Every finding on record at Regents Park of Sunrise

Based on observation, interview, and record review, the facility failed to provide supervision and a safe environment to prevent an elopement for 1 of 4 sampled residents (Resident #1). Resident #1 was a vulnerable resident who exited the facility's main front door unsupervised on 10/11/25. She was found about half mile away from the facility on a very busy 6-lane roadway at 7:32 PM by the police who were driving down the road by chance and noticed she needed assistance. The police took the resident to the facility, and the facility staff were unaware Resident #1 had left. The facility's failure to prevent Resident #1 from eloping placed this resident at a likelihood of serious harm, injury or death. While out of the facility on 10/11/25, Resident #1 was confused and unable to report to the police officer where she lived. Resident #1 could have fallen and sustained injuries, particularly while walking in the dark; drowned in nearby bodies of water; or have been struck by a car. The Nursing Home Administrator was given the Immediate Jeopardy Template on 10/28/25 at 4:39 PM. The Immediate Jeopardy (IJ) began on 10/11/25 and was removed on 10/13/25 according to the facility's Immediate Jeopardy Removal Plan. The findings included: Review of the facility policy titled Elopement and Wandering Residents revised on 03/16/23 revealed the following: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach of monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Record review revealed Resident #1 was admitted to the facility on [DATE]. The residents' diagnoses included Dementia, Memory deficit, Cerebral infarction, Atrial fibrillation and Type 2 Diabetes mellitus. The resident's medications included Aricept and Memantine for Dementia; Eliquis (a blood thinner) for Atrial fibrillation; and Metformin for Diabetes. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview of Mental Status (BIMS) score was 06/15, which indicated severe cognitive impairment. An Elopement Risk Evaluation dated 08/11/25 showed that Resident #1 was at risk for elopement with a score of 1 (0 indicating no risk for elopement and 1 indicating risk for elopement). Further review indicated that Resident #1 needed a walker to ambulate. After the elopement incident, Resident #1's daughter had the resident moved to a facility with a secure unit to care for residents who are at risk for eloping on 10/21/25. Review of the Police Report dated 10/11/25 documented that Resident #1 was found by the police while she was walking in traffic after sunset (sunset at 6:56 PM) East bound on a busy 6-lane roadway at 7:32 PM. In that report Resident #1 told the police officer that she walking to her daughter's house in Miami and when asked where she was coming from, she was unable to provide a location. Resident #1 was wearing dark clothing and was only able to provide her first and last name. The police officer's report indicated the officer was concerned for her safety under these hazardous conditions. The police officer had another officer check the surrounding facilities in the area, who then contacted an employee of the facility in question and confirmed that Resident #1 lived there. Resident was then returned to the facility by the police. Review of the facility's timeline investigation revealed that on 10/11/25 Resident #1 was seen by Staff B, Licensed Practical Nurse (LPN) at 7:15 PM on the B Wing and was last seen between 7:00 and 7:30 PM by Staff A, Physical Therapy Assistant (PTA) on the B Wing hallway. At 7:48 PM a police officer arrived at the facility to let them know that they found Resident #1. At 8:05 PM Resident #1 was brought back to the facility by another police officer. The facility staff timeline did not align with the time police found the resident after she walked about a half mile. On 10/28/25 at 9:02 AM, the surveyor retraced the probable steps the resident took. The walk started on B wing. Walked to the front main lobby doors and exited the facility. Walked the green sidewalk towards the parking lot. At the end of the sidewalk there's a ramp for wheelchair accessible into the parking lot. Continued walking towards the front entrance of the facility's driveway, turned left onto the sidewalk and within a few steps noted there is a non-fenced body of water on the left of the sidewalk (photographic evidence obtained). Continued walking following the sidewalk, Resident #1 crossed a driveway (a Tennis Club opened till 9:30 PM) where the sidewalks have ramps for wheelchair access on both sides. Resident #1 then crossed 95th Terrace and walked by a park and she passed another non-fenced body of water. Resident #1 again crossed a street, NW 94th Avenue, which has a traffic light for turning options between Oakland Park Boulevard into NW 94th Avenue (photographic evidence obtained), and after crossing this street (NW 94th Avenue) Resident #1 was around the 9000 block (which is where the police found her). The walk was about 0.6 miles away from the facility and took the surveyor about 16 minutes. During an interview conducted on 10/27/25 at 9:10 AM with the Director of Nursing (DON), she stated that she received a call from the facility staff around 7:50 PM letting her know that Resident #1 was found by the Police. She arrived at the facility at 8:30 PM and entered through the back door ambulance entrance. While walking towards the B Wing, she heard a beeping alarm sound coming from the front main lobby door. She did not see any staff at the front door and could not remember the code for the keypad to stop the beeping alarm. She then asked Staff C, Registered Nurse (RN) B Wing Unit Manager, for the code to the keypad to turn off the alarm. During an interview conducted on 10/27/25 at 10:36 AM with Staff D, Registered Nurse Supervisor, she stated that she was working as the manager on duty on the C Wing on the day of the elopement. She was at the nurse's station around 7:45 PM when the Police officer spoke to another Staff member to let them know that Resident #1 was found out of the facility walking on a main street. When asked by this surveyor if she heard an alarm/beeping noise around the time the resident eloped and she said no. During a phone interview conducted on 10/27/25 at 1:50 PM with Staff E, Certified Nursing Assistant (CNA) who was assigned to Resident #1 at the time of the elopement, Staff E stated that she saw Resident #1 eating her dinner in the Television Room and was later seen at the nurse's station but could not recall the exact time. A nurse approached her later to ask her about the whereabouts of Resident #1, and she answered that she did not know. Staff E stated that there was no alarm or beeping sound going off at the nurse's station at the time of the alleged elopement. When Staff E was asked if she knew that Resident #1 was at risk for elopement, she said no. During an interview conducted on 10/27/25 at 3:40 PM with Staff B, LPN, she stated that when she returned from her lunch break on 10/11/25 around 7:50 PM, she was told by Staff G, LPN that the police were coming back to the facility with Resident #1. Staff B said that she last saw Resident #1 walking in the B Wing hallway towards Staff A, PTA, around 7:15 PM. She further explained that she did not know that Resident #1 was an elopement risk. According to Staff B, no alarm was heard on the B Wing when the front main lobby door was pushed open. Staff B acknowledged that earlier that day (10/11/25) around 6:00 PM, Resident #1 asked her to speak to her daughter on the phone. However, Staff B stated she was too busy with other nursing assignments and could not help Resident #1. Resident #1 then asked the other nurse in the Unit who was also busy. Neither nurse attempted to redirect the resident or provide additional supervision. During an interview conducted on 10/27/25 at 12:55 PM with Staff C, RN Unit Manager for B Wing, she stated that Resident #1 had a daily routine which consisted of sitting on her rolling walker and looking through glass door, near the activity room, labelled as door #14. She would then come to the nurse's station and ask to talk to her daughter. On 08/11/25 Staff C noticed that Resident #1 was more agitated than usual and was pacing the B Wing hallways toward the exit doors which made her question the unusual behavior. This prompted Staff C to complete an Elopement Risk Evaluation which resulted in placing Resident #1 at risk for elopement. Resident #1's daughter was called the same day to speak to her mother to help calm her down. According to Staff C, she verbally updated all staff on the risk of elopement for Resident #1. She also said she updated the care plan with interventions to prevent elopement. Record review of Resident #1's Medical record revealed no care plan with interventions was put in place on 08/11/25 regarding risk of elopement. Further review indicated that Resident #1 did not have a care plan to address behaviors of seeking to communicate with family and daughter, or of pacing around exit doors. During an interview conducted on 10/27/25 at 4:30 PM with Staff H, CNA she stated that she worked on the C Wing on 10/11/25 from 3:00 PM to 11:00 PM. She further stated that she never heard any alarm or saw a light at the nurse's station at the C Wing. According to Staff H if someone opens the front lobby main door and the door is engaged, she will hear a sound and see the light go ON at the nurse's station. During an interview conducted on 10/27/25 at 4:35 PM with Staff I, CNA who worked on C wing, she stated that when someone tries to go out of the front main lobby door an alarm will go off, but no alarm went off on 10/11/25. During an interview conducted on 10/27/25 at 4:40 PM with Staff D, Registered Nurse Supervisor, she stated that normally no alarm or light comes ON at the nurse's station if someone attempts to open an engaged/locked door. According to Staff D on 10/11/25 between 7:00 PM and 8:00 PM she was at the C Wing nurse's station. She did not hear an alarm at the C Wing but acknowledged hearing the alarm when she came closer to the facility main lobby and assisted the DON with the code to disengage the front door alarm. In a phone interview conducted on 10/27/25 at 5:35 PM with Staff A, PTA, he stated that he worked on 10/11/25, and last saw Resident #1 between 7:00 PM to 7:30 PM, judging by the light outside. He recognized Resident #1 who was ambulating in the hallway near the activity room and appeared agitated. He helped to redirect Resident #1 towards the B Wing and continued with his assignments. During an interview conducted on 10/28/25 at 12:00 PM with the Maintenance Director, he stated that he came into the facility the next day (10/12/25) after the resident eloped to ensure all door alarms were properly functioning. He explained that the front main lobby door is equipped with a Magnetic Lock which connects to a device called Door Annunciator, located at both nurse's stations. The front main lobby door, when the bar is pressed, opens after 15 seconds and the magnetic lock alarm goes off. A passcode is needed to stop the alarm. He also explained that the main front lobby door has a red round alarm box called Screamer located on the left side of the door. The Screamer is turned on with a key and once activated (opening the door) it would go off for 30 seconds and stop. On 10/12/25, when testing the doors, he realized that the Door Annunciator device on the C Wing showed that the main lobby switch light was ON but no sound was heard. A closer look at the device showed that the red button (Audible Shunt) was pushed in the silent position/mode. When he went to the B wing, he realized that the Door Annunciator device did not have a designated alarm switch for the main lobby door. He explained that the Door Annunciator is a device that was placed on the back wall of each of the nurse's station (B and C Wing) to notify staff that a specific exit door in the facility has been dislodged. In addition, he pointed out that the Audible Shunt red button on the devices can disable the alarm sound when pushed in the silent position/mode. During an interview conducted on 10/28/25 at 8:34 AM with Staff K, Receptionist, she stated that she works from 10:00 AM to 6:00 PM every other weekend. Prior to the incident, the front main lobby doors were unlocked between 8:00 AM to 7:00 PM, and visitors would be able to come in and out without any alarm sounding off (doors were disengaged). Staff K reported that an elopement binder is located at the receptionist desk with a picture and the name of all residents that are at risk of elopement. When asked about Resident #1 she said that she did not remember if she was one of the residents in the binder. According to Staff K, Resident #1 was not safe to go out on her own and would only go out when family came to visit. During an interview conducted on 10/28/25 at 5:16 PM with Staff J, Receptionist, she stated she was working the night of the elopement on 10/11/25 (Saturday) and left around 6:30 PM but normally leaves at 6 PM on Saturdays. She confirmed the front main lobby doors automatically locked at 7:00 PM. Prior to the incident, the front main lobby doors used to remain unattended and unlocked from 6:00 PM to 7:00 PM, locked from 7:00 PM to 8:00 AM, and then would unlock at 8:00 AM. Upon starting her shift she reviews the elopement binder located at the receptionist desk. When asked if she was aware that Resident #1 was at risk for elopement and she stated no. At the end of her shift, she puts everything away, lets the C Wing staff know that she is leaving and closes the double doors that lead from the main lobby to the two units (B wing and C wing). The facility submitted an acceptable Immediate Jeopardy removal plan on 10/29/25, and it stated the Immediate Jeopardy was removed on 10/13/25. The implementation of the removal plan was verified onsite by the surveyors on 10/28/25 and 10/29/25: 1. On 10/11/25 at approximately 8:05 pm Resident # 1 returned to facility, placed on one-on-one supervision. Evaluation by LPN revealed no signs of injury or distress. Care Plan updated to reflect current care needs. A head count was conducted of current residents at the facility by RN supervisor. No concerns were identified. Record review of Resident #1's verified the resident was placed on one-on-one supervision as noted in the observation work sheets from 10/11/25 starting at 8:15 PM to 10/21/25. Evaluation by LPN revealed no signs of injury or distress. Care Plan updated to reflect current care needs on 10/11/25.Verified the head count audit, which listed 118 residents, completed by the facility on 10/11/25. 2. On 10/11/25 current facility residents had elopement risk screens completed. Two additional residents triggered at risk for elopement. Orders and Care Plan were updated to reflect current needs based on updated Elopement Risk Evaluations. Verified the Elopement Evaluations conducted on 10/11/2025 for all the residents (118). 3. On 10/12/25, elopement risk binders were reviewed to ensure they contain photos and demographic information of residents evaluated to be at risk for elopement. The surveyors reviewed and verified the 3 elopement binders located at the Receptionist desk, C Wing nurse's station and B Wing nurse's station were accurate. 4. Elopement Drills to include door alarm drills conducted each shift starting on 10/11/25 through 10/26/25. Education on elopement process, exit seeking behaviors and exit seeking behavior process/procedures discussed after each drill. Verified sign-in sheets by all staff for elopement drills completed from 10/12/25 and 10/13/25. 5. Education for current staff initiated on 10/11/25 related to the facility Elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. Licensed nurses received specific education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk assessment in the computer and notifying nursing management. Receptionist received specific education followed by specific competencies on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified. Education was conducted on 10/12/2025 with IDT team on the process of identification, care planning, prevention, and response of elopement/exit seeking behaviors in morning meeting by progress/behavior note review and a review of the elopement risk UDAs, admission and readmission assessments (that contain the elopement risk evaluation for new residents) completed. Verified In-Services conducted for all in-house staff from 10/11/25 to 10/13/25 on all three shifts by interviews with staff on all three shifts. 6. Huddles are conducted at the beginning of each shift to discuss elopement risk and fall risk residents. This is an added communication to ensure staff are aware of at-risk residents. Verified with multiple staff interviews on all three shifts. 7. Door function and alarms were checked by the Administrator on 10/11/2025 and the Maintenance Director on 10/12/25, all doors and alarms were functioning appropriately. During the review by Maintenance Director on 10/12/2025, the C wing annunciator was noted to be muted. The volume of the annunciator was increased, and the button was disabled to remove the ability of staff to adjust the volume by vendor on 10/13/2025. Verified by observation and testing of the door annunciators on both Wings (C and B Wings). 8. Education provided by Staff Development Coordinator, DON and Administrator.There are156 total facility employees (Nursing, Dietary, Laundry, Housekeeping, Therapy, Administrative staff, Receptionists, Maintenance).All156 staff received education on the facility elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors.There are 43 total licensed nurses in the facility and 4 total receptionists in the facility.All 43 licensed nurses received education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk UDA and notifying nursing management. as of 10/13/25.All 4 receptionists have been educated on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified as of 10/13/2025.Verified In-Services conducted for all in-house staff from 10/11/25 to 10/13/25 on all three shifts.Also verified by interviews with staff on all three shifts, including licensed nurses, and 3 of 4 of the Receptionists. 9. Newly hired staff and staff members on leave will receive education at orientation or prior to working their next scheduled shift. Verified the educational material the facility will use for orientation of new employees. 10. Root Cause Analysis (RCA) completed on 10/12/25 and reviewed by QAPI. Additional contributing root causes were identified and addressed in QAPI on 10/13/2025, as outlined below. These factors were staff response, staff knowledge of elopement risks and resident safety, appropriate plan of care/interventions for residents, muting of the C wing annunciator. Reviewed the original Root Cause Analysis completed by the facility. 11. The facility conducted an ad hoc QAPI meeting on 10/13/25 which included the Facility Administrator, DON, Medical Director via telephone, and additional staff members. The Performance Improvement Plan was accepted by the committee. The annunciator and the correction plan of the annunciator was reviewed in QAPI as indicated by the review of the maintenance enhancement plan. Door alarm annunciator volume increased on C wing, mute button on C wing annunciator disabled. Reviewed staff education completed including identification and response/process of exit seeking behaviors, elopement drills conducted. No additional recommendations were made at that time.Record review verified the sign-in sheet for the ad-hoc meeting on 10/13/25.Interviews conducted with the DON, Administrator, and the Medical Director confirmed that the ad hoc meeting was conducted on 10/13/25, and the door annunciators and staff education were addressed.

Based on observations, interviews and record reviews, the facility failed to follow their menu for the Regular diet for 1 of 1 visit to the main kitchen. This has the potential to affect 70 residents on regular diet. The census at the time of survey was 113. The findings included: An observation was conducted on 08/26/25 at 11:30 AM in the main kitchen. The lunch menu consisted of 3 ounces (oz) of BBQ [Barbeque] riblet in a sandwich, 1 serving of Cottage Cheese and Fruit Plate, 1 Corn Cobette, 1/2 cup of Macaroni Salad, 2 Oatmeal Raisin Cookies, 8oz of Coffee or Tea and 8oz of Beverage of choice. The surveyor requested to have the 3 oz of BBQ riblet weighed. It weighed 2.5 oz instead of 3 oz (protein).During an observation conducted on 08/26/25 at 11:35 AM in the main kitchen, the resident's lunch meal ticket consisted of double protein which would mean serving 6 ounces of BBQ riblet, 2 Corn Cobette, 3/4 cup of macaroni salad, 2 oatmeal raisin cookies and 8oz. of iced tea. The surveyor requested the lunch meal be weighed. The lunch meal weighed as follows: the BBQ riblet weighed 4.5 oz instead of 6 oz (protein).In an interview conducted on 08/26/25 at 11:30 AM, Certified Dietary Manager (CDM) stated that the double protein plate was going to be reviewed by her checker. The surveyor proceeded by pointing out that the plate was covered and the 3rd one was waiting to be put on the cart. The surveyor continued explaining to the CDM that it was not the first double protein that was served as a single portion.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to ensure the prevention of foodborne illnesses for 2 of 2 visits to the central kitchen; and failed to discard expired products, to appropriately separate dented cans, and to date and properly cover food in the walk-in refrigerator.The findings included:In a tour conducted on 08/24/25 at 8:55 AM in the main kitchen with Certified Dietary Manager (CDM), the following were noted:The walk-in refrigerator was noted with the following:1. Uncovered and undated cart of dessert.2. Four (4) packets of 10 pounds ground meat dated respectively 08/18/2025, 08/18/2025, 08/23/2025 and 08/24/2025.3. Expired boxes of 48 cups of Cranberry Juice dated 07/05/254. Expired box of Lite Ranch Dressing dated 08/15/255. An uncovered and undated bin on a shelf filled with undated sandwiches partially covered, desserts and beverage can. The dried storage was noted with the following:6. Multiple dented cans on the shelf with undented cans and ready to use.7. Expired boxes of Moderately thick - honey consistency Apple Juice from concentrate dated 07/15/258. Expired cans of Pulled Chichen with broth dated 01/11/2025 and 02/01/25. The main kitchen was noted with the following:9. A cart containing cans designated to use to cook lunch contained a dented 6.88 pounds of Dark Red Kidney Beans. Review of the lunch menu for 08/24/25 consisted of chili with beans, tossed salad, cornbread, sweet potato pie, coffee or tea, beverage of choice and chicken tenders with dipping sauce as an alternative.An interview was conducted on 08/24/25 at 12:00 PM with the CDM who stated that the ground beef dated 08/18/25 was thrown away and not used. The recipe indicated that for 150 people they need to cook 21 pounds of ground beef. The CDM explained that they used 1 ground beef of 10 pounds and 2 other small ground beef that they had stored. When the CDM was asked to show where the ground beef was discarded or where the other ground beef similar to the ones she used were stored, the CDM was unable to do so.A tour of the walk-in refrigerator conducted on 08/24/25 at 12:10 PM revealed that only one of the 4 previously dated ground beef were on the shelf and was dated 08/24/25. This indicated that the two packages of 10 pounds of ground beef dated 08/18/25 were used to cook the lunch.An interview was conducted on 08/27/25 at 2:45 PM with the CDM who stated she has been working in this facility for 30 years. She stated she doesn't know what happened, she is going to conduct a lot of in-services and make a lot of changes. The CDM expressed that she is very disappointed in herself for not checking.

Based on observations, interviews, and record review, the facility failed to honor residents' dignity for 1 out of 1 resident reviewed for assistance during dining. (Resident # 10).The findings included: Record review revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Periprosthetic Fracture around internal prosthetic left hip joint and Type 2 Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score was 01, indicating severe cognitive impairment. Review of section GG of the MDS revealed Resident #10 is fully dependent on staff regarding the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.Review of the care plan dated 08/26/25 documented that Resident #10 is at high nutritional / hydration risk related to nutrition, related comorbidities and conditions associated with diagnosis of Hyperlipidemia, Hypertension, Dementia, Gastroenteric Reflux Disease and use of laxatives. Goals were to maintain adequate nutrition and hydration by providing PO [oral] meals, enteral feeds and flushes as ordered through the next review date. Interventions were to set up trays, supervise, cue, assist as needed with meals and allow adequate time to consume food/fluids provided.During an observation conducted on 08/26/25 at 12:05 PM, Staff C (Occupational Therapist Assistant / OTA), was seen standing over Resident # 10 and feeding her.In an interview conducted on 08/27/25 at 1:00 PM, the Director of Nursing (DON) stated that she has been working for the facility for 6 and a half years. She explained that a staff member feeding a resident should be always sitting on a chair during the whole feeding period.In an interview conducted on 08/27/25 at 1:20 PM, the Assistant Director of Nursing (ADON) stated that she has been working for this facility for 6 years. She further stated that when a staff member is feeding a resident, the staff has to be at eye level, most of the time seating and a position that is comfortable for the resident.

Based on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP), for residents with urinary catheter drainage systems for 2 of 36 sampled residents for EBP, and 2 of 4 sampled residents for urinary care (Resident # 94 and Resident #69); failed to care and manage a urinary catheter system according to the nursing care plan for 1 of 36 sampled residents for EBP, and 1 of 4 sampled residents for urinary care (Resident #36); failed to care and manage a resident with post-surgical incision for 1 of 36 residents for EBP (Resident # 123); and failed to manage the care of a resident with an intravenous (IV) access line for 1 of 36 sampled residents for EBP (Resident #57). The findings included: According to CDC, EBP documented that: Everyone must clean their hands, including when both entering and leaving the room: https://www.cdc.gov/long-term-care facilities/media/pdfs/ Review of a policy, titled, Enhanced Barrier Precautions (EBP), implemented on 10/22/23, documented the following: EBP is the use of gowns and gloves for use during high contact resident care activities, for residents known to be colonized or infected with Multiple Drug-Resistant Organism (MDRO), as well as those at increased risk of MDRO acquisition.An order for EBP will be obtained for residents with any of the following: 1. Wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds) 2. Indwelling medical devices (central lines, hemodialysis catheters, urinary catheters, feeding tubes), even if the resident is not known to be infected or colonized with an MDRO 3. High- contact resident care activities include: a. Dressing b. Bathing c. Providing hygiene d. Changing linens e. Chaning briefs or assisting with toileting f. Device care or use of central lines, urinary catheters, feeding tubes.1. Record review documented Resident # 94 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with Hypoxia, Pneumonia, Segmental and Somatic Dysfunction of Cervical Region, Urinary Tract Infections, and Pseudomonas Aeruginosa.Review of Minimum Data Set (MDS) assessment dated [DATE] under Section C of the Brief Interview for Mental Status (BIMS), revealed a score of 15, indicating Resident #94 had no cognitive impairment. Section GG documented the resident was dependent on toileting hygiene which included the ability to maintain perineal hygiene and adjust clothes before and after voiding. Section O documented yes on antibiotics, IV medications and midline IV access. An observation was conducted on 08/24/25 at 2:12 PM. Resident #94 was observed lying in bed with her head slightly elevated. A suction tubing was coming out from her left side. This suction tubing was connected to a canister on top of the bedside table. The canister was observed with dark tea colored urine of about 150 to 200 milliliters (ml). There was no EBP sign above Resident #94's bed. When Resident #94 was asked about the purpose of suction tubing and the canister, she responded, It is my external urinary catheter collection system.Another observation conducted on 08/25/25 at 11:44 AM, and the canister contained light tea colored urine of about 200 ml. It was connected to a suction tubing observed coming out of this resident's left side. There was no EBP post above this resident's bed. An electronic record review of the physician orders and nursing care plans for Resident #94 did not document EBP to be used for the external urinary catheter system device.An observation and an interview were conducted with Staff E and Staff F, both Certified Nursing Assistants (CNAs), on 08/25/25 at 3:50 PM. They stated Resident #94 only uses the female catheter system device at night. When they were asked if the system was being used by this resident now, they responded, Yes, she was wearing the wick pad that was connected to the suction and the canister. When they were asked why they were not wearing the Personal Protective Equipment (PPE) gowns to perform perineal care for this resident, they both responded, We do not wear gowns, just gloves when providing bed bath and perineal care for this resident. This resident does not have wounds on her toes. An interview was conducted with the Infection Control Registered Nurse (RN) on 08/25/25 at 3:41 PM, who was asked how facility staff would know the resident care is following the EBP guidelines from CDC, responded, An EBP post is found on top of resident's bed. When she was asked if a resident with an external urinary catheter system device must follow the EBP protocol, she responded, No. When she was asked why Resident #94 did not have an EBP post above her bed, she responded, Her care is not under the CDC guidelines for EBP. An interview was conducted with Staff D, Licensed Practical Nurse (LPN), on 08/26 25 at 3:41 PM, who was asked about the urinary system device of this resident. She responded, I did not see any urinary device inside the resident's room. When she was asked if she dons a gown and gloves when providing care for Resident #94, she responded, I do not see any EBP post on top of her bed, so I only use gloves when caring for her. An interview was conducted with Staff K, LPN, on 08/26/25 at 4:04 PM, who was asked if a resident with an external urinary catheter device must follow the CDC EBP guidelines, she responded, Yes, because it is a drainage system. An interview was conducted with Staff M, MDS Coordinator on 08/27/25 at 10:54 AM, who when asked if she completed the MDS assessment of Resident #94, she responded, This resident was admitted on [DATE] and I assessed her a few days after admission. I did not see any external catheter system device during my assessment, so I documented a no response under Section H of the MDS for an external catheter. When she was asked how she verifies the resident has a urinary catheter device, she responded, I look at the resident, interview the nurses, check for physician orders and read the nursing care plan. She added there was no physician order for an external urinary catheter, and there was also no nursing care plan for an external urinary catheter for Resident #94. She added that she has never encountered an external urinary catheter before. 2. An electronic record review documented Resident # 69 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Affecting the Left Non-Dominant Side, Dependence on Dialysis, and Obstructive Reflux Uropathy.Review of the MDS assessment dated [DATE], under Section C, revealed a BIMS score of 03 indicating Resident #69 had severe cognitive impairment. Section O documented a yes response to dialysis.An electronic review of the physician orders dated 05/29/25, documented, Enhanced Barrier Precautions for dialysis, wound and Foley; Foley catheter 16 French balloon for the diagnosis of Obstructive and Reflux Uropathy. An observation and interview were conducted with Staff K, LPN, on 08/25/25 at 4:00 PM, who when asked where Resident #169 was, responded, He was transferred to another wing. An observation of the resident's new room revealed that there was no EBP sign above the resident's bed inside his new room. An interview was conducted with the Infection Control Registered Nurse (ICRN) on 08/26/25 at 11:00 AM, who was asked how soon an EBP sign is posted above the resident's bed after a room transfer, she responded, As soon as possible or within the same day of transfer. When she was asked where the EBP sign is posted, she responded, We put the sign above the resident's bed. During another observation conducted on 08/26/25 at 10:00 AM and at 12:00 PM, there was no EBP sign posted above this resident's bed. During an additional observation conducted on 08/26/25 at 11:35 AM, Staff N, CNA, was observed entering Resident #69's room without performing hand hygiene. She went straight into the Resident #69's meal tray and started cutting the meat on a plate. She asked this resident to eat, and handed him a fork, but did not provide Resident #69 any hand hygiene. When Staff N was asked if she had provided hand hygiene to this resident, she responded, I offered him a basin with warm water and soap before lunch. When she was asked how long ago that was, she responded, During the morning care, not too long ago. When she was asked if she sees an EBP sign above the resident's bed, she responded, There is no EBP sign above his bed. Staff N left the Resident #69's room without performing hand hygiene. An interview was conducted with Staff O, LPN, on 08/26/25 at 4:04 PM, who was asked if Resident #69 should have an EBP post above his bed, she responded, He should have one since he is a dialysis resident and has a chest dialysis access site. She added that yesterday was her first time caring for Resident #69. She was asked if she had worn PPE gown and gloves when care was provided for this resident, she responded, I do not remember. Staff O stated she has been working in the facility for 12 years and was not sure if this resident has an EBP posted sign above his bed. When she was asked how she manages and cares for the dialysis access site, she responded that she monitors it every shift, checks to make sure there is no drainage, and the dressing is intact. 3. An electronic record review documented Resident #36 was admitted to the facility on [DATE] with diagnoses that included Sepsis, Type 2 Diabetes Mellitus without Complications, and Obstructive and Reflux Uropathy.Review of the most recent MDS assessment dated [DATE], under Section C, revealed a BIMS score of 04 indicating Resident #36 had severe cognitive impairment. Section GG documented substantial maximal assistance on toileting which included the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.An electronic review of physician orders documented an order for EBP. An additional review of nursing care plan documented a focus that Resident #36 is at risk for infections related to urinary catheter. The nursing care plan included interventions to minimize tension on urinary meatus from catheter, and to keep catheter below level of bladder but off the floor. An observation was conducted on 08/25/25 at 10:00 AM with Staff H, Physical Therapy (PT) who was observed dropping Resident #36's urinary bag on the floor. He continued to assist Resident #36 with exercises and did not bother to pick up the urinary bag. When the surveyor made a sound and went closer inside this resident's room, Staff H, PT immediately picked up the urinary bag on the floor and hung it on Resident #36's bed. Staff H was asked why he dropped and kept the urinary bag on the floor while this resident was performing PT exercises and responded he did it accidentally. During another observation conducted on 08/26/25 at 11:54 AM, Resident #36's urinary bag revealed dark colored urine with whitish particles inside the urinary tubing. When the resident was asked if he had any discomfort related to the urinary catheter, he responded, No, but I had not taken anything to drink. A urinary care observation was conducted on 08/26/25 at 4:23 PM with Staff K, LPN, who stated that the urinary anchor is changed per doctor's order. When she was asked if staff members date the urinary anchor when changed, she responded, Yes, we put the date on urinary anchor. When she was asked if she saw a date on Resident #36's urinary anchor observed on the left inner thigh, she responded, No, I do not see a written date on the urinary anchor. She was observed leaving Resident #36's room without changing the urinary anchor with a dated one. An interview was conducted with the Rehabilitation Director on 08/27/25 at 12:28 PM, who stated that all Physical and Occupational Therapy Staff attended the annual in-services for EBP and Infection Control. She stated that her staff followed the nursing care plan intervention of making sure the residents' urinary bags are not dropped on the floor during Physical Therapy (PT) and Occupational Therapy (OT) sessions. 4. An electronic record review documented Resident #123 was admitted to the facility on [DATE] with diagnoses that included Benign Prostatic Hyperplasia without Lower Urinary Tract Infections, Type 2 Diabetes Mellitus without Complications, Bradycardia, Syncope and Collapse.Review of the most recent MDS assessment documented no BIMS score during the survey. An additional review of an electronic document, titled, Nursing Skilled Notes. v6, dated 08/25/25, revealed that Resident #123's cognition was alert, and under skin condition, no wounds were present. An additional review of the admission skin assessment dated [DATE] documented that Resident #123' skin was intact indicating the pacemaker insertion site was not assessed on admission. A further electronic review revealed no physician order for EBP related to unhealed surgical incision on 08/26/25 at 11:00 AM. [NAME] an observation and interview conducted on 08/25/25 at 9:25 AM, Staff G, PT, was inside the resident's room and was assisting Resident #123 from bed to wheelchair. Staff G was not wearing a PPE gown. When he was asked why he was not wearing a PPE gown, he stated that there is no EBP post sign above the resident's bed. In an interview conducted with the resident on 08/25/25 at 9:18 AM, he stated that he had a pacemaker insertion a week ago. He added that his surgical incision was located on the right inner upper thigh, which was still sensitive and painful at times. The resident showed the surgical incision which was uncovered and stated that he is not wearing underwear because the clothing material bothered the surgical site. When he was asked if staff donned on PPE gown and glove when proving care like changing his bed linen, and during his care he responded, No. A continued daily observation revealed there was no EBP sign above his bed from 08/24/25 until 08/27/25. During another observation conducted on 08/27/25 at 1:53 PM, Resident # 123 was inside his room sitting in a wheelchair. There was a visiting doctor attending to his roommate. This roommate had an EBP sign above his bed. The visiting doctor was not wearing PPE gown, but only gloves when inspecting the foot dressing of room [ROOM NUMBER]'s roommate. This visiting doctor removed his gloves, did not perform hand hygiene, and immediately sat in front of Resident #123, to start performing assessment. 5. Record review documented Resident #57 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease with Acute Lower Respiratory Infection, Chronic Kidney Disease, Cellulitis of Left Toe, Osteomyelitis of Left Foot and Ankle, and status post Vascular Surgery of the Left Foot. Resident #57 was discharged from the facility on 08/26/25, during the third day of this survey. Review of the latest MDS assessment dated [DATE] revealed Resident #57 had a BIMS score of 15 indicating intact cognitive function. Section N documented she was receiving an antibiotic, diuretic, opioid, antiplatelet and an anticonvulsant. An electronic record review of a physician order dated 08/04/25 revealed EBP for wound and IV (Intravenous). This EBP order related to wound and IV was discontinued on 08/26/25. During an observation conducted on 08/24/2025 at 3:01 PM, Staff P and Staff L, both CNAs, were in the middle of perineal care and linen changing for this resident. There was an EBP sign posted above Resident #57's bed. CNAS were observed not wearing Personal Protective Equipment (PPE) gowns. When they were asked, they responded, We do not wear gowns just gloves when changing the underwear and bed sheets for this resident.

Based on observations, interviews and record reviews, the facility failed to provide food that meets residents' preferences, for 2 of 23 sampled residents observed during dining, Resident #91 and Resident #107.The findings included:1. Record review revealed Resident #91 was admitted on [DATE] with diagnosis of Polyneuropathy and Psoriatic Arthritis Mutilans. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score was 14, indicating no cognitive impairment.In an observation conducted on 08/24/25 at 12:30 PM, the surveyor observed Resident #91's meal ticket consisted of 6 ounces (oz) of chili with beans, 1/2 cup of tossed salad, 1 piece (pc) of dressing, 1 pc of cornbread, 1packet of margarine 1/2 slice of sweet potato pie, 8 oz of iced tea x3, green apple x1 on Fridays only, no fish, turkey sandwich on tray with meal. Resident #91's meal tray did not have the turkey sandwich on it.An interview was conducted on 08/24/25 at 12:30 PM with Resident #91 who stated it is pointless to select between the choices on the menus because he never gets what he chooses.2. Record review revealed Resident #107 was admitted on [DATE] and readmitted on [DATE] with diagnosis of Acute Respiratory Failure with hypoxia and Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation. The Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 12 indicating mild cognitive impairment.In an observation conducted on 08/24/25 at 12:15 PM, the surveyor observed that Resident #107's tray consisted of Chili with beans, cornbread, tossed salad and a slice of sweet potato pie. Resident #107's tray was untouched.An interview was conducted on 08/24/25 at 12:20 PM with Resident #107 who stated he was never aware he could choose from different menus. He was never asked his preferences. He further explained that he usually gets the food that they want to serve him. When he likes it, he eats and when he doesn't, he doesn't eat.An interview was conducted on 08/27/25 at 1:45 PM with the Certified Dietary Manager (CDM) who stated she has been working in this facility for 30 years. She stated that when a resident gets admitted she goes to the room with a sheet to write down their likes and not likes. She explained that they get a weekly menu only if they request one and they can also look at the board in the hall that has the menu. The CDM was made aware of the findings who stated that maybe providing weekly menus to the residents would help. She explained that they have a checker at the end of the tray line and the nurse on their wings also makes sure that the meal ticket matches the tray.

Based on observations, interviews and record review, the facility failed to revise and update care plans in timely manner for 2 of 23 sampled residents, Residents #7 and #96. The findings included:Review of the facility's policy titled, Comprehensive Care Plans with a revised date of 07/27/22 included in part the following: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive quarterly MDS (Minimum Data Set) assessment. Review of the facility's policy titles, Comprehensive Care Plans with a revised date of 07/27/22 included in part the following: 1. Record review for Resident #96 revealed the resident was originally admitted to the facility on [DATE] with readmission on [DATE] with diagnoses that included in part the following: Metabolic Encephalopathy and Dementia. Review of the Minimum Data Set assessment dated [DATE] documented in Section C, a Brief Interview of Mental Status score of 1, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #96 revealed an order dated 11/07/24 for Code Status: Full Code. Review of the Care Plan for Resident #96 with an initiated date of 12/22/23 and a revised date of 04/11/25 and with a focus on the Resident has Advance Directives is as follows: authorized responsible party request DNR (Do Not Resuscitate) wish to be honored. The goal was for the Advance Directives to be honored as indicated through next review. The interventions included in part the following: DNR status: Verify presence of physicians' order for DNR. Review DNR Status and orders quarterly and as needed. An interview was conducted on 08/26/25 11:52 AM with Director of Social Services who stated she has worked at the facility for 3 years. She stated she addresses the code status, unless it is on weekend or evening and then it is addressed by nurse who admits the resident, and she would follow up. When asked about initiating the care plan, she stated it is her, unless the resident is admitted overnight or on the weekend. She updates the care plan quarterly or when there are changes. When asked about Resident #96, she verified the code status as being full code based on the face sheet and the order. She verified the advanced directive care plan indicated the resident is a DNR. She then excused herself to check the code status book and verified the resident was a full code. She stated there may have been a discussion of hospice and talk of a DNR, but the resident is full code. An interview was conducted on 08/26/25 at 12:50 PM with the Director of Nursing (DON) who stated she has worked at the facility for 2 years. When asked about how nurses determine the code status, she said they check the banner at the top of the electronic medical record and the order. When asked about Resident #96, she acknowledged the code status for the resident was for a full code and the care plan was not updated to reflect the code status of full code until updated today, after surveyor interview. 2. Review of the physician's orders for Resident #7 revealed in part the following:An order dated 12/26/23 documented, Delegate to dietitian the responsibility to alter, change, or modify dietary orders including oral supplements, measurement of height and weight, modification to or addition of diet restrictions/therapeutics, downgrade of diet consistency in consultation with SLP when needed, enteral feeding and water flushes An order dated 12/26/23 documented, Resident to have Dialysis on days: Tuesday, Thursday Saturday Chair time: 5:30AM Catheter site: left arm Dialysis Transport, Bag meal/snack to go with resident to Dialysis yes, Fluid Restriction yes. Pick up time 4:45 AM to 5:15 AM An interview was conducted on 08/25/25 at 9:45 AM with Resident #7 who was asked if he goes to dialysis, and responded, 'yes, he goes on Tuesdays, Thursdays and Saturdays around 4:00 PM'. When asked if they send a snack, sandwich or dinner with him, he said sometimes. When asked if he is on any type of fluid restriction, he said he cannot have anything to drink except what they bring him, which is very small cups of water and his Nepro supplement. The resident stated he was compliant with the fluid restriction and watches his fluid intake. There were no extra drinks or fluids at the bedside. An interview was conducted on 08/26/25 at 12:18 PM with the Registered Dietitian who stated she has been with the facility since October 2024. Assessments are on done annually, quarterly and as needed for significant change or readmission. When asked about Resident #7, she said he is on dialysis and on a renal diet and no fluid restrictions. The fluid restrictions were discontinued on 06/12/25 because he has had no issues with fluid. She discussed Resident #7 with the renal dietitian from the Dialysis Center and agreed to discontinue fluid restrictions in part because of non-compliance. She stated she is in charge of updating the nutrition care plan. The nutrition care plan was updated on 08/07/25 to reflect fluid restrictions being discontinued. She said the resident is aware of not having fluid restrictions in place any longer. She said she attends the quarterly care plan meeting An interview was conducted on 08/26/25 at 12:40 PM with Staff A MDS Coordinator who stated she has worked here 2 years. When asked about updating care plans, she said she updates care plans for more of the medical related care plans, dietary updates the nutrition and social services updates behaviors and activities updated activity care plans. When asked about Resident #7's care plan for fluid restriction, she said he has an active care plan for fluid restrictions, and she verified this by the order for dialysis that included fluid restrictions. An interview was conducted on 08/26/25 at 12:50 PM with the Director of Nursing (DON) who stated she has worked at the facility for 2 years. When asked about Resident #7, she acknowledged the resident had an order for dialysis that included fluid restrictions and acknowledged the care plans and the orders were not updated to reflect that the resident was no longer on fluid restrictions.

Based on observations, interviews, and record reviews, the facility failed to initiate a nursing care plan for an external urinary catheter system device for 1 of 4 sampled residents, reviewed for urinary care, Resident 94. The findings included: Record review of the policy titled, Comprehensive Care Plan, revised 07/27/22, documented the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in resident's comprehensive assessment. The comprehensive care plan will be developed within 7 days after the completion of comprehensive MDS assessment. The comprehensive care plan will describe at a minimum the following: resident specific interventions that reflect the resident's needs and preferences. Review of the policy titled, External Catheter for Female Urinary Incontinence Management, revised 09/01/22, documented that the nurse will obtain and verify orders for use of external female catheter (.2).Electronic record review documented Resident # 94 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with Hypoxia, Pneumonia, Segmental and Somatic Dysfunction of Cervical Region, Urinary Tract Infections, and Pseudomonas Aeruginosa. Review of Minimum Data Set (MDS) assessment dated [DATE] under Section C of the Brief Interview for Mental Status (BIMS) revealed a score of 15, indicating no cognitive impairment. Section GG documented that the resident was dependent on toileting, hygiene which included the ability to maintain perineal hygiene and adjust clothes before and after voiding. Section O documented yes on antibiotics, intravenous (IV) medications and midline IV access.Record review of the physician orders did not document any care and management related to Resident #94's female external urinary catheter system device. Review of the nursing care plans did not include focus, goals and interventions related to the external urinary catheter system device.An observation was conducted on 08/24/25 at 2:12 PM. Resident #94 was lying in bed with a slightly elevated head. A suction tubing was coming out from her left side. This suction tubing was connected to a canister on top of the bedside table. The canister was observed with dark tea colored urine of about 150 to 200 milliliters (ml). An observation was conducted on 08/25/25 at 11:44 AM. The canister contained light tea colored urine of about 200 ml. It was connected to a suction tubing observed coming out of this resident's left side. An observation and interview was conducted with Staff E and Staff F, both Certified Nursing Assistants (CNAs), on 08/25/25 at 3:50 PM, who they stated that Resident #94 only uses the urinary catheter system device at night. When they were asked if the system was being used by this resident now, they responded, Yes, she was wearing the wick pad that was connected to the suction and the canister. An interview was conducted with the Infection Control Registered Nurse (ICRN) on 08/25/25 at 3:41 PM, who when asked how facility staff would know that resident's care is following the Enhanced Barrier Precautions (EBP) guidelines from the Center for Disease Control and Prevention (CDC), responded, An EBP post is found on top of resident's bed. When she was asked if an external urinary catheter system device must follow CDC's EBP protocol, she responded, No. When she was asked why Resident #94 did not have an EBP sign above her bed, she responded, Her urinary care is not included in CDC guidelines for EBP.An interview was conducted with Staff K, Licensed Practical Nurse (LPN), on 08/26 25 at 3:41 PM, who was asked if there were an order and a nursing care plan for the urinary catheter system device, she responded, I do not know. An interview was conducted with Staff M, MDS Coordinator, on 08/27/25 at 10:54 AM, when she was asked if she completed the MDS assessment of Resident #94, she responded, This resident was admitted on [DATE], and I assessed her a few days after admission. I did not see any external catheter system device during my assessment, so I documented a no response under Section H of the MDS for an external urinary catheter. She stated there was no order for an external catheter, and she did not see any nursing care plans for any external urinary catheter. She stated she had never encountered an external urinary catheter before.

Based on interviews and record review, the facility failed to ensure residents funds account were disbursed in 30 days to the representative after the residents' death for 3 of 3 sampled residents, Resident #1, #2 and #3. The findings included: Review of the facility's policy, titled, Resident Personal Funds, date implemented [DATE], documented, in part, .conveyance upon discharge, eviction, or death: upon discharge, eviction or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident, in case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. 1. Review of Resident #1 clinical record documented an admission on [DATE] and an expiration date of [DATE] in the facility. Review of the resident's nursing noted dated [DATE] documented .nurse was called inside patient's room, resident was assessed and noted with no pulse, no respiration .Rescue called in, and pronounce patient's death. Review of the resident's profile record documented the resident had a Power of Attorney (POA) listed on the record. On [DATE] at 12:05 PM, an interview was conducted with the Business Office Manager (BOM) who stated she had been working at the facility as BOM since ,d+[DATE]. she stated her role included management of the residents' personal funds account utilizing the Resident Funds Management System (RFMS). The BOM stated the facility had a new owner effective [DATE] and was waiting for the RFMS accounts to merge. The BOM stated that as of [DATE], the merged had not been completed. On [DATE] at 12:35 PM, a side-by-side review with the BOM of the Resident #1's Resident Fund Management Services (RFMA) account report, provided by the BOM, dated [DATE] through [DATE], was conducted. The report documented an entry described as Care Cost Payment with amount of $165 debited to account [# provided]. The BOM was asked why the account number was different from all other debited monies (account # provided]. She stated she was not working back then and did not know what happened. Further review revealed that Resident #1's account was closed dated [DATE], and a check had been disbursed to POA dated [DATE]. The BOM stated Resident #1's POA came to the facility every day, every week, was always in touch with the BOM regarding the funds and was given a copy of the statement when she was in the building. The BOM added the POA was handling everything for the resident. The BOM stated Resident #1 had $394.86 when the account was closed, and the account was transferred from old owner to the facility's new owner in [DATE]. The BOM stated she did not have access to the resident's old account system and the new owner was effective [DATE] and some records did not transfer over. The BOM stated the POA got a refund for $130 prepared on [DATE], added she remembered the daughter calling her because the check was made out on the resident's name and she called to have it redone. The refund was made because of the company owner change and every account with a credit had to be refunded. The BOM was asked why it was taking so long to refund / disburse Resident #1's funds to the POA. The BOM stated the facility was waiting for everything to merge. The BOM was asked regarding the timeline to refund funds and stated it had to be done in 30 days. 2. Record review of Resident #2's nursing note dated [DATE] documented Resident's granddaughter is informed that resident has expired. The clinical record documented a granddaughter as an emergency contact #1, Son as an emergency contact #2 and a daughter-in-law as an emergency contact #3. On [DATE] at 12:45 PM, a side-by-side review of Resident #2's RFMA was conducted with the BOM that revealed the resident had a current balance account for the amount of $100.02. The BOM stated Resident #2 was admitted to the facility on [DATE], was on hospice care and had expired in the facility on [DATE]. The BOM was asked if she sent a letter to the resident representative regarding the account funds and replied that the account was still open, and she had not sent a letter to the representative. The BOM stated she usually closed the account right then and there and I own this one. The BOM stated she does not send letters out. 3. Record review of Resident #3's nursing progress notes dated [DATE] documented Called [hospital] ED [Emergency Department] and spoke with [staff name]. He informed this writer that the resident was still in the ED but would be admitted to the Progressive Care Unit with diagnoses of Pneumonia and Sepsis. The clinical record documented a cousin as the responsible party / guardian and emergency contact. On [DATE] at 1:05 PM, a side-by-side review of Resident #3's RFMA was conducted with the BOM that revealed the resident had current balance account for the amount of $63.03. The BOM stated Resident #3 was admitted to the facility on [DATE], was transferred to a local hospital on [DATE] and did not return to the facility and was told the resident had expired. The BOM was asked if she sent a letter to the resident representative regarding the account funds and replied that the account was still open and did not send a letter to the representative. The BOM stated Resident #3's funds account was still open. She would be sending to unclaimed property since there was no POA on file. The BOM stated there was a cousin as an emergency contact on file and she did not know if she had POA papers. On [DATE] at 1:45 PM, a joint interview was conducted with the Administrator and the BOM. The Administrator was asked for the regulation regarding timeline to refund resident's funds and stated 30 days. The Administrator was apprised of the findings. The Administrator stated the facility's transition to new owner happened in [DATE].

Based on interviews and record review, the facility failed to making prompt efforts to resolve a resident's Power of Attorney (POA) grievance sent on [DATE], as evidenced by the lack of written documentation of follow-up communication with the representative until the representative sent another communication on [DATE], for 1 of 3 sampled residents, Resident #1. The findings included: On [DATE] at 12:05 PM, an interview was conducted with the Business Office Manager (BOM) who stated she had been working at the facility as BOM since ,d+[DATE], and her role included management of the resident's personal funds account utilizing the Resident Funds Management System (RFMS). The BOM stated the facility had a new owner effective [DATE] and was waiting for the RFMS accounts to merge, and added, that as of [DATE], the merged had not been completed. The BOM stated that Resident #1 was admitted to the facility on [DATE] and had expired in the facility on [DATE]. The BOM stated the resident's Power of Attorney (POA) was aware of the merge. The BOM was asked to submit letters or written evidence of communicating with the resident's POA regarding Resident #1's funds reimbursement. The BOM stated she did not send the POA a letter but had an electronic communication from the POA. A side-by-side review of Resident #1's POA electronic communication to the Administrator dated [DATE] documented, I need assistance in getting in touch with your home office .Resident name (Resident #1) passed away on [DATE] still has a trust account that I am trying to close and receive the remaining funds .let me know what needs to be done . The BOM's response via electronic communication dated [DATE] documented, .had previously explained we had to transfer funds from the old owners to the new owner's bank .everything has been finalized .account has been closed today. It takes about 24 hours to update, and the account will be closed. Once the account is closed, I will be able to issue the payment . A side-by-side review of the resident's POA's electronic communication to the Administrator and the BOM dated [DATE] documented, Please provide me with an update on the status of check for closed account (Resident #1). The POA-mailing address was noted. The BOM's response dated [DATE] documented, I will have the check ready for pick up this week. I will call you Monday to coordinate a time or I can put it in the mail. The resident's POA response dated [DATE] documented, please mail to address below and make check payable to . During the review, the BOM was asked what happened from [DATE] since the POA request for assistance and there was no response to her request until she contacted you again on [DATE]. The BOM stated they were waiting for the merge of the funds accounts from the old owner to the new owner. The resident's POA reimbursement check was dated [DATE].

Based on observation, interviews, record and policy review, the facility failed to implement an effective infection control program as evidenced by the facility failed to follow recommendations by the Centers for Disease Control (CDC) and failed to follow through with N95 mask recommendations by the Florida Department of Health (DOH) after 3 visits by DOH were made to the facility following a COVID-19 outbreak, affecting 3 of 5 Personal Protective Equipement (PPE) linen carts on the first and 2nd floor of the facility. The findings included: 1. Review of the CDC recommendations for Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated March 18, 2024, recommended, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard (29 CFR 1910.134) On 07/08/24 at 9:09 AM, an initial tour of the facility was conducted which focused on the isolation carts. The surveyor observed the 100 unit, which revealed a three (3) drawer isolation cart outsideof room [ROOM NUMBER]. The sign by the door read Special Droplet / Contact precautions. Photographic Evidence Obtained. Further observation revealed a box of KN95 and a box of surgical facial masks in the cart first drawer. The observation revealed no N95 respirators (mask) in any of the cart drawers or eye protection. Photographic Evidence Obtained. Three of the five PPE carts observed throughout the facility did not have N95 masks or face shields in the carts upon the initial tour of the facility. 2. Review of the Florida Department of Health (DOH) recommendations provided to the facility post DOH visit on 06/29/24 revealed during the facility tour, the Personal Protective Equipment (PPE) carts were not readily accessible near the room of residents on isolation for COVID-19. The PPE carts were not stocked with N95 masks. Addionally, DOH had observed that staff exited a resident's isolation room wearing a KN95 mask instead of a National Institute for Occupational Safety and Health (NIOSH) approved particulate N95 mask. An interview was conducted with the Director of Nurses (DON) on 07/08/24 at 10:30 AM. She stated an Infection Preventionist (IP) from the Florida Department of Health (DOH) visited the facility on 06/28/24, 07/01/24 and 07/02/24 and made the following recomendations. She made recommendations that the N95 masks needed to be in the isolation carts, and they needed more carts out. On 07/02/24, the DOH emailed the DON and IP stating she was able to obtain a Fit Testing kit for the facility free of charge and to let her know when they are ready to do that. The DON stated that she put more carts out and put N95 masks on the carts. She stated that everyone is responsible for making sure the carts are stocked with N95 masks but she and the IP from the facility make sure when they come in that the carts are stocked. The DON stated that on the weekend, the supervisor stocks the carts, and during the week central supply stocks when she starts her shift at 2:00 PM and when she leaves for the day. The DON was asked who is ultimately responsible for keeping the carts stocked and she replied that we all are. All nurses have access to central supply where the masks are kept and there are plenty of masks. Discussed with the DON that some carts have 3 different types of masks in them. She stated that she was making it easier for the staff to obtain all types of masks available if they do not need an N95 for an isolation room. Discussed how staff know what type of mask to wear upon entering an isolation room and she replied that she did constant education for the staff regarding the type of mask and handed each one an N95 mask as an example of the mask to wear when they enter an isolation room. Discussed with the DON that upon the initial tour of the facility, N95 masks were not available in 3 of 5 carts and no eye protection was available in the carts. She stated she was surprised that that was true but when she looked at the pictures taken, she acknowledged that there were no N95 masks or eye protection in 3 of the carts. The DON was then asked about the start of the COVID-19 outbreak. She stated on 06/24/24, she became aware that one of the residents had tested positive for COVID-19 when they went to the hospital for a urinary tract infection (UTI). She then tested the whole facility and found that 18 residents tested positive on 06/24/24. Eight (8) residents tested positive on 06/26/24. Four (4) residents tested positive on 07/02/24. One (1) resident tested positive on 07/03/24. At that time, a total of 39 residents had tested positive and 16 staff had tested positive from 06/24/24 to 07/05/24. They immediately closed the dining room down and did room visits for activities on 06/24/24. After today (07/08/24), there are 6 residents positvie with COVID-19. Two (2) residents were admitted from the hospital with COVID-19. On 07/08/24 at 11:40 AM, an interview was conducted with Staff A, Certified Nursing Assistant (CNA). Staff A stated she had in-services about how to wear a mask and make sure before they enter the room that that put on a mask and gloves and gown. She was asked what type of mask she would wear to enter a resident's room with COVID-19. She chose a KN95 mask that she was wearing at the time of the interview. The surveyor pointed to an N95 mask on the table in front of her and asked her if she would ever put that mask on and she said she would not. She has no residents with COVID-19 now, but she had residents with COVID-19 previously. She stated there were always masks available and she would ask a supervisor if she did not see any masks in the cart. She is a full-time employee. An interview was conducted with the IP on 07/08/24 at 2:33 PM. She stated she returned to work on July 1 after being on leave for 6 weeks. When she returned, the COVID-19 positive residents were isolated in their rooms, testing and notification was done to the DOH. She was aware that the IP from the DOH was here. She said she was coming in early to do staff in-services. Central supply was accountable for putting the masks in the carts, but she starts her shift at 2 PM. In the mornings her and the DON were putting masks in. The Supervisor stocks on the weekend. The surveyor asked why all of the carts were not stocked this morning with N95 masks and she stated that she was doing other tasks this morning and the DON was not scheduled to come in today. She felt she was caught up to speed with the COVID-19 outbreak when she returned. She was asked about the Fit testing recommendations and she stated that she would have to bring this up to the Regional Nurse. When asked if she had discussed this with her yet, she replied that she did not. An interview was conducted with Staff K, Central Supply person, on 07/08/24 at 3:13 PM. She stated she has worked in central supply for about a year. When she comes in, she makes sure everything is in the carts. Face shield, gloves and the KN95 and the N95 and the surgical masks are stocked. Then she checks in between and when she leaves. She works Monday through Friday. On the weekend the supervisor does it for her. The DON helps in the daytime. She always had enough N95 masks even before the outbreak. There are usually 1-2 masks left when she comes in. She does not track how many are used. She puts a full box of N95 in the carts before she leaves at night. She does not get complaints about lack of supplies. 36057 3. Review of the facility's Standards and Guidelines: Screening, Testing, Return to Work (HCP), Personal Protective Equipment, Isolation, Reporting- Section Infection Control COVID-19 issued on 01/15/24 provided by the Director of Nursing documented under PPE (Personal Protective Equipment) Hand Hygiene, .Transmission Based Precautions will be implemented and signage instructing the appropriate use of PPE's will be posted outside the resident's door. Hand hygiene should be performed for at least 20 seconds with soap and water: before donning and doffing PPE . On 07/08/24 at 9:13 AM, observation revealed a three (3) drawer isolation cart outside room [ROOM NUMBER]. Further observation revealed a box of KN95 and a box of surgical facial masks in the cart first drawer. Further observation revealed no N95 respirators (mask) in any of the cart drawers (Photographic evidence). On 07/08/24 at 9:18 AM, observation revealed two isolation cart next to room [ROOM NUMBER]'s door. Further observation revealed neither cart contained N95 masks or eye protection gears /face shields. Photographic Evidence Obtained. On 07/08/24 at 9:21 AM, observation revealed Staff E, Licensed Practical Nurse (LPN), wearing a KN95 mask. An interview was conducted with Staff E who stated she had residents in room [ROOM NUMBER] and 226 on isolation due to a positive COVID-19 testing. Staff E stated she wore a KN95 mask and switch to an N95 mask when entering a resident's room who was positive for COVID-19. Staff E was asked where she would get the N95 mask from and pointed to room [ROOM NUMBER] isolation cart. A side by side observations with Staff E of room [ROOM NUMBER]'s isolation cart was conducted and Staff E confirmed there was no N95 masks in the cart. On 07/08/24 at 9:24 AM, observations revealed room [ROOM NUMBER]'s door wide open, no isolation cart noted outside the room. The room door had a sign that read Special Droplet / Contact Precaution - Personal Protective Equipment .put on mask and eye protection . Further observation revealed the lack of an isolation cart next to room [ROOM NUMBER]'s door. Observation of room [ROOM NUMBER] door's sign read Special Droplet / Contact Precaution - Personal Protective Equipment .everyone MUST clean hands when entering and leaving the room .wear a NIOSH-approved N95 wear an eye protection .keep door close . Further observation revealed that there was no consistent with the door signs for residents on Droplet / Contact Precautions as evidenced by one sign specified the use of N95 and the other sign did not. On 07/08/24 at 9:26 AM, an interview was conducted with Unit Manager (UM) who stated that residents in room [ROOM NUMBER] and 215 recovered and would be removed from isolation today. Observation revealed the isolation cart for room [ROOM NUMBER] did not contain any eye protection gear / face shields. On 07/08/24 at 9:08 AM, a tour to the facility's C-wing revealed Staff B, Registered Nurse, at the nurses station wearing a KN95 facial mask. An interview was conducted with Staff B who stated she worked the night shift (11:00 PM to 7:00 AM) and finishing up her documentation. Staff B was asked how many residents she had that were on precautions due to a positive test for COVID-19 infection and replied five (5). Staff B was asked which facial mask she wore when she entered those residents' room and pointed to the one she wearing. On 07/08/24 at 9:15 AM, observation revealed Staff C, Certified Nursing Assistant / CNA, wearing a KN95 facial mask. An interview was conducted with Staff C who stated she used an N95 mask for a week when the COVID-19 outbreak started, then was out due to COVID-19 infection. Staff C stated on her return she was told she did not have to use an N95 mask. Staff C was asked if she was assigned to any residents that were currently on precautions due to a positive test for COVID-19 infection and replied she had residents in room [ROOM NUMBER] and room [ROOM NUMBER]. Staff C was asked which mask she wore while caring for those residents and pointed to the one she was wearing (KN95). Staff C was asked why she was not wearing an N95 when taking care of a resident positive with COVID-19 and replied the residents were in the facility for a while and she did not have to use an N95 mask to work with them. Staff C was stated she did not change her KN95 mask every time she enter room [ROOM NUMBER] or 230 and added, foe example, like when she answered a call light for residents positive for COVID-19 infection. On 07/08/24 at 9:18 AM, observation revealed Staff D, CNA, wearing a surgical mask, then she removed the surgical mask and put on a KN95 mask. Staff D stated she had a resident in room [ROOM NUMBER] who was positive for COVID-19. When asked which mask she uses when taking care of a resident on isolation due to COVID-19, Staff D pointed to the mask she had just changed to, a KN95 mask. On 07/08/24 at 9:27 AM, observation revealed Staff F, CNA, walking down the C wing hallway and wearing a surgical mask. Staff F stated she wore a surgical mask while on break and just came back from break. Staff F was asked which mask she would use when taking care of a resident positive for COVID and stated she would use a KN95 mask. Staff F then pulled a KN95 from her uniform pocket. Staff F was assigned to rooms [ROOM NUMBERS], who had residents who were positive for COVID-19. On 07/08/24 at 11:50 AM, observation revealed Staff E, LPN, in room [ROOM NUMBER]. The door was slightly opened and Staff E was observed wearing a gown, gloves and an N95 mask. Further observation revealed an isolation cart with N95 masks and surgical mask on the first drawer next to room [ROOM NUMBER]'s door. This cart was not there earlier during the morning tour. On 07/08/24 at 11:57 AM, observation revealed a random resident in the facility's gymnasium exercising, not wearing a facial mask and Staff G, Occupational Therapist (OT), sitting by her desk apart from the resident and was not wearing a facial mask. An interview was conducted with Staff G who stated the resident was not on contact isolation and she was more than six feet apart from the resident. Observation revealed a KN95 mask on top of her desk. Staff G was asked when she would use a facial mask and replied that she would use a KN95, while picking up the KN95 on top of her desk, when she goes to an isolation room then would change it to a regular, surgical mask. Staff G stated she attended the facility's in-service provided related to COVID-19 and what personal protective equipment to use when providing care to a resident on isolation due to COVID infection. On 07/08/24 at 12:04 PM, observation revealed Staff H, Physical Therapist (PT), in the therapy gymnasium wearing a KN95 mask. An interview was conducted with Staff H who stated she had been using a KN95 mask since the facility's COVID-19 outbreak. Staff H stated that she wore a KN95 when treating residents positive for COVID-19 in their room. Staff H stated she attended the facility's in-service provided related to COVID-19 and what personal protective equipment to use when providing care to a resident on isolation due to COVID infection. 3a. Review of Resident #1's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's physician order dated 07/03/24 documented, Transmission Based Precautions due to r/o [related to] COVID-19 and/or possible exposure every shift. The resident nursing progress note dated 07/03/24 documented Aware of COVID positive status. Sister too. On 07/08/24 at 12:35 PM, observation revealed Staff I, CNA, standing by room [ROOM NUMBER] with a sign of Droplet / Contact Precautions, with the door wide open, wearing a disposable yellow gown and a KN95 mask, and no eye protection was noted. Staff I came out of the room and rummaged through the isolation cart's first drawer. The isolation cart was now next to room [ROOM NUMBER]'s door which it was not there before. Staff I then moved to rummaged through isolation cart next to room [ROOM NUMBER]'s door and retrieved an N95 mask. Further observation revealed Staff I placed the two N95 mask's straps and left them on top of her head, rather that placing one over her neck to obtain a good seal. Further observation revealed Staff I asked for both residents' lunch tray to be delivered at the same time. On 07/08/24 at 12:36 PM, observation revealed Staff I, CNA, entered Resident #1's room and delivered his lunch tray. At 12:37 PM, Staff I came out of the room wearing the yellow gown, and N95, and kept the room door wide open while waiting for Staff E to bring the roommate's tray. On 07/08/24 at 12:47 PM, observation revealed Staff J, Occupational Therapist Assistant (OTA), donning a PPE gown, gloves and wearing KN95 mask. Staff J entered Resident #1's without donning an N95 mask. At 1:06 PM, observation revealed Staff J in the residnet's room, who stated he was treating Resident #1 and had 7 more minutes to go of treatment. On 07/08/24 at 3:36 PM, a telephone interview was conducted with Staff J, OTA, who stated he was supposed to wear an N95 when he was providing therapy session today to Resident #1. He added it slipped on me and stated he was aware that they have to use an N95 when in room with resident positive with COVID-19. 3b. Review of Resident #2's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's physician order dated 07/03/24 documented, Transmission Based Precautions due to r/o COVID-19 and/or possible exposure every shift. The resident nursing progress note dated 07/02/24 documented, Late Entry: wife and MD [medical doctor] notified of COVID positive status. On 07/08/24 at 12:39 PM, observation revealed Staff E, LPN, brought Resident #2's lunch tray and handed it to Staff I, CNA, who then proceeded to set up the food for the resident, the room door was open from 12:35 PM to 12:45 PM. Staff I did not change her gown or N95 mask before caring for Resident #2. Staff I removed the yellow gown at the resident's room door, and walked away with the N95 mask on. An interview was conducted with Staff I who stated she was supposed to take the N95 mask off and forgot. On 07/08/24 at 12:42 PM, an interview was conducted with Staff E, LPN, who stated Resident #1's door was supposed to be closed at all times and the staff had to change gowns between resident care and confirmed Staff I did not keep the door closed or change the gown between the 2 residents' lunch tray's set up. On 07/08/24 at 12:57 PM, observation revealed Staff I, CNA, wearing a gown, delivered a lunch tray to room [ROOM NUMBER] and kept the room door wide open. On 07/08/24 at 1:02 PM, observation revealed the Unit Manager stated Staff I, CNA, did not need a red bag and instructed her to drop the yellow gown in a regular trash bag. Staff I then performed hand hygiene by using hand sanitizer from the canister outside room [ROOM NUMBER] rather than soap and water as per the facility's guidelines. Staff I then retrieved a resident's lunch tray from the trays cart.

Based on observation, interview, and record review, the facility failed to address a skin rash for 1 of 1 resident sampled for skin condition, Resident #97; and failed to address new symptoms of a Urinary Tract Infection in a timely manner for 1 of 1 sampled resident, Resident #59. The findings included: 1. Record review documented Resident #97 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, was dependent for activities of daily living, and had a tracheostomy and feeding tube. The record documented Resident #97 was care planned for a rash/itching to upper back on 04/01/24. Interventions included: give anti-pruritic (anti-itching) medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor skin rash for increased spread or signs of infection. Record review revealed an order dated 03/30/24 for Permethrin External Lotion 1 % (medication to treat Scabies) to apply to right lower back topically two times a day for Itching. Review of the progress note dated 03/30/24 at 4:05 PM documented: Resident's family inquire about cream for itching and rash on right lower back. Order received today to start on Permethrin 1% lotion to apply to lower back for itching. Review of Resident #97's Medication Administration Record revealed the medication was not administered until 04/05/24 at 5:00 PM. Further record review did not reveal any documentation of why the medication was not administered when ordered. Further record review revealed an order dated 04/21/24 for Permethrin External Lotion 1% to apply to upper back topically every day and evening shift for Itching for 2 weeks. There was no documentation of the condition of Resident #97's rash since the initial order of the medication for itching on 03/30/24. An interview was conducted with the Director of Nursing (DON) on 04/24/24 at 11:00 AM. The DON stated she was not aware of Resident #97's rash and prescribed treatment. The DON acknowledged the prescribed treatment is used to treat scabies. The DON further acknowledged the lack of documentation of the resident's rash, and the resident did not have a dermatologist consult ordered. An interview was conducted with Staff G, Licensed Practical Nurse (LPN), on 04/24/24 at 11:20 PM. Staff G stated she was aware of the rash on Resident #97's back. Staff G stated she did not know if the rash itched, as the resident could not verbalize if it did. An interview was conducted with Resident #97's Power of Attorney (POA) at bedside on 04/25/24 at 11:00 AM. The POA stated she was aware of the rash on the resident's back and the facility had prescribed a cream for the rash. The POA stated she had inquired if the rash was scabies and was told no. The POA did not know if the resident was still receiving the cream. A phone interview was conducted with the Nurse Practitioner (NP) on 04/25/24 at 1:15 PM. The NP stated Resident #97 did not have Scabies. The NP stated she prescribed Permethrin for Resident #97 due to the fact the resident was in the hospital for 2 months, was now bedbound, and at high risk for infection. The medication is to prevent an infection. The surveyor questioned the NP about a dermatologist consult for the resident's rash. The NP replied, That's a good idea. A phone interview was conducted with the Consultant Pharmacist on 04/25/24 at 1:25 PM. The Consultant Pharmacist stated Permethrin is used to treat Scabies. The Consultant Pharmacist stated he was not aware of any off-label use for the medication. 39026 2. Record review documented Resident #59 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes. Review of the annual Minimum Data Set (MDS) with an assessment reference date of 04/06/24 documented the Brief Interview for Mental Status (BIMS) score was 12, indicating the resident had mild cognitive impairment. On 04/23/24 at 10:21 AM, an interview was conducted with the resident. She stated she was having burning with urination. Upon leaving the room, Staff C, LPN was standing outside of the room. Staff C was asked if she was the nurse for this resident and she said that she was. The surveyor relayed to Staff C that the resident stated she had burning with urination and asked if she could go to check on her. Staff C stated she would follow up and speak with the resident. On 04/24/24 at 11:00 AM while doing a record review for Resident #59, there were no progress notes written about a conversation with the resident regarding burning with urination or any new orders. On 04/24/24 at 1:55 PM, the surveyor spoke with Staff C again and asked if she followed up with the resident since there are no progress notes to this effect. She stated she called the resident's primary doctor yesterday and he said no new orders. She stated that she did not write a progress note but will put one in the record today. Review of a 'general note', dated 04/24/24 at 2:00 PM, documented: nurse follow up with resident regarding resident stating that she has pain while urinating. Resident stated, I still have a little bit of pain while urinating. Nurse called MD and left a message, waiting for a call back. Care continues. Review of the progress note written by Staff C dated 04/24/24 at 2:50 PM revealed Nurse followed up with resident today, resident stated I still have a little bit of pain while urinating. Nurse called MD yesterday and received NNO [no new orders]. Nurse called MD [Medical Director] back today regarding resident still c/o [complaining of] pain while urinating, received new orders for U/A C&S [Urinalysis Culture & Sensitivity] to be collected. On 04/24/24 at 2:57 PM, the surveyor called the nurse who stated she takes care of the nursing home calls for the doctor. She stated the facility called an hour ago and got an order from the physician for a urine problem for that resident. She was asked if the facility had called yesterday for this resident, and she looked in her records and stated that there was no call yesterday. On 04/24/24 at 4:30 PM, a phone interview was conducted with the Physician, who stated there was no call yesterday to him regarding this resident. On 04/24/24 at 5:00 PM, the findings were discussed with the Regional Nurse Consultant. On 04/24/24 at 7:20 PM, the Director of Nurses received an order for Pyridium for Resident #59. Pyridium is a medication used to relieve symptoms caused by irritation of the urinary tract such as pain and burning. On 04/25/24 at 12:30 PM during interview the resident stated that she is not feeling the burning today. On 04/25/24 at 1:00 PM, the Regional Nurse Consultant revealed that a urine sample was obtained and was picked up this morning by the lab.

Based on observation, interviews, record, and policy review; the facility failed to maintain physician oversight for worsening pressure wounds for 1 of 1 sampled resident reviewed for pressure wounds, Resident #64. The findings included: The facility's policy, titled, Pressure Injury Prevention and Management, implemented 11/2020 and revised 07/25/22, revealed The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Record review revealed Resident #64 was admitted to the facility on [DATE] post hospitalization . The documented diagnoses included Cerebral Infarction, Type 2 Diabetes, and Dysphagia. The quarterly Minimum Data Set (MDS) with an assessment reference date of 02/21/24, documented the Brief Interview for Mental Status (BIMS) score was 01, indicating the resident had severe cognitive impairment. Review of the wound documentation included: On admission (11/17/20), the resident was evaluated with the Braden Scale for Predicting Pressure Sore Risk with a score of 13, indicating the resident had a mild risk of developing pressure sores. On 01/05/24, an event note was created in the electronic health record (EHR) that revealed open skin to sacrum area 4 cm (centimeter) length x 5 cm width x 1 cm depth. On 01/25/24, the wound to the sacrum measured 4 cm x 1.5 cm. On 02/01/24, the wound on the sacrum was unstageable and measured 3.5 cm x 2.5 cm x 0.1 cm. On 02/07/24, a 6.0 cm x 4.0 x 0.1 cm unstageable pressure wound was found on the right hip. On 02/10/24, a nursing progress note documented the skin on the right hip worsened and has become a Stage 2 pressure ulcer (partial thickness skin loss). On 02/15/24, the wound note revealed the sacrum had slough, (non-viable stringy tissue) and was worsening. It documented 25 % necrotic and measured 6 cm x 6 cm x 0 unstageable. On 02/21/24, the wound note revealed the right hip was necrotic and measured 5.5 cm x 4 cm x 0. The wound was worsening. The sacrum measured 6 cm x 7 cm x 0 cm and was 10% necrotic. The right hip had 100% necrotic tissue and measured 5.5 cm x 3.5cm x 0. On 02/29/24, the sacrum had granulation tissue present and measured 5 cm x 4.5 cm x 0. The right hip was necrotic and measured 6 cm x 6 cm x 0 with the wound worsening. On 03/06/24, the right hip was necrotic and measured 5 cm x 5 cm x 0. The sacrum had granulation and slough tissue and measured 5 cm x 5 cm x 0.5 cm. On 03/15/24, the sacrum was unstageable and measured 5 cm x 5 cm x 0 cm. The right hip had necrotic tissue present and measured 6 cm x 5.5 cm x 0 cm with purulent (contains pus) drainage. On 03/21/24, the sacrum measured 6 cm x 5 cm x 0 and unstageable. The right hip is unstageable at 6 cm x 4.5 cm x 0.2 cm with purulent drainage. On 03/21/24, a nursing progress note revealed the resident was noted with redness and scab to left hip. On 03/29/24, the resident was first seen by a wound care nurse practitioner. The Wound assessment of the right hip wound revealed a pressure wound stage 4 (full thickness skin and tissue loss). Size of 5.5 cm x 5 cm x 4.5 cm. Undermining from 11 o'clock to 7 o'clock, 4 cm. (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface.) Sacrum wound. pressure stage 3 (full thickness skin loss). Size 4.5 cm x 5 cm x 0.2 cm. Wound left hip. Pressure wound and unstageable measured 3 cm x 2 cm x 0.1 cm. On 040/5/24, the right hip measured 5 cm x 5 cm x 4.5 cm undermining from 11 o'clock to 7 o'clock, 4 cm. Surgical Wound Debridement done to the right hip. Sacrum wound measured 4.5 cm x 5 cm x 0.2 cm. The left hip wound is unstageable 3 cm x 1.5 cm x 0.1 cm. On 04/12/24, the right hip measured 5 cm x 5 cm x 4.5 cm with undermining from 11 o'clock to 7 o'clock, 4 cm. The sacrum measured 4 cm x 4 cm x 0.2 cm. The left hip measured 5 cm x 1.5 cm x 0.1 cm. On 04/19/24, the right hip measured 5 cm x 5 cm x 4.5 cm with undermining from 11 o'clock to 7 o'clock, 4 cm. The sacrum measured 3.5 cm x 4 cm x 0.2 cm. The left hip stable eschar 5 cm x 1.5 cm x 0.1 cm. Review of the Physician note dated 01/05/24 revealed the patient used to be on PO (by mouth) and PEG (Percutaneous Endoscopic Gastrostomy) feeds but got overweight, so PEG was d/c [discontinued]. Now weight loss, weight change -13 pounds. Her previous weight was 158 pounds, now she is 146 pounds. On 01/08/24, seen by the Nurse Practitioner (NP) with no note regarding a wound. On 01/10/24, Physician visit with no note regarding a wound. On 01/12/24, Physician visit with no wound note. On 01/24/24, Physician visit with no wound note. On 03/05/24, NP visit with no wound note. On 03/29/24, the resident had the PEG tube reinserted. On 04/02/24, NP visit note with no wound note. An interview was conducted with the son of Resident #64 on 04/24/24 at 1:28 PM. He had a concern that on Wednesday through Sunday when he feeds her, she doesn't always have protein with her meal, sometimes it is 2 starches. He said she is very fussy with meals and textures and doesn't always want to eat the food she is given. The Dietician encouraged putting back the PEG tube due to weight loss. The first time she had a PEG tube was due to a bowel resection. Interview with the Dietary Manager on 04/25/24 at 9:23 AM revealed she is aware that they always need puree chicken and beef available for this resident and she says she goes through the ticket daily. They realized there was a problem with meal tracker with the protein-and her dislikes and it was brought to her attention by one of the cooks that there was no protein on her plate. She stated this could have happened a few times. This was identified with the transition, and they started the new meal tracker in February 2024 and now they know they have to scan the tickets. Observation of wound care with Staff G, Licensed Practical Nurse / LPN, was conducted on 04/25/24 at 10:32 AM. The right hip was cleansed with wound cleanser / normal saline, patted dry and Collagen and Medi Honey was applied. The wound was covered with Bordered Foam. The sacrum was cleansed with wound cleanser / normal saline, patted dry and Medi-honey and Collagen were applied. The wound was covered with bordered gauze. The resident had slight discomfort while the wound was being cleaned. The wound care to left hip was not observed. On 04/25/24 at 12:15 PM, an interview was conducted with the Director of Nurses (DON) regarding wound care in the facility. She stated that prior to January 2024, they had a directive to stop the wound care physician from coming in and the nurse manager would do the weekly pressure wound checks. The wound care physician started coming to the facility again on 03/29/24 and comes weekly. An interview was conducted with the resident's physician via telephone on 04/25/24 at 1:50 PM. He stated that he cannot say that he visually saw the wounds on Resident #64, but he did say that if he saw them, he would have documented it in his notes. Interview was conducted with Staff H, Certified Nursing Assistant (CNA), on 04/25/24 at 2:03 PM. She stated every 2 hours she turns and repositions Resident #64. It takes 2 of them to do that. They had been putting her from bed to chair but after the wounds she stays mostly in bed. Interview was conducted with Staff D, CNA, on 04/25/24 at 2:08 PM. She stated that she is aware of the wounds, they go in, 2 of them, every 2 hours to turn her. Even before the wounds started, they would turn and reposition her. She mostly stays in bed now. Staff D stated before the wounds, she would get up. Interview was conducted with Staff I, Registered Nurse (RN) / Unit Manager, on 04/25/24 at 2:12 PM. She stated the physician knew of the wounds and if there was a change she notified the physician. The physician was not with her during weekly wound rounds. She previously did wound rounds with the prior wound physician, so she was asked to do the wound rounds after the wound care physician was no longer coming. She stated it had been a while since he came. She stated that sometimes the wounds looked better and sometimes they looked worse. Orders were changed when the wounds looked worse. She stated the physician comes to the facility on Monday, Wednesday, and Friday. She stated that they spoke in general about the wounds, but he was not given the specific measurements of the wounds. An interview was conducted with the DON on 04/25/24 at 2:19 PM. She stated she kept the physician updated about the wounds and she would tell him the wounds were stable, or if they got worse, then she would call him to get orders. She stated she was happy when the wound care physician came because the wounds needed to be debrided.

Based on observations, interviews, and record review, the facility failed to provide assistance during dining for 1 of 2 sampled residents reviewed for nutrition (Resident #44). The findings included: Record review revealed Resident #44 was initially admitted to the facility on [DATE] with diagnoses of muscle wasting, anemia, and depression. The Quarterly Minimum Data Set (MDS) assessment revealed Resident #44 has a Brief Interview of Metal Status (BIMS) score of 03, indicating severe cognitive impairment. Section GG of this MDS under eating showed that Resident #44 required supervision with touch-up assistance. In an observation conducted on 04/22/24 at 9:56 AM, Resident #44 was asleep in bed. Closer observation showed a breakfast tray untouched with the following food items: one slice of bread, two pieces of bacon, cereal, and one carton of milk. Continued observation did not show that the staff encouraged or queued Resident #44 to eat her breakfast meal. In an observation conducted on 04/22/24 at 12:06 PM, the staff finished passing all the lunch trays on the B-wing. At 12:07 PM, the Surveyor observed the resident did not have her tray, and asked Staff J, Registered Nurse (RN), why Resident #44 did not get her lunch tray. Staff J then said she would call the central kitchen to request Resident #44's lunch tray. Further observation revealed that her tray arrived from the kitchen at 12:14 PM. The lunch tray consisted of the following food items: Regular diet, chicken parmesan, linguine pasta, broccoli, garlic bread, and a fruit cup. At 12:24 PM, Staff J took the lunch tray untouched from Resident #44's room and left with the tray. In an interview conducted on 04/23/24 at 9:00 AM, Staff K, Certified Nursing Assistant (CNA), stated that Resident #44 ate about 25% of her breakfast meal and can eat independently with no issues. In an observation conducted on 04/23/24 at 11:56 AM, Resident #44 was asleep in her bed. The lunch tray arrived in the room and was placed near her. A continued observation at 12:15 PM revealed the tray untouched, with Resident #44 asleep in the bed. In an observation conducted on 04/23/24 at 12:28 PM, Resident #44 was asleep in her bed. The lunch tray was still untouched, and no staff was noted in the room encouraging or attempting to wake her up to eat her lunch meal. In an observation conducted on 04/24/24 at 8:16 AM, Resident #44 was asleep in her bed. At 8:20 AM, Staff L, CNA, brought the breakfast tray into the room and set it up for Resident #44. In this observation, Staff L stated that Resident #44 can eat on her own with no issues and that she usually eats 100% of her meals when she has an appetite. Record review of the CNAs' tasks, under section 'task' for eating, revealed the following: on 04/22/24, Resident #44 ate 26% to 50% of her breakfast meal, and 26% to 50% of her lunch meal, which was not as observed by the surveyor. Review of the weight log revealed that Resident #44's weight was trending down from 149 pounds on 12/06/23 to 141.8 pounds on 04/04/24. A new weight of 139.6 pounds, was taken on 04/24/24. In an interview conducted on 04/24/24 at 10:09 AM with Staff A, Minimum Data Set Coordinator, she stated that Resident #44 is coded for supervision with touch-up assistance for eating. According to Staff A, Resident #44 needs to be watched over, placed tray closer for better access, and may be struggling or trying to reach the food items on the tray. State A stated it also means Resident #44 may need reminders to eat periodically. In an interview conducted on 04/24/24 at 12:00 PM, Staff A stated that she reassessed Resident #44 and that she needed supervision with touch-up assistance during dining.

Based on observations, interviews, and record review, the facility failed to timely identify residents with malnutrition status and provide nutritional interventions, which resulted in weight loss and pressure ulcer development for 1 of 4 sampled residents, Resident #64, reviewed for tube feeding (GT). The findings included: Review of the Clinical Nutrition: the American Society for Parenteral and Enteral Nutrition (ASPEN) / Academy of Nutrition and Dietetics Consensus: Characteristics of Protein / Calorie Malnutrition, dated 07/2018, documented in part, the following two characteristics: severe calories and protein malnutrition is classified as eating less than 75% of estimated energy requirement for over one month, and 5% weight loss in one month. A minimum of 2 of the six characteristics (as shown above) is recommended for diagnosis of either severe or moderate protein-calorie malnutrition. (https://www.[NAME].com/searchq=aspen+malnutrition+assessment+pdf&FORM=QSRE1&ntref=1). Record review showed Resident #64 was initially admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Dysphagia, Muscle Weakness, and Type 2 Diabetes. Resident #64 had a Percutaneous Endoscopic Gastrostomy (PEG) tube, which was removed on 11/07/23 and reinserted on 03/29/24. Review of the Minimum Data Set (MDS) quarterly assessment, dated 02/21/24, revealed a Brief Interview of Mental Status (BIMS) score of 01, indicating severe cognitive impairment. Record review of the current physician order showed the following: On 04/22/24, Jevity 1.2 at 75 ml an hour for 12 hours once. On 04/19/24, House 2.0 nutritional supplements two times a day. On 04/05/14, Every shift administer Glucerna 1.5 (tube feeding formulary type) continuous at 75 ml an hour for 12 hours for a total volume of 900 ml and to start at 6:00 PM. On 12/27/23, Carbohydrate diet, pureed texture, thin consistency. Review of the weight log for Resident #64 revealed the following: On 01/05/24, a physician note documented the patient used to be on PO (by mouth) and PEG (Percutaneous Endoscopic Gastrostomy) feeds but got overweight, so PEG was d/c [discontinued]. Now weight loss, weight change -13 pounds. Her previous weight was 158 pounds, now she is 146 pounds. On 01/25/24, 147 pounds. On 02/14/24, 142 pounds. On 02/21/24, 140.6 pounds. On 02/28/24, 137 pounds. On 03/13/24, 133 pounds. On 04/11/24 , 132 pounds. On 04/19/24, 130 pounds. In an observation conducted on 04/23/24 at 4:17 PM, Resident #64 was in bed with the tube (Percutaneous Endoscopic Gastrostomy (PEG) tube) feeding bottle on hold with a formulary Jevity 1.2 at 75 milliliters (ml) an hour. The tube feeding had a start date of 04/22/24 with no start time. The tube feeding bottle was noted at the 250 ml mark out of the 1000 ml capacity bottle. The tube feeding, Jevity 1.2 at 75 ml an hour for 12 hours, provided 1080 calories and 50 grams of protein. In an observation conducted on 04/24/24 at 7:40 AM, the tube feeding bag noted formulary Glucerna 1.5 running at 75 ml an hour. Closer observation revealed the start date on the bottle was 04/23/24, but there was no start time. The tube feeding bag was noted at the 450 ml mark out of a 1000 ml capacity bottle. The tube feeding Glucerna 1.5 times 75 ml an hour for 12 hours provided 1350 calories and 75 grams of protein. In an interview conducted on 04/24/24 at 7:43 AM, Staff C, Licensed Practical Nurse (LPN), stated that Resident #64 tolerates her tube feeding well. She further said that the tube feeding bag was already started and running when she arrived for her shift this morning. In an interview conducted on 04/24/24 at 7:45 AM, Staff B, LPN, stated that when she arrived at her shift last night at 11:00 PM, the tube feeding bag was already started by the 3:00 PM to 11:00 PM shift nurse. According to Staff B, the tube feeding was still noted at the top level when she arrived for her shift (11 PM). In an observation conducted on 04/24/24 at 8:47 AM, Resident #64 was in the room with the tube feeding running at 75 ml an hour. Staff D, Certified Nursing Assistant (CNA), was noted at the bedside, sitting near Resident #64, feeding her the breakfast tray while the tube feeding was still running. In an observation conducted on 04/24/24 at 9:23 AM, Staff D was in the room still feeding Resident #64 her breakfast meal. The tube feeding was still running at the time of this observation and was noted at the 300 ml mark out of a 1000 ml capacity bottle. In an interview conducted on 04/24/24 at 12:30 PM, Resident #64's family stated that at times, the meal trays would not have any protein on the trays and only had servings of starches and vegetables. They further stated that they come to visit Resident #64 at least four times a week, that many times the meal trays were missing the nutritional supplements, and that they needed to call the kitchen to request the supplements. Review of the Physician's note dated 01/12/24 revealed Resident #64 used to eat by mouth with a PEG in place but got overweight, and the PEG was removed. No weight loss was noted, but Resident #64 was still with poor intake. The diet was modified to a mechanical soft diet with a dietitian consultation. Another Physician's note dated 01/24/24 revealed Resident #64's appetite was better, with diet modification and dietitian consultation in place. The next Physician' progress note was not until 03/05/24, 41 days later. Review of the Medication Administration Record (MAR) for the month of January 2024 showed that an order for 30 ml (milliliters) of Prostat (protein supplement) was added twice a day, which provided 200 calories and 30 grams of protein a day. Review of the Nutrition Risk Screen completed on 01/25/24 by the facility's Dietitian revealed the following: Resident #64 was on a pureed diet texture and receiving Mighty Shakes (nutritional supplements) twice a day with no proof of documentation provided showing that Resident #64 received the Mighty Shakes daily. On this note, Resident #64 ate between 0-75% of her meals, with estimated daily caloric needs between 1670 calories and 2000 calories and between 84 and 100 grams of protein. Review of Resident #64's weight log showed that from 02/05/24 to 03/06/24, the resident dropped from 145 pounds to 135 pounds in one month, a 6.9% weight loss. Review of the follow-up nutrition note dated 02/14/24 revealed Resident #64's weight was trending down, and a house 2.0 nutritional supplement was recommended, which provided an extra 240 calories and 10 grams of protein a day. A nutrition progress note dated 02/21/24 revealed Resident #64 had a severe weight loss of 11.1 % in 90 days. Intake of meals was noted between 0-75%, and Resident #64 was to be receiving a House 2.0 nutritional shake twice a day (no evidence it was provided twice daily) and was only receiving it once a day. Review of the Nutrition Risk Screen dated 02/28/24 revealed Resident #64's meal intake was between 26% and 50%, with weight trending down. It further revealed that Resident #64 received one house 2.0 supplement and 30 grams of protein daily. Estimated caloric needs were changed from 1910 calories to 2237 calories a day and 80 grams to 97 grams of protein a day. Resident #64 was on a diet by mouth, providing about 2000 calories and 100 grams of protein daily. The resident's 25% intake of meals with the nutritional supplements provided 940 calories a day and 65 grams of protein a day. The resident's 50% intake of meals with dietary supplements provided 1440 calories a day and 90 grams of protein a day. Review of the Nutrition Risk Screen completed on 03/07/24 showed that Resident #64 was still eating between 26% and 50% of her meals. A severe weight loss of 6.9% was noted, with pressure ulcer wounds noted to the sacrum and right hip areas. On this note, the facility's Dietitian recommended continuing the same nutritional supplements in place (Prostat twice a day and House 2.0 once a day). There were no other additional supplements were recommended or provided. The Dietitian recommended the insertion of the PEG in place, which was done on 03/29/24. Further review of the MAR revealed that the house 2.0 nutritional supplements were not documented as provided from 04/01/24 to 04/12/24. It further showed that an order for house 2.0 nutritional supplements increased to twice a day on 04/19/24, after poor intake of 0 to 50% of meals. Review of the nutrition progress note dated 03/13/24 revealed Resident #64's Body Mass Index (BMI) was at 21.5, which dropped from 23.7 on 01/25/24 to 21.5 on 03/13/24. The BMI range of 21.5 is within normal ranges (underweight range is 19 and below). On this note, the facility's Dietitian reported an intake of 0 to 50% of meals for Resident #64. Resident #64 was still receiving two scoops of Prostat (providing 200 calories and 30 grams of protein) and a house 2.0 nutritional supplement once a day, which was providing an extra 240 calories and 10 grams of protein. The facility's Dietitian did not recommend increasing the house 2.0 to twice or three times a day to provide additional calories and protein to Resident #64. Review of another follow-up nutritional progress note dated 03/20/24 revealed that Resident #64 had a severe weight loss of 5.1% in one month and was still eating 0 to 50% of her meals. The resident was on a pureed texture diet and received two scoops of Prostat (200 calories and 30 grams of protein) and a house 2.0 nutritional supplement once a day, providing an extra 240 calories and 10 grams of protein. On this progress note, the facility's Dietitian failed to identify or document Resident #64 at moderate to severe malnutrition status as per ASPEN guidelines above. The facility's Dietitian failed to recommend an additional nutritional supplement that could have been given by nursing with the percent intake documented to aid with the 0-50% intake of meals. Review of the Nutrition Risk Screen dated 04/05/24 showed the following: Resident #64 was receiving tube feeding with Glucerna 1.5 at 65 ml an hour, which provided 1170 calories and 64 grams of protein, and was eating by mouth with 0 to 50% intake of meals. On this note, the facility's Dietitian recommended increasing the rate to 75 ml an hour for 12 hours because Resident #64 had inadequate oral intake with increased protein needs related to pressure injuries. The tube feeding Glucerna 1.5 at 75 ml an hour provides 1350 calories and 75 grams of protein. The Dietitian also recommended decreasing the protein supplements from twice a day to once a day, providing 15 grams extra protein a day instead of 30 grams of protein a day. Review of the Certified Nursing Assistant tasks for intake of meals showed the following percentages for Resident #64: from 03/25/24 to 04/23/24, 86 meals were consumed between 26% to 31% for a total of 86 meals documented. Review of the Weekly Pressure Wound Evaluation dated 02/08/24 and 03/15/24 showed a right hip pressure wound was acquired on 02/07/24. Review of the Weekly Pressure Wound Evaluation dated 02/21/24 and 03/21/24 showed a sacrum pressure wound was acquired on 02/05/24. Review of the nutrition progress note dated 04/23/24 revealed Resident #64 had a stage 3 pressure ulcer on the sacrum area and a stage 4 pressure ulcer on the right hip. Review of Resident #64's primary Physician's follow up assessments did not show that the nutritional status of Resident #64, the development of pressure ulcers, weight loss, and poor appetite were addressed. Further review did not show that an appetite stimulant was recommended or ordered for Resident #64. Review of the care plan initiated on 04/01/24 revealed Resident #64 received enteral feeding to supplement dietary intake. It showed tube feeding was administered as ordered to obtain adequate nutrition and hydration. A nutritional care plan revised on 04/08/24 showed that Resident #64 will have no signs and symptoms of malnutrition and will consume at least 25% of at least three meals daily. In an interview conducted on 04/24/24 at 12:53 PM with the facility's Dietitian, she stated that she placed an order for Jevity 1.2 (one day only 04/22/24) instead of Glucerna 1.5 for Resident #64 because they were out of the Glucerna 1.5 but did not adjust the tube feeding rate and hours, for the change in the tube feeding formulary. She acknowledged that Resident #64 had a severe weight loss of 6.9% from 02/05/24 to 03/06/24. When asked why she did not increase the House 2.0 nutritional supplement daily, she said she provided Resident #64 with a Mighty Shake supplement on the meal trays. She could not show documentation that the Mighty Shakes were provided on the meal trays or ordered on the MAR According to the facility's Dietitian, the Mighty Shakes are provided on the trays, but the percent intake of these nutritional supplements was not documented. She stated this is why she went ahead and increased the house shake to 2.0 twice a day, which was on 04/19/24. These would have provided higher calories and ensured that they were given by nursing staff with the percentage of intake documented, which was better than the mighty shakes on the meal trays. When asked why she did not provide additional nutritional supplements until 04/19/24, she did not have an answer. The clinical Dietitian acknowledged that Jevity 1.2 at 75 ml an hour did not provide the same calories and protein as the Glucerna 1.5 at 75 ml an hour. She further said that she discussed restarting the tube feeding with Resident #64's family around March of 2024 and it was placed later on 03/29/24. She was then asked why Resident #64 did not have protein food items on her meal trays. The facility's Dietitian stated that Resident #64 had over 86 dislikes on her food preference list and that she only eats meat and chicken, which may not have been on the menu that day. The surveyor expressed concerns regarding the nutritional interventions that were not implemented in a timely manner from January 2024 to April 2024. An interview was conducted on 04/24/24 at 2:00 PM with the facility's Dietitian who stated that the tube feeding needs to be on hold during meal times for Resident #64 to eat her meals.

Based on observation, interviews, policy and record review, the facility failed to limit a new order for a psychotropic drug used on a PRN (as needed) basis for 1 of 5 sampled residents reviewed for unnecessary medication review, Resident #156. The findings included: The facility's policy, titled, Unnecessary Drugs-Without Adequate Indication for Use, implemented 11/2020 and revised 08/02/22, revealed in part, A new order for a psychotropic or antipsychotic medications used on a PRN basis should follow the requirements for PRN use of psychotropic or antipsychotic medications. Record review documented Resident #156 was admitted to the facility on [DATE], post hospitalization with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Syncope, Diabetes Type 2, and Anxiety Disorder. Review of the admission Minimum Data Set (MDS) with an assessment reference date of 04/08/24 documented the Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. On 04/04/24, the physician documented an order for Alprazolam Oral Tablet 2 MG (milligrams) Give 1 tablet by mouth as needed for sleep at bedtime. On 04/24/24 at 10:07 AM, pharmacy recommendations were discussed with the consultant pharmacist. The consultant pharmacist revealed that he reviewed the medications for Resident #156 on 04/10/24 and recommended to either discontinue or add a stop date to the PRN Alprazolam, or update to schedule dosing. The physician disagreed with the recommendation on 04/12/24 but gave no rational in the medical record or no indication for the duration for the PRN order. The finding was reviewed and discussed with the Regional Nurse Consultant on 04/24/24 at 5:00 PM who stated she was aware of the recommendation and the order had just been changed to Alprazolam 1 milligram, give 1 tablet by mouth at bedtime for Anxiety.

Based on observations and interviews, the facility failed to maintain a clean, sanitary, homelike environment for the residents in the facility. The findings included: 1. During the initial tour of the facility conducted on 02/06/23 at 9:30 AM, it was observed that the resident in room [ROOM NUMBER]B had a broken, jagged stone windowsill. This jagged edge could potentially cause injury to a resident, staff member, or visitor due to the uneven and jagged surface. Photographic evidence obtained. 2. During the initial tour of the facility conducted on 02/06/23 at 9:45 AM, it was observed that the resident in room [ROOM NUMBER]A had a nightstand with chipped, missing and broken facade visible on the front leg of the nightstand. Photographic evidence obtained. 3. During the initial tour of the facility conducted on 02/06/23 at 9:45 AM, it was observed by the surveyor that the resident in room [ROOM NUMBER]B had a dresser with a broken drawer. The drawer was observed to be hanging out of the dresser at an odd angle. Further observation also revealed the chair in the resident's room had two large, dark stains on the seat cushion. Photographic evidence obtained. 4. During the initial tour of the facility conducted on 02/06/23 at 10:23 AM, it was observed that the resident in room [ROOM NUMBER]B had a large, dark, point-shaped chip present in the middle of the flooring of her side of the room. Photographic evidence obtained. 5. During the initial tour of the facility conducted on 02/06/23 at 10:30 AM, it was observed that the resident in room [ROOM NUMBER]A had a large crack present in the flooring of his side of the room. Further observation also revealed a nightstand with chipped, missing and broken facade visible on the front leg of the nightstand. Photographic evidence obtained. 6. During the initial tour of the facility conducted on 02/06/23 at 10:35 AM, it was observed that the resident in room [ROOM NUMBER]B had a nightstand with chipped/missing/broken facade visible on the front leg of the nightstand. Further observation also revealed this resident's bedside rolling table had a broken and chipped top which was being held together with clear box tape. Photographic evidence obtained. 7. During the initial tour of the facility conducted on 02/06/23 at 10:45 AM, it was observed that the resident in room [ROOM NUMBER] had a leaking faucet in her bathroom. Further observation of the bathroom revealed the raised toilet seat had two large rust spots and cracked, jagged and peeling paint. These rust spots and peeling paint posed a potential hazard, as these could cause a skin tear when a resident is sitting on the seat. Further observation of the resident room revealed the flooring transition (from the hallway into the resident room) was missing flooring, causing a large gap, approximately 1 inch wide. This gap posed a potential tripping hazard; it was also not possible for the staff to properly clean this area of the floor, which caused a potential for contamination. Photographic evidence obtained of these three areas of concern. 8. During the initial tour of the facility conducted on 02/06/23 at 10:50 AM, it was observed that the resident in room [ROOM NUMBER] had paint which was raised, bubbled and stained surrounding the air conditioning vent in the ceiling of entry way of the room. Photographic evidence obtained. 9. During the initial tour of the facility conducted on 02/06/23 at 12:08 PM, it was observed that the Women's Shower Room on the 200 Unit had a large area of black and slimy substance on the floor of the shower area. It appeared that this area of the shower room had not been cleaned recently. Photographic evidence obtained. 10. During the initial tour of the facility conducted on 02/06/23 at 12:10 PM, it was observed that the Men's Shower Room on the 200 Unit had 2 of 2 floor drains caked with dirt, dust, and hair along with a small area of black and slimy substance on the floor of the shower area. It appeared that these areas of the shower room had not been cleaned recently. Photographic evidence obtained. A tour of the facility was conducted on 02/09/23 at 9:50 AM with the facility's Maintenance Director, the facility's Housekeeping Director, and a Corporate Environmental Services Director-in-Training. During this tour, the above-mentioned areas of concern were shared with all of these directors. During this tour, in the Men's Shower Room on the 200 Unit, the shower had been left running by an unknown staff member and it was observed that this shower room was flooding and not properly draining due to the clogged drains. The facility's Maintenance Director stated he would conduct a full tour of the facility to identify any further areas of concern later.

Based on observations, interviews and record review, the facility failed to ensure the E-kit (emergency medications kit), kept in the locked medication room refrigerator, had not expired medications for 1 of 2 medication storage room's refrigerator reviewed on the C-wing. The findings included: Review of the facility's policy, titled, Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 2007, documented, in part, .the nursing staff, consultant pharmacist and provider pharmacy designee checks the emergency kits regularly for expiration dating of the contents. The date of expiration is noted on the outside of the kit . Review of the pharmacy E-Kit swap out record history provided by the facility's Director of Nursing documented the last E-Kit was delivered on 06/15/22 with an expiration date on 07/22. On 02/07/23 at 12:10 PM, a side by side review of the C-wing's medication room was conducted with Staff H, Licensed Practical Nurse (LPN) and Staff D, Registered Nurse (RN). The review revealed a refrigerator with a medication box under a double lock, labeled E-kit. The outside label documented multiple medications with expired dates. A side by side review of E-kit box medication box from the refrigerator was conducted with Staff H, LPN. The box contained the following expired medications and insulin pen needles: - One (1) Insulin Lispro Pen with an expiration date on 07/2022 - One (1) Lantus Insulin Pen with an expiration date on 11/2022 - One (1) Novolin N- multi dose vial Insulin with an expiration date on 07/2022 - Four (4) Promethegan 25 mg suppositories with an expiration date on 01/2023 - Five (5) Auto shield insulin pen needle with an expiration date on 11/2022 During the review, Staff D, RN, stated that it was the pharmacy responsibility to check on the E-kit medications expiration dates, not nursing. On 02/09/23 at 12:49 PM, an interview was conducted with the facility's Director of Nursing (DON). The facility's E-kit policy was reviewed during the interview. The DON stated the consultant pharmacist comes to the facility monthly and was supposed to review the E-kit. The DON stated in addition to the monthly check, the pharmacy sends new E-kits periodically to the facility to swap out. When asked if anyone on the staff was responsible to check the E-kits or if they depend on the pharmacy for this responsibility, the DON stated, 'we depend on the pharmacy'. When asked if anyone at the facility was responsible for conducting any checks of the E-kit, the DON said 'no'. When asked if she was aware of the expired E-kit identified by the surveyor during the medication storage observations, the DON stated she was aware there were expired medications found during the medication storage observations. The DON then stated she spoke to pharmacist and the pharmacist was not aware of where the breakdown was but he would look into it and let her know. 45951

Based on observations, interviews, and record review, the facility failed to assist a resident during dining for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADL), Resident #16. The findings included: The facility's policy, titled, ADL: Assitance, effective July 2022, stated that resident evaluations would be conducted by nursing staff and results documented for the level of assistance needed. The information will be added to the care plan. Record review documented Resident #16 was admitted on [DATE] with diagnoses to iinclude Dementia, Respiratory Disorder, and Anemia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #16 had a Brief Interview of Mental Status (BIMS) score of 03, which is severely cognitively impaired. Section G for eating showed that Resident #16 needs total independence with one person's assistance. Review of the care plan dated 02/14/23 documented Resident #16 had a nutritional problem with a history of weight loss and electrolyte imbalance. The care plan indicated to: Observe / document as indicated: Meal Consumption, Amount of assistance needed with the meal, tolerance to diet/fluids. It further showed to provide physical assistance with bathing, dressing, nail/hair care and hygiene, eating, or other ADLs as indicated. A review of the Task/Eating under question 3, showed that Resident #16 was documented as set up only for 20 meals, and four meals were documented as one-person assistance from 02/01/23 to 02/08/23. In an observation conducted on 02/6/23 at 12:06 PM, the lunch tray was brought into Resident #16's room and placed at the bedside. The tray was observed with oven-fried chicken, mashed potatoes, spinach, fortified pudding, and 4 ounces of a mighty shake (nutritional supplements). Staff was not in the room and Resident #16 did not eat anything on her lunch tray. Continued observation at 12:34 PM did not show any staff in the room assisting Resident #16 with her meal which was 100% untouched. At 12:45 PM, the lunch tray was taken out of the room. In an observation conducted on 02/07/23 at 7:46 AM, the second meal cart arrived on the Unit. The tray was taken into the room at 8:16 AM and was set up by Staff. Closer observation showed the following: two hard-boiled eggs, wheat toast, and fortified oatmeal. In an observation conducted at 8:25 AM, Resident #16 was eating on her own with no staff in the room. Continued observation at 8:38 AM, showed that she only ate one boiled egg and her oatmeal with no staff in the room. In an interview conducted on 02/08/23 at 10:00 AM, Staff A, Certified Nursing Assistant (CNA), stated Resident #16 does not need any help with her meals and can eat on her own consistently. When asked how well she eats, she said that she eats about 75% of breakfast and she eats about 25% of her meals for lunch. In an interview conducted on 02/08/23 at 11:20 AM, Staff B, MDS coordinator, stated the resident uses the interviews with staff and observations to evaluate residents' needs with all ADLs' activities and to eat. She also said Resident #16 was coded as needing total dependence on one person's assistance. When asked what this meant, she said that someone had to be in the room at all times to assist Resident #16 with her meals. Staff B stated that staff need to do all the work for Resident #16 because she depends on staff for eating.

Based on observations, interviews and record review, the facility failed to provide podiatry care in a timely manner for 1 of 1 sampled resident reviewed for Podiatry Care, Resident #100. The findings included: Review of the facility's policy, titled, Referral Services, effective 02/21, documented in part, .the Social Services Director or designee works with the interdisciplinary team to identify needs, evaluate resources and coordinate community resources to meet the needs of resident .referral services may include .Podiatry Care .assist with arranging appointments .follow up on referrals .as appropriate and document the outcome of referrals . in the resident chart . Review of Resident #100's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Essential (Primary) Hypertension, Type 2 Diabetes Mellitus, Malignant Neoplasm of Bladder, Dysphagia following Cerebral Infarction, Major Depressive Disorder, Bacteremia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Atrial Fibrillation, Congestive Heart Failure, Presence of Cardiac Pacemaker, Cardiomyopathy, Edema, Memory Deficit Following Cerebral Infarction and Other Speech and Language Deficits following Cerebral Infarction. Review of Resident #100's Minimum Data Set (MDS) quarterly assessment, dated 01/28/23, documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident has no cognition impairment. The assessment documented under Functional Status the resident needed extensive to total assistance from the staff with his activities of daily living (ADLs). Review of Resident #100's care plan, titled, documented, Diabetes Mellitus: The resident has Diabetes Mellitus as evidence by: CVA (stroke), High Cholesterol, Hypertension, Type 2 Diabetes initiated on 10/26/22. The care plan interventions included: to Inspect feet weekly - initiated on 10/26/22; Podiatry Consult as Needed - initiated on 10/26/22. Review of Resident #100's physician order, dated 10/26/22, documented, Ophthalmic, Auditory, Psychological, Psychiatric, Dental, Physiatry, and Podiatry services as needed. On 02/06/23 at 10:52 AM, during an interview Resident #100 stated he had an in-grown toe nail and the Podiatrist came in when he was not in the facility. The resident stated he told the nurse that he missed the Podiatrist visit and nothing have been done about it. On 02/08/23 at 10:49 AM, an interview was conducted with the facility's Social Services Director (SSD) who stated the Social Services department did not do Podiatry Care arrangements. The SSD stated that nursing arranged for Podiatry care. The SSD stated the facility had a Podiatrist that comes to the facility. On 02/08/23 at 11:47 AM, an interview was conducted with Staff D, Registered Nurse, (RN). Staff D stated Resident #100 had an X-ray of left ankle due to pain and added that the X-rays done 01/19/23 showed an old fracture to the distal tibia. Staff D added the resident was ordered a Podiatry Consult. A side by side review of Resident #100's physician's order for Podiatry Consult, dated 01/04/23 for Ingrown toenails, was conducted with Staff D. Staff D stated the Podiatry came to the facility over three (3) weeks later on 01/28/23 (Saturday) and the resident was out with his family. Staff D was asked why Resident #100 had not been rescheduled to be seen by the Podiatrist since it was missed on 01/28/23. Staff D did not have an answer and searched for nursing documentation related to missed visits. Staff D stated she did not see any documentation regarding contacting the Podiatry to see the resident again. Staff D, RN stated they will call the podiatry to come back to see the resident, but it had not done. Staff D and the DON (Director of Nursing) were asked to submit a copy of the last Podiatry care visit note. On 02/09/23 at 11:08 AM, an interview was conducted with Staff D, RN who stated the podiatrist came in on 02/08/23 to see Resident #100. Staff D stated that the podiatrist ordered treatment for a scab on the resident's left foot and did not see that the resident had an ingrown toe nail. Staff D stated the Podiatrist told her that she comes to the facility every other Friday. On 02/09/23 at 2:10 PM, the DON provided Resident #100's podiatry consult note, dated 02/08/23. The note documented .seen at bedside for .right great toe pain. Patient states foot is sensitive to touch .left lateral ankle noted superficial skin ulcer .black scab .3.1 x 3.4 x 0.1 .Toenails plates dystrophy, discolor .A/P (assessment/plan) right and left distal .ingrown excised .TAO (triple antibiotic ointment) applied .dorsal foot skin scalp - skin prep applied to continue .left lateral ankle ulcer - Diabetic - cleansed area with moist saline gauze, TAO . At the end of the survey, previous Podiatry Care note had not been provided.

Based on interview and record review, the facility failed to conduct appropriate skin assessments for 1 of 3 sampled residents reviewed for wounds, Resident #1, as evidenced by inadequate documentation of an assessment of Resident #1's surgical incision resulting in the surgical incision becoming infected and dehisced, and failing to address a newly identified skin tear for Resident #1. The findings included: Review of the facility policy and definition of Neglect states in part, 'Failure to provide goods and/or services necessary to avoid physical harm, mental anguish or mental illness. Neglect may be a single act or several episodes of carelessness.' Review of the clinical record revealed Resident #1 was admitted to the facility for skilled nursing and skilled therapy services on 03/20/20 with pertinent [DIAGNOSES REDACTED]. Resident #1 resided on the B-unit. Review a MDS (Minimum Data Set) admission comprehensive assessment of Resident #1 dated 03/24/20 documents under Section C Cognitive Patterns, Resident has a Brief Interview for Mental Status (BIMS) rating of 2, indicating severe cognitive impairment. Review of Section M, Skin Conditions, documents Resident #1 has a surgical wound with the application of nonsurgical dressings (with or without topical medications). Review of a Care Plan dated initiated 03/21/20 documents 'Resident has actual wound surgical right hip. Goal - promote wound healing. Interventions - Treatment as ordered (refer to orders for current order). Observe that dressing is covering and adhering. Report loose dressing to nurse.' Review of the admission Physician Orders for Resident #1 dated 03/20/20, revealed no evidence of an order for [REDACTED]. Review of Resident #1's Medication Administration Orders (MAR) for March 2020 revealed no documentation of any assessment, monitoring or dressing changes conducted for Resident #1. Review of Resident #1's Treatment Administration Orders (TAR) for March 2020 revealed no documentation of any assessment, monitoring or dressing changes conducted for Resident #1. Review of the Nursing Progress Notes initial Nursing Assessment conducted by a Registered Nurse (RN) dated 03/20/20 at 7:40 PM, states in part under the category Skin Condition, 'Observation of skin integrity with routine care was provided during shift. Application of ointments/medication was provided during shift. Application of dressings (with or without topical medications) was provided. This is an existing skin condition. Care plan continues as it relates to skin.' There is no documentation in the Initial Nursing Assessment that indicates Resident #1 was admitted with a right hip surgical incision, the size of the incision or what the incision looked like. Review of a Nursing Progress by an RN dated 03/21/20 at 3:40 AM, revealed no documentation of an assessment of the right hip dressing or incision. Review of a Nursing Progress Note by a Licensed Practical Nurse (LPN) dated 03/21/20 at 11:40 AM, revealed no documentation of an assessment of the right hip dressing or incision. Review of a Skin Grid for All Other Skin Problems form, an RN documents on 03/21/20, no time documented, the site as 'Right Femur Fracture' length 3.5 centimeters (cm), width 0.1 cm, no drainage, wound bed pink, no odor, monitor site (glue).' Review of the clinical record, MAR and TAR for 03/21/20 revealed no documentation of any hip dressing removal, change or replacement provided to be able to document the length of the incision. Review of a Nursing Progress Note by an LPN dated 03/21/20 at 7:40 PM, documents 'non-removable dressing intact to right hip No signs/symptoms of bleeding noted.' Review of the Skilled Nursing Daily Note by a LPN dated 03/21/20 at 8:19 PM, reveals no documentation of an assessment of the right hip dressing or incision. Review of a Nursing Progress Notes by an LPN dated 03/22/20 at 2:04 AM, reveals no documentation of an assessment of the right hip dressing or incision. Review of the Skilled Nursing Daily Note by a LPN dated 03/22/20 at 2:11 AM, reveals no documentation of an assessment of the right hip dressing or incision. Review of the Skilled Nursing Daily Note dated 03/22/10 at 11:57 AM, documents 'Non-removable dressing intact to right hip. No signs/symptoms bleeding noted.' Review of a Nursing Progress Note by an LPN dated 03/22/20 at 6:04 PM, reveal no documentation of an assessment of the right hip dressing or incision. Review of the Skilled Nursing Daily Note dated 03/22/20 at 7:36 PM, documents 'Non-removable dressing intact to right hip. No signs/symptoms bleeding noted.' Review of the Skilled Nursing Daily Note dated 03/23/20 at 3:11 AM, reveals no documentation of an assessment of the right hip dressing or incision. Review of a Nursing Progress Note by an LPN dated 03/23/20 at 10:04 AM, reveals no documentation of an assessment of the right hip dressing or incision. Review of an Advanced Registered Nurse Practitioner (ANRP) Progress Note dated 03/23/20 documents the resident has a right hip surgical wound. There is no assessment of the incision or wound dressing documented. Review of a Skilled Nursing Daily Note dated 03/23/20 at 6:04 PM, reveals no documentation of an assessment of the right hip dressing or incision. Review of a Nursing Progress Note dated 03/24/20 at 12:43 PM by the RN, reveals no documentation of an assessment of the right hip dressing or incision. Review of a Skilled Nursing Daily Note dated 03/24/20 at 12:43 PM by the RN, reveals no documentation of an assessment of the right hip dressing or incision. Review of a Skilled Nursing Daily Note dated 03/24/20 at 1:57 PM, documents 'Right trochanter hip wound covered with brown surgical dressing, no drainage. Staples not present. No sign infection.' It is unclear how staples were determined not to be present when the observation was of a brown surgical dressing. Review of a Nursing Progress Note dated 03/25/20 at 1:20 PM by the LPN, documents 'Right hip dressing in place and no s/s (signs/symptoms) of infection noted. There are no staples or sutures present. No signs of infection. No drainage noted.' It is unclear how staples and sutures were determined not to be present when the observation was of a right hip dressing. Review of a Physician History and Physical note dated 03/25/20 documents the resident sustained [REDACTED]. The Physician documented under Skin: right hip surgical incision. There is no documentation of any assessment of the incision or surgical dressing. Review of a Nursing Progress Note dated 03/26/20 at 3:21 AM by the LPN, revealed no documentation of an assessment of the right hip dressing or incision. Review of a Skilled Nursing Daily Note dated 03/26/20 at 3:21 AM by the LPN, revealed no documentation of an assessment of the right hip dressing or incision. Review of a Nursing Progress Note dated 03/26/20 at 2:31 PM by the LPN, revealed no documentation of an assessment of the right hip dressing or incision. Review of a Skilled Nursing Daily Note dated 03/26/20 at 2:31 PM by the LPN, revealed no documentation of an assessment of the right hip dressing or incision. Review of the clinical record for 03/27/20 revealed no documentation of any Nursing Progress Notes or of Skilled Nursing Daily Notes for the day. Review of a Physician Geriatric Progress Note dated 03/27/20, documents the resident has a past medical history of [REDACTED]. Review of a Nursing Progress Note dated 03/28/20 at 1:33 AM by the LPN, revealed no documentation of an assessment of the right hip dressing or incision. Review of a Skilled Nursing Daily Note dated 03/28/20 at 1:33 AM by the LPN, revealed no documentation of an assessment of the right hip dressing or incision. Review of the clinical record for 03/29/20, revealed no documentation of any Nursing Progress Notes or Skilled Nursing Daily Notes for the day. Review of a Skilled Nursing Daily Note dated 03/30/20 at 1:58 PM by the LPN, documented 'Right trochanter hip surgical dressing in place no s/s infection noted. No sutures or staples present, no s/s of infection.' It is unclear how sutures and staples were determined not to be present when the observation was of a surgical dressing in place. Review of a Nursing Progress Note dated 03/30/20 at 1:58 PM, documents 'Surgical dressing in place, no s/s of infection noted. No staple or sutures present. No signs of infection. Continue to monitor.' It is unclear how sutures and staples were determined not to be present when the observation was of a surgical dressing in place. Review of an ARNP note dated 03/30/20 documents the resident is status [REDACTED]. Review of a Skilled Nursing Daily Note dated 03/31/20 at 1:58 PM by the LPN, revealed no documentation of an assessment of the right hip dressing or incision. Review of a Nursing Progress Note dated 03/31/20 at 2:50 PM, documents 'During routine care residents surgical dressing is noted with drainage and foul odor. MD is informed and order is received for wound C & S (culture and sensitivity) to surgical site.' Review of a Skilled Nursing Daily Note dated 04/01/20 post event nursing note at 11:47 AM by the LPN documents 'Observation of skin integrity with routine care. Application of dressings (with or without topical medications). Will continue with plan of care.' There is no assessment of the right hip surgical incision that was noted draining and with a foul odor as documented on 03/31/20 at 2:50 PM. Review of a Physician Geriatric Progress Notes dated 04/01/20, the Physician documents under Chief Complaint: Surgical incision with moderate foul odor drainage. Patient complains of pain. Patient going to (Hospital A) for surgical incision evaluation. C & S done yesterday. Review of a Nursing Progress Note dated 04/01/20 at 11:47 AM by the LPN, documents 'Resident surgical site is noted with foul drainage. Recommendations send to (Hospital A) for evaluation of status [REDACTED]. Review of a Nursing Progress Note dated 04/01/20 at 12:35 PM by the LPN, documents 'Resident surgical site to right hip noted with drainage and foul odor. MD is informed and order send to ER (emergency room ) at (Hospital A) for evaluation to right hip surgical site. Leave in stretcher.' Review of a Nursing Progress Note dated 04/01/20 at 12:35 PM by the LPN, documents 'Resident leave facility via transport going to (Hospital A) Medicated for pain.' Review of the MAR revealed on 04/01/20 at 10:08 AM, Resident #1 received Tylenol 650 milligrams for pain. Further, review of the MARs for March and April 2020, revealed Resident #1 was having a [MEDICATION NAME]-Menthol patch applied to the right hip daily for pain. In addition to the pain patch, Resident #1 was receiving [MEDICATION NAME] (pain medication) every 8 hours routinely for pain. Included with the nurse's initial who administered the medication, is a Pain Level indicating the level of pain on a scale from 1 to 10. Review of the documentation of pain from 03/21/20 through 04/01/20, revealed the [MEDICATION NAME] pain medication was administered 35 times on 35 shifts, and of those 35 doses, Resident #1 continued to complain of pain for 27 of the 35 doses administered, ranging from a level 2 to 8 out of 10. The LPN documented the resident's pain level for the 2:00 PM dose on 04/01/20 as an 8 out of 10. Review of the (Hospital A) Emergency Department (ED) records revealed Resident #1 arrived to (Hospital A) on 04/01/20 at 1:12 PM. Review of the ED History & Physical note completed by the ED physician on 04/01/20 states in part, 'Patient presented to the ED with chief complaint of right hip infection status [REDACTED]. Review of the results of a pelvic x-ray and lateral right hip x-ray completed on 04/01/20 at 2:30 PM documents in part, 'Abnormal gas is identified within the right hip soft tissue which may reflect soft tissue infection [DIAGNOSES REDACTED] (infection of the bone)/infection is not entirely excluded.' Review of the ED physician note dated 04/01/20 at 1:53 PM, documents under procedures - Consults - Nurse Practitioner with ortho and reviewed images (x-ray results). They are okay to discharge home with wet to dry dressings. Case discussed with Social Worker (SW) and has spoken with rehab facility and arranged wound care. Clinical Impression: [DIAGNOSES REDACTED].' Review of the hospital SW follow up note dated 04/01/20 at 3:34 PM documents 'SW placed call to (rehab facility) main line and discussed above with (Admissions Coordinator). Confirmed that patient is welcome to return today and will only need RN orders for wound care. (Admissions Coordinator) advised that her nursing staff will take care of it.' Review of a ED RN Progress Note dated 04/01/20 at 4:30 PM documents 'Patient and EMS verbalized understanding of discharge instructions.' Resident #1 was discharged from (Hospital A) ED on 04/01/20 at 4:35 PM with discharge instructions for 'Wound Check' with specific instructions in large bold capital letter print to 'PLEASE PERFORM WET TO DRY DRESSING CHANGES TO RIGHT HIP WOUND TWICE DAILY.' Review of a Nursing Progress Note dated 04/01/20 at 6:04 PM by the LPN, documents 'Resident is back from (Hospital A). Noted with a skin tear to left forearm that is covered with a gauze and secured with tape.' Review of the clinical record revealed no evidence of documentation Resident #1's physician was notified of the new development of a skin tear to the left forearm when the resident returned from the hospital. There is no evidence of any treatment ordered to address the newly identified skin tear to the left forearm. Further, there is no evidence of documentation the physician was notified of the ED and orthopedic wound care orders to include the wet to dry dressing changes to the right hip wound twice daily. Review of the clinical record revealed no right hip dressing changes were performed on 04/01/20 or 04/02/20. Review of the TAR revealed an order dated 04/02/20 at 6:03 PM for a dressing change to include 'Cleanse surgical site to right hip with normal saline solution, apply Medi-honey then cover with dry dressing daily every day shift.' The first right hip dressing is documented as performed on 04/03/20 on the day shift. There is no documentation of an order for [REDACTED]. The purpose of a wet to dry dressing is to draw the incision wound drainage out of the incision. Review of a Skilled Nursing Daily Note dated 04/01/20 at 7:35 PM by the LPN, documents 'Application of dressings (with or without topical medications) observation of skin integrity with routine wound care.' There is no documentation of an assessment of the surgical incision that had foul smelling drainage. Review of a Nursing Progress Note dated 04/01/20 at 7:35 PM by the LPN, documents 'Resident is observe on the floor on a left side lying position on the left of his bed MD is made aware and order is receive to send resident to (Hospital B) for evaluation due to fall .Resident leave the facility on a stretcher going to the hospital.' Review of a Skilled Nursing Daily Note dated 04/02/20 at 1:30 AM for the Readmission Return from Leave Data Collection, revealed no documentation of an assessment of the resident's right hip dressing or surgical incision or the assessment of the left forearm skin tear the resident returned with from Hospital A. Review of a Nursing Progress Note dated 04/02/20 at 1:08 PM documents 'Right trochanter surgical site. No staple or sutures present. No signs of infection.' There is no documentation of a dressing or if a dressing change was done. There is no documentation of an assessment of the left forearm skin tear. Review of a Nursing Progress Note dated 04/03/20 at 1:10 by the LPN, documents 'Right trochanter hip dressing change in place as ordered. There are no staple or sutures present. There are signs of infection that include odor. Resident has a skin/wound infection. Resident is receiving ABT (antibiotics).' There is no documentation of an assessment of the left forearm skin tear. Review of a Skilled Nursing Daily Note dated 04/03/20 at 1:10 by the LPN, documents 'Right trochanter hip dressing change in place as ordered. No sutures/staples present. Sign of infection -yes. Odor. Newly identified this shift. Contacted NP (nurse practitioner). Skin/wound infection. On po ABT (oral antibiotics).' There is no documentation of an assessment of the left forearm skin tear. Review of an ARNP Geriatric Progress Note dated 04/03/20, documents the resident has a right hip surgical incision with serosanguinous drainage. Under assessment: Right hip site infection. Start Keflex 250 milligrams (antibiotic) every 6 hours for 10 days. Review of the results of the wound culture that was obtained on 04/01/20 and available on 04/03/20, revealed the right hip incision wound was positive for a heavy growth of a bacteria called Providencia Stuartii. Review of a Nursing Progress Note dated 04/03/20 at 5:38 PM documents 'CNA (Certified Nursing Assistant) assigned to resident inform that resident is observe in lying position on floor with the head on the foot of the bed. Resident is transferred to bed via Hoyer lift and position to bed for comfort. Resident is in pain. Nurse Practitioner is made aware and order is received to send resident to (Hospital B) for evaluation due to fall.' Review of the Nursing Progress Notes from 03/20/20 through 04/03/20, revealed 4 Registered Nurses and 4 Licensed Practical Nurses, for a total of 8 licensed nurses, cared for Resident #1, all of whom failed to appropriately assess and monitor the resident's right hip surgical incision. On 09/10/20 at 12:45 PM an interview was conducted with LPN Staff 'A' working on the B Wing, and an inquiry made about surgical incision assessments. LPN Staff 'A' stated the incision dressing is assessed every shift and the dressing is changed normally once a day or per physician orders. An inquiry was made what would be done if the resident was admitted with no incision care orders to which she stated you would have to call the physician to see what he wanted done, stating some physicians like the incision open to air and some like a dressing on it. An inquiry was made if there would be any time a surgical incision dressing would be left on for 11 days to which she stated 'Absolutely not. You have to check the incision to make sure it is not getting infected for example redness, swelling, drainage or increased temperature around the area.' On 09/10/20 at 1:00 PM an interview was conducted with LPN Staff 'B' working on the C Wing and an inquiry made about surgical incision assessments. LPN Staff 'B' stated she would follow physician orders if he wanted it dressed or open to air. She stated you have to observe the incision dressing every shift and dressings are done daily. She stated if there are no physician orders you would call the surgeon or primary physician for dressing orders. An inquiry was made if it would be appropriate to leave a surgical dressing on for 11 days to which she stated, 'No, you have to look at the incision to make sure it is not getting infected, that is why you change the dressing daily.' On 09/10/20 at 3:36 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator and an inquiry made if they would update the care plan if a surgical incision infection was identified to which he stated he would have to check the care plans. He stated the following day after an event they discuss all new issues in the morning meeting and then update the care plan to reflect the changes. The MDS Coordinator proceeded to leave and returned 5 minutes later, however was unable to explain why the care plan was not updated to reflect the development of a surgical incision infection with the initiation of antibiotics or the newly identified left forearm skin tear. On 09/10/20 at 3:45 PM an interview was conducted with the Director of Nurses (DON) and an inquiry made if it is their protocol to leave a surgical incision dressing in place for 11 days without changing it to which she stated the dressing would not be left in place for 11 days. An inquiry was made if there were no physician orders on admission for the care or assessment of a surgical incision, what is their process, to which she stated they would call the doctor for treatment orders. The DON was provided with the opportunity to review Resident #1's admission physician orders, MARs and TARs for March 2020 and she concurred there was no order of documentation of the surgical incision assessment or treatment. The DON then stated Resident #1's wound dehisced and the hardware was coming through and had to be replaced that is why they sent him out, then quickly stated it was a healing surgical site so there would be no point in assessing it. The DON was reminded Resident #1 had right hip surgery on 03/18/20 and was admitted to the facility on [DATE] so it was a fresh surgical incision, one that had not been appropriately assessed from 03/20 through 03/31 when it was discovered there was drainage and a foul odor seeping through the surgical incision dressing. The DON had no further comment. A request was made to the DON for the facility policy for surgical incision assessment and care. On 09/10/20 at 5:00 PM, before leaving the facility, the surgical incision assessment and care policy was not forthcoming. On 09/11/20 at 12:15 PM, the facility Administrator called stating they had additional information related to Resident #1 and would like to know what would be required. The Administrator was advised any additional information submitted will be reviewed. A request was made to the Administrator to also forward their policy for surgical incision care as that was not provided while onsite. The Administrator stated she will take care of it. On 09/14/20 at 2:02 PM, the clinical records from Hospital B for Resident #1 were received to include the resident's admission to the hospital on [DATE] post second fall. Review of a Discharge Summary note documented Resident #1 was admitted to the hospital post fall on 04/03/20 and discharged on [DATE]. The discharging physician documented 'The patient was admitted for pain in his right hip as well as a dehisced necrotic wound . He did develop some purulent drainage which was sent for cultures that showed Proteus Mirabilis as well as Morganella Morgani. He was seen by orthopedics who noted that his prosthesis is rotated on imaging and that there are gas bubbles concerning for deeper infection and possible impending infection of prosthesis and recommended the patient return to his original surgeon. The Discharge [DIAGNOSES REDACTED].' Resident #1 was discharged to Hospital A on 04/08/20, after a 5 day stay at Hospital B, to be followed by his original orthopedic surgeon and according to the DON's recollection, required surgery to replace the infected right hip hardware that was surgically implanted on 03/18/20. Review of the Center for Disease Control and Prevention (CDC) website revealed an article dated 05/09/19 related to surgical site infections (SSI) stating, 'A SSI is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other SSI are more serious and can involve tissues under the skin, organs or implanted material. Symptoms include redness and pain around the area where you had surgery; drainage of cloudy fluid from your surgical wound.' Review of the WebMD.com website, an Internet medical resource for nonmedical persons, with easy to understand language and explanations, was reviewed under How to Take Care of Your Wound After Surgery. The instructions included: 'When you're back home after your operation, make sure the cut made by your surgeon doesn't get infected. When do I take off the bandage? Your doctor will give you exact instructions on when and how to change it. Most wounds don't need one after a few days, but if you keep the area covered, it may help protect the cut from injury and it may heal faster. If you do keep a bandage on, change it every day. When should I call the doctor? Call if you see any signs that you're getting an infection around your wound. Some things to watch out for: pain that gets worse; redness or swelling; bleeding or oozing pus; increasing drainage from the wound; a bad smell.' As of 09/15/20 at 5:00 PM, no additional information was forthcoming from the facility and no policy for surgical incision care was provided.

Based on observation, interview and record review the facility compromised the residents' function and the ability to reach the highest practicable well being as a result of the failure to recognize significant episodic pain and failure to implement adequate pain management interventions for 8 of 8 sampled residents, (Resident #16, #63, #65, #124, #151,#216, #219 and #224). The findings include: 1. Resident #216 was admitted to the facility for rehabilitation services on 4/7/2012 after surgical repair of a fractured left hip. On 4/23/2012 at approximately 11:20 AM during an interview with the resident she stated she was very uncomfortable sitting in the wheelchair due to her recent hip surgery. The resident stated that she had received medication early in the morning on that day but did not have relief. She stated she was waiting to go to a physical therapy session and requested additional pain medication. The nurse gave the resident [MEDICATION NAME] 325 mg 2 tablets by mouth for pain as prescribed for break thru pain. Record review of the chart revealed that on admission the resident was prescribed [MEDICATION NAME] 5/500mg by mouth every 6 hours as needed. Review of the Pain Management Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Further review of the medical record revealed a telephone physician order dated 4/9/2012, 7:00 PM, for [MEDICATION NAME] 1 tablet by mouth every 8 hours. The Pain Management Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The form had "PRN" circled at the top of the form. Review of the form revealed the resident did not received the prescribed pain medication three times daily as ordered from 4/9/2012 until surveyor intervention on 4/24/2012. On 4/24/2012 at approximately 5:30 PM during an interview with the Director of Nursing she reviewed resident # 216 Pain Management Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated the initial admission order for [MEDICATION NAME] had not been discontinued and the updated 4/9/2012 [MEDICATION NAME] every 8 hours order was documented on the Pain Management Medication Administration Record, not as ordered by the physician. The DON and Unit Manager stated the resident's pain would be re-assessed and the physician would be notified regarding the medication error. On 4/25/2012 a new order was written for [MEDICATION NAME] 5/500 mg q (every) AM, prior to therapy then q 6 hours PRN for Pain. On 4/24/2012 at 5:00PM during an interview, Resident #216's family member states the resident does not use the call bell, doesn't want to bother staff, she is a retired nurse, has had pain but will not let anyone know. Interview with the resident reveals she feels much better today; she had PT(physical therapy) and is able to walk few steps. On 4/26/2012 at 9:30AM an interview with the PT (physical therapist) revealed the resident was seen yesterday for PT and was able to complete ROM (range of motion) in bed and sat up in bed. The resident received pain medication before the PT session. The therapist stated she went back later in the afternoon and the resident was able to ambulate 2x length bars with family in attendance. The therapist stated the resident seems confused at times when she is asked about her level of pain. The PT was not aware of a change in the pain medication order and stated she relies on nurses to give meds On 4/26/2012 at 1:30 PM during an interview with the ARNP, associated with the resident's doctor, she stated her scope of practice did not included prescribing narcotic medication. She stated she was aware the resident had a physician order for [REDACTED]. She stated that the staff was not administering the pain medication in a safe and effective manner. She stated the physician could not properly assess the residents response to the pain medication as result of the error in administration. Review of the facility policy for " Medication Administration General Guidelines" documents all medications are to be administered in accordance with written orders of the physician. 2. Resident #65 was admitted on [DATE] with a medical history of [REDACTED]. The resident is non-ambulatory, he utilizes a motorized wheelchair for mobility. Record review of Physical Therapy Notes from 4/24/2012 documents the resident having lower back pain, rated from 8 out of 10 on pain scale to 2 out to 10. The resident is able to perform bed mobility and out of bed transfers, secondary to the decreased complaint of lower back pain. The discharge plan includes the resident to receive Home Health therapy prescribed for strength and endurance deficits along with bilateral amputation impairment. Review of the Physician Note dated 4/23/2012 documents the resident complaining of not enough pain medications. Also, the resident complains he is not receiving therapy for his prosthetic leg. The physician changes the residents pain management orders of [MEDICATION NAME] 100 mg by mouth twice a day, 7 AM and 2 PM increasing the dose to [MEDICATION NAME] 100 mg by mouth three times a day, 7 AM, 2 PM and 7 PM. During record review of the Pain Management Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident did not receive the 7 PM dose of pain medication on 4/23, 4/24, and 4/25/2012 as prescribed by the physician. On 4/26/2012 at approximately 3:30 PM during an interview with the resident's physician, he reviewed the resident's medication orders and MAR. The physician stated that the resident had requested the pain medication be increased due to discomfort. This was after an attempt had been made to taper the resident from the pain medication due to constipation issues. The physician confirmed he had increased the [MEDICATION NAME] 100 mg by mouth to three times a day on 4/23/2012 at the request of the resident. He was surprised to learn that the resident had not received the [MEDICATION NAME] 100 mg by mouth three times a day as prescribed on 4/23/201. The resident had only continued to received 2 doses of the [MEDICATION NAME] 100 mg by mouth daily. The physician stated he was not notified of the missed doses. The physician stated that the resident was experiencing chronic uncontrolled pain and he had recommended a pain management consultation for the resident. On 4/26/2012 at approximately 4:00 PM during an interview with an Occupational Therapist, he stated the resident had a history of [REDACTED]. The therapist stated he recalls the resident had not had any therapy with his prosthetic limb due to the limb not fitting properly, causing additional pain for the resident. He stated a prosthetic evaluation had been ordered to address the limb issues with the resident. On 4/26/2012 at approximately 3:35 PM during an interview with the C-Wing RN Unit Manager she reviewed the physician order dated 4/23/2012 and the Pain MAR and confirmed the resident had not received the pain medication as ordered by the physician. She was unable to provide any further documentation regarding the missed doses of pain medication. 3. Review of the medical record for Resident #16 revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Pain medication orders were documented as: 03/27/12 [MEDICATION NAME] 50 mg by mouth at 9am & 5 pm 09/07/11- [MEDICATION NAME] 325 mg, give 2 tabs every 4 hours as needed for mild pain. Review of the Pain Management MAR for April 2012 revealed the resident received only one dose of [MEDICATION NAME] on 04/10/12 at 2 :00 PM. Review of the Pain MAR for March 2012 revealed she started receiving [MEDICATION NAME] 50 mg by mouth twice daily for pain at 9 AM & 5 PM on 03/27/12 . The resident also received [MEDICATION NAME] (Tylenol) 325 mg 2 tabs by mouth every 4 hours as needed for mild pain and received it one day on 03/31/12 at 2:00 PM- for mild pain and once on 04/10/12 at 2 PM for mild pain. Later review of the Pain MAR for April 2012 revealed Resident receives [MEDICATION NAME] 50 mg by mouth twice daily at 9 AM & 5 PM for pain and received it at 9 AM on 04/27/12. On 04/27/12 at approximately 10:15 AM, an interview was conducted with Resident #16. The resident stated she was feeling pain at that time and it was located on her lower left leg. She described it as a constant dull pain which radiates up to her knee. She stated she broke her foot twice and usually feels more pain after her physical therapy. She stated she has not seen her doctor for about three weeks and has not informed the doctor of her pain. Review of the Care Plan for Pain, with onset date of 09/08/11 and updated on 03/20/12 revealed that Resident #16 has acute pain, with verbal complaint on a 1-10 scale, and had [DIAGNOSES REDACTED]. Review of the Physical Therapy Progress Report, dated 04/25/12. Under the section: Remaining Functional Deficits/Underlying Impairments, included documentation stating: Resident complains of pain on left ankle and knee, occasional complaint of right knee pain. An interview was conducted with the Director of Physical Therapy/Rehab. on 04/28/12 at 12:40 PM. She stated that Resident #16 usually receives therapy after lunch between 1:30pm -3 pm. She further stated that the resident has occasional pain during therapy and if she does have pain, they will bring her back to nursing who will medicate her, and they will resume therapy after 20-30 minutes. 4. Review of the medical record for Resident #63 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plans, revealed Care Plans with an onset date of: 01/24/12 and updated on 04/27/12- Resident has chronic pain located in hip with dx (diagnosis) of a fracture. Interventions included monitoring and reporting signs and symptoms of pain, worsening of pain, reporting changes. 04/24/12 Care Plan for ADL (Activities of Daily Living) deficit. One of the interventions included to observe for pain during activity and report to nurse. Review of the Standards of Care Monthly Assessment Form, for March 2012, dated 03/22/12 revealed the following documentation: The resident may be experiencing pain; the reported or assessed/observed pain level at its worst was mild; resident displays the symptom of crying that may indicate pain; condition that can be reasonably associated with pain= history of fracture; resident has rehab screen for evaluation for pain management/ positioning. Resident was on routine pain regimen [MEDICATION NAME] 5 mg by mouth 3 times per day for chronic pain. An interview was conducted with Resident #63 on 04/27/12 at approximately 10:30 AM revealed she responded that she was experiencing pain at that time. The pain was all over her body, including her stomach, both feet and her upper left leg. She described it as a burning type of pain and it was a constant pain. She stated this pain was due to a fall from a chair she had prior to admission to the facility. She described the pain as being terrible, like she wanted to jump off a building. She further stated the nurse usually asks her if she needs pain medication, but the nurse had not asked her that morning. She stated she no longer goes to therapy. Review of the local hospital discharge instructions, dated 12/30/11 revealed the resident had prescribed [MEDICATION NAME] 25 mg by mouth every 6 hours for pain routinely. Review of Physicians' Telephone Orders (PTOs), dated: 01/21/12 -[MEDICATION NAME] 25 mg by mouth three times per day, at 9am, 1 pm & 5 pm routinely and then it was discontinued on 03/22/12. This ordered was replaced on 03/21/12-for a new order to give the pain medication [MEDICATION NAME] 50 mg by mouth every 6 hours as needed for pain. However, review of the Pain Management MARs for March & April 2012 revealed the Resident did not receive any [MEDICATION NAME] pain medication in March 2012 and only once in April 2012 on 04/27/12 for moderate pain at 11:00 AM. Review of the Physician Order Sheet dated April 2012 revealed the resident has a PRN (as needed) order dated 12/30/11, for [MEDICATION NAME] 325 mg, give 2 tabs (650 mg) every 4 hours as needed for mild pain. There was no documentation that the resident has been receiving any [MEDICATION NAME] in the past two months. An interview was conducted with 200s Wing Unit Manager. She stated she cannot find the Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated it probably got mixed up with another resident's paperwork. She was unable to state whether the resident received any PRN Tylenol in March 2012. Review of the PRN Tylenol MAR for April 2012 revealed that Resident did not receive any for April 2012. An interview was conducted on 04/27/12 at 11:30 AM, with the LPN who was in the process of passing medications to residents on the hallway where Resident #63 lives. She stated that on that same morning at 11:00 AM the resident complained of pain and she administered her PRN pain medication. An interview was conducted on 04/27/12 at 2:15 PM with the Certified Nursing Assistant (CNA) for Resident #63 who works on the 7AM-3 PM shift. She stated the resident has only complained of pain to her when she is being assisted with turning her and she would complain of pain in her upper left leg. She stated she has reported this to the nurse when the resident complains of pain. Review of the Physical Therapy Progress Report and Discharge Summary, dated 01/13/12, revealed Start of Care- 01/1/12 and End of Care 01/12/12. Analysis of Functional Outcome/ Clinical Impression documented that resident sustained [REDACTED]. Patient received 2 treatment sessions for therapeutic exercises at right lower extremity with free weights and bed mobility training. However, per conversation with MD, PT to be discontinued at this time and to be resumed after improved pain level. An interview was conducted with the Director of Therapy/Rehab on 04/28/12 at 2:45 PM. She stated that the physician has not resumed therapy for Resident #63. The resident ' s family elected for the resident not to have surgery and to allow the [MEDICAL CONDITION] to heal by itself and she is on Palliative care. 5. Resident #219 was admitted to the facility on [DATE] for rehabilitation services to include physical therapy (PT) 6 times a week for 8 weeks and occupational therapy (OT) 5 times a week for 60 days status [REDACTED]. On 04/27/12 at 10:15 a.m. Resident #219 was observed walking with the use of a walker in the presence of the PT. On 04/27/12 at 10:30 a.m. Resident #219 was observed being wheeled in a wheelchair by the PT. An inquiry was made to Resident #219 on 04/27/12 at 10:30 a.m. if she was finished with therapy and going back to her room and the resident replied she is going back to therapy and she just received a pain pill because she couldn't walk anymore due to the pain. An inquiry was made as to the severity of the pain and Resident #219 stated on 04/27/12 at 10:30 a.m. the pain is a dull ache down the right side of her leg and on a scale of 1 to 10 the severity was a 10. Additionally she stated the pain is aggravated by physical activity and she hopes she can get through the whole therapy now that she has had a pain pill. On 04/27/12 at 3:15 p.m. an interview was conducted with Resident #219's Licensed Practical Nurse (LPN) who stated Resident #219 has a PRN (as needed) pain medication and the resident did not need it before she went to therapy. The LPN further stated the therapist brought the resident back to her room around 10:00 a.m., she medicated her for pain and the therapist took her back to the therapy room. On 04/28/12 at 9:55 a.m. an interview was conducted with Resident #219's primary PT who stated when residents come to therapy she asks if they are having any pain and if they are not, they will receive therapy. If during therapy the resident has pain they stop and take the resident back to their unit for a pain pill, wait 15-20 minutes for the pill to work then they will resume therapy. She further stated when Resident #219 started therapy yesterday; she was not having any pain but as soon as she started the physical activity the pain started and she took her back to her unit to get medicated. On 04/28/12 at 10:50 a.m. an interview was conducted with Resident #219 in her room. An inquiry was made if she was asked if she wanted anything for pain prior to therapy and she stated the nurse gave her a pain pill around 9:30 a.m. and she is due in therapy at 11:00 a.m. The resident expressed she cannot go home until she gets stronger with walking with the walker. The resident further stated during the interview on 04/28/12 at 10:50 a.m. it was terrible at therapy yesterday with the pain and she had to stop therapy to take a pain pill and then after it started to work she went back to therapy. She reiterated the pain was 10 out of 10 on the pain scale. Additionally she stated she was under the impression they were routinely giving her pain medication 3 times a day and she did not realize she was not receiving anything for pain. She further stated that explains why she was having pain during therapy and she is looking forward to therapy today because the nurse gave her a pain pill and she hopes that she can get through therapy from start to finish. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the clinical record revealed an initial admission assessment dated [DATE] indicating the resident described the intensity of her pain as a 6 out of 10 with interventions to include monitor for pain every 4-6 hours and resident/family teaching related to pain management. Review of the Standards of Care assessment dated [DATE] under the category 'Pain' the resident documents a 'yes' response to 'The resident experiences or may be experiencing pain.' The assessment of the pain, management and interventions section is blank. Review of the care plan for pain dated 04/16/12 and updated on 04/26/12 documents under interventions 'Educate resident/family about comfort measure, [MEDICATION NAME] medications, and discuss fears/concerns regarding pain, comfort and disease process.' Review of the Physical Therapy care plan dated 04/16/12 documents 'Nursing to monitor and document on pain level and medication effectiveness.' Review of the Occupational Therapy care plan dated 04/17/12 documents ' Nursing to monitor and document on pain level and medication effectiveness.' 6. Resident #151 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Resident was receiving rehabilitation services to include physical therapy (PT). Interview on 4/27/12 at 1:20 PM revealed Resident #151 was sitting in front of the therapy room in their wheelchair. The resident was asked if she was having any pain or provided pain medication. The resident stated she always has some pain in her lower back, the pain medications they were giving her did not help and she had not received any medication prior to therapy today. The resident was observed in therapy at 1:55 PM. The resident stated she was walking and had some pain. The therapist stated she did good but could benefit from a pain pill prior to therapy. The resident stated "it might make me feel better". Record review revealed Resident #151 on 4/2/12,was found on the floor in room on their left side and complained of pain in both hips. On 4/3/12 the resident sustained [REDACTED]. During an interview on 4/27/12 at 2:40 PM with the rehabilitation director she stated the OT therapist put a hot pack on the residents back and forgot to remove it resulting in a burn to the lower back with some fluid filled blisters. the facility did not have an order for [REDACTED]. Review of the Standards of Care assessment updated on 4/4/12 under the category 'Pain' documents a 'yes'. The pain location is the back and pain is triggered with ambulation. Review of the Physical and Occupational Therapy care plans document 'Nursing to monitor and document on pain level and medication effectiveness.' The care plan does not address pain management prior to therapy when the resident will be ambulating. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pain management MAR indicated [REDACTED]. There was no documentation why the facility held the patch. From 4/5/12 through 4/23/12 the resident only received 5 doses of Tylenol 650 mg every 4 hours as needed for pain. During an interview on 4/27/12 at 3:10 PM with the nurse consultant, resident's nurse, and rehabilitation director to review the resident's record it was revealed the facility did not contact the physician for 7 days after stopping the residents [MEDICATION NAME] 5% patch for pain. The resident's nurse stated she stopped the patch because of the burn/ blisters sustained on the residents back. It was determined the patch was prescribed prior to the burn for pain and could have been placed in a different location on the residents back. 7. During an interview on 4/2712 with Resident #124 he stated he has pain when he goes to therapy because they put a brace between his legs in order to separate them. He also stated they only give him Tylenol when he requests pain medication and it really doesn't do too much. The resident's bilateral lower extremities are contracted. The resident also stated they do not give him any pain medications prior to therapy. Review of the Standards of Care assessment updated on 3/1/12 under the category 'Pain' documents a 'yes' assessed or observed pain level at worst is a 1-3. Pain type is documented as chronic and neuropathic. The assessment does not accurately reflect the resident's pain. The pain MAR indicated [REDACTED]. A review of the therapy note dated 4/26/12 documents during therapy the resident rated their pain as a 5 out of 10 with the prior level of pain noted as a 6 out of 10. The MAR indicated [REDACTED]. 8. Resident #224 was identified by the facility as someone who has pain during therapy. Review of the admission/readmission data collection and initial plan of care form dated 4/16/12 under Pain documents the resident does not have a [DIAGNOSES REDACTED]. Review of the Standards of Care assessment dated on 4/17/12 under the category 'Pain' documents a 'yes' assessed or observed pain level at worst is a 1-3. Rehab screen or evaluation for pain management "yes: recommendations "medicate pt prior to therapy" current pain regimen Tylenol prn. Pain type is documented as post trauma to the right knee. A review of the resident's care plans did not address pain or therapy. A review of the Physical therapy plan of care dated 4/9/12 documents in the section for underlying impairments: Pain at rest "moderate to severe(moderately heavy pain medication. patient requires very strong pain medication". pain with activity is "severe" therapy note dated 4/21/12 documents the resident's current level of pain as moderate to severe. A review of the MAR indicated [REDACTED]. On 04/28/12 at 3:30 PM an interview was conducted with the rehabilitation director, nurse consultant, DON, C unit manager, B unit manager and the administrator regarding assessing residents with pain and those who come to therapy in pain. The rehabilitation director stated they ask the residents if they are having any pain prior to therapy and if they are not, they will continue. If the resident has pain during therapy they stop and take the resident back to their unit for a pain pill, wait for the pill to work then see if the resident wants to continue. "Therapy will coordinate with nursing to give pain medications prior to therapy". Both of the unit managers stated they do not always know residents therapy schedules. All of the facility staff stated pain is addressed in the morning meetings. A list was provided from the therapy department identifying the date and time for all residents scheduled for therapy. Forty nine residents identified by the facility participate in the pain management program. 30 of those residents were identified as participating in either physical therapy or occupational therapy. A copy of the list was shown to both unit managers who stated they do not receive a copy of this information. The facility failed to accurately assess residents at risk for pain and document their pain management program resulting in an increased number of residents complaining of pain, not getting pain medications as ordered and less participation in therapy due to pain.

Based on observation, interview and record review, the facility's quality assurance and assessment (QAA) committee failed to reevaluate a systemic breakdown related to pain management, as evidenced by: lack of assessment; lack of administering pain medications and implementing appropriate care plans to address the pain for eight of eight sampled residents (Residents #16, #63, #65, #124, #151, #216, #219, and #224), who were not receiving routine medications and/or PRN (as needed) pain medications as ordered and failed to ensure staff were trained to address quality of care concerns as evidenced by not educating all staff on pain management, an identified concern from June 2011. The findings include: During the annual recertification survey conducted from 04/23/12- 04/28/12 eight residents were determined to be at risk for harm due to not be receiving their pain medications appropriately. This substandard quality of care resulted in an extended survey. As a result of this failure, residents may not achieve their highest potential in Physical Therapy and /or their highest practicable well-being. During an interview on 4/28/12 with the director of nursing (DON) and nurse consultant regarding educating staff on pain management. The DON stated the facility first identified a medication/pain management problem in June 2011. A review of the facility inservices revealed the following: 7/28/11 Inservice regarding "How when and what pain medications for pain management". The DON stated the signatures included staff on the first and second shift. 3/30/12 Inservice regarding "Procedure for all new admissions". The documentation provided showed only 6 signatures. The DON stated the inservice was only done on the C wing. 4/23/12 Inservice regarding "Documentation before and after, Documenting on MAR indicated [REDACTED]. It was also noted the inservice was completed after surveyor intervention. During the interview when asked why all shifts were not included with the inservices the DON stated she posted a notice but they are not mandatory. At 4:00 PM on 4/28/12 the nurse consultant stated she could not find written documentation any additional inservices were completed. No evidence was forthcoming during the survey that the concern regarding pain management had been assessed to determined if the desired outcome had been achieved, or if the plan had been reevaluated to develop and/or implement an appropriate plan to address the concern. The concerns with appropriate pain management continue for Residents #16, #63, #65, #124, #151, #216, #219, and #224 as outlined in the citation at F309.