Every finding on record at Port St Lucie Rehabilitation and Healthcare

Based on observations and interviews, the facility failed to provide proper sanitation of dishes and sanitizing towels, maintain access to hot water in the kitchen sinks, maintain sanitary conditions of the ice machine in the kitchen, and maintain sanitary conditions of 1 cooler in a unit pantry. This has the potential to affect 146 of 151 residents who consume food, according to the facility's census. The findings included:During a tour of the main kitchen on 03/02/26 at 8:55AM with the Certified Dietary Manager (CDM) who has worked at the facility for one month, the following issues were noted:1) The Chemical Sanitizing (Low Temp) dish washing machine water temperature was 70 degrees and did not reach the 120 degrees necessary for sanitizing as per manufacturers recommendations, and the staff continued to wash dishes using the dish washing machine. At the time of the observation, the CDM acknowledged the concerns and stated that the facility had ordered new hot water heaters for the kitchen but that they were not delivered yet and they have continued to wash dishes in the machine. During further interview, the CDM stated that the water temperature for the dishwasher has been below the recommended level of 120 degrees since she started this job on 02/04/26 and that they should have been using disposable paper goods/single use items instead of dishes.A review of the Dish Machine Log for February and March 2026 revealed that the daily temperatures were all below the manufacturers recommended level of 120-140 degrees Fahrenheit for both wash and rinse cycles. The CDM acknowledged that the sentence on the bottom of the dish wash log states that if the temperature or chemical concentration does not meet parameters, stop washing and alert a manager.2) A stationary sanitizing bucket used for wiping towels was tested and the CDM stated the concentration level should be 200 parts per million (ppm) and should be a light green, but the level came up as 100ppm and was yellow on the testing strip. The CDM acknowledged the low level of sanitizer and stated that there were too many towels in the bucket and that can lower the concentration level. The CDM was asked how many towels there should be in the bucket, and she stated just one towel per bucket. The bucket contained more than one towel.3) The Ice machine had black buildup in the inside door closing mechanism and on the white shield. The CDM was asked if there is a cleaning schedule or cleaning log for the ice machine and she responded, No. 4) During a third tour of the main kitchen on 03/04/26 at 11:20 AM, the hand-washing sink did not have any hot water and the CDM stated that the entire kitchen does not have hot water due to the issue with the hot water heaters. The CDM was asked how they had been cleaning pots and pans without hot water, and she stated that they use boiling water from the stove to fill the three-part sink.5) During a tour of Unit C's pantry on 03/05/26 at 9:55 AM, the ice cooler had pink residue around the interior aspect of the cooler.Photographic Evidence Obtained.

Based on policy review, record review, and interview, the facility failed to ensure complete and accurate medical records for 3 of 32 sampled residents, as evidenced by the failure to ensure there was a signed consent for psychotropic medications for Resident #2 was in the record; failure to discontinue physician orders for side rails and seizure precautions for Resident #109 when no longer needed; and failure to discontinue duplicate PRN (as needed) medication orders for Resident #111.The findings included:Review of the policy, titled, Medical Record Content, effective 01/20/21, documented in part, that the facility shall maintain medical records on each resident that are complete and accurately documented. 1. Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 5, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This same MDS documented the resident was receiving an antipsychotic medication. Review of the current physician orders documented the use of Seroquel, an antipsychotic medication, since admission. Review of the medical record lacked any consent for the use of the Seroquel. During an interview on 03/05/26 at 1:58 PM, Staff F, Registered Nurse (RN)/Unit Manager, confirmed the Seroquel for Resident #2 was initiated on 11/26/25 with 25 mg (milligram) dose at bedtime and was increased to 50 mg on 12/02/25. When asked to locate and provide the written consent for Seroquel use for Resident #2, the Unit Manager was unable to do so. On 03/05/26 at 3:02 PM, the Director of Nursing (DON) provided an email from the son who stated he was aware of and agreed to the Seroquel use. The DON agreed that the record lacked the signed consent. 2. Review of the record for Resident #109 revealed the resident was admitted to the facility on [DATE]. The medical diagnoses included: Encephalitis (inflammation and swelling of the brain), Diabetes, Cerebral Atherosclerosis (hardening of the arteries to the brain), Cerebral Vascular Accident (stroke) and Hemiplegia (severe weakness or total paralysis of one side of the body). Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00, on a 0-15 scale, indicating the resident had severe cognitive impairment. Review of the physician's orders documented Resident #109 had an order dated 02/25/26 for seizure precautions which instructed the staff to observe, document and keep the resident safe for seizure activity. There was another order dated 02/26/26 for both side rails to be padded while the resident was in bed. Review of the current care plan dated 02/26/26 documented Resident #109 was at risk for seizure related injuries with a goal to minimize the risk of injuries. During an observation on 03/02/26 at 3:12 PM, Resident #109 was observed in bed with Glucerna tube feeding running at 65ml/hr (milliliters per hour). The head of the bed was elevated with both upper bedside rails in place. No side rail pads were observed. During an observation on 03/03/26 at 11:18 AM, the resident was again observed in bed with no side rail padding in place. During a side-by-side record review and interview on 03/04/26 at 2:23 PM Staff B, Licensed Practical Nurse (LPN), confirmed the resident was on seizure precautions. When asked about the specific precautions taken, she mentioned that the resident's bed should be maintained in a low position with side rails. The LPN was asked if there were orders for padded side rails. She reviewed the order and confirmed there was an order, but the resident did not have side rail pads. During an interview on 03/04/26 at 9:34 AM, the Director of Nursing (DON) stated in the presence of Staff F, Registered Nurse /Unit Manager (RN/UM), that Resident #109 had an electroencephalogram (a test that records the brain's electrical activity) done in the hospital which showed no seizure activity. The doctors decided to discontinue seizure precautions when the resident returned to the facility on [DATE]. When asked about the order for padded side rails, the DON stated that the order was to be discontinued as well. They proceeded to discontinue both orders at the end of the interview. During an interview on 03/04/26 at 1:45 PM, Staff C, the MDS Coordinator, was asked to explain the care plan process. She indicated that a care plan was done based on the MDS, which looks at the resident's assessment, orders and medications. Staff C further explained that Resident #109 was diagnosed with Cerebral Atherosclerosis and prescribed an anticonvulsant. Therefore, seizure precautions were documented as a part of the resident's care plan on 02/26/26. Staff C confirmed that the order was discontinued on 03/04/26. During a follow-up interview on 03/04/26 at 1:55 PM, the DON was informed of the conversation with the MDS Coordinator that the resident's care plan continued to reflect seizure precautions because of the resident's diagnosis and orders. The DON acknowledged that the care plan and orders for Resident #109 should have been updated to reflect the doctor's decision to discontinue seizure precautions and padded side rails. 3. Record review for Resident # 111 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Anemia, blood condition characterized by low levels of red blood cells and shortness of breath. Review of Section C of the MDS dated [DATE] revealed Resident #111 had a Brief Interview for Mental Status of 12, that indicated she was moderately cognitively impaired. Review of the Physician's Orders showed Resident #111 had two active orders for Albuterol Sulfate HFA (hydrofluoroalkane inhaler) aerosol inhaler, 1 inhalation every 4 hours as needed for shortness of breath dated 07/14/25 and 02/25/26. Review of the care plan dated 02/09/26 documented Resident # 111 is at risk for respiratory distress related to periods of Cough and Shortness of Breath (SOB). Goals were to have no more than minimal shortness of breath while resting. Interventions were to administer medications as ordered and provide nebulizer treatments. During an interview conducted on 03/05/26 at 12:32PM, Licensed Practical Nurse, Staff Nurse H, was asked about administration and documentation for as needed medications. During a side-by-side review of the electronic medical record (EMR) for Resident #111 two orders for albuterol were noted under the as needed section. When asked if there is more than one order for the same medication how do you know which medication to administer and to reassess, she stated that the task will re-direct the response back to the medication that was administered. During an interview conducted on 03/05/26 at 3:48PM with Staff I, Unit Manager (UM), the surveyor asked to review the EMR and agreed that there was a duplicate order for albuterol for Resident #111. When asked what the process is when there is a duplicate medication order, she stated that the provider will discontinue the first order. Review of the Physician's Orders showed that Resident #111 order for albuterol sulfate HFA (hydrofluoroalkane inhaler) aerosol inhaler, 1 inhalation every 4 hours as needed for shortness of breath dated 07/14/25 was discontinued on 03/05/26.

Based on interviews and record review, the facility failed to maintain residents' dignity by arguing loudly about staff assignments in areas where residents could hear. The facility also failed to treat residents with respect by speaking in a language the residents could not understand and raising their voice at a resident when the call light was used to request care, for 2 of 32 sampled residents reviewed, Resident #32 and Resident #94. The findings included:1. Clinical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including fracture and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] recorded Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS recorded no mood or behavioral concerns. The assessment indicated the resident required partial to moderate assistance with toileting hygiene and substantial to maximal assistance with showering/bathing, dressing, footwear, and personal hygiene.Review of the care plan dated 02/12/26 indicated the resident had a self-care deficit and required assistance with activities of daily living due to a decline in function related to hospitalization. Interventions included assisting the resident with hygiene and grooming, setting up oral hygiene equipment, assisting with toileting and bathing as needed, and setting out clothes and assisting with dressing as needed.Review of the grievance log dated 01/30/26 documented Resident #32's grievance that call light response time during the day shift was too long.On 03/04/26 at 9:28 AM, during an interview, Resident #32 stated that over the weekend staff were arguing loudly among themselves about resident assignments. The resident stated staff could be heard saying things such as I don't want this resident and I don't want that resident. The resident stated the arguing could be heard from her room, which is located near the nursing station. The resident stated it sounded like the staff had too many residents. She stated she's not a very demanding person, and hardly uses the call light for anybody to do anything for her which makes her feel awful. She further stated, that's a bad attitude to take from the staff. You have people like me who hardly put the light on and to come in with that attitude is hurtful. The resident also stated that a few days earlier she had to wait approximately 3-4 hours for care.On 03/05/26 at 12:13 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of Resident #32's concerns. 2. Clinical record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and depression. The quarterly MDS assessment with a reference date of 02/02/26 recorded a BIMS score of 15, indicating the resident was cognitively intact. The assessment documented mood symptoms including little interest or pleasure in doing things, feeling down or depressed, trouble sleeping, and feeling tired or having little energy. No behavioral symptoms were recorded. The assessment indicated the resident required assistance with several activities of daily living including oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene.Review of the care plan dated 02/03/26 indicated the resident had a self-care deficit and required assistance with activities of daily living due to a decline in function related to Parkinson's disease.Review of the grievance log dated 02/09/26 documented Resident #94's grievance regarding long call light response times during the day shift.On 03/02/26 at 11:08 AM, during an interview, Resident #94 stated that when she used the call light to request assistance to be changed, staff sometimes entered the room and yelled at her, asking why she had put on the call light. The resident stated staff would tell her she needed to wait because they were taking care of someone else. The resident also reported that staff frequently speak in another language in her room or while on the phone, they don't pay attention to her. The resident stated she had previously reported these concerns to the head nurse.On 03/04/26 at 12:25 PM, during a follow-up interview, Resident #94 stated staff continued speaking in another language in her room. When asked when this last occurred, the resident stated it had happened that morning.On 03/04/26 at 1:06 PM, while the surveyor was in the 500 unit resident television room, staff were observed speaking loudly to each other in another language in the hallway.On 03/05/26 at 11:18 AM, an interview was conducted with the 500 Unit Manager (UM). The UM stated residents' grievances are documented and forwarded to the social worker for follow-up. When asked if Resident #94 had voiced concerns, the UM stated the resident had complained about call light response times. The UM voiced the expectation was call lights should be answered within 10 minutes. The UM stated she had heard concerns regarding call light response time and staff using cell phones in hallways but had not been made aware of concerns about staff yelling at residents. The UM stated staff had received in-services regarding speaking another language around residents before.On 03/05/26 at 11:56 AM, the DON and ADON were informed of the concerns regarding staff speaking another language around residents.

Based on observation and interview, the facility failed to ensure a clean and sanitary environment on 4 of 6 units (100, 300, 400, and 600) affecting 8 of 32 sampled residents (Residents #46, #22, #104, #50, #73, #2, #159 and #1).The findings included:During the initial pool process on 03/02/26 and 03/03/26, the survey team identified the following concerns, with Photographic Evidence Obtained:a) On 03/02/26 at 10:19 AM, the wall in the bathroom for Resident #46 was bubbled and there was a gap varying from 1/4 inch to one inch between the wall and the base board. The toilet had green corrosive type residue over most of the metal piping. The inside of the brown bathroom door had about a foot of white residue.b) On 03/02/26 at 10:32 AM, the metal base of the bed for Resident #22 was corroded with a rust-like surface. The floor below the base of the bed was scarred with the rust-like substance.c) On 03/02/26 at 10:38 AM, the two floor fall mats for Resident #104 were dirty as evidenced by the black mats covered in white spots and gray stains and smudge marks. A brown coffee-like stain was noted on the top of the resident's dresser.d) On 03/02/26 at 10:42 AM, Resident #50's bathroom wall was covered with a thin paper-like material from about 3 feet above the floor down to the floor. This material was sparsely screwed into the wall with gaps noted. The base board was missing along the wall next to the toilet, behind the toilet, and under the sink. The toilet anchors were covered in a rust-like substance. The toilet had green corrosive type residue over most of the metal piping.e) On 03/02/26 at 10:45 AM, the toilet paper holder for Resident #73 was covered in a corroded rust-like substance.f) On 03/02/26 at 11:01 AM, about 2 to 3 feet of the rubber edging for the over-the-bed table for Resident #2 was peeled off the table and hanging down to the floor. The vinyl-like covering on the right arm rest of the resident's wheelchair was peeled off in spots from about the middle to front of the arm rest.g) On 03/02/16 at 11:22 AM, the grates on the window air conditioning unit for Resident #159 had visible dust. The dark brown wall behind the resident's bed had a spackled area approximately 8 to 12 inches wide and 4 to 5 feet high and needed paint.h) During the survey process on 03/05/26 at 8:17 AM, a ceiling tile was noted to be missing the corner in the room of Resident #1.During an observation tour on 03/05/26 at 12:00 PM, the Plant Operations Director agreed with the above findings. The Plant Operations Director volunteered she had asked her maintenance man to replace the ceiling tile for Resident #1 on Monday 03/02/26.

Based on policy review, observation, interview, and record review, the facility staff failed to ensure access to and the provision of fluids for 2 of 2 sampled residents who showed signs of or complained of thirst. Staff did not maintain fluids within reach of Resident #2, failed to open the resident's milk container to allow her to drink, and failed to ensure fluids were within reach for Resident #104.The findings included:Review of the policy, titled, Resident Hydration and Prevention of Dehydration, revised October 2015, documented in part, Policy . 7. Nurses' Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care.1. Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 5, on a 0 to 15 scale, indicating severe cognitive impairment. This MDS also indicated that the resident needed supervision for eating.A current care plan initiated on 11/27/25 documented the resident was at risk for constipation with an intervention for staff to encourage hydration.An observation on 03/02/26 at 11:01 AM revealed Resident #2 in bed. Upon entering the room and greeting the resident, she first began speaking in English and then changed to Spanish. While speaking, the resident's mouth was noted to be quite dry with her lips sticking together when talking. In Spanish, Resident #2 stated she needed water. There was no water within her reach.On 03/04/26 at 12:00 PM, Resident #2 was observed in the Day Room, independently drinking a Mighty Shake, a nutritional supplement.During an observation and interview on 03/05/26 at 8:13 AM, Resident #2 was sitting up in her bed and had eaten about 50 to 75% of her breakfast. Resident #2 stated in Spanish that she was done eating, but that she could not open her milk. The resident was holding a container of milk with a closed screw top lid. When told in Spanish that she needed to ask one of the staff to help her, the resident did not seem to understand. Resident #2 again stated in Spanish her milk was not opened. The Medical Records staff person, who was also a Certified Nursing Assistant (CNA), was in the room feeding the roommate, but did not understand what the resident was saying in Spanish. Continued observation outside of the room revealed the resident playing with her food tray and trying to open the milk. At 8:35 AM a student CNA entered the room to remove the breakfast tray. Resident #2, speaking in Spanish, asked the student CNA to open her milk, but the student did not understand. Resident #2 then stated in English open this which the student did. When asked if she would prefer to drink her milk with her meal, Resident #2 stated, claro which translated is of course.On 03/05/26 at 8:43 AM, Staff F, Registered Nurse (RN)/Unit Manager and the Director of Nursing (DON) were made aware of the observations and agreed with the findings. 2. Review of the record revealed Resident #104 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented the resident had a BIMS of 5, on a 0 to 15 scale, indicating severe cognitive impairment. This MDS also documented the resident needed supervision with eating.A current care plan initiated on 03/15/22 and revised 03/03/26 documented Resident #104 had a self-care deficit, needed assistance with activities of daily living, and staff were to encourage the resident to promote independence. A second care plan initiated on 03/07/22 and revised on 03/03/26, documented the resident was at risk for malnutrition and staff were to provide fluids of choice within her diet order.An observation on 03/02/26 at 10:48 AM revealed Resident #104 sitting up in bed. A full cool Styrofoam cup of water was out of reach, as it was on the over-the-bed table located at the foot of the bed. The resident was not able to answer if she was thirsty or not at that time.On 03/04/26 at 8:42 AM, the relative of Resident #104 was in the resident's room and stated, Here [name], here is your milk to drink that they did not give you. As per the relative, she found the milk on the dresser, still cool to touch, at the end of the bed, out of reach and unopened. When asked if staff are providing fluids for the resident, the relative said sometimes, but volunteered, I've also found milk from the previous day in her room. Milk that was warm and unopened.During an interview on 03/04/26 at 12:35 PM, when asked if Resident #140 needed assistance eating or drinking, Staff D, Certified Nursing Assistant (CNA), stated staff just needed to set the food or fluids in front of the resident and she will eat and drink what she wants. The CNA confirmed the resident could not get out of bed by herself and stated she was unaware the milk had been out of her reach that morning.On 03/05/26 at 8:43 AM, Staff F, Registered Nurse (RN)/Unit Manager, and the Director of Nursing (DON) were made aware of the observations and agreed with the findings.

Based on observation and interview, the facility failed to maintain sanitary conditions of the garbage area. This has the potential to affect 151 residents, according to the facilities census.The findings included: A tour of the outside garbage area was conducted on 03/02/26 at 8:55 AM. It was observed that the side of the garbage compactor machine was filled with random items (a plastic bin filled with yellow liquid in the bottom, a red bucket, a broom, an orange towel, a Brillo pad, and other small items). The Certified Dietary Manager (CDM) stated these items should not be there.Photographic Evidence Obtained.

Based on observation, interview and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) as ordered for 2 of 7 sampled residents as evidenced by the failure to ensure an accurate order for EBP for Resident #7, failure to use EBP during care for Resident #7; failure to ensure posting of an EBP sign for Resident #95; and failure to maintain the laundry equipment and ceiling vents in a clean and sanitary condition.The findings included:Review of the policy, titled, MDROs and Enhanced Barrier Precautions, dated 2024, documented in part, With Enhanced Barrier Precautions (EBP), the use of personal protective equipment (PPE) is expanded for everyone's protection. Staff are required to use gown and gloves during high contact care that might result in the transfer of multi-drug-resistant organisms (MDROs) to staff hands and clothing. MDROs then may be indirectly transferred from resident to resident during these high contact activities, such as.Device care or use: Central line, Indwelling Urinary Catheter, Feeding tube, Tracheostomy/Ventilator. The facility will communicate to staff which residents will require the use of EBP through subtle signages that will be placed near the headboard. The health care team will also see which resident is under EBP through the Matrix Care System. 1. Review of the record revealed Resident #7 was admitted to the facility on [DATE] with medical diagnoses which included, Neurogenic Bladder (loss of bladder control caused by nerve damage), Urinary Tract Infection (UTI), Right Hip Fracture and Non-Alzheimer's Dementia( brain disease causing memory, thinking and behavior decline that is not caused by Alzheimer's). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) score of 7, on a scale of 0 to 15, indicating the resident had severe cognitive impairment. The MDS also documented Resident #7 was dependent on staff for toileting, dressing and hygiene. Review of the physician's orders documented as of 01/28/26 that Resident #7 was on EBP precautions for the presence of a Foley catheter and a wound. An order updated as of 02/07/26 documented a Foley catheter due to a neurogenic bladder and instructed for catheter care each shift. Review of the current care plan dated 12/22/25 documented Resident #7 had a Foley catheter and will remain free from catheter related trauma. On12/25/25, Resident #7 was placed on Enhanced Barrier Precautions with a goal to minimize the risk of MDRO infections. Also, documented as of 02/09/26 was that the resident had a history of Urinary Tract Infections with a goal to minimize the risk of infection. Review of the lab results on 03/05/26 documented the urine analysis resulted in yeast and bacteria. During an observation on 03/04/26 at 8:43 AM, Staff A, Certified Nursing Assistant (CNA), performed the resident's hygiene and Foley catheter care, without using a gown. During an interview on 03/04/26 at 9:00 AM, Staff A was asked to explain EBP. Staff A read the EBP sign at the door, then stated that she forgot to put on a gown. During a side-by-side record review and interview on 03/05/26 at 2:24 PM, the Director of Nursing (DON) with the Infection Preventionist (IP) were asked about EBP for Resident #7. The IP confirmed that Resident #7 was placed on EBP on 01/28/26 for a Foley catheter and a wound. When asked where the resident's wound was, the IP replied that Resident #7 had surgical wounds and a wound to the buttock. They reviewed the record then confirmed that the resident's wound had been healed since 01/30/26. The order was still in place for EBP related to the wound. 2. On 03/05/26 at 12:30 PM, an observation tour of the facility's laundry area was conducted with the Housekeeping Lead and the Plant Operations Director, identifying the following concerns, with Photographic Evidence Obtained: There were 4 commercial dryers and 3 commercial washing machines. The Housekeeping Lead stated that 3 of the 4 dryers were functional. Two of four dryer tumblers were observed with dark brown, rust-like stains: green and yellow paste-like substances coating the bases. Three of three washing machines were not in a sanitary condition, as evidenced by: a. Dried brown and opaque liquid stains were observed on the front and sides of the machines. b. The front and side panels of the washing machines were separating from the frames with rust like markings. c. The crevices were filled with gray and white residue. d. There were two laundry bins in the area with rust like stains on the metal spring straps; these stains were also on the cloths attached. The two ceiling vents were covered with dust. The Housekeeping Lead and Plant Operations Director agreed with the findings. 3. Clinical record review revealed Resident #95 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) with a reference date of 02/02/26 recorded a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Review of physician orders dated 02/25/26 indicated Enhanced Barrier Precautions (EBP) related to a history of Extended-Spectrum Beta-Lactamase (ESBL) producing organisms in the urine, Methicillin-Resistant Staphylococcus Aureus (MRSA), and Vancomycin-Resistant Enterococcus (VRE), and the presence of a Foley catheter, to be followed every shift (day, evening, and night). Review of an additional physician order dated 02/26/26 indicated Resident #95 had a left heel wound. Treatment orders included cleansing with normal saline, pat dry gently, and applying a foam dressing once daily on Monday, Wednesday, and Friday during the day shift. Review of the care plan dated 02/03/26 documented Resident #95 had vascular wounds to the right lateral shin and left heel (arterial). The care plan also indicated the resident was on Enhanced Barrier Precautions related to a history of ESBL in urine, MRSA, and VRE. Review of a progress note dated 02/05/26 at 1:29 PM revealed Resident #95 was seen by the wound physician on 02/04/26 related to an arterial wound of the right lateral shin with light serosanguinous drainage and approximately 30% granulation tissue in the wound bed, and an arterial wound of the left heel with hyper-granulation tissue within the wound margins. On 03/02/26 at 11:40 AM, as the surveyor attempted to enter the resident's room. A personal protective equipment (PPE) kit was observed attached to the door; however, no signage was posted to indicate the type of precautions required prior to entering the room. The attending nurse was observed exiting the room. When asked what type of precaution was required to enter the room, the nurse stated the resident in bed B had a catheter. The surveyor informed the nurse there was no sign posted to indicate the type of precaution required and it was unclear whether a gown and gloves were needed before entering the room. The nurse stated she was unsure and proceeded to review the resident's electronic record. After reviewing the record, the nurse confirmed there was an order for wound care and Enhanced Barrier Precautions. On 03/02/26 at 1:36 PM, during an interview, Resident #95 stated she had two wounds on her feet. On 03/05/26 at 11:34 AM, during an interview, the 500 Unit Manager was informed that the resident with wounds and Enhanced Barrier Precautions did not have precaution signage posted outside the room. The Unit Manager acknowledged the concern. On 03/05/26 at 12:06 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the concern regarding the lack of precaution signage for Enhanced Barrier Precautions.

Based on record review and interview, the facility failed to ensure physician orders were followed for 1 of 32 sampled residents, Resident #156, as evidenced by lack of evidence that 'as needed' antihypertensive medication was administered to the resident for medication with blood pressure parameters. The findings included:Review of the record revealed Resident #156 was admitted to the facility on [DATE] and passed away at the facility on 12/22/25. The resident had diagnoses to include Hypertension (high blood pressure), A-Fib (atrial fibrillation which is a fast heart rate), and Heart Disease. A care plan initiated on 10/06/25 documented the resident had the potential for altered cardiac output related to hypertension, high lipid (fat) levels, heart disease, a-fib, and the presence of a pacemaker.Review of the physician orders indicated Resident #156 was to receive as of 10/03/25, Clonidine 0.2 mg (milligrams) twice daily, as needed, for a systolic (top number of the blood pressure reading) blood pressure greater than 160 or a diastolic (lower number) blood pressure greater than 100.Review of the resident's blood pressure reading compared to the Medication Administration Records for October, November, and December of 2025, revealed the following elevated blood pressure readings without the administration of the ordered clonidine:a) On 10/15/25 at 8:34 AM, the resident's blood pressure was 161/99.b) On 10/18/25 at 9:58 AM, the resident's blood pressure was 164/90.c) On 10/23/25 at 7:45 PM, the resident's blood pressure was 164/95.d) On 10/26/25 at 11:20 AM, the resident's blood pressure was 162/90.e) On 10/30/25 at 8:26 PM, the resident's blood pressure was 163/100.f) On 11/05/25 at 2:58 PM, the resident's blood pressure was 164/101.g) On 11/06/25 at 9:08 AM, the residents' blood pressure was 161/97.h) On 12/11/25 at 8:00 PM, the resident's blood pressure was 161/106.i) On 12/12/25 at 11:33 AM, the resident's blood pressure was 158/102.j) On 12/13/25 at 10:07 AM, the resident's blood pressure was 155/102.k) On 12/17/25 at 9:08 AM, the resident's blood pressure was 155/102.l) On 12/18/25 at 11:26 AM, the resident's blood pressure was 161/99.m) On 12/21/25 at 10:55 AM, the resident's blood pressure was 168/63.During a side-by-side review of the record and interview on 03/04/26 at 4:29 PM, Staff G, Registered Nurse (RN)/Unit Manager stated she recalled Resident #156 and that he was on an 'as needed' medication for high blood pressure along with a routine blood pressure medication. When asked specifically about the two medications, the Unit Manager reviewed the orders and stated the routine medication was to be given and if the resident's blood pressure was over the physicians ordered parameters, the 'as needed' Clonidine should have been administered. The RN reviewed the blood pressure readings and agreed with the findings.

Based on record review and interview, the facility failed to ensure resident rights for 3 of 55 sampled residents as evidenced by the failure to clearly communicate the residents right to change their mind at any time within thirty business days about entering into an Arbitration Agreement with the facility for Resident #'s 5, 8 and 71 who all signed the Arbitration Agreement.The findings included:Review of the facilities Voluntary Arbitration Agreement form revealed that there was inconsistent information about the ability to grant the resident or his or her representative the right to rescind the Arbitration agreement within 30 days. The facilities Arbitration Agreement had a sentence written just above the signature section that was in bold lettering and underlined and stated, The Resident is aware that he/she may rescind this Agreement at any time within 10 business days of the date of its execution.Review of the records for Resident #'s 5, 8, and 71 revealed that they or their representative had all signed the Voluntary Arbitration Agreement with the incorrect statement, The Resident is aware that he/she may rescind this Agreement at any time within 10 business days of the date of its execution which may have affected the residents right to change their mind about signing the Arbitration Agreement if they had wanted to rescind between the 10th day and the 30th day.An interview was conducted on 03/05/26 at 10:41 AM with the admission Coordinator who has worked at the facility for 6 months. The admission Coordinator was asked about the process for allowing a resident to change their mind about signing the Arbitration Agreement and she stated that residents or their representatives have 48 hours after signing to change their mind and then the Admissions Coordinator stated that she was wrong, that it is 10 business days and showed the surveyor the sentence on the Arbitration Agreement that was in bold lettering and underlined above the signature area on the facilities form that had 10 days written.During further discussion, the admission Coordinator stated that there is another sentence within the body of the agreement that does state the correct requirement of 30 days and stated that the information on their form is conflicting and confirmed that the forms should be corrected to reflect 30 days and not 10 business days.

Based on observations, interviews and record reviews, the facility failed to provide foods prepared, served, and stored under sanitary conditions and in accordance with professional standards for food safety. The findings included: 1. During the initial kitchen tour, on 09/16/24 at 9:08 AM, accompanied by the Registered Dietitian (RD) and the Certified Dietary Manager (CDM), the following was noted: a. The concentration of chlorine used for sanitizing wares in the mechanical ware washing machine was less than 50 parts per million. b. The temperature of the wash, rinse and sanitizing cycles did not reach 120 degrees Fahrenheit (F). c. There was an accumulation of mold in the basin of the ice machine. d. The wall behind the coffee stations was damage. e. There was an accumulation of residue on the knobs of the range and convection oven handles. f. There was a red bucket of sanitizer kept on a shelf directly over the oven and the flat top range. g. Foam containers that were stored in the tray assembly and the hot holding areas were not stored inverted to prevent dust and debris from falling in them. h. Small bowls were stored on a cart uncovered. i. There was an accumulation of ice on the curtains inside of the entrance to the walk-in freezer. j. The exterior wall of the walk-in cooler and freezer was dirty and had some spots of rust. k. The floor tiles that formed the baseboard along the wall of the walk-in cooler and freezer were not secured to the wall. l. Aluminum foil was used to line the shelving of a food preparation table in a processing area outside of the walk-in cooler. At the conclusion of the initial kitchen tour, the RD and the CDM acknowledged understanding of the findings. 2) During a follow up visit to the kitchen, on 09/18/24 at 7:02 AM, accompanied by the CDM, Staff A, Dietary Aide, was observed portioning salads to be used for the lunch meal. It was noted that the Dietary Aide was removing lettuce from a bag with his bare hands. The Dietary Aide was instructed by the CDM to perform hand hygiene and don clean single use gloves. 3. During the follow up kitchen tour, on 09/18/24 at 11:11 AM, accompanied by the CDM, the following was noted: a. Staff A, Dietary Aide, Staff B, Dietary Aide, and Staff C, Dietary Aide, were observed rolling silverware in paper napkins and preparing to serve the lunch meal without a proper restraint to cover their beards. b. The handle of a wire whisk that was being used was damaged to a point that it was no longer cleanable. c. Staff D, Dietary Aide, was observed entering the kitchen and began handling and rolling silverware with bare hands and fingers in direct contact with the food and lip contact surface of utensils. d. An employee's personal clothing and lunch box were stored on a shelf with single use and disposable wares. At the conclusion of the tour, the CDM acknowledged understanding of the findings.

Based on observation, interview, record and policy review, the facility failed to follow through with request for pain medication for 1 of 3 sampled residents reviewed for pain management, Resident #51. The findings included: Review of the facility's policy, titled, Controlled Drug Management, effective December 2020, documented, in part, Controlled substance drugs may be ordered from the Pharmacy, a script must be sent to the pharmacy. The physician may call in a controlled substance to the pharmacy. After the pharmacy has the script or the order from the physician, they may provide a code to the nurse which will allow him/her to remove the controlled substance from the emergency narcotic kit if the medication is available in the kit. Nurses will enter in the log the number of pills removed and the approval pharmacy code provided. Narcotics will be filled by the pharmacy as soon as all required elements are provided and delivered to the facility on the next scheduled delivery. Record review revealed Resident #51 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included, Chronic Obstructive Pulmonary Disease, unspecified, Chronic pain syndrome, Primary Osteoarthritis, right hand and left hand, and Generalized anxiety disorder. Review of the quarterly Minimum Data Assessment (MDS) assessment, with an assessment reference date of 09/28/24, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of the resident's pain care plan dated 01/31/24 revealed a problem of: Resident reports pain related to overall condition. Has diagnosis (dx) of Chronic pain syndrome. Goal: Resident's comfort will be maximized as evidenced by decreased verbal expressions of pain thru next review date. Approach: Medications as ordered, observe for effectiveness and side effects, Notify Medical Doctor (MD) if interventions are unsuccessful or if current compliant is significant change from resident past experience with pain. An interview was conducted with Resident #51 on 09/18/24 at 10:00 AM. The resident stated she went to the emergency room last evening because she had pain in her neck and the facility had not given her the pain medication that helped in 2 days. She stated she was told it was not available. On 09/18/24 at 10:35 AM, an interview was conducted with Staff E, Licensed Practical Nurse (LPN). She confirmed that the resident did not currently have Norco available. Norco (hydrocodone-acetaminophen 5-325 milligrams (mg) is a pain medication that contains an opioid that is used to manage severe pain when other non-opioid pain medications do not treat pain well enough. Staff E stated Resident #51's primary physician is on vacation and her nurse practitioner could only write a prescription for 7 days which ran out this weekend. Staff E stated the resident went to the hospital last evening due to the pain and the hospital sent the prescription for Norco to the wrong pharmacy so they still do not have the medication. Review of the Nursing note dated 09/15/24 at 7:34 AM revealed, Contacted pharmacy to refill Hydrocodone prescription. Representative states a new prescription is needed. Information passed in shift report. Review of the Nursing note dated 09/16/24 at 8:17 PM revealed, Resident continues to offer complaints of head/neck pain. Review of the Nursing note dated 09/17/24 at 6:38 PM revealed, Resident has been complaining of pain 12/10 pain level throughout the day. Resident has been without medication for 2 days and I was unable to get a new prescription for resident. Resident decided she would like to be sent out due to the pain. Review of the Nursing note dated 09/17/24 at 11:30 PM revealed, Resident returned from (Name provided) Hospital with a prescription for Oxycodone 5 mg by mouth (po) every (Q) 6 hours/as needed (PRN) x 3 days.Resident was given morphine 4mg at the hospital and her pain scale (P/S) was at 3 upon admission. Review of the Nursing note dated 09/18/24 at 11:05 AM revealed, The resident was seen by (pain management) due to chronic pain. The resident was open to meeting with [pain management] for this consultation. The pain management nurse practitioner discontinued the Oxycodone prescription from the hospital and ordered Hydro/APAP (Norco) 5-325 mg Q 8 hr PRN. Review of the emergency room discharge instructions dated 09/17/24 revealed the resident was seen for acute exacerbation of chronic low back pain and acute exacerbation of chronic leg pain. Review of the pain medications on the September 2024 Medication Administration Record (MAR) revealed: Hydrocodone-acetaminophen 5-325 mg 1 tablet every 8 hours PRN for moderate to severe pain. Lidocaine 4% patch topical, apply to left hand once a day for pain. Meloxicam 7.5 mg once a day for pain unspecified. Tramadol 50 mg 1 tablet every 6 hours PRN for chronic pain syndrome . Voltaren Arthritis pain gel twice a day give one gram on left wrist twice a day for acute pain. Ibuprofen 200mg 3 tabs three times a day every 8 hours as needed for pain. Ketorlac 10 mg 1 tablet every 6 hours as needed for pain. Review of the MAR for Resident #51 for 09/12/24 - 09/15/24 revealed she was given the following: On 09/12/24 at 6:27 AM, Norco for a pain level of 6; On 09/12/24 at 2:04 PM, Norco for a pain level of 7; and On 09/12/24 at 8:07 PM, Norco for a pain level of 7. On 09/13/24, she was given Norco as follows: At 9:20 AM for a pain level of 9, At 8:05 PM for a pain level of 5. On 09/14/24, she was given Norco at 1:53 PM for a pain level of 8 and 9:10 PM for a pain level that was not indicated on the MAR. On 09/15/24, she was given Norco at 10:24 AM for a pain level of 8. There was no more Norco left after this dose. On 09/18/24, the surveyor was presented with a signed statement from 09/16/24 from Resident #51 that she was offered Tylenol/Ibuprofen and declined - I wanted hydrocodone. An interview was conducted with the Director of Nursing (DON) on 09/18/24 at 1:07 PM. The pharmacy sent a 72 hour supply of Norco because the prescription did not specify for non acute pain. She used up the 72 hour supply. The last dose was 09/15/24 at 10:24 AM. An interview was conducted with the Consultant Pharmacist on 09/19/24 at 12:15 PM, who stated the facility could not have used Norco from the emergency kit (e-kit) Controlled Narcotic box because they did not have a current prescription. The facility would have had to obtain a new prescription for Norco, then it would be sent to the pharmacy, then the pharmacist would be able to give them a code to open the e-kit. The Norco would have been able to dispense at that time. The nurse was able to dispense Norco on 09/18/24 in the evening from the e-kit and Norco was delivered from the pharmacy in the morning on 09/19/24.

Based on observation, record review, and interview, the facility failed to ensure accuracy of records for 2 of 38 sampled residents, Residents #206 and #65. The findings included: Review of the policy, titled, Charting and Documentation, revised [DATE], documented, in part, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 1. Review of the record revealed Resident #206 was admitted to the facility on [DATE] and expired at the facility on [DATE]. The following inconsistencies or lack of documentation was identified: A progress note dated [DATE] at 7:32 PM and [DATE] at 5:55 AM, documented Resident #206 remained on droplet isolation. The record lacked any documentation of the need for droplet isolation. A progress note dated [DATE] at 5:55 AM, documented the oxygen saturation level for Resident #206 was 90% on room air. The vital sign record documented an oxygen saturation level of 90% on [DATE] at 11:14 PM. An interview was conducted on [DATE] at 5:22 PM, with Staff I, night Licensed Practical Nurse (LPN), who stated he must have either put the head of the bed up and the saturation level went back up on [DATE], or it was a typo. Staff I agreed there were no documented interventions or resolution to that saturation level of [DATE]. A progress note dated [DATE] at 8:07 AM by Staff I, LPN, documented, COVID test negative. Notified daughter. During an interview on [DATE] at 5:22 PM, Staff I, night LPN, stated he did a rapid COVID test, and it was negative, which was confirmed by the ADON (Assistant Director of Nursing). The record lacked any documented COVID test result from Staff I. During a phone interview on [DATE] at 3:27 PM, the daughter of Resident #206 stated she was at the facility on [DATE] and was informed her mother had a temperature of 101 degrees Fahrenheit (F), that staff were unsure of the reason, but were providing Tylenol. Review of the vital sign record documented Resident #206 had a low-grade fever of 99.4 degrees on [DATE] at 12:20 AM, but lacked any documented fever of 101 F. degrees, and lacked any documented order or provision of Tylenol. During a phone interview on [DATE] at 3:27 PM, the daughter of Resident #206 voiced Staff I assured her the ADON would initiate a transfer to the hospital for her mother on the morning of [DATE]. The record lacked this conversation. During an interview on [DATE] at 2:12 PM, Staff G, Certified Nursing Assistant (CNA), stated she recalled Resident #206, and had worked with her a couple of times. The CNA volunteered that on the day the resident passed, she had noted she was sweating and didn't look too good, so she put the air conditioner on and washed her up, and the resident felt better. Staff G stated she told Staff H, LPN, that she was sweaty and wasn't feeling well, because she could not find the ADON. The record lacked any documentation related to the CNA's report of diaphoresis (being sweaty). 2. On [DATE], the COVID-19 negative results completed by Staff I, night LPN, for Resident #206 was requested from the Director of Nursing (DON). On [DATE] at 1:25 PM, the surveyor entered the 'Nursing Administration' offices on the way to the MDS (Minimum Data Set) office. which was located at the back of the Nursing Administration office area. Upon entering the offices, the DON and ADON were standing at the front desk, and the ADON was in the process of signing a COVID-19 test result. On [DATE] at 2:02 PM, the DON provided the COVID-19 negative test result for Resident #206. When asked why this test, dated [DATE], was not signed by Staff I, LPN, who stated and documented in the progress notes that he completed the test, the DON stated, He did the test and it was witnessed by the ADON, but he did not fill out the paper. When asked if they just now filled out and signed the COVID-19 test result, as the surveyor walked into the Nursing Administration area, the DON stated yes, because Staff I had not filled out the paper and the ADON had witnessed the test. Further review of this test result documented it was completed by the ADON and witnessed by the DON. On [DATE] at 2:28 PM, the ADON came to the surveyor and confirmed she did justt fill out the COVID-19 paperwork for Resident #206, as witnessed by the surveyor. The ADON stated she also did a COVID-19 test on Resident #206 that morning to ensure the negative results. This intervention was not documented in the medical record. 3. Review of the orders for Resident #65 documented as of [DATE] that the resident was to receive a magic cup as a nutritional supplement three times daily with each meal. A progress note dated [DATE] documented by the Registered Dietician (RD) revealed he changed the frequency of the magic cup to twice daily. The physician's order was not changed. On [DATE] at 9:21 AM, Resident #65 was just finishing her breakfast. She was fed by Staff R, CNA, who confirmed she ate her yogurt and sausage, encompassing about 25% of her meal. A magic cup was not observed on the breakfast tray, and the CNA confirmed it was not served with her breakfast, but usually was provided with lunch. During an interview on [DATE] at 10:11 AM, the RD confirmed he had changed the magic cup to twice daily, as he doesn't usually provide the magic cup for breakfast as it is like ice cream. The RD stated he must have not changed the physician's order, although he had changed it to twice daily in the meal ticket documentation system, so the resident was only getting it at lunch and dinner. Review of the corresponding Medication Administration Records (MARs) for Resident #65 revealed the nurses were continuing to document the provision and consumption values of the breakfast magic cup, even though the resident had not received it for breakfast since [DATE]. During an interview on [DATE] at 10:41 AM, Staff Q, LPN, who had signed off on the Medication Administration Record (MAR) that Resident #65 had consumed all of the magic cup at breakfast, was asked how she would know if a resident consumed their magic cup when provided with a meal. The LPN stated she would have to observe the meal or ask the CNA. When asked if Resident #65 had a magic cup that morning, the LPN stated she did not know yet. When asked why she already documented that it had been 100% consumed, the LPN had no answer.

Based on observations, interviews, and record review, the facility failed to accommodate resident food preferences for 3 of 17 cognitively intact sampled residents, Residents #46, #91, #89. The findings included: Review of the facility's policy, titled, Resident Food Preferences with a revised date of December 2022, included, in part: Nutritional assessments will include an evaluation of individual food preferences. The resident's food preferences, likes/dislikes will be documented on the resident tray card. This will include special dietary instructions or limitations such as altered food consistency and caloric restrictions. 1. Record review for Resident #46 revealed the resident was admitted to the facility on [DATE] with most recent readmission on 01/21/20. The resident's diagnoses included: Spinal stenosis, thoracic region, Type 2 Diabetes Mellitus, and Morbid (Severe) Obesity, Review of the Minimum Data Set (MDS) for Resident #46 dated 06/12/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 15 of 15, indicating an intact cognitive response. Review of the Physician's Orders for Resident #46 revealed an order dated 01/21/20 for 'No added salt, no concentrated sweets, regular texture, thin liquids.' Review of the Care Plan for Resident #46 revealed a care plan dated 07/05/22 with a problem of: Resident is at nutritional / dehydration risk related to status post right below the knee amputation, atherosclerosis, type 2 Diabetes Mellitus, smoker and obese. The resident chooses not to follow therapeutic diet restrictions, history of compromised skin integrity related to diabetes / peripheral artery and vascular disease. The goal was for the resident to maintain adequate nutritional status as evidenced by no undesired weight changes, no sign / symptom of malnutrition and dehydration, and consuming an average of 50-100% of meals through next review date. The approaches included: Assess resident's food preferences; and Offer available substitutes if the resident has problems with the food being served. During an observation conducted on 07/19/23 at 8:56 AM of meal tray being delivered to Resident #46's room, the meal tray consisted of 1 (not 2) fried egg, 1 slice of toast cut in half, 1 slice of bacon, 2 orange wedges with peel, and 1 cup of coffee; and 1 container of cold milk. There were no grits on the meal tray. The meal ticket for Resident #46 listed special request as fried eggs x2, grits, orange slices, listed beverages at coffee, and milk. An interview was conducted on 07/17/23 at 10:22 AM with Resident #46 who stated the food is always cold and often missing items he has ordered or requested. An interview was conducted on 07/19/23 at 10:10 AM with the Registered Dietician (RD), who stated he has been with the facility for 5 months, and with the Consultant Dietician who has been with and helping in the facility for 3 or 4 years. The RD stated that he just wanted to follow-up on the likes and dislikes (preferences) for residents who are put directly into the SNOW system for the kitchen and that system does not interface with the Matrix system for the residents. The SNOW system does not maintain a history of likes and dislikes. When the RD was asked how often the likes and dislikes (preferences) are reviewed for the residents, he stated they are reviewed minimally with quarterly reviews. He added that he will update the like/dislikes (preferences) more often as needed. The RD said he just did an in-service with the kitchen staff to double check the meal tickets for each resident and check with the next kitchen staff member to make sure they are double checking the meal tickets to make sure the items on the tray are correct and match the meal ticket. 2. Record review for Resident #91 revealed the resident was admitted to the facility on [DATE] with the most recent readmitted [DATE] with diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-dominant side, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, and Morbid Obesity. Review of the Minimum Data Set (MDS) for Resident #91 dated 06/08/23 revealed in Section C, a BIMS score of 15, indicating an intact cognitive response. Review of the Physician's Order for Resident #91 revealed an order dated 02/27/23 for no concentrated sweets, no added salt, regular texture, thin liquids. Review of the care plan for Resident #91 dated 02/28/23 with a problem on resident is at malnutrition / hydration risk related to acute disease process and decline in functional skills. The goal was for resident to maintain weights =/- 3 pounds with encouragement of weight loss through food choices using selective menus; and Maintain meal / supplement intakes of 51-100% through next review date. The interventions included diet as ordered - encourage / monitor / assist / adjust; offer / encourage fluid consumption during hours awake and follow MD orders as indicated. An observation was conducted on 07/19/23 at 9:20 AM of Resident #91 who was sitting up in her bed with her breakfast meal tray in front of her on the overbed table. On the meal tray, there were 2 fried eggs, an English muffin, a slice of bacon, a cup of cut watermelon, and a cup of coffee. There were no utensils, no condiments, no butter or jelly, no milk or juice. The resident's meal ticket listed bacon, English muffin, fresh fruit, fried eggs x2, 2% milk, coffee, and orange juice. An interview was conducted on 07/19/23 at 9:24 AM with Resident #91 who was asked how her breakfast was, and she replied, the aide had to get me some silverware, they forgot to send me some. An interview was conducted on 07/19/23 at 9:25 AM with Staff D, Certified Nursing Assistant (CNA), who stated she has been working at the facility for [AGE] years. Staff D stated Resident #91 had no silverware on her tray and had to go to the kitchen to get some. She said when she returned with the silverware, the resident wanted butter on her English muffin and she had to get butter and orange juice because the resident did not have any butter or juice on her tray. An interview was conducted on 07/19/23 at 10:10 AM with the Registered Dietician (RD) and the Consultant Dietician. The RD stated that he just wanted to follow-up on the likes and dislikes (preferences) for residents are put directly into the SNOW system for the kitchen and that system does not interface with the Matrix system for the residents. The SNOW system does not maintain a history of likes and dislikes. When the RD was asked how often the likes and dislikes (preferences) are reviewed for the residents, he stated they are reviewed minimally with quarterly reviews. He added that he will update the like / dislikes (preferences) more often as needed. The RD said he just did an in-service with the kitchen staff to double check the meal tickets for each resident and check with the next kitchen staff member to make sure they are double checking the meal tickets to make sure the items on the tray are correct and match the meal ticket. 39026 3. Record review documented Resident #89 was admitted to the facility on [DATE]. Review of the BIMS done on 06/21/23 during a quarterly Minimum Data Set, documented a score of 13 of 15, indicating the resident was cognitively intact. The diagnoses included: Diabetes Mellitus, Hyperlipidemia, and Hypertension. On 07/19/23, the food cart for breakfast came to the 500 unit at 8:45 AM. At 9:13 AM, two surveyors intercepted the tray going into Resident #89's room. On the tray was scrambled eggs with ham, 2 pieces of bacon, one slice of toast, oatmeal, orange juice, milk and coffee. An interview was conducted with Resident #89 at 9:15 AM. The resident stated his food is always cold. He stated he 'doesn't want to eat eggs that have anything mixed in them. Boiled eggs are ok. Does not drink milk and he does not like oatmeal.' At 9:18 AM, the RD came into the room and heard the resident did not like eggs. The RD stated, You don't like eggs? He brought a replacement tray to the room which had scrambled eggs on it with 2 sausages. The resident stated he would 'like to eat the sausages but he could take the eggs back'. The resident stated he would like hot cakes. Review of the resident's meal ticket documented the dislikes of cheese and eggs (Photographic evidence obtained).

Based on observation, interview and record review, the facility failed to provide dental services for 1 of 1 sampled resident reviewed for dental services, Resident #40. The findings included: Resident #40 was admitted to the facility for skilled care from an acute care hospital on 04/10/23 with diagnoses that included: Metabolic encephalopathy, Hydrocephalus, unspecified and Hypotension. A scheduled 5-day Minimum Data Set (MDS) with an assessment reference date of 06/23/23 revealed his Brief Interview for Mental Status was 14 of 15, which indicated he was cognitively intact. On 07/17/23 at 9:53 AM during the initial tour of the facility, an interview was conducted with Resident #40 who stated he has no teeth and wanted to see a dentist. On 04/11/23 a social service note in the Electronic Health Record stated the resident has no dentition, states he is interested in seeing a dentist to fabricate dentures. On 07/19/23 at 1:53 PM, an interview was conducted with the Social Service Director (SSD). The SSD stated at the time of the note, the resident did not have Medicaid and they were waiting for insurance. Interview with the Business Office Manager on 07/20/23 at 1:29 PM revealed the resident has MCNA dental (a government dental insurance) which means he had to go to a provider outside of the facility. On 07/19/23, he was put on a list for dental service after surveyor intervention.

Based on record review and interview, facility staff failed to follow through with an ordered laboratory test for 1 of 1 sampled resident (Resident #128). The findings included: Record review revealed Resident #128 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including: anemia and malnutrition. The 5 day minimum data set (MDS) assessment, reference date 06/12/23, recorded a BIMS score of 14, indicating Resident #128 was cognitively intact. This MDS recorded mood of Feeling tired or having little energy. No behavior exhibited. This MDS indicated Resident #128 required extensive assistance with activity of daily living (ADLs). Review of Resident #128's record revealed a Physician order for a laboratory (LAB) test, dated 07/07/23, for complete blood count (CBC). Further review of Resident #128's records lacked evidence of the CBC test result. It was revealed that on 06/24/23, an order for CBC was completed which showed low red blood cell (2.54, range is 4.40 5.80), low hemoglobin (7.9, range is 13.8 17.2), low hematocrit (23.4%, range is 41.0 50.0%) and high red cell distribution width (17.9%, range is 9.0 15.0%). Upon further review of records, under the lab section ancillary order review, it indicated on 07/04/23 the test was not performed. On 07/20/23 at 2:12 PM, a side by side review of Resident #128's records and interview were held with Staff F, Registered Nurse (RN), who searched for the lab result unsuccessfully. She voiced the records showed the phlebotomist (a person who draw blood) came on 07/08/23 to obtain the lab. The summary indicated the lab was not performed. Staff F then called the laboratory in the surveyor's presence. Staff F revealed the lab representative stated, they weren't able to obtain the lab, they called the facility to notify them, there was no response. The representative added the laboratory had no lab test result for July of 2023 for Resident #128. Review of nutritional assessment dated [DATE] indicated Resident (#128) had altered labs. He was sent to the hospital on 06/01/23 for critical low hemoglobin and hematocrit labs of 6.9/17.1. Review of the comprehensive care plan with a start date of 03/24/23, and a reviewed / revised date of 06/11/23, indicated Resident #128 met the criteria for malnutrition / altered hydration, decline in functional skills and altered labs. Intervention included: Monitor labs. On 07/20/23 at 3:21 PM, another interview was conducted with Staff F, who was asked why the CBC was ordered on 07/07/23, who voiced it was ordered as a follow up from the previous lab on 06/24/23, as the red blood cell, hemoglobin and hematocrit were low from the previous LAB results. On 07/17/23 at 11:08 AM, an interview was conducted with Resident #128, who stated he didn't feel good, he felt woozy, feeling weak, and dizzy.

Based on observations, interviews, and record review, the facility failed to obtain a physician order for oxygen for 1 of 2 sampled residents reviewed for respiratory care, Resident #61, failed to document oxygen administration, and change of oxygen tubing for 1 of 2 sampled residents observed for respiratory care, Resident #32, and failed to have a respiratory care plan for 2 of 2 sampled residents observed for respiratory care, Residents #32 and #61. The findings included: Review of the facility's policy, titled, Oxygen Administration with a revised date of December 2021, documented, in part: 'The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. (as needed) administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. ' 1. Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on 12/20/22. The resident's diagnoses included: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant Side, Obesity, Anxiety Disorder, Type 2 Diabetes Mellitus, Chest Pain, and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the [NAME] Data Set (MDS) for Resident #32 dated 07/03/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 8 of 15, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #32 revealed an order dated 02/09/23 for oxygen at 2 liters per minute via nasal canula for shortness of breath as needed. Review of the Medication Administration Record / Treatment Administration Record (MAR/TAR) for Resident #32 for June 2023 and July 2023 revealed no documentation of oxygen being administered. Review of the Care Plans for Resident #32 revealed no care plans for respiratory care or oxygen use. An observation was conducted on 07/17/23 at 11:32 AM of Resident #32 sitting up in bed with oxygen at 2 liters per minute via nasal canula, with no date on tubing. An observation was conducted on 07/18/23 at 1:20 PM of Resident #32 sitting up in bed wearing oxygen at 2 liters per minute via nasal canula with no date on the tubing. An observation was conducted on 07/19/23 at 3:15 PM of Resident #32 sitting in wheelchair in her room wearing oxygen at 2 liters per minute via nasal canula with no date on the tubing. An observation was conducted on 07/20/23 at 10:10 AM of Resident #32 sitting up in bed wearing oxygen at 2 liters per minute via nasal canula with no date on the tubing. An interview was conducted on 07/19/23 at 3:15 PM with Resident #32 who was asked if she needed her oxygen all of the time. She said, 'mostly it is at night but for the past couple of days she has been using it during the day too.' An interview was conducted on 07/20/23 at 11:00 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has been with the facility for almost 1 year. When asked if Resident #32 uses oxygen she stated 'yes, as needed mostly at night'. When asked if the resident was using oxygen today, she said 'yes'. When asked how long the resident had been ordered oxygen, she said 'she has been using the oxygen for as long as she has been working at the facility (about 1 year)'. An interview was conducted on 07/20/23 at 11:11 PM with Staff B, Registered Nurse (RN Unit Manager), who was asked if Resident #32 uses oxygen, stated 'yes'. When asked how often the oxygen tubing is changed, she said it is changed weekly and it would be on the MAR/TAR for the nurse to document the tubing was changed. When asked where the nurse documented that the resident using oxygen, she stated it would be documented on the MAR/TAR if the resident is using the oxygen. Staff B acknowledged there was no order for the oxygen tubing to be changed and she also acknowledged there was no care plan for respiratory or oxygen for the resident. 2. Record review for Resident #61 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on 05/28/23. The resident's diagnoses included: Heart Failure, Hypertensive Heart Disease With Heart Failure, and Generalized Anxiety Disorder. Review of the MDS for Resident #61 dated 06/14/23 revealed in Section C a BIMS score of 15 of 15, indicating an intact cognitive response. Review of the Physician's Orders for Resident #61 revealed no orders for oxygen. Review of the Physician's Orders for Resident #61 revealed no orders to change oxygen tubing. Review of the Care Plans for Resident #61 revealed no care plans for Respiratory or oxygen. Review of the Nurse Progress Note for Resident #61, dated 07/14/23, included: 'continued cough and dyspnea noted new orders obtained from ARNP [Advanced Registered Nurse Practitioner] chest x-ray 2 views and O2 (oxygen) at 2 liters via nasal canula [N/C] prn [as needed] to maintain SPO2 [O2 saturation]'. Review of the Nurse Progress Note for Resident #61, dated 07/15/23, included: 'Patient alert, with episode of coughing observed, with mild congestion, schedule meds administered well tolerated. PRN Robitussin administered somewhat effectively. vitals stable. Rested in bed throughout the shift. Staff Will continue to monitor'. Review of the Nurse Progress Note for Resident #61, dated 07/16/23 at 1:43 AM, included: 'Resident in bed with HOB [head of bed] elevated to improve breathing, wearing O2 at 2L/min via N/C for SOB [shortness of breath]. O2 sat 95%, Resp 20/min. Occasional moist cough with crackles to BLL [bilateral lower lung] upon auscultation. Medicated with Geri-Tussin 10 mls as per order with fair effect. Call placed to Medical imagine to check on C [chest] X-Ray result. Result received via fax, no infiltration, no effusion, no acute findings identified. Result faxed to Dr [name] office. Will continue to monitor and provide safety'. An observation was conducted on 07/17/23 at 11:07 AM of Resident #61 in bed with oxygen at 4 liters via nasal canula with no date on tubing. An observation was conducted on 07/18/23 at 1:10 PM of Resident #61 lying in bed with oxygen at 4 liters via nasal canula, with no date on tubing. An observation was conducted on 07/19/23 at 3:00 PM of Resident #61 lying in bed with family members at bedside. Upon closer observation, the resident had oxygen at 4 liters via nasal canula, with no date on the tubing. An observation was conducted on 07/20/23 at 10:00 AM of Resident #61 lying in bed with family at bedside. Upon closer observation, the resident had oxygen at 5 liters via nasal canula, with no date on the tubing. An interview was conducted on 07/20/23 at 10:05 AM with Resident #61's son who was asked how long his mother had been using the oxygen. He stated since Friday and she really needs it, she is now on hospice. An interview was conducted on 07/20/23 at 11:00 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has been with the facility for almost 1 year. When asked if Resident #61 used oxygen she stated 'yes, as needed mostly at night'. When asked if the resident was using oxygen today, she said 'yes'. An interview was conducted on 07/20/23 at 11:11 PM with Staff B, Registered Nurse (RN Unit Manager), who was asked if Resident #61 uses oxygen, she said 'yes, she has had it since Friday' (07/14/23). When asked if there was a physician order for oxygen, she acknowledged there was no order for oxygen. When asked if there was an order for oxygen tubing to be changed, she acknowledged there was no order for the oxygen tubing to be changed. When asked about a care plan for respiratory or oxygen, she acknowledged there was no care plan for respiratory or oxygen.

Based on observation, interview, and record review, the facility failed to ensure nutritional services to meet the needs for 2 of 5 sampled residents, Residents #65 and #137. The Registered Dietician (RD) failed to do an accurate quarterly assessment for Resident #65, failed to initiate weekly weights with the identification of a significant weight loss, and failed to follow up with the physician on his recommendation for an appetite stimulant. The RD failed to ensure timely interventions for Resident #137, who had a significant weight loss. The findings included: Review of the facility's Policy, titled, for Weight Assessment and Intervention documented, in part, the following: 3) Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, the nursing will immediately notify the Dietitian. 4) The Dietitian will respond within 72 hours of receipt of notification. Care Planning 10) Individualized care plans shall address, to the extent possible: p. The identified causes of weight loss; q. Goals and benchmarks for improvement; and r. Time frames and parameters for monitoring and reassessment. This policy also described a significant weight loss as 5% or more in one month, 7.5% or more in 3 months, or 10% or more in 6 months. 1. Review of the record revealed Resident #65 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment, dated 07/04/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS documented the resident's weight as 107 pounds and the resident had had a significant weight loss. Review of the current weight revealed Resident #65 had a current weight of 103.5 pounds. On 12/05/22, the resident weighed 131.1 pounds, and on 06/05/23 the resident weighed 107.1 pounds (the dates utilized by the RD during his last assessment, indicated Resident #65 had a significant weight loss of 18.31% in the past 6 months). Review of the nutritional assessment dated [DATE], completed by the RD, documented the quarterly review with a non-significant weight loss trend since in April 2023 of 3.4%, and a 90-day weight loss of 6.7%. This assessment documented a net significant weight loss of 21.8% over the past year. This assessment continued and documented the RD changed the Ensure to Med Pass (a protein supplement) to three times daily (Note this had been done on 04/12/23, not with this assessment), along with magic cup twice daily (Note Resident #65 had an order for magic cup three times daily since 02/16/23) to help with trending weight loss which it seems to have slowed down recently. This assessment continued with the weight loss is still concerning with a BMI (body mass index which should be over 20) now less than 20. Appetite stimulant recommended per RD as resident continues to lose weight despite aggressive supplement support and meal/snack intakes. Goal: Halt weight loss and promote weight gain back to desired BMI of 23. Current BMI = 19.59. This nutritional assessment lacked a six-month weight calculation, which was part of their policy in order to determine significant weight loss, which would be 10% or more in the 6-month timeframe. During an observation and interview on 07/17/23 at 12:24 PM, Resident #65 stated she had lost a significant amount of weight but was ok with her current weight. The resident appeared quite thin. On 07/20/23 at 9:21 AM, Resident #65 was just finishing her breakfast. She was fed by Staff R, Certified Nursing Assistant (CNA), who confirmed she ate her yogurt and sausage, encompassing about 25% of her meal. A magic cup was not observed on the breakfast tray, and the CNA confirmed it was not served with her breakfast, but usually was provided with lunch. During an interview on 07/20/23 at 10:11 AM, the RD was shown his nutritional assessment of 07/03/23, and was asked what happened to the recommended appetite stimulant. The RD was unable to find the order, and stated to Staff B, RN/Unit Manager, Did I say I was going to follow up with (name of doctor) about the appetite stimulant? The Unit Manager stated, Yes, you did, but I can text him now; I'll take care of it. When asked about weekly weights, the RD stated if there was a significant weight loss, the resident would be put on weekly weights, but he was not sure of the specifics because he was fairly new and would check with restorative. The RD was asked to provide their nutrition policy that included information on significant weight loss and weights. The RD was also asked about the magic cup that was ordered three times daily with meals, but not provided on that morning's breakfast tray. The RD stated he does not generally order the magic cup for the breakfast meal as it is like ice cream, and stated the meal ticket system would have the magic cup as twice daily, with lunch and dinner. On 07/20/23 at 10:36 AM, the RD returned with the policy. Upon review of the 6-month weights, the RD agreed Resident #65 had had an 18.31% weight loss in 6 months and should have been put on the weekly weight schedule. 32078 2. Resident #137 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Bipolar Disorder with psychotic features, Vascular Dementia with other behavioral disturbance, Mood Disorder, Major Depressive Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Muscle Weakness, Cognitive Communication Deficit, Hyperlipidemia, Hypertension, Atrial Fibrillation, Seizures, and Gastrointestinal hemorrhage. The facility's Policy, titled, Weight Assessment and Intervention stated, in part: 3) Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, the nursing will immediately notify the Dietitian. 4) The Dietitian will respond within 72 hours of receipt of notification. Care Planning 10) Individualized care plans shall address, to the extent possible: p. The identified causes of weight loss; q. Goals and benchmarks for improvement; and r. Time frames and parameters for monitoring and reassessment. On 06/13/23, the resident weighed 226 lbs. On 06/13/23, the resident weighed 226 lbs. On 07/01/23, the resident weighed 203 pounds which is a -10.18 % Loss. On 07/09/23, the resident weighed 200 pounds which is a -11.50 % Loss. No further weights were recorded since 07/09/23. On 07/19/23 at 10:15 AM, during an interview with Registered Dietitian (RD), he stated that he began working for this facility in February 2023. He acknowledged the significant weight loss for Resident #137. The RD was asked to provide all the documentation related to Resident #137's nutritional assessment and any interventions put into place. On 07/19/23, the RD submitted a Nutritional Evaluation for Resident #137 completed on 05/09/23. This evaluation documented the following: Resident meets criteria for malnutrition / altered hydration r/t [related to] MNA [monthly nutrition assessment] score, comorbidities, decline in functional status; recent stroke, hx [history] of dysphagia. [Resident #137] presented to the ER [emergency room ] for psych eval r/t suicidal ideation. He has PMHx [prior medical history] of major neurocognitive disorder, dementia, dysphagia, bipolar, stroke. Residents spouse [spouse's name] reports that he had gastric bypass surgery ~3 yrs ago and a stroke back in February of this year. [Spouse] reports lowest weight after gastric bypass was ~213#. He then gained weight back to ~230#. After the stroke in February 2023 and went back down to 213# per spouse report. Weight loss of ~17#/7.3%/~90 days noted. He has history of dysphagia post stroke. Spouse reports that he was on mechanical diet for ~4-5 weeks after but has been on regular diet since. Facility SLP [speech/language pathology] evaluated resident today and upgraded diet to regular. RD will monitor facility intakes and weights to determine need for oral nutrition supplement. Resident is lactose intolerant and is limited to the supplements he likes. Care plan initiated. There was no further assessment completed by the RD after 07/01/23 when Resident #137's weights showed a significant weight loss of 10.18% within 19 days (06/13/23 - 07/01/23), and 11.5% within a months' time (06/13/23 - 07/09/23). Review of the MDS Entry Assessment completed on 05/20/23 documented that Resident #137 required supervision / set up for eating. There were no swallowing issues or weight loss noted at this time. An updated MDS Assessment completed on 07/05/23 noted that Resident #137 required supervision / touch assistance for eating. The Care Plan for Resident #137 showed the following areas of concern related to nutrition: 07/06/23 Speech Therapy Evaluation - Problem: Impaired chewing and/or swallowing skills which affects: nutrition intake, and weight loss. Requires modified diet due to: pharyngeal skills impairment and cognitive impairments. Requires Modified diet: Regular textures and nectar thick liquids. 05/09/23 Nutritional Status - Problem: [Resident #137] meets criteria for malnutrition / altered hydration related to MNA score, comorbidities, decline in functional status; recent stroke, hx of dysphagia. (Last reviewed 06/11/23). No other nutritional interventions were found in the care plan. Resident #137's dietary orders were reviewed. Resident #137's diet was to include no added salt, regular consistencies, with nectar thick liquids, crush meds, ordered 07/06/23. Dietary liberties on special occasions, ordered 05/15/23. Monthly weights once between 1st and 7th of month, ordered 06/06/23. There were no updates to the orders for weights considering the significant weight loss noted on 07/01/23. Health Shakes with meals (8:30 AM, 12:30 PM, 5:30 PM) were ordered on 07/11/23. Even though greater than 10% weight loss was noted on 07/01/23, the Health Shakes were not ordered until 07/11/23. General Order dated 05/17/23 noted that Resident required assistance with eating each shift; however, the MDS documented Resident #137 required supervision with eating. On 07/19/23 at 12:30 PM, a lunch observation was made of Resident #137. The resident was observed sitting in his wheelchair in the day room on unit 300. One Certified Nursing Assistant (CNA), working in the day room, set up the resident's tray by opening his vanilla shake and mixing thickeners into his beverages. Resident #137 was seen picking up his coffee cup with his left hand and drinking from the cup; however Resident #137 could not use his eating utensil (fork) to get the food from his plate to his mouth, as he kept trying to use his right hand to do so. Resident #137 spent 10 minutes (from 12:30 PM - 12:40 PM) trying to get the mandarin orange segments out of small cup and into his mouth. He was trying to pour out the segments into his mouth, but the segments would not come out of the cup. After 10 minutes, one of the segments came out of the cup and went into the resident's mouth. At 12:42 PM, a second CNA came by and used the resident's fork to put a bite of meat onto the fork and fed it to the resident. When the aide left, the resident tried to pick up the fork to use it, but it immediately fell out of his hand and onto the floor. The second aide noticed that I was observing Resident #137 during his meal. At 12:45 PM, the second aide came back and sat down beside Resident #137 and began assisting him by feeding him his meal. The resident was seen accepting each bite offered by the CNA.

Based on record review and interview, the facility failed to follow the care plan related to use of bed and chair alarms, for 1 of 5 sampled residents reviewed for falls. Resident #20 had a history of falls, one of which was an assisted fall to the floor when a Certified Nursing Assistant (CNA) heard the alarm, thus preventing injury. The findings included: Review of the record revealed Resident #20 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, on a 0 to 15 scale, indicating the resident was cognitively impaired. This MDS lacked any documented behaviors, and documented the resident needed the extensive assistance of one staff for transfers and ambulation. The MDS documented Resident #20 had falls in the past 2 to 6 months. Review of the current fall risk assessment dated [DATE], documented Resident #20 was a high risk for falls, with a score of 19. This assessment documented any score above a 13 indicated the resident was at a high risk. Review of a progress note dated 02/18/23 at 7:45 AM, revealed the nurse was called into the room of Resident #20, and observed the resident sitting on the floor. This note further documented the Certified Nursing Assistant (CNA) said she lowered the resident to the floor, as she had heard the bed alarm go off, and was able to assist him safely to the floor. No injuries were noted. Review of the care plan dated 01/08/23, documented Resident #20 was at risk for falls related to decreased mobility, weakness, and oxygen use. One of the documented interventions was the use of the pressure alarm. An observation on 07/17/23 at 11:10 AM, revealed Resident #20 sleeping in bed. He was dressed, lying on top of the covers, with his wheelchair facing the side of the bed, as if he had propelled himself to the bed and transferred himself into the bed. The bed and wheelchair lacked any type of pressure alarm. A low beeping was heard in the room, and the alarm pad and box was noted on the top of the dresser, located across from the foot of the bed, and the low battery light was flashing with each soft beep (Photographic evidence obtained). On 07/18/23 at 8:28 AM, Resident #20 was again observed in bed, with the wheelchair in a similar location as the previous day. The low battery light was still flashing with the soft beeping heard (Photographic evidence obtained). The alarm pad and box had been moved to a different location on the dresser. During an interview on 07/19/23 at 12:09 PM, when shown the alarm pad on the dresser, and asked if Resident #20 needed it, Staff, N, CNA, stated, I don't know. The CNA said something about working other units, but was very difficult to understand. The alarm box was no longer on the dresser and no beeping was heard. The telephone-like cord was noted coming from under the bed sheets, but was not hooked up to the alarm box. Resident #20 was lying in bed. During an interview 07/19/23 at 12:14 PM, when asked if Resident #20 was a fall risk, Staff P, Licensed Practical Nurse (LPN), stated Oh yes, he tries to get up all the time. When asked what interventions were in place for the resident, the LPN stated the bed and chair alarm. The LPN stated we try to educate and encourage the use of the call light and to ask for help. When asked if she was aware of the low battery beeping and light for his alarm, the LPN stated she thought it was his alarm that needed battery changes yesterday. The LPN explained that the Social Services Director brought her the alarm yesterday, and she sent it to maintenance, as she is unable to open the back of the alarm box as she doesn't have that tiny little screwdriver. An observation with LPN at this time revealed the alarm box was hanging from the top of the bed rail, but not hooked to the pad in the bed. The LPN stated, When I don't have my regulars . this happens, as she proceeded to hook up the bed alarm.

Based on record review and interview, facility staff failed to follow-up on a pharmacy request for a physician clarification related to an ordered medication for 1 of 38 sampled residents (Resident #206). The findings included: Review of the record revealed two current orders, both dated 06/07/23, for the medication Budesonide, a 3 mg (milligram) tablet, for Resident #206. One order was for the tablet to be given once daily, while the second order was for the medication to be given three times daily. Budesonide is a class of medication called corticosteroids that works by decreasing inflammation (swelling) in the digestive tract. Review of the Medication Administration Record (MAR) for Resident #206 revealed both orders had been entered into the electronic medical record (EMR), and Resident #206 received the 3 mg tablet daily at 9 AM, for the daily dose, and at 6 AM, 2 PM, and 10 PM for the three times daily dose. Review of a progress note dated 06/19/23 at 7:42 PM documented Resident #206 did not receive the budesonide, as the drug was currently unavailable. This note further documented that the pharmacy was contacted, and the nurse was advised the medication was received on 06/07/23, and it was too soon to refill. The nurse documented there were multiple orders on file, the order needed to be clarified, and the Assistant Director of Nursing (ADON) was made aware. During an interview on 07/18/23 at 2:08 PM, when asked the usual dose for the 3 mg tablet form of budesonide, upon research of the drug, the Consultant Pharmacist stated 9 mg daily or 3 mg three times daily. During a side by side review of the record, when shown the two orders, the Consultant Pharmacist had no answer, but stated he would look into it. During a side by side review of the record on 07/18/23 at 2:44 PM, Staff A, LPN, who entered both orders, recalled the daughter told her that Resident #206 was previously on the budesonide four times a day, but that she wanted it three times daily, with a one time as needed dose each day. Staff A stated she spoke with the resident's physician, who agreed with the three times daily routine dosage, and one as needed dose daily. Upon review of the orders and the MAR, the LPN agreed Resident #206 had received the budesonide daily at 6 AM, 9 AM, 2 PM, and 10 PM, which was not the intent of the physician. The LPN stated she entered the daily as needed dose incorrectly into the system, further stating she was kind of new with that particular EMR system. During a subsequent interview on 07/19/23 at 1:29 PM, the Consultant Pharmacist provided a copy of the three times daily order dated 06/07/23 from the pharmacy that documented, Please clarify dose and relation to duplicate medication for QD (daily) dosing. The Consultant Pharmacist stated it was faxed to the facility, but the facility staff do not have a record of this or know what happened. During an interview on 07/20/23 at 3:36 PM, when asked if he recalled anything about the budesonide 3 mg tablet for Resident #206, the physician stated he did not. The physician was shown the two orders, the daily dose that was signed by his nurse practitioner, and the three times daily dose that remained unsigned. The physician again stated he did not recall any conversation about the medication, asked if she received the medication four times daily and had no further comment.

Based on observation, interview and record review, the facility failed to prepare, store and serve food in accordance with professional standards and in a manner to prevent the possible growth of pathogens that cause foodborne illness. The findings included: 1. During the initial kitchen tour, on 03/13/22 at 9:21 AM, accompanied by the Kitchen Manager / Certified Dietary Manager (CDM), the following were noted: a. A portion of the wall to the left of the coffee station and underneath water filters for the ice machine was noted to be damaged and missing tiles. b. A staff member's purse was kept on a shelf with food (bread) and single use and disposable napkins. c. Cutting boards were scored and stained and appeared to be uncleanable. d. The handle of a knife that was stored was noted to be melted in one area, creating an uncleanable surface. e. The exterior of the door and wall of the w/i cooler was stained. f. The gasket on the interior of the door to the walk in cooler was noted to be torn in a manner that creates an uncleanable surfaces. g. In the walk-in freezer, the facility was using plastic milk crates that are not designed to be easily cleanable for shelving. h. There was an accumulation of ice on the inside of a top loading chest freezer containing pre-portioned individual servings of ice cream. i. The 'wash' basin of the three-compartment sink used for manual ware washing contained dirty water with food particles floating in the basin. j. The 'wash' basin of the three-compartment sink used for manual ware washing, was being used for rinsing cleaned items. When asked why the sink was not set up to wash, rinse and sanitized in the proper order, the Kitchen Manager stated that the 'wash' basin did not hold water and that the plug did not work. 2. During the follow up tour of the kitchen, on 03/15/22 at 11:14 AM, accompanied by the Kitchen Manager, the following were noted: a. Staff F, Dietary Aide, was observed handling residents' open and uncovered foods while wearing a watch. b. Personal items, including a charging cable for a cellular device, insulated personal cup and opened bottle of water were stored on a shelf that contained a container with breads and single use and disposable napkins c. The internal temperature of meatloaf that was in the process of cooling after being cooked the previous day, according to the Kitchen Manager, was 46 degrees Fahrenheit (F), 44 degrees F and 49 degrees F. The meatloaf was discarded by the Kitchen Manager, who stated that the meal would be replaced with Salisbury steak, with the approval of the Dietitian. 3. During a tour of the unit pantries, on 03/15/22 at 1:19 PM, accompanied by the Dietitian, the following were noted: a. In the unit pantry for the 500 and 600 units, the inside of the cabinet underneath the hand sink was damaged, there was an accumulation of a black mold-like substance inside of the cabinet underneath the hand [NAME], and there was an accumulation of debris on the counter underneath the microwave oven. b. In the unit pantry for the 300 and 400 unit, the cabinet underneath the hand sink was damaged and there was an accumulation of a mold-like substance inside of the cabinet.

Based on record review and interview, it was determined the facility failed to prevent resident to resident abuse. This failure affected 1 of sampled 3 reviewed residents (Resident #1). The facility failed to ensure the perpetrator (Resident #2) had an adequate level of supervision and failed to implement safety approaches to minimize the resident to resident altercation. The findings included: Review of the facility logs, for November 2020, December 2020 and January 2021, conducted on 01/11/21 revealed an entry related to Resident #1, alleging an assault by Resident #2. The facility provided evidence of an immediate investigation. This investigation entailed an interview with the victim (Resident #1). The investigation did not address the level of supervision provided to the alleged perpetrator prior to the event, there were no interviews or statements with the staff involved, and there is no evidence of additional interventions put in place to minimize re-occurrence of the event. Clinical record review revealed, Resident #2 (perpetrator) was admitted to the facility on [DATE] with multiple medical conditions including [CONDITION(S)]. The Minimum Data Set, quarterly assessment with reference date 12/07/20 documented, the resident was assessed as severely impaired for skills of daily decision making and had a rejection of care. The resident required supervision with locomotion in the unit and extensive assistance with activity of daily living. The Care Plans initiated for the resident included the following: Behavioral Symptoms, initiated on 06/24/20 and reviewed on 01/11/21 documented the problem as Resident has displayed behaviors/has history of aggressive/combative behaviors related to history of dementia, severe cognitive impairment, [CONDITION(S)], and depression. She is prescribed medication for this diagnosis. The resident also wanders at times on the unit, will enter the wrong room related to cognitive impairment, requiring frequent redirection. The approaches in place included: Allow the opportunity to calm down and re-approach the resident for care; Encourage involvement in activities of interest. Provide resources and assistance as needed; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed and Licensed Nurse will document a behavior note for observed behaviors. Infection care plan initiated on 12/16/20 documented the problem as Resident is at risk for complications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Psychiatric Note, dated 12/04/20, documented the resident has become more paranoid and agitated, will benefit from restarting antipsychotic medications. Nurses notes, dated 01/04/21, documented the resident refused all medications this shift. Nurses Notes dated 01/04/21 documented Resident (#2) was yelling at her roommate telling her she was ugly and telling her that everything in the room was hers. This writer explained to resident that it was not nice to be calling her roommate names. This writer also explained to resident which side of the room had her belongings and which side was her roommates. Resident (#2) self propels out of room stating yeah, yeah, yeah. Resident was going up and down the hallway trying to get into other resident's rooms. Some residents were yelling at her and resident states that they are just {b }. Resident #2's clinical record failed to provide documentation of the incident between Residents #1 and Resident #2 on 12/18/20. The care plans failed to provide evidence of revised interventions put in place to minimize risk of re-occurrence and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses notes, dated 12/18/20 for Resident #1, documented the resident's son called while receiving report from another nurse at approximately 7:20 PM, stated mom called him and stated that she was being insulted by another resident in her room. Resident stated (Resident #2) came to her room and grabbed her blanket and told her to get out of her room. Resident stated (Resident #2) grabbed her right arm and left a purple mark on her lower arm. Administrator spoke to resident's son. (Resident #2) has dementia and redirected to her room. The Nurses Notes, dated 12/19/20, documented Resident #1 was received by the nurse as being alert, oriented, denies pain or discomfort. Small purple discoloration to right arm, skin intact no bleeding noted. Interview with the Administrator conducted on 01/11/21 at 1:55 PM revealed he recalls the events on 12/18/20. He had left the facility for the day, then received a call around 7:00 PM that the screening machine was acting up, so he returned to the facility and after fixing the issue, he decided to make rounds. When he got to the long-term care unit, he observed the nurse on the phone, the nurse seemed upset and frustrated. He then asked, what is going on and the nurse replied there is a family member on the phone who is upset. He asked the nurse to tell the family member the administrator wanted to speak to him and got on the phone. Resident #1's son was highly upset and told him his mother was assaulted; he could not understand what was happening and asked when, by who and the son replied just know, I think it was a woman. The administrator told him, he would go and check on his mother and placed the call on hold. The administrator went in the room, and the resident was lying in bed, there was no one else in the room, and asked the resident if she was okay, she replied, yes I am fine, and just said I don't want this woman in my room again. He again asked the resident if she felt safe and if she was hurt and she replied she was fine. Then he noticed a small bruise to the top of the forearm, the resident had fragile skin and multiple areas of purpura (red or purple discolored spots on the skin that do not blanch on applying pressure) were noted. The administrator stated he investigated the concern immediately, and based on her skin condition, and interview with the resident who stated her son is an excitable person, the incident was closed and therefore not reported. Phone interview with Staff A, a License Practical Nurse, conducted on 01/11/21 at 2:25 PM revealed she recalls the incident related to Resident #1, during the nurses shift change, the incoming nurse was dealing with a difficult phone call. Staff A was at the desk and assisted the nurse by picking up the phone call while the other nurse went out to check on Resident #1. Staff A explained the resident's son called the facility and stated the resident called him to report that another resident, later identified as Resident #2 had assaulted her. Staff A does not recall any further discussions regarding the incident. The nurse confirmed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Phone interview with Staff B, a Licensed Nurse, conducted on 01/11/21 at 4 PM revealed on 12/18/20 when she arrived for her shift, the phone rang, she answered the phone, and Resident #1's son was highly upset, he stated the resident called him and told him she was assaulted by another resident (Resident #2). The nurse then asked the resident's son to hold while she checked on the resident. When she got to the room, the resident told her, another resident got in her room, grabbed her arm, left a bruise and took her blanket. The nurse verbalized the resident had a bruise with the shape of a thumb print to her right arm. The nurse then learned Resident #2 was removed from the room by an aide. The resident had no other injuries. The Nurse explained Resident #2 has dementia, and at times she goes into other residents' rooms but has no prior knowledge of the resident being physically aggressive towards others. Staff B confirmed she was not involved in the investigation of the incident; the administrator took over the incident and Staff B did not recall further discussions regarding the alleged abuse or supervision of the resident. Interview with the Social Worker conducted on 01/13/21 at 9:46 AM revealed she was not involved in the review of the alleged incident / altercation resident to resident. Interview with the Assistant Director of Nursing (ADON) conducted on 01/13/21 at 11:09 AM revealed that after she had reviewed the clinical records, there was no evidence the nurses accurately documented the wandering behavior for Resident #2 on 12/18/20, and she confirmed there were no revised interventions after the resident's altercation with Resident #1 to minimize re-occurrence. Phone interview with Staff C, a Certified Nursing Assistant, conducted on 01/13/21 at 12:10 PM revealed on 12/18/20, Resident #1 put her call light on, at the time she was caring for another resident, when she finished, she went into Resident #1's room, there was no one else in the room but the resident told her another resident kept coming into her room, and was taking her stuff. She immediately reported the incident to the nurse. The aide stated after the report, she never heard anything else regarding the incident. Phone interview with Staff D, a Certified Nursing Assistant, conducted on 01/13/21 at 12:26 PM revealed after questioning about the resident to resident incident on 12/18/20, the staff replied, I know nothing about it. The aide confirmed she was assigned to care for Resident #2 on 12/18/20 on the evening shift and repeatedly stated she was never asked or told anything regarding Resident #2's behavior (the alleged perpetrator). The staff confirmed again she was assigned to care for Resident #2. At the time, the resident was in isolation in the COVID unit and was supposed to remain in her room. The aide could not give specifics regarding time when the resident was last observed before or after the evening meal, Staff D stated in general she checks the residents every 10 minutes and Resident #2 was always in her room. The aide could not explain how Resident #2 went from the end of the hallway, room [ROOM NUMBER] to room [ROOM NUMBER], at the opposite end of the unit without being seen or redirected by staff, if she was monitored every 10 minutes. Record review and interview validates the facility received an allegation of abuse related to the resident to resident altercation on 12/18/20. The facility investigation lacked information regarding Resident #2's, level of supervision prior to the incident. The nurse confirmed the incident occurred and Resident #2 inflicted a bruise on Resident #1's arm. The record failed to provide evidence that Resident #2's wandering behavior for 12/18/20 was accurately completed, there were no additional interventions implemented after the incident, and neither were documented on the record or verbalized by the staff interviewed during the investigation.