Every finding on record at Pompano Health and Rehabilitation Center

Based on record review and interview, the facility failed to address and resolve a resident representative's grievances related to transportation and billing for 1 of 3 sampled residents (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment and required substantial/maximum assistance with activities of daily living.A telephone interview was conducted with Resident #1's Power of Attorney (POA) on 01/13/26 at 12:00 PM. The POA stated she had expressed concerns to the facility related to Resident #1's transportation from the hospital and billing. The POA stated Resident #1 had a fall on 12/04/25, which the resident was sent out to the hospital via 911 for evaluation. Resident #1's POA was contacted by the hospital concerning the return of the resident back to the facility. The POA stated she contacted the facility and was told by the Unit Manager (UM) not to worry, they would handle it and call the POA back. Resident #1's POA ultimately paid 150.00 for the return of the resident back to the facility.The POA further stated she received a bill for Resident #1 in November of 2025 that included charges from August, September, and October. The POA stated she still had not received a response to the inquiry of the bill.A review of the facility's grievances revealed a grievance for Resident #1 dated 12/09/25. A review of the grievance revealed a concern with Resident #1's POA related to not receiving a call back from the facility in reference to transportation of Resident #1 from the hospital back to the facility. In response, education was provided to staff in regards of communication concerns. On 12/09/25 education on customer service specific to setting expectations; When communicating with residents or families, if you say you are going to follow up with a call or service, follow through.An interview was conducted with the UM on 01/13/26 at 2:00 PM. The UM stated she had been working at the facility for 2 months. She had worked at other nursing facilities as well as hospitals and never had a nurse call for transportation arrangements. The UM stated usually the hospital gets residents back to the facility. The UM stated she was told by the hospital that Resident #1's insurance would not cover transportation back to the facility. An interview was conducted with the Director of Nursing (DON) on 01/13/26 at 3:00 PM. The DON stated it was Admission's responsibility to arrange for the return of a resident from the hospital back to the facility. The DON further stated Admissions was available 24/7.An interview was conducted with the Admissions Coordinator on 01/14/26 at 12:30 PM. The Admissions Coordinator stated when a resident goes out to the hospital, the hospital will contact admissions or the facility to inform them the resident was coming back to the facility. For Resident #1, on 12/4/25, the hospital should have gotten in touch with admissions for the resident's return. The Admissions Coordinator did not know why the hospital told the resident's family to pay. Resident #1 was long term care, and facility should have paid. Insurance does not matter.A review of a grievance dated 12/16/25 revealed a concern with billing process for Resident #1. The resident's POA requested a complete itemized billing statement from the start of the resident's stay, including a clear explanation of services rendered and included. An email was sent from the Business Office Manager (BOM) itemizing costs related to stay at the facility. A review of the attached billing email dated 11/19/25. Further review of the attached billing statement revealed it was not itemized. An interview was conducted with the Business Office Manager (BOM) on 01/13/26 at 12:00 PM. The BOM stated she spoke with Resident #1's POA via phone. The BOM sent copy of the bill via e-mail. The BOM provided a copy of the email, dated 11/19/25, sent to the POA. The BOM stated she was not aware that Resident #1's POA requested an itemized bill and confirmed she had not had any other contact with the POA since the 11/19/25 email.

Based on observation and staff interviews, the facility failed to keep food safety requirements in accordance with the professional standard of food service safety 2 visits to the main kitchen. The findings included: In a tour of the main kitchen conducted on 09/29/25 at 9:30 AM, the following issues were noted: a. The sanitation solution was checked in the 3-compartment sinks, which showed that the solution was between 400 and 500 parts per million. Using a facility's Hydrion strip, it was revealed that there was too much sanitizing solution and it was not within the normal ranges of sanitizers, which typically fall between 100 and 400, with a recommended range closer to 200. b. The reach in the freezer was noted with four containers of ice cream cups that were melted and partially opened. c. The back of the reach-in freezer was noted with debris, plastic containers, and napkins. d. Insects were noted in all stages of life, on the walls and the floor of the main kitchen. In this observation, the Kitchen Manager stated that she was not aware of any insects in the kitchen and that no staff had complained of seeing any insects. In an interview conducted on 09/29/25 at 12:30 PM with the Kitchen Manager, she stated that the cook in the kitchen observed insects and reported it in a special pest control binder on 09/21/25. A review of the pest control visit forms, which were provided by the facility's Administrator, showed the following: a visit was conducted on 03/28/25 and on 09/02/25. Another visit was conducted on 09/29/25 after the surveyor's intervention. In an observation conducted on 10/01/25 at 11:00 AM during the lunch tray line, the following were noted:Staff D, Cook, was observed at the tray line taking the temperatures of the food items. She took the temperature of cooked pasta using a facility-calibrated thermometer. Staff D inserted the thermometer deep into the past tray, touching the pasta with her bare hands in the process. Staff D, Cook, was observed taking the temperature of the fortified pureed pasta using a facility-calibrated thermometer. She was observed taking the thermometer of the pasta tray while touching the serving ladle with her bare hands. Staff D, Cook, was observed taking the temperature of the mashed potato using a facility-calibrated thermometer. She was observed taking the thermometer of the pasta tray while touching the serving ladle with her bare hands. She did not replace the serving ladle with a new, clean one.

Based on observations, interviews and record reviews, the facility failed to initiate a care plan for advance directives for 5 of 5 sampled residents, Resident #10, Resident #27, Resident #60, Resident #72 and Resident #99; and failed to initiate care plans for 1 of 1 sampled resident reviewed for catheter, Resident #126.The findings included:1. Record review showed Resident #10 was admitted on [DATE] with diagnosis of cerebrovascular disease and vascular dementia, severe with anxiety. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score was 06, indicating severe cognitive impairment. A review of the Physician's Orders showed Resident #10 had an order dated 02/03/25 for DNR (Do Not Resuscitate). A review of the Care Plan dated 08/25/25 documented that Resident #10 had a terminal diagnosis. The Goals were to support with management of signs and symptoms of depression and/or anxiety by the next review date. The interventions included honoring advanced directives (refer to advanced directives care plan). No advanced directives care plan were noted in the care plans. 2. Record review showed Resident #27 was admitted on [DATE] and readmitted on [DATE] with diagnosis of nontraumatic compartment syndrome of left lower extremity and chronic obstructive pulmonary disease. The Quarterly MDS dated [DATE] revealed the BIMS score was 09, indicating severe cognitive impairment. A review of the Physician's Orders showed Resident #10 had an order dated 01/31/25 for DNR. A review of the Care Plans dated 09/22/25 revealed that no care plan for advanced directives was elaborated. In an interview conducted on 10/01/25 at 5:25 PM with the Director of Nursing (DON), she stated she acknowledged the issue about the terminal diagnosis care plan for Resident #10 stating to refer to the advance directives care plan no advance directives care plan to review. 3. Record review for Resident #126 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Bladder-Neck Obstruction. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 14, intact cognition. Review of the Physician's Orders for Resident #126 revealed in part the following: An order dated 09/19/25 for Enhanced Barrier Precautions every shift: An order dated 09/19/25 for urinary catheter care daily and PRN (as needed). Record review revealed there was no order for Contact Precautions. Review of the care plan for Resident #126 dated 09/17/25 documented a focus on trauma informed care with a goal of the frequency or severity of my trauma related signs and symptoms will not increase. The interventions included in part the following: Know what triggers are and minimize exposure if possible. On 09/29/25 at 10:40 AM an observation was made of Resident #126 sitting in his wheelchair in his room with urinary drainage bag covered hanging from the side of his wheelchair. There was an Enhanced Barrier Precaution sign on the entrance door to the resident's room. An interview was conducted on 09/29/25 at 10:40 AM with Resident #126 who was asked if staff provide care for his catheter. He said some do and some do not, it is not done every day. Sometimes he has to empty his own bag. There was no care plan for EBP and no order for contact precautions but the care plan for Contact precaution for blood infection documented Resident #126. 4. (a) Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Cerebral Infarction Due to Embolism of Left Middle Cerebral Artery, Other Lack of Coordination, and Aphasia. Review of the Minimum Data Set, dated [DATE] documented in Section C a could not be conducted due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #99 revealed no order for any ointments or gels to be applied topically. Record review revealed no assessment for self-administration of medication. On 09/29/25 at 10:39 AM an observation was made of 2 over the counter medications (Ultra Strength Muscle Rub with active ingredients: Camphor 4%, Menthol 10% and Methyl Salicylate 30% and triple antibiotic ointment with active ingredients: Bacitracin Zinc, Neomycin Sulfate, and Polymyxin B Sulfate) on the overbed table next to Resident #99 who was sitting next to the overbed table. During an interview conducted on 09/29/25 at 10:39 AM with Resident #99 who was asked if she uses the creams on her overbed table, she shook her head yes. When asked where she puts the medicine, she pointed to the muscle rub and motioned a rubbing motion on her left arm. When asked about the triple antibiotic ointment she stroked her right leg. An interview was conducted on 09/30/25 at 11:38 AM with Staff B Licensed Practical Nurse (LPN), who was asked if residents can have medications at the bedside. The LPN stated no, the residents are not supposed to have medications at the bedside. On 09/30/25 at 11:42 AM a side-by-side observation was made with Staff A, Registered Nurse/Unit Manager (RN/UM), of Resident #99 in her room sitting next to her overbed table and on the overbed table was a tube of triple antibiotic ointment. The RN/UM acknowledged the triple antibiotic ointment was on the overbed table and stated residents are not supposed to have medications at the bedside. There was no care plan in place for the resident to self-administer medications. Review of the Physician's Orders for Resident #99 revealed an order dated 02/10/25 for full resuscitation (full code). Review of the Care Plan for Resident #99 revealed no care plan for code status or advance directives. An interview was conducted on 10/01/25 at 11:15 AM with Staff the Clinical Reimbursement Specialist (LPN /CR). The CRD had left as of 09/12/25.When asked about care plans, she said the CRD who had left was in charge and they both (CRS's) and all nurses put in care plans. Social services does advanced directives and behavioral care plans. Further interview with the CRS revealed that every resident had an Advance directive care plan and as of 04/30/25 she was instructed by Palm Beach office to remove all advanced directive care plans and that is what she did, she removed all advanced care plans for every resident. She had questioned the removal, but she was instructed to remove all advance directive care plans for all residents. At the care plan meetings for the residents the social worker discusses advanced directives and verifies the code status for the resident and asks if they wish to continue with current code status or change it. An interview was conducted on 10/01/25 at 11:52 AM with the Social Services Director (SSD) who stated she has worked at the facility for 1 year. When asked about advance directives, the SSD said she addresses the advance directives at the time of admission, and it is discussed for sign change and quarterly reviews. The code status is on the face sheet and in the orders and if they are a DNR (Do Not Resuscitate), it is in front of the chart. The SSD said she believes that is why they do not have an advanced directive care plan. The SSD acknowledged there is no advance care plans are in place for any resident. 5. Resident #60 was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease, Acute Pulmonary Edema and Allergic Bronchopulmonary Aspergillosis. The Minimum Data Set, dated [DATE] documented in Section C, a BIMS score of 15 indicating a cognitive response. Review of the Physician's Order for Resident #60 revealed an order dated 06/17/25 for DNR (Do Not Resuscitate), Review of the Care Plan for Resident #60 revealed no care plan for advanced directives or for code status. 6. Record review revealed Resident #72 was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Guillain-Barre Syndrome, Pain due to other Internal Prosthetic Devices, Implants and Grafts. Review of the Minimum Data Set assessment dated [DATE] documented in Section C, a BIMS score of 15, indicating a cognitive response. Review of the Physician's Orders for Resident #72 revealed an order dated 08/23/25 for full resuscitation. Review of the Care Plans for Resident #72 revealed no care plan for advanced directives or code status.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide services with reasonable accommodation of resident needs and preferences for 3 of 27 sampled residents, (Resident #44, Resident #90, and Resident #104), whose call lights were not within their reach. The findings included: Review of the provided Policy and Procedure titled, Physical Environment, included #5: Assure an applicable working system is in place and within reach for the resident to summon assistance, including, but not limited to a typical call light with cord. The findings included:1. Record review revealed Resident #44 was readmitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, Weakness, Lack of Coordination, and Dementia. The Annual Minimum Data Set (MDS) dated [DATE], section C, documented a Brief Interview of Mental Status (BIMS) score of 06, on a scale of 0 to 15, indicating severe cognitively impaired. Review of the Activities of Daily Living (ADL) Care Plan had an intervention dated 10/06/22 Call Bell within reach while in room/bathroom/shower room and remind to use.During an observation conducted on 09/29/25 at 11:08 AM Resident #44 was noted in bed. The surveyor observed the resident's call light hanging on the back of the bed and not accessible to the resident. Photographic Evidence Obtained.2. Record review revealed Resident #90 was admitted on [DATE] with diagnoses that include: Lack of Coordination, Hypertension, Repeated Falls (05/15/2025), Anemia, Diabetes, and Dementia. The Quarterly MDS dated [DATE] section C, documented a BIMS score of 01 indicating severe cognitive impairment. The Care Plan for Resident #90 included a Fall Care Plan which stated, Provide environmental adaptations: Call light within reach, which was revised 09/22/25.During an observation on 09/30/25 at 9:22 AM, the call light for Resident #90 was on the floor next to his bed and not accessible to the resident. Photographic Evidence Obtained.3. Record review revealed Resident #104 was last readmitted on [DATE] with diagnoses that included Multiple Sclerosis, Hemiplegia and Hemiparesis after Cerebral Infarction (Stroke), Lack of Coordination, Malaise, and Chronic Pain. Her MDS readmission assessment dated [DATE] section C, reflected a BIMS score of 15 indicating cognition is intact. Section GG documented Resident #104 required substantial/maximum assistance to Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. The Plan of Care for Resident #104 had a Fall Care Plan with an intervention that stated Provide environmental adaptations: Call light within reach initiated on 07/28/25. During an observation on 09/30/25 at 9:20 AM, the call light for Resident #104 was on the floor next to her bed where she could not reach. Photographic Evidence Obtained. An interview was conducted on 10/01/25 at 10:45 AM, with Staff H, Certified Nursing Assistant (CNA), when asked about training she had been provided regarding call light policies, she replied that when daily care is completed, the call light is placed on the resident's bed near the resident's hand and then informed to call for help if needed. An interview was conducted on 10/01/25 at 1:00 PM with Staff J, CNA, regarding the call light policy. Staff J stated that once resident care was completed, she places the call light next to the resident on the bed where the resident can reach it.

Based on observations, interviews, and record reviews, the facility failed to support the choices, activities, and schedules for 1 of 4 sampled residents reviewed for choices, Resident #8.The findings included: Record review revealed Resident #8 was readmitted to the facility on [DATE] with diagnoses of Heart Failure and Diabetes. Review of the Annual Minimum Data Set, dated [DATE], section C for Brief Interview of Mental Status (BIMS), showed a score of 15, indicating intact cognition. On 09/29/25 at 11:46 AM, Resident #8 stated that about a month ago, he noticed the television (TV) screen on his side was shattered and was on top of the nightstand, which was not his TV. He reported the findings to staff, who all denied breaking it, and was told that he would need to buy one on his own to replace the broken TV. The Quarterly Activity assessment dated [DATE] revealed that Resident #8's activity of choice was watching TV. The Activity Care Plan dated 07/23/25 revealed that Resident #8 will be encouraged to participate in activities of choice. In an interview with the Maintenance Director on 10/01/25 at 12:39 PM, he stated when he started working, he was told that only the South Wing, which is the short-term wing residents, have TVs in their rooms (Rooms 1-26). They provide some rooms with TVs for the long-term residents, but not for all the rooms. If other residents want TVs, they must purchase them themselves or have a family member buy their own TVs. When asked about Resident #8, he stated that he had a TV on the nightstand, which fell off and broke. He threw the broken TV out and told Resident #8 that he would ask the former Administrator if he was willing to purchase a new TV, which was about two to three months ago. The Maintenance Director stated he also spoke to Staff F, the Social Worker, regarding replacing the broken TV for Patient #8. He was also told by the former Administrator that they were purchasing extra TVs, but he did not hear anything back regarding the new TVs. In an interview conducted on 10/01/2025 at 12:50 PM with Staff F, she stated that only the skilled nursing residents who are here for the short term have TVs in their rooms. Resident #8 came to her office to let her know that his TV was broken, which was about 6 weeks ago, and told her that he did not break the TV. She told Resident #8 that he was a long-term resident, and if he wanted his TV replaced, he would have to purchase his own TV. Resident #8 was also told that his family could buy the TV or pay the facility for the TV, and they would be pleased to purchase the TV for him. Resident #8 refused to buy the TV on his own or have his family pay for the TV. Staff F also offered Resident #8 a room change to another room, which had a TV in it, and he refused. When asked if she filed a grievance regarding the broken TV for Resident #8, she said, To be honest, I do not know. A tour of the facility, conducted by the Maintenance Director on 10/01/25, at 2:00 PM, revealed that 21 rooms were missing televisions, while 42 rooms had televisions in them. After this tour, the Surveyor expressed concerns that some rooms have TVs in them, and some do not.

Based on observation, interviews and record review, the facility failed to ensure that the resident environment remained free of accident hazards and failed to ensure that fall interventions were followed for 1 of 1 sampled resident reviewed for accidents, Resident #90. The findings included:Review of the Fall and Injury Reduction Policy effective March 2023 stated that the facility had designated and implemented processes, which strove to reduce the risk for falls and injuries. The policy guided the identification and implementation of appropriate interventions. One of the specifications included implementation of a plan of care based on individual resident needs. Record review revealed Resident #90 was admitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Repeated Falls, and Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], section C, documented Resident #90 had a Brief Interview for Mental Status (BIMS) score of 1, on a 0 to 15 scale, indicating the resident's cognition was severely impaired. Resident #90 experienced two documented falls on 09/18/25 and 06/28/25. Resident #90's care plan was updated after the falls and included the following interventions: floor mats when in bed, checking on the Resident every 30 minutes, call light within reach, and area free of clutter. In an observation conducted on 09/30/25 at 9:22 AM, the call light for Resident #90 was on the floor next to his bed and not within reach. Photographic Evidence Obtained. In an observation conducted on 09/30/25 at 4:32 PM and at 6:00 PM, Resident #90 was noted in his bed sleeping with bilateral mats on both sides of the bed. A wheelchair was noted next to the air conditioner on top of the right mat blocking it, if a fall was to occur. Photographic Evidence Obtained. During an interview with the Director of Nursing (DON) on 09/30/25 at 4:40 PM, she provided the facility's policy for falls. During the interview, she was asked what was implemented after Resident #90 had a fall. She replied that any new interventions are recorded in the care plan on the same day or the next day. The interventions are placed in the care plan but not necessarily ordered. After the first fall, Resident #90 care plan was updated with every 30-minute checks and after the second fall, bilateral mats were initiated and care planned. An interview was conducted on 10/01/25 at 10:45 AM with Staff H, Certified Nursing Assistant (CNA) who stated that she had been working for the facility for about 4 to 5 months. When asked regarding call light procedures, Staff H stated that when daily care is completed, the call light is placed on the resident's bed near the resident's hand and then informed to call for help if needed. Staff H was then asked how often she checks on Resident #90 when in his room, she replied every 30-40 minutes. Staff H was asked if Resident #90 was at risk for falls. She stated, No. When asked if Resident #90 had any interventions for falls she replied, No. Staff H then added Resident #90 had mats and his bed was placed in low position when in bed. According to Staff H the floor mats were dirty and cleaned that day. Staff H was asked where the wheelchair is placed when Resident #90 is in bed, she replied, I fold the wheelchair and place it behind the bed. Staff H also stated that the footrests are placed in the closet.

Based on observations, interviews, and record reviews, the facility failed to ensure tube feeding orders were followed as per the physicians' orders and failed to address a significant weight loss in a timely manner for 1 of 3 sampled residents reviewed for tube feeding (Resident #5). The findings included: Review of the facility's policy titled Weight Management, dated January 2021, showed the following: the Dietitian will document assessment of weight change and intervention. The Dietitian will identify significant weight changes with the following: 1 week 2%, 1 month 5%, 3 months 7.5% and 6 months 10%. Record review revealed Resident #5 was readmitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Moderate Calorie and Protein Malnutrition, and Type 2 Diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C, showed Resident #5 had severe cognitive impairment.Review of Resident #5's weight log showed the following:On 09/05/25, the weight was 124.8 pounds. On 08/07/25, the weight was 125.6 pounds. On 07/04/25, the weight was 139.2 pounds. This showed a weight loss of 10% in two months.An order was noted for two times Jevity 1.5 (tube feeding formulary) at 85 milliliters (ml) per hour for a total of 1,275 ml infused over 24 hours, starting at 4:00 PM on 07/11/2025.On 09/30/25 at 8:35 AM, an observation noted Resident #5 in bed with the Jevity 1.5 tube feeding running at 85 mL/hour. The tube feeding bottle was started on 09/30/25 at 4:00 AM and was noted at the 850 ml mark out of a 1000 ml capacity bottle. The tube feeding that started at 4:00 AM, running at 85 ml per hour, should have been around the 618 ml level, not around the 850 ml level.In an observation conducted on 09/30/25 at 11:25 AM, Resident #5 was noted in bed with the tube feeding Jevity 1.5 formulary on hold. The same bottle observed earlier was noted at the 750 ml mark out of a 1000 ml capacity bottle. In an observation conducted on 09/30/25 at 4:11 PM, with tube feeding Jevity 1.5 running at 85ml an hour. The same tube feeding bottle observed earlier was still noted at the 750 ml mark out of a 1000 ml capacity bottle. In an observation conducted on 09/30/25 at 6:25 PM, with tube feeding Jevity 1.5 running at 85 ml an hour. The same tube feeding bottle observed earlier was noted at the 600 ml mark out of a 1000 ml capacity bottle.An observation conducted on 10/01/25 at 8:13 AM revealed that Resident #5 was in bed with the tube feeding on hold. Tube feeding was initiated with Jevity 1.5 at 85 mL/hour, starting on 10/01/25 at 6:40 AM. The tube feeding was noted at the 950 ml mark out of a 1000 ml capacity bottle.A review of the Quarterly Nutrition Note dated 09/24/25, which was about 3 weeks after Resident #5's significant weight loss was identified, showed the following: Triggering for substantial weight loss times 3 months, weight fluctuations anticipated secondary to diagnosis and medications with diuretic tendencies. It further showed Resident #5 had increased needs secondary to a low underweight Body Mass Index (BMI) of 18.4.The Care plan dated 07/10/25 outlined the following: maintaining adequate nutrition and hydration to prevent significant weight changes, collaborating with the dialysis center, and monitoring weight changes. In an interview conducted on 10/01/25 at 9:17 AM, with the facility's Registered Dietitian, she stated that weights are taken upon admission, once a week for 4 weeks, and monthly thereafter unless more weights are needed. Residents on dialysis are considered high-risk residents and are followed once a month by her. When asked about significant weight loss, she reported the following: 1 week, 2%; 1 month, 5%; 3 months, 7.5%; and 6 months, 10%. For any significant weight loss, they intervene immediately and discuss the weight loss in the morning meetings. When asked how she knew that someone had experienced considerable weight loss, she stated that she runs the weekly weights from the electronic system and compares them to the weights from prior weeks. For the monthly weights, a list of all residents is provided to the nursing team. Weights are taken on the first day of the month and are due to be entered into the electronic system by the 7th of the month. She runs the monthly weight report so she can intervene immediately for any residents experiencing significant weight loss. In this interview, the Dietitian agreed that Resident #5 had a considerable weight loss and that she had not addressed it promptly. In an interview conducted on 10/01/2025 at 1:30 PM with Staff E, Licensed Practical Nurse (LPN), she stated that Resident #5 is tolerating the tube feeding well with no issues. She further noted that the tube feeding bottle had started this morning at 6:40 AM and was already running when she arrived for her shift.

Based on observation, interview and record review, the facility failed to provide respiratory care in a manner consistent with physician orders for 2 of 2 sampled residents (Residents #85 and #46) reviewed for respiratory and failed to assure resident care policies and procedures for respiratory care and services are developed affecting 1 of 3 tracheostomy residents (Resident #85.)The findings included: 1. Review of the record revealed Resident #85 was admitted to the facility 04/08/25 with diagnoses of Traumatic Subdural Hemorrhage (a type of bleeding near your brain that can happen after a head injury); acute and chronic respiratory failure with hypoxia, and anoxic brain damage. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #85 had a Brief Interview for Mental Status (BIMS) score of 0, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This same MDS indicated Resident #85 received treatments such as tracheostomy care, oxygen therapy, and suctioning. Review of active orders revealed Resident #85 had an order that documented Trach: Suction Trach Pre Record Lung Sounds, HR (heat rate) and Respirations as needed for suction prn (as needed) and an order that documented Trach: Suction Trach Post Record Amount of Secretions Characteristics of secretions: (Color, Odor, Viscosity) Lung Sounds, HR, Respirations and Tolerance as needed for Suction prn. Review of Resident #85's care plan dated 07/16/25 documented Focus: Tracheostomy: The resident has a Tracheostomy. Goal: The resident will have no signs and symptoms of infection through the review date; Will have no abnormal drainage around trach site through the review date. Interventions/Tasks: Monitor/document respiratory rate, depth and quality. Check and document every shift/as ordered. Trach care per order. The care plan also documented, Focus: Altered Respiratory Status: The resident has altered respiratory status/Difficulty breathing related to tracheostomy status, Respiratory Failure with hypoxia. Review of Resident #85's Treatment Administration Record (TAR) from September 1st-30th revealed there was no documentation for the pre and post tracheostomy suction assessments for the entire month. A tracheostomy care observation for Resident #85 was conducted on 10/01/25 at 11:37 AM with Staff B, Licensed Practical Nurse (LPN). Upon entering the room Staff B performed hand hygiene and donned Personal Protective Equipment (PPE) which included a gown and gloves. Staff B began by setting up her supplies and continued with tracheostomy care. A respiratory assessment was not performed by Staff B. Staff B stated she would require assistance from another staff member to put on Resident #85's tracheostomy collar due to safety concerns. On 10/01/25 at 11:55 AM, Staff P, Certified Nursing Assistant (CNA) entered the room to assist. Staff B changed Resident #85's collar and during the process the resident began to cough and expel secretions, Staff B verbalized that she would suction the Resident. Staff B performed deep suctioning, mouth suctioning, and cleansed the resident's secretions. Staff B concluded her care, discarded her supplies, and washed her hands. Staff B was asked if she was done with her care and stated yes then walked out of Resident #85's room. Again, Staff B did not perform a respiratory assessment on Resident #85. An interview was conducted with Staff B on 10/01/25 at 12:17 PM. When asked, how would you perform a respiratory assessment, Staff B stated she would check their oxygen, check for lung sounds, and check for respirations. When asked when would you perform a respiratory assessment, Staff B stated, If they are wheezing, coughing, in distress, or if there is a change of condition. When asked if she would do an assessment for an administration of a respiratory treatment, Staff B stated yes and verbalized she would do it for any nebulizer treatment and tracheostomy care. When asked why she didn't perform an assessment before and after performing tracheostomy care that included deep suctioning, for Resident #85, Staff B stated she forgot her stethoscope and had left it out on her medication cart and had her pulse oximeter in her pocket but forgot to use it. Staff B stated she would have also checked respirations but didn't because she was nervous. Staff B voiced they were rushing me to do tracheostomy care. On 10/01/25 at 2:30 PM, when asked to provide a respiratory and tracheostomy policy, the Regional Nurse Consultant voiced they did not have a respiratory or tracheostomy policy and used the tracheostomy care competency skills checklist. Staff B's competencies were requested for review. Review of Staff B's competency titled Tracheostomy Care Competency Skills Checklist dated 07/01/25 and labeled New Hire documented, Competency Criteria: Tracheostomy Care . 1. Check TAR to verify physician orders for trach care . yes. All other criteria for the skill had also been checked of as yes and was signed by both Staff B and a representative facilitating the competency on 07/01/25. Review of Staff B's competency titled Competency Review Nurses dated 07/01/25 documented, Required competency . Nursing Care to Residents . Demonstrates knowledge and understanding of physical assessment as follows: Respiratory 1. Breath Sounds: Trach care/suctioning. All skills were verified and signed off by the evaluator as well as by Staff B on 07/01/25. On 10/02/25 at 12:54 PM, the Regional Nurse Consultant asked the surveyor how Staff B did with Tracheostomy care. She was informed Staff B did not perform a pre and post assessment when she performed care. The Regional Nurse Consultant stated Staff B was really nervous and was a newer nurse. She agreed with all findings. 2. Review of the facility policy for Oxygen Therapy stated that oxygen is provided to residents based on physician orders and the first step of the policy is to verify the physician order. Review of the record revealed Resident #46 was last readmitted on [DATE] with diagnoses that included Acute Respiratory Failure, Chronic Respiratory Failure, Morbid (Severe) Obesity, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Shortness of Breath, and Pleural Effusion. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE], section C, documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident's cognition was intact. Further review of Resident #46 is record indicated there was no physician order for oxygen therapy. The care plans initiated 12/03/20 and revised 03/25/25 for Resident #46 however did have a current plan for oxygen and included monitoring for signs and symptoms (S/S) of respiratory distress and breathing difficulty. Resident #46's Treatment Administration Record (TAR) for the months of September and October 2025 did not include monitoring for these S/S. Review of the Nursing progress notes did not address oxygen use after 05/25/25. Oxygen saturation, a medical measurement which is a key indicator of oxygen levels, was not measured after the month of July 2025. On 09/29/25 at 11:10 AM, during Resident #46 she was observed in her room sitting in her wheelchair wearing a nasal canula. Further observation revealed that an oxygen concentrator was running with the flow meter above the highest mark (5 liters/L). Photographic Evidence Obtained. On 09/29/25 at 1:55 PM, Resident #46 was observed in her room. The resident stated that she needed oxygen all the time when asked how often it was used. The resident also used the portable oxygen tank on the wheelchair outside of her room. Resident #46 stated that she previously needed 1-2 L but it was increased to 3-4 L. On 09/30/25 at 8:36 AM, Resident #46 was observed with a portable oxygen tank attached to her wheelchair which was turned off since she was using the concentrator. The oxygen concentrator was running with the flow meter above the highest mark. Photographic Evidence Obtained of both concentrator and oxygen tank. On 10/01/25 at 8:37 AM, Resident #46 was observed using the oxygen concentrator running with the flow meter at 4.5 L. Photographic Evidence Obtained. During an interview on 10/01/25 at 1:00 PM with Staff J, Certified Nursing Assistant (CNA), Staff J stated that when Resident #46 was in bed, the concentrator was used and when she was in the wheelchair Resident #46 used the portable oxygen tank. Staff J stated that she helped Resident #46 into the chair and set the tank to 2 L but the concentrator was always set up ahead of time. When asked who set it up, Staff J did not provide a name or title. An interview was conducted on 10/01/25 at 2:10 PM Staff G, Nurses who stated that Resident #46 required oxygen most of the time. Staff G explained that Resident #46 used the concentrator at night, and the portable oxygen tank on wheelchair in the day. Staff G stated that the second shift nurse would set up the concentrator according to the order in the chart. Staff G could not locate an oxygen therapy order for Resident #46 in the chart. The Assistant Director of Nursing (ADON) came over during the interview and could not find oxygen orders and noted they were discontinued in July of 2025.

Based on observations, interviews, and record review, the facility failed to obtain dialysis communication sheets for 1 of 1 sampled resident reviewed for dialysis (Resident #117). The findings included:A review of the facility's policy titled Dialysis Management, dated October 2021, revealed the following: The facility will coordinate care and services for hemodialysis residents. Complete the Dialysis Communication Tool before and after dialysis and follow up on any special instructions from the dialysis center. A record review revealed Resident #117 was readmitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and was dependent on dialysis. A review of the physician's orders showed an order for the Resident to undergo dialysis on Tuesdays, Thursdays, and Saturdays, dated 09/26/25.The Nutrition Risk assessment dated [DATE] revealed the following: Resident #117 has a hyponatremic (low blood sodium) diagnosis and fluid fluctuations that are anticipated secondary to dialysis. Resident #117's care plan showed Collaboration with the dialysis center as one of the interventions.A review of the dialysis communication sheets for Resident #117, which were noted in the nurse's station, showed the following for the month of January 2025: Missing communication sheets were not in the dialysis binder for 09/04/25, 09/06/25, 09/13/25, 09/23/25, and 09/27/25. In an interview conducted on 09/30/25 at 4:15 PM with Staff C, the Registered Nurse stated that the communication sheets are filled out before the Resident goes to dialysis treatment. It is then filled out at the dialysis center and brought back to the facility with the Resident. All communication sheets are placed in a dialysis communication binder located in the nurse's station. In an interview conducted on 09/30/25, at 5:00 PM with the Director of Nursing (DON), she stated that when a resident goes to dialysis, facility staff fill out communication sheets. It is later completed by the dialysis center and returned to the facility. The nursing staff will review the communication sheets for any new orders or fluid restrictions and make the necessary changes. The communication sheets are later placed in the dialysis binder in the nurse's station, the same day. According to the DON, it is essential to review all communication sheets the same day after the residents come back from dialysis.

Based on record review and interview, the facility failed to identify triggers and implement care plans with triggers for residents with PTSD (Post Traumatic Stress Disorders) for 1 of 1 sampled resident, Resident #3.The fundings included:Record review revealed Resident #3 was admitted on [DATE] with diagnoses that included of the Psychosocial History and Assessment for Resident #3 dated 07/16/25 documented the following, resident has been diagnosed with PTSD. Is there a smell, sound, touch, taste, sight or other sensation that causes a flashback or trigger was answered yes. If yes, what causes flashbacks or triggers was answered being in situations where he feels anxiety. When asked what happens when the resident experiences a trigger was answered Increased anxiety. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive response. Review of the Care Plan for Resident #3 dated 07/14/25 documented with a focus on Trauma Informed Care. The goals were for staff to make efforts to avoid flashback or trigger, staff will assist in managing the resident's response to trigger, and the frequency or severity of the trauma related signs and symptoms will not increase. The interventions included in part the following: Know what triggers are and minimize exposure if possible. Observe for reported symptoms of a trigger. During an interview conducted on 10/01/25 at 11:15 AM with Staff LPN/CRS (Clinical Reimbursement Specialist) and has been in this role at the facility since November 2024. When asked about care plans, she said the CRD (Director) that just left was in charge and both her, the Director and all nurses put in care plans. Social Services does advance directives and behavioral care plans. During an interview with the Social Services Director (SSD) on 10/01/25 at 11:52 AM, when asked about residents with diagnosis of PTSD, the SSD stated if a resident has PTSD, this is addressed by her on the admission psychosocial assessment, and this would include the triggers for the PTSD. She stated the trauma informed care portion of the psychosocial assessment would automatically pull over to the care plan for the resident and create a trauma informed care plan. When asked about Resident #3, the SSD stated he does have PTSD and he also has triggers. When asked what the triggers are, the SSD stated being in situations where he feels anxiety. It's a delicate situation and use a calm delicate quiet approach.Sense of situational anxiety, and she feels the resident is still trying to figure it out. An interview was conducted on 10/01/25 at 1:20 PM with the Director of Nursing, the Social Service Director and Staff R, Psychologist, to review Resident #3 and his triggers. Staff R stated she has been seeing the resident since July of this year. When asked if he has any triggers for the PTSD she said yes, he mentioned it 2 to 3 times about the yelling that he does not like it and he gets anxious. Staff R said she has mentioned this to staff and asked to have his room or roommate changed to help and staff did change his room a couple of times and this has helped the resident.

Based on record review and interview, the facility failed to ensure adequate medication for 1 of 6 residents, Resident #39, reviewed for medication reconciliation.The findings included:On [DATE] at 11:50 AM, a review of the North medication care was conducted with Staff G, Licensed Practical Nurse (LPN) for Resident #39. Record review reveled Resident #39 was admitted on [DATE] with diagnoses that included Parkinson's Disease, and Dementia Review of the physician's order, dated [DATE], documented Alprazolam Oral Tablet 0.25 MG (Alprazolam), a *Controlled Drug,*Give 1 tablet by mouth every 12 hours as needed for Anxiety/Agitation for 14 Days and was discontinued on [DATE]. Review of the Controlled Drug Declining Inventory Sheet for Resident #39 for the Alprazolam .25mg tablet documented the medication was signed out on [DATE] at 8:24 PM. Review of medication administration record from 0701/25 to [DATE] revealed no documentation of Alprazolam 0.25mg being administered. Review of the nurse progress notes from [DATE] revealed no documentation of Alprazolam 0.25mg being administered. During an interview conducted on [DATE] at 1:00 PM with the Director of Nursing who was asked about controlled medication reconciliation, she said she reviews the carts regularly with the nurses to ensure expired or discontinued medication or medications for residents who have been discharged are removed from the carts. When asked about the Alprazolam 0.25mg for Resident #39, she acknolwedged the medication was discontinued was not documented as being administered on [DATE].

Based on record review, observation and interview, the facility failed to ensure medication were secured, for 1 of 27 sampled residents, Residents #99, reviewed for medications. The findings included:Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Cerebral Infarction Due to Embolism of Left Middle Cerebral Artery, Other Lack of Coordination, and Aphasia. Review of the Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status could not be conducted due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #99 revealed no order for ointments or gels to be applied topically. Record review revealed no assessment for self-administration of medication(s). On 09/29/25 at 10:39 AM, an observation was made of 2 over the counter medications (Ultra Strength Muscle Rub with active ingredients: Camphor 4%, Menthol 10% and Methyl Salicylate 30% and triple antibiotic ointment with active ingredients: Bacitracin Zinc, Neomycin Sulfate, and Polymyxin B Sulfate) on the overbed table next to Resident #99 who was sitting next to the overbed table. An interview was conducted on 09/29/25 at 10:39 AM with Resident #99 who was asked if she uses the creams on her overbed table. She nodded her head yes. When asked where she puts the medicine, she pointed to the muscle rub and motioned a rubbing motion on her left arm. When asked about the triple antibiotic ointment, she stroked her right leg. During an interview conducted on 09/30/25 at 11:38 AM with Staff B Licensed Practical Nurse (LPN) who was asked if residents can have medications at the bedside, the LPN stated, no the residents are not supposed to have medications at the bedside. On 09/30/25 at 11:42 AM, a side-by-side observation was made with Staff A Registered Nurse/Unit Manager (RN/UM), of Resident #99 in her room sitting next to her overbed table and on the over bed table was a tube of triple antibiotic ointment. The RN/UM acknowledged the triple antibiotic ointment was on the overbed table and stated residents are not supposed to have medications at the bedside.

Based on observations, interviews, and record review, the facility failed ensure they implemented an effective infection control program, as evidenced by failure to follow enhanced barrier precautions guidelines for 1 of 42 residents on enhanced barrier precautions, Resident #25.The findings included:Review of the facility's policy titled, Barrier Precautions dated August 2025, included the following: During high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting for Residents on Enhanced Barrier Precautions, Personal Protective Equipment (PPE) is required. PPE consists of wearing gloves and gown prior to the high contact care activity.Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gowns and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room. A record review showed that Resident #25 was admitted on [DATE] and readmitted on [DATE] with diagnosis of type 2 Diabetes Mellitus with diabetic neuropathy and foot ulcer. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score was 12, moderate cognitive impairment.A review of the Physician's Orders showed that Resident #25 had an order dated 06/13/25 for Enhanced Barrier Precautions.A review of the Care Plan dated 08/04/2025 documented that Resident #25 had diabetic ulcer of left medial foot. Goals were the improvement of ulcers without complications by the next review date. The interventions included enhanced barrier precautions.In an observation conducted on 09/29/25 at 12:30 PM, the surveyor called Staff K, Unit Manager Registered Nurse (RN) per Resident #25s request. Staff K entered Resident #25 accompanied by Staff L, Staff M and Staff N. The staff members washed their hands, put gloves on and dressed Resident #25, transferred, the resident from the bed to the wheelchair and wheeled resident to the bathroom. Resident #25 urinated on the wheelchair. Staff members wheeled Resident #25 to the room, took its vital signs, transferred the resident back to bed and provided care. During this event Staff K, Staff L, Staff M, and Staff N did not wear the required Personal Protective Equipment (PPE).In an interview conducted on 10/02/25 at 11:00 AM, the Director of Nursing (DON) stated that whenever staff are providing ADL (activities of daily living) care they would use PPE. The staff would use PPE that consists of gloves and a gown, and the mask is optional when they are transferring, toileting and providing care. The DON was made aware of the findings.In an interview conducted on 10/02/25 at 1:15 PM with Staff K, Unit Manager Registered Nurse, she further stated that when a resident is on enhanced barrier precaution, she has to wear a gown and gloves if she is going to care for the resident or transfer the resident. The only time she doesn't need to wear the personal protective equipment is if she is just going to check on the resident.In an interview conducted on 10/02/25 at 1:30 PM with Staff O, Certified Nurse Assistant, she stated that the enhanced barrier precautions mean when she goes in the room, she has to wear a gown and gloves because the resident could be on tube feeding, on ventilator, or tracheostomy, or could have wounds.

Based on record review and interview, the facility failed to provide influenza and pneumococcal vaccines for 2 of 5 sampled residents, Resident #60 and Resident #126.The findings included: 1. Record review for Resident #126 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Muscle Wasting and Atrophy and Pneumonia. Review of the Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the Physician's Orders for Resident #126 revealed an order dated 10/02/25 for Inactivated Influenza Quadrivalent Vaccine 0.5 ML (Inactivated Influenza Quadrivalent Vaccine) Inject 0.5 ml intramuscularly one time only for Immunization for 1 Day Please employ the appropriate VIS for Flu vaccines. Please obtain consents for vaccines as well as enter information under the immunization tab. Review of the Vaccine Consent Form with no date for Resident #126 revealed it was signed by the resident and indicated he wanted the influenza and the PCV20 (Prevnar 20) (there was a check next to both immunizations. On the form was written Refused that did not look like the same pen/handwriting as the resident).Review of the declination of Influenza or Pneumococcal Vaccination dated 09/16/25 indicated Influenza (circled) and was signed by Resident #126.Review of the Vaccine Consent Form for Resident #126 dated 10/01/25 signed by the resident indicated he wanted the influenza vaccine (there was a check next to influenza).On 10/01/25 at 4:00 PM, the Staff I, the Unit Manager/Infection Preventionist, informed the surveyor that she had asked Resident #126 if he would like to receive the influenza vaccine and showed the surveyor the fax that she had sent to the pharmacy ordering the influenza vaccine for the resident. 2.Record review revealed Resident #60 was admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease, Acute Pulmonary Edema, Allergic Bronchopulmonary Aspergillosis, Morbid (Severer) Obesity, and Presence of Heart Assist Device. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #60 revealed an order dated 10/01/25 for Prevnar 20 Intramuscular Suspension Prefilled Syringe 0.5 ML (Pneumococcal 20-Valent Conjugate Vaccine) Inject 0.5 ml intramuscularly one time only for Immunization for 2 Days. Review of the Declination of Influenza or Pneumococcal Vaccine form dated 07/07/25 which indicated Prevnar 20 was not signed by the resident.Review of the Consent for Flu and Pneumococcal Vaccine with dated 09/25/25 signed by Resident #60 documented the resident was administered the Flucel vaxOn 10/01/25 at 4:00 PM the Staff I; Unit Manager/Infection Preventionist informed the surveyor that she had asked Resident #60 if he would like to receive the pneumococcal vaccine and showed the surveyor the Vaccine Consent Form dated 10/01/25 signed by Resident #60 documenting the Prevnar20 was checked. During an interview conducted on 10/01/25 at 3:30 PM with Staff I was asked about immunizations being offered to residents, Staff I stated they are offered on admission and annually during the month of September. An interview was conducted on 10/01/25 at 10:20 AM with Resident #126 who was asked if he wanted the flu or pneumonia vaccine. He said he has always taken the flu vaccine so he would take that. He said he never had the pneumonia vaccine but should take it because he has had pneumonia in the past. When asked if staff ever offered him the flu or pneumonia vaccine, he said he did not remember it being offered to him.

Based on observations, interviews and record review, the facility failed to ensure a physician order for a special study was scheduled and completed in a timely manner for 1 of 3 sampled resident reviewed, Resident #1.The findings included: Review of Resident #1's clinical record revealed an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Dysphagia, Oropharyngeal Phase, Traumatic Hemorrhage of Cerebrum and Gastrostomy Status. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 04 indicating severe cognition impairment and that the resident had a feeding tube. The resident‘s care plan titled Tube Feeding documented, The resident is receiving enteral nutrition r/t (related to) gastrostomy status and Dysphagia initiated on 05/10/25 with interventions to include obtain and review lab (laboratories) / diagnostic work as ordered, report results to MD [physician] and follow up as indicated.Review of Resident #1's clinical record documented a physician order dated 07/29/25 for a MBSS (Modified Barium Swallow Study) to determine the function of the oropharyngeal phase of the swallow function. Further record revealed the lack of the MBSS results on file.Review of the following Speech Therapy (ST) visits documented the following:-Date 08/06/25- .SLP (Speech Language Pathologist) completed pt's (patient's) oral care and proceeded with trials of crushed ice 1/4 to 1/2 teaspoonful boluses. Pt tolerated 17/20 boluses when provided faded verbal prompts to occasionally clear throat.-Date 08/10/25- .SLP provided pt's oral care. Pt tolerated 21 1/2 teaspoonful boluses of ice chips via guided bolus placement with efficient swallow trigger and no overt s/s (sign or symptoms) of aspiration and/or penetration.-Date 08/16/25- .SLP completed oral care and presented pt with trials of crushed ice. Pt tolerated 17 p.o. (orally) boluses of 1/4 teaspoonful of ice. Pt demonstrated no overt s/s of aspiration and/or penetration.-Date 08/20/25- .SLP completed oral care. Facilitation of Frazier free water protocol. Pt tolerated 2 oz of thin liquid water w/o (without) any overt s/s of aspiration and/or penetration.-Date 08/23/25- .ST services targeting conversational intelligibility.Patient is able to converse at 80% of the conversation.Review of Resident #1's Certified Nursing Assistant Plan of Care (POC) task response related to behavior from 07/30/25 to 08/27/25 documented no behaviors reported. On 08/27/25 at 12:32 PM, an interview was conducted with Resident #1 who stated she was in the facility for four (4) months, and she was ready to go home. The resident stated something happened to my stomach, she was crippled and could not walk. The resident added that she couldn't eat, was very hungry, couldn't drink and was very thirsty. The resident was asked if she was getting tube feeding and stated she did not want it because it makes her sick and vomit. The resident stated she was not getting water and was dying of thirsty. Resident #1 stated she asked for ice chips, they don't bother to respond, they are not together, the doctor said she is dehydrated, and they would not give her water. During the interview, observation revealed the resident had a dressing over her trachea area, a basin next to the resident with no vomiting noted, and the resident's tongue was slightly dry. On 08/27/25 at 12:38 PM, an interview was conducted with Staff A, Licensed Practical Nurse (LPN), who stated the last time the Speech Therapist saw Resident #1 she was going to start her on pleasure food. Staff A stated the resident was NPO (nothing by mouth) and could not have ice ships. On 08/27/25 at 1:32 PM, an interview was conducted with the Rehabilitation Director who stated Resident #1 was out of it when she came in to the facility, now she is more alert and asking for water and food, but her swallowing is profound, and the water and food will go to her lungs as per the Speech Language Pathologist (SLP). The Rehabilitation Director stated the resident was currently receiving ST (speech therapy). On 08/27/25 at 3:15 PM, a joint interview with the Rehabilitation Director and Staff B, SLP, was conducted. Staff B stated she was waiting for Resident #1's MBSS [Modified Barium Swallow Study] results, added she spoke to the nurse recently who asked for when they can give her ice ships and told her she was waiting for the test results. Staff B stated she did a thermal / tactile stimulation and did not hear any wet vocal quality, the time of her swallow trigger was very quick, meaning that they progress to ice ships, for trial. Staff B stated she had Resident #1 brush her teeth, the Frazier free water protocol, she cleaned in her checks with a sponge and under her lips and gave her ice chips; the resident tolerated that well. Staff B stated the Frazier free water protocol is a safe way to test that would not cause pneumonia. The Rehabilitation Director was asked how long it takes to scheduled and get an MBSS done and stated the therapy department give the referral to nursing and nursing do the scheduling, added that therapy did not schedule the study. During the joint interview, the Director and Staff B were apprised that the referral for the MBSS was dated 07/29/25. Staff B stated she has inquired about the MBSS results asked the nurse and told her she was going to inquired about it and have not heard back. Staff B stated Resident #1 was receiving ST visits five days a week to do thermal/tactile stimulation, communicating using simple sentences, the resident is confused but much alert, more intelligent speaking. Staff B was asked for the goal of care and stated eventually to get the resident on a diet and added the MBSS results will let her know who she can proceed, be more aggressive with therapy. On 08/27/25 at 5:07 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated whenever the therapy department give her a referral, she calls the doctor for an order then they call to make an appointment either at the hospital or ambulatory. The ADON added that the facility was not doing mobile Swallowing test, it was started back on last month. An inquiry was made regarding Resident #1's MBSS ordered on 07/29/25 that had not been done as of 08/27/25. The ADON responded that she was not sure why it had not been done and added she needed an actual written script and will get it from the doctor tomorrow. The ADON stated the doctor comes to the facility every Monday and Thursday. On 08/28/25 at 9:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that if a MBSS is ordered and recommend by ST, they will get it done. The DON was asked how long it take to get it done and stated it depends and added Resident #1 had some recent transfer to hospital, pulled out of her trach, her cognition had changed, at those times, she was not at her best to take the test, now she is more aware and cognitively intact. The DON stated the facility was doing the MBSS test at a local Hospital and added, it has been a process to schedule. The DON was asked to submit written documentation regarding attempt to schedule the resident's MBSS and stated there was none. The DON stated the facility has recently contracted with diagnostics, stated Resident #1's MBSS is scheduled for next Tuesday and is on standby to do today if there is a cancellation. Consequently, a side-by-side review with the DON of Resident #1's revealed a transfer to the hospital on [DATE] due to the resident pulling her trach, returned to the facility on [DATE] and an emergency room visit on 08/02/25 due to a fall. The DON was apprised of the delayed on providing Resident #1's MBSS and the resident's begging for ice chips.

Based on observations, interviews and record review, the facility failed to maintain the residents' medical records that are accurately documented in accordance with accepted professional standards and practices for 1 of 3 sampled resident reviewed, Resident #1. The findings included: Review of Resident #1's clinical record revealed an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Traumatic Hemorrhage of Cerebrum, Obstructive and Reflux Uropathy, Unspecified. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 04 indicating severe cognition impairment. Review of Resident #1's clinical record documented a physician order dated 08/06/25 for remove foley catheter.Review of Resident #1's clinical record August 2025 Treatment administration Record (TAR) documented a foley catheter was removed on 08/07/25. On 08/28/25 at 9:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that a Urology Nurse Practitioner (NP) comes to the facility every week to see residents on consultation basis. On 08/28/25 at 11:15 AM, a joint interview was conducted with the facility's Urology Nurse Practitioner (NP) and the Director of Nursing (DON). The NP stated he has been coming to facility for three (3) months, gets a consult from the facility nurses or the in-house NP. The NP was asked if he contacted the resident's family / representative to discuss the plan of care and responded if the patient/resident is alert, he will talk with the resident, will talk to the nurse, and will get a hold a family member if needed. The NP was asked if he get in touch with resident representative, especially those with a BIMS score of 4. The NP replied he never communicated with Resident #1's family / representative, did not talk to the family/representative related to a right kidney mass revealed on ultrasound done on 08/05/25. The NP stated it is important to communicate with the resident's family / representative. A side-by-side review of Resident #1's Urology-NP consult notes was conducted for the following notes:-Service date 06/24/25 documents .sex: female. Genitourinary: External Genitalia: foley catheter; Penis: normal, no lesions, no discharge; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. Current assessment and plan discussed with patient and nursing staff.-Service date 07/22/25 documents .sex: female. Genitourinary: External Genitalia: foley catheter; Penis: normal, no lesions, no discharge; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. Current assessment and plan discussed with patient and nursing staff.-Service date 07/30/25 documents .sex: female. Genitourinary: External Genitalia: foley catheter; Penis: normal, no lesions, no discharge; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. Current assessment and plan discussed with patient and nursing staff.-Service date 08/05/25 documents .sex: female. GU (Genitourinary) + obstructive uropathy.Genitourinary: External Genitalia: Penis: normal, no lesions, no discharge; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. assessment: unspecified urinary incontinence.Current assessment and plan discussed with patient and nursing staff.-Service date 08/13/25 documents .sex: female.foley catheter was removed.patient remains incontinent.GU: + foley catheter.Genitourinary: External Genitalia: Penis: normal, no lesions, no discharge, + foley catheter; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. Current assessment and plan discussed with patient and nursing staff.During the review, the NP confirmed Resident #1 was a female and that external genitalia male information should have to be removed. The NP was apprised that his note dated 08/13/25 documented + foley catheter when the resident catheter was removed on 08/07/25.

Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure it obtained a current physician order for an Intravenous (IV) dressing and IV site; and failed to change the Intravenous (IV) dressing to the right upper chest for 1 of 1 sampled resident observed, Resident #4. The findings included: Review of the facility policy and procedure, titled, Dressing Change for Vascular Access Devices, provided by the Director of Nursing (DON), reviewed 2011, documented in the Policy Statement Purpose: To prevent local and systemic infection related to the IV catheter. Policy: A sterile dressing is maintained on all peripheral and central vascular access devices to protect the site, provide a microbial barrier, and to provide vascular access device securement .3. Central venous access device and peripheral midline dressings are changed every 7 days and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further assessment if infection is suspected .Midline and Central Venous Access Device Dressing Change Procedure: .4. Assess site for: Erythema, Induration, Swelling, Drainage .18. Apply label on dressing with date and nurse's initials 20. Suggested charting: Site assessment, Measured external length of the catheter, Prep used, Type of dressing, Catheter securement (integrity of sutures, other devices) and Resident response. Record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Diabetes Mellitus Type II, Hypertension, Dementia, Alzheimer's Disease, Chronic Kidney Disease and Hypertensive Heart Disease with Heart Failure. The record documented a Brief Interview Mental Status (BIMS) score of 00, indicative of (severe impairment). During an observation on 05/14/25 at 10:37 AM, Resident #4 was observed sitting in the wheelchair in the hallway. It was noted the resident had an intravenous (IV) chest dressing dated 04/25/25. Closer observation on 05/14/25 at 2:08 PM, with the Director Of Nursing (DON) revealed the dressing was still dated 04/25/25 that was on the resident's right IV subclavian Opti Flow chest port double lumen dressing (for Hemodialysis which was not required at that time) with the nurse's initials. Photographic Evidence Obtained. Review of the physician orders revealed that 04/25/25 was the last and most recent order for: Change IV dressing to right upper chest every seven (7) days as well as needed (PRN) for soiling and/or dislodgement every evening shift every Monday - order date 04/25/25 14:43 [2:43] PM D/C [discontinue] date 05/06/25 at 15:00 PM. There was no current physician's order for the right upper chest IV dressing as of his re-admitted to the facility on [DATE]. Record review of Resident #4's Hemodialysis care plan, initiated 04/05/25 and revised 04/14/25, indicated Focus: Hemodialysis---the resident has Renal Failure and is on Hemodialysis. Interventions: Dialysis Catheter Site---Observe for signs and symptoms of Bleeding, for gross bleeding at access consider calling 911 .Goal: Will have minimal to no complications . There was no specific care plan reviewed pertaining to Resident #4's right upper chest (IV) dressing. Review of the April 2025 Medication Administration Record (MAR) revealed the resident's right chest IV dressing had been documented as having been changed on each of the following days: 04/05/25, 04/12/25, 04/19/25 and 04/21/25, 04/26/25, with the last documented time that Resident #4's right chest IV dressing was changed was on: 04/28/25, per the nurses' initials on the MARs. Review of the April 2025 Treatment Administration Record (TAR) revealed no documentation pertaining to the resident's right chest IV dressing, per the lack of nurses' initials. Review of the May 2025 MARs revealed the resident's right chest IV dressing was documented as having been changed on 05/03/25 and 05/05/25, per the nurses' initials on the MAR. Review of the May 2025 TARs revealed no documentation pertaining to the resident's right chest IV dressing, per lack of nurses' initials. The date of 04/25/25 was observed on the resident's right IV subclavian Opti Flow chest port double lumen dressing during this current survey. There was no documentation reviewed in the nursing progress notes dated 04/04/25 to 05/11/25 that indicated Resident #4's right upper chest (IV) dressing had been changed during these dates-of-service (DOS). There was no documentation to describe the resident's IV site status or the condition of the resident's skin underneath the outdated dressing. An interview was conducted on 05/14/25 at 2:05 PM with Staff B, Registered Nurse (RN) / South Unit Manager (UM) and the current direct care nurse for Resident #4, who stated she had not changed the IV right port dressing. She acknowledged he IV right port dressing was outdated and should have been changed. A side-by-side record review was conducted with the DON of all of the documentation notated above. The resident's right IV chest port dressing site was not changed since 04/25/25 and documented on the TAR as being done, until after surveyor intervention. The DON acknowledged the findings on 05/14/25 at 4:10 PM that Resident #4's right IV subclavian Opti Flow chest port double lumen dressing should have had a current physician order and should have been changed and documented as per protocol.

Based on review of policy and procedure, observation and interview, the facility failed to ensure that it posted the current date for the Nurse Staffing Information for 2 of 5 posting areas observed. The findings included: Record review of the facility policy and procedure, titled, Staffing, provided by the Director of Nursing (DON) effective August 2024, documented in the Policy Statement: The Administrator and DON [Director Of Nursing] are responsible to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by federal law and sufficient staff to meet applicable state law requirements (include minimum staffing ratios.) .The facility Administrator and the DON should evaluate staffing on a daily basis Staffing: Daily Staffing Sheets 3. Post sheets daily .Other 1. Post the daily staffing hours . An observation on the entrance tour conducted on 05/14/25 at 9:10 AM and again at 10:23 AM revealed there was an Nursing Staff Posting Form located at the front desk with the date of 05/13/25. Photographic Evidence Obtained. On 05/14/25 at 10:23 AM, it was observed there was a 'Nursing Staff Posting Form' posted in the main hallway near the conference room on the bulletin board, dated 05/13/25. Photographic Evidence Obtained. Review of the bottom, lower portion of the posted 05/13/25 Nursing Staff Posting Form indicated on the form itself that, 'this document is posted and updated daily'. An interview was conducted with Staff A, Staffing Coordinator and Central Supply, on 05/14/25 at 4:34 PM, regarding the 'Nurse Staff Postings', who stated that during the previous evening shift, she would post the following upcoming day Nurse Staff Posting Form 'behind' the current days Nurse Staff Posting Form. Staff A explained that the night nurse, who works the 11 PM to 7:30 AM shift, is the person responsible for changing out and removing the old Nurse Staff Posting, to expose the new Nurse Staff Posting, at midnight. Staff A acknowledged that the previous days Nurse Staff Posting Form was still posted, as of today, in both of the following areas: at the front desk receptionist area and in the main hallway bulletin board. On 05/14/25 at 4:40 PM, the Administrator and the DON both acknowledged the Nurse Staffing Information Form must be posted daily with the current date.

Based on observation and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 3 wings in the facility, [NAME] wing. The findings included: On 05/28/24 at 9:53 AM, an observation was made in Resident #67's room of an offensive urine-like odor noted in the resident's room. On 05/28/24, a side-by-side observation of Resident #67's room bathroom was conducted with the Housekeeping Manager and District Housekeeping Manager. They both acknowledged the offensive odor. The Housekeeping Manager stated that the Certified Nursing Assistants (CNAs) inform them when the room has odors, they do use deodorizers, and clean the room as necessary. The District Housekeeping Manager stated they were aware of other rooms which are in their focus cleaning list and will add Resident #67's room to the list. On 05/30/24 at 1:00 PM, an observation was made of an overwhelming smell of urine in the hallway between rooms 60 to 62. An interview was on 05/28/24, at 9:55 AM with Staff E, CNA, who stated Resident #67 gets out of bed and walks to the bathroom to urinate and that he also urinates on the floor. Staff E stated that when the resident urinates on the floor, she puts a sheet over because his roommate goes to the bathroom also, and she then calls housekeeping to clean the floor. An interview was conducted on 05/30/24 at 1:10 PM with the District Manager of Housekeeping who stated he has worked for the company for [AGE] years. When asked about the strong urine like odor in the hallway between rooms [ROOM NUMBERS], he said the residents in the rooms are incontinent, have behavior issues, and are care planned for their behaviors. He acknowledged there was an odor and housekeeping clean the rooms several times a day with cleaners including enzyme cleaners. An interview was conducted on 05/30/24 at 1:15 PM with the Housekeeping Manager who stated she has worked at the facility for 5 years. When asked about the strong odor in the hallway between rooms [ROOM NUMBERS] she said it is an ongoing issue and they clean those resident rooms at least 3 times a day every day.

Based on observations, interviews, and record review, the facility failed to properly document and thoroughly investigate an injury of unknown origin for 1 of 1 sampled resident reviewed for skin discoloration, Resident #120. The findings included: Review of the facility's policy, titled, Abuse Prevention Program, dated August 2022, included, in part, the following: These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. Injury of Unknown source: An injury should be classified as an injury of unknown source when all of the following criteria are met: No person observed the source of the injury. The resident could not explain the source of the injury. The injury is suspicious because of its extent or location. Procedure: The facility has implemented the following processes: The Administrator is responsible for designating an Abuse Coordinator. The designed shift supervisor is identified as responsible for immediate initiation of the reporting process. The Administrator, DON and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. Identification: Events of inquiries of unknown origin/source, such as suspicious bruising occurrences, patterns, and trends or other resident injury that may constitute abuse, neglect, or mistreatment are identified and thoroughly investigated, with appropriate reporting as indicated. Investigation: Investigation may include but may not limited to: Resident statements/interviews; Employee statements/interviews; Visitor statements/interviews; Observation of resident(s), staff, environment; Document review i.e. chart reviews, policy review, education programs, appropriate resource review. Record review for Resident #120 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cerebral Atherosclerosis, Alzheimer's Disease, Generalized Anxiety Disorder, History of Falling, and Chronic Kidney Disease. Review of Section C of the Minimum Data Set (MDS) dated [DATE], revealed Resident #120 had a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Review of the Physician's Orders showed Resident #120 had an order dated 04/19/24 for admission to Vitas Hospice Healthcare on 03/23/24, with diagnosis of Cerebral Atherosclerosis; Seroquel Oral Tablet 50 mg (Quetiapine Fumarate), give 1 tablet by mouth at bedtime for Psychosis; Tylenol Oral Tablet 325 mg (Acetaminophen), give 2 tablet by mouth every 4 hours as needed for Pain; and Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, give 5 mg by mouth every 4 hours as needed for Pain. Review of the Care Plan dated 05/07/24 documented Resident #120 had Risk for falls or fall-related injury because of Gait/balance problems and a history of falls. The goals were to minimize the risk of falls and have no untreated fall-related injury. Interventions included: Encourage to wear Non-Skid socks / shoes when out of bed; Encourage resident when rising from a lying position, sit on side of bed for a few minutes before transferring / standing; Observe for side effects of drugs including but not limited to gait disturbance, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness and change of mental status; and Report to physician any side effects associated with the residents medication. During an initial tour of the facility conducted on 05/28/24 at 9:23 AM, the surveyor observed Resident #120 in her room in bed. She was awake and alert. Upon further inspection of the resident's face, a blue, purplish-like bruise was noted around her right eye to go to her right forehead and right temple. When this surveyor inquired about the bruise around the eye, Resident #120 appeared confused and stated that she could not recall why she had a bruise. Review of the Nurses Progress Notes dated 04/18/24 to 05/28/24 revealed no documentation of a fall event or report of a bruise for Resident #120. Review of Weekly Skin Assessments dated 04/21/24, 04/28/24, 05/05/24, 05/12/24, 05/19/24, and 05/26/24 documented, No New Areas of Skin Impairment for Resident #120. On 05/30/24 at 2:23 PM, an interview was conducted with Staff N, South Wing Unit Manager and a Registered Nurse (RN), who stated Resident #120 had a fall, but she was not working when the fall happened about a week ago. She acknowledged receiving report from the Vitas Hospice nurse that Resident #120 was doing okay and that the resident reported no pain. She also stated that she had yet to review the report or documentation of the fall event, but this information can be found in the electronic chart. After searching for the event report, Staff N acknowledged that no fall event had been reported and that there were no nurse progress notes for the incident. On 05/30/24 at 3:35 PM, an interview was conducted with the facility's Director of Nursing (DON). She stated that she contacted Vitas Hospice, and Resident #120 had an incident on 05/17/24. The DON stated that she spoke with the floor nurse on duty that night. The floor nurse stated that she heard a noise coming from Resident #120's room. She went to check on the resident and found her sitting on her bed, and appeared to have bumped her head on the nightstand. She called Vitas Hospice and reported the incident to the Hospice team. The DON stated the floor nurse took Resident #120's vital signs, applied ice to the injury, and assessed the resident. She stated she did not document the incident nor file an incident report. The DON also stated that the Vitas Hospice nurse came in on 05/18/24 to assess Resident #120. An interview was conducted on 05/30/24 at 3:46 PM with Staff J, Licensed Practical Nurse (LPN). Staff J stated that on 05/17/24, she was working the 3-11PM shift, and around 10:00 PM, she was at the nurses' station when she heard a noise coming from Resident #120's room. She entered the room and found the resident sitting in bed, leaning to the right. She noticed the resident had a red spot above her right eye and assumed Resident #120 might have hit her head against the nightstand. She assessed the resident, who appeared okay. She stated that Resident #120 has always been confused but was alert and able to respond to her questions. Staff J stated that at 10:15 PM, she called her supervisor and directed Staff J to contact Vitas Hospice. The supervisor did not inquire about the incident report. Staff J acknowledged not documenting the incident in the nurse progress notes 05/17/24. On 05/30/24 at 4:21 PM, the facility's Assistant Director of Nursing (ADON) was interviewed. She stated that on 05/17/24, she worked the 7-3 PM shift. The ADON stated she was aware Staff J had mentioned that she called her, but she did not recall receiving a phone call. In addition, she stated that she went on vacation after her shift on 05/17/24 and returned to the facility on [DATE]. On 05/30/24 at 5:24 PM, an interview was conducted with Staff P, LPN. He stated that on 05/17/24, he was working the 11 PM-7 AM shift. During rounds, he noticed the bump on Resident #120's head and asked Staff J if she had reported it and if an incident report was filed because he would have to follow up. Staff J stated that she reported it to the supervisor, and Staff P was not concerned. There were no nurse progress notes documented from 05/17/24 to 05/18/24.