privacy curtains were stained and worn. Photographic evidence was obtained.

Based on observation, interview and record review, the facility failed to develop a care plan related to hand contracture for 1 of 1 resident reviewed for contracture (Resident #129). The finding included: Record review revealed that Resident #129 was admitted to the facility on [DATE] with diagnosis included aphasia (difficulty speaking). The admission Minimum Data Set (MDS) assessment, reference date 10/26/23, recorded a BIMS score of 00, which indicated Resident #129 was severely cognitively impaired. Additional review of the comprehensive care plans dated 11/02/23 and target completion date 11/08/23, lacked documented evidence of care plans to reflect Resident #129's hand contracture. On 01/08/24 at 10:13 AM and 01/11/24 at 10:48 AM Resident #129 was observed with left hand contracture. On 01/11/24 at 1:04 PM an interview was held with Staff A (MDS specialist), she was made aware of the lack of care plan for Resident #129's hand contracture. Staff A reviewed Resident #129's record and agreed with the lack of care plan. She was advised to go and make observation on Resident #129. Staff A and two other MDS coordinators immediately went to visit Resident #129. At 1:18 PM Staff A voiced they went to assess Resident #129 and noted that she had left hand contracture, Staff A voiced that she will generate a care plan.

Based on observation, interview, and record review, the facility failed to ensure the completion of weekly weights and a reweigh for accuracy, for 1 of 8 sampled residents who were reviewed for nutrition. Resident #95 was under her usual body weight (UBW) and ideal weight (IBW), and policy along with Registered Dietitian recommendations were not followed. The findings included: Review of the policy Obtaining Weights revised September 2018 documented, Policy: All residents will have weight measured upon admission and as clinically indicated thereafter. Procedure: . 2. The nursing staff will weigh and record all residents' weights monthly or as clinically indicated or per physician order. 9. Significant variances of 5% in a month or 3% in a week are to be re-weighed upon completion to verify the accuracy of the weight. Review of the record revealed Resident #95 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating some cognitive impairment. A Nutritional Evaluation dated 02/01/23 documented the resident's UBW as 95 to 100 pounds, and her IBW as 120.4 pounds. Fortified foods and a House Shake were in place with the resident's appetite documented as fair, with an average consumption of 51 to 75% of her meal. The corresponding nutritional care plan initiated at this time documented to weigh per protocol. Review of the documented weights revealed the following: On 01/31/23, upon admission to the facility, the resident weighed 91.2 pounds. Between 07/07/23 and 11/03/23 the resident had a slow decline to 95.4 pounds. On 12/05/23 the resident weighed 92.2 pounds and the Registered Dietian (RD) recommended weekly weights. The record lacked any documented weight during the week of 12/10/23. On 12/21/23 the resident weighed 90.0 pounds. On 12/28/23 the resident weight 90.8 pounds. On 01/06/24 the resident weighed 87.4 pounds, which represented a 5.21% significant weight loss since 12/05/23, one month prior. This weight also represented a 3.89% loss in one week. A progress note documented by the RD and dated 01/08/24 documented the resident had a significant weight change. The RD did add a magic cup for nutritional support, but also recommended a reweigh for accuracy, and to continue weekly weights with new interventions as needed. During an interview on 01/08/24 at 9:56 AM and again on 01/08/24 at 1:10 PM, Resident #95 voiced complaints about the texture and taste of the food. During a subsequent observation and interview on 01/10/24 at 9:02 AM, Resident #95 was sitting up in her wheelchair eating candy. When asked about her breakfast that morning, both she and her roommate stated the eggs were ice cold. When asked what she ate from the tray, Resident #95 stated, Only the muffin or biscuit, or whatever it was. (Refer to F804). Review of the record on 01/11/24 lacked any reweigh for Resident #95. During an interview on 01/11/24 at 11:42 AM, the RD confirmed her request to reweigh Resident #95, requested on 01/06/24, and confirmed it had not been done as of yet. When asked when she would expect a reweigh to be completed, the RD stated it should be done today. When asked if it should have been done prior to today, the RD again stated it should be done today. When asked the process for weights, the RD stated the weights are completed by Staff K, Certified Nursing Assistant (CNA), who is usually told on Monday which residents need to be either re-weighed or need weekly weights. When asked if five days to obtain a reweigh is acceptable, the RD would not comment. During an interview on 01/11/24 at 12:05 PM, Staff K, CNA, confirmed she was told of the need to reweigh Resident #95 earlier this week, but had not done it yet because she had been pulled to the floor to work an assignment that whole week. Staff K stated she had not been able to do any weights yet that week. Staff K stated she always has an assignment every Monday, and then will do weekly weights whenever her first day is without an assignment. The documented reweigh on 01/11/24, after sureyor intervention, was 85.4 pounds.

Based on administration and staff interview, policy review, and record review, the facility failed to honor a resident's expressed Advanced Directives, for 1 of 3 sampled residents, Resident #1. The staff failed to follow facility policy and procedure of verifying the resident's code status and initiated CPR on a resident that had a Do Not Resuscitate (DNR) order. There were 137 residents (83 of who had a DNR order) in the facility at the time of survey, all of which could be affected by this failure of verifying code status as per policy. On [DATE], it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the residents residing in the facility. The facility's Administrator was informed of the immediate jeopardy on [DATE] at 12:10 PM. Immediate jeopardy was identified on [DATE], as beginning on [DATE], and removed on [DATE]. The scope and severity were decreased to a D, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The scope and severity were lowered as a result of the facility's corrective actions implemented as of [DATE] at 3:45 PM. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of corrective action. The findings included: A review of the Policy and Procedure titled Advanced Directives and Code Status, effective [DATE] and revised on [DATE] revealed under the Procedure section Bullet point #8 If a resident is found unresponsive the EHR (Electronic Health Record) must be accessed to determine the code status order. For any resident without a physician's orders [REDACTED]. The Advanced Directive Code Status Quick View Guide further states, the yellow Florida DNR form is for transport communication for EMT's (Emergency Medical Technicians), Medics, and ER (emergency room ) staff only. The code status order entered into PCC (Point Click Care - the Electronic medical record software) is the primary source for validating a resident's code status. In the event a resident becomes unresponsive and without pulse or respirations, check the order in PCC. A record review for Resident #1 revealed the resident was admitted to the facility on [DATE] and had a diagnose to include [MEDICAL CONDITION] Disease, anorexia, dysphagia, anxiety, hypertension and [MEDICAL CONDITION]. A State of Florida Do Not Resuscitate Order was signed by the resident's health care surrogate on [DATE] and signed by the resident's physician on [DATE]. A DNR order was in Resident #1's EHR. A nurse's note by Staff A (Registered Nurse/RN), dated [DATE], documented, At 1335 (1:35 PM), resident (#1) was transferred by two CNA's (Certified Nursing Assistants) from her wheelchair to her bed. They made the resident comfortable and then proceeded to the team huddle at the nursing station. Immediately following the huddle, the primary CNA (Staff D) returned to the resident's room and found her unresponsive. CNA called the nurses to the room. This writer (Staff A) ran to the resident's room and checked for pulse and found resident to be pulse-less. Writer then exited the room towards the nursing station to confirm code status. Nursing staff (Staff C, an LPN) at nursing station reported to this writer that the resident was a full code. At 1347 (1:47 PM) CPR initiated, code blue called, and 911 called. 1353 (1:53 PM) Nurse reported resident was not a full code that she was a DNR. CPR continued until 911 arrived at 1355 (1:55 PM). EMT (Emergency Medical Technician) took over code. They pronounced resident's TOD (Time of Death) at 1403 (2:03 PM). Daughter phoned and informed of mother's expiration. Daughter arrived at facility at 1800 (6:00 PM). DCS (Director of Clinical Services) and ED (Executive Director) spoke with daughter concerning mother receiving CPR. Daughter was thankful for the good care that her mother received while in the facility and had no concerns with her receiving CPR. A review of Resident #1's care plans revealed a care plan, initiated on [DATE], stated the resident had an Advanced Directive on record, a health care surrogate (HCS). and a living will, with the DNR dated [DATE]. The care plan stated if resident's heart stop, or resident stops breathing, CPR will not be initiated in honor of the residents DNR wishes. On [DATE] at approximately 11:00 AM, the facility Executive Director and DCS (Director of Clinical Services) agreed the staff failed to correctly verify a resident's code status and performed CPR on a resident who had a DNR order. On [DATE] at 2:00 PM, evidence of clinical nursing staff re-education post event, after [DATE], was requested from the DCS. The DCS responded stating she can do an audit to ensure they have gotten everyone. DCS was not sure all nursing staff have been captured in the drills. The DCS stated they had done 2 drills since the event on [DATE]. An interview was conducted with the DCS on [DATE] at 2:00 PM. During this interview, the DCS stated that the nurse (Staff C, an LPN), who had checked Resident #1's code status, had looked in the paper chart and did not locate a yellow DNR form and assumed the resident was a full code. Staff C did not look in the EMR (electronic medical record) for the code status of the resident. The DCS stated that Staff A was the unit manager and she had checked the EMR system and saw the resident was a DNR. The DCS stated that she went to the resident's room and informed the nurses, but that EMS had already arrived and taken over the code. The DCS further stated that EMS called the resident's death after being informed the resident was a DNR. The DCS stated the yellow DNR form was located later. Subsequent interview with the DCS revealed she completed 1:1 education with the nursing staff involved in the event and gave them a copy of the policy and the nursing staff took a written test. She said that medical records staff had conducted audits on all resident records to ensure correct documentation was in place regarding advanced directives and DNR orders/forms. The DCS further stated the facility had conducted two code blue drills since the event. An interview on [DATE] at 2:25 PM with Staff A revealed the morning of the event Resident #1 was in a wheelchair and in front of the nurse's station for most of the morning. The resident had no concerns that day but did say she had been declining. Staff A (RN) stated that Staff D, (CNA) had put the resident to bed after lunch just prior to a staff huddle at the nurse's station with all the unit staff. After the huddle, Staff D went back to check on the resident and found her unresponsive and asked Staff A for help. Staff A found the resident without a pulse and stated she yelled down the hall for the code status. She had Staff D remove the resident's roommate from the room. Staff C (LPN) replied that Resident #1 was a full code. Staff A went back in the room and started CPR. Other staff called 911 and called a code blue in the facility overhead. After a few minutes of CPR, Staff B,(LPN) came to the room and informed the staff in the resident's room that this resident was a DNR. Staff B had checked the EMR and there was a DNR order and the yellow form was scanned into the EMR system. Staff A stated the person doing CPR at that time had put their hands up, but Staff A informed them that they had to continue CPR until EMS arrived. EMS arrived shortly after and when the EMT's were informed of the resident's code status, they called/pronounced the time of death at 2:03 PM. Staff A further stated she did not look for the order, but that Staff C and B checked the record for the orders. Staff A had stayed with the resident and initiated CPR. Staff A stated she has received additional training since the event, regarding checking for code status and where the information is located. On [DATE] at 10:17 AM, an interview with Staff E (LPN) revealed on the afternoon of the event, she was working on the Seaway unit and heard an overhead page for a code blue to room [ROOM NUMBER]. Staff E stated that she grabbed a backboard and ran to the unit. When Staff E arrived, she asked for the resident's code status. Staff E stated there were about 6 people at the nurse's station shouting she was a full code. When Staff E arrived at the resident's room, CPR was in progress and she began to take notes. After ,[DATE] minutes, 'someone' came in and stated the resident was a DNR. CPR continued until EMS arrived. Once a DNR form was produced to EMS, they stopped CPR and pronounced the resident's death. EMS was shown a scanned copy in the EMR. The yellow form was not in the paper chart. On [DATE] at 10:25 AM, an interview with Staff D (CNA) revealed she was Resident #1's CNA starting in the morning of [DATE]. Staff D stated she felt the resident did not look so well and had informed Staff C (LPN) of her concerns. Staff D stated she informed Staff C that she was going to put the resident back to bed because she had not been looking so good since she arrived in the morning at 7:00 AM. After putting the resident back to bed after lunch, Staff D went back to the resident's room about 15 minutes later and found the resident unresponsive. Staff D has taken care of this resident prior to this date and she was 'total care' resident, but she was responsive and would talk. She stated the resident wasn't herself this day. Staff D stated the CNAs do not verify code status. They do have access to it on PCC, but it is a nursing function to verify code status. CNAs do not 'respond' to a code blue, but the CNAs on the unit will see if the nurses need help to get equipment or remove clutter from rooms. On [DATE] at 11:00 AM, an interview was conducted with the Health Information Specialist (HIS) in reference to the yellow DNR form not being in Resident #1's paper chart. The HIS stated that she had no idea why the yellow form was not in the physical chart. She stated she conducted an audit when she thinned this particular chart in [DATE], and it was there at that time. The HIS checked the information that was thinned from the resident's chart and it was not there either. Post event, the HIS completed a full house audit and Resident #1's chart was the only one that did not have the yellow DNR form, of all the residents who had a DNR order. She stated the form was never found, but that she did print a new form on yellow paper from PCC and placed it in the paper chart. On [DATE] at 11:05 AM an interview was conducted with Staff C (LPN) that revealed Staff C was working the nursing desk on the Independence unit on [DATE]. Staff C stated she saw people go to the room and heard someone say she was a full code. Staff C stated she saw other staff looking in the paper chart and there was no form in the chart, so they stated she was a full code. Staff C stated Staff B checked the computer about five minutes later and saw the resident was a DNR. Staff C stated she was trained to check the paper chart for a yellow form and for some reason her chart did not have the form in place. Staff C stated she has received training since this occurred and they went over code procedure. We now have DNR form in the front of the chart and a doctors order in the chart. Staff C stated that no one reported any concerns about Resident #1 on the date of the event. Staff C has not been part of any code blue drill since the event or prior to the event. Staff C further stated that prior to this event, she was trained on the Seaway unit to look in the paper chart for the yellow form. Staff C stated she has not received code blue, code verification or advanced directive education. Staff C has been provided abuse/neglect training approximately three times in the year that she has been working in the facility. Staff C was not aware of the policy and procedure (P&P) on code blue response. The surveyor read the portion of the advanced directive policy pertaining to verifying code status, and Staff C stated she had never been informed of that, but that she is now aware of the P&P. On [DATE] at 11:25 AM, an interview was conducted with the Medical Director (MD) of the facility. The MD stated that he was informed of the event immediately after it occurred, and that he understands it was a system error and that some staff were not aware of how to locate code status for a resident. He understood the DNR form was not located in the paper chart and that the staff neglected to check the EMR. The MD stated that the DCS has re-educated staff on how to verify code status. The MD feels there should be no delay in starting CPR on a resident who is found unresponsive. He feels time is wasted looking for code status and there should not be a delay. The MD would like to see a system put into place, such as a symbol above the resident's bed or in the room to let staff know what the code status is for a resident. The MD stated staff should have stopped CPR once they found out the resident was a DNR and that he felt that was an error. The MD feels that the resident was deceased and not able to feel pain, so he does not believe the staff harmed the resident by doing CPR. On [DATE] at 11:40 AM, an interview conducted with Staff F (LPN) revealed the facility has provided her with code response training. Staff F stated she did participate in a code blue drill but was unsure how long ago that was. Staff F stated to verify code status she would check PCC for an order and writes it on her daily assignment sheet, so she is aware of who is a full code and who is a DNR. On [DATE] at 1030 AM, an interview with Staff G (LPN) revealed training was provided by the facility last week regarding verifying code status. Staff G has not participated in a code blue drill since the event occurred. Staff G has received abuse/neglect training. On [DATE] at 10:40 AM, an interview was conducted with Staff H, a clinical support specialist, that revealed her role is to remain at the desk and make calls as needed. Staff H did confirm additional training regarding code status and code blue response. Staff H has received abuse/neglect training from the facility. On [DATE] at 10:43 AM, an interview was conducted with Staff I, an agency LPN. Staff I stated that this was his first day in this facility and that he was aware to look for the code status of a resident in the electronic record. Staff I stated that he also writes down all the residents code status that he is assigned to. On [DATE] at 12:10 PM, the DCS and ED were informed of Immediate Jeopardy, and a Removal Plan was requested. The facility provided a Removal Plan on [DATE] at 4:05 PM, that was not acceptable and required revision to include review of the facility's policies to all staff. The ED provided a revised Removal Plan on [DATE] at 12:30 PM. On [DATE] at 2:00 PM and on ,[DATE] at 10:00 AM, the surveyor had requested documentation or evidence of training to the nursing staff, related to staff knowing the P&P related to the location of the DNR status for residents who were DNR. The DCS said she would need to complete an audit to determine the number of nurses who had received education. The documentation was not provided until [DATE] at 11:00 AM. On [DATE] at approximately 2:00 PM, the sign in sheets for code blue drills for the past 6 months were presented to the surveyor. The DCS informed surveyor that a drill was done 'last night'. This information was not included in the sign in sheets given to the surveyor at this time. One drill was dated post event on [DATE] at 2:00 PM. A mock drill code sheet was not included with the sign in sheet and the sign in sheet had signatures of only CNA's, and no nurses. The sign in sheets for licensed nurses were lacking. This had been requested along with the code blue drill completed on [DATE] at 7:58 PM per DCS. The facility's Immediate Jeopardy revised Removal Plan, dated [DATE], but provided to the surveyor on [DATE] at 12:30 PM, included the following: Resident #1 was the only resident affected by the deficient practice and had expired. The resident's daughter was contacted at 2:15 PM to inform her of the resident expiration. The daughter was updated on the events at approximately 6:00 PM. Immediate education on Advanced Directives - Code Status was initiated by the DCS with all licensed staff. The education consisted of one on one review of the Advanced Directive Code Status Policy, the Advanced Directive Quick View Guide, as well as Code Documentation form. The education was initiated on [DATE] with all licensed nursing staff and completed on [DATE]. Details of the code were reviewed with the Medical Director on [DATE]. The HIS initiated weekly code status audits on [DATE] consisting of a review of the DNR order and the DNR form in the physical record and on PCC EMR. The audits are reviewed by the DCS. Code blue drill completed by DCS/designee on [DATE] at 2:00 PM with nursing staff. Post review of the drill consisted of code called via intercom, code status identified, 911 called, crash cart obtained, airway assessed (Mock Code Checklist attached for full details). A Code Blue Drill was completed on [DATE] at 7:58 PM with nursing staff. (Mock Code Checklist attached for details). The P&P for Resident Rights were reviewed. Staff were educated on Resident Rights on [DATE]. All newly hired licensed nurses will be educated on Advanced Directive Code Status Policy, the Advanced Directive Quick Guide, the Code Documentation form and Resident Rights prior to floor orientation. Random audits of Resident Rights will be continued by department managers for compliance. The DCS will bring results of random audits to QAPI meeting monthly for 3 months, then quarterly for 3 quarters. The plan will be revised as needed. On [DATE] at approximately 11:00 AM, the RN and LPN education was provided to the surveyor. At this time, 100% of RN's and LPN were documented as completing the education either in person or via telephone and it was dated ,[DATE], 14, and ,[DATE]. The mock code blue drill forms were requested again. On [DATE], the information in the facility's removal plan was verified. Staff members were interviewed to confirm the implementation of the facility's removal plan and included 2 RN's, 12 LPN's, 4 CNA's, and 1 Clinical Support Specialist. All staff member voiced that they did receive education post event on code blue response. The licensed nurses, except for one (See Staff C interview above) voiced the code status of a resident is to be verified by looking into the electronic health record (PCC). Approximately 20 random charts were reviewed and there were no discrepancies identified in reference to code status for all residents reviewed. The Code Blue drills included 17 of 46 nurses who participated in the drills. The sign-in sheets for education included 100% of nurses, including RNs and LPNs. Interviews to verify the removal plan included: On [DATE] at 10:17 AM, Staff E stated that training was received immediately that day on code status, and a chart audit was completed for the entire facility. Staff E stated that she has not participated in a code blue drill since this event as of the date of this interview. She further stated code blue drills are done every few months. Staff E confirmed she had education on advanced directives and abuse/neglect training. Staff E verified the correct process to verify code status was to check PCC (point click care - electronic record system). On [DATE] at 10:47 AM, an interview was conducted with Staff J, an LPN, who was a contract employee. Staff J stated that she was given copies of the abuse/neglect policy and the advanced directive P&P prior to starting on the floor at this facility. Staff J stated she would look for a residents' code status in the electronic medical record and she also took it upon herself to write down all her resident's code status on her daily assignment sheet. On [DATE] at 12:42 PM, a phone interview was conducted with Staff L, an RN, that revealed she was aware of the Advanced Directive/Code P&P. She stated they were to check the electronic record for code status. Staff L further stated that she has received training over the past week for advanced directives and how to verify code status of a resident. Staff L has been trained on the abuse/neglect P&P. On [DATE] at 1:10 PM, a phone interview with Staff K, an LPN, revealed she was aware to check for code status in the electronic health record and has been re-educated on the advanced directive P&P within the past week. Staff K stated she has received training on abuse/neglect from the facility. On [DATE] at 1:20 PM, a phone interview with Staff M, an LPN, revealed she was aware to check for code status in the electronic health record and has been re-educated on the advanced directive P&P within the past week. Staff M stated she has received training on abuse/neglect from the facility. On [DATE] at 1:23 PM, a phone interview with Staff O, an LPN, revealed she was aware to check for code status in the electronic health record and has been re-educated on the advanced directive P&P within the past week. Staff O stated she has received training on abuse/neglect from the facility. On [DATE] at 1:25 PM, a phone interview with Staff N, an LPN, revealed she was aware to check for code status in the electronic health record and has been re-educated on the advanced directive P&P within the past week. Staff N stated she has received training on abuse/neglect from the facility. On [DATE] at 3:05 PM, an interview with Staff P, an CNA, revealed she received training on code blue response and participated in a code blue drill recently. Staff P stated in a code situation she would grab the crash cart and see what else was needed. If nothing was needed at the time, she would stay near in case any assistance was needed. On [DATE] at 3:08 PM an interview with Staff Q, a CNA, revealed she had received additional education on code blue response. If a code blue was called, she would respond by going to the area of the code to see if assistance was needed. She stated she participated in a code blue drill about a week ago. On [DATE] at 3:10 PM, an interview with Staff R, a CNA and Staffing Coordinator, revealed she had participated in a code blue drill during the past two weeks but was unsure of the date. Staff Q stated additional code blue education was done by the facility last week. When she responds to a code blue, she reports to the area and awaits instructions. It is the nurse's responsibility to check code status. On [DATE] at approximately 11:00 AM, the mock code blue drill forms were presented to the surveyor for [DATE] and [DATE] along with sign in sheets for the licensed nursing staff. At this time, 17 of 46 licensed nursing staff have participated in code blue drills as of exit on [DATE]. A review of the sign in sheet dated [DATE] contains Staff C's name and signature. The interview conducted on [DATE] at 11:05 AM with Staff C revealed she had not participated in any code blue drills since [DATE]. The facility's immediate jeopardy was removed on [DATE] at 3:45 PM.

Based on interview, policy review and record review, the facility staff neglected to follow facility policy and procedure of verifying the resident's code status and performed CPR on a resident that was a Do Not Resuscitate (DNR). The facility neglected to ensure the Advanced Directives were followed as per the resident's wishes, for 1 of 3 sampled residents, Resident #1. This medical neglect potentially harmed or caused the resident undue pain during cardiopulmonary resuscitation. There were 137 residents, 83 of who had a DNR order, in the facility at the time of survey, all of which could be affected by this medical neglect. On [DATE], it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the residents residing in the facility. The facility's Administrator was informed of the immediate jeopardy on [DATE] at 12:10 PM. The immediate jeopardy was identified on [DATE], as beginning on [DATE] and removed on [DATE] at 3:45 PM. The scope and severity were decreased to a D, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The scope and severity were lowered as a result of the facility's corrective actions completed as of [DATE]. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of corrective action. The findings included: A review of the facility policy titled Abuse Prohibition Policy and Procedure effective [DATE] and revised [DATE] revealed: Neglect means the Failure of the center, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This policy further states that All employees have a duty to respect the rights of all resident's, to treat them with dignity and to prevent others from violating the resident's rights. A review of the Policy and Procedure titled Advanced Directives and Code Status, effective [DATE] and revised on [DATE] revealed under the Procedure section Bullet point #8 If a resident is found unresponsive the EHR (Electronic Health Record) must be accessed to determine the code status order. For any resident without a physician's order for DNR (Do Not Resuscitate), or without documented wishes to withhold CPR (Cardiopulmonary Resuscitation), EMS (Emergency Medical Services)/911 must be called, the attending physician notified, and emergency basic life support (CPR) must begin. The Advanced Directive Code Status Quick View Guide further states, the yellow Florida DNR form is for transport communication for EMT's (Emergency Medical Technicians), Medics, and ER (emergency room ) staff only. The code status order entered into PCC (Point Click Care - the Electronic medical record software) is the primary source for validating a resident's code status. In the event a resident becomes unresponsive and without pulse or respirations, check the order in PCC. A record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. A State of Florida Do Not Resuscitate Order was signed by the resident's health care surrogate on [DATE] and signed by the resident's physician on [DATE]. A DNR order was in Resident #1's EHR. A nurse's note by Staff A (Registered Nurse/RN), dated [DATE], documented, At 1335 (1:35 PM), resident (#1) was transferred by two CNA's (Certified Nursing Assistants) from her wheelchair to her bed. They made the resident comfortable and then proceeded to the team huddle at the nursing station. Immediately following the huddle, the primary CNA (Staff D) returned to the resident's room and found her unresponsive. CNA called the nurses to the room. This writer (Staff A) ran to the resident's room and checked for pulse and found resident to be pulse-less. Writer then exited the room towards the nursing station to confirm code status. Nursing staff (Staff C, an LPN) at nursing station reported to this writer that the resident was a full code. At 1347 (1:47 PM) CPR initiated, code blue called, and 911 called. 1353 (1:53 PM) Nurse reported resident was not a full code that she was a DNR. CPR continued until 911 arrived at 1355 (1:55 PM). EMT (Emergency Medical Technician) took over code. They pronounced resident's TOD (Time of Death) at 1403 (2:03 PM). Daughter phoned and informed of mother's expiration. Daughter arrived at facility at 1800 (6:00 PM). DCS (Director of Clinical Services) and ED (Executive Director) spoke with daughter concerning mother receiving CPR. Daughter was thankful for the good care that her mother received while in the facility and had no concerns with her receiving CPR. A review of Resident #1's care plans revealed a care plan, initiated on [DATE], stating the resident has an Advanced Directive on record, a health care surrogate (HCS). and a living will, with the DNR dated [DATE]. The care plan stated if resident's heart stop, or resident stops breathing, CPR will not be initiated in honor of the residents DNR wishes. On [DATE] at approximately 11:00 AM, the facility Executive Director and DCS (Director of Clinical Services) agreed the staff failed to correctly verify a resident's code status and performed CPR on a resident who had a DNR order. On [DATE] at 2:00 PM, evidence of clinical nursing staff training was requested from the DCS. The DCS responded stating she can do an audit to ensure they have gotten everyone. The DCS was not sure that all nursing staff have been captured in the drills. The DCS stated they had done 2 drills since the event on [DATE]. An interview was conducted with the DCS on [DATE] at 2:00 PM. During this interview, the DCS stated that the nurse (Staff C, LPN) who checked Resident #1's code status had looked in the paper chart and did not locate a yellow DNR form and assumed the resident was a full code. Staff C did not look in the EMR (electronic medical record) for the code status of the resident. The DCS further stated that Staff A was the unit manager and she checked the EMR system and saw the resident was a DNR. The DCS stated that she went to the resident's room and informed the nurses, but that EMS had already arrived and taken over the code. The DCS further stated that EMS called / pronounced the resident's death after being informed the resident was a DNR. The DCS stated the yellow DNR form was located later. An interview on [DATE] at 2:25 PM with Staff A (RN) revealed the morning of the event Resident #1 was in a wheelchair and in front of the nurse's station for most of the morning. The resident had no concerns that day but did say she had been declining. Staff A stated the Staff D (CNA) had put the resident to bed after lunch just prior to a staff huddle at the nurse's station with all the unit staff. After the huddle, Staff D went back to check on the resident and found her unresponsive and asked Staff A for help. Staff A found the resident without a pulse and stated she yelled down the hall for the code status. She had Staff D remove the resident's roommate from the room. Staff C replied that Resident #1 was a full code. Staff A went back in the room and started CPR. Other staff called 911 and called a code blue in the facility overhead. After 'a few minutes' of CPR Staff B (LPN) came to the room and informed the staff in the resident's room that this resident was a DNR. Staff B had checked the EMR and there was a DNR order and the yellow form was scanned into the EMR system. Staff A stated the person doing CPR at that time put their hands up, but Staff A informed them that they had to continue CPR until EMS arrives. EMS arrived shortly after and when the EMT's were informed of the resident's code status, the celled the time of death at 2:03 PM. Staff A stated she did not look for the order and that Staff C and B checked the record for the orders. Staff A stayed with the resident and initiated CPR. On [DATE] at 10:17 AM, an interview with Staff E (LPN) revealed on the afternoon of the event, she was working on the Seaway unit and heard an overhead page for a code blue to room [ROOM NUMBER]. Staff E stated she grabbed a backboard and ran to the unit. When Staff E arrived, she asked for the resident's code status. Staff E stated there was about 6 people at the nurse's station shouting she was a full code. When Staff E arrived at the resident's room, CPR was in progress and she began to take notes. After ,[DATE] minutes, 'someone' came in and stated the resident was a DNR. CPR continued until EMS arrived. Once the DNR form was provided to EMS they stopped CPR and pronounced the resident's death. EMS was shown a scanned copy in the EMR. The yellow form was not in the paper chart. On [DATE] at 10:25 AM, an interview with Staff D (CNA) revealed she was Resident #1's CNA starting in the morning of [DATE]. Staff D stated she felt the resident did not look so well, and had informed Staff C (LPN) of her concerns. Staff D stated she informed Staff C that she was going to put the resident back to bed because she has not been looking so good since she arrived in the morning at 7:00 AM. After putting the resident back to bed after lunch, Staff D went back to the resident's room about 15 minutes later and found the resident unresponsive. Staff D has taken care of this resident prior to this date and she required total care, but she was responsive and would talk. She stated she wasn't herself this day. Staff D stated CNA's do not verify code status. They do have access to it on PCC, but it is a nursing function to verify code status. She said CNAs do not respond to a code blue, but the CNAs on the unit will see if they need help to get equipment or remove clutter from rooms. Staff D is CPR certified and said she does receive abuse/neglect training often. On [DATE] at 11:00 AM, an interview was conducted with the Health Information Specialist (HIS) in reference to the yellow DNR form for not being in Resident #1's paper chart. The HIS stated that she had no idea why the yellow form was not in the physical chart. She stated she conducted an audit when she thinned this chart in [DATE], and it was there at that time. The HIS checked the information that was thinned from the resident's chart and it was not there either. On [DATE] at 11:05 AM, an interview conducted with Staff C (LPN) revealed that Staff C was working the nursing desk on the Independence unit on [DATE]. Staff C stated she saw people go to the room and heard someone say she was a full code. Staff C stated she saw other staff looking in the paper chart and there was no form in the chart, so they stated she was a full code. Staff C stated Staff B checked the computer about five minutes later; and saw the resident was a DNR. Staff C further stated that no one reported and concerns about Resident #1 on the date of the event. Staff C had not been part of any code blue drill since the event or prior to the event. Staff C further stated that prior to this event, she was trained on the Seaway unit to look in the paper chart for the yellow form. Staff C stated she has not received code blue, code verification or advanced directive education. Staff C has been provided abuse/neglect training approximately three times in the year she has been working in the facility. Staff C was not aware of the policy and procedure (P&P) on code blue response. The surveyor read the portion of the advanced directive policy pertaining to verifying code status, and Staff C stated she had never been informed of that, but that she is now aware of the P&P. On [DATE] at 11:25 AM, an interview was conducted with the Medical Director (MD) of the facility. The MD stated that he was informed of the event immediately after it occurred, and that he understands it was a system error and that some staff were not aware of how to locate code status for a resident. He understood the DNR form was not located in the paper chart and that the staff neglected to check the EMR. The MD stated that the DCS has re-educated staff on how to verify code status. The MD feels there should be no delay in starting CPR on a resident who is found unresponsive. He feels time is wasted looking for code status and there should not be a delay. The MD would like to see a system put into place, such as a symbol above the resident's bed or in the room to let staff know what the code status is for a resident. The MD stated staff should have stopped CPR once they found out the resident was a DNR and that he felt that was an error. The MD feels that the resident was deceased and not able to feel pain, so he does not believe the staff harmed the resident by doing CPR. On [DATE] at 12:10 PM, the DCS and ED were informed of Immediate Jeopardy, and a Removal Plan was requested. The facility provided a Removal Plan on [DATE] at 4:05 PM, that was not acceptable and required revision to include review of the facility's policies to all staff. The ED provided a revised Removal Plan on [DATE] at 12:30 PM. On [DATE] at 2:00 PM and on ,[DATE] at 10:00 AM, the surveyor had requested documentation or evidence of training to the nursing staff, related to staff knowing the P&P related to the location of the DNR status for residents who were DNR. The DCS said she would need to complete an audit to determine the number of nurses who had received education. The documentation was not provided until [DATE] at 11:10 AM. On [DATE] at approximately 2:00 PM, the sign in sheets for code blue drills for the past 6 months were presented to the surveyor. The DCS informed surveyor that a drill was done 'last night'. This information was not included in the sign in sheets given to the surveyor at this time. One drill was dated post event on [DATE] at 2:00 PM. A mock drill code sheet was not included with the sign in sheet and the sign in sheet had signatures of only CNA's, and no nurses. The sign in sheets for licensed nurses were lacking. This had been requested along with the code blue drill completed on [DATE] at 7:58 PM per DCS. The facility's Immediate Jeopardy revised Removal Plan, dated [DATE], but provided to the surveyor on [DATE] at 12:30 PM, included the following: Resident #1 was the only resident affected by the deficient practice and has expired. The resident's daughter was contacted at 2:15 PM to inform her of the resident expiration. The daughter was updated on the events at approximately 6:00 PM. Details of the code were reviewed with the Medical Director on [DATE]. The Health Information Manager initiated weekly code status audits on [DATE], consisting of a review of the DNR order and the DNR form in the physical record and on PCC EMR. The audits are reviewed by the DCS. Code blue drill completed by DCS/designee on [DATE] at 2:00 PM with nursing staff. Post review of the drill consisted of code called via intercom, code status identified, 911 called, crash cart obtained, airway assessed. A Code Blue Drill was completed on [DATE] at 7:58 PM with nursing staff. An interview on [DATE] at approximately 2:15 PM, with the DCS revealed she completed 1:1 education with the nursing staff involved in the event and gave then a copy of the policy and the nursing staff took a written test. Immediate education on Advanced Directives - Code Status was initiated by the DCS with all licensed nursing staff. The education consisted of one on one review of the Advanced Directive Code Status Policy, the Advanced Directive Quick View Guide, as well as Code Documentation form. The education was initiated on [DATE] with all licensed nursing staff and completed on [DATE]. On [DATE] at 2:25 PM, an interview with Staff A revealed she had received additional training since the event regarding checking for code status and where the information is located. Staff A is CPR certified. Staff A stated the facility has provided her with multiple training on abuse and neglect. In an interview on [DATE] at 10:17 AM, Staff E stated that training was received immediately that day on code status, and a chart audit was completed for the entire facility. In this interview on [DATE] at 10:17 AM, Staff E stated that she has not participated in a code blue drill since this event, as of the date of this interview. She further stated code blue drills are done every few months. Staff E confirmed she had education on advanced directives and abuse/neglect training. Staff E verified the correct was top verify code status is to check PCC. An interview with the HIS on [DATE] at 11:00 AM, revealed post event, the HIS completed a full house audit and that was the only chart that did not have the yellow DNR form, of those who had a DNR order. She stated the form was never found, but that she did print a new form on yellow paper from PCC and placed it in the paper chart. In an interview on [DATE] at 11:05 AM, Staff C stated she was trained to check the paper chart for a yellow form and for some reason Resident #1's chart did not have the form in place. Staff C stated she has received training since this occurred and they went over code procedure. We now have DNR form in the front of the chart and a doctors order in the chart. On [DATE] at 11:40 AM, an interview conducted with Staff F (LPN) revealed the facility had provided her with abuse/neglect training often and has received code response training. Staff F stated she did participate in a code blue drill but was unsure how long ago that was. Staff F stated to verify code status, she would check PCC for an order and write it on her daily assignment sheet, so she is aware of who is a full code and who is a DNR. On [DATE] at 1030 AM, an interview with Staff G (LPN) revealed training was provided by the facility last week regarding verifying code status. Staff G has not participated in a code blue drill since the event occurred. Stagg G has received abuse/neglect training. On [DATE] at 10:40 AM, an interview was conducted with Staff H, a clinical support specialist, who revealed her role is to remain at the desk and make calls as needed. Staff H did confirm additional training regarding code status and code blue response. Staff H has received abuse/neglect training from the facility. On [DATE] at 10:47 AM, an interview was conducted with Staff J (LPN), who is a contract employee. Staff J stated that she was given copies of the abuse/neglect policy and the advanced directive P&P prior to starting on the floor at this facility. Staff J stated she would look for a resident's code status in the electronic medical record and she also took it upon herself to write down all her resident's code status on her daily assignment sheet. On [DATE] at 12:42 PM, a phone interview was conducted with Staff L (RN), who revealed she was aware of the Advanced Directive/Code P&P. She stated they were to check the electronic record for code status. Staff L further stated that she has received training over the past week for advanced directives and how to verify code status of a resident. Staff L has been trained on the abuse/neglect P&P. On [DATE] at 1:10 PM, a phone interview with Staff K (LPN) revealed she was aware to check for code status in the electronic health record and has been re-educated on the advanced directive P&P within the past week. Staff K stated she has received training on abuse/neglect from the facility. On [DATE] at 1:20 PM, a phone interview with Staff M (LPN) revealed she was aware to check for code status in the electronic health record and has been re-educated on the advanced directive P&P within the past week. Staff M stated she has received training on abuse/neglect from the facility. On [DATE] at 1:23 PM, a phone interview with Staff O (LPN) revealed she was aware to check for code status in the electronic health record and has been re-educated on the advanced directive P&P within the past week. Staff O stated she has received training on abuse/neglect from the facility. On [DATE] at 1:25 PM, a phone interview with Staff N (LPN) revealed she was aware to check for code status in the electronic health record and has been re-educated on the advanced directive P&P within the past week. Staff N stated she has received training on abuse/neglect from the facility. On [DATE] at 3:05 PM, an interview with Staff P (CNA) revealed she received training on code blue response and participated in a code blue drill recently. Staff P stated in a code situation, she would grab the crash cart and see what else was needed. If nothing was needed at the time, she would stay near in case any assistance was needed. Staff P stated she has received abuse/neglect training recently. On [DATE] at 3:08 PM, an interview with Staff Q (CNA) revealed she had received additional education on code blue response. If a code blue was called, she would respond by going to the area of the code to see if assistance was needed. She stated she participated in a code blue drill about a week ago. Staff Q stated she has received abuse/neglect training from the facility. On [DATE] at 3:10 PM, an interview with Staff R (CNA and Staffing Coordinator) revealed she had participated in a code blue drill during the past two weeks but was unsure of the date. Staff Q stated additional code blue education was done by the facility last week. When she responds to a code blue, she reports to the area and awaits instructions. She said it is the nurse's responsibility to check code status. Staff R stated she has received abuse/neglect training from the facility. A review of the facility education revealed several Abuse/Neglect in-services over the past year. All newly hired licensed nurses will be educated on Advanced Directive Code Status Policy, the Advanced Directive Quick Guide, the Code Documentation form and Resident Rights prior to floor orientation. Monthly code blue drills on each shift will be conducted by the DCS/designee for compliance. The DCS will bring results of random audits to QAPI meeting monthly for 3 months, then quarterly for 3 quarters. The plan will be revised as needed. On [DATE], the prior (,[DATE] and [DATE]) requested sign-in sheets were provided at approximately 11:00 AM. On [DATE], the information in the facility's removal plan was verified. Staff members were interviewed (see interviews above) to confirm the implementation of the facility's removal plan and included 2 RN's, 11 LPN's, 4 CNA's, and 1 Clinical Support Specialist. All staff member voiced that they did receive education post event on code blue response. The licensed nurses, except for one (See Staff C interview above) voiced the code status of a resident is to be verified by looking into the electronic health record (PCC). The Code Blue drills included 17 of 46 nurses who participated in the drills. Approximately 20 random charts were reviewed and there were no discrepancies identified in reference to code status for all residents reviewed. On [DATE] at approximately 11:00 AM, the sign-in sheets / forms were presented to the surveyor for the ,[DATE]-,[DATE] trainings for the licensed nursing staff. At this time, a 100 % of nursing staff had received training and education. The facility's immediate jeopardy was removed on [DATE] at 3:45 PM.

Based on observation, interview and record review, it was determined the facility failed to provide nursing care that meets the professional standards of quality in following physician orders [REDACTED].#96). The findings include: Resident #96 was admitted on [DATE] with [DIAGNOSES REDACTED]. The ANA Standards of Professional Performance describes a competent level of behavior in the professional role, including activities related to quality of care, performance appraisal , education, collegiality, ethics, collaboration, research, and resource utilization. This document serves as objective guidelines for nurses to be accountable for their actions, their patients, and their peers . The standards provide a method to assure clients that they are receiving high-quality care, that the nurses know exactly what is necessary to provide nursing care, and that measure are in place to determine whether the care meets the standards. The Standards of Care in the ANA Nursing: Scopes and Standards of practice (2004) describe a competent level of nursing care. The levels of care are demonstrated through the nursing process. The nursing process is the foundation of clinical decision making and includes all significant actions taken by nurses in providing care to clients. Within these are the nursing responsibilities for diversity, safety, education, health promotion, treatment , self-care, and planning for the continuity of care. An observation was made of Resident #96 on 2/13/13 at 8:30 AM to be holding his hands over his genital area. A review of the medical record documents a physician order [REDACTED]. The February Physician order [REDACTED]. There is an order on the POS for weekly skin assessment due Friday shift 3-11. Catheter care was observed on 2/13/13 at 8:33 AM. As the Certified Nursing Assistant (CNA) started to perform the catheter care, Resident #96 moved into the fetal position and started moaning and grunting. The CNA stated this is normal for the resident. As the CNA moved the resident ' s scrotum, the left groin area was noted to be bright red and patchy. Resident #96 yelled out and tried crossing his legs. He was not asked if he was in pain. The CNA drew back the foreskin of the penis and it appeared to be bright red and excoriated. The resident was moaning when touched, mumbling " Oh God " . He kept crossing his legs and trying to get back into the fetal position and the CNA would reposition the resident onto his back to wash the catheter and genital area. At one point, the resident lifted his head and groaned loudly, with a grimace on his face and his eyes bulging. At this point the CNA asked Resident #96 if he was in pain. The resident stated " a little " . [MEDICATION NAME] Jelly 2% was not applied to the urethra. The catheter was then brought out the bottom of the adult brief, not anchored to any anatomical site. In an interview with the Registered Nurse (RN) who was providing care for Resident #96 on 2/13/13 at 9:01 AM, she stated that she will check his catheter to make sure it is patent and positioned properly. The RN checked for exudate on the penis and checked the indwelling catheter to make sure it was draining properly. She stated that the catheter was positioned properly. The catheter was still thread thru the bottom of the adult brief and not taped to the resident ' s abdomen. A review of the February Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Treatment Administration Record (TAR) documents " keep Foley catheter taped to abdomen and position out of top of pants." The last skin sweep documented is 2/1/13 and does not document anything about redness to the groin area. In an interview with the Unit Manager at 9:28 AM on 2/13/13, she acknowledged that there is an order written [REDACTED]. She also verified that there was nothing in the chart to indicate a rash or redness to the groin of Resident #96 nor was the weekly skin sweep done as ordered on [DATE]. The Unit Manager went with the surveyor to assess the resident at 9:35 AM. She acknowledged that the catheter tubing was not taped to the resident ' s abdomen, nor was it up and over the top of his adult brief. She also acknowledged excoriation in the left groin and penis. Resident #96 would still flinch and moan when touched, and the Unit Manager stated he was in pain. Resident #96 was observed with the Licensed Practical Nurse (LPN) on 2/14/13 at 11:03 AM. The resident was fidgeting in the wheelchair. When asked, the resident stated the catheter did not feel okay. The catheter was angled downwards through the leg of the brief and not taped to the abdomen as ordered. The LPN acknowledged the catheter tubing was incorrectly placed and not taped to the abdomen as ordered.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 28 residents (Residents #96) regarding failure to assess and manage pain for a resident with an urethral erosion. The findings include: Resident #96 was admitted on [DATE] with [DIAGNOSES REDACTED]. An observation was made of Resident #96 on 2/13/13 at 8:30 AM to be holding his hands over his genital area. Catheter care was observed on 2/13/13 at 8:33 AM. As the Certified Nursing Assistant (CNA) started to perform the catheter care, Resident #96 moved into the fetal position and started moaning and grunting. The CNA stated this is normal for the resident. As the CNA moved the resident ' s scrotum, the left groin area was noted to be bright red and patchy. Resident #96 yelled out and tried crossing his legs. He was not asked if he was in pain. The CNA drew back the foreskin of the penis and it appeared to be bright red and excoriated. The resident was moaning when touched, mumbling " Oh God " . He kept crossing his legs and trying to get back into the fetal position and the CNA would reposition the resident to wash the catheter and genital area. At one point, the resident lifted his head and groaned loudly, with a grimace on his face and his eyes bulging. At this point the CNA asked Resident #96 if he was in pain. The resident stated " a little " . The catheter was then brought out the bottom of the adult brief, not anchored to any anatomical site. There is a Pain Evaluation in Advanced Dementia sheet in the resident ' s chart that has his name on it but is not filled out. Based on the criteria listed on the form, the combination of "repeated calling out, loud moaning or groaning, crying", "facial grimacing" and "rigid, fists clenched, knee pulled up, pulling or pushing away" indicates distressing pain. On 2/14/13 at 1:13 PM,the Director of Nursing (DON) acknowledged the form was in the chart and should have been filled out. In an interview with the Registered Nurse (RN) on 2/13/13 at 9:01 AM, she stated that she will first give the resident his medications, then she will check his catheter to make sure it is patent and positioned properly. The RN checked for exudate on the penis and checked the indwelling catheter to make sure it was draining properly. She stated that the catheter was positioned properly and did not assess the groin or pull back the foreskin to properly assess the penis. Resident #96 was still moaning and the nurse asked if he was in pain but the resident said no. He appeared more relaxed in bed, not grimacing. The RN stated the CNA is supposed to tell the nurse when the resident states he is in pain. A review of the medical record documents a physician order [REDACTED]. The February Physician order [REDACTED]. A review of the February Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Treatment Administration Record (TAR) documents " keep Foley catheter taped to abdomen and position out of top of pants. The last skin sweep found is 2/1/13 and does not document anything about redness to the groin or penis. In an interview with the Unit Manager at 9:28 AM on 2/13/13, she acknowledged that there is an order written [REDACTED]. She also verified that there was nothing in the chart to indicate a rash or redness to the groin of Resident #96. The Unit Manager went with the surveyor to assess the resident at 9:35 AM. She acknowledged that the catheter tubing was not taped to the resident ' s abdomen, nor was it up and over the top of his adult brief. She also acknowledged excoriation in the left groin and penis. She acknowledged Resident #96 was acting as if he was in pain, as he was groaning and guarding when she touched him. In an interview with the Director of Nursing (DON) on 2/13/13 at 2:42 PM, she stated Resident #96 was transferred to the Reflections unit for behaviors of yelling out and screaming and was given a care plan to reflect the behaviors. The DON stated the resident is not necessarily in pain, this is just how he acts. In a subsequent interview with the DON 2/14/13 at 1:13 PM, she acknowledged the care plan indicates the resident has behaviors of resisting care, not yelling and screaming. She also stated she was unable to find any documentation in the chart that indicates the resident has yelling behaviors. A nurse ' s note dated 1/22/13 documents that the resident had pain which was manifested by fidgeting and shouting out intermittently. Routine pain medication was given and the effect was good with decreased fidgeting and decreased shouting. The pain assessment dated [DATE] documents under the question " Does the patient/resident exhibit any non-verbal signs that would indicate pain? " Moaning is checked off. Under nursing interventions, no evidence of pain is checked off. The monthly summary dated 2/12/13 indicates the resident is alert and confused, quiet and cooperative with a flat affect. His speech is listed as difficulty. A review of the 14 day Minimum Data Set (MDS) assessment with an Assessment Reference Date of 1/24/13, reveals the resident to be severely impaired with cognition. No behavioral symptoms are exhibited, including screaming and disruptive sounds. The MDS identifies Resident #96 as having pain occasionally in 5 of the 7 previous days, with the level being 5 out of 10. In an interview with Resident #96 Licensed Practical Nurse (LPN) on 2/14/13 at 11:03 AM,she stated the catheter is to be positioned up over the brief and taped to the abdomen to prevent further irritation to the urethra. He has had a catheter for a long time. Because the resident is confused, the LPN stated she will watch for grimacing or fidgeting as signs of pain and that Resident #96 tries to stand on his own if the catheter is placed incorrectly. She stated that the staff does not use yelling as an indicator for pain because he often does yell. Because Resident #96 was trying to stand up in the activity room, the LPN brought him back into his room to check on the catheter. The resident stated to the nurse that the catheter "does not feel ok". The resident keeps crossing his legs and fidgeting in the chair. A CNA came into the room to assist the LPN stand the resident. Resident #96 stood to have his pants pulled down and his brief opened. The catheter was angled down and not taped to his abdomen as ordered. This was acknowledged by the LPN. When the nurse touched the resident he would yell out. There was also tape tangled in the pubic hair and as the nurse tried to remove it, Resident #96 yelled out " It hurts a lot " . He kept trying to grab the nurse to make her stop but the CNA held his hands still. The catheter was then placed correctly. The resident stated he felt much better when the catheter was properly positioned.