Every finding on record at Savannas Park Health and Rehabilitation Center

Based on policy review, record review, and interview, the facility failed to ensure resident rights for 1of 3 sampled residents, as evidenced by the failure to assess Resident #20 for self-administration of medications.The findings included:Review of the policy titled, Resident Rights, implemented 11/2020 and revised on 01/2023, documented in part, 1. The right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Record review revealed Resident #20 was admitted to the facility on [DATE] with a recent readmission date of 05/06/25. Review of the current Minimum Data Set (MDS) assessment documented Resident #20 had a Brief Interview for Mental Status (BIMS) score of 12 on a 0-15 scale, indicating the resident had moderate cognitive impairment. Further review of the record revealed Resident #20's diagnosis documented in part, Pleural Effusion, Chronic Obstructive Pulmonary Disease (COPD), and Acute and Chronic Respiratory Failure with Hypoxia.Review of the physician orders documented in part, Pulmicort Inhalation Suspension 0.5 MG\/2ML Give 1 vial by mouth two times a day for Shortness of Breath via nebulizer, and Albuterol Sulfate Nebulization Solution (2.5 MG\/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 4 hours as needed for Shortness of Breath.An interview was conducted on 08/27/25 at 8:23 AM. Resident #20 stated she gets her nebulizer treatments daily and as needed throughout the day and night and wanted to be able to give herself the nebulizer treatments like she did at home. Another interview was conducted on 08/28/25 at 8:22 AM. Resident #20 was asked if she told the nursing staff that she wanted to give herself the nebulizer breathing treatment. She stated that she tells the nurse that she wants to give herself the nebulizer treatments all the time and that she has asked the nurses to leave the medication in her room so she could do it herself and the nursing staff told her they are not allowed to leave the medication in her room.An interview was conducted on 08/28/25 at 8:38 AM with Staff E, Licensed Practical Nurse (LPN), who was asked if Resident #20 wanted to administer her nebulizer breathing treatments herself. Staff E stated she knew Resident #20 from another nursing home where Resident #20 used to self-administer her nebulizer treatments. Staff E was asked if Resident #20 had been assessed to self-administer her nebulizer medication at this facility to which she responded that she was not sure and when she checked she stated Resident #20 had not been assessed to self-administer the nebulizer medications. Record review after the staff interview on 08/28/25 revealed that a Self-Administration of Medication Evaluation was initiated for Resident #20.

Based on observations, interviews, and record review, the facility failed to respond to a resident's request to remove food allergies from the meal ticket for 1 of 8 sampled residents reviewed regarding choices, Resident #34. The findings included: Record review revealed Resident #34 was admitted to the facility on [DATE] and 07/09/25 with a diagnosis of Anemia. An review of the care plans, revised on 07/29/25, showed that Resident #34 was at risk for altered nutrition and lab values.On 08/25/25 at 9:19 AM, Resident #34 was interviewed. She voiced her meal ticket recorded that she had allergies to shellfish and shrimp, but she did not have these allergies. She expressed frustration about her attempts to have the facility correct this information, saying, It's like talking to a brick wall.On 08/27/25 at 8:09 AM, the resident was observed lying in bed and her breakfast tray on the table. She reiterated that she does not have allergies to shellfish and shrimp. On 08/27/25 at 1:14 PM, the resident was again observed in bed, consuming her lunch. She stated she had been complaining to everyone who entered her room, requesting them to remove the allergy information from the meal ticket, stating, Sometimes complaining around here doesn't go very far. She recounted, overhearing a dietary staff talking to another resident across the hall regarding allergies to shellfish and shrimp; subsequently, the dietary staff came to speak to her. Resident #34 stated she believes the dietary staff may have mistakenly entered the other resident's food allergy information in her records. She expressed her disappointment and stated, she missed out on shrimp salads that was served at the facility, it pissed her off; and it upset her because she loves shrimp.On 08/28/25 at 9:31 AM, an interview was conducted with the Registered Dietitian (RD) regarding the documented food allergies. The RD reviewed the computer system and was surprised that it recorded these allergies. She confirmed the allergies were recorded on the meal ticket as well. She said Resident #34 had no allergies to shellfish and shrimp and noted that the resident had told her she loves shrimp and seafood. The RD acknowledged that allergies had been removed from the meal tracker but remained in the computer system. She commented, I understand if everyone else is getting it, and she [Resident #34] feels excluded.

Based on observations, record review and interviews the facility failed to provide a safe, clean comfortable homelike environment for 3 of 4 units. The findings included: A tour of the facility was completed on 08/27/25 at 1:45 PM with the Maintenance Director and the Director of Housekeeping. The following was observed, and they acknowledged these findings: a. room [ROOM NUMBER] - there was white caulking patches on the wall, the tile in the bathroom below the sink was cracked, there was a metal bar above the toilet that was moved and the holes from the screws remained and the rust stains not repaired, the floor in the bathroom was dirty with black stains on beige tile and floor caulking was black, and the door trim outside the door had come off the wall. b. room [ROOM NUMBER] - Resident #30 stopped the surveyor and Maintenance Director during the tour on 08/27/25 at 2:45 PM and stated that his left brake on his wheelchair did not lock. c. room [ROOM NUMBER]-A - A water stain was noted on the ceiling tile above entrance door and Bed A. The left arm rest of the wheelchair in the room had rubber peeling off it. d. room [ROOM NUMBER]-A - There were numerous white patches of caulking behind the head of the bed. e. room [ROOM NUMBER]-A - The blind on the window was broken, wall patches noted without paint. In the bathroom, the white seat cushion that is part of the shower chair had multiple hard dried dark brown pieces of an unknown substance attached to the cushion. f. room [ROOM NUMBER]-A - There were stains dripping down the wall across from the left side of the bed, the ceiling tile was stained above the entrance door and above bed A, the vinyl baseboard is torn along with the wall and was damaged at the corner of the bathroom and room wall meet. g. room [ROOM NUMBER]-A - The resident's wheelchair seat was torn at the front of the seat, and the tire was bald with the rubber on the tires disintegrating / rotting away from wheel. h. room [ROOM NUMBER]-B - The resident's wheelchair's rubber on both tires were bald and disintegrating. i. room [ROOM NUMBER]-B - The resident's wheelchair's tires were bald with the rubber on the tires disintegrating / rotting away from the wheel, and the right and left arm rests were cracked and torn, the wall under the window was scuffed, there was a crack in the wall in several places where the wall and the vinyl baseboard meet, and the vinyl baseboard was pulling away from the wall. j. room [ROOM NUMBER]-A - the resident's wheelchair tires had rubber that was disintegrating. The surveyor requested a policy on wheelchair maintenance and cleaning multiple times on 08/27/25 and 08/28/25. The Administrator stated on 08/28/25 at 8:05 AM that he was unable to find one and reached out to the regional office. The surveyor was not provided a policy. An interview was conducted on 08/28/25 at 2:08 PM with the Director of Rehabilitation who was asked if she had anything to do with the maintenance of the wheelchairs. She stated that she does an audit on the wheelchairs monthly. It shows who was looked at and who needs maintenance on chairs. She said she is not responsible for the cleaning of the wheelchairs but changing out the arm rest and the wheelchairs' back and seats. She said that a resident leaves that wheelchair that the resident used to be disinfected. She said that maintenance came to her yesterday after the tour and she said she can't order replacement backs and seats for the current chairs but obtained permission from the Administrator to order new chairs. The Director of Rehabilitation brought a copy of documentation to the surveyor on 08/28/25 at 2:40 PM showing that she goes around monthly and checks residents' wheelchair. It does not show any residents' wheels needing replacing. She also brought in a checklist for wheelchairs that included: checking bilateral brakes to see if they work safely and would fix as needed; checking bilateral arm rests for damage and to replace as needed; checking the wheelchair seats and back for damage and replace as needed; checking the wheelchair cushions and covers for damage and to request replacement as needed; checking wheels for wear and tear and damage and replace as needed; and to check the alignment of wheelchair when pushed and fix wheel bearings as needed.

Based on record review and interviews, the facility failed to ensure a PRN (as needed) antipsychotic medication was addressed in a timely manner for 2 of 7 sampled residents, as evidenced by the Lorazepam (antipsychotic) prescribed to Resident #96 and Resident #85 did not have a discontinue date or documented rationale by the doctor to extend the order.1.Review of the record revealed Resident #96 was admitted to the facility on [DATE]. The annual comprehensive assessment dated [DATE], documented that the resident had a Brief Interview for Mental Status Score of 10 on a 0 to15 scale, indicating moderate cognitive impairment. The resident had a documented medical diagnosis history of anxiety disorder and mood disorder. Review of the record revealed an order dated 07/07/25 for Resident #96 to administer Lorazepam 0.5 milligrams (mg) 1 tablet every four hours as needed f[PRN] or anxiety with no date to discontinue or documented rationale by the doctor to extend the medication. A second order dated 05/31/24 instructed staff to administer 0.5 mg every 8 hours for anxiety. Review of the care plan revealed Resident #96 is at risk for complications related to the use of psychotropic drugs: antidepressant for management of depression symptoms and antianxiety for management of anxiety symptoms, appetite with a goal that the resident will have the smallest most effective dose without side effects. Review of the pharmacy medication review dated 07/31/25 recommended to the physician that the PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to continue and provides a clinical rationale and duration for the PRN Lorazepam prescribed since 07/07/05. The Advanced Registered Nurse Practitioner (ARNP) responded on 08/05/25 by disagreeing and writing that the resident is under hospice care. The medication was never discontinued or appropriate rationale provided. Photographic Evidence Obtained. An interview was conducted on 08/29/25 at 10:52 AM with the Director Of Nursing (DON) who was made aware that Resident #96 had an PRN order for Lorazepam dated 07/07/25 and the pharmacy had recommended on 07/31/25 that the medication be discontinued or a clinical rationale be given for use. The order in the record was provided for the DON to review, and she stated, The resident is on hospice. The DON was made aware that the order was written by the facility's attending physician not hospice. When asked if a resident being on hospice mean there can be an open-ended order for an antipsychotic, she gave no response. The DON stated, The hospice physician does not have privileges in the facility to write orders for psychotropic medication. I will reach out to the attending physician regarding the order. 2. Review of the record revealed Resident #85 was admitted to the facility on [DATE] under hospice care and services. Review of the physician order dated 07/16/25 documented staff were to provided Ativan, an antianxiety medication, 0.5 milligrams (mg), every four hours as needed for anxiety. This order lacked any duration or stop date as evidenced by the duration documented as indefinite in the order details. Further review of the record revealed a Consultant Pharmacist Medication Regimen Review dated 07/31/25 that documented Resident #85 had been on the as needed Ativan since 07/16/25, and that the as needed psychotropic orders were limited to 14 days unless the prescriber deemed it appropriate to extend the order and provide a duration of use. This recommendation was addressed by the Advanced Practical Registered Nurse (APRN) of the resident's physician, who documented, disagree with the response documented as, Patient is under the care of hospice.

Based on observation, interview, and record review, the facility failed to ensure timely and appropriate care and services for 5 of 34 sampled residents as evidenced by the failure to clarify multiple physician orders and appropriately treat a rash for Resident #8; failure to ensure timely initiation of an antibiotic for Resident #96, who had an infected wound; failure to ensure medications were not provided by mouth for Resident #3, who had orders for nothing by mouth; failure to ensure treatment for a skin cancer wound for Resident #61; and failure to follow physician ordered blood pressure medication parameters for Resident #6.The findings included:1. Record review revealed Resident #8 was admitted to the facility 03/04/23, with the most recent readmission on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status Score (BIMS) of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident was totally dependent upon staff for toileting. Review of the current active physician orders for Resident #8 revealed the following: a) As of 05/30/25 staff were to apply Triad Cream to the resident's coccyx and buttocks every shift. This order was signed off as completed by Staff D, Licensed Practical Nurse (LPN) on 08/28/25 for day shift (7 AM to 3 PM), as per the August 2025 Medication Administration Record (MAR) . b) As of 08/01/25 staff were to apply Ketoconazole cream 2% to multiple areas of the resident's body to include her groin, once daily. This cream was scheduled for 9 AM and signed off by Staff C, LPN, on 08/28/25 at 9 AM. c) As of 08/26/25 staff were to apply Ketoconazole powder to the resident's perineal area and thighs, twice daily for a rash. This powder was scheduled for 9 AM and 5 PM and was signed off by Staff C on 08/28/25 at 9 AM. d) As of 08/26/25 staff were to apply [NAME] External Paste 40% to the resident's perineal area and thighs twice daily for a rash. This paste was scheduled for 9 AM and 5 PM and was signed off by Staff C on 08/28/25 at 9 AM. A current care plan initiated on 06/04/24 documented Resident #8 was at risk for complications due to being incontinent of urine and bowels related to immobility. The goal was to have the resident's incontinence care needs met by staff and to maintain dignity and comfort throughout. During an interview on 08/26/25 at 9:11 AM, Resident #8 stated, My butt hurts from lying in urine too long. The resident denied any wounds but stated it must be like a rash. The resident further stated she could not handle sitting up in her chair for more than a couple of hours anymore or her bottom would be killing her. An observation of personal care was made on 08/28/25 beginning at 11:00 AM for Resident #8. Staff B, Certified Nursing Assistant (CNA), provided perineal care to include the resident's front and back sides, and stated, You are very red (name of Resident #8) during the care. During the very gentle care, Resident #8 cried out in pain, but stated she knew it had to be done. An observation at that time revealed a bright red rash to the resident's groin and back side from her buttock down to her mid-thigh. When asked if this was something new, the CNA explained she hadn't worked with the resident in a while, but the last time she did, the resident was a little red. Staff B proceeded to apply Triad cream to the resident's groin, buttock, and back of thighs on the reddened parts. During a side-by-side record review and interview on 08/28/25 at 11:45 AM, when asked about Resident #8's rash, Staff A, LPN/Unit Manager, confirmed there were multiple orders for treatment to the perineum and groin. Staff A stated if she would have taken those orders she would have asked the doctor about the timing of each for clarification. When told Staff B applied the Triad cream to Resident #8, the Unit Manager stated that should be done by a nurse. An interview was conducted with Staff C, LPN, and Staff D, LPN, on 08/28/25 at 11:54 AM. When asked if she had applied any type of treatment for Resident #8's rash that day, Staff D stated she was helping out with treatments that day but had not gotten to Resident #8 yet, but she was on her to do list. Staff D stated the CNAs usually tell her when they had cleaned the resident, but she had not been told as of yet. Staff C, the resident's direct care nurse, stated she had not put anything on the resident's rash that morning, but she thought Staff D had done so. When asked why she signed off a treatment that she did not apply, Staff C stated, Yes, that's a problem. We sometimes go together but confirmed neither had provided any treatment that day although both had signed the record as completed. 2. Record review revealed Resident #96 was admitted to the facility on [DATE]. Review of the record revealed a wound culture was collected on 07/17/25, reported to the facility on [DATE] at 2:25 PM, and reviewed by facility staff on 07/20/25 at 11:40 AM. Review of the current active physician orders documented as of 08/22/25, Cefepime 2 grams, an antibiotic, was to be provided intravenously, every eight hours for a left heel wound infection, until 09/13/25 at 6 AM. Review of the July 2025 discontinued orders and Medication Administration Record (MAR) revealed the following: a) An order dated 07/23/25 documented to start the Cefepime antibiotic at 10 PM. The corresponding MAR documented the medication was not given as, Vitals Outside of Parameters for Administration. There were no parameters related to the antibiotic. b) An order dated 07/24/25 documented to start the Cefepime antibiotic at 9 AM. The antibiotic was not provided as per order. c) An order dated 07/25/25 documented to start the Cefepime antibiotic at 9 AM. The antibiotic was initiated at this date and time, six days after receiving the results of the wound culture. d) Further review of the July 2025 MAR revealed the antibiotic was not provided on 07/28/25 at 6 AM, as evidenced by a blank on the MAR. During an interview on 08/27/25 at approximately 1:00 PM, the Director of Nursing (DON) was made aware of the findings and agreed the antibiotics were delayed for Resident #96. 3. Record review revealed Resident #3 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE], documented the resident was rarely or never understood and was totally dependent upon staff for eating, as she was not allowed anything by mouth and fed through a tube. A current care plan initiated on 12/28/23 documented Resident #3 required a feeding tube to meet her nutritional and hydration needs related to dysphagia, and difficulty swallowing. An intervention instructed staff to keep the resident NPO, meaning nothing by mouth. Review of the current active physician orders revealed the following: a) As of 04/17/25, Glycopyrrolate 1 mg was to be given by mouth three times daily as a salivary inhibitor. b) As of 02/24/25, Methenamine Hippurate 1 gm, an antibiotic, was to be given by mouth every 12 hours for recurrent urinary tract infections. c) As of 04/21/25, Tylenol 325 mg, two tablets were to be given by mouth every 4 hours as needed for pain. d) As of 04/21/25, Tylenol 325 mg, two tablets were to be given by mouth every 4 hours as needed for a temperature greater than 100.4 degrees F. During an interview on 08/28/25 at approximately 4:00 PM, the DON agreed with the findings. 4. Record review revealed Resident #61 was readmitted to the facility on [DATE]. Review of the quarterly MDS assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 10 on a 0-15 scale, indicating moderate cognitive impairment. Review of documented medical history revealed a diagnosis of localized swelling, mass and lump. An observation was conducted on 08/25/25 at 9:55 AM. Resident #61 was observed sitting upright in bed. An area to his right jaw was draining a moderate amount of clear red drainage onto his gown. The area was not covered. An interview was conducted on 08/26/25 at 10:45 AM with the relative of Resident #61, who when asked if the staff is covering the area on his face, the relative stated, Well there is not much they can do about it because it's a type of skin cancer. When asked about the drainage that gets on his clothing, and the soiled towel noted on the bed, the relative stated, He uses that towel to wipe the area, if you think it's a concern please address it. During an observation conducted on 08/27/25 at 9:08 AM, Resident #61 was noted resting in bed with his head elevated. The cancer site to his right lower jaw was draining clear red drainage on a cloth napkin that was lying on his chest. Photographic Evidence Obtained. An interview was conducted on 08/27/25 at 9:20 AM., Observation of the area on Resident #61 right jaw was observed with Staff H, Licensed Practical Nurse (LPN), who when asked if there are any wound care orders for the area to the resident's jaw, Staff H, LPN stated, I think the wound care nurse was putting on a dressing, but the resident takes it off. When asked had the nurses ever performed wound care in the past to the area she stated, I don't think so, let me ask Staff I, Unit Manger (UM). An interview was conducted on 08/27/25 at 9:21 AM, who when asked if there was a treatment to the cancer area for Resident #61's right jaw, Staff I stated, I will have to check. An interview was conducted on 08/27/25 at 9:35 AM with Staff I who stated, Before Resident #61 went out to the hospital we were doing wound care treatment to the area on his jaw. The resident went out to the hospital a couple of weeks ago to get some treatment done to the area and he didn't come back with any orders; it wasn't draining when he came back. Are you saying that the area is draining now? An observation of Resident #61 right jaw was conducted with Staff I. She was made aware that the area had been draining a moderate amount since Monday and the resident was using a towel to clean the area. Staff I stated, Thank you for letting me know I will address it right away. An interview was conducted on 08/27/25 at 10:25 AM, Staff I who stated, I spoke to hospice to let them know that they need to reevaluate the site to Resident #61 right jaw. The relative does not want him to have any procedures or anything. I did get an order to cover the area. 5. Record review revealed Resident #6 was admitted to the facility 10/26/23 with several readmissions with the last one being 07/16/25, with diagnoses that included End Stage Renal Disease, Primary Hypertension, and Type II Diabetes Mellitus with Diabetic Neuropathy. Review of the physician orders revealed the following: Start date 07/16/25 at 2200 (10 PM): Hydralazine HCL Oral tablet 100 Give 100 MG by mouth every 8 hours every Monday, Wednesday, Friday, Sunday for hypertension. Hold if SBP (Systolic blood pressure < (is less than) 115, Heart rate (HR) < (is less than) 60. On the following dates, documentation on the Medication Administration Record (MAR) showed the medications were 'held' when the medication should have been given: a. 08/04/25 at 0600 (AM), B/P 121/59 HR 61 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. b. 08/08/25 at 0600, B/P 120/59 HR 60 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. c. 08/13/25 at 0600, B/P 126/63 HR 63 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. d. 08/17/25 at 0600, B/P 118/66 HR 63 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. e. 08/22/25 at 0600, B/P 123/59 HR 61 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. f. 07/27/25 at 2:00 PM, B/P 123/58 HR 61 - documents a #4 which in the chart codes means vitals outside the parameters for administration. This medication was not given but should have been given. On the following dates, documentation on the MAR showed the medication should have been held but were given: a. 08/11/25 at 0600, B/P 156/72 HR 59 - documents the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. b. 07/18/25at 0600, B/P 121/66 HR 59 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. c. 07/20/25 at 0600, B/P 145/54 HR 55 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. d. 07/23/25 at 0600, no B/P documented, HR 56 - tThe medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. e. 07/25/25 at 0600, 137/61 HR 59 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. f. 07/27/25 at 0600 B/P 146/54 HR 57 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. g. 07/30/25 at 0600, B/P 147/59 HR 54 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. Review of the Physician order with a start date of 04/25/25 and discontinued on 07/12/25 documented for Hydralazine HCL Oral tablet Give 100 MG by mouth every 8 hours every Monday, Wednesday, Friday, Sunday. For hypertension. Give if SBP (Systolic blood pressure >160 (is more then) Diastolic Blood Pressure > (DBP) (is more then). Start date 04/25/25 0600 AM and discontinued 07/12/25 01:58 AM. On the following dates documentation on the MAR showed the medication was given when it was outside the physician's parameters and should have been held: a. 07/01/25 at 10:00 PM, B/P 133/69 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. b. 07/02/25 at 0600, B/P 132/63 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. c. 07/02/25 at 10:00 PM, B/P 130/62 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. d. 07/03/25 at 10:00 PM, B/P 137/89 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. e. 07/04/25 at 10:00 PM B/P 126/60 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. f. 07/05/25 at 10:00 PM, B/P 147/70 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. g. 07/06/25 at 10:00 PM, B/P 130/60 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered h. 07/07/25 at 0600, B/P 143/66 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. i. 07/07/25 at 2:00 PM, B/P 132/78 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. j. 07/09/25 at 2:00 PM, B/P 149/60 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. k. 07/09/25 at 10:00 PM, B/P 136/60 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. l. 07/10/25 at 2:00 PM, B/P 152/66 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. m. 07/11/25 at 0600, B/P 157/66 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. n. 07/11/25 at 2:00 PM, B/P 140/82 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. o. 07/11/25 at 10:00 PM, B/P 135/79 - the medication should have been held but was given. There is a check mark in the box with nurse's initials. The chart codes document that a check in the box means administered. An interview was conducted on 08/27/25 at 11:15 AM with Staff F, LPN (Licensed Practical Nurse) who was asked about the resident on Hydralazine and the BPs. She said she does not normally take care of this resident and did not have an answer. An interview was conducted on 08/27/25 at 11:25 AM with Staff A, Unit Manager, who was asked to review the MAR for this resident. She was asked about the order for Hydralazine. Staff A reviewed the MAR and acknowledged the findings. An interview was conducted on 08/27/25 at 12:55 PM with the DON (Director of Nursing) who reviewed this resident's MAR and acknowledged the findings related to Hydralazine.

Based on facility policy, observations, record reviews, and interviews, the facility failed to provide care and services to prevent further decrease in range of motion for 1 of 3 sampled residents as evidenced by not applying the splints on Resident #25. The findings included: Review of the policy titled Restorative Nursing Program revised 05/2022 documented in part . It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Compliance Guidelines: 6. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services include: a. Passive or active range of motion. b. Splint or brace assistance. Record review revealed Resident #25 was admitted to the facility on [DATE]. Review of the annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 10 on a 0-10 scale indicating moderate cognitive impairment. Further review revealed a documented medical diagnosis of unspecified lack of coordination. An observation was conducted on 08/25/25 at 10:15 AM. Resident #25 was observed lying in her bed sleeping on her back, she was dressed, and her hands appeared to be folded inward. Review of a physician order dated 07/30/25 revealed Resident #25 was on the restorative nursing program for application of bilateral hand splints. Review of the order dated 08/06/25 revealed Resident #25 is to wear bilateral hand splints up to five hours per day three times per week. Review of the care plan dated 05/25/05 revealed a focus that stated restorative nursing is to assist Resident #25 with bilateral lower extremity active range of motion (ROM) and bilateral upper extremity passive range of motion (PROM) then apply splints to bilateral upper extremities, with a goal to increase bilateral lower extremity strength and maintain hand range of motion. The restorative certified nursing assistant is to document participation. An observation conducted on 08/26/25 at 10:35 AM. Resident #25 was observed lying in bed fully dressed, with her hands folded inward. There were no splints on her hands.An observation was conducted on 08/27/25 at 1:42 PM Resident #25 observed lying in bed sleeping, with her hands folded inward. There were no splints on her hands.Another observation was conducted on 08/28/25 at 9:4 AM. Resident #25 was noted lying on her back in her bed fully dressed sleeping, with her hands folded, there was 2 grey colored splints noted on the nightstand next to her bed. Photographic Evidence Obtained. Review of the Task in the record for Resident #25 revealed the splints were only applied on 08/07/25, 08/09/25, 08/17/25, and 08/22/25. An interview was conducted on 8/28/25 at 9:48 AM with the Restorative Nurse (RN) who was asked how it is determined who cares for the residents on restorative. She stated, At the beginning of the shift, the assignment is split between the restorative aides. There are usually three restorative aides for the day shift (7:00 AM - 3:30 PM) and an evening aide comes in at 4:00 PM to10:00 PM. There is a book that has the assignments, and it is located on Reflections Unit on a desk in the area where the residents on restorative will have their meal. When asked if she is familiar with Resident #25, she stated, Yes, but I don't know what exact program she is on. The RN was made aware that Resident #25 is on the restorative program for ROM and splints to be applied. She stated, Oh yes, three times a week. When asked if the aides should be documenting in the task on the computer whatever they do for the resident, she stated, Yes. The RN was made aware that the splints were not being applied on Resident #25 as ordered according to documentation, and the resident was observed for two days without the splints. When asked if the staff apply the splints a 9:00 PM, she stated, No they should be taking them off at that time. The RN asked if the restorative aides were documenting that the resident refused to have the splints. She was then asked if the refusal would be documented anywhere else besides on the task, and stated No, it would be on the task. The RN reviewed the task documentation for Resident #25 that revealed there had been no documentation of the resident refusing. Photographic Evidence Obtained. Review of the restorative weekly resident binder on 08/28/25 did not reveal documentation of which aides were assigned to the residents on restorative.An interview was conducted on 08/28/25 at 10:29 AM with Staff G, Certified Nursing Assistant (CNA), who was asked how it is determined which residents on restorative you see daily. She stated, Me and the other aides, kind of work together. We don't really split up an assignment. There is a list of residents on restorative, and it tells us what they are on the restorative program for. When asked how they document what is done for the residents, Staff G stated, We bubble the circle next to their name on the sheet, and we also document it on the computer. When asked what if a resident had splints ordered three times a week, what do you do, she stated, well sometimes it might be for certain days like Monday, Wednesday, Friday. When asked what if no one saw the resident on Monday is the resident seen on another day, Staff G stated, Yes. Staff G and surveyor reviewed the rehab service recommendation sheet that was signed by Staff G and other staff on 07/08/25. It indicated Resident #25 was to have splints three times a week. When asked if it was an old sheet that was completed for the resident, Staff G stated, No, because it said the service was started on 07/29/25.

Based on observation, interview, record review, and policy review, the facility failed to follow physician orders for nutritional support via a feeding tube for 2 of 2 sampled residents, Residents #3 and #5.The findings included:Review of the policy Care and Treatment of Feeding Tubes reviewed 11/27/23, documented in part, 1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. 9. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided: . e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders.1. Record review revealed Resident #3 was admitted to the facility on [DATE]. The current Minimum Data Set (MDS) assessment lacked a cognitive rating as the resident was rarely or never understood. This MDS also documented the resident was dependent on staff for eating related to her nothing by mouth status and nutritional needs being met by a feeding tube.A current care plan initiated on 12/28/23 documented the resident required feeding via a tube to meet nutritional needs and also documented the resident could not have anything by mouth. A current physician order dated 06/17/25 documented Resident #3 was to receive Osmolite 1.5 at 50 milliliters (ml) per hour 9h), for a total of 20h or until 1000mL administered. A full canister of Osmolite was 1000 ml in volume. The order specified to start the feeding at 2 PM and to stop the feeding at 10 AM.An order dated 02/19/25 documented the resident was not allowed anything by mouth.An observation on 08/26/25 at 9:58 AM revealed the Osmolite 1.5 canister was started on 08/25/25 at 2 PM. At the time of the observation, the tube feeding had been discontinued and there was about 300 ml of feeding left in the canister. Resident #3 only received about 700 of the prescribed 1000 ml of nutrition.An observation on 08/27/25 at 10:42 AM revealed the Osmolite 1.5 had been initiated on 08/26/25 at 1:37 PM and had been discontinued with about 150 ml left in the container. Resident #3 received about 850 of the prescribed 1000 ml of nutrition. A supplemental observation on 08/27/25 at 2:14 PM revealed the same bottle of Osmolite 1.5 now running with the 150 ml of feeding remaining, indicating the nurse had just recently started the feeding.During an interview on 08/28/25 at 2:46 PM, when asked the intent of the Osmolite 1.5 ml order for Resident #3, the Registered Dietician (RD) confirmed Resident #3 was to receive the 1000 ml of feeding during that 20-hour time period. When told of the feeding not administered to Resident #3, the RD stated it was the responsibility of nursing to ensure the provision of nutrition. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses to include Dysphagia (difficulty swallowing) and G-tube (Gastrostomy tube - tube within the stomach to provide nutrition). Review of the current MDS dated [DATE] documented the resident was not to eat by mouth and had a feeding tube for nutrition.Review of the current order dated 08/06/25 documented staff were to administer Nepro at 50 mL per hour for a total of 20 hours or until 1000 ml was administered. Staff were to initiate the feeding at 2 PM and discontinue it at 10 AM. A current care plan initiated on 07/01/24 documented the need for Resident #5 to receive feeding via a tube and instructed staff to provide the diet as ordered. An observation by two surveyors on 08/26/25 at 10:01 AM revealed the feeding of Nepro 1.8 running at 30 ml per hour.An observation on 08/27/25 at 2:16 PM revealed the Nepro 1.8 was started on 08/26/25 at 1:41 PM. The feeding had been stopped at this time but there was about 100 ml left in the canister.During an interview on 08/28/25 at 3:09 PM, when told of the observation of the tube feeding for Resident #5 running at 30 ml per hour, Staff A, Licensed Practical Nurse (LPN)/Unit Manager, stated she had not been aware of the decreased feeding. The Unit Manager reviewed the record, to include the orders and progress notes, and did not find a reason for the decreased rate of administration. The Unit Manager was also made aware of the failure to provide the feeding as per order for both Residents #3 and #5 and agreed with the findings.

Based on observation, interview, and record review, the facility failed to ensure oxygen orders and cleanliness of oxygen equipment for 1 of 3 sampled residents, Resident #5, who lacked any order for oxygen, failure of staff to change an oxygen nasal cannula that had been on the floor, and failure to ensure a clean oxygen canister filter.The findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses to include Respiratory Failure and dependence upon supplemental oxygen. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident was receiving supplemental oxygen.Review of the current physician orders lacked any order for the administration of the oxygen with an ordered rate of administration. The orders did document to clean the oxygen filter every night shift on Sundays.A current care plan initiated on 02/13/24 documented Resident #5 was dependent upon oxygen and to administer the oxygen as per physician order.An observation on 08/25/25 at 1:15 PM revealed Resident #5 receiving oxygen via nasal cannula at 4 liters. Photographic Evidence Obtained.An observation and interview on 08/26/25 at 10:01 AM revealed the oxygen remained at 4 liters via nasal cannula. Resident #5 stated she used the oxygen at 3 liters via nasal cannula.An observation on 08/27/25 at 8:28 AM revealed the oxygen remained at 4 liters via nasal cannula. The filter was dust laden. Photographic Evidence Obtained.An observation on 08/27/25 at 2:18 PM revealed Resident #5 was out of her room, but the oxygen concentrator was running at 4 liters via nasal cannula. The oxygen tubing, including the nasal cannula (the part the goes directly into the resident's nose to administer the oxygen) was lying directly on the floor, near the head of the bed and slightly behind the concentrator. The date on the tubing was documented as 08/24 with an unidentifiable name on a piece of tape wrapped around the tubing. Photographic Evidence Obtained.An observation on 08/28/25 at 10:31 AM revealed Resident #5 lying in bed, wearing the same oxygen tubing dated 08/24 with the same unidentifiable name on the tape. The oxygen was being administered at 4 liters per minute. Photographic Evidence Obtained.During a side-by-side record review and interview on 08/28/25 at 3:09 PM, Staff A, Licensed Practical Nurse (LPN)/Unit Manager revealed an order for oxygen to be administered at 2 liters per nasal cannula that was entered on 08/26/25 at 3 PM. When told the oxygen had been set at 4 liters per minute that week, and shown the photographs, the Unit Manager had no response. When told the nasal cannula had been found on the floor on 08/27/25 at 2:18 PM and the same oxygen tubing was observed being used by Resident #5 on 08/28/25 at 10:31 AM, the Unit Manager immediately asked another staff member to change out the tubing for a new set and had no other response.

Based on observations, record review and interviews, the facility failed to ensure that it was free of medication errors for 2 of 4 sampled residents, as evidenced by a medication error rate of 14.81% with 27 opportunities due to failure to ensure that Resident #22 received medications prescribed to him and was available for him, failure to ensure Resident #86 received medications prescribed to him and was available and failure to follow physician orders for a narcotic prescribed to Resident #86.The findings included:1. An observation of medication administration pass was conducted on 08/27/25 at 5:05 PM with Staff J, Licensed Practical Nurse (LPN), who prepared medications for Resident #22. She prepared Acetaminophen 325mg 2 tablets, Vitamin C 500mg 1 tablet, Atorvastatin 40mg 1 tablet, Methocarbamol 500mg 1 tablet. After preparing the medications, Staff J was asked how many pills she had in the medicine cup and she stated, 5 pills. Staff J crushed the medications all together and added applesauce to the cup. Staff J was observed administering the 5 medications to Resident #22.Review of the physician orders for Resident #22 revealed that staff were instructed to administer Vitamin D 50mcg 1 tablet in the evening and Eliquis 5mg 1 tablet twice and day at 9:00 AM and 5:00 PM.An interview was conducted on 08/27/25 at 5:45PM, who when asked if she would verify which medications were administered during the observation of med pass, Staff, J opened the computer to Resident #22 medication record and reviewed them. The Vitamin D 50mcg or Eliquis 5mg was not signed off on the medication record. When asked how many pills she had administered during observation of med pass, Staff J stated, Acetaminophen, Vitamin C, Atorvastatin, Methocarbamol. When asked why she didn't administer the Vitamin D 50mcg and Eliquis 5mg, she stated, I did administer the Vitamin D. Staff J was reminded that she only had 5 pills in the cup, which was the Acetaminophen 2 tablets, Vitamin C 1 tablet, Atorvastatin 1 tablet and Methocarbamol 1 tablet, which made 5 pills. Staff J stated, You're right. When asked why she didn't administer the Eliquis, Staff J stated, I don't have it. I have to look for it, it may be in the pyxis.An interview was conducted on 08/28/25 at 9:37 AM with Staff E, LPN, who was asked about the Eliquis medication prescribed to Resident #22. She looked in the medication cart and could not find the medication. Staff E, stated, Let go check and see if it's in the med room. Staff E came back to the medication cart without medication. She stated, Let me check when the last time the medication was reordered. Staff E looked in the computer and stated, The medication was last ordered on 08/12/25. I will reorder it. 2. An observation of medication administration pass was conducted on 08/27/25 at 5:20 PM with Staff K, Registered Nurse (RN), who prepared Oxycodone 15mg 1 tablet for Resident #86. She stated The resident is supposed to get Folic Acid, but I can't find it. I'm going to go ahead and give him the Oxycodone. Staff K was observed administering 1 pill to Resident #86. After administering the medication, Staff K stated, I'm going to check the medication room to see if the Folic Acid is in the overflow. She came out of the medication room with a bottle of folic acid and stated, This is not the right dose, but I'm going to give him this one. Staff K was asked if the nurse could order medications from the computer directly and she stated, Yes. When asked could you tell when the last time the Folic Acid was reordered, Staff K looked in the record and stated, It said the last time is was reordered was 03/15/25, but I will call the pharmacy to confirm. Staff K placed a call to the pharmacy, and confirmed, per the pharmacy, that the last time the folic acid was reordered was on 03/15/25. Staff K stated, I will call the doctor to make him aware that the medication was not available to give to the resident. Review of a physician order dated 05/16/25 instructed staff to administer Oxycodone 15mg Immediate Release 1 tablet three times a day at 6:00 AM, 1:00 PM and 10:00 PM. Review of the MAR documented the administrfative times were scheduled at 12:00 AM, 12:00 PM, 6:00 PM. An interview was conducted on 08/28/25 at 11:05 AM with the Director Of Nursing (DON) who was made aware of the order for Oxycodone HCL 15 mg and that the times scheduled on the Medication Administration Record (MAR) did not coinciding with what the physician orders for administration. The DON stated, I will look at the order, but there should be an actual script uploaded in the resident's record, because he is seen by pain management outside of the facility.Review of the prescription dated 05/16/25 with the DON, written for Resident #86, instructed staff to administer Oxycodone HCL 15 mg three times a day at 6:00 AM, 1:00 PM, and 10:00 PM. Photographic Evidence Obtained.Review of the August 2025 MAR for Resident #86 revealed Oxycodone Hcl 15 mg was being administered by staff at 12:00 AM, 12:00 PM, and 6:00 PM.

Based on interview and record review, the facility failed to ensure that the laboratory test was completed as ordered for 1 of 5 sampled resident records reviewed, Resident #5. The findings included: Record review revealed Resident #5 was re-admitted to the facility on [DATE], with diagnoses that included Diabetes and cancer. Review of the care plan, revised on 08/04/25, noted that Resident #5 was at risk for nutritional problems due to type 2 Diabetes, altered nutrition-related lab values, Dysphagia (difficulty swallowing), and dependence on enteral nutrition. The intervention outlined in the care plan included reviewing labs as indicated.Review of physician orders dated 08/22/25 revealed that a blood laboratory test for A1C (a test that measures the average blood glucose levels over the past two to three months) was ordered. There was no evidence that the A1C test was completed, as the test result could not be found in the records. There was no documentation revealing that the test was refused. On 08/28/25 at 9:19 AM, the Director of Nursing (DON) was interviewed regarding the A1C level. After reviewing the records, she stated, she didn't see it under results in the computer system. She said she would check the lab book to see if it was recorded there. The DON confirmed that she could not locate the test result.

Based on observation, interview, and record review the facility failed to ensure infection control standards for 4 of X34 sampled residents as evidenced by the failure to ensure timely contact precautions for Resident #33 who had symptoms of C-diff (Clostridium difficile, a highly contagious infection characterized by diarrhea); failure to collect a stool sample timely to ensure timely treatment for C-diff for Resident #51; failure to follow contact precautions during the medication pass observation for Residents #51 and #22; and failure to follow Enhanced Barrier Precautions (EBP) for Resident #129. The findings included:1. Record review revealed Resident #33 was admitted to the facility on [DATE]. A stool sample was collected on 07/13/25 with reports of C-diff positive results reported to the facility on [DATE] at 11:16 AM. This result was reviewed by facility staff on 07/16/25 at 8:08 PM. Review of progress notes revealed Resident #33 had frequent loose stools as of 07/13/25 and an order to collect the stool sample was received and collected the same day. Further review of the orders revealed contact precautions were not initiated until 07/15/25, two days after the identification of loose stools. 2. Record review revealed Resident #51 was admitted to the facility on [DATE]. A physician order dated 07/20/25 documented staff were to collect a stool sample to rule out C-diff. A stool sample was collected on 08/07/25, 18 days after the order, which indicated the resident had C-diff. Review of the Certified Nursing Assistant (CNA) documentation revealed Resident #55 had loose/diarrhea stools on 07/20/25 during the day shift; on 07/21/25 during the day and evening shifts, on 07/22/25 during the day shift; on 07/23/25 during the day shift; on 07/24/25 during the evening shift; and on 07/25/25 during the day shift. The stool specimen was not collected during any of those shifts. During an interview on 08/27/25 at 3:54 PM, when asked the reason the stool sample was not collected as per the physician order of 07/20/25, Staff A, Licensed Practical Nurse (LPN) / Unit Manager stated she thought the resident did not have an appropriate specimen, meaning no loose/diarrhea stools. The Unit Manager was made aware of the CNA documentation of numerous loose/diarrhea stools and agreed with the findings. 3. Record review revealed Resident #51 was readmitted to the facility on [DATE] with a medical diagnosis of Extended Spectrum Beta Lactamase bacteria (ESBL/contagious infection) in the urine. Review of the physician orders dated 08/25/25 instructed staff to administer Fosfomycin Tromethamine Oral Packet 3 GM 1 packet by mouth one time a day for ESBL in the Urine. An observation was conducted on 08/27/25 at 10:00 AM of Resident #51, who was noted to have a blue sign on her door that stated Contact Precautions (need to wear gown and gloves to prevent an infection). Staff L, LPN, entered Resident #51's room and placed a medication cup and 1 nasal spray and 1 inhaler directly on the resident's bedside table without a barrier. Staff L proceeded to check the resident's blood pressure with a blood pressure cuff that she placed on the resident's wrist. Staff L did not wash her hands when she entered the resident's room or prior to touching the resident. Staff L did not apply a gown or gloves prior to providing care to the resident. Staff L administered the medications in the cup. She donned gloves then assisted the resident with administering the nasal spray. Staff L offered the resident something to clean her nose with and handed the resident a paper towel that was laying on the bedside table. She prepared the inhaler to give to the resident, but she could not get the inhaler to work. Staff L left the resident's room and put the blood pressure cuff that she used on Resident #51 directly on the medication cart without cleaning it. She proceeded down the hallway to get another nurse to assist her with the inhaler. Staff I, UM, came to the medication cart and took the same wrist blood pressure cuff, without cleaning it, and was observed checking Resident #45 blood pressure with the wrist blood pressure cuff. Staff L came back to the medication cart and the other nurse demonstrated to her how to use the inhaler. Staff L took the inhaler and as she was getting ready to walk back into Resident #51's room, Staff I, UM stopped her and stated Look up and read the instructions on the door. At that time Staff L applied her PPE before proceeding into the resident's room. 4. Record review revealed Resident #129 was admitted to the facility on [DATE] with a primary diagnosis of necrotizing fasciitis, a bacterial infection affecting the tissue under the skin called fascia. The care plan dated 08/05/25 documented Resident #129 was at risk for skin breakdown due to a surgical wound on the right posterior leg. An intervention documented in the care planb included enhanced barrier precautions (EBP). Review of the progress notes for 08/05/25 documented Resident #129 had a primary diagnosis of necrotizing fasciitis and had undergone debridement of the right calf. Review of the physician orders dated 08/06/25 included enhanced barrier precautions related to the right calf wound. On 08/25/25 at 10:40 AM while the surveyor was standing in the hallway near Resident #129's room, it was observed that the resident's door was wide open and two staff members, the wound care nurse and a nurse practitioner, were providing wound care for the right calf. Notably, neither staff member was wearing a gown. At 10:43 AM, when the wound care nurse approached the door to obtain items from the treatment cart, an interview was conducted with her. She confirmed that they were caring for the resident's surgical leg wound. On 08/28/25 at 11:21 AM, the Director of Nursing (DON) was interviewed. She was informed about concerns regarding the observed lack of EBP in which the nurse practitioner and the wound care nurse performed wound care without wearing gowns.

Based on observations, interviews and record reviews, the facility failed to store, prepare and serve foods in a sanitary manner in accordance with professional standards for food safety. The census at the time of the survey was 117 residents. The findings included: The facility's policy, titled, Use and Storage of Food Brought in by Family or Visitors, with a reference date of 11/03/20 and a revision date of 03/20/23, documented, in part: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. The facility staff will assist residents in accessing and consuming food that is brought in by resident and family or visitors if the resident is not able to do so. On their own. The facility's policy, titled, General Food Preparation and Handling, with a reference date of 2005, documented, in part: Food items shall be prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of injurious organisms and substances. Procedure: 2. The kitchen and equipment are clean. 15. Leftovers must be cooled to <40 degrees F [Fahrenheit] within 4 hours (or cooled to 70 degrees F within 2 hours and then down to 40 degrees F within another 4 hours). 1. During the initial kitchen tour, on 04/28/24 at 8:51 AM, accompanied by the Food Service Director (FSD), the following were noted: a. the FSD was observed handling open foods without the use of a restraint to cover facial hair. b. Staff B, Dietary Aide, was observed removing single use and disposable gloves and then don new gloves without performing hand hygiene at the hand washing sink. Staff B then picked up some trays, utensils and knives before reaching for single use bags for cookies. The surveyor intervened and instructed the Dietary Aide to remove the gloves and perform hand hygiene. c. there were 3 drink cups on top of the food preparation table that Staff B was using to portion cookies into bags. Staff B confirmed that the cups were of her personal drinks and removed them from the food preparation table. d. the handles of knives that were stored in the preparation area were damaged to a point of creating a non-food contact surface that were uncleanable. e. inside of the walk-in freezer, there was an open case of garlic bread on the floor. The case of garlic bread was directly on top of ice that had accumulated on the floor. f. there was an accumulation of ice on the ceiling of the walk-in freezer over boxes of foods. g. inside of the walk-in cooler, there was a full sized 6-inch deep pan of a chicken and vegetable mixture that was to be used for the lunch meal on this day. The FSD confirmed that the chicken and vegetable mixture was in the process of cooling from the previous day. The surveyor requested the temperature of the item. The FSD took a digital metal stemmed probe-style thermometer to a sink and rinsed it. The FSD did not use any method to disinfect the probe of the thermometer prior to attempting to insert the probe into the food. h. the internal temperature of a full sized 6 inch deep hotel pan of a chicken mixture to be used for lunch today was in the process of cooling from the previous day was at 58 degrees F. The FSD confirmed that the food was cooked the previous day and was in the process of cooling. It was noted that the food was tightly covered with foil and plastic under the foil. 2. During a follow up tour of the Main Kitchen, on 04/30/24 at 10:56 AM, the internal temperature of containers of yogurt was 50 degrees F. It was noted that the 4 ounce containers of yogurt were on the top of a tub containing cartons of milk, shakes and juices that were covered in ice and the containers of yogurt were positioned on top of the ice. 3. During an observation of the Transitions Unit pantry (100 unit and 301 to 308) on 04/30/24 at 12:11 PM, it was noted that there was a platter of quiche in the reach-in cooler. During an interview with Staff D, Certified Nursing Assistant, when asked about reheating the quiche for the resident, Staff D replied, I put it in the microwave for a minute or 30 seconds and then bring it to the resident. Staff D was not able to demonstrate knowledge of safely reheating foods using a thermometer. It was noted that there was no thermometer available for staff to use to safely reheat items for the residents.

Based on observation, interview and record review, the facility failed to follow the approved menu for meals, for French Dip on a Roll, that was to be served for lunch on 04/30/24 from the Main Kitchen and the satellite kitchen on the Oasis Unit (400 unit). This regular menu could potentially affect 113 residents, including residents receiving the puree diet, of the 117 residents in the facility. The findings included: Review of the approved menu documented that residents were to be served 'French Dip on a Roll' for lunch on 04/30/24. The recipe for the 'French Dip on a Roll' was as follows: 6. slice each roll into bottom and top halves. 7. Assemble each sandwich by portioning 2.5 oz of meat on bottom roll of half roll using tongs. Top with second half. 8. Standard portion: Serve one assembled sandwich or serve per menu/tray card. Place 1 fl. Oz. (Fluid ounce) of Au jus in a souffle cup using a ladle and serve on the side with the sandwich. During the follow up kitchen tour, on 04/30/24 at 10:56 AM, the Food Service Director was observed using tongs to place the sliced meat directly on the plate and passing it to Staff C, Dietary Aide, who used a ladle to pour 'au jus' onto the sliced meat and finish plating the rest of the hot items from the steam table and passing it on to staff to complete the tray. The surveyor asked the Food Service Director (FSD) about serving, as a sandwich, as menu had documented. The Food Service Director immediately went to a rack that had assorted rolls on it. The Food Service Director began cutting the rolls in half diagonally and then cutting again to create a top bun and a bottom bun and placed 2.5 ounces of the sliced meat between them and then passed them to Staff C who used a ladle to pour the 'au jus' directly on the meat instead of portioning in a souffle cup as the approved recipe dictated. During an observation of lunch being served on the Oasis unit, on 04/30/24 at 12:11 PM, Staff O, Dietary Aide, was observed assembling the 'French Dip on a Roll' by cutting rolls to make a top and bottom roll. Staff O then placed 2.5 ounces of sliced meat on the bottom of the roll. It was noted that Staff O did not cut the roll diagonally as they did in the main kitchen and the sandwich appeared to be a whole sandwich as opposed to the half that was being served from the Main Kitchen. It was noted that staff again were not portioning the 'au jus' in a souffle cup as the approved recipe dictated.

Based on interview and record review, the facility failed to provide care and services per residents' request and choice for 2 of 2 sampled residents, as evidenced by failure to ensure showers as per preference and schedule for Resident #56, and failed to provide meals in the dining room per residents' request for Resident #56 and #78. The findings included: 1. Review of the record revealed Resident #56 was admitted to the facility on [DATE]. Review of the MDS (Minimum Data Set) assessment for Admission/Medicare Part A Stay dated 01/29/24 revealed the Brief Interview for Mental Status (BIMS) score was 15, indicating cognition was intact. This MDS also documented the resident was Substantial / Maximal Assistance for showers. Review of the current care plan for Activities of Daily Living (ADL) self-care performance deficit related to paraplegia, and other clinical history, documented provide sponge bath when a full bath or shower cannot be tolerated. Review of the shower schedule revealed Resident #56 was scheduled for a shower on Tuesdays and Thursdays during the 3 PM to 11 PM shifts and is a 2-person assist. During an interview on 04/28/24 at 10:47 AM, Resident #56 stated he has only had 1 shower since he's been here. He said they do bed baths every day. Resident #56 stated when I asked for a shower they said, I don't fit in the chair, and they don't have the staff. Review of the tasks section of the electronic medical record for 03/31/24 through 04/29/24 documented no data found under the shower task. Review of the task Bathing PRN [as needed] resident request documented 5 days: 1 day dated Tuesday 04/02/24 is marked as having a shower; 3 days are marked as having a bed bath (Thursday 04/04/22, Monday 04/22/22, and Friday 04/26/24) and 1 as not applicable dated Monday 04/15/22. An interview was conducted on 04/30/24 at 3:10 PM with Staff G, Certified Nursing Assistant (CNA), who when asked if she takes care of Resident #56 on the 3-11PM shift., acknowledged that she cares for him. She was asked about his showers and stated he refuses many times to take his shower. The task concerning the shower and bath schedule were reviewed. Staff G was asked if she ever tells the nurse when he refuses or if it was charted somewhere. Staff G stated she does not speak to the nurse about the resident refusal and if refuses she puts it under the 'not applicable' heading of the task. An interview was conducted with Staff H, Unit Nurse Manager, and task for showers were reviewed where the CNA documents for showers. Under Tasks where the CNA's document showers, there was a place to document if the resident refuses. There was no documentation found for this resident which identified him as refusing a shower. It was reviewed with the Nurse Manager about documentation, who stated, if it isn't documented then it wasn't done. An interview was conducted on 05/01/24 at 9:00 AM with Resident #56 who was asked if he had a shower yesterday. The resident stated, yes they gave me one. The CNA stated when she got done with the shower that I am going to recommend you for a bed bath, it's too much trouble to give you a shower. The resident stated they use a shower chair, and it is hard. When I ask them to shower me, they tell me I am not scheduled. During an interview on 05/01/24 at 1:33 PM with Director of Nursing (DON), she acknowledged that the CNA's go in the Point Click Care resident records under task and document the showers. The PRN task is when the resident is requesting a shower not on the scheduled shower day. 2. An observation was conducted on Sunday 04/28/24 at 12:00 PM, of the main dining room and there were no residents in the main dining room. The Dietary Manager (DM) was asked at that time where all the residents were for lunch. The DM stated that since he has been here, it has been closed on the weekend for all 3 meals. During the Resident Council meeting on 04/30/24 at 10:08 AM, residents stated they can only eat in the dining room for lunch Monday through Friday. You have to eat in your room for breakfast and dinner during the week and on the weekends. We asked the residents and they said there were not enough staff. Resident #78 further stated that she spoke to the Administrator about opening up the dining room and he told her there were not enough staff. During an interview on 05/01/24 at 1:44 PM the DON was asked why the dining room was closed on weekends and breakfast and dinner during the week. The DON stated it is not that we don't have staff, it's that we have to figure out who will be working there. During an interview on 05/01/24 at 2:00 PM, Resident #56 was asked about his grievance that he put in about wanting to eat in the Oasis dining room. He stated that he wanted to but it's too far for him to go and I don't wake up in time to eat in Oasis (Oasis is the rehab unit dining room). He stated if the dining room was open then everybody would eat in there. During an interview on 05/01/24 at 2:04 PM with the Social Service Director, she stated that Resident #56 was on the rehab unit when he came in and then went to a long-term care room. She said that the Restorative residents eats in the main dining room in the mornings and all other residents can eat breakfast in the rehab unit but not the main dining room. She stated she doesn't know why. She stated that during lunch, the rehab dining room is only open for rehab residents on that unit, and long term eats in main dining room for lunch. 39026 3. Resident #78 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Dependence on Renal Dialysis and Depression. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 04/03/24 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. On 04/28/24 at 10:30 AM, an initial interview was conducted with the resident. The resident stated she eats lunch in the dining room, but breakfast and dinner were served in her room. On 04/28/24 at 12:00 PM, there were no residents observed in the main dining room. The Dietary Manager stated that since he has been here it has been closed on the weekends for all 3 meals. On 04/28/24 at 12:32 PM, an interview was conducted with Staff F, Registered Nurse / Weekend Supervisor, regarding using the dining room for lunch. She stated it is not used on the weekends. She stated she does not know why but you should ask dietary. An interview with Staff E, Licensed Practical Nurse / Infection Preventionist was conducted at the same time who stated that they are in the process of getting both dining rooms open on the weekends as well. On 05/01/24 at 1:48 PM, an additional interview was conducted with Resident #78. She stated she would like to have the dining room open 7 days a week for all meals. She is tired of eating in her room. She was aware that she can go to the OASIS dining room for breakfast, but she felt like she didn't belong there with the residents because it was by the rehab area. She stated this has been brought up in Resident Council, but the dining room is still only open Monday through Friday for lunch. On 05/01/24 at 2:00 PM, an interview was conducted with the Administrator. He stated he was aware that Resident #78 would like the dining room open for meals but he has not tried to open the dining room for a couple of months. He stated that there was poor interest at that time, and he did not try since then. He stated he was dragging his feet on reopening the dining room.

Based on observation and interview, the facility failed to ensure it provided a safe, clean comfortable homelike environment, as evidenced by damaged and dirty equipment, peeling paint, bathroom issues, and stained walls and doors. The findings included: Review of the Preventive Maintenance for wheelchairs, dated 11/03/20 with a revision date of 06/07/23, documented, in part; It is the practice of the facility to develop and implement a preventive maintenance program to ensure wheelchairs are maintained in a safe and operable manner. 2. All staff have the responsibility to ensure that wheelchairs in need of repair are not used and are reported for repairs. 3. The Maintenance Director is responsible for developing and maintaining a schedule of preventative maintenance services to ensure that equipment is maintained in a safe and operable manner. e. Check seats, backs, arm rests and cushions for tears, cracks or missing screws-replace or repair if present. 5. If the wheelchair fails any element of the preventative maintenance check, the wheelchair should be identified for repair and taken out of service until the repair is completed. During the initial tour of the facility, including resident rooms, on 04/28/24 through 04/29/24, and a secondary tour completed on 05/01/24 at 11:22 AM with the Maintenance Director and the Housekeeping Manager, the following was observed and acknowledged by the Managers: a. room [ROOM NUMBER], the resident's call bell wire had wiring exposed, head of bed had the cork board splintered and the bump guard damaged behind the head of bed. b. room [ROOM NUMBER], the bathroom entryway on both sides of doorway were scuffed up and had peeling paint. The sink was backed up with soap suds. An Aide was observed washing her hands and stated she had to make it quick because the sink stays clogged. c. room [ROOM NUMBER], there was white caulking on the wall behind Bed-B that needed painting. The vinyl sideboard peeling away from wall. Bed A the bump guard behind bed on wall damaged. d. room [ROOM NUMBER]-A, the resident's high back wheelchair's bilateral arm rests were cracked. e. room [ROOM NUMBER]-A, the bilateral arm rests on the wheelchair were torn. f. room [ROOM NUMBER], the bilateral arm rests on the wheelchair were torn and had tape around the left arm rest. g. Hallway on high-200's, there was brown splatter on walls above and below the chair rail in the hallway. h. the sit-to-stand lift was dirty on the black pads and feet rests. Photographic Evidence Obtained.

Based on observations, interviews, policy and record reviews, the facility failed to follow policies and procedures to ensure a safe smoking environment for residents that choose to smoke for 3 of 3 residents reviewed for smoking, Residents #60, 110 and 112. The findings included: The facility's policy, titled, Smoking Policy, (no reference date), documented, in part: This facility will establish and maintain safe resident smoking practices for all residents. To assure maximized safety, all residents who choose to smoke will be supervised smokers. Policy Interpretation and Implementation: 2e. All smokers will be supervised during smoking without exception. 4. Th designated smoking area will be staff-supervised at times posted at the entrance to the smoking area. Those who wish to smoke outside designated times designated time blocks will request assistance from staff who will provide supervision at the earliest convenience. 15. All smoking materials will be kept in a lock box at the adjacent nurse's station. Residents who smoke will turn in all smoking materials and paraphernalia to the staff person in charge when leaving the smoking area. No resident may have or keep any smoking materials or paraphernalia, including cigarettes, tobacco, lighters, matches etc. in their possession outside the designated smoking area. 19. All smoking materials and/or paraphernalia brought into the facility must be turned over to staff for securing in the lock box system. On 04/28/24 at 10:20 AM, 3 residents, that included Residents #110, #112 and a random resident were observed on the smoking patio with no supervision. a. Record review revealed Resident #60 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #60 had a Brief Interview for Mental States (BIMS) score of 15, indicating the resident was cognitively intact. On 04/29/24 at 9:37 AM, Resident #60 was observed on the smoking patio, smoking with no supervision. b. Record review documented Resident #110 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Medicare 5-day MDS, dated [DATE], documented Resident #110 had a BIMS score of 15. On 04/28/24 at 11:18 AM, Resident #110 was observed on the smoking patio, smoking with no supervision. During an interview, on 04/29/24 at 10:26 AM, with Resident #110, when asked about smoking materials, Resident #110 replied, normally they would be on me. Someone came in this morning and asked for all of my stuff, and I was sound asleep in my bed, and I couldn't remember where they were. The same thing happened to Resident #112 too. I used to keep them in my wheelchair. Resident #110 also stated that it was the first day that there had been supervision during smoking. c. Record review documented Resident #112 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Medicare 5-day MDS, dated [DATE], documented Resident #112 had a BIMS score of 15. During an interview, on 04/29/24 at 10:28 AM, Resident #112 confirmed that facility staff had taken the smoking paraphernalia that she had kept in her room until that time. Resident #112 further stated that it was Staff F, RN/Weekend Supervisor who had removed the items. Resident #112 also stated that it was the first day that there had been supervision during smoking. On 04/29/24 at 1:30 PM, Staff J, Cook, was observed providing supervision on the smoking patio with Residents #110 and #112, when asked about providing supervision to the residents, Staff I replied, they changed it today to have me out here. I am normally in the kitchen, and I am on light duty from an injury in November. Normally, I work with the menus, I set up the dining room, I do what I am told and what I can do while I am on light duty. On 04/29/24 at 2:55 PM, the surveyor requested a copy of the smoking schedule from the Administrator. The Administrator stated, we were forced to liberalize the smoking schedule to be open because the residents were grossly noncompliant with the smoking schedule, and we caught a couple trying to smoke in their rooms. We instituted an open schedule and have somebody available to supervise. I know that we had a couple of misses yesterday (referring to not providing supervision). On 04/29/24 at 3:22 PM, Staff K, Housekeeping, was observed providing supervision on the smoking patio, with Residents #60, 110, 112 and a random resident. When asked how often he provides supervision to the residents that smoke, stated, I have never done it before. My supervisor called me and asked me to relieve Staff I . On 04/30/24 at 7:49 AM, Staff L, Dietary Aide, was observed on the smoking patio providing supervision to Residents #60, 112, while Resident #110 was arriving to the patio. When asked about providing supervision, Staff K replied, today is my first day. I went to the laundry today to do my light duty and they said that I had to come out here and watch the residents. I have to do it today and tomorrow. Staff K further stated that he came to the patio at 7:00 AM and will be here until 12:00 PM. During an interview, on 04/30/24 at 10:26 AM with Staff F, RN / Weekend Supervisor, when asked about removing the smoking paraphernalia from the residents' rooms, Staff F replied, because we keep it in here in a locked box, since we have been doing this for a year. I asked for them and they willingly gave them to me. On 04/30/24 at approximately 10:30 AM, a copy of a schedule for staff to provide supervision on the smoking patio was provided to the surveyor. During an interview with Staff M, Licensed Practical Nurse / Unit Manager, when asked about the schedule, Staff M replied, the Administrator made a schedule for staff to supervise smokers that started a couple of days ago.

Based on observations, interviews and record reviews, the facility failed to provide nutrition via enteral means as ordered by physicians for 1 of 1 sampled resident, Resident #108, reviewed for tube feeding. The findings included: Record review revealed Resident #108 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an Admission Minimum Data Set (MDS), dated [DATE], documented Resident #108 had a Brief Interview for Mental Status (BIMS) score of 06, indicating the resident had severe cognitive impairment. Resident #108's dietary orders included: a. On 04/19/24, CCHO (Controlled Carbohydrate) diet, Mechanical Soft texture, Thin consistency. b. On 04/19/24, Enteral Feed - in the afternoon for NUTRITION OFF AT 10AM - ON 2PM Glucerna 1.5 at 40 milliliters per hour (ml/hr). Resident #108's care plan for tube feeding dated 04/28/24, documented, Resident requires an enteral feeding tube to meet nutrition and hydration needs related to: Cerebrovascular Accident) and Dysphagia. The goal of the care plan was documented as, Will tolerate enteral feeding without signs or symptoms of aspiration throughout next review date 04/28/24 with a target date of 07/22/24. Interventions included: Provide tube feeding as ordered, Date Initiated: 04/28/24, Created on 04/28/24. Resident #108's care plan for nutrition, dated 04/11/24 with a revision date of 04/29/24, documented, Resident has a nutritional problem r/t Hx [related to / history] of CVA w/ [Cerebral Vascular Accident with] Dysphagia requiring a GTube [Gastrostomy Tube] for meeting needs. Hx of ESRD {End Stage Renal Disease] (HD[hemodialysis] discontinued 04/17/24) Resident has a preference to avoid pork and an allergy to shrimp, Date Initiated: 04/11/24. Goals: One of the goals of the care plan was documented as, The resident will maintain adequate nutritional status as evidenced by maintaining weight within (95)% of (146), no signs/symptoms of malnutrition, and tolerating TF [tube feeding] through review date. Date Initiated: 04/11/24 Created on 04/11/24, Revision on: 04/11/24, Target Date: 07/22/24. Review of a patient transfer form from an Acute Care Hospital, dated 03/29/24, documented the resident with an NPO (nothing by mouth) diet order. Further review of Resident #108's record revealed the resident received nutrition via enteral methods upon admission. On 04/30/24 at approximately 7:30 AM, Resident #108 was observed in the Main dining room having breakfast. On 04/30/24 at 8:20 AM, the resident was being assisted by staff back to the unit and left the resident at the nurse's station on the Transitions Unit. Resident #108 stated I was having breakfast in the Dining Room. On 04/30/24 at 9:43 AM, Resident #108 was observed in therapy in a wheelchair actively participating in therapy. On 04/30/24 at 10:30 AM, Resident #108 was assisted back to her room by staff. Upon being returned to her room, Resident #108 was noted to not have the tube feeding restarted since being observed in the Main Dining Room during breakfast. During an interview, on 04/30/24 at 2:15 PM, with Staff N, Licensed Practical Nurse (LPN), when asked about stopping Resident #108's tube feeding, Staff N replied, She was already disconnected before I walked in and before my shift [7AM-3PM]. I did my round. She was in her room when I gave her medication at 10:37 AM. Staff N confirmed that Resident #108 did not have the tube feeding regimen started again until the next scheduled start time (2:00 PM).

Based on observations interviews and record reviews, the facility failed have nurse staffing information posted daily and failed to update the nursing staff information, including names of staff providing care to the residents and residents' census on 2 of 3 units. The findings included: 1. Upon entering the facility, on 04/28/24 at 8:30 AM, it was noted that the nurse staffing hours were not able to be located by members of the survey team. During a tour of the facility, on 04/28/24, beginning at 9:26 AM, the staffing data was again not able to be located. On 04/28/24 at approximately 10:30 AM, the staffing data was on the reception desk in the Main Lobby, where the information was not available during the previous observations. 2. During a unit by unit tour of the facility, on 04/28/24 at 9:26 AM, the following were noted: a. On the Reflections Unit, 200 unit and rooms 309-316, the white board that was used to list the names of the nursing staff providing care to the residents was dated Friday, 04/26/24. b. On the Oasis Unit (400 unit), the white board that was used to list the names of the nursing staff providing care to the residents was dated Saturday, 04/27/24. During an interview, on 05/01/24 12:58 PM, the Administrator stated the Unit Mangers are responsible for ensuring that staffing is posted. During an interview, on 05/01/24 12:59 PM, with Staff I Registered Nurse / Unit Manager, when asked about the staffing information not being updated, Staff K replied, we are working on a system to make sure that the staff on the weekends are updating them (referring to the white boards used to list the names of nursing staff providing care to the residents). During the interview, Staff K confirmed that the staff listed on were from previous days' shifts. Staff K stated, It has been a problem on the weekends.

Based on observation, interview and record review, the facility failed to prepare and provide meals in a manner to conserve the nutritive value of pureed vegetables. The findings included: The facility's policy, titled, General Food Preparation and Handling, with a reference date of 2005, documented, in part: 15. Food items shall be prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of injurious organisms and substances. Procedure: 15. Leftovers must be cooled to <40 degrees F within 4 hours (or cooled to 70 degrees F within 2 hours and then down to 40 degrees F within another 4 hours) .Leftovers are not to be used for as pureed food. The facility's approved recipe for Pureed Buttered Broccoli Florets (no reference date) frozen broccoli pieces lightly seasoned with margarine then pureed to a pudding texture was as follows: 2. Prepare Broccoli according to the attached/printed sub recipe (referring to the recipe for broccoli to be steamed from frozen florets). 3. drain vegetables and place in food processor, add margarine, then puree. During the initial kitchen tour, on 04/28/24 at 8:51 AM accompanied by the Food Service Director (FSD), Staff A, Dietary Aide, was observed handling a 6-inch deep container of sliced carrots and a 6-inch deep container of broccoli. When asked about the vegetables in the containers, Staff A stated that they will be used for making puree vegetables later in the week. Staff A confirmed that the vegetables would have to be reheated and then pureed and then placed in the hot holding unit for service. During an interview with the Food Service Director at the time of the observation, the FSD acknowledged that reheating the vegetables that had already been cooked would significantly diminish the nutritional value of the vegetables.

Based on observation, interview and record review, the facility failed to provide foods per residents' religious preferences for 1 of 4 sampled residents reviewed for food concerns, Resident #108. The findings included: Record review revealed Resident #108 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an Admission Minimum Data Set (MDS), dated [DATE], documented Resident #108 had a Brief Interview for Mental Status (BIMS) score of 06, indicating that the resident had severe cognitive impairment. Resident #108's dietary orders included: a. CCHO (Controlled Carbohydrate) diet, mechanical Soft texture, thin consistency - dated 04/19/24. Review of Resident #108's electronic health record (EHR) showed that the resident was allergic to pork. During an interview, on 04/29/24 at 7:40 AM, with Resident #108, when asked about the food served in the facility, Resident #108 replied, the food is terrible. They keep serving me food that I don't like. I don't like pork (including sausage, bacon, ham). Resident #108 further stated that she did not eat pork products as she is of a specific religion. During an observation of breakfast being served to the residents in their rooms, on 04/29/24 at 8:31 AM, Resident #108 was served mechanical soft (ground) pork. Review of the tray ticket that accompanied the meal revealed the resident's preference for not having pork was not documented on the tray ticket. During an interview, on 04/29/24 at 8:43 AM, with the Food Service Director and the Registered Dietitian, when informed that the resident's allergies and dislikes were not included on the tray ticket, the Food Service Director stated, If we don't put it in the system, it will not show up on the tray ticket. An observation of the sausage products that were stored in the walk in freezer at the conclusion of the interview confimed that all of the sausage that was served to the residents in the facility were pork based sausage.

Based on observation, interview and record review the facility failed to prohibit physical and verbal abuse of 1 of 3 sampled residents (Resident #264). The findings include: Resident #264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview and observation on [DATE] at 1:55 PM resident #264 stated approximately 2 or 3 days ago during the night shift a " Haitian lady " who works here came into his room after he used the call bell for assistance. She came in "with a bad attitude." He stated she took off his sweater and he told her that it was clean. He stated, "She ripped the bag off, and the mess went everywhere on me." (He was referring to his [MEDICAL CONDITION] bag.) He stated, the following night she came back into his room and "prayed for me to die." He stated she kicked his coat aside with her feet. He asked her to please pick it up. He stated she then said, "You ' re not going to get out of that bed." He stated, "She wants God to kill me." He was unable to recall her name. He stated the lady had short hair and was heavy set. He said, " She works at night. " She had been back to see the resident since she prayed for him to die. He stated he told the physical therapist and he was informed by her that she would report these incidents. He stated no one has come back to talk to him (about the incidents). A review of the Admission MDS with an assessment reference date of [DATE] documented the resident understands others and makes himself understood. The Brief Interview for Mental Status summary score was a 10, moderate impairment. Section D, Mood, documented the resident never had any problems related to feeling down in the last two weeks. Section E, Behavior, documented no hallucinations or [MEDICAL CONDITION]. Section E, Behavior, documented no change in the resident's behavior status. Section G, Functional Status, documented the resident requires limited assistance with one person physical assist for bed mobility, locomotion off unit, toilet use, and personal hygiene. The resident uses a walker and a wheelchair. Section H, Bladder and Bowel, documented the resident has an ostomy and in always continent of urine. Bowel continence was not rated due to the ostomy. The resident weighed 136 pounds. A review of the Care Plan dated [DATE] documented the resident feels anxious related to his perception of staff treatment/approach during care. Approaches include referral to psychological counseling/mental health specialist, allow resident to verbalize feelings and listen in a non-judgment manner, schedule an initial psychiatric evaluation, provide resident with reassurance and support, help resident determine source of anxiety and precipitating events, observe for changes in mood status, and always use warm smile, gentle touch, and friendly conversation with care. Further review of the Care Plan dated [DATE] documented the resident is at risk for fearfulness related to perception of staff treatment/approach during care. Approaches included providing the resident a place where he feels comfortable and safe, notify physician, family and caregivers of assessed problems and immediate approaches, encourage resident to attend activities of choice, and provide resident mental health services as needed. A review of the Nurses Notes documented no notations related to the incidents. In an interview on [DATE] at 3:00 PM with the director of nursing, she stated she has no knowledge of these incidents. In an interview on [DATE] at 3:05 PM with the director of rehabilitation, she stated she has no knowledge of these incidents. In an interview on [DATE] at 3:10 PM with the resident ' s physical therapist, she stated she had knowledge of "something was said to him and he was upset." She stated the resident did not identify to her anything more specific. She stated she reported that to the registered nurse unit manager. In an interview on [DATE] at 3:44 PM with the registered nurse unit manager, she stated the resident ' s physical therapist, reported "something" to her but it was not related to abuse. She stated it was recent. The physical therapist reported to her about the way the resident was spoken to by one of the nurses ' aides who worked on night shift. She stated she does not remember it being abusive. She works at the front desk on the wing. In a telephone interview on [DATE] at 4:43 PM with the resident's physical therapist, she stated the resident was quiet, upset, and told her it was about one of the nurse's aides from the night before. The physical therapist stated she went out and told the registered nurse unit manager. She stated she then went back and told the resident that she had reported it. She stated the abuse coordinator was not in the building at that time. She stated she failed to follow-up to make sure the abuse coordinator was informed of the incident. She stated she assumed the unit manager would tell the abuse coordinator. She stated she did not call the Abuse Hotline because she did not think of it as abuse. She admitted , "I don't know the fine line of when to call them. I have never called the Abuse Hotline." The last in-service she had on abuse prevention was last week. She admitted she did not go back to the resident and question him further. In a further interview on [DATE] at 4:52 PM with the registered nurse unit manager, she stated she spoke with the resident and he was "fine." The resident did not voice any concerns regarding an aide not being polite to him. The resident stated that everything was fine. She stated she did not tell the abuse coordinator because the resident did not voice any abuse. She confirmed that he did tell the other employee, the physical therapist, that he had an issue regarding a nurse ' s aide. The last in-service she had on Abuse Prevention was within the last month. She stated she did not call the Abuse Hotline because the resident did not voice anything she thought was abuse. In an interview on [DATE] at 5:06 PM with the administrator, he stated one of the nurse ' s aides was suspended yesterday for her involvement in another abuse incident, involving another resident. The administrator reported the facility has identified the nurse ' s aide involved in this incident. He stated the nurse ' s aide had been in-serviced within the last month. He stated a licensed practical nurse who works the 3:00 PM-11:00 PM shift had indicated that the nurse ' s aide was in the resident's room on a recent night, and the resident complained to the nurse about the aide's behavior. The licensed practical nurse instructed the nurse ' s aide not to continue with the communication and care of the resident. The administrator stated that tonight's schedule for 3:00 PM - 11:00 PM has a different nurse ' s aide for the resident. For the 11:00 PM - 7:00 AM shift, the nurse ' s aide for the resident is yet another different one. Regarding the physical therapist that was aware of an incident with the resident and nurse ' s aide, he confirmed she did not do the right thing. He stated the right thing would have been to call the Abuse Hotline and report it to the abuse coordinator. In an interview on [DATE] at 5:49 PM with the risk manager she stated a meeting with the resident, herself and the social services director took place today at 3:30 PM. The resident told the details about what happened. At 4:00 PM the facility reported this to the Department of Children and Families (DCF) today. The risk manager looked at the schedule for [DATE] nurses aides. She looked at the nurses schedule and the same nurse was on staff tonight. She asked him for a statement. He is a licensed practical nurse. She stated he named the nurse ' s aide involved in the incident. The nurse ' s aide has already been suspended related to another incident with another resident. She stated she asked the licensed practical nurse why he did not report the incident and he told her he did not know it was abuse. The licensed practical nurse is a brand new employee and he had just completed his in-service for abuse prevention. In an interview on [DATE] at 5:57 PM with the licensed practical nurse he stated he was hired by the facility last week. He stated he walked in the resident's room one night last week at approximately 7:30 PM, and the resident said he did not like what the nurse ' s aide said to him that night or the tone she used with him. He told the nurse ' s aide to not go back into the resident's room that shift. He took care of all the resident's needs that night. He did not suspect abuse in this situation so the abuse coordinator and the abuse hotline were not called. He was in-serviced when he was recently hired for abuse prevention. In the training he stated the definition of abuse could include verbal, psychological, physical abuse. In a further interview on [DATE] at 6:30 PM with the resident he stated he remembered talking to the nurse that night. He stated the nurse ' s aide was going to say something bad to the resident and the nurse said "stop it. Don't do that." The nurse sent the nurse ' s aide away and the resident was happy with that. He stated the male nurse gave the facility the nurse ' s aide's name. He stated he feels good now that the nurse ' s aide will not be working with him anymore. He stated the incident happened at approximately 9:00 PM - 10:00 PM. He stated he had no further details. In an interview on [DATE] at 4:02 PM with the risk manager and the social services director, the facility found out about the alleged abuse on [DATE] due to the surveyor's inquiries regarding the matter. The risk manager interviewed the physical therapist and the registered nurse unit manager on [DATE]. They are both on suspension pending the outcome of the investigation. The physical therapist, reported the incident happened approximately [DATE]. The resident told her this during his physical therapy session. He stated an aide was nasty to him. The physical therapist did not identify any abuse and reported it to the unit manager. The risk manager called the unit manager on [DATE] and she told the risk manager that she did not feel the need to see the resident at that time, but later on that shift she did go ask the resident how he was doing and he said he was fine. The licensed practical nurse was not suspended because the risk manager had no knowledge of his involvement past the point of him knowing who the aide was. This was reported to the abuse hotline on [DATE] at 4:08 PM and the Day 1 was reported 8:30 PM. The aide was suspended at approximately 5:00 PM on [DATE]. Consequently this aide was terminated because she was named in an additional abuse allegation. The risk manager went to see the resident on [DATE] to discuss the case and assure him the staff member would not be working with him. The director of social services followed up with the resident and he told her he was happy the nurse ' s aide was terminated. He stated he now felt safe. She stated psychologist consult was arranged for him and he agreed to the meeting. The care plan was revised to reflect the resident's new anxiety during staff care. This is still an active open investigation. The DCF investigator came in to investigate last night. The resident's attending physician came in to see the resident today and he is stable. The resident's daughter was notified on [DATE] at 2:09 PM. The risk manager and the social services director who is the abuse coordinator both stated this incident constituted physical and verbal abuse. A review of the Abuse Prohibition/Investigative Policy with a revision date of Feb. 2010 documented the facility will prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents. The Administrator is responsible for implementation of the policies and procedures. The facility will screen potential employees for a history of abuse, neglect, or mistreatment of [REDACTED]. Training will be provided to all employees through orientation, annual education, and on-going session. Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property will include providing information on how and to whom to report concerns, incidents and grievances and provide feedback regarding the concerns that they have expressed, identifying correcting and intervening in situations in which abuse, neglect and/or misappropriation of property are more likely to occur, and developing a care plan identifying appropriate intervention to prevent occurrence. Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, or misappropriation of resident property is to tell the abuser to stop immediately and report it to the nursing supervisor immediately. All reports of suspected abuse must be reported to the Administrator immediately, as well as the Abuse Coordinator. The family/POA/surrogate is to be notified of the facts surrounding the allegations. The state/federal reporting requirements for alleged incidents must be followed. The facility will protect the resident from further harm during the investigation and provide the resident with a safe environment. Upon receiving the information concerning an allegation of abuse, neglect, or exploitation of a resident, the Administrator will report immediately to DCF, notify the resident family or designated party, notify the resident's physician, notify the Complaint Administration Unit "as soon as possible" but no later than 24 hours of learning of the allegation. A review of the Abuse Investigation Policy/Procedure with a revision date of Feb. 2010 documented all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by the Abuse Coordinator and involve facility management as needed. The "Resident Abuse Report Form" will be initiated by the Abuse Coordinator; allegations of sexual abuse will notify law enforcement and the Medical Director, as well as the abuse hotline, Federal Immediate Report. The investigation process then is completed by the Abuse Coordinator. Witness Reports will be written. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents, and employees of the facility who have been accused or resident abuse will be immediately suspended from duty until the results of the investigation have been reviewed by the Administrator. The Abuse Coordinator will consult daily with the Administrator, keep the resident informed of the progress, record results on the Resident Abuse Investigation Form, and review this form with the Administrator. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to Complaint Administration Unit using the Federal 5 Day Report which will be sent within 5 working days, as well as to other state survey and certification agencies as requested/required. A review of the social services progress notes documented on [DATE] the social services director met with the resident to discuss any psychosocial needs. The resident stated he is "alright now." The social services director asked the resident if he felt safe and he stated, "Oh yeah." She discussed the case with the Psychologist and the Psychologist will be here tomorrow ([DATE]). A review of the Psychotherapy Notes dated [DATE] documented the resident was seen on [DATE]. The visit notes documented that the resident was seen following concerns about inappropriate behavior by a nurse ' s aide. The resident presents as alert, oriented in all spheres with good memory function. He exhibits full range of affect with mildly depressed mood. He speaks openly with her about the incident with the nurse ' s aide. He is a deeply religious man who at this point is only interested in praying for the nurse ' s aide. He is quite forgiving and repeatedly told her he hopes the lady grows from the experience. He actually spent much more time telling her about his family, his deceased wife, and his life and beliefs. He has had a difficult year following a fall and spinal fracture with ongoing pain issues. Allowed to vent and discussed his expectations and hopes for the future. The Mental Status box was marked with "depressed (mild)."