Every finding on record at Pavilion at Jacksonville, The

Based on observations, interviews, and record review, the facility failed to properly store, prepare, distribute and serve food in accordance with professional standards for food service safety. The ice machine had a buildup of a dark fuzzy residue on the seams and edges of the lid, food processor had dried yellowish food residue with buildup, meat slicer had miscellaneous debris in the crevices/seams under the blade, milk cooler's seal was detached, onions in storeroom were soft and slimy, no pots in the kitchen, and nourishment room had debris and staining on cabinet floor surface. This could potentially affect the 60 residents residing in the facility. The findings include:During an initial tour of the kitchen on 3/9/3026 at 9:38 AM, the following items were observed.The ice machine had a buildup of a dark fuzzy residue on the seams and edges of the lid with scattered debris along the gasket/seams. (Photographic evidence obtained)The food processor's clear bowl and plastic center spindle contained visible dried yellowish food residue with buildup on the seams.The meat slicer contained miscellaneous debris in the crevices/seams under the blade.The milk cooler's seal was detached with pools of water at the bottom of the cooler. Inside the cooler there was a box containing several sealed juice cups. Some of them were leaking with clumps of ice melting in the middle of the box. (Photographic evidence obtained)The Certified Dietary Manager (CDM) approached on 3/9/2026 at 9:45 am and stated that there was a work order for the cooler seal. She explained that Maintenance had ordered the part and it was waiting for delivery. A box of onions was observed in the dry storage room. Some of them had soft slimy wet spots with a dark fuzzy substance along the neck and under the papery skin.On 3/9/2026 at 10:05 AM. Employee L, a Cook/Dietary Aide, was observed preparing the meal in the kitchen. The menu posted: Meatloaf Homestyle, Parsley Mashed Potatoes, Seasoned [NAME] Beans, Dinner Roll and Brownies. Two (2) unidentifiable loaves were observed covered in a dark red sauce on top of charred paper on a flat pan. There were several spots of a dark black crusty substance on top of as well as in the middles of the loaves.During the observation, the CDM explained that the loaves in the pan on the stove were the meatloaf which would be served to residents for lunch. An interview was conducted with the Maintenance Director on 3/9/2026 at 10:37 AM. When he was asked about the timeframe for the cooler seal to be repaired. He stated that he had not made any orders for repairs. He explained that he had advised the CDM that it was something she needed to do. He confirmed that he was not waiting for any delivery of parts to repair the cooler.A second tour of the kitchen was conducted on 3/10/2026 at 9:47 AM. The ice machine was once again observed with dark residue in the seams and along the top of the lid. (Photographic evidence obtained)During the tour the CDM was asked who was responsible for cleaning the ice machine. She stated that Maintenance is responsible for cleaning it monthly and that she keeps a log of when it is cleaned. The box of onions was observed in the same condition as the day before with gnats circling above and inside of the box. (Photographic evidence obtained)The meat slicer continued to have miscellaneous debris in the crevices/seams under the blade.The food processor bowl still had the dried yellowish food residue and buildup on the seams.During the kitchen observations, Employee L, Dietary Aide was asked who cleaned the slicer. She stated it was the night cook's responsibility to clean the slicer. When the CDM was asked if the slicer had been used the night before, she said she didn't know. After the CDM was shown the food processor. She explained to the Dietary Aide that it needed to be cleaned with a certain tool. They proceeded to look for the tool, but the CDM stated that she may have to order another one. During a third tour of the kitchen conducted on 3/11/2026 at 9:40 AM, the ice machine continued to have a dark substance in the seams. The CDM approached during the observation and said that she cleaned the ice machine the previous night. After being shown the debris that remained in the seams and top of the lid, the CDM acknowledged the presence of the residue. (Photographic evidence obtained). She stated that she would put the ice machine in out of order status. A review of the ice machine cleaning log revealed it was last cleaned on 2/20/26.On 3/11/2026 at 11:11 AM. Employee O, the Dietary Supervisor, was observed preparing lunch in the kitchen. Food was being cooked in metal serving dishes. Spaghetti noodles were observed in a small metal serving dish on the stove. The noodles appeared to be dried and hard, though they had been cooked. When Employee O was asked about the observation, she stated there were no cooking pots or pans in the facility. She explained it had been this way since she began working in the facility. The CDM interjected and stated that she was in the process of ordering new pots. She stated there were no pots when she started as the CDM in the facility in July 2025. When Employee O was asked what she would use to prepare a large soup or a stew. She responded, Use a longer pan.On 3/11/2026 at 11:15 AM, a cell phone was observed on a food prep counter in the kitchen. (Photographic evidence obtained) A telephone interview was conducted with Employee K, Registered Dietician (RD) on 3/11/2026 at 3:49 PM. She confirmed that she was contracted with Dietary Solutions and that this facility is one of several that she works in. She stated that she is familiar with the residents in this facility as they have been in her care since 10/2025. She stated that she usually comes to the facility once a week and that she had been on sick leave for a week prior to the week of the survey. When she was told that the kitchen did not have any cooking pots, she replied that she was not aware of that fact. She went on to say that it was not safe for staff to be preparing the food without having the proper cooking pots.A tour of the facility's nourishment room was conducted on 3/12/2026 at 10:40 AM. Employee D, a Registered Nurse (RN) accompanied this surveyor during this time. An accumulation of debris and staining was observed on the cabinet floor surface. Multiple small specks were observed scattered across the surface along with several dark droplet-like spots with some brownish residue. A dead insect was also observed underneath the pipe. The RN stated that she wasn't sure if the specks were roaches or rust. She explained that staff were responsible for cleaning the area. She said that it used to be worse but acknowledged it needed to be cleaned.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that menus met the nutritional needs of residents in accordance with established national guidelines (S483.60) which included not following menu recipes. This has the potential to affect all residents that consume their meals prepared by the facility. There were 60 residents in the facility at the time of the survey. The findings include:A tour of the kitchen was conducted on 3/9/2026 at 10:05 AM. Employee L, a Cook/Dietary Aide, was observed preparing the meal. The menu posted: Meatloaf Homestyle, Parsley Mashed Potatoes, Seasoned [NAME] Beans, Dinner Roll and Brownies.Two (2) unidentifiable loaves were observed covered in a dark red sauce on top of charred paper on a flat pan. There were several spots of a dark black crusty substance on top of as well as in the middles of the loaves.During the observation, Employee I, the Certified Dietary Manager (CDM), explained that the loaves on the pan on the stove were the meatloaf which would be served to residents for lunch. As the tour continued, Employee L was observed scooping one of the loaves into the clear bowl of a food processor. She added water from the kitchen sink into a container then pouring it into the clear bowl of the food processor which contained the broken loave of meat. She proceeded to blend the water with the loaf of meat and intermittently added water to the mix. She failed to measure the amount of water and loaf of meat added to the food processor and poured white flakes into a large pan. She poured milk from a carton into the white flakes and mixing sporadically. She alternated mixing with adding more milk from the carton until a thick potato-like substance was produced. Again, Employee L failed to measure the ingredients. During this time the [NAME] continued to prepare the meal. She was observed preparing what was later identified as mashed potatoes. She poured the flakes from the container adding various seasonings. She did not measure the seasonings. She poured milk from a carton and stirred intermittingly. Again, she did not measure the milk nor the potato flakes. An interview was conducted with the CDM on 3/9/2026 at 10:21 AM. She was asked about the observations of the cook not measuring the ingredients for the meal. She stated that the recipes are standard. She stated that they make minor changes citing specifically they used Manwich sauce instead of tomato paste in the meatloaf. She stated the Registered Dietitian (RD) was fine with things like this as long as they did not change the menu. She stated that the meatloaf was something they created and used their own recipe for. She stated that they substitute Manwich for tomato sauce and spices. She stated that there are budget concerns which limit the food orders. She stated seasoning is usually hard to get so they use the Manwich because it comes with seasoning and spices. She provided a copy of this recipe which had not been reviewed/signed by the RD. (Photographic evidence obtained) During a follow-up tour of the kitchen on 3/10/2026 at 9:47 AM, the CDM was asked to provide the menus/recipes for the meals to be served during the week of the survey. She stated that she had the menus but not the recipes. She stated that they don't always follow the recipes because they don't always have the ingredients. Again, she noted the adjustment to the meatloaf recipe. When she was asked how the nutritive value established in the menus created by the RD could be maintained with the changes, she shrugged her shoulders. During a follow-up tour of the kitchen on 3/11/2026 at 11:11 AM. Employee O, the Dietary Supervisor, was observed preparing lunch. Food was being cooked in metal serving dishes. Spaghetti noodles were observed in a small metal serving dish on the stove. The noodles appeared to be dried and hard, though they had been cooked. When Employee O was asked about the observation, she stated there were no cooking pots or pans in the facility. She explained it had been this way since she began working in the facility. The CDM interjected and stated that she was in the process of ordering new pots. She stated there were no pots when she started as the CDM in the facility in July 2025. When Employee O was asked what she would use to prepare a large soup or a stew. She responded, Use a longer pan.On 3/11/2026, at 12 noon, Employee O was observed bringing a cart to the meal prep area. Several small clear bowls were observed containing a small wedge of lettuce covered with clear plastic wrap. Employee O stated the clear bowls contained the salads for residents on renal diets. When she was asked about the salads for the residents with regular diets. She retrieved a green bowl covered with a plastic lid from the cart. She removed the lid revealing a small amount of shredded lettuce. When she was asked about a bowl containing lettuce, tomato, black olives, cheese, purple onions, and croutons. She stated that it belonged to the resident that is president of the Resident Council in the facility. (Photographic evidence obtained)An interview was conducted with the CDM on 3/11/2026 at 12:15 PM, concerning the recent observations. When she was asked why only of the salads had several toppings and the rest were just shredded or chopped lettuce with no additional toppings. She stated that salad was on the menu for today. When asked why one was different from the others? She said, Oh that is [Mr. Resident], he is the Resident Council President, so I had gotten that for him. I get him different stuff from time to time. The CDM was advised of the bias that could cause division between the residents who did not receive the same salad and/or meals as [Mr. Resident]. The CDM stated they, nodding towards the kitchen staff, messed that up. She explained that instead of giving them all salads with lettuce, cabbage and carrots, they opened the wrong bag of lettuce and did not want to throw it out. A telephone interview was conducted with Employee K, RD on 3/11/2026 at 3:49 PM. She confirmed that she is contracted with Dietary Solutions and that this facility is one of several that she works in. She stated that she is familiar with the residents in this facility as they have been in her care since 10/2025. She stated that she usually comes to the facility once a week and that she had been on sick leave for a week prior to the week of the survey. She stated the menus were developed prior to her starting and that she hadn't reviewed them. She was advised of the observations of staff not following the recipes. She stated that menus/recipes needed to be followed. She was asked about the CDMs report that she was ok with menu adjustments. She denied this and confirmed that adjusting the recipes compromised the nutritive value of the meals determined by the RD. She stated that she was aware of issues with availability of items due to budget. She was advised of the observation of the salads that were served for lunch. She stated that it was insufficient and should have included more than lettuce. A review of Dietary policies revealed the followingStandardized Menus Date Implemented: 1/13/2023 Date Reviewed/Revised 1/13/2023 The facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances (RDA) of the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences, standardized cycle menus are planned in advance and utilized.1. The facility will make reasonable efforts to provide food that is appetizing and culturally appropriate for residents Menus will be planned to meet basic nutritional needs by providing meals based on individual nutritional assessment and the individualized plan of care.Menus and Adequate Nutrition Date Implemented: 1/13/2023 Date Reviewed/Revised 1/13/2023 The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. Policy Explanation and Compliance Guidelines: 1. The facility will ensure that menus meet the nutritional needs of residents in accordance with established national guidelines. 7. The facility's dietitian or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus. A review of the job description for Dietary [NAME] revealed the followingTasks included:Ensures that food procedures are followed in accordance with established policies.Prepares meals in accordance with planned menus.Prepares and serves meals that are appetizing and palatable in appearance. A review of the job description for Dietary Manager revealed the following. Tasks included:Follows standards and procedures for preparing food. Inspects meals and ensures that standards for appearance, palatability, temperature, and serving times are met. Ensures that foods are prepared according to production schedules, menus, and standardized recipes. Review of facility menus and recipes for items served revealed that the recipes for meals prepared for lunch on 3/9/2026 and 3/11/2026 were not followed. (Photographic evidence obtained)Menu:Day: Monday 3/9 Lunch 3 oz Meatloaf Homestyle* 4 oz Parsley Mashed Potatoes* 4 oz Seasoned [NAME] Beans* 1 Dinner Roll 2 x 2 Brownie Homestyle Meatloaf - 4084 *(Contains Egg Product) Recipe Summary Card Yield: 100 Category: Combination Food, Dish, MeatSource: Custom No. Ingredients: 16 Manufacturer: (None) Ingredient 15 Ib. Beef, Ground5lb. Ground Turkey9 item Egg, Large1 qt. Beef stock1c. Milk 1 c. Water 1 T. Pepper 1 1/2 c. Paste, Tomato, Canned2 1/2 c. Oatmeal, Instant 3 c. Onions, Chopped1 1/2 c. Celery, Diced1/4 c. Thyme, Ground1/2 c. Parsley flakes1/4 c. Oregano, Ground2 T. Garlic powder1/4 c. Basil, Ground Page 1 of 2 Instructions *Preheat oven to 350*F. *In mixer using paddle attachment combine: tomato paste, eggs, milk, water, beef stock, oats. Mix for approximately 2 minutes on medium speed.*In small bowl combine dry herbs/seasoning. *Add ground beef, onions, celery, & dry seasoning mixture. Mix low speed for 2-3 minutes (DO NOT OVERMIX).*Divide mixture evenly into hotel pans. Form into loaves.*Place in oven & bake for 1 - 1 1/2 hours or until internal temperature of 155*F is reached. *Drain fat from pans & let meatloaf stand for approximately 20 minutes before slicing for service.*Hold at 135*F> for service. Serving size: 3 ounces Puree Steps: Remove desired number of servings and add nutritive liquid, milk, broth, etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed.Mechanical Soft Steps: Remove desired number of servings to chop for the mechanical soft diets. Use a knife/fork or processor to chop foods to the desired consistency. Parsley Potatoes-2023 Recipe Summary Card Yield: 50 Category: Vegetable Starchy Source: Custom No. Ingredients: 6 Manufacturer: (None) Ingredient c. 3 1 Salt T. 3/4 Parsley c. 6 T. Onions, minced, dried Ground 1 Black, Pepper, T. 12lb. Skin and Flesh Red, Potatoes, Instructions: 375'F. to oven Preheat Place butter in a large baking dish and melt in preheating oven Toss potatoes and onion in melted butter to coat Bake in preheated oven until potatoes are tender, about 40 minutes. Sprinkle parsley over potatoes and season with salt and pepper ; toss. Transfer to service pans, cover, & hold at 135*F>. Serving size: 4 ounces Puree Steps: Remove desired number of servings and add nutritive liquid, milk, broth, etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. Day: Wednesday 3/11 Lunch 8 oz Pasta w/Meat Sauce4 oz Tossed Salad w/ Dressing1 sl Garlic Bread*4 oz Fruit Cocktail* Tossed [NAME] Salad - 1080 Recipe Summary Card Yield: 25 Category: Combination Food, Salad, VegetableSource: Custom No. Ingredients: 4 Manufacturer: (None) Ingredient 1 3/4 lbs. Lettuce, Iceberg, chopped1/2 Ib. Carrots, sliced1 Ib. Tomatoes, Diced1 1/2 cups Salad Dressing, Italian Facility Developed Recipe for Meatloaf:Homestyle Meatloaf - #4084 Prep. Time Servings 65 Portion 3 oz. Ingredients Name Amount Beef, ground, 80% lean meat / 20% fat, raw Egg scrambled 1 qt carton ea. 10. lb. Spices, pepper, black 13/8 t. Sauce Manwich 1 # 10 can Cereals, oats, regular and quick, 4 cups (1/2-2/3 of box) Onions, fresh, chopped, unprepared 2 whole lg Spices, garlic powder 11/2 T., 1 1/4 t.

Based on record review, observation, interview, and facility policy review, the facility failed to maintain residents' medical records that were complete and accurately documented for one (Resident #6) of four residents reviewed for indwelling catheter, from a total survey sample of 24 residents. The findings include:A review of the medical record for Resident #6 revealed she was originally admitted to the facility on [DATE], and most recently readmitted to the facility from the hospital on 1/16/26. Her primary diagnosis is quadriplegia, C5-C7. Secondary medical diagnoses included neuromuscular dysfunction of bladder and presence of urogenital implantsA review of the facility's Resident Matrix on 3/9/2026, listed resident #6 as having an indwelling catheter. (Copy obtained)On 3/9/2026 at 12:30 PM, Resident #6 was observed in her room without an indwelling catheter, bag or tubing.A review of Resident #6's minimum data set (MDS) quarterly assessment dated [DATE] revealed the following: Section H - documented indwelling catheter present. (Copy obtained)A review of the resident's progress note dated 1/17/2026, read, morning assessment noted the resident to have a change of status. She returned from the hospital late last night with a diagnosis of sepsis. She returned without Foley Cath but voiding well. 1/16/2026 - 3008 revealed no foley catheter.A review of the Resident #6's Care Plan revealed the following: Resident requires use of foley catheter related to (r/t) urinary retention secondary to neurogenic bladder. Enhanced barrier precautions in place. Date Initiated: 03/01/2024 Revision on: 08/19/2024 Resident will have no signs or symptoms of UTI through next review date. Date Initiated: 03/01/2024 Revision on: 08/12/2024 Target Date: 06/05/2026. (Copy obtained)During an interview with Certified Nursing Assistant (CNA) H on 3/11/2026 at 11:30 AM, she stated, She (Resident #6) had a catheter, but it has been gone for over 2 months. She returned from the hospital without it.An interview was conducted with MDS Coordinator/Assistant Director of Nursing (DON) on 3/12/2026 at 11:45 AM. When she was asked about Resident #6 being listed as currently having foley catheter. She stated, I did not see that, I must have missed it. I haven't done anything with the care plans.A review of facility's policy titled Comprehensive Assessments, reads.1. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using Resident Assessment Instrument specified by CMS. 2. The comprehensive assessment process includes direct observation and communication with residents, as well as communication with licensed and non-licensed direct care staff members on each shift. (Copy obtained)

Based on observation, record review, interviews, and facility policy review, the facility failed to practice proper infection control measures for one (Resident #16) of five residents observed during medication administration, and failed to ensure a safe, clean, comfortable and home-like environment for one (Resident #25) of 24 residents sampled. Specifically, the facility failed to properly clean a multidose vial stopper of insulin prior to injecting a clean insulin needle into Resident #16 and failed to clean a dried reddish-brown stain on the floor in Resident #25's room. Failure to appropriately clean and sanitize bloodborne pathogens could pose health risk to vulnerable residents including the possibility to spread blood borne infections to employees and residents. The findings include1. On 3/11/2026 at 11:33 AM, Staff A, RN, was observed providing insulin administration to Resident #16. The nurse reviewed the medication order to check blood glucose before meals and at bedtime. He checked the resident's blood sugar via fingerstick. Results showed that the resident required 1 unit of insulin coverage per sliding scale order. The nurse proceeded to inject a clean insulin needle into the stopper of the resident's multi-dose vial without first cleaning the surface per standard infection control procedures.During an interview with Staff A, RN on 3/11/2026 at 11:40 AM, he stated, What did I forget? I forgot to clean the stopper.Review of Resident #16's clinical record indicated she was admitted to the facility on [DATE] and had a primary diagnosis metabolic encephalopathy. His secondary diagnosis included but were not limited to type 2 Diabetes Mellitus with foot ulcer, type 2 Diabetes Mellitus with Hyperglycemia, and other specified anemias.The resident's physician's order dated 2/17/2026 revealed, Insulin Lispro 100 Unit/ML Solution - Inject as per sliding scale subcutaneously before meals and bedtime related to Type 2 Diabetes Mellitus with Hyperglycemia.Review of the facility policy entitled Administering Medications states Procedure. 25. Staff follows established facility infection control procedures (.gloves, aseptic technique, isolation precautions) for the administration of medications, as applicable.2. An observation of resident room [ROOM NUMBER]-B on 03/09/2026 at 10:07 AM, revealed a dried reddish-brown stain on the floor near the window side of the bed. During an interview with Resident #25, he stated the substance on the floor was blood from his foot and it happened over the weekend. (Photographic evidence obtained)On 03/10/2026 at 9:14 AM, a second observation of room [ROOM NUMBER]-B, revealed a partial removal of the reddish-brown stain on the floor. (Photographic evidence obtained)An interview was conducted with Employee P, Housekeeper on 03/12/2026 at 07:47 AM regarding room [ROOM NUMBER]-B. She explained that when she returned to work on Tuesday, she noticed a dried blob blood stain in the resident's room. She sprayed the orange cleaning substance in a bottle titled acid bathroom cleaner to sanitize the blood, mopped it up with a clean mop, then discarded the mop and rag in a red bag, and put a wet floor sign up. Employee P stated that the facility does not use a bleach cleaner and she did not report the blood stain to anyone.During an interview with the Housekeeping Supervisor on 03/12/2026 at 03:26 PM, he stated the housekeeping staff are supposed to clean blood spills by sanitizing with spray, mop it up, place the mop aside and then used a clean mop to mop the floor. The blood stained item is then washed separately from other laundry. A tour of the housekeeping chemical storage was conducted; there was no bleach available. The Housekeeping Supervisor confirmed the housekeepers do not use bleach. (Photographic evidence obtained)Review of the facility's policy titled Cleaning Spills or Splashes of Blood or Body Fluids dated January 2012, instructed under Section titled Equipment and Supplies 2. Bleach (EPA registered sodium hypochlorite 5.25%). Sections titled Steps in Procedures: 1. Arrange the supplies so they can be easily reached; Using appropriate personal protective measures, mix and label the following disinfectant solutions; One (1) part bleach and ten (10) parts water (written as 1:10); and/or One (1) part bleach and one hundred (100) parts water (written as 1:100); Put on nonsterile exam gloves or heavy-duty gloves; If the spill involves large amounts of blood (two cups or more), spray the area with 1:10 disinfectant solution until thoroughly saturated; Use forceps, tongs, or brush and dustpan to pick up broken glass; If the spill involves large amounts of blood (two cups or more), spray the area with 1:10 disinfectant solution until thoroughly saturated. If the spill involves large amounts of blood (two cups or more), spray the area with 1:10 disinfectant solution until thoroughly saturated; Use forceps, tongs, or brush and dustpan to pick up broken glass; Place contaminated items, including equipment used to pick up glass fragments, in properly labeled receptacle for decontamination; Wipe up the spill or splash with a cloth or paper towels or use granules to absorb spill; Discard the saturated cloth or paper towels into the plastic biohazard bag; Repeat as necessary until the spill or splash area is dry; Disinfect the area by swabbing with a cloth or paper towel which has been moderately saturated with a 1:100 bleach solution. Allow to air dry; Discard the contaminated cleaning cloth or paper towels into the plastic biohazard bag; Spray disinfectant solution onto the discarded cloth or paper towels inside the plastic bag; Tie the bag. If the outside of the plastic bag becomes contaminated with blood, body fluids, secretions, or excretions, place the contaminated bag into a clean plastic bag; Place the plastic bag into a designated container for medical waste; Remove gloves and place them into designated container. Wash and dry hands thoroughly; Return unused supplies or equipment to the designated storage areas; Wash and dry your hands thoroughly. (Copy obtained)

Based on interviews, record review, and policy and procedure review, the facility failed to ensure food served was prepared by methods that conserved nutritive value and flavor, by failing to follow standardized recipes to provide palatable and appetizing food in accordance with professional standards for food service. This practice can result in decreased food consumption by residents who consume foods from the facility's kitchen. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. The findings include: During a follow-up tour of the kitchen on 5/1/24 at 11:50 a.m., Employee D was asked to provide the recipes used for today's menu. Employee D confirmed that no recipes were used today. When she was asked how staff would know how to prepare the cabbage, she replied, It's just basic steaming of the cabbage. I talk staff through it. You use a little butter in the bottom of the pan, water and steam. I go back to working with my granny on how she would cook and not measure. I've been cooking by sight since 2001. During the same follow up tour of the kitchen on 5/1/24 at 11:50 a.m., a regular diet test tray was ordered. The test tray left the kitchen at 12:53 p.m. and arrived on the west hallways at 12:56 p.m. The regular diet test tray food items included fried chicken leg, steamed rice, cabbage, and peach cobbler. The test tray was received at 1:11 p.m. Results of the test tray concluded that the cabbage flavor was unpalatable. It tasted highly of pepper. On 5/2/24 at 11:05 a.m., an interview was conducted with Cook A. When asked what was used to follow and prepare menu items, such as pureed meat or cabbage, she stated the shredded cabbage was received from the food distributor precooked. She used the shredded carrots of the cabbage but not the purple cabbage. Seasoned salt was added to the cabbage. We don't have a recipe. [Employee D] would have already printed a menu of what was to be prepared and provided all of the food components to cook the meal (meat, starch, vegetable, and dessert). If she prepared hamburger, the hamburger was cooked or blended fine. A thickener was added, bread, or mashed potatoes for pureed menu items. When asked again how she followed meal recipes as she was preparing each meal item, Cook A replied, No, if you know how to cook, you know how to cook. If you don't know, you ask somebody. On 5/2/24 at 11:17 a.m., an interview was conducted with Employee B, Cook. She reported she had been a cook at the facility for one year. When asked what was used or followed to prepare menu items such as pureed meat or cabbage, she replied, The manager provides a menu, cooks the meat and separates some for puree. Hot water or bread was added for pureed items if the kitchen was out of thickener. When asked whether meal recipes were used to prepare meal items, she replied, I don't think we have any. [Employee D] shows the cooks how to prepare almost all menu items. She stated she really did not know how much seasoning to add. I know not to put too much. When asked whether the kitchen had the correct food items to serve the menu, she replied, Some, but a lot don't come in. When asked if they ever ran out of food, she replied, Yes, maybe one to two days per week. If they run out of a food item, a substitute is used; a vegetable is substituted with another vegetable or the entire meal is changed. On 05/02/24 at 11:38 a.m., an interview was conducted with Employee C, Cook. When asked what was used or what menu was followed to prepare menu items such as pureed meat or cabbage, she replied, A menu is printed and placed on the table. The recipe book is in the Manager's office. I've cooked cabbage a lot so I already know. If something is new, I look at the recipe. When asked if she followed meal recipes as she was preparing the meal item, she replied, Yes, because I've already cooked the item before. She stated, The kitchen may be short of food or does not have the correct food items to serve the menu a day before food delivery. She also stated the kitchen did not run out of food and they did not have to make a lot of substitutions. On 5/2/24 at 11:53 a.m., an interview was conducted with Employee D, which revealed that the Dietary Department did not get the correct food items to serve the menu because some ordered items were not delivered. She stated she called the RD to ensure the appropriate nutrients were included for the meal served. She stated the kitchen did not run out of food, but if a food item was needed, the Administrator would purchase it from the local store. Employee D stated substitutions were used on the menu maybe two times per month. There had not been any changes to the food budget. There were no issues with food theft. Employee D stated she was responsible for overseeing the food budget. If she was over budget, corporate would notify her regarding the overage. She was responsible for purchasing food and supplies for the kitchen. When asked what was the status of her CDM application, she reported that she had not taken CDM classes or applied for the exam. I'm working on it, it is a long process. I should have it before the end of this year. She reported completing the SafeServ course and exam in January 2024. When asked what were some of the complaints received from the resident council meeting, she stated, Cold food, food is spicy, request for double portions, or not enough food. She discussed corrective actions with the RD to ensure temperatures were warmer and likes/dislikes were documented on the meal ticket. She stated spices were not used; seasoned salt and table salt were used to season food when preparing meal items. In an interview on 5/2/24 at 12:34 p.m. with the RD, she stated she was contracted and worked about 16 hours per month. When she was asked what her role was in the facility, she replied, Mostly a clinical dietitian and to be of any assistance to [Employee D]. The facility previously had a Certified Dietary Manager (CDM) and she would assist the CDM with menu changes and kitchen inspections in the past. Since the Dietary Manager role had been filled, the RD stated she was still assessing what kind of assistance was needed. The CDM had more training than [Employee D], so I might need to assist more. She has been working in a lead role for a long time, so I don't want to offend or overstep, or question skills and knowledge. We're working through that and trying to discover that. Her title is Dietary Manager; she is not a CDM. She can't complete clinical duties, so I have taken on more clinical responsibilities. The RD was asked whether she knew if the facility is getting the correct food items required to serve the menus. She replied, For the most part. Most of the time yes, but she has had difficulty getting some things for one reason or another. When asked whether the kitchen had ever run out of food, the RD replied, No, they do not run out of food. When asked what was the frequency of substitutions being used, the RD stated she was not notified every time a substitution was offered. We're working on that, for her to contact me. She was not aware of any changes in the food budget. Corporate, the Administrator and Employee D were responsible for overseeing the food budget. Employee D was responsible for the purchasing of food and supplies. When asked whether she was aware of some of the complaints received from the resident council meeting, the RD replied, From time to time, it's been a while. The RD and Employee D discussed resident preferences, likes, and dislikes during the RD visit. An interview on 5/2/24 at 2:25 p.m. with the Administrator revealed he was not aware of the status of Employee D's CDM application. He had been at the facility since February 2024 and was not aware of the process. He stated corporate oversaw the food budget. Employee D purchased food and supplies for the kitchen. The RD was contracted and was responsible for the clinical aspect of the department to include assessments and diets. Employee D was responsible for food service operations. A review of the facility's policy and procedure title Food Preparation Guidelines, revealed, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. 2. Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. This includes but is not limited to: . b. preparing foods as directed. 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: . b. using spices or herbs to season food in accordance with recipes. c. serving hot food/drinks hot and cold foods/drinks cold. d. addressing resident complaints about foods/drinks. (Copy obtained).

Based on record review and staff interview, the facility failed to obtain a pre-admission screening and resident review (PASARR), Level II, for two (Residents #25 and #33) of 21 residents sampled. Resident #25 was diagnosed with bipolar disorder on admission to the facility, and Resident #33 was diagnosed with schizoaffective disorder after admission. Neither resident was referred for a Level II PASARR (in-depth evaluation by the state-designated mental health or intellectual disability authority). The Level II evaluation report must be used by the facility when conducting assessments of the resident, developing the care plan, and when transitions of care occur. Incorporating the Level II information in these processes promotes comprehensive assessment and provision of care for residents with MD (mental disorders) or ID (intellectual disability). The findings include: 1. A record review revealed that Resident #25 was admitted to the facility on [DATE]. Her admission diagnoses included bipolar disorder, Parkinson's disease with dyskinesia (involuntary, erratic movements), general anxiety disorder, and unspecified dementia. She was also diagnosed with hallucinations, major depressive disorder and mood disorder. Further review of the record revealed that a facility nurse completed the admission PASARR for Resident #25. The PASARR did not reflect that Resident #25 had diagnoses of dementia or bipolar disorder. A review of the 2/7/2024 Annual Minimum Data Set (MDS) assessment, revealed that under Section B (Hearing, Speech, and Vision), the resident had clear speech, was sometimes understood, and was sometimes able to understand others. Under Section C (Cognitive Patterns), the resident was documented as unable to participate in a brief interview for mental status (BIMS) because she was rarely/never understood. Staff documented this section of the assessment as follows for Resident #25: Long and short-term memory problems, and severely impaired cognitive skills for daily decision-making. She was noted with an acute change in mental status from her baseline as follows: Inattention - behavior continuously present. Disorganized thinking - behavior continuously present. The resident was not interviewed for Mood (Section D) because she was rarely/never understood. Staff documented the following: Appearing down, depressed or hopeless nearly every day. Trouble concentrating on things nearly every day. Social isolation: Sometimes. Diagnoses identified in the MDS included: dementia, parkinson's disease, seizure disorder/epiliepsy, anxiety, depression, and manic depression (bipolar disorder). 2. A record review revealed that Resident #33 was admitted to the facility on [DATE]. His admission diagnoses included unspecified dementia, major depressive disorder, epilepsy, and schizoaffective disorder. Further review of the record revealed that the admission PASARR for Resident #33 did not reflect the diagnosis of schizoaffective disorder. A review of the resident's 11/8/2023 Quarterly MDS, revealed the following diagnoses: dementia, Parkinson's disease, seizure disorder/epilepsy, anxiety, depression, and manic depression (bipolar disease). Schizoaffective disorder was not noted. A review of the 3/20/24 Annual MDS, revealed the following diagnoses: dementia, Parkinson's disease, seizure disorder/epilepsy, anxiety, depression, and manic depression (bipolar disease). Schizoaffective disorder was not noted. Section B (Hearing, Speech, and Vision) indicated the resident had clear speech, was sometimes understood, and was sometimes able to understand others. Under Section C (Cognitive Patterns), the resident was documented as unable to participate in a brief interview for mental status (BIMS) because he was rarely/never understood. Under Section C (Cognitive Patterns), the resident was documented as unable to participate in a brief interview for mental status (BIMS) because he was rarely/never understood. Staff documented this section of the assessment as follows for Resident #33: Long and short-term memory problems, and severely impaired cognitive skills for daily decision-making. He was noted with an acute change in mental status from his baseline as follows: Inattention - behavior continuously present. Disorganized thinking - behavior continuously present. The resident was not interviewed for Mood (Section D) because he was rarely/never understood. Staff documented the following: Appearing down, depressed or hopeless nearly every day. Trouble concentrating on things nearly every day. Social isolation: Sometimes. On 5/2/2024 at 1:55 p.m. during an interview with the Social Services Director, she stated she had been employed with the facility since December 2023. She stated she was aware of the issues with the facility's PASARRs. She was shown the PASARRs for Residents #25 and #33. She agreed a Level II review should have been done for both residents. She confirmed that Resident #25's bipolar diagnosis was present upon admission in the facility. She stated the schizoaffective diagnosis for Resident #33 was added after his admission and the facility failed to perform an updated screening with the new diagnosis.

Based on record reviews and interviews, the facility failed to provide an appropriate discharge summary including a recapitulation of the stay, for two (Residents #54 and #208) of three residents sampled for discharges, from a total sample of 21 residents. The findings include: 1. A record review revealed Resident #54 was admitted to the facility on [DATE] and was discharged on [DATE]. A review of the admission minimum data set (MDS) assessment, completed on 4/1/24, revealed Resident #54 scored 00 out of 15 possible points on the brief interview for mental status (BIMS), indicating severe cognitive impairment. He was dependent for self-care. He had impairment on both sides and was always incontinent of bladder and frequently incontinent of bowel. The resident's family participated in the assessment. Discharge was not planned. Based on the assessment, the goal was to for Resident #54 to remain in the facility. An interview was conducted on 5/2/24 at 11:54 a.m. with Employee F, a physical therapist assistant (PTA) who was familiar with Resident #54. He stated the resident received therapy and was discharged home. He referred to the resident as being totally limp on the left side. He stated the resident required the use of a Hoyer lift (mechanical lift). He was unable to say if the resident was discharged with or had the necessary equipment at home. An interview was conducted on 5/2/24 at 1:37 p.m. with the Social Services Director (SSD) who stated Resident #54 was discharged home. She stated Resident #54 received home health and medical equipment; however, she could not provide any specifics or additional information on either. 2. A record review revealed that Resident #208 was admitted to the facility on [DATE], and was discharged home on 4/8/24. A review of the 5-day MDS assessment, dated 2/28/24, revealed that Resident #208 scored 9 out of 15 possible points on the BIMS assessment, indicating moderate cognitive impairment. The resident required some assistance with self-care. He had no impairment in his upper/lower extremities. During an interview conducted on 5/2/24 at 11:54 a.m. with Employee F, he stated Resident #208 was discharged based on insurance coverage. He stated to his knowledge the resident received therapy services at home. He could not provide any specific or additional information. During an interview on 5/1/24 at 1:23 p.m. with the SSD, she was asked to provide the discharge summaries for Residents #54 and #208. She stated a discharge summary was not done for either of the residents. In a follow-up interview at 2:55 p.m., she advised the survey team that the facility had not been providing discharged residents with a recapitulation of their stay at the time Residents #54 and #208 were discharged .

Based on kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, by failing to employ a qualified food service manager who met state requirements for food service managers and who did not frequently receive consultations from a qualified dietitian or other clinically qualified nutrition professional. The findings include: During the initial kitchen tour, conducted on 4/29/24 at 10:20 a.m., Employee D stated she was responsible for the Dietary Department and the kitchen staff; the Registered Dietitian (RD) would not be at the facility until Thursday, 5/2/24. A follow-up tour of the kitchen was conducted on 5/1/24 at 11:50 a.m. Employee D confirmed that no recipes were used for the lunch meal. When she was asked how staff would know how to prepare the cabbage, she replied, It's just basic steaming of the cabbage. I talk staff through it. You use a little butter in the bottom of the pan, water and steam. I go back to working with my granny on how she would cook and not measure. She stated she had been cooking by sight since 2001. A review of facility documentation titled Employee Status Change Form, dated: 9/21/23, revealed that Employee D's job title was changed to Dietary Manager at that time. (Photographic evidence obtained) A review of facility documentation titled Dietary Manager - Job Description, revealed that minimum requirements for the position included one of the following: Certification as a dietary manager; certification as a food service manager; has similar national certification for food service management and safety from a national certifying body; has an associate's or higher degree in food service management or in hospitality if the course of study includes food service or restaurant management from an accredited institution of higher learning; has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting, and has completed a course of study in food safety and management by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. Must also meet State requirements for food service managers or dietary managers. Two years' experience in food service management. Prior experience in healthcare food service preferred. (Photographic evidence obtained) On 5/2/24 at 11:53 a.m., an interview was conducted with Employee D, which revealed that the Dietary Department did not get the correct food items to serve the menu because some ordered items were not delivered. She stated she called the RD to ensure the appropriate nutrients were included for the meal served. She stated the kitchen did not run out of food, but if a food item was needed, the Administrator would purchase it from the local store. Employee D stated substitutions were used on the menu maybe two times per month. There had not been any changes to the food budget. There were no issues with food theft. Employee D stated she was responsible for overseeing the food budget. If she was over budget, corporate would notify her regarding the overage. She was responsible for purchasing food and supplies for the kitchen. When asked what was the status of her CDM application, she reported that she had not taken CDM classes or applied for the exam. I'm working on it, it is a long process. I should have it before the end of this year. She reported completing the SafeServ course and exam in January 2024. When asked what were some of the complaints received from the resident council meeting, she stated, Cold food, food is spicy, request for double portions, or not enough food. She discussed corrective actions with the RD to ensure temperatures were warmer and likes/dislikes were documented on the meal ticket. She stated spices were not used; seasoned salt and table salt were used to season food when preparing meal items. In an interview on 5/2/24 at 12:34 p.m. with the RD, she stated she was contracted and worked about 16 hours per month. When she was asked what her role was in the facility, she replied, Mostly a clinical dietitian and to be of any assistance to [Employee D]. The facility previously had a Certified Dietary Manager (CDM) and she would assist the CDM with menu changes and kitchen inspections in the past. Since the Dietary Manager role had been filled, the RD stated she was still assessing what kind of assistance was needed. The CDM had more training than [Employee D], so I might need to assist more. She has been working in a lead role for a long time, so I don't want to offend or overstep, or question skills and knowledge. We're working through that and trying to discover that. Her title is Dietary Manager; she is not a CDM. She can't complete clinical duties, so I have taken on more clinical responsibilities. The RD was asked whether she knew if the facility is getting the correct food items required to serve the menus. She replied, For the most part. Most of the time yes, but she has had difficulty getting some things for one reason or another. When asked whether the kitchen had ever run out of food, the RD replied, No, they do not run out of food. When asked what was the frequency of substitutions being used, the RD stated she was not notified every time a substitution was offered. We're working on that, for her to contact me. She was not aware of any changes in the food budget. Corporate, the Administrator and Employee D were responsible for overseeing the food budget. Employee D was responsible for the purchasing of food and supplies. When asked whether she was aware of some of the complaints received from the resident council meeting, the RD replied, From time to time, it's been a while. The RD and Employee D discussed resident preferences, likes, and dislikes during the RD visit. An interview on 5/2/24 at 2:25 p.m. with the Administrator, revealed he was not aware of the status of Employee D's CDM application. He had been at the facility since February 2024 and was not aware of the process. He stated corporate oversaw the food budget. Employee D purchased food and supplies for the kitchen. The RD was contracted and was responsible for the clinical aspect of the department to include assessments and diets. Employee D was responsible for food service operations. An interview was conducted with the Administrator on 5/2/24 at 2:30 p.m. He stated the RD did not attend QAPI meetings because they fell on Fridays. The RD worked at the facility on Thursday's. He stated going forward he would have the RD work on Fridays during QAPI so she could be involved. A review of the facility's policy and procedure titled Dietary Services - Staffing (revised 1/13/2023), revealed: The facility employs sufficient staff with the appropriate competencies and skills sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Policy Explanation and Compliance Guidelines for staffing: . 3. If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility will designate a person to serve as the director of food and nutrition services who: a. For designations prior to November 28, 2016, meets these requirements not later than 5 years after November 28, 2016 or no later than one year after November 28, 2016 for designations after November 28, 2016 is: i. A certified dietary manager; ii. A certified food service manager; iii. Has similar national certification for food service management and safety from a national certifying body; or iv. Has an associate's or higher degree in food service management or in hospitality if the course study includes food service or restaurant management, from an accredited institution of higher learning; and b. In states that have established standards for food service managers or dietary managers; meets State requirements for food service managers or dietary managers. c. Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. (Copy obtained)

Based on observations, interviews, and record review, the facility failed to 1) Ensure food items had not expired, 2) Document food items' use by dates, 3) Keep thermometers in cooling units that contained food, 4) Use sanitizer in the three-compartment sink every time it was used, and 5) Keep food temperature logs for every meal. This deficient practice could potentially affect all residents receiving food from the facility's kitchen. The findings include: On [DATE] at 10:35 AM an observation of the kitchen was made revealing the following: A bag of hotdog buns with a green/yellow substance on them was observed on the bread rack. Also observed were two bags of hamburger buns with a green substance on several of the buns. The bags were dated [DATE]. (Photographic evidence obtained) The Certified Dietary Manager (CDM), present during the observation, was asked about the bread and stated that the bread delivery usually switches the old bread out for new bread. He was asked about the last delivery and reported it was on [DATE]. The CDM stated bread was delivered every week. White flour was seen being stored in a large plastic container which had no date on it. Observations were made of a milk cooler having five expired milk cartons dated [DATE] on them. It was also noted that there was no thermometer in this unit. The small freezer across from the milk cooler was also noted with no thermometer inside. On [DATE] at 10:45 AM, the CDM was asked to find the thermometers in these units. He was unable to locate them. He was asked if these two units should have had thermometers in them and he stated yes. The three-compartment sink was filled with water and had pots in it. At 10:55 AM, Dietary Aide Z was asked to test the sink's sanitizer at this time. The test strip did not change color, and was tested two more times with the same result. The CDM told Dietary Aise Z to change out the sanitizer bucket. The sink was tested after the sanitizer was added and the test strip revealed the appropriate 200 Parts Per Million (PPM). Dietary Aide Z was asked about the use of the sanitizer. She stated she put the sanitizer solution in the sink before adding the pots or dishes to the sink. She was asked about the sanitizer and she stated she had gotten busy and did not test the sanitizer this morning. On [DATE] at 10:27 AM, an observation of the food temperature logs was made. More than one day was observed in which meal temperatures had not been documented on the log. At this time the CDM was asked how many times a day the food temperatures should be taken when the food was on the steam table. He stated, three. A review of facility's policy titled Sanitation inspection was conducted. There was no policy date noted. The policy instructed staff to conduct inspections to ensure food service areas were clean, sanitary, and in compliance with applicable state and federal regulations.

Based on observations, record review and interviews, the facility failed to monitor behaviors for one (Resident #6) of five residents selected for unnecessary medications review, from a total of 23 residents in the sample. The findings include: An observation and interview was conducted with Resident #6 in her room on 5/10/22 at 3:36 p.m. The resident was sitting in her wheelchair at bedside smiling and talking. She did not remember which medications she took. A medical record review revealed an admitted [DATE] and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The active care plan included the following Focus Areas: Behavior Problem - manipulative due to ineffective coping skills. Intervention: Monitor behavior and side effects of [CONDITION(S)] medication. Uses antianxiety medication. Intervention: Monitor behaviors and administer medications as ordered. A review of the May 2022 Medication Administration Record (MAR) revealed no documentation of behaviors, medication side effects, or nonpharmacological interventions for [MEDICATION(S)]. (Photographic Evidence Obtained) There was no documentation in the medical record to verify that behaviors, medication side effects, or nonpharmacological interventions were being monitored/provided. An interview was conducted with Licensed Practical Nurse (LPN) B on 5/12/22 at 10:59 a.m. She stated resident behaviors were monitored and documented on the Medication Administration Record (MAR). An interview was conducted with LPN A on 5/12/22 at 11:04 a.m. He stated resident behaviors were documented on the MAR daily. He confirmed there was no behavior monitoring documented for Resident #6. An interview was conducted with the Assistant Director of Nursing (ADON) on 5/12/22 at 12:10 p.m. She confirmed behavior monitoring for Resident #6 was not documented and should have been on the MAR. The ADON stated she would initiate that now.

Based on medical record review, interviews with staff, and a review of the Policy and Procedure for General Guidelines for Medication Administration, the facility failed to monitor apical pulses for [MEDICATION(S)] administration and to obtain a [MEDICATION(S)] level for one (Resident #29) of 23 sampled residents. An apical pulse should be obtained before administering [MEDICATION(S)] (heart medication), because it is not administered if the apical pulse is below 60. The medication should be monitored through laboratory work due to a narrow safety range. The findings include: A medical record review was conducted for Resident #29 revealing an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no apical pulses documented before administration of the medication. The April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record found no documentation of a laboratory order to monitor [MEDICATION(S)] levels. The manufacturer recommended that levels must be monitored because the drug had a narrow safety range. Therapeutic levels were between 0.8 - 2.0 ng/ml (nanograms per milliliter). A toxic level was greater than 2.4 ng/ml (emedicine.medscape.com, accessed on 5/12/22 at 4:30 p.m.) A review of the resident's vital signs documentation revealed his radial pulses were usually taken at 12:00 p.m. or later. (Photographic Evidence Obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 5/11/22 at 2:05 p.m. She stated the apical pulse was taken and documented before administering [MEDICATION(S)] and should be documented on the resident's MAR. An interview was conducted with the ADON on 5/12/22 at 10:51 a.m. She confirmed the apical pulses were not being documented, and the order was changed in the computer with parameters for apical pulse monitoring. After reviewing the resident's medical record, the ADON reported a [MEDICATION(S)] level was not ordered and the physician was notified. A STAT (immediate) order for a [MEDICATION(S)] level was obtained. A review of the Policy and Procedure for General Guidelines for Medication Administration (dated 9/2018), noted Medications are administered as prescribed in accordance with good nursing principles and practices.

Based on observations, record reviews, and interviews, the facility failed to ensure medical records were complete and accurate for one (Resident #41) of 22 sampled residents. The findings include: A medical record review was conducted for Resident #41 which noted an admission date of [DATE] with a [DIAGNOSES REDACTED]. A review of the current Treatment Administration Orders (TAR) revealed instructions to check blood pressure prior to giving all blood pressure medications, and '0' was observed with nurses initials. There were no blood pressures documented. A record review was also conducted for Advance Directives, which noted the resident was a full code in the electronic medical record and a 'Do Not Resuscitate' (DNR) in the paper medical chart. A record review of the current physician's orders [REDACTED]. 4/7/18. An interview was conducted with the Social Services Director (SSD) on 12/12/18 at 2:13 PM. The SSD reported she oversaw the Advanced Directives when residents were admitted , and they were discussed every quarter. There was a copy of the Advanced Directives in the paper record, and in a DNR book on the nursing unit. The SSD reported Resident #41 was a 'Do Not Resuscitate' resident. The SSD reviewed the electronic medical record for Resident #41 and reported the electronic medical record stated full code. She did not know who ensured the Advanced Directives are updated on the electronic medical record. An interview was conducted with Employee A, Licensed Practical Nurse (LPN), on 12/12/18 at 2:23 PM. The LPN was asked about Advance Directives for Resident #41. She looked in the electronic medical record, and reported the resident was a full code. Employee A reported there was a DNR book at the nurses' desk, and if there was a medical emergency, she would check the paper medical record for a copy of the Advanced Directives signed by the physician, resident, and or family, which was sent with the resident to the hospital. The LPN was asked where residents' blood pressures were documented. She checked the electronic medical record, MARs, and TARs, and reported blood pressures were not recorded. The LPN confirmed the physician's orders [REDACTED]. On 12/12/18 at 2:45 PM the SSD reported that Resident #41 had a DNR in the paper chart, in the DNR book, and in the physician's orders [REDACTED]. .

Based on observations, medical record reviews and interviews, the facility failed to follow the physician's orders for administration of insulin for one (Resident #14) of 22 sampled residents , which could have resulted in a medical emergency. The findings include: A medical record review was conducted for Resident #14, which noted an admission date of [DATE] with a [DIAGNOSES REDACTED]. The current Medication Administration Record [REDACTED]. A review of the medical record for laboratory tests revealed an HA1C (a blood test that reflects your average blood glucose levels over the past three months) was received on 9/12/18 with a note that the physician was notified at 6:30 PM, and a new order for [MEDICATION NAME] 32 units SQ twice a day was received. A review of the physician's orders for (MONTH) (YEAR) noted [MEDICATION NAME] 32 units SQ twice a day, dated 9/12/18, and the (MONTH) physician's orders noted [MEDICATION NAME] 28 units SQ twice daily, dated 9/12/18. The MARs for (MONTH) and (MONTH) (YEAR) were reviewed and noted [MEDICATION NAME] 32 units SQ twice a day was administered (MONTH) 12 through (MONTH) 15, (YEAR). An interview was conducted with the Director of Nurses (DON) on 12/13/18 at 12:15 PM concerning the orders for the [MEDICATION NAME]. The DON confirmed the resident received 32 units of [MEDICATION NAME] between (MONTH) 12th and (MONTH) 15, (YEAR). She reviewed the HA1C on 9/12/18, and confirmed documentation of a new order for [MEDICATION NAME] 32 units SQ twice a day. The DON reported a medication error was going to be initiated for that time period due to not having a physician's order written. She stated, The only physician's order we have is for the [MEDICATION NAME] 28 units SQ twice a day, and I am going to call the physician for guidance. An interview was conducted with the DON on 12/13/18 at 2:25 PM. The DON reported the [MEDICATION NAME] 32 units was not an order, someone may have put it in by accident, but there was never an order. Someone discovered there was not an order, and reinstated the [MEDICATION NAME] 28 Units SQ twice a day. The DON stated, That is why I am doing a medication error. I notified the primary physician, and he wants to continue the [MEDICATION NAME] 28 units SQ twice daily and ordered an HA1C in the morning. An interview was conducted during the Quality Assurance Improvement Plan task on 12/13/18 at 2:15 PM. The Administrator reported the DON was responsible for reconciling the physicians' orders monthly.

Based on observations, interviews and record reviews, the facility failed to ensure its medication error rate did not exceed five (5) percent (%). This involved three (Residents #4, #54 and #13) of eight residents observed during medication administration and was related to the facility's failure to assess pain relief timely, and refrain from crushing medication that should not be crushed. There were 34 opportunities for error with three errors observed, resulting in a medication error rate of 8.82%. The findings include: An administration of medication observation was conducted on 12/11/18 at 1:50 PM with Employee A, Licensed Practical Nurse (LPN), for Resident #4 in room [ROOM NUMBER] B. The LPN reported the resident received [MEDICATION NAME] 10/325 mg (milligrams) at 10:00 AM for pain, and she was going to check to see whether the pain was relieved (almost 4 hours after administration of the medication). The LPN entered the room and when asked, the resident reported his pain level at a zero on a scale of 0 - 10, ten being the worst possible pain. At 1:58 PM the LPN reported that Resident #54 in room [ROOM NUMBER] received [MEDICATION NAME] 5 mg at 9:30 AM for left leg pain. The LPN entered the room and asked whether the resident had any pain (4 hours and 28 minutes after administration of the medication). Resident #54 reported the pain level at zero. A review of the current Medication Administration Record [REDACTED]. On 12/11/18, the current MAR indicated [REDACTED]. The current MAR for Resident #54 was reviewed and revealed an order for [REDACTED]. A medication observation was conducted on 12/12/18 at 8:42 AM with Employee B, Licensed Practical Nurse (LPN). Employee B gathered the following medications for Resident #13 in room [ROOM NUMBER] A: Iron 325 milligrams (mg), [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 10 mg. The LPN crushed the three medications and added applesauce, then carried the crushed medications into the resident's room and the resident took the medication orally. An interview was conducted with Employee B, LPN on 12/12/18 at 8:55 AM. The LPN was asked if there was a list of medications that could not be crushed on her cart. The LPN could not find the list and reported she would find the answer and return. An interview was conducted with the Director of Nursing (DON) on 12/12/18 at 11:05 AM, and the policy and procedure for checking residents after receiving pain medications was requested. The DON stated the facility staff followed the standards of practice which was to check the resident 15 minutes to 1 hour after administering pain medications. The DON reported that there was no policy and procedure for assessing residents after receiving pain medications. An interview was conducted with Employee B, LPN, on 12/12/18 at 11:40 AM. The LPN confirmed that iron could not be crushed, and stated the iron had been changed to a liquid dose for the resident. Employee B was asked when residents were checked for pain relief after administration of pain medication. She replied one hour. A review of the Medications Not to be Crushed list revised 7/2015 noted iron was not to be crushed. An interview was conducted with Employee A, LPN, on 12/13/18 at 11:14 AM. The LPN reported that after administering pain medication to residents, she tried to go back 1.5 to 2 hours after administration to check their pain level. An interview was conducted with the DON on 12/13/18 at 12:20 PM regarding Residents #4 and #54 being checked for pain relief after administration of pain medication. The DON reported Resident #4 was checked at 1:48 PM and Resident #54 was checked at 2:01 PM. A review of the Joint Commission Journal on Quality and Patient Safety, dated 2008, reported that pain should be assessed after each pain management intervention, and once a sufficient time has elapsed for treatment to reach peak effect (for example 15-30 minutes after [MEDICATION NAME] medication and one hour after oral medications).

Based on observations, record reviews and interviews, the facility failed to follow the care plan to ensure fall mats were on both sides of the bed one (Resident #41) of 22 sampled residents. This placed a resident who was at known risk for injuries at further risk for injuries. The findings include: A medical record review was conducted for Resident #41, which reported an admission date of [DATE] and the following Diagnoses: [REDACTED]. The care plan, updated on 10/27/17, was reviewed and revealed a focus area related to falls. The resident had falls with no injury, minor injury, serious injury, and was at risk for falls. The medical record noted falls on 12/27/17, 3/14/18, 4/17/18, 5/3/18 with [MEDICAL CONDITION], and on 9/29/18. The interventions included ensuring fall mats were implemented on both sides of the bed, dated 4/17/18. An observation was made of Resident #41's room on 12/11/18 at 9:13 AM. A floor mat was observed on the left side of the bed, but the mat on the right side was partially under the bed. An observation was conducted of Resident #41 sitting in the wheelchair in the room on 12/11/18 at 2:10 PM. The floor mat had been changed on the left side, and there was no mat on the right side. An observation was made of Resident #41 sitting in a wheelchair on 12/12/18 at 11:44 AM in the room. One mat was observed on the left side of bed. An observation was made of Resident #41 in the room on 12/12/18 at 2:15 PM. There was a floor mat observed on the left side of the bed, and no mat on the right side. An interview was conducted with Employee A, Licensed Practical Nurse (LPN), on 12/12/18 at 2:23 PM. Employee A reported the resident had falls in the past. Employee A was asked about the mats beside the bed, and she went into the room to check them. The LPN confirmed there was only one mat on the left side. The LPN reviewed the physician's orders [REDACTED].

Based on medical record reviews and staff interviews, the facility failed to provide a notice of the bed hold policy to two residents (Residents #1 and #3) out of 4 sampled residents and to their families. The findings include: 1. During a complaint investigation survey on 11/11/2015, a medical record review was conducted for 4 sampled residents. Review of Resident #1's medical record revealed a transfer form, dated 10/09/2015, that indicated Resident #1 was transferred to another facility for crisis stabilization on 10/09/2015. Review of the medical record revealed no Notice of the Bed Hold Policy in his record. 2. Review of Resident #3's medical record revealed a transfer form, dated 09/23/2015, that indicated the resident had been transferred to an acute care hospital due to a change of condition. Review of the medical record revealed no Notice of the Bed Hold Policy in the record. During an interview with the Director of Nursing (DON) on 11/11/2015 at 1:00 pm, she stated she did not know why there was not a copy of the bed hold policy in the residents' files. She stated that the staff was to make a copy of everything that was sent with the resident when they were transferred. She stated she did not know that a written notification of the duration of the bed hold was to be sent to the family of a resident when they were sent out of the building. She had the nurses call the family to inform them of the transfer, but she did not know it had to be in writing. During an interview with the Administrator and the DON at 1:50 pm, the Administrator stated, They are supposed to make a copy of everything that goes with the resident to the hospital and put it in their chart.

Based on observations, record review, and staff interviews, the facility failed to properly lock and store medications for 2 out of the 2 medication carts used in the facility. The findings include: An observation was conducted on 08/11/2015 at 12:17 PM of Employee E, Licensed Practical Nurse, walking away from the East Wing's medication cart and not locking the cart. An observation was conducted on 08/11/2015 at 12:23 PM of Employee E returning back to the medication cart for the East Wing and upon her return, realizing the medication cart was unlocked and locked the cart at that time. An interview was conducted on 08/11/2015 12:47 PM with Employee E and she confirmed she did not lock the medication cart and she walked away from the unlocked cart. The employee stated, This cart is crazy. You think that it's locked and then you walk away and come back, and it's open. The drawers don't close all the way and the cart won't lock. I've told them we need a new cart but no luck. An observation was conducted on 08/11/2015 at 12:48 PM of Employee E, showing this surveyor that if the drawers are not closed properly, the cart does not lock. An observation was conducted on 08/13/2015 at 9:28 AM of the DON and maintenance working on the medication cart for the East Wing. The DON confirmed that the cart was not locking properly, and said she would call the pharmacy to come in and look at the carts. A staff interview was conducted with Employee B on 08/13/2015 10:41:53 AM, and he stated that the bottom drawers needed to be adjusted, and he adjusted them both, and the cart is now locking properly. An observation was conducted on 08/12/2015 at 1:34 PM of the West Wing's medication cart not being locked by Employee D as she walked away from the medication cart to pass medications to Resident #37. An interview was conducted with Employee D on 08/12/2015 at 1:51 PM as she returned to the medication cart, and she confirmed the medication cart was not in her sight and left unlocked. During an interview with the Director of Nursing, DON, on 08/13/2015 at 9:12 a.m., she explained the policy for locking the medication carts. If the nurse is in the doorway of a room and can see the cart, it's okay to leave the cart unlocked. If the cart is out of line of sight of the nurse's view, it needs to be locked. Review of the facility's Policy and Procedure for Administering Medications, revised December 2012, showed under Safety of Medication Carts: During administration of medications, the medication cart will be kept closed and locked when out of the sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on interviews and record review, the facility failed to ensure the safety of 1 of 4 sampled residents related to the use of mechanical lifts and the use of chemicals (Resident #38). The findings include: 1. During an interview with Resident #38 on 8/10/2015 at 1:48 PM, she stated that on the proceeding Monday, Employee K sprayed room air freshener in her room. She stated the fan was on and the air freshener went in her eyes. She stated the nurse had to come into her room and rinse out her eyes. Resident #38 also stated that on the same day, her CNA (certified nursing assistant, Employee K) hit her head on the headboard of her bed while using the mechanical lift to put her in bed. She stated Employee K was in a rush when getting her back into bed, and pressed the button on the lift too fast when lowering her. She stated her head hurt, so her boyfriend brought her a topical pain reliever. Record review for Resident #38 found she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the admission Minimum Data Set (MDS) for Resident #38, dated 7/29/2015, found her Brief Interview for Mental Status score was 15 out of 15 (no cognitive impairment). Her bed mobility was extensive one person assist; transfer was total three person assist. Functional range of motion impairment noted on both sides. Record review of the incident/ accident report, dated 8/3/2015, found Resident #38 informed the physical therapist that she bumped her head when the CNA was putting her back to bed Monday night. The additional comments and/or steps taken to prevent recurrence were documented as Staff reminded to use caution when transferring via mechanical lift, secure limbs and other body parts during transfer, and move slow and as a team. Under the section Who witnessed the incident, it showed Called Employee K several times at listed number and asked her to call back but no response. Need to know her awareness and involvement and request her to write a statement and identify other witness. During an interview with the Director of Nursing (DON) on 8/12/15 at 1:50 PM, she stated she left messages for Employee K, who the resident stated hit her head on the bed. The DON stated she had not received a call back from Employee K. She stated she planned to give the employee education. She stated she did not know if Employee K had worked at the facility after the incident. An interview was held with Employee N (Medical Records/Staffing) on 8/12/15 at 12:26 PM. She stated Employee K worked Fridays and Mondays every other week, and Saturday and Sunday every other week. She stated Employee K worked on Saturday 8/8/15 and Sunday 8/9/15. She confirmed Employee K worked after the incident on 8/3/15. She said Employee K was on the schedule to work until the DON told Employee N the morning of 8/12/15 to take Employee K off the schedule for Friday. Record review of the schedule found Employee was scheduled to work on 8/8/15, 8/9/15, 8/14/15, 8/17/15, 8/22/15, 8/23/15, 8/29/15, and 8/31/15. Review of Resident #38's record found no documentation of the 8/3/15 incident regarding air freshener prior to 8/11/2015 at 4:45 PM. During an interview on 8/11/15 at 1:50 PM with the DON, she stated she had not been aware of the incident with the air freshener prior to 8/11/15. She stated it was a facility policy not to allow air fresheners in resident rooms, and the staff member should not have used the spray. She stated she would be providing education to staff and the employee once she does her investigation. She confirmed the resident record did not have documentation of the event prior to 8/11/15. She stated she would be educating the nurse, as well. During an interview with Employee M (CNA) on 8/12/15 at 2:35 PM, she stated that Resident #38 had told her about hitting her head. She stated that she had training on using the resident lift over a year ago. She stated that about a month ago, staff were reminded to have two people to use the lift, but that was the extent of the training. She stated she had not received any training on the use of mechanical lifts after Resident #38 hit her head.

Based on observations, staff interview, and record review, the facility failed to ensure 2 of 3 residents with limited range of motion received application of devices or services to prevent further decrease in range of motion or contractures in extremities (Residents # 6 and #18). The findings include: 1. During an interview on 08/11/2015 at 1:07 PM with Employee E, nurse, she stated that all residents' splints are applied by 10:00 AM. She further stated the facility makes an announcement over the intercom to ensure all splints are applied. Record review for Resident #6 found he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].#6 had upper extremity impairment on one side. On 8/11/15 at 10:16 AM, Resident #6's splints were observed on the cabinet beside his bed. On 8/11/15 at 11:06 AM, the splints were not on the resident. Resident #6 was observed again on 8/11/15, and he was still not wearing the splints. Observations of Resident #6 on 8/12/15 at 8:33 AM found he was not wearing a splint. During an interview on 8/11/15 a t 3:45 PM with Resident #6's certified nursing assistant (CNA), Employee I, she stated she was going to work the 3:00 PM to 11:00 PM shift. She stated Resident #6 does not wear a splint during her shift. She stated she had worked with him twice and she was not aware he had a splint. During further interview with Employee I on 8/12/2015 at 9:28 AM, she confirmed that last night on the 3PM to 11 PM shift, Resident #6 did not wear a splint. An additional interview on 8/12/2015 at 2:45 PM with Employee E, nurse, revealed she worked the 7 AM to 3 PM shift with Resident #6 often. She stated she was not aware of the resident wearing a splint. Record review of the care plans for Resident #6 revealed an activities of daily living (ADL) self-care deficit care plan. The care plan included a 2/19/15 approach of a splint to the right hand. Review of the interdisciplinary therapy screen, dated 6/4/14, found a note stating, Hand splint to left elbow. Splint times 6-8 hours. Continue with plan of care. Review of the log for the Functional Maintenance Program on 8/12/15 at 3:22 PM found that on 8/11/15, the area where the use of the splint was recorded was left blank for Resident #6. During an interview with Employee G on 8/12/15 at 3:30 PM, she stated Resident #6's splints are put on during the day by the restorative nurse. She stated she worked with Resident #6 last night and he did not wear a splint. An interview was held with the Restorative Nurse (Employee J) on 8/12/15 at 3:34 PM. She stated the nurses and CNAs should know that B-beds have their splints on during the 3PM to 11PM shift. She stated the treatment book should have the list of the residents with splints. She went to the treatment book for the East Hall where Resident #6 resides in a B bed, and there was no record for the resident to wear a splint. 2. Resident #18 had a Restorative Transfer form from Therapy, dated 6/23/15. The program was for ROM/ Splinting. The goal was to maintain joint integrity and prevent contracture; maintain right upper quadrant strength/ endurance for selfcare. Recommended frequency was daily. Strategies/techniques included passive range of motion to left upper extremity (Shoulder, Elbow, Wrist/Hand). Apply left hand splint X 8hrs/day; Active range of motion with 2lbs weights 3X10 repititions. precautions included monitor splint for increased pain, redness, swelling and or skin breakdown. On 8/13/2015 at 3PM, the resident was observed without a splint. The resident was not in her room, while the splint was on her dresser table. The surveyor observed the splint in that same location on Monday, 8/10/2015 at 9:30am. Interview with an aide (Employee P) on 8/13/2014 at 3:15pm revealed that the resident always refused the splints to her left hand. Surveyor requested to review the documentation in the ADL book. Employee P stated that she would get the book for surveyor; however, staff was found 5 minutes later trying to document in the book instead of bringing the book to the surveyor. An interview with the Restorative Program Nurse (Employee Q) at 3:55pm on 8/13/2015 revealed that staff was to document daily whether the resident refused the splint. Review of the ADL documentation showed that there were holes in the documentation of the application of Resident #18's left hand splint. There were no refusal codes on the document. With surveyor intervention, Resident #18 was observed at 4:30pm on 8/13/15 on the patio with the splints applied.

Based on observations and staff interview, the facility failed to ensure privacy curtains in 7 of 31 resident rooms were maintained in a safe and sanitary manner (Rooms #5, #8, #9, #13, #14, , #17 and #25). The findings include: The following observations were made in resident rooms on 8/13/2015 from 9:45 AM until 10:45 AM: The privacy curtains in resident room 5 located in front of bed A and bed B had a reddish brown area approximately 2 inches in diameter, along with several other brown marks. The privacy curtain in resident room 8 located between bed A and bed B had numerous brown colored areas. The privacy curtain in resident room 9 located between bed A and bed B had numerous reddish/brown areas. The privacy curtain in resident room 13 located between bed A and bed B had numerous brown colored areas. The privacy curtain in resident room 14 had several reddish brown areas. The privacy curtain in resident room 17 located between bed A and B had a brown area approximately 2 feet in size. The privacy curtain located between bed A and bed B in resident room 25 had numerous brown marks. (Photographic evidence was obtained of several of the curtains.) During an interview on 8/13/15 at 11:06 AM with the Housekeeping Director (Employee C), she explained the process of cleaning the privacy curtains. She stated that every room should have a deep cleaning each month and the privacy curtain should be taken down and cleaned at that time. During further interview on 8/13/15 at 1:06 PM with the Housekeeping Director, she confirmed the findings. She stated she was in the process of removing the curtains and washing them.

Based on observation, interview and record review, the facility failed to provide care and services to attain the highest practicable level of well-being related to pain for 1 resident (Residents #68) out of 1 resident reviewed for pain, and related to blood sugar control for 2 residents (Residents #24 and #45), out of 5 residents reviewed for unnecessary medications, out of 29 sampled residents. The findings include: 1. Record review for Resident #68 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. On 7/14/2014 at 1:09 PM an interview with Resident #68 revealed her feet were hurting, and she said she was waiting for her nurse to come back. In an interview on 7/17/2014 at 8:35 AM with the wound care nurse, she stated that the wound doctor had never seen Resident #68 before July 11, 2014. On that date a nursing assistant told the wound care nurse that the resident had an open spot on her bottom. The wound care nurse said she and the wound doctor observed the wound on the resident's bottom, and discovered the blister on her left heel. She described the heel wound as a large fluid filled blister. She said you could tell it was a deep tissue injury, and it was purplish in color. She said the wound doctor unroofed the blister and did some debridement (removal of dead tissue). She said the wound doctor numbed the area with some topical spray. She said after the treatment to the heel, she called the primary doctor "just to notify him of the wound." She said she did not go into detail to tell him about the debridement, she only told him they discovered a wound. She said she thought wound care consults were a standing order in the facility. She stated that the wound care doctor gives a recommendation for follow-up care of the wound, and the primary doctor usually okays the orders. She said in this case, the wound doctor never called the primary doctor to tell him what was going on. She stated that the wound doctor said the primary doctor orders the pain medication for the patient. She confirmed that the primary doctor was not notified until Tuesday July 15, 2014 that a procedure was done to the resident's heel, and the resident was in pain. Record review for Resident #68 revealed a Wound Care Specialist Evaluation dated 7/11/2014, which stated the wound care consult was requested for left plantar heel wound by a physician (not the resident's physician). The history of present illness section described an unstageable deep tissue injury on the left heel for greater than 6 days, with moderate serous (bloody) drainage. The pre-procedure note stated "there is no indication of pain associated with this condition." The heel wound treatment was described as "unroofed leaking blister." The wound was described as a pressure wound, size 6.5cm x 6.5cm x not measurable. The dressing ordered was: Foam-every two days, dry protective dressing-every two days, polymem ag (protects wound from contamination). Record review revealed there was no order to consult with the wound care doctor, and there was no documentation that the primary doctor was notified of the procedure done to the resident's heel wound. On 7/15/2014 at 12:50 PM an interview with Resident #68's daughter revealed the resident had an ulcer on her foot and a wound on her buttock. She said the wound doctor cut on the resident's foot last Friday, July 11, 2014. She said the resident was grimacing when the doctor was cutting, and drew up because it was hurting. The daughter said she stayed during the procedure, and she comes in about once a day to see the resident. She said the resident has been complaining every day to her that since the doctor cut on her foot, it has been hurting. The daughter said she told the nurses about her mother's pain. She said the resident told her that staff don't answer her when she tells them her foot hurts. She said a few days ago the resident told the nurse about her foot hurting. The nurse said she would check the resident, but she never did anything about the resident's pain. On 7/16/2014 at 10:40 AM an observation of Resident #68 was made during wound care of the left foot and right buttock. The wound care nurse stated Resident #68 had already received her pain medication prior to the treatment, about 30 minutes ago. The wound care nurse cleaned the left heel wound with normal saline, and the resident winced and grimaced. Resident #68 said she was in pain. The observation of the wound revealed a large open wound with cuts of missing skin, and a thick black eschar (dead tissue) center. The tissue around the black eschar was pink and clean. Resident #68 began moaning and drew back as the wound care nurse applied 4 x 4 dressings and wrapped the left foot with gauze and an ace bandage. On 7/16/2014 at 10:50 AM, review of the Medication Administration Record (MAR) for Resident #68 revealed a handwritten entry for [MEDICATION NAME] (a pain medication) 25 mg 1 tablet by mouth every 6 hours as needed for pain (ordered by the Medical Director/primary physician on 7/15/14). There was one entry of [MEDICATION NAME] signed as given on 7/16/14. Documentation on the back of the MAR stated that the medication was given at 10:48 AM for facial grimacing, with effective response documented at 10:50 AM. Pain assessments documented on the MAR since the 7/11/14 debridement of the heel recorded no pain for the resident, until the surveyor inquired about the resident's pain on 7/16/14. On 7/16/2014 at 10:52 AM an interview with Employee #11, LPN, revealed she just gave a pain pill to the resident. She stated that after the resident's wound treatment was completed, the wound care nurse asked her to give the resident something for pain. In an interview with the Medical Director/primary physician, on 7/16/2014 at 4:05 PM, he stated that the wound care nurse called him yesterday (7/15/14) to tell him that the wound care doctor performed the procedure on the resident's left heel, and the resident was having pain. He said when the wound care nurse told him this, he was mad. He said the resident is a [AGE] years old, "why put her through that." He then learned that the procedure to the resident's heel actually occurred on Friday, July 11, 2014. He said he was never told about this. He said he was just finding out that the resident was in pain, and the wound care doctor had not ordered any pain medications after the procedure. He said of course he ordered pain medication for the resident when he was notified of her pain yesterday, because he doesn't want her to suffer. He said the resident had been in pain for all these days with no pain medication, and he was never contacted. He said the wound doctor should have taken care of the order for pain medication. He said the resident cannot express her pain adequately in her condition. He said just because she is old and demented, does not mean she has to suffer in pain; it isn't right. He said he needed to speak to the wound care nurse right away. On 7/16/2014 at 4:20 PM the wound care nurse approached the Medical Director at the nurses' station. The Medical Director told the wound care nurse that she had led him to believe the resident's debridement occurred yesterday. The wound care nurse responded that she told him it occurred "recently." She said the wound doctor that conducted the debridement gave Resident #68 something topical for pain. The Medical Director said a topical anesthetic would not help the pain. The said that yesterday, after the wound care treatment was over, was the first day the resident complained of pain. She said that is when she called the Medical Director. She said the pain medication was delivered either last night or this morning, she wasn't sure. She said she was not on the medication cart (dispensing medications), but she got the order for the pain medication and reported it to the nurse who was taking care of the resident (the order was received 7/15/14, but the resident was not medicated until the surveyor asked on 7/16/14 if the resident had been medicated for pain). On 7/16/2014 at 4:45 PM the Medical Director said the staff should have called him back yesterday if they could not get the pain medication for the resident. He said he would have ordered her something else that was available to hold her over until the pain medication was delivered. In an interview on 7/17/2014 at 8:28 AM with the unit manager, she said the wound doctor comes every Friday to see anyone with wounds. She said that Resident #68's wound on her left heel was just discovered on Friday July 11, 2014. She said the nurse should notify the primary doctor and get an order for [REDACTED]. She confirmed that this procedure was not followed for Resident #68. In an interview on 7/17/2014 at 9:50 AM with the Director of Nursing (DON), she stated that the wound doctor should have contacted the primary doctor, prior to any procedure being done. The DON said the wound care nurse should have known to get an order for [REDACTED]. She said she also should have known not to allow the wound care doctor to perform a procedure before speaking with the primary doctor. Review of Resident #68's Minimum Data Set (MDS) revealed that for both her quarterly MDS dated [DATE], and her change in status MDS dated [DATE] in section J, the resident was coded as having no pain and not receiving scheduled or as needed pain medications. Record review revealed that after the procedure was performed on the resident's heel wound on June 11, 2014, there was no nursing documentation that the resident was assessed for pain. The resident was not care planned for pain after the procedure. 2. A medical record review for Resident #24 revealed [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of a physician's orders [REDACTED].= give 2 units; 201-250 = give 4 units; 251-300 = give 6 units; 301-350 = give 8 units; 351-400 = give 10 units; if blood sugar level is less than 60 or more than 400 call the physician. A review of the MAR dated from 3/01/2014 through 7/16/2014 revealed on 3/09/2014 the resident's blood sugar level at 4:30 pm was 458 and at 9:00 pm it was 433. On 3/27/2014 the resident's blood sugar level at 9:00 pm was 407. On 7/11/2014 the resident's blood sugar level at 6:30 am was 415. A review of the nursing notes for 3/1/14, 3/09/2014, 3/27/2014 and 7/11/2014 revealed no documentation of notifying the physician of the elevated blood sugar values. The resident was also receiving [MEDICATION NAME]65 units by subcutaneous injection twice daily in March and July, 2014. MDS dated [DATE] revealed the resident was coded for active [DIAGNOSES REDACTED]. 3. A medical record review for Resident #45 revealed [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. A review of the physician's orders [REDACTED].= give 0 units; 151-200 = give 2 units; 201-250 = give 4 units; 251-300 = give 6 units; 301-350 = give 8 units; 351-400 = give 10 units; if blood sugar level is less than 60 or more than 400 call the physician. A review of the MAR dated from 6/01/2014 through 7/15/2014 revealed on 6/08/2014 the resident's blood sugar level was documented as 60, but appeared to be written over another number. The resident was also receiving [MEDICATION NAME]15 units subcutaneous injection every 12 hours in June, 2014. A review of the nursing notes for 6/08/2014 revealed a note that read: "4:30 pm resident appears sleepy and would not awake. Glucose (blood sugar) check read 59mg/dL. [MEDICATION NAME] (raises blood sugar) 1Gm administered via Intramuscular injection. Resident was not able to take anything po (by mouth). 4:49 pm Resident awake but drowsy and was able to take juice. Glucose read 69 mg/dL. 5 pm Resident was able to consume more food and was fully awake. Glucose 106mg/dL, blood pressure 134/54, P 48, R 20, T 97. 9:00 pm Glucose 120 mg/dL and is fully awake and able to talk." There was no documentation on the MAR or in the nursing notes indicating that the nurse had notified the physician of the resident's low blood sugar with symptoms. Further review of the MAR revealed that on 7/03/2014 at 4:30 pm the resident's blood sugar level was 468. On 7/06/2014 the resident's blood sugar was 401. A review of the nursing notes and the MAR revealed no documentation that the nurse notified the physician of the resident's high blood sugar on either day. MDS dated [DATE] revealed the resident was coded for active [DIAGNOSES REDACTED]. During an interview on 7/17/2014 at 11:30 am with the Unit Manager and the Assistant Director of Nursing, the Unit Manager reviewed the physician's orders [REDACTED].#24 and #45 with this surveyor. She confirmed that the physician was not notified of Residents #24 and #45's blood sugar values as ordered. .

Based on record review and interviews the facility failed to provide services that meet professional standards of quality related to pain for 1 resident (Residents #68) out of 1 resident reviewed for pain, related to blood sugar control for 2 residents (Residents #24 and #45) and related to blood pressure monitoring for 3 residents (Residents #31, #56, and #60), out of 5 residents reviewed for unnecessary medications, out of 29 sampled residents. Professional Standard of Care is defined in Chapter 766.102 as "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers." According to the Florida Nurse Practice Act, Chapter 464.003: (3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (e) "Nursing diagnosis" means the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal. (f) "Nursing treatment" means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. Nursing Standard of Practice Protocol: Pain Management in Older Adults Horgas, A. L., Yoon, S. L., & Grall, M. (2012). Pain management in Older Adults. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker, (Eds.) Evidence-based geriatric nursing protocols for best practice (4th ed.) (pp. 258-263). New York: Springer Publishing Company, LLC. Standard: All older adults will either be pain free, or their pain will be controlled to a level that is acceptable to the patient and allows the person to maintain the highest level of functioning possible. Nurses have a key role in pain management. The promotion of comfort and relief of pain is fundamental to nursing practice. Nurses need to be knowledgeable about pain in late life to provide optimal care, to educate patients and families, and to work effectively in interdisciplinary health care teams. Assessment parameters: Older adults with cognitive impairment experience pain but are often unable to verbalize it. Assess older adults who present with acute pain of moderate-to-severe intensity or who appear to be in distress. Assess pain localization, intensity, duration, quality, and onset. The findings include: 1. Record review for Resident #68 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. On 7/14/2014 at 1:09 PM an interview with Resident #68 revealed her feet were hurting, and she said she was waiting for her nurse to come back. In an interview on 7/17/2014 at 8:35 AM with the wound care nurse, she stated that the wound doctor had never seen Resident #68 before July 11, 2014. On that date a nursing assistant told the wound care nurse that the resident had an open spot on her bottom. The wound care nurse said she and the wound doctor observed the wound on the resident's bottom, and discovered the blister on her left heel. She described the heel wound as a large fluid filled blister. She said you could tell it was a deep tissue injury, and it was purplish in color. She said the wound doctor unroofed the blister and did some debridement (removal of dead tissue). She said the wound doctor numbed the area with some topical spray. She said after the treatment to the heel, she called the primary doctor "just to notify him of the wound." She said she did not go into detail to tell him about the debridement, she only told him they discovered a wound. She said she thought wound care consults were a standing order in the facility. She stated that the wound care doctor gives a recommendation for follow-up care of the wound, and the primary doctor usually Okays the orders. She said in this case, the wound doctor never called the primary doctor to tell him what was going on. She stated that the wound doctor said the primary doctor orders the pain medication for the patient. She confirmed that the primary doctor was not notified until Tuesday July 15, 2014 that a procedure was done to the resident's heel, and the resident was in pain. Record review for Resident #68 revealed a Wound Care Specialist Evaluation dated 7/11/2014, which stated the wound care consult was requested for left plantar heel wound by a physician (not the resident's physician). The history of present illness section described an unstageable deep tissue injury on the left heel for greater than 6 days, with moderate serous (bloody) drainage. The pre-procedure note stated "there is no indication of pain associated with this condition." The heel wound treatment was described as "unroofed leaking blister." The wound was described as a pressure wound, size 6.5cm x 6.5cm x not measurable. The dressing ordered was: Foam-every two days, dry protective dressing-every two days, polymem ag (protects wound from contamination). Record review revealed there was no order to consult with the wound care doctor, and there was no documentation that the primary doctor was notified of the procedure done to the resident's heel wound. On 7/15/2014 at 12:50 PM an interview with Resident #68's daughter revealed the resident had an ulcer on her foot and a wound on her buttock. She said the wound doctor cut on the resident's foot last Friday, July 11, 2014. She said the resident was grimacing when the doctor was cutting, and drew up because it was hurting. The daughter said she stayed during the procedure, and she comes in about once a day to see the resident. She said the resident has been complaining every day to her that since the doctor cut on her foot, it has been hurting. The daughter said she told the nurses about her mother's pain. She said the resident told her that staff don't answer her when she tells them her foot hurts. She said a few days ago the resident told the nurse about her foot hurting. The nurse said she would check the resident, but she never did anything about the resident's pain. On 7/16/2014 at 10:40 AM an observation of Resident #68 was made during wound care of the left foot and right buttock. The wound care nurse stated Resident #68 had already received her pain medication prior to the treatment, about 30 minutes ago. The wound care nurse cleaned the left heel wound with normal saline, and the resident winced and grimaced. Resident #68 said she was in pain. The observation of the wound revealed a large open wound with cuts of missing skin, and a thick black eschar (dead tissue) center. The tissue around the black eschar was pink and clean. Resident #68 began moaning and drew back as the wound care nurse applied 4 x 4 dressings and wrapped the left foot with gauze and an ace bandage. On 7/16/2014 at 10:50 AM, review of the Medication Administration Record (MAR) for Resident #68 revealed a handwritten entry for [MEDICATION NAME] (a pain medication) 25 mg 1 tablet by mouth every 6 hours as needed for pain (ordered by the Medical Director/primary physician on 7/15/14). There was one entry of [MEDICATION NAME] signed as given on 7/16/14. Documentation on the back of the MAR stated that the medication was given at 10:48 AM for facial grimacing, with effective response documented at 10:50 AM. Pain assessments documented on the MAR since the 7/11/14 debridement of the heel recorded no pain for the resident, until the surveyor inquired about the resident's pain on 7/16/14. On 7/16/2014 at 10:52 AM an interview with Employee #11, LPN, revealed she just gave a pain pill to the resident. She stated that after the resident's wound treatment was completed, the wound care nurse asked her to give the resident something for pain. In an interview with the Medical Director/primary physician, on 7/16/2014 at 4:05 PM, he stated that the wound care nurse called him yesterday (7/15/14) to tell him that the wound care doctor performed the procedure on the resident's left heel, and the resident was having pain. He said when the wound care nurse told him this, he was mad. He said the resident is a [AGE] years old, "why put her through that." He then learned that the procedure to the resident's heel actually occurred on Friday, July 11, 2014. He said he was never told about this. He said he was just finding out that the resident was in pain, and the wound care doctor had not ordered any pain medications after the procedure. He said of course he ordered pain medication for the resident when he was notified of her pain yesterday, because he doesn't want her to suffer. He said the resident had been in pain for all these days with no pain medication, and he was never contacted. He said the wound doctor should have taken care of the order for pain medication. He said the resident cannot express her pain adequately in her condition. He said just because she is old and demented, does not mean she has to suffer in pain; it isn't right. He said he needed to speak to the wound care nurse right away. On 7/16/2014 at 4:20 PM the wound care nurse approached the Medical Director at the nurses' station. The Medical Director told the wound care nurse that she had led him to believe the resident's debridement occurred yesterday. The wound care nurse responded that she told him it occurred "recently." She said the wound doctor that conducted the debridement gave Resident #68 something topical for pain. The Medical Director said a topical anesthetic would not help the pain. The said that yesterday, after the wound care treatment was over, was the first day the resident complained of pain. She said that is when she called the Medical Director. She said the pain medication was delivered either last night or this morning, she wasn't sure. She said she was not on the medication cart (dispensing medications), but she got the order for the pain medication and reported it to the nurse who was taking care of the resident (the order was received 7/15/14, but the resident was not medicated until the surveyor asked on 7/16/14 if the resident had been medicated for pain). On 7/16/2014 at 4:45 PM the Medical Director said the staff should have called him back yesterday if they could not get the pain medication for the resident. He said he would have ordered her something else that was available to hold her over until the pain medication was delivered. In an interview on 7/17/2014 at 8:28 AM with the unit manager, she said the wound doctor comes every Friday to see anyone with wounds. She said that Resident #68's wound on her left heel was just discovered on Friday July 11, 2014. She said the nurse should notify the primary doctor and get an order for [REDACTED]. She confirmed that this procedure was not followed for Resident #68. In an interview on 7/17/2014 at 9:50 AM with the Director of Nursing (DON), she stated that the wound doctor should have contacted the primary doctor, prior to any procedure being done. The DON said the wound care nurse should have known to get an order for [REDACTED]. She said she also should have known not to allow the wound care doctor to perform a procedure before speaking with the primary doctor. Review of Resident #68's Minimum Data Set (MDS) revealed that for both her quarterly MDS dated [DATE], and her change in status MDS dated [DATE] in section J, the resident was coded as having no pain and not receiving scheduled or as needed pain medications. Record review revealed that after the procedure was performed on the resident's heel wound on June 11, 2014, there was no nursing documentation that the resident was assessed for pain. The resident was not care planned for pain after the procedure. 2. A medical record review for Resident #24 revealed [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of a physician's orders [REDACTED].= give 2 units; 201-250 = give 4 units; 251-300 = give 6 units; 301-350 = give 8 units; 351-400 = give 10 units; if blood sugar level is less than 60 or more than 400 call the physician. A review of the MAR dated from 3/01/2014 through 7/16/2014 revealed on 3/09/2014 the resident's blood sugar level at 4:30 pm was 458 and at 9:00 pm it was 433. On 3/27/2014 the resident's blood sugar level at 9:00 pm was 407. On 7/11/2014 the resident's blood sugar level at 6:30 am was 415. A review of the nursing notes for 3/1/14, 3/09/2014, 3/27/2014 and 7/11/2014 revealed no documentation of notifying the physician of the elevated blood sugar values. The resident was also receiving [MEDICATION NAME]65 units by subcutaneous injection twice daily in March and July, 2014. MDS dated [DATE] revealed the resident was coded for active [DIAGNOSES REDACTED]. 3. A medical record review for Resident #45 revealed [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. A review of the physician's orders [REDACTED].= give 0 units; 151-200 = give 2 units; 201-250 = give 4 units; 251-300 = give 6 units; 301-350 = give 8 units; 351-400 = give 10 units; if blood sugar level is less than 60 or more than 400 call the physician. A review of the MAR dated from 6/01/2014 through 7/15/2014 revealed on 6/08/2014 the resident's blood sugar level was documented as 60, but appeared to be written over another number. The resident was also receiving [MEDICATION NAME]15 units subcutaneous injection every 12 hours in June, 2014. A review of the nursing notes for 6/08/2014 revealed a note that read: "4:30 pm resident appears sleepy and would not awake. Glucose (blood sugar) check read 59mg/dL. [MEDICATION NAME] (raises blood sugar) 1Gm administered via Intramuscular injection. Resident was not able to take anything po (by mouth). 4:49 pm Resident awake but drowsy and was able to take juice. Glucose read 69 mg/dL. 5 pm Resident was able to consume more food and was fully awake. Glucose 106mg/dL, blood pressure 134/54, P 48, R 20, T 97. 9:00 pm Glucose 120 mg/dL and is fully awake and able to talk." There was no documentation on the MAR or in the nursing notes indicating that the nurse had notified the physician of the resident's low blood sugar with symptoms. Further review of the MAR revealed that on 7/03/2014 at 4:30 pm the resident's blood sugar level was 468. On 7/06/2014 the resident's blood sugar was 401. A review of the nursing notes and the MAR revealed no documentation that the nurse notified the physician of the resident's high blood sugar on either day. MDS dated [DATE] revealed the resident was coded for active [DIAGNOSES REDACTED]. During an interview on 7/17/2014 at 11:30 am with the Unit Manager and the Assistant Director of Nursing, the Unit Manager reviewed the physician's orders [REDACTED].#24 and #45 with this surveyor. She confirmed that the physician was not notified of Residents #24 and #45's blood sugar values as ordered. 4. Review of the medical record for Resident #56 revealed [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. A physician order [REDACTED]. Review of the Medication Administration Record (MAR) for July, 2014 revealed no blood pressures were documented. Review of the care plan revealed a problem identified with high blood pressure, and the need to monitor blood pressure and pulse routinely. Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded for active [DIAGNOSES REDACTED]. Interview with LPN #6 on 7/15/14 at 2:15 PM revealed all residents get their vitals taken monthly. If a physician wants it more often he will order parameters with medications, and then we will take the blood pressure prior to giving the medication. She stated Resident #56 does not have any parameters listed on the MAR with his medication. The LPN reviewed the MAR and confirmed there was an order for [REDACTED]. Interview on 7/15/14 at 2:26 PM with the Unit Manager confirmed that Resident #56 had a physician order [REDACTED]. She stated that she did not know why the nurses were not following the order. Interview on 7/16/14 at 12:50 PM with the Medical Director revealed the problem is the facility does not reconcile the POS with the MAR. 5. A medical record review for Resident #31 revealed [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. A review of the MAR dated from 3/01/2014 through 7/16/2014 revealed on 3/11/2014 at 9:00 pm the resident's SBP was 104. On 3/12/2014 at 9:00 pm the resident's SBP was 108. The [MEDICATION NAME] was not held as ordered for those doses. The resident was also receiving [MEDICATION NAME] 25mg daily for high blood pressure in March, 2014. For the month of April, 2014 the resident's blood pressure and pulse were not taken for the 9:00 am or 9:00 pm doses of [MEDICATION NAME]. The resident was also receiving [MEDICATION NAME] 12.5mg three times per day for high blood pressure in April, 2014. The spaces on the MAR for the blood pressure and pulse with the 9:00 am dose of [MEDICATION NAME] were left blank on 5/1-2/14, 5/6-8/14, 5/12/14, 5/14/14, 5/19-23/14, 5/25/14, and 5/27-29/14. The spaces on the MAR for the pulse with the 9:00 pm dose of [MEDICATION NAME] were left blank on 5/1-2/14, 5/6/14, 5/9-11/14, 5/20/14, and 5/23-29/14. The resident was also receiving [MEDICATION NAME] 12.5mg three times per day for high blood pressure in May, 2014. MDS dated [DATE] revealed the resident was coded for active [DIAGNOSES REDACTED]. During an interview on 7/17/2014 at 11:30 am with the Unit Manager and the Assistant Director of Nursing, the Unit Manager reviewed the physician's orders [REDACTED].#31 with this surveyor. She confirmed that the resident's blood pressures had not been taken prior to giving the [MEDICATION NAME] for blood pressure on the dates as noted above. 6. Record review for Resident #60 revealed [DIAGNOSES REDACTED]. Review of the resident's MARs revealed [MEDICATION NAME] 5 mg (for high blood pressure), take 1 tablet by mouth once daily, hold for blood pressure less than 110. There were no blood pressures recorded on the May, June, and July, 2014 MARs. Review of the resident's care plan revealed a problem dated 9/4/13 for high blood pressure. The stated goal was the resident would be free of complications, signs and symptoms of high blood pressure with a early detection and therapeutic regimen. Approaches included check blood pressure and pulse routinely. MDS dated [DATE] revealed the resident was coded for active [DIAGNOSES REDACTED]. On 7/16/2014 at 9:20 AM an interview with the unit manager revealed that the resident's blood pressure should be written on the MAR with the medication. She reviewed Resident #60's MAR and confirmed there were no blood pressures recorded. She observed the vital sign sheet and said, "These are monthly vital signs only." She said if there is an order to obtain the blood pressure before giving the medication, then it should be done and documented on the MAR with the medication administration. .