Every finding on record at Savoy at Fort Lauderdale Rehabilitation and Nursin

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was observed during 1 of 2 visits conducted in the Main Kitchen. The findings included:A tour of the main kitchen was conducted on 03/16/26 at 9:00 AM with the following issues noted: a. A personal 16-ounce Styrofoam cup was noted near the breakfast tray line. b. Two boxes of disinfecting towelettes were noted in the food production area. c. A Hydrion meter was used to check the sanitation solution in the one red bucket. Further observation showed a measurement of 500 parts per million, indicating that too much sanitization solution was in the red bucket. d. A Hydrion meter was used to check the sanitation solution in the three-compartment sink. Further observation showed a measurement of 400 to 500 parts per million, indicating that too much solution was used in the three-compartment sink. In this observation, the staff stated that the solution was replaced at 6:00 AM this morning and was expected to be replaced again at 10:00 AM. e. Used rags were found in a water bucket without a sanitizing solution. f. One frying pan noted with the bottom and sides darkened with black and brown residue, likely from burnt oil and repeated use. g. One square cooking tray with the bottom and sides darkened with black and brown residue, likely from burnt oil and repeated use. In an interview conducted on 03/16/26 at 9:30 AM with the Dietary Manager, she was informed of the findings.

Based on observation, interview, and record review, the facility failed to provide an alternative means to notify staff for assistance to visually impaired residents for 1 of 22 sampled residents, Resident #66, regarding accommodation of needs. The findings included: Review of the record for Resident #66 revealed the resident was admitted to the facility on [DATE], with diagnoses that included Cerebral Infarction (stroke caused by a blockage), Cataracts, and Generalized Muscle Weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #66 with a Brief Interview for Mental Status (BIMS) score of 14 on a scale of 0 to 15, which indicated the resident was cognitively intact. The MDS also documented Resident #66 had an impairment in one side of the upper and lower extremities; was dependent on the staff for assistance with toileting, personal hygiene, and dressing; and required substantial assistance from the staff for eating and transferring. The current care plan, dated 03/12/26, documented Resident #66 was at risk for falls related to muscle weakness and decreased mobility, with the goal of being free from falls. The interventions included anticipating and meeting the resident's needs, ensuring the call light was within reach, and encouraging the resident to use it for assistance. During an observation on 03/16/26 at 12:52 PM, Resident #66 was resting in bed with the call light on the left side of the bed. The left hand appeared weak and folded toward the body. A 360 milliliter (ml) Styrofoam cup sat on top of the tray table on the left side of the resident's bed. During an observation on 03/17/26 at 7:47 AM, the resident was again observed resting in bed. The call light was hanging from the left side of the bed towards the floor. A 360 ml cup sat on top of the tray table at the foot of the bed, away from the resident. During an interview on 03/18/26 at 9:02 AM, Staff C, Licensed Practical Nurse (LPN), who spoke Creole, was asked to have the resident demonstrate using the call light to request help. She stated when Resident #66 arrived at the facility, he could see, but over time, his vision became blurry. Staff C waved her hand across the resident's eyes. The resident did not follow her hand motion. He stated he could not see. The resident's call light was on his left side. Staff C asked the resident in Creole to press the call light. The resident's hands were weak and trembling. The resident was unable to locate it. Staff C guided his hands to reach the cord, but the resident was unable to press the call light. Staff C confirmed that Resident #66 was unable to use the call light. Staff C was asked how the resident requested help. She replied, the resident would yell or ask the roommate to call for help. During an interview on 03/18/26 at 11:08 AM, Staff I, Certified Nursing Assistant (CNA), was asked how she assisted a visually impaired resident. She stated it depended on the need. For example, if she was feeding a resident, she would introduce herself, describe the food, and talk to the resident throughout the process. Staff I was asked how Resident #66 asked for help. She acknowledged that the resident was unable to use the call light, so she asked him to call for her. She would usually check on the resident between 1 and 2 hours. Staff I further stated in the case of an emergency, she would ask the roommate to use the call light for the resident or ask another CNA to assist her. During an interview on 03/18/26 at 1:32 PM, Staff D, Unit Supervisor, was asked how Resident #66 made his needs known. She also acknowledged that the resident called from his room or that his roommate called on his behalf. She stated the resident may need an evaluation to determine whether another method, such as a bell, that could be used.

Based on observations, interviews, and record review, the facility failed to assist 2 of 10 sampled residents reviewed for nutrition, Resident #70 and Resident #44, with Activities of Daily Living (ADLs) regarding assistance during dining. The findings included;1. Record review for Resident #70 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Altered Mental Status, Dementia, Dysphagia following other Cerebrovascular Disease; and Other Speech and Language Deficits following other Cerebrovascular Disease. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had a Brief Interview for Mental Status (BIMS) of 04, indicating he was severely cognitively impaired. Section GG of the same MDS revealed Resident #70 had no upper extremity impairment and required staff to assist with set up or clean up during meals. In addition, section K of the MDS revealed Resident #70 had experienced coughing or choking during meals and was on a Mechanically Altered Diet. Review of the care plan dated 02/28/26 documented Resident #70 was at high risk for nutrition related to diagnoses such as Dementia, Dysphagia and Body Mass Index (BMI) of 19.7. The Goal was for the resident to gain at least 1-2 lbs. (pounds) per month. Interventions were to allow the resident to eat/drink at own pace, monitor the oral intake of food and fluids, and monitor weight monthly and/or weekly. Review of the weights for Resident #70 revealed the following:On 02/19/26, the resident's admission weight was documented as 0.0 lbs (pounds). via Mechanical Lift and was not re-taken until 02/21/26.On 02/21/26, the resident was 133.5 lbs. via Mechanical Lift. On 03/06/26, the resident was 130.8 lbs. via Mechanical Lift. This indicates Resident #70 lost 2.7 lbs. in 2 weeks. During a dining observation conducted on 03/16/26 at 12:48 PM for Resident #70, who was accompanied by two family members, Resident #70's spouse went out to retrieve the lunch tray from the staff and set it in front of the resident. The wife stated she visits daily and she assists Resident #70 with meals if needed. She stated she is not sure if the staff does the same when she is not around. At this time, Resident #70 was observed using utensils and eating on his own without assistance. On 03/18/26 at 8:45 AM, a breakfast dining observation was conducted on the 2nd floor, and the tray cart was in the hallway near Resident #70's room. At 8:55 AM, Resident #70's roommate was observed with his breakfast tray in front of him but stated he did not want it. Further observation revealed Resident #70 had no breakfast tray and the bedside table was at the foot of the bed without a meal tray. When Resident #70 was asked if he had eaten his breakfast, he stated, no one has come in. At this time, the surveyor moved to the hallway outside of Resident #70's room. At 9:09 AM, one Certified Nursing Assistant (CNA) was observed starting to bring finished breakfast trays to the tray cart. Then at 9:12 AM, Staff K, CNA, was observed coming out of the room next to Resident #70's room with a breakfast tray and placed it inside the tray cart. She and the two other CNAs went into other rooms collecting the breakfast trays, then Staff K went into Resident #70's room and collected the roommate's tray and placed it into the tray cart. At 9:20 AM, the CNAs appeared to have finished collecting the meal trays and were observed moving the tray cart towards the elevator. At this time, they were stopped and asked to see if Resident #70's tray was in the cart. The tray was found in the cart, and it was untouched. An interview was conducted on 03/18/26 at 9:24 AM with Staff K who stated she has worked at the facility for 9 months and Resident #70 requires assistance with meals. She stated when she finished with the other residents and returned to the tray cart, there were already dirty trays in the cart. When she was asked if she was aware that Resident #70 had not had his breakfast, she appeared confused and stated she's aware that Resident #70 needs assistance with meals. An interview was conducted on 03/18/26 at 2:19 PM with Staff K, and the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were present. She stated that she did feed the resident this morning. She was asked if the surveyor had not brought up Resident #70's breakfast tray, would she have noticed that Resident #70 did not have his breakfast. Staff K then stated that she went to the kitchen and brought another breakfast tray to the resident and assisted with feeding this morning. She was again asked would she had done that if the surveyor had not reminded her. She stated the nurse had told her that Resident #70 required assistance with feeding. She stated she remembered and would of went to get a breakfast tray for Resident #70. At this time, she left and the ADON and DON were made aware of the observation conducted this morning by the surveyor. On 03/19/26 at 8:35 AM, an interview was conducted with the DON. He stated that the usual protocol is for the CNA to get the tray from the kitchen prior to collecting dirty trays on the floor. He was informed of Resident #70's weight loss since admission and the family's concerns. 2. Record review revealed Resident #44 was readmitted to the facility on [DATE] with diagnoses of hemiplegia and dysphagia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] showed that Resident #44 had a Brief Interview of Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. Section GG (eating) of the MDS revealed Resident #44 needed partial to moderate assistance with eating. The care plan dated 03/10/26 revealed Resident #44 has the potential for weight fluctuation and is at high nutritional risk related to diagnoses of dementia and depression. Resident #44 needs assistance with feeding. During an observation conducted on 03/16/26 at 12:48 PM, Resident #44 was observed in the room eating his lunch. No staff were noted in the room to assist the resident with his meal. Resident #44 ate about 10% of his meal. At 1:01 PM, no staff were noted in the room, and the lunch tray was still only 10% consumed. Continued observation showed that no staff entered the room to assist Resident #44 with his lunch from 12:48 PM to 1:15 PM. Review of the weights log for Resident #44 showed the following: 01/05/26, a weight of 159 pounds. 02/04/26, a weight of 162 pounds. 03/04/26, a weight of 161.5 pounds. In an interview conducted on 03/17/26 at 8:30 AM, Staff B, Certified Nursing Assistant (CNA), stated Resident #44 needs assistance with his meals and has no refusal issues with staff helping him. She further said that Resident #44 takes too long to eat his meals, which is why they assist him with every meal. According to Staff B, Resident #44 eats very well between 75% to 100% of his meals. The surveyor requested a new weight for the resident on 03/17/26. The weight showed that Resident #44 weighed 155.5 pounds. This showed a weight decrease from 161.5 pounds on 03/04/26 to 155.5 pounds on 03/17/26. In an interview conducted on 03/18/26 at 8:30 AM with Staff A, CNA, she stated that Resident #44 eats most of his meals and needs assistance during mealtimes. In an interview conducted on 03/18/26 at 12:35 PM with Staff H, MDS coordinator, she stated that when a resident is coded for partial to moderate assistance with eating, staff must be in the room and assist with the eating process throughout the meal.

Based on observation, interview and record review, the facility failed to ensure follow-up on Ophthalmologist consultation for vision impairment related to cataract for 1 of 1 sampled resident, Resident #66.The findings included:Review of the record for Resident #66 revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included Cerebral Infarction (stroke caused by a blockage) and Cataracts. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #66 with a Brief Interview for Mental Status (BIMS) score of 14 on a scale of 0 to 15 indicating the resident was cognitively intact. The MDS also documented the resident's vision as adequate requiring no corrective lens.Review of the current care plan dated 03/09/26 documented Resident #66 had impaired vision with a goal to show no decline in visual function. The intervention was to consult with an eye care practitioner as required. During an observation on 03/16/26 at10:58 AM, Resident #66 was observed lying in bed listening to music in [the resident's language] on an iPad. The resident's English was limited to short greetings. Resident #66 appeared to have limited vision. The resident was unable to recognize a wave of the hand. On further observation, the resident's left eye was half closed and covered with a mucous like substance. During an interview on 3/16/26 at 3:46 PM, Resident #66, with interpretation from a [language] spoken by the surveyor, was asked about his care. The resident responded he was unable to see and the staff were aware. There was mention of surgery to which he agreed and the staff told him that they would check the insurance but there was no follow-up.On 06/03/25, the Optometrist's assessment showed the following: Resident #66 required an Ophthalmologist referral for cataract surgery. It also documented the resident was [language]-speaking and wanted the surgery. The assessment and plan indicated Resident #66 had severe Cataracts to both eyes, decreased visual acuity and to monitor the progression.Review of the physician's orders from 06/01/25 to 03/17/26 for Resident #66 indicated no orders from an eye care practitioner or a consultation for an Ophthalmologist.During an interview on 03/17/26 at 4:09 PM, Staff E, Social Worker (SW), was asked about the process when a resident requested a specialist. She explained that upon being informed, she would complete a referral, then the resident was placed on a list. The nurses would schedule the appointment, then she would schedule for transportation. Staff E stated the Recreations Director informed her of the resident's decline in vision. She confirmed placing the referral but did not update the resident or document in the resident's chart.During an interview on 03/17/26 at 4:12 PM, the Recreations Director was asked when it was reported to the SW that Resident #66 had a decline in vision. She stated she notified Staff E approximately three weeks ago, after working with the resident and reviewing the care plan.The Optometrist's assessment and plan documented on 01/08/26, Resident #66 had stable, moderate Cataracts to both eyes. The resident refused dilation and declined Cataract surgery. Staff E was asked if the resident had surgery since the recommendation dated 06/03/25. She stated she would have to check if a referral was done.A review of the progress notes from 06/03/25 to 01/14/26 lacked any documentation on whether the resident had or refused the surgery recommended on 06/03/25, with any follow up.During an interview on 03/17/26 at 5:24 PM, Staff D, Unit Supervisor, stated when a doctor gives an order, whether written or verbal, the nurse would document the order and schedule the appointment; a written order would be scanned into the resident's chart then the social worker would schedule the transportation. When asked to explain the lack of documentation for cataract surgery for Resident #66, she stated the doctors usually communicate with the nursing staff, but she did not know what happened in this case. During an interview on 03/18/26 at 9:31 AM, the Optometrist was asked to explain the assessment done on 06/03/25 for Resident #66. The optometrist explained that the resident required a referral to the Ophthalmologist for cataract surgery. She indicated that although the assessment showed severe cataract on 06/03/25 then on 01/08/26, stable, moderate Cataract, the resident would still be referred for surgery. The Optometrist further explained although the resident would not lose vision, the resident would be unable to see through the cataract. The Optometrist stated when she first evaluated Resident #66 on 06/03/25, she was told that the resident was able to see with glasses. Based on her assessment, the resident was not seeing well and did not have glasses at that time. She also stated since the resident agreed, she would have written the order on 06/03/25 for surgery and given it to a nurse or a social worker. When asked about the 01/08/26 assessment when she returned to see the resident, and if there was any follow up on the recommended surgery since 06/03/25, the Optometrist stated the resident was not interactive to get much information, but the resident declined to have Cataract surgery on 01/08/26.During an interview on 03/18/26 at 3:02 PM, Resident #66, with interpretation from a [language]-speaking surveyor, was asked how his vision had been since he was admitted to the facility. The resident stated he could see big things but was now unable to see anything at all. The resident also stated he knew if he got the surgery, he would be able to see.Review of a letter from the Optometrist's office on 03/18/26, documented Resident #66 had declined the surgery but had wanted it on 06/03/25. It indicated that there was no medical harm to the resident by not doing the surgery. The resident would visually benefit from cataract surgery.

Based on observations, interviews and record review, the facility failed to identify a severe weight loss in a timely manner, provide adequate nutritional supplements to prevent further severe weight loss and follow weight policy for 2 of 10 sampled residents reviewed for nutrition, Resident #3, Resident #130; and failed to identify, monitor, implement interventions, and verify weights as needed for 1 of 3 sampled residents reviewed for Tube Feeding, Resident #2 The findings included:Review of the facility's policy titled, Weight Assessment, with no reference date provided, documented in the policy statement: Resident weights are monitored for undesirable or unintended weight loss or gain. In the Policy Interpretation and Implementation: Residents are weighed upon admission and at intervals established by the interdisciplinary team; any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation; if the weight is verified, nursing will immediately notify the dietitian in writing; The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month – 5% weight loss is significant; greater than 5% is severe; 3 months – 7.5% weight loss is significant; greater than 7.5% is severe; 6 months – 10% weight loss is significant; greater than 10% is severe. In Evaluation: Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: the resident's target weight range, the resident's calories, protein, and other nutrient needs compared with the resident's current intake. In Care Planning: care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address, to the extent possible; the identified causes of weight loss, goals and benchmarks for improvement; and time frames and parameters for monitoring and reassessment. In Interventions: Interventions for undesirable weight loss are based on careful consideration of the following: the use of supplementation and/ or feeding tubes. 1. Record review showed that Resident #3 was admitted on [DATE] and readmitted on : 01/02/26 with diagnosis of Pneumonia and Type 2 diabetes mellitus. The Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score is 03, indicating severe cognitive impairment. Review of the weight log for Resident #3 showed the following respectively: 03/13/26: 119.6 Pounds. 03/10/26:119.0 Pounds. 01/02/26: 155.0 Pounds. 12/16/25: 155.0 Pounds. 12/16/25: 150.0 Pounds. These weights show a 36-pound weight loss from 01/02/26 to 03/10/26 which traduces an 22.83% weight loss in 70 days (2 months and 10 days). Per surveyor's request Resident #3 was weighed on 03/18/26 at 1:50 PM, which was 121.5 pounds. Weights were not taken weekly as ordered for 4 weeks nor monthly as stated in the policy. Review of the medical orders for Resident #3 indicated that on 01/02/26 an order was put in place for weekly weight times 4 upon admission, then monthly. On 01/04/26, an order was put in place for consistent carbohydrate (CCD) and no added salt (NAS) diet, mechanically altered chopped texture, thin liquids consistency. On 03/17/26, an order was put in place for two calories High nutrient (HN) 4 ounces (oz.) three times a day (TID) for nutrition supplement 120 milliliters (ml) oral. No orders were placed for Glucerna shake twice a day. Review of the Dietary progress note dated 01/06/26 revealed the following: care plan meeting with resident's niece via phone. Diet discussed with niece. Weight of 155 discussed with niece. She reports residents did have some weight loss over the past year. Mr. Johnson's appetite has been good with average intake of 75=100%. RD will order Glucerna shake twice a day to help with weight resident and to ensure adequate nutrient intake. Weekly weight x 2 to observe for trend. Adjusted intake as needed. Review of the Dietary progress note dated 03/15/26 revealed the following: Resident #3 was noted to have significant weight loss of 20.4% in a month. Resident has excellent oral intake. RD observes resident at breakfast almost every day on rounds with 100% intake. Noted hospital weight prior to admission 123lbs. Weight of 150 may have been an error. Diet order CCD/NAS/Mechanical altered diet/Thin liquids. Resident uses built up curved utensils and lipped plate at meals. Recommend 2 calories HN 4 ounces TID = 720 kcal, 30gm protein. Will observe weight x 4 weeks for trend and adjust intake as needed. Review of the Dietary progress note dated 03/18/26 revealed the following: Certified Nurse Assistant (CNA) weighed Resident #3 on 03/18/26 and it was 121.5 pounds. Significant weight loss noted PO intake is excellent with 100% intake at most meals. Diet order CCD/NAS/Mech altered chopped / Thin liquids. Resident is on 4 ounces 2 Cal HN TID = 720 kcal, 30 gm protein. Will continue to weight x 3 weeks for trend. admission weight may have been an error. Review of the nutritional risk assessment dated [DATE] revealed the following: Resident #3 was readmitted with a weight of 155 and BMI 24.2. Weight maintenance acceptable and desired. Will continue to observe intake, weight, laboratory, changes and adjust intake as needed. Review of the intake from 02/18/26 to 03/18/26 indicated that Resident #3 had an average intake of 100% for breakfast, lunch and dinner. Review of the care plan dated 03/15/26 stated that Resident #3 had a significant weight loss of 20% in a month. Excellent oral intake. Suspect of a possible error with admission weight of 150 pounds. Review of the care plan initially dated 08/30/24 and revised on 03/28/25 documented Resident #51 is at risk for nutritional and hydration problems. Risk related to nocturnal tube feeding as a supplement route of nutrition and hydration related to Cerebro Vascular Accident. Medical diagnosis includes Respiratory failure, Seizure, Essential Hypertension, Hypernatremia, Gastroesophageal Reflux Disease (GERD), and Diabetes Mellitus (DM). Mechanical soft diet provided PO at all meals. In an interview conducted on 03/17/26 at 3:30 PM with the restorative Certified Nursing Assistant (CNA), Staff L stated that she has been working for the facility since 2009 and has been doing restorative for less than a year. She explained that she must get the weight of new admissions (she gets the list on the second floor) which are weekly for 4 weeks and they also do monthly for the whole building. She is the only designated staff that does weights and when she is off there is another staff that replaces her. When the weights are weekly, the registered dietitian (RD) gives her a list with the residents. Staff L explained that the weekly weights are prioritized on the monthly weight. The weights are reported to the RD within 48 hours so she can document them on point click care (PCC). When a resident doesn't want to get weighed Staff L documents it and reports it to the RD. Staff L mentioned that this week the list of residents to be weighed was not provided due to not having an RD and is only doing the new admissions weights. She further mentioned that she keeps a record of the weights to compare them. She continued by explaining that the facility has a standing scale on the second floor, a Hoyer lift on each floor and chair scales (that she doesn't use). In an interview conducted on 03/17/26 at 3:40 PM, the Director of Maintenance stated that he has been working for the facility for 3 years. He further stated that the facility has 1 sitting chair, 1 standing scale, 2 Hoyer lift and someone to calibrate them yearly. The 2 Hoyer lifts were put in use in February. From December 5th to February, they had rentals of Hoyer lifts with scale. They decided that the old Hoyer lift needed to be discarded, which was done in December. In a phone interview conducted on 03/17/26 at 4:25 PM, the Registered Dietitian (RD) stated that she left the company last Wednesday but before quitting she was working for the facility for 20 years. She explained that weights are taken 24 hours on admission and weekly for a month to see the trend and decide if the resident is stable to continue monthly; if they are not stable, they will keep weekly weight. For the residents who have unstable weights, they have IDT meetings (Interdisciplinary Team - to know if they have an underlying condition) and talk to the family to know their end goal and try different options (supplements, appetite stimulants) to help. The RD explained the facility doesn't have fortified food, but they have a higher protein breakfast. As options, they provide double portion or large portion of what they like, snacks. The RD further explained that the initial nutritional assessment starts within 72 hours and is completed within 10 days and quarterly follow-up assessments are done after for stable residents and for residents that are losing weights weekly follow up are conducted. RD continued by explaining that high nutritional risk residents are residents with significant weight loss (5% in a month, 7.5% in 3 months, 10% in 6 months), dialysis, poor intake or wounds. The process to obtain the residents weighs is that the CNA weighs the residents within 24 hours of admission and reports it to her so she can report it in PCC. Staff L is the one that usually covers about 75% of the weights and when she is not at the facility another CNA would cover. The RD stated that they have weekly weight list at the end of the week that she provides to be used for the following week and completed by Wednesday. The monthly weights are done on all residents during the first week of the month and it follows the census, and a reweight is done and reported separately. If any discrepancy is noted in the weights, I request a reweight as soon as I notice it. The RD stated she would identify a significant weight loss by comparing the weights or sometimes nursing would point out that a resident is not eating and reweight would be requested. A resident with a significant weight loss would be assessed and seen as soon as I see it or know of it. Per the surveyor's question of not having weekly weights for several residents, the RD did not have an answer. In a phone interview conducted on 03/19/26 at 1:00 PM, the RD acknowledged the Glucerna twice a day for Resident #3 was not ordered as stated in her progress notes dated 01/06/26. The RD acknowledged that no weekly weights were done on admission now monthly weights for Resident #3. Due to large weight loss in the past 2 months (36 pounds), the RD stated that it was possible that the admission weight was an error, but she doesn't really know, she used to see Resident #3 eat 100% every day, a weight loss of 36 pounds in 2 months is a severe a weight loss, and that she doesn't believe Resident #3 had weight loss. The RD stated that it looks like the facility on two occasions and the hospital did not have proper weights on resident #3. The RD said she did not have more explanation because she wasn't the one taking the weights that it would be better if I asked staff that took the weight. The RD concluded that it was a hard case and was unsure about what to say. 2. Record review revealed Resident #130 was admitted to the facility to 03/09/26 with diagnoses of sepsis and urinary tract infection. The care plan initiated on 03/15/26 revealed Resident #130 was at high nutritional risk related to sepsis and urinary tract infection. The resident has refused to be weighed, and his weight was reported as 150 pounds. Review of the physician's orders showed a regular diet for Resident #130, but no nutritional supplements were ordered. In an interview conducted on 03/16/26 at 10:30 AM, Resident #130 stated that he had lost some weight but was unsure how much. He has not been eating well and is only eating around 50% of his meals. During an observation conducted on 03/17/26 at 9:45 AM, Resident #130 had finished his breakfast. Closer observation showed that he ate only one piece of pancake and two slices of bacon. He did not touch the oatmeal, juice, or the carton of milk. In this observation, Resident #130 reported eating less than 50% of his meals and, when asked how much he weighed, said around 120 pounds. He further denied that he refused to have his weight taken and said, Why would I do that? In an interview conducted on 03/18/26 at 8:24 AM with Resident #130, he stated that he did not eat his dinner last night because he had no appetite. During an observation conducted on 03/18/26 at 1:10 PM, Resident #130 ate 10% of his lunch. Review of Resident #130's weight log showed the following: 03/10/26, a weight of 126.3 pounds. The Nutrition Risk assessment dated [DATE] showed the following: Resident #130's most recent weight was 0.0 because Resident #130 has refused to be weighed since admission, and a weight of 150 pounds based on stated weight was used for this assessment. Resident #130 will maintain a weight of 150 pounds plus or minus 5 pounds, and no nutritional supplements or interventions were provided for Resident #130. In this assessment, the clinical dietitian did not use the actual weight of 126.5 pounds; instead, they used 150 pounds. Review of the hospital records dated 03/09/26 showed that Resident #130 weighed 141 pounds prior to his admission to the facility on [DATE]. In a phone interview conducted on 03/17/26 at 4:30 PM with the clinical dietitian, she stated that Weights are taken by facility staff and entered into the electronic system by her. She would ask for reweights for any noted discrepancies. For low body weight and weight loss, the following interventions are given: snacks, supplements, double/large portions, and an appetite stimulant. The surveyor expressed concern regarding weights not entered into the electronic system and incorrect nutritional assessments. 3. Review of the facility's policy titled, Nutrition Screening, Assessment and Monitoring, dated 09/20/22, included the following: All residents admitted to the facility will receive a nutrition assessment and nutrition risk factor identification initially and periodically. The nutrition assessment dictates nutrition care interventions and follows - up care. Procedures: Dietitian: The dietitian will monitor regularly to ensure residents maintain acceptable parameters of nutritional status. Nutrition assessments: Interval assessment/follow up notes/monthly progress note will be completed for the following but are not limited to: 1. Resident who are high risk: tube fed, receives parenteral nutrition, pressure injury, hemodialysis, palliative/ comfort care measures and/ or identify with significant weight change, will receive depending on the changes: reassessment as soon as possible, 3 to no longer than five days after notification; Follow up/ monthly note assessment (monthly pressure ulcer/ enteral feed form in EMR). -Residents with a confirmed significant weight loss, re-assessment will be completed, and then follow-up notes will be done a minimum of weekly until weight stabilization occurs or there is a determination in the plan of care to discontinue weekly weights. -Residence on prescribed tube feeding /TPN monthly follow up assessment is required. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses to include Sepsis (Unspecified Organism), Pressure Ulcer of Sacral Region (Unstageable), Dysphagia following Cerebral Infarction, and Gastrostomy Status. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. Review of the physician's orders showed Resident #2 had an order dated 01/15/26 for Enteral Feed, one time a day for Dysphagia Following Cerebral Infarction via G-Tube (Gastrostomy Tube); Formula: Glucerna 1.2 amount: 1000 mL/day for Continuous Feeding at 60mL/hr. (hour) x 15 hours until completion; Water (H2O) Flushes [700ml] 40ml/hr. x 15 hours until completion. The order was discontinued on 01/20/26. Review of the physician's orders showed Resident #2 had an order dated 01/17/26 for Enteral Feed, one time a day for tube feeding (TF) via G-tube; Formula: Glucerna 1.5 amount: 1000ml/day for Continuous Feeding at 66ml/hr. x 15hrs until complete and Water Flushes 1000ml at 66ml/hr. x 15 hrs. until complete *See additional bolus feeding order Total Kcal 2299/Day GM Pro 122/day; No pleasure feeding. Review of the physician's orders showed Resident #2 had an order dated 01/17/26 for Enteral Feed, two times a day for tube feeding. Give one carton Glucerna 1.5 (237ml) via G Tube. Give 90 ml H20 flush before and after each bolus feeding, discontinued on 03/12/26. Review of the physician's orders showed Resident #2 had an order dated 03/13/26 for Enteral Feed, one time a day for tube feeding; Give one carton Glucerna 1.5 (237ml) via G-tube. Give 90 ml H20 flush before and after each bolus feeding. Review of the weights for Resident #2 revealed the following: On 01/15/26, the resident weighed 184.0 lbs. (pounds) via Mechanical Lift. On 01/27/26, the resident weighed 172.6 lbs. via Mechanical Lift. On 02/04/26, the resident weighed 173.0 lbs. via Mechanical Lift. On 02/12/26, the resident weighed 172.2 lbs. via Mechanical Lift. On 03/11/26, the resident weighed 169.0 lbs. via Mechanical Lift. This indicated from 01/15/26 to 02/12/26, Resident #2 lost 11.8 lbs., which is a significant weight loss of 6.41% over less than one month. Further review of the weights revealed on 03/05/26, the dietitian crossed out the 01/15/26 weight of 184 lbs. There was no assessment or progress note documented on 03/05/26 explaining why she crossed out the initial/admission weight. On 03/18/26 at 11:33 AM, the surveyor asked for Resident #2 to be weighed, and she was 168 lbs. via Mechanical Lift. Review of the Nutrition Risk Assessment (NRA) for Resident #2 dated 01/16/26 included the following in part: Resident has wounds to right medial heel, Lateral left ankle and sacrum. Most recent height was 60.0 (Inches), most recent weight was184.0 lbs. (83.46 kilograms (kg)). Using the most recent weight the Estimated Nutritional Needs was 84 (kg) x 25-30= 2100-2520 Kcal/kg; Protein: 84 x 1.3 - 1.6 = 109-134 gm/kg; Fluids: 84 x 30-35 = 2520-2940 ml/kg. The resident is getting adequate nutrients for wound healing via tube feeding formula. Will observe tolerance to TF and adjust as needed. Review of the Resident #2's Nutrition Assessments and progress notes dated from 01/17/26 to 03/16/26 revealed no monthly follow-up nutritional assessments or follow-up notes documented from the dietitian addressing the weight loss or the reason for crossing out of the initial weight of 184 lbs. During a phone interview conducted on 03/19/26 at 12:41PM with the Registered Dietitian (RD), she stated she has worked at the facility for over 20 years but her last day at the facility as the full-time RD was on 03/11/26 but continues to do consultant work for the facility. She stated residents who are at high risk for nutrition, such as TF residents, would be followed up twice a week after admission to check the pumps and ensure there are no concerns, then will follow-up with a monthly note in the computer under nutrition progress notes. She then stated if there are concerns such as the resident is not tolerating the TF, she would contact the doctor and monitor closely. The RD was asked why she crossed out Resident #2's admission weight on 03/05/26, almost two months later; she stated the weight was given to her by the restorative Certified Nursing Assistant (CNA) and it might have been an error. She was then asked if it was an error, why did you use it as the most recent weight in Resident #2's NRA conducted on 01/16/26. She stated the admission NRA is used to identify the resident's Body Mass Index (BMI) and then conclude if the resident is underweight or overweight. Resident #2 was overweight. She was again asked why she crossed out the admission weight, which she stated she does not remember why she crossed it out, and was unable to find a progress note to explain the discrepancy. The RD was asked to review Resident #2's weights. She stated she did not document any notes regarding the weight loss on 01/27/26 or on 02/12/26, maybe because she felt there was a discrepancy in the weights and that's probably why she crossed it out, however, she acknowledged not able to find any documentation to support the discrepancy. She then stated if the resident had lost the weight, it would have been about 5.4% and it would be a significant weight loss. The RD then mentioned that maybe someone told her that the admission weight was the wrong weight; however, she should have documented the weight discrepancy and if the resident had lost weight, she would have addressed it. She stated the system would alert her only if there was a significant weight loss in the last 30 days; and again, she felt Resident #2's admission weight was wrong and that's why she crossed it out. The RD continued to dodge the questions and was unable to present documentation to support the admission weight was an error and not addressing the weight loss.

Based on observations, interviews and record reviews, the facility failed to follow oxygen order for 1 of 1 sampled resident reviewed for oxygen therapy and has the potential to affect 11 residents on oxygen therapy, Resident #133, and failed to develop a care plan for oxygen therapy for 1 of 1 sampled resident reviewed for oxygen therapy, Resident #133.The findings included:Review of the facility policy titled, Oxygen Administration, provided by the Director of Nursing (DON) revised in 10/08/25, documented in the Policy Statement: Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess any special needs of the resident.1. Record review showed Resident #133 was admitted on [DATE] and readmitted on [DATE] with diagnosis of encounter for palliative care and cerebral infarction. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score is 09, indicating moderate cognitive impairment. Review of section O (Special treatments, Procedures and Programs) of the MDS indicated that Resident #133 was not coded for oxygen therapy on admission or while in the facility due to oxygen therapy initiated after the look back period of the quarterly MDS.Review of the physician's orders documented on 02/28/26 an order for oxygen concentrator with humidifier was placed in for 2 liters per minute via nasal cannula.Review of the care plans indicated that no care plans were elaborated for oxygen therapy for Resident #133.In an observation conducted on 03/16/26 at 10:50 AM, and 03/16/26 at 1:15 PM, Resident #133 was seen in bed with oxygen in place and concentrator at 1 liter/minute.In an observation conducted on 03/17/26 at 9:15 AM, Resident #133 was seen in bed with oxygen in place and concentrating at 1 liter/minute.In an interview conducted on 03/18/26 at 12:30 PM with Unit Manager Registered Nurse (RN), Staff M stated that she has been working for the facility for a year. She further stated that the nurses are responsible for levelling the oxygen concentrator. She explained that they would go by the doctors' order in the chart to set the oxygen concentration in the concentrator. Staff M was made aware of the findings and explained that it should always be on 2 liters and doesn't understand why anyone would change it.In an interview conducted on 03/18/26 at 12:40 PM with Registered Nurse (RN), Staff N stated that she has been working for the facility for a year. She further stated that the oxygen concentrators must be regularized by respiratory therapists and nurses. Staff N also explained that the orders for oxygen administration are checked in the electronic charts to adjust the concentrator. They are also revised when they do rounds.In an interview conducted on 03/18/26 at 12:45 PM, the Respiratory Therapist stated that he has been working part-time for a year and a half now in the facility. He further stated that the oxygen is set according to a prescription from a doctor and that setting the oxygen concentrator is not his responsibility but the nurses. In an interview conducted on 03/18/26 at 1:00 PM, MDS Director stated that she has been working for the facility for 16 years. She further stated that if a resident is started on oxygen therapy and there is an order for it, there should be a care plan put in place right away unless its weekends then it would be put on Monday. The MDS Director acknowledged that no care plan was put in place for oxygen therapy for Resident #133.

Based on observations, interviews, and record review, the facility failed to ensure the closet space in residents' rooms had doors or coverings to maintain the residents' clothing clean, protected, and to provide privacy for 30 of 60 total residents' rooms, located on the 3rd floor, that were reviewed for a home-like environment. The findings included: During the initial tour of the facility conducted on 09/30/24 at 9:37 AM, it was observed that all the residents' rooms on the third floor were missing closet doors revealing residents' personal clothing and items. In several of those rooms, observation revealed the resident's clothing whad been thrown on the bottom shelf of the closet in a disorganized manner and visible to residents and visitors. An interview was conducted on 10/02/24 at 9:34 AM with Staff S, Certified Nursing Assistant (CNA). Staff S stated she has worked at the facility for one year and always works on the third floor. Staff S stated since she has been working in the facility, the closets in the residents' rooms have always been without a curtain or a door. An interview was conducted on 10/02/24 at 9:45 AM with Staff T, CNA. Staff T stated she has been working at the facility for about 9 months and has been assigned mainly to the third floor. Staff T acknowledged never seeing the residents' closets with doors. On 10/03/24 at 9:00 AM, an environmental tour was conducted with the Director of Maintenance (DOM) who acknowledged the findings that the residents' closets on the third floor did not have doors or coverings.

Based on observations, interview and record review, the facility failed to treat residents in dignified manner during catheter care for 1 of 1 sampled resident observed for catheter care, Resident #35; during medication administration in the hallway for 1 of 25 sampled residents, Resident #249; and staff referring to residents who need assistance with dining as feeders. The findings included: Review of the facility's policy, titled, Dignity, with a revised date of February 2021, included in part the following: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 1. On 10/02/24 at 10:59 AM, an observation was conducted of catheter care for Resident #35 performed by Staff K, Certified Nursing Assistant (CNA). Staff K adjusted the bed, pulled the covers down, said to resident I am going to remove your diaper as she was removing the adult brief from the resident. Once the CNA was finished with the catheter care, she then had resident roll side to side to remove and replace the pad under resident. The CNA then proceeded to place a new adult brief under the resident, and as she did, she asked the resident to turn again so she could but the diaper on him. An interview was conducted on 10/02/24 at 11:19 AM with Staff K who stated she has worked at the facility for 4 months. When asked about referring to the adult brief as a diaper, she said that is what it is. During an interview conducted on 10/02/24 at 11:46 AM with Resident #35 who was asked how it made him feel that Staff K CNA had referred to his adult brief as a diaper during his catheter care, he said it is not very nice. 2. On 10/01/24 at 5:00 PM, an observation was made of Staff C, Licensed Practical Nurse (LPN), who was administering medication to Resident #249 in the hallway next to the med cart. An interview was conducted on 10/01/24 at 5:07 PM with Staff C who stated she has worked at the facility since February 2024. When asked if she normally administers medications to residents in hallway next to the med cart, she said 'normally yes'. Staff C said sometimes it is the resident's choice. If the resident is in the hallway and asks for their medications and they are due to be given, she will give it. When Staff C was asked about administering medication in the hallway to Resident #249, the LPN said it that is the resident's choice. During an interview conducted on 10/01/24 at 5:15 PM with Resident #249 who was asked about the nurse administering her the medication in the hallway, how it made her feel, she said I don't want to get anyone in trouble. When asked if requested the medications be given to her while she was in the hallway, the resident refused to answer anymore of the surveyor's questions. 3. An interview was conducted on 10/01/24 at 5:11 PM with Staff C, LPN, who when asked about a tube feeding for a resident, she said she hung the tube feeding one hour early, because they usually get the dinner trays on the floor around 5:00 PM and they have a lot of feeders. She was asked if referring to residents who need dining assistance as feeders is something she normally does, she said 'yes, they all do it. There is a lot of staff that don't speak English to well, so we need to speak to them very clear about which residents need to be fed, so we call them feeders, it is just common sense.' 38893 4. During an observation of lunch being served to the residents in their rooms, on 09/30/24 at 12:40 PM, Staff B, RN/Unit Manager, was overheard by the surveyor calling to staff, Are you ready for a feeder, referring to Resident #201. Staff B then pulled a tray out of the cart containing the lunch trays and stated, she is a feeder, referring to Resident #199. When asked about referring to the residents as 'feeders' and labeling the residents, Staff B replied, If he's a feed, you have to stay in there with him (referring to #201). Staff B further stated that she was not aware of the facility's policy to not label residents in a manner such as referring to a resident as a 'feeder'.

Based on observations, interviews and record review, the facility failed to implement care plans for 2 of 5 sampled residents reviewed for smoking, Residents #19, and #8; failed to implement care plans for 1 of 1 sampled resident reviewed with an urinary catheter, Resident #35; failed to implement care plans for 1 of 1 sampled resident reviewed with significant weight loss and receiving tube feedings, Resident #90; and failed to develop care plans for 1 of 1 sampled resident reviewed with a diagnosis of Post Traumatic Stress Disorder (PTSD), Resident #70. The findings included: 1. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Fracture of Humerus Right Arm Subsequent Encounter for Fracture with Routine Healing, History of Falling, Anxiety and Muscle Weakness (Generalized). Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 05/09/34 documented in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating an intact cognitive response. Review of the Nursing Progress Note for Resident #8 dated 08/18/23 documented the following: Resident AAOX3 (Awake, alert, and oriented times 3). Spoke to MD (Medical Doctor) about resident decision not to smoke anymore and asked to discontinue Nicotine patch and Spiriva. OK given verbally by MD. Review of the Nursing Progress Note for Resident #8 dated 09/10/23 documented the following: Resident AAOX3; no distress noted. Administer medications as per order with fluid. Resident started smoking again. Care rendered by staff. All safety measures in place; will continue to monitor. Review of the Nursing Progress Note for Resident #8 dated 12/20/23 documented the following: Pt [patient] complained of pain in lung area after coming back from smoking, pain pills provided to pt as requested. Pt taught to keep HOB [head of bed] elevated for lung expansion and comfort. Thoracic X-ray ordered for pt. Pt left awake, watching television with HOB elevated, all safety and comfort measures maintained. Review of the Smoking Risk Form for Resident #8 dated 12/01/23 documented in part the following: D Frequency: morning, afternoon, and evening E Safety: 6. resident can light own cigarette - yes 8. plan of care is initiated to assure resident is safe while smoking - yes. Review of the Smoking Risk Form for Resident #8 dated 10/01/24 documented in part the following: D Frequency: morning and afternoon E Safety: 6. resident can light own cigarette - yes Resident need for adaptive equipment: 7c. supervision 8. plan of care is initiated to assure resident is safe while smoking - yes. On 09/30/24, review of the Care Plans for Resident #8 dated 12/04/24 with a focus on the resident chooses to smoke with a goal of the resident will remain free from injury was conducted. The interventions included: Instruct resident / family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Resident may keep cigarette and smoking items in her possession. Cigarettes and lighter to be kept in a secure location. Smoking in designated area only. On 09/30/24 at 12:19 PM, an observation was made of Resident #8 with cigarettes, lighter in a Styrofoam bowl and vaping device on the overbed table. On 09/30/24 at 12:23 PM, an interview with Resident #8 was conducted who was asked if she was a smoker, she said, 'yes'. When asked if she has smoked since being admitted to the facility, she said, 'yes'. When asked if staff hold her cigarettes and lighter, she said, 'no, she holds them, and they know it.' When asked if staff supervise her while smoking, she said, 'they come in and out, its different staff all of the time.' On 10/01/24 at 10:17 AM, during a side-by-side observation with Staff B, Registered Nurse / Unit Manager (RN UM), she acknowledged the resident should not have the cigarettes, lighter and vape device at the bedside. Staff B took them and informed the resident she could not have those items at the bedside. On 10/01/24 at 10:30 AM, an interview was conducted with Staff B who was asked if residents are assessed for smoking, she said she does not do the smoking assessments, that would be administration. When asked how often the smoking assessments or evaluations are completed, she said she is not sure. When asked if a resident can have cigarettes, lighter and vape device at the bedside, she said no, it needs to be secured. An interview was conducted on 10/03/24 at 2:35 PM with Staff O, MDS coordinator, who stated she has worked at the facility for [AGE] years. When asked about care plans related to smoking, she stated she would not update smoking care plan unless the status changed regarding smoking. The smoking items, lighter and electronic cigarettes were not secured. 2. Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Cerebral Infarction, Type 2 Diabetes with Hyperglycemia, and Epilepsy. Review of the Quarterly MDS assessment for Resident #19 dated 08/29/24 revealed in Section C, a BIMS score of 13 indicating an intact cognitive response. Review of the Smoking Risk Form for Resident #19 dated 08/31/23 documented in part the following: D Frequency - evenings E Safety: 6. Can resident light own cigarette - no Resident need for adaptive equipment: 7a. Smoking apron 8. Plan of care is initiated to assure resident is safe while smoking - yes. Review of the Smoking Risk Form for Resident #19 dated 12/05/23 documented in part the following: D Frequency- morning, afternoon, and evenings E Safety: 6. Can resident light own cigarette - yes Resident need for adaptive equipment: 7a. Smoking apron 8. Plan of care is initiated to assure resident is safe while smoking - yes. Review of the Care Plan for Resident #19 dated 09/01/23 with focus on the resident chooses to smoke, documented the resident as: Non-compliant with smoking policy despite education. The goal was for the resident to remain free from smoking related injury. The interventions included: Cigarettes and lighter to be kept in a secure location. Instruct resident / family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Smoking apron to be worn when smoking. Smoking in designated area only. Supervised smoking by staff member. An interview was conducted on 09/30/24 at 1:45 PM with Resident #19 who was asked how long she has smoked at the facility, and she said, 'years'. When asked about the covering (smoking apron) on her she said she, 'keeps it on the back of her wheelchair and puts it on herself when she comes out to smoke'. When asked if staff come out to supervise her smoking, she said, 'sometimes staff come out for a few minutes when they come out, but they do not come out every time'. When asked if she can light her own cigarettes, she said, 'sometimes she cannot, but most times she can.' When asked where her cigarettes and lighter are kept, she said, 'the nurse hold her cigarettes and lighter and give them to her when she asks then she will bring them back when she is done smoking.' On 10/02/24 at 1:15 PM, Resident #19 was observed on the smoking patio with smoking apron partially covering her and she lit her own cigarette, and no staff member was present. At approximately 1:22 PM, Staff N, Certified Nursing Assistant (CNA), came to smoking patio to observe the resident. An interview was conducted on 10/02/24 at 1:20 PM with Staff M, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 3-4 months. When asked about Resident #19, she said she was not aware the resident was an unsafe smoker until today. Staff M stated she holds the resident's cigarettes and lighter in the med [medication] cart. Staff M had come down this morning with the resident to smoking area and helped her with the smoking apron and with lighting a cigarette. There was another staff member on the smoking patio, and she was under the impression the staff member was assigned to the smoking patio to observe the residents. When the resident requested cigarettes to smoke around 1:10 PM on 10/02/24, Staff M gave the resident 2 cigarettes and the resident went downstairs, and she assumed the resident would be supervised by another staff member that she thought was assigned to the smoking patio. On 10/02/24 at 1:23 PM, a side-by-side observation with the Administrator was conducted of Resident #19 with smoking apron partially covering her and smoking a cigarette on the smoking patio. There was no risk assessment form since the 12/05/23 date, until after it was brought to their attention. 3. Record review for Resident #35 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on 09/26/24 with diagnoses that included in part the following: Urinary Tract Infection (UTI), Acute Kidney Failure, Type 2 Diabetes Mellitus without Complications, Encounter for Fitting and Adjustment of Urinary Device, and Obstructive and Reflux Uropathy. Review of the MDS for Resident #35 dated 09/02/24 documented in Section C, a BIMS score of14 indicating an intact cognitive response. Review of the Physician's Orders for Resident #35 revealed an order dated 09/30/24 for Catheter / Foley: Catheter care every shift. every shift and as needed. Review of the Physician's Orders for Resident #35 revealed an order dated 09/26/24 for Eliquis Oral Tablet 5 MG (Apixaban) give 1 tablet by mouth two times a day for Atrial Fibrillation (Eliquis is a blood thinner). Review of the Care Plan for Resident #35 dated 09/05/24 and revised on 09/30/24 with a focus on the resident has an Indwelling Catheter r/t (related to) Obstructive Uropathy 16f/10cc documented the following: The goal was for the resident to be/remain free from catheter-related trauma through review date. The interventions included the following: The resident will show no s/sx [signs and symptoms] of Urinary infection through review date; Catheter: The resident has 16f/10cc. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks every shift. Enhanced Barrier Precautions: wear gown and gloves during assistance with dressing, bathing, transferring, hygiene, changing linens, changing briefs & toileting, and catheter care. Monitor and document intake and output as per facility policy. Monitor for s/sx of discomfort on urination and frequency. Monitor / document for pain / discomfort due to catheter. Monitor / record / report to MD [Medical Doctor] for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of progress notes for Resident #35 for 10/02/24 revealed no documentation of the nurse contacting physician to report bleeding or pain during catheter care. On 09/30/24 at 12:55 PM, an observation was made of Resident #35 with an indwelling urinary catheter drainage bag on side of bed covered with privacy cover. An interview was conducted on 10/02/24 at 8:58 AM with Resident #35 who was asked if he recently went to the hospital for pain with his indwelling catheter, he said, 'yes'. He said they changed the catheter in the hospital, and he returned to the facility with the new catheter in place. When asked if the staff have been performing catheter care since he returned, he said, 'yes, they come and put cream on it'. On 10/02/24 at 10:59 AM, an observation was conducted of catheter care for Resident # 35 performed by Staff K, Certified Nursing Assistant (CNA). During the catheter care while washing the tip of the penis around where the catheter was inserted, there was blood observed on the white washcloth. Staff K then proceeded to dry the resident with a dry bath towel, and he screamed out in pain. An interview was conducted on 10/02/24 at 11:19 AM with Staff K who stated she has worked at the facility for 4 months. When asked if she notified the nurse about Resident #35 having pain and bleeding during catheter care, she said 'they already knows this'. An interview was conducted on 10/02/24 at 11:24 AM with Staff L, Registered Nurse (RN), who was assigned to take care of Resident #35 and stated she has worked at the facility for 1 year. When asked about Resident #35 and having any pain or bleeding with catheter care, she said before he had a UTI and went out to the hospital recently and just came back last week. She said sometimes he has pain with catheter care, and he has pain medication, but they only give him pain medication if he asks for it. When asked if the resident has pain with catheter care, she said, 'yes sometimes'. 4. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Progressive Supranuclear Ophthalmoplegia [Steel-[NAME]-[NAME]] (a rare brain disease that affects walking, balance and eye movements and swallowing), Gastrostomy Status, Dysphagia, Crohn's Disease, and Parkinson's Disease. Review of the MDS assessment for Resident #90 dated 09/07/24 documented in Section C a BIMS score of 'could not be conducted due to the resident is rarely/never understood'. Review of the Physician's Orders for Resident #90 revealed an order dated 08/27/24 for Enteral Feed Order two times a day Give Osmolite 1.5 (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hours [hrs]) Give H20 (water) Flush (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm and was discontinued on 09/21/24 Review of the Physician's Orders for Resident #90 revealed an order dated 09/22/24 for Enteral Feed Order one time a day give Osmolite 1.5/1000ml @ @50ml/hour. Give H20 Flush/1000ml @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm and was discontinued on 09/26/24 Review of the Physician's Orders for Resident #90 revealed an order dated 09/27/24 for Enteral Feed Order one time a day via Gtube give Osmolite 1.5/1000ml @62ml/hr. give H20 flush/500ml @31ml/hr. Start at 5pm and run until complete (~16hrs) Total kcal 1500, Total Pro 62.7gm. See additional H20 flush order. Total Kcal 1500,Total Pro 62.7, Total Fluid 1620ml -and was discontinued on 09/30/24. Review of the Physician's Orders for Resident #90 revealed an order dated 09/30/24 for Enteral Feed Order one time a day via Gtube give Osmolite 1.5/1000ml @62ml/hr. give H20 flush/500ml @62ml/hr. Start at 5pm and run until complete *See additional H20 flush order. Total Kcal 1500, Total Pro 62.7, Total Fluid 1620ml. Review of the weights for Resident #90 revealed the following: On 08/27/24 at 10:25 AM, the resident weighed 92.0 Lbs (pounds) via Mechanical Lift. On 08/27/24 at 4:20 PM, the resident weighed 92.0 Lbs via Mechanical Lift. On 08/27/24 at 4:22 PM, the resident weighed 92.0 Lbs via Mechanical Lift. On 08/27/24 at 5:06PM, the resident weighed 92.0 Lbs via Mechanical Lift. On 09/05/24 at 9:54 AM, the resident weighed 82.0 Lbs via Standing. On 09/27/24 at 4:35 PM, the resident weighed 83.0 Lbs via Standing. In summary, this indicated form 08/27/24, to 09/05/27, the resident lost 10 Lbs which is a significant 10.87% Loss. On 10/01/24 at 10:15 AM, Resident #90 was weighed with the Staff J, Restorative Aide, the Director of Nursing and the surveyor present. The resident weighed 77.6 Lbs which indicated the resident has had a weight loss of 14.4 pounds from 08/27/24 to 10/01/24 which was a significant weight loss of 15.65%. Review of the Nutrition Risk Assessment for Resident #90 dated 08/26/24 included the following in part: Continuous feeding - Osmolite 1.5 (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hours) give H20 Flush (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total feeding - Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm, Free water 1762ml. Estimated Nutritional Needs (Kcal/kg): 42 x 35-40= 1470 - 1680; Protein: 42 x 1.2 - 1.3 = 50-55: MDS Triggers BMI <18.5 or >/= 24.9. Care plan resident will gain 1-21 lbs/month by nrd (next review date). Review of the Care Plan for Resident #90 dated 09/02/24 with a focus on the resident required tube feeding for nutritional support BMI [Body Mass Index] 16. Dx (Diagnosis) dysphagia. The goals were for the resident to tolerate tube feeding without complications such as: aspiration, infection, abdominal pain/distention, dehydration, diarrhea, constipation/fecal impaction, vomiting and the resident will gain at least 1-2 lbs monthly by next review date 12/11/24 . The interventions included: Monitor labs when available - report abnormal data to physician / provider promptly. Monitor tolerance of tube feeding. Monitor weight monthly / weekly. Provide tube feeding as ordered. Provide water flush as order. Review of the Nutrition / Dietary Note for Resident #90 dated 09/05/24 included the following: Resident's care plan meeting today with resident's [spouse], MDS nurse, Therapy director and this RD. Tube feeding regimen reviewed with resident's [spouse]. Resident has been tolerating tube feeding. [The spouse] is in agreement with poc [plan of care] regarding tube feeding at this time. Weight gain desired as [spouse] stated that resident had lost weight prior to admission. Current tube feeding will provide enough calories for gradual weight gain. F/U [follow up] for weekly weight x 3. Adjust poc as needed. Review of the Nutrition / Dietary Note for Resident #90 dated 09/09/24 included the following: Resident's weight on 09/05/24 was 82lbs. Admit weight recorded as 92lbs. Resident is NPO [nothing by mouth] on tube feeding which is providing adequate nutrition / hydrations. F/U with resident's [spouse] who stated she is definitely not 92. [The spouse] stated that she was 78 in the hospital and that he observed her being weighed in this facility on standing scale at 82lbs. 92 lbs may have been an error in recording the weight. Will request reweigh as gradual weight gain is desired. Current estimated needs = 37 x 35-40 = 1295-1480 calories/day, 37 x 1.2 -1.3 = 44-48 gm protein /day, 37 x 30-35 = 1110-1295 ml fluid. F/U for reweigh. Per nursing resident is tolerating tube feeding well. Adjust poc as needed. Review of the Nutrition / Dietary Note for Resident #90 dated 09/26/24 included the following: Resident's tube feeding to be adjusted. Recommend changing to Osmolite 1.5/1000ml @ 62ml/hour via G Tube. Start at 5pm and run until complete (~16 hrs) H2O flush/1000ml @ 31ml/hour via G tube with total of 500ml H20. Start at 5pm and run ~16 hrs. Tube feeding will provide 1500 kcal, 62.7 gm protein, 1262 free H20. Recommend H20 flush 120ml once daily via G tube. Total free water 1382ml Weight 82lbs. Tube feeding provides 40 kcal/kg, 1.6 gm/kg protein, Total free water 37ml/kg. F/U for tolerance/weight/changes. Adjust POC as needed. An interview was conducted on 10/01/24 at 12:12 PM with spouse of Resident #90 who stated the resident's normal body weight was 135 pounds and the last time she was weighed her normal body weight was in March. He said this disease is terrible and now she cannot swallow so she has to be on tube feeding. He said they had some kind of meeting when his wife first arrived at the facility just over a month ago. He expressed his concern over his wife's weight and does not want her to lose any more weight and hopes she can gain weight. He said during that meeting was the only time he talked to the dietician, and they told him they would adjust the tube feeding as they went along. He stated he was never told she had any weight loss since being in the facility, he was under the impression she would have gained weight, but nobody really talks to him or answers question when he asks. He said he comes to the facility just about every day and he sees the tube feeding bottle off and still has about 3 inches of tube feeding left in it and they throw it away and start a new bottle later. He feels she may not be getting all of the tube feeding she is supposed to for this reason. On 10/02/24 at 10:31 AM, an observation was made of Resident #90 sitting up in bed with bottle Osmolite 1.5 tube feeding below the 200 mark out of a 1,000-milliliter capacity bottle. The tube feeding was infusing via pump at 62 milliliters per hour. The tube feeding bottle was labeled with start date of 10/01/24 at 4:00 PM. An interview was conducted on 10/03/24 11:18 AM with the Registered Dietician (RD) who stated she has worked at the facility for [AGE] years and is full time since June 2024. When asked about residents who receive tube feeding, she said for a resident receiving tube feeding, she would generally not expect to see weight loss. She stated she rounds to spot check resident to make sure the tube feeding orders are followed as ordered. When asked about Resident #90 and weight loss, she said when the resident was admitted , she weighed 92 pound and on 09/05/24 she weighed 82 pounds. When asked if that was a significant weight loss, she said, 'yes it was 10%'. When asked what interventions were put in place, the RD stated that on 09/05/24 she did not change the tube feeding orders because it was meeting the resident needs even though she had a 10% weight loss but after her conversation with the husband on 09/09/24, he reported her weight from the hospital was 78 pounds and she was definitely not 92 pounds, and he had observed her being weighed on the standing scale at 82 pounds. 49060 5. Review of the facility's policy, titled, Trauma-Informed and Culturally Competent Care, dated 05/19/23, included the following: Resident Care Planning 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. 3. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety, and depression). Record review for Resident #70 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included: Malignant Neoplasm of Endometrium, Bipolar Disorder, Psychosis Not Due to a Substance or Known Physiological Condition, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of Section C of the MDS dated [DATE] revealed that Resident #70 had a BIMS score of 15, which indicated that she was cognitively intact. Review of section I revealed Resident #70 diagnosis included: Bipolar Disorder, Psychotic Disorder, Depression, PTSD, and anxiety disorder. Review of Resident #70's Care Plans dated 08/12/24 revealed there was no care plan developed to address PTSD, which would have included implementation of individualized interventions. An interview was conducted on 10/02/24 at 1:31 PM with Staff O, MDS coordinator, who stated she has been working at the facility for [AGE] years. She stated she uses the information from the resident assessments, notes, and physician orders to put together the resident's MDS and care plans. Staff O acknowledged that for Resident #70's care plan dated 08/22/24, her diagnoses were added including anxiety, psychosis, and depression along with individualized interventions, but the PTSD diagnosis was not used because she felt it was covered under those diagnosis. Staff O was unsure if there was anything under the MDS coding for PTSD. An interview was conducted on 10/02/24 at 4:59 PM with the Social Services Director (SSD), who stated she has been working at the facility for [AGE] years. She stated the resident's diagnoses are derived from the hospital documentation when the resident is transferred to the facility, and the physician would be the one to diagnose the resident with PTSD. The SSD stated during Resident #70's initial assessment, the resident was not assessed for PTSD and the resident did not show signs of any acute PTSD. She acknowledged not questioning Resident #70 about her PTSD since the resident had no change in mood and did not express any sign of PTSD.

Based on record review, observations and interviews, the facility failed to provide the necessary care and services to ensure residents' abilities in activities of daily living (ADLs) do not diminish including transfer, ambulation and walking for 1 of 1 sampled resident reviewed for rehabilitation services, Resident #80. The findings included: Review of Resident #80's clinical record documented an admission on 10/27/23 with a readmission on 04/08/24. The resident's diagnoses included Difficulty in Walking, Metabolic Encephalopathy, Diabetes Mellitus, Muscle Weakness, and Acquired Absence of Right Leg Below Knee (BKA). Review of Resident #80's Minimum Data Set (MDS) end-of-skilled-services assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13 indicating the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff for putting on and taking off footwear and needed partial to moderate assistance with transfers and most activities of daily living (ADLs). Review of Resident #80's care plan initiated on 04/04/24 and revised on 06/18/24, documented, [resident name] requires assist with activities of daily living related to Dementia, Right BKA with prosthesis, .interventions included: RLE [right lower extremity] prosthesis to be worn when out of bed for transfers and activity participation . Chair / bed to chair transfer: Partial / moderate assistance required by two (2) Staff . On 10/01/24 at 12:15 PM, observation revealed Resident #80 in bed, and awake. An interview was conducted with the resident who stated that he walked three times wearing the right leg prosthesis, from the gymnasium to the 'birds area' before, but Medicare benefits ended. The resident added that for about a week or 10 days he had not been able to wear his right leg prosthesis because he had a sore behind his right knee (below the knee amputee extremity - BKA). Observation revealed Resident #80 lifted his below the knee amputee (BKA) right leg and showed the sore to the surveyor. Photographic Evidence Obtained. Observation revealed a round open skin area, approximately 0.2 x 0.2 centimeters (cm), with bright redness surrounding skin. The resident stated that he spoke with the nurse and believes the therapist came in and looked at the sore. The resident added the prosthesis is loose, and it hurts when he puts it on, it needs adjustment, and he was waiting on the therapist who was going to check on it and had not heard anything back. On 10/02/24 at 8:58 AM, observation revealed Resident # 80 wheeling himself down the hallway entering his room. Observation revealed the resident had his right leg prosthesis on. An interview was conducted with the resident who stated he had to use the prosthesis to go to eat but it hurts. On 10/02/24 at 9:00 AM, an interview was conducted with the Unit Manager who stated that Resident #80 goes to the dining room to eat. On 10/03/24 at 9:40 AM, an interview was conducted with the Director of Rehabilitation (DOR) who stated Resident #80's spoke with her regarding his prosthesis in the morning of 10/02/24 and she called [name], the prosthesis specialist, and was waiting on a call back from them. The DOR added the resident came to the therapy gym later, spoke with her and told her he felt his prosthesis was digging into his leg. The DOR stated the resident told her he had a sore and asked if he told the nurse and told her he did. The DOR was asked if she notified the nurse and replied she did not tell the nurse. The DOR stated resident was discharge from Physical Therapy (PT) on 07/16/24 and was currently receiving Occupational Therapy (OT) since 07/18/24. The DOR stated that on discharge from PT, Resident #80 was walking 150 feet, was not hurting then and the plan was to receive OT. The DOR was asked if the OT plan was to walk with the resident since he was able to walk on discharge and stated that OT will work with the resident transfer and functional skills. The DOR was asked why the resident was not referred to Restorative Care so he can continue to walk and stated because he could not receive both OT and Restorative Care at the same time. The DOR was apprised that the resident wanted to walk and had not done so for at least a week or two. The DOR was asked to provide Resident #80's PT discharge summary. On 10/03/24 at 10:06 AM, an interview was conducted with Staff X, Occupational Therapist (OT), who stated she had worked with Resident #80 for the most part. The OT stated Resident #80 was very motivated, the resident wanted to walk and did some functional mobility, like walked the resident from bed to the bathroom. Staff X stated the last therapy treatment was on 10/02/24. Staff X was asked if Resident #80 complaint of any issues with his right leg prosthesis and replied that a week ago the resident told her that something did not feel right with the prosthesis. Staff X was asked if she documented or notify the DOR of the resident's prosthesis concerns and replied she did not document it or tell the DOR. Review of Resident #80's PT discharge summary dated 07/16/24 documented .Baseline - 04/09/24 -distance on feet: Zero (0) 07/16/24- distance on feet: 150 feet-supervision or touching assistance .patient progress and response to treatment: patient is slowly progression with current treatment interventions and plan of treatment. Patient's condition has potential to improve as a result of skilled rehab and patient's functional performance is progressing as a result of exercises.

Based on record review, observations and interviews, the facility failed to provide care and services to 2 of 2 sampled residents reviewed for skin conditions, Residents #63 and #80, as evidenced by the physician orders not being followed for Resident #36 and an open would not being timely identified for Resident #80. The findings included: 1. Review of Resident #63's clinical record documented an admission on 05/03/24 and no readmissions. The resident's diagnoses included Chronic Systolic (Congestive) Heart Failure, Malignant Neoplasm of Prostate, and Muscle Weakness. Review of Resident #63's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The assessment documented under Functional Abilities and Goals that the resident needed substantial assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #63's care plan initiated on 09/24/24 and revised on 09/24/24, titled, Alteration in skin integrity - skin tear to left elbow. Interventions that included: .Administer treatments / medications as ordered and monitor for effectiveness . Review of Resident #63's active physician order dated 09/23/24 documented Cleanse skin tear to left elbow with N/S (normal saline) apply Xeroform, and cover with a silicone dressing every day shift. Review of Resident #63's September 2024 Treatment Administration Record (TAR) documented Cleanse skin tear to left elbow with N/S (normal saline) apply Xeroform, and cover with a silicone dressing every day shift, start date 09/24/24. The TAR was initialed as care administered by the nurses on 09/24/24, 09/25/24, 09/26/24, 09/27/24, 09/28/24 and 09/29/24. On 09/30/24 at 10:17 AM, observation revealed Resident #63 in his room sitting in a wheelchair accompanied by his Private Duty Aide (PDA). Further observation revealed the resident had a dressing on his left elbow dated 09/23/24. Resident # 63 was asked what happened to his left elbow and stated he bumps into things. The PDA stated the resident had fragile skin. On 09/30/24 at 10:23 AM, a side-by-side review of Resident #63 physician order for the left elbow was conducted with Staff U, Licensed Practical Nurse (LPN). Staff U stated the dressing to the left elbow skin tear was ordered to be done every day shift. On 09/30/24 at 10:25 AM, an interview was conducted with Staff Q, LPN who stated working in the facility for 2 years on and off and did not know who was responsible to change the resident's wound care dressing. On 09/30/24 at 10:27 AM, an interview was conducted with the Unit Manager (UM) who was apprised of Resident #63's left elbow dressing dated 09/23/24. On 09/30/24 at 10:29 AM, an interview was conducted with the dedicated Wound Care Nurse (WCN) who stated she works Monday through Friday but was off from last Thursday (09/26/24) until today (09/30/24). The WCN stated she was responsible for all resident's wound care including skin tears. The WCN was asked who was responsible to do the residents' wound care on the weekends and replied sometimes the facility designates someone (nurse) to do the wounds or the floor nurse do it. The WCN was asked how she knew about resident's skin tears and replied that residents with new wound, somebody will tell her, the CNA, the Unit Manager, and added she would look at the computer first for new residents and new orders. The WCN stated she was not aware of Resident #63 left elbow skin tear. The WCN was directed to see Resident #63's left elbow dressing date. On 09/30/24 at 10:39 AM, observation revealed the Unit Manager (UM) at Resident's #63 bedside. The UM stated she removed the dressing. A side-by-side observation of Resident #63 left elbow wound was conducted with the UM and the WCN. The wound was bleeding and had an approximately one (1) inch skin flab. The manager was asked to provide the wound measurements. On 10/02/24 at 10:19 AM, an interview was conducted with Staff O, MDS Coordinator, who stated the team is notified during daily morning meeting of resident's skin tears. Staff O stated that on 09/24/24, the resident sustained a left elbow skin tear and a care plan was initiated. On 10/02/24 at 10:30 AM, during an interview, the Unit Manager was asked to submit the notes for the wound care provided on 09/30/24 with the wound description and measurements. The Manger replied she documented the care on the TAR, did not documented the measurements. On 10/02/24 at 2:14 PM, an interview was conducted with Staff M, LPN, who had been working in the facility for three (3) months. Staff M stated her responsibilities included to pass medications, take vital sings, give enemas and change dressings. Staff M was asked if she had done dressing changes to Resident #63 and stated she did one dressing change to the leg in the past. Staff M was asked if she changed the resident's left elbow dressing and stated she did not. Staff M was apprised that she signed off the resident's left elbow treatment in the TAR three times (09/24/24, 09/25/24 and 09/28/24). Staff M stated she did not do the treatment and was under the impression the WCN done it. She added she won't touch the dressing, will leave to the WCN, and will wait to the end of the shift to sign it off. Staff M stated that she signed off at the end of the shift because she was under the impression that the WCN would do it. Staff M was asked if she coordinated, contacted the WCN or looked at the resident's dressing before she signed it off and stated she did not check with the WCN or check the resident's dressing. Staff M stated that when the WCN is not in the facility, they rotate one of the Registered Nurse to do the residents' wound care. On 10/03/24 at 9:43 AM, an interview was conducted with Staff R, RN, who stated he has been working in the facility for eight (8) months and his responsibilities were to give care (helping the residents), safety, administration of medications and assist with dining. Staff R stated he does not know who does the resident's wound care on the weekends. Staff R was asked what his initial on the TAR meant and replied when he signed the TAR, it means that he did the treatment. Staff R was apprised that on 09/30/24, Resident #63's left elbow dressing was dated 09/23/24 and that he signed off the resident's TAR on 09/27/24 as treatment done. Staff R stated he 'clicked it by mistake'. Staff R was asked if he checked with the WCN to see if the treatment was done and replied he did not. 2. Review of Resident #80's clinical record documented an admission on 10/27/23 with a readmission on 04/08/24. The resident's diagnoses included Difficulty in Walking, Metabolic Encephalopathy, Diabetes Mellitus, Muscle Weakness, and Acquired Absence of Right Leg Below Knee. Review of Resident #80's Minimum Data Set (MDS) end-of-skilled-services assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13 indicating no cognitive impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to put on and take off footwear. Review of Resident #80's care plan initiated on 04/04/24 and revised on 06/18/24 documented (resident name) requires assist with activities of daily living related to Dementia, Right BKA with prosthesis .interventions included: RLE (right lower extremity) prosthesis to be worn when out of bed for transfers and activity participation .Remove before bed, for skin checks and hygiene .Skin inspection: monitor for redness, open areas, scratches, cuts, bruises and immediately report changes to the nurse . Review of Resident #80's care plan initiated on 10/30/23 and revised on 06/18/24 documented (resident's name) is at risk for pressure injury development related to decrease in mobility, diagnosis of PVD (Peripheral Vascular Disease) and DM (Diabetes Mellitus), has right BKA (below knee amputation), interventions included: Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care . Review of Resident #80's care plan initiated on 02/12/24 and revised on 08/12/24 documented (resident's name) has Diabetes Mellitus, interventions include: .check all of body for breaks in skin and treat promptly as ordered by doctor . Review of Resident # 80's nursing progress notes dated 09/30/24 at 6:52 AM documented the resident was medicated for right leg pain. Further review of skilled nursing Flowsheet from 09/20/24 through 09/27/24 documented .skin was also observed; has no skin concerns . Review of nursing progress note dated 09/25/24 documented alert and oriented .received a shower . On 10/01/24 at 12:15 PM, observation revealed Resident #80 in bed uncovered wearing an adult brief. During an interview, Resident #80 stated that he used to walk three times wearing the right leg prosthesis, from the gymnasium to the 'birds area' before, but for about a week or 10 days he had not been able to because he had a sore behind his right knee (below the knee amputee extremity- BKA) where the prosthesis sits in. Observation revealed Resident #80 lifted his below the knee amputee right leg and showed the sore to the surveyor. Photographic Evidence Obtained. Observation revealed a round open skin area, approximately 0.2 x 0.2 centimeters (cm), with bright redness skin surrounding the open sore. The resident stated that he spoke with the nurse and believe the therapist came in and looked at the sore. The resident was unable to provide the staffs' name). The resident added the prosthesis was loose, it hurts when he put it on, stated, needs adjustment, and that he was waiting on the therapist who was going to check on it and had not heard anything back. On 10/02/24 at 8:58 AM, observation revealed Resident #80 wheeling himself down the hallway entering his room. Observation revealed the resident had his right leg prosthesis on. An interview was conducted with the resident at this time who stated he had to use the prosthesis to go to eat but it hurts. The resident was asked if the nurse had seen the open sore and stated no. On 10/02/24 at 9:00 AM, an interview was conducted with the Unit Manager who stated that Resident #80 goes to the dining room to eat. An observation was conducted on 10/02/24 at 9:25 AM of Resident #80 in his wheelchair by his room door speaking with a therapy staff about his prosthesis. Staff U, Licensed Practical Nurse (LPN), was actively preparing medication right next to Resident #80's room. After the therapy staff left, Resident #80 turned to Staff U and stated that she needed to see his leg wound and his prosthesis. Staff U stated she would look at it after she was done with the medications. As the surveyor passed by, Staff U turned to Resident #80 and stated, let me see your leg. On 10/03/24 at 8:50 AM, a side-by-side review of Resident # 80's Weekly Skin Evaluation dated 10/02/24 was conducted with the Unit Manager (UM). The evaluation documented skin observation - no new open areas noted . A joint interview was conducted with the UM and Staff U, LPN, who signed the skin evaluation. Staff U confirmed she checked Resident #80's skin on 10/02/24 and did not see any new open skin, and stated the resident had an ankle and back rash from before. The UM and Staff U were apprised that on 10/01/24, Resident #80 complained of pain behind his right BKA to the surveyor and showed an open skin area where the prosthesis sits. A side-by-side observation of Resident #80's behind the right BKA skin was conducted with the UM and Staff U. Staff U stated, It is open. During the observation, Resident #80 stated the wound was checked by the therapist on 10/02/24 and knew about the open wound. The resident added he did not want the sore to get bad and to have his knee cut off higher. Staff U was asked to measure the open wound and stated the measurements were 0.3 x 0.4 cm. On 10/03/24 at 9:40 AM, an interview was conducted with the Director of Rehabilitation (DOR) who stated Resident #80's spoke with her regarding his prosthesis in the morning of 10/02/24 and she called [Name] (Prosthesis Specialist), and was waiting on a call back from them. The DOR added the resident came to the therapy gym later, he spoke with her and told her he felt his prosthesis was digging into his leg. The DOR stated the resident told her he had a sore and asked if he told the nurse and told her he did. The DOR was asked if she notified the nurse and replied she did not tell the nurse.

Based on observations, interviews and record reviews, the facility failed to act on recommendations for an air mattress for a resident admitted with a Stage 4 pressure for 1 of 1 sampled resident reviewed for pressure ulcers, Resident #200. The findings included: Record review revealed Resident #200 was admitted to the facility on [DATE]. Review of the Nursing Progress note upon admission documented the resident as alert and oriented and that resident was bed-bound. Review of Resident #200's care plan for skin integrity, dated 09/25/24 with a revision date of 09/27/24, documented, Alteration in skin integrity-actual pressure injury present upon admission related to Recent hospitalization Wound with vac to right knee. Stage 4 to sacrum and Stage 3 to right gluteal. The goals of the care plan were documented as: o Resident will be free of further alteration in skin integrity through next review date. With a target date of 12/24/24. o Stage 4 to sacrum will resolve and show no s/s [signs and symptoms] of infection through next review. With a target date of 12/24/24. o Stage 3 to right gluteal will show s/s of healing and no s/s of infection through next review. With a target date of 12/24/24. Interventions in the care plan included: o Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, and odor-notify physician of significant findings. o Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. o Remind/assist resident to frequently change position when in bed and/or chair. Review of Resident #200's care plan for Pressure Ulcer Development, initiated on 09/25/24, documented, At risk for pressure injury development related to Recent hospitalization . The goal of the care plan was documented as, Resident will be free of pressure injury development through next review date.09/25/24 with a target date of 12/25/24. Interventions included: o Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. o Remind/assist resident to frequently change position when in bed and/or chair. Review of a Skin and Wound Evaluation, dated 09/26/24, completed by Staff D, Registered Nurse (RN), documented Resident #200 had a Stage 3 pressure injury to the right gluteus that was present on admission (09/25/24) with treatment that included an air mattress. A second Skin and wound Evaluation, dated 09/26/24, completed by Staff D, RN, documented Resident #200 had a Stage 4 Pressure injury to the sacrum upon admission (09/25/24) with treatment that included an air mattress. During an interview with Resident #200, on 09/30/24 at 1:32 PM, when asked about having any skin issues or impairments, Resident #200 replied, I am supposed to get a new mattress, I got sores on my butt and my doctor wants me on an air mattress. They found them bleeding a little in the hospital (prior to admission). During the interview, Resident #200 was noted to be on a standard mattress. During an observation of Resident #200, on 10/01/24 at 4:08 PM, Resident #200 was noted to be on a standard mattress. During an interview, on 10/01/24 at 10:40 AM, with Staff B (RN/Unit Manager / UM), when asked about the Skin and Wound Evaluations, Staff B confirmed that she did the evaluations and recommended an air mattress. When asked about the air mattress not being provided to the resident, Staff replied, I just forgot to order it. Staff B further stated that the facility had the air mattress on site and that the resident would be getting one prior to returning from a doctor's appointment later this day. During an interview with Resident #200, on 10/02/24 at 7:17 AM, Resident #200 was noted to be on a standard mattress. On 10/02/24 at 12:49 PM, Resident #200 was not in her bed and had left for an appointment, Staff B reported to the surveyor, I just told maintenance, and they should be bringing it.

Based on observations, interviews and record reviews, the facility failed to ensure adequate protection and assistance to residents who smoke with smoking aprons for 1 of 5 sampled residents reviewed for smoking, Resident #19; failed to provide adequate supervision for 5 of 5 sampled residents reviewed and observed for smoking, Residents #19, #8, #249, #46, and #197; failed to secure smoking materials for 1 of 5 sampled residents reviewed for smoking, Resident #8; and failed to ensure the environment remained as free of hazards as possible for 1 of 1 supply room on the second floor. The findings included: Review of the facility's policy, titled, Smoking Policy - Residents, with a revised date of October 2023, included, in part, the following: This facility has established and maintains safe resident smoking practices. 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking in not allowed inside the facility under any circumstances. 3. Electronic cigarettes and smokeless tobacco are permitted in designated areas only. 5. Metal containers with self-closing covers are available in smoking areas. 6. Ashtrays are emptied into designated receptacles. 7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. Current level of tobacco consumption b. Method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipe, etc.) c. Desire to quit smoking d. Ability to smoke safely with or without supervision (per Safe Smoking Evaluation) 8. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation 9. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. 10. Any smoking-related privileges, restrictions and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 11. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 12. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 13. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. 14. Residents are not permitted to give smoking items to other residents. Review of the manufacturer's instructions for the Smoker's Apron with no date included, in part, the following: Application for Instructions: 1) Place the apron over the resident and attach the neck strap to the apron by engaging the hook and loop located on the strap and at the top of the apron. 2) Adjust the strap until the apron reaches the neckline 3) To protect cigarettes and ashes from falling between resident and their wheelchair, wrap the side straps around the wheelchair frame and engage the hook and loop under the apron. Warning: This apron is not a substitute for proper supervision. Patients or residents should always be closely supervised while smoking. 1. Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Cerebral Infarction, Type 2 Diabetes, and Epilepsy Unspecified Intractable without Status Epilepticus. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #19 dated 08/29/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 13 indicating an intact cognitive response. Review of the Annual MDS assessment for Resident #19 dated 05/29/24 revealed in Section J for tobacco use, is 'yes'. Review of the Smoking Risk Form for Resident #19 dated 12/05/23 documented the resident smokes 2-5 times per day and likes to smoke in the morning, afternoon and evening. She can light her own cigarette and needs adaptive equipment: smoking apron. There were no other Smoking Risk forms completed until surveyor intervention. Review of the Smoking Risk Form for Resident #19 dated 10/01/24 documented the resident smokes 1-2 times per day in the morning and afternoon. She can light her own cigarette. She needs adaptive equipment to include a smoking apron and supervision. Record review for Resident #19 from 12/06/23 to 09/30/24 revealed no Smoking Risk Form. This indicated the resident was not re-evaluated quarterly for safe smoking. Review of the Alteration in Skin Integrity documentation for Resident #19 dated 05/20/24 documented in part the following: Incident description: Resident was observed with a new cigarette burn on her upper left thigh in the healing process. Per resident the cigarette burn happened over a week ago. Immediate action taken: wound was clean and dry, healing observed. The resident was not taken to the hospital. Predisposing Physiological Factors: none of the above. Predisposing Situation Factors: none of the above. People notified: Physician and Family member/responsible family member. Review of the care plan for Resident #19 dated 09/01/23 with a focus on the resident chooses to smoke. Non-compliant with smoking policy despite education. The goal was for the resident to remain free from smoking related injury. The interventions included the following: Cigarettes and lighter to be kept in a secure location. Instruct resident/family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Smoking apron to be worn when smoking. Smoking in designated area only. Supervised smoking by staff member. On 09/30/24 at 1:40 PM, an observation was made of Resident #19 and Resident #249 smoking on the smoking patio. Resident #19 had a smoking apron that was not secured, laying across her and only partially covering her chest and lap. Resident #19's ashes from her cigarette were dropping unto the ground. She was positioned in her wheelchair away from the ashtray on a table and it was out of her reach. When Resident #19 finished with her cigarette, she placed it in the red smoking post. An interview was conducted on 09/30/24 at 1:45 PM with Resident #19 who was asked how long she has smoked at the facility, and she said, 'years'. When asked about the covering on her (smoking apron), she said she keeps it on the back of her wheelchair and puts it on herself when she comes out to smoke. When asked if staff come out to supervise her smoking, she said sometimes staff come out for a few minutes but not every time. When asked if she can light her own cigarettes, she said sometimes she cannot, but most times she can. When asked where her cigarettes and lighter are kept, she said the nurse holds her cigarettes and lighter and gives them to her when she asked for them, then she will bring them back when she is done smoking. On 10/02/24 at 1:15 PM, an observation was made of Resident #19 on the smoking patio with a smoking apron not secured around her neck and was partially covering her chest and lap as she lit her own cigarette. No staff member was present. At approximately 1:22 PM, Staff N, Certified Nursing Assistant (CNA), came to smoking patio to supervise the resident. An interview was conducted on 10/02/24 at 1:20 PM with Staff M, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 3-4 months. When asked about the resident, she said she was not aware the resident was an unsafe smoker until today. The LPN stated she hold the resident's cigarettes and lighter in the med cart. The LPN stated she came down this morning with the resident to smoking area and helped her with the smoking apron and with lighting a cigarette. There was another staff member on the smoking patio, and she was under the impression the staff member was assigned to the smoking patio to observe the residents. She stated when the resident requested cigarettes to smoke around 1:10 PM on 10/02/24, she gave the resident 2 cigarettes and the resident went downstairs, and she assumed she would be supervised by another staff member she thought was assigned to the smoking patio. An interview was conducted on 10/02/24 at 1:23 PM with administrator who did side-by-side observation of resident with smoking apron partially covering her and smoking a cigarette on the smoking patio. 2. Record review for Resident #249 revealed the resident was admitted to the facility on [DATE] with diagnoses including in part the following: Thyrotoxicosis with Diffuse Goiter Without Thyrotoxic Crisis or Storm, Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, Unsteadiness on Feet, Muscle Weakness, and Parkinson's Disease Without Dyskinesia. Review of the Social Service Evaluation for Resident #249 dated 09/25/24 documented a BIMS score of 9 indicating moderately impaired cognition. Review of Smoking Risk Form for Resident #249 dated 09/30/24 documented the resident has a cognitive loss, cannot light own cigarette, needs supervision, and other listed as needs assist to light cigarette / stay with. Review of the Care Plan for Resident #249 dated 09/30/24 was a care plan with a focus on the residents' choices to smoke. The goal was for the resident to remain free from smoking related injury. The interventions included: Cigarettes and lighter to be kept in a secure location. Instruct resident / family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Needs assist to light cigarette. Smoking in designated area only. Supervised smoking by staff member On 09/30/24 1:40 PM, an observation was conducted of Resident #249 smoking on smoking patio with Resident #19 unsupervised. Resident #249 was using the covered ashtray with the cover off. There were cigarette butts on the patio floor. During an interview conducted on 09/30/24 at 1:40 PM with Resident #249 who was asked how long she has been smoking at the facility, she said since she got here about a week ago. When asked who holds her cigarettes and lighter, she said she usually gets cigarettes from some of the other residents when she comes outside on the smoking patio to smoke. When asked if any staff supervise them or come out to the patio when she is smoking, she said sometimes they come out to see them smoking but they do not stay. 3. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Unspecified Fracture of Humerus, History of Falling, Anxiety and Muscle Weakness (Generalized). Review of the annual MDS assessment for Resident #8 dated 05/09/24 documented in Section J tobacco use, documented 'no'. Review of the MDS assessment for Resident #8 dated 08/09/24 documented in Section C, a Brief interview of Mental Status score of 15, indicating an intact cognitive response. Review of the Smoking Risk Form for Resident #8 dated 12/01/23 documented the resident smokes 2-5 times per day in the morning, afternoon and evening. The Resident can light her won cigarette. No adaptive equipment needed including supervision. Review of the Smoking Risk Form for Resident #8 dated 10/01/24 documented the resident smokes 1-2 times per day in the morning and afternoon. Resident can light her won cigarette. Need for adaptive equipment documented supervision. Record review from 12/02/23 to 09/30/24 for Resident #8 revealed no Smoking Risk Form was completed. Review of the Care Plan for Resident #8 dated 12/04/23 with a focus on the resident chooses to smoke. The goal was for the resident to remain free from smoking related injury. Instruct resident / family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Smoking in designated area only. Supervised smoking by staff member On 09/30/24 at 12:19 PM, an observation was made of Resident #8 sitting up in bed with electronic cigarette, regular cigarettes and lighter on overbed table. Photographic Evidence Obtained. On 10/01/24 at 10:17 AM, a side-by-side observation was made with Staff B, Registered Nurse / Unit Manager (RN/UM), who acknowledged the resident should not have the cigarettes, lighter and electronic cigarette at the bedside and took them. The RN/UM informed the resident she could not have those items at the bedside. An interview was conducted on 09/30/24 at 12:23 PM with Resident #8 who was asked if she was a smoker, who responded 'yes'. When asked if she has always smoked since being a resident at the facility, she said yes. When asked if staff hold her cigarettes and lighter, she said no, she holds them, and they know it. When asked if staff supervises her while smoking, she said they come in and out, but nobody stays with them. She said it is different staff all of the time. An interview was conducted on 10/01/24 at 10:30 AM with Staff B who was asked if residents are assessed for smoking. She said she does not do the smoking assessments, that would be administration. When asked how often the smoking assessments or evaluations are completed, she said she is not sure. When asked if a resident can have cigarettes, lighter and electric cigarette at the bedside, she said no, it needs to be secured. An interview was conducted on 10/03/24 at 2:35 PM with Staff O, RN / Minimum Data Set Coordinator who stated she has worked at the facility for [AGE] years. When asked about smoking care plans being updated, she said she would not update smoking care plans for any resident unless the smoking status changed for the resident. 38893 4. Record review revealed Resident #46 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly MDS, dated [DATE], revealed Resident #46 had a BIMS score of 15, indicating the resident was cognitively intact. The MDS documented the resident ambulated independently via manual wheelchair and required minimal assistance for bed mobility and transfer. Resident #46's diagnoses at the time of the assessment included Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Muscle weakness, and History of falling, Resident #46's care plan for smoking, initiated on 07/12/23, documented, Resident chooses to smoke / has been evaluated to be safe and knows to keep smoking materials secure. The goal of the care plan was documented as Resident will remain free from smoking related injury. Date Initiated: 07/12/2023. Revision on: 04/02/2024. Target Date: 12/11/2024. Interventions in the care plan included: o Instruct resident/family on smoking policy o Smoking in designated area only Date Initiated: 07/12/2023. On 09/30/24 at 10:06 AM, two residents, including Resident #46, were observed in the designated smoking area. It was noted that there were no staff members on the patio to provide supervision for the residents. On 09/30/24 at 10:22 AM, the MDS Coordinator arrived at the smoking patio. During an interview, on 09/30/24 at 11:04 PM with the MDS Coordinator, when asked about providing supervision to residents while smoking, the MDS Coordinator replied, Normally there is someone there to supervise them. The Administrator was supposed to go with them this morning. On 09/30/24 at 11:51 AM, Resident #46 was observed going to the smoking patio and smoking independently. It was noted that there were no staff to provide supervision while Resident #46 was smoking. On 10/01/24, at 6:45 AM, Resident #46 was observed going to the smoking patio and smoking independently. It was noted that there were no staff to provide supervision while Resident #46 was smoking. On 10/02/24, at 6:30 AM, Resident #46 was observed on the smoking patio and smoking independently. It was noted that there were no staff to provide supervision while Resident #46 was smoking. 5. Record review revealed Resident #197 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, a Medicare 5-day MDS, dated [DATE], revealed Resident #197 had a BIMS score of 14, indicating an intact cognitively response. The assessment documented that Resident #197 required partial / moderate assist for bed mobility and transfer and ambulated independently with use of a manual wheelchair (w/c). [The resident was observed walking behind w/c on multiple occasions during the survey.] Resident #197's diagnoses at the time of the assessment included: Hypertension, Depression, and Chronic lung disease. Resident #197's care plan for smoking, imitated on 09/20/24 with a revision date of 10/01/24, documented, Resident chooses to smoke. The goal of the care plan was documented as, Resident will remain free from smoking related injury, dated 09/20/24 with a target date of 10/02/24. Interventions of the care plan included: o Cigarettes and lighter to be kept in a secure location o Instruct resident/family on smoking policy o Smoking in designated area only. Review of the Smoking Risk Form, dated 09/12/24, and second form dated 09/30/24, indicated: No cognitive loss, No visual deficit, and No safety concerns. On 09/30/24 10:06 AM, two residents, including Resident #197, were observed in the designated smoking area. It was noted that there were no staff on the patio to provide supervision for the residents. On 09/30/24 at 10:22 AM, the MDS Coordinator arrived at the smoking patio. During an interview, on 09/30/24 at 11:04 PM with the MDS Coordinator, when asked about providing supervision to residents while smoking, the MDS Coordinator replied, Normally there is someone there to supervise them. The Administrator was supposed to go with them this morning. During an interview, on 10/01/24 at 12:46 PM, when asked about smoking without staff supervision, Resident #197 stated that there is normally no supervision. Resident #197 further stated, I keep them (cigarettes) in the pocket of my wheelchair. My daughter will bring me in a pack or two and I keep them with me. The pocket is good for keeping them. On 10/02/24 at 9:12 AM, Resident #197 was observed walking behind a wheelchair to the elevator and did not stop at nurse's station on the second floor for smoking supplies (cigarettes and lighter). On 10/02/24 at 9:15 AM, Resident #197 was observed on the smoking patio smoking independently. On 10/02/24 at 12:52 PM, Resident #197 was observed walking behind a wheelchair to the elevator and did not stop at nurse's station on the second floor for smoking supplies (cigarettes and lighter). On 10/03/24 at 10:00 AM, Resident #197 was observed on the smoking patio with Resident #19. Resident #197 was observed providing a cigarette and lighter to Resident #19 with no staff intervention. 6. On 09/30/24 at 10:00 AM, an observation was made of the supply room on the second floor across from the nursing station The supply room was unlocked, and no staff were present inside. Inside the supply room, there were 19 razors. An interview was conducted on 09/30/24 at 10:05 AM with Staff B, RN/UM, who was asked about the supply room. She said normally it will automatically lock when the door shuts. She acknowledged that the supply room was unlocked and unattended with 19 razor blades.

Based on observation, interview and record review, the facility failed to obtain physician orders for catheter care, provide catheter care, and report complications associated with catheter care and failed to ensure adequate hand hygiene for 1 of 1 sampled resident observed for urinary catheter care, Resident #35. The findings included: Review of the facility's policy, titled, Catheter Care, Urinary, with a revised date of August 2022, included, in part, the following: The purpose of this procedure is to prevent urinary catheter -associated complications, including urinary tract infections. Complications 1. Observe resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately. a. If the resident indicated that his or her bladder is full or that he or she needs to void (urinate). b. If urine has an unusual appearance (i.e., color, blood, etc.). c. Complains of burning, tenderness, or pain in the urethral area; or d. If signs and symptoms of urinary tract infection or urinary retention occur. Review of the facility's policy, titled, Handwashing/Hand Hygiene, with a published date of 12/29/22 included, in part, the following: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff to use to encourage compliance with hand hygiene policies. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Procedure Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down and folding it into the first glove. 5. Perform hand hygiene. Record review for Resident #35 revealed the resident was originally admitted to the facility on [DATE], transferred to the hospital on 09/22/24 and was readmitted to the facility on [DATE]. The resident's diagnoses included in part the following: Urinary Tract Infection Site not Specified, Acute Kidney Failure, Type 2 Diabetes Mellitus without Complications, Encounter for Fitting and Adjustment of Urinary Device, and Obstructive and Reflux Uropathy Unspecified. Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 09/02/24 documented the resident had a Brief Interview of Mental Status (BIMS) score of 14 indicating an intact cognitive response. Review of the Physician's Orders for Resident #35 from 09/26/24 to 09/29/24 revealed no orders for urinary catheter care. Review of the Physician's orders for Resident #35 revealed an order dated 09/30/24 for Catheter/ Foley: Catheter care every shift. every shift and as needed. Review of the Physician's orders for Resident #35 revealed an order dated 09/26/24 for Eliquis (to prevent a blood clot from forming) Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Atrial Fibrillation. Review of the 3008 form from the hospital dated 09/26/24 documented in Section E, Medical Condition, as Complicated UTI [Urinary Tract Infection]. Section P, Patient Health Status, had Foley catheter checked. The Treatment Administration Record (TAR) for Resident #35 from 09/26/24 to 09/29/24 revealed no documentation of catheter care. Review of the Care Plan for Resident #35 dated 09/05/24 documented a focus on the resident has an Indwelling Catheter r/t [related to] Obstructive Uropathy 16f/10cc. The goals were for the resident to be / remain free from catheter-related trauma and for the resident to show no s/sx [signs/symptoms] of Urinary infection through review date. The interventions included in part the following: Monitor / document for pain / discomfort due to catheter. Monitor / record / report to MD [Medical Doctor] for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating. Review of progress notes for Resident #35 for 10/02/24 revealed no documentation of the nurse contacting physician to report bleeding or pain during catheter care. On 09/30/24 at 12:55 PM, an observation was made of Resident # 35 with an indwelling urinary catheter drainage bag on the side of bed covered with a privacy cover. On 10/02/24 at 10:59 AM, an observation was conducted of catheter care for Resident #35 performed by Staff K, Certified Nursing Assistant (CNA). Staff K gathered supplies, donned appropriate PPE including gown, mask, washed hands and applied and gloves. She adjusted the privacy curtain, touched the bed control to adjust the bed, pulled the covers down, removed brief and said to resident I am going to remove your diaper. The resident asked if the staff was going to put medicine inside, she said no. She added soap to water and washed the resident with soapy washcloth twice moving from tip of penis down tubing away from resident and around meatus of penis. Blood was noted, and the CNA then used a washcloth with just water to wipe tubing and meatus. She removed her gloves, did not perform hand hygiene, and put new gloves on. The resident asked if she was going to put cream on, and she said she was going to dry him. She then proceeded to dry the resident with a dry bath towel, removed her gloves, did not perform hand hygiene, and applied new gloves. She then used wipes to clean the resident's fold under the abdomen and creases on each side of the groin. The resident screamed in pain. She removed her gloves, did no hand hygiene, applied new gloves, and applied cream to abdominal fold and creases next to groin. She then had resident roll side-to-side to remove and replace the pad under the resident. The CNA removed her gloves, did no hand hygiene, had the resident roll side-to-side to place a clean brief on him. She gathered all the garbage into a bag, placed in trash, removed her gloves, did no hand hygiene, applied gloves, pulled the covers over resident, and adjusted the bed. The CNA then removed her gloves and washed her hands. In summary Staff K changed her gloves 5 times during the procedure without performing hand hygiene. When asked how often she checks the drainage bag, she said every 2 hours. An interview was conducted on 10/02/24 at 8:58 AM with Resident #35 who was asked if he recently went to the hospital for pain with his indwelling catheter. He said yes. He said they changed the catheter in the hospital, and he returned to the facility with the new catheter in place. When asked if the staff have been performing catheter care since he returned, he said yes, they come and put cream on it. An interview was conducted on 10/02/24 at 11:19 AM with Staff K, CNA, who stated she has worked at the facility for 4 months. When asked if she notified the nurse about Resident #35 having pain and bleeding during catheter care, she said they already know this. When asked about hand hygiene during glove changes, she said sometimes she uses hand sanitizer, but she could not find any today. An interview was conducted on 10/02/24 at 11:24 AM with Staff L, Registered Nurse (RN), who was assigned to take care of Resident #35 who stated she has worked at the facility for 1 year. When asked about Resident #35 and having any pain or bleeding with catheter care, she said, 'before he had a UTI and went out to the hospital recently and just came back last week'. She said, 'sometimes he has pain with catheter care, and he has pain medication, but they only give him pain medication if he asks for it'. When asked if the resident has pain with catheter care, she said, 'yes sometimes'. When asked how often urinary catheter care is performed, she said, 'every shift'.

Based on observations, interviews and record review, the facility failed to ensure a resident receiving enteral feeding (tube feeding) received appropriate care and services to prevent complications for 1 of 2 sampled residents reviewed for tube feeding with significant weight loss not addressed in a timely manner, Resident #90; and for 1 of 2 sampled residents reviewed for tube feeding to ensure residents are receiving tube feeding in a manner to prevent complications, Resident #199. The findings included: Review of the facility's policy, titled, Nutrition Support: Enteral Feed, with a date of 11/10/22 included in part the following: Policy: To provide appropriate nutritional care to all patients who require enteral nutrition support. Procedure: Indication for Enteral Nutrition (EN) Enteral feeding is generally indicated for patients who are unable to meet their nutrient requirements orally and have a functioning gastrointestinal tract. Initiation of Enteral Nutrition Patients who are at high nutrition risk or severely malnourished should be advanced to goal as quickly as tolerated over 24-48 hours while monitoring for refeeding syndrome. (efforts to provide >80% of estimated or calculated goal energy and protein within 48-72 hours should be made to achieve the clinical benefit of EN over the first week). Nurses: c) Administer enteral feeding as per order d) Minimize or avoid holding feedings e) Document intake and output as per MD order as applicable. Document if feeding held, reason for holding and rate adjustment. Complete feeding as applicable. f) Ensure head of bed is elevated at least 30 to 45 degrees, unless contraindicated. Dieticians: a) Assess nutritional status and nutritional needs of all patients on enteral nutrition support, as per Evidence Based Nutrition Care Practice Guidelines (Aspen/Academy of Nutrition and Dietetics). The nutrition assessment will include an estimation of calories, protein, and free water provided through the enteral feeding. The RD (Registered Dietician) will compare these to the estimated needs to ensure nutrient needs are met utilizing Aspen method of documentation: actual feeding provided via kg. (When calculating free water, include water provided through formula and through free water flush.) Recommend enteral feeding and fluid flush adjustments as needed to meet the resident's estimate needs adequately. b) Make recommendations as to formula selection, administration, rate, free water flushes, monitoring, and intolerance issues for optimal outcomes. c) The dietician will review the written physician order to ensure that it meets requirement (or use the Enteral Feeding Form/EMR process). Estimating Nutritional Needs Nutritional needs are dependent on the patient's current medical status, presence of inflammation, mechanical ventilation, wounds, weight, age and gender among many other factors. Ideally caloric needs should be estimated using indirect calorimetry. Mifflin-St Jeor (MSJ) can be used in estimating caloric needs. Otherwise, a good starting point for estimating caloric needs can be as follows: For a malnourished, underweight individual (BMI <18.5 to <30): 25-30 kcal/kg/day protein. Review of the facility's policy, titled, Policy Interdisciplinary Management and Prevention of Significant Weight Loss Of Nursing Facility Residents, with a revised date of 11/01/22, included in part the following: Policy: There will be a systemic an interdisciplinary approach to monitoring resident weights in the facility. The facility will develop a standardized process in the management and prevention of unplanned significant weight loss of Nursing Facility residents. Residents who lose weight will be identified and managed in a timely manner. Purpose: The purpose is to provide guidelines for detection of early unplanned weight loss. This includes communication and appropriate action by the interdisciplinary team to maintain acceptable parameters of nutritional status of nursing facility residents. For the purpose of this policy the early unplanned weight loss is defined as 5 pounds in 30 days. Procedure: The nursing staff will: weigh all new admissions and readmissions upon admission and the day after if necessary. Weights ae then taken weekly x 4 weeks (one month) and [NAME] monthly unless the physician order states otherwise. All heights and weights are recorded in the Electronic Medical Records (EMR) per facility policy. Weight discrepancy: a) Reweigh residents with significant weight discrepancies within 24 hours, if needed reweigh the following: Residents weighing ,/+ to 100 pounds - if the weight variance ins +/- >3 pounds weight variance from the previous weight, the resident will be reweighed within 24 hours. As applicable in the EMR, strikeout the incorrect weight. 2. The Clinical Dietician will: If a discrepancy still exists and the change is unplanned or undesirable, place the resident on weekly weights or more often as ordered by physician. The physician will be notified of any weekly or monthly significant weight changes, or as needed. The dietician will be responsible for reviewing all monthly weights. Residents who have a weight loss of >3% or insidious weight change should be seen by the RD by the 9th of each month. Monitor all of the interventions for efficacy and feasibility. Care Plans will be under continuous revisions to meet resident's needs with goal of achieving a desired outcome. A) Calculate percentage of resident's weight loss. B) Monitor appropriateness of the diet prescription. I) Coordinate with the interdisciplinary clinical team/other disciplines (IDT) for a Focus Meeting to discuss significant weight loss and findings J) Modify and/or change current interventions. K) Monitor resident's progress and document weekly or sooner in the medical record until weight status resolve. Significant Weight Loss For the purposes of this policy, the facility considers significant unplanned weight loss a Significant Change which would require IDT Meeting be held to discuss the reason(s) and to review and/or modify the plan of care. Suggested parameters as per Regulatory Standards for evaluating significance of unplanned and undesired weight loss are: 1 month 5% Greater than 5% Appendix CMS Definitions: Avoidable means that the resident did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following: evaluate the resident's clinical condition and nutritional risk factors; define and implement interventions that are consistent with resident needs, resident goals and recognized standard of practice; monitor and evaluate the impact of the interventions/ or revise the interventions as appropriate. ' 1. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following Progressive Supranuclear Ophthalmoplegia [Steel-[NAME]-[NAME]] (a rare brain disease that affects walking, balance and eye movements and swallowing), Gastrostomy Status, Dysphagia, Crohn's Disease, and Parkinson's Disease. Review of the Minimum Data Set (MDS) assessment for Resident #90 dated 09/07/24 documented in Section C, a Brief Interview of Mental Status (BIMS) score could not be conducted due to the resident is rarely / never understood. Review of the Physician's Orders for Resident #90 revealed an order dated 08/27/24 for Enteral Feed Order two times a day Give Osmolite 1.5 (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hours [hrs]) Give H20 (water) Flush (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm and was discontinued on 09/21/24. Review of the Physician's Orders for Resident #90 revealed an order dated 09/22/24 for Enteral Feed Order one time a day give Osmolite 1.5/1000ml @ @50ml/hour. Give H20 Flush/1000ml @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm and was discontinued on 09/26/24. Review of the Physician's Orders for Resident #90 revealed an order dated 09/27/24 for Enteral Feed Order one time a day via Gtube give Osmolite 1.5/1000ml @62ml/hr. give H20 flush/500ml @31ml/hr. Start at 5pm and run until complete (~16hrs) Total kcal 1500, Total Pro 62.7gm. See additional H20 flush order. Total Kcal 1500, Total Pro 62.7, Total Fluid 1620ml - and was discontinued on 09/30/24. Review of the Physician's Orders for Resident #90 revealed an order dated 09/30/24 for Enteral Feed Order one time a day via Gtube give Osmolite 1.5/1000ml @62ml/hr. give H20 flush/500ml @62ml/hr. Start at 5pm and run until complete *See additional H20 flush order. Total Kcal 1500, Total Pro 62.7, Total Fluid 1620ml. Review of the weights for Resident #90 revealed the following: On 08/27/24 at 10:25 AM, the resident weighed 92.0 # (pounds) via Mechanical Lift. On 09/05/24 at 9:54 AM, the resident weighed 82.0 # via Standing. On 09/27/24 at 4:35 PM, the resident weighed 83.0 # via Standing. In summary, this indicated from 08/27/24 to 09/05/27, the resident lost 10#, which is a significant weight loss of 10.87%. On 10/01/24 at 10:15 AM, Resident #90 was weighed by Staff J, Restorative Aide, with the Director of Nursing and the surveyor present, and the resident weighed 77.6 pounds. If initial weight of 92 pounds is accurate, this would have indicated the resident had a weight loss of 14.4 pounds from 08/27/24 to 10/01/24 and was a significant weight loss of 15.65%. If initial weight was 82 pounds, as noted by the spouse and RD (Registered Dietician), this would have indicated the resident had a weight loss of 4.4 pounds , which is a weight loss of 5.3%. Review of the Nutrition Risk Assessment for Resident #90 dated 08/26/24 included the following in part: Continuous feeding - Osmolite 1.5 (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hours) give H20 Flush (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total feeding - Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm, Free water 1762ml. Estimated Nutritional Needs (Kcal/kg): 42 x 35-40= 1470 - 1680; Protein: 42 x 1.2 - 1.3 = 50-55: MDS Triggers BMI <18.5 or >/= 24.9. Care plan resident will gain 1-21 lbs/month by nrd (next review date). Review of the Nutrition / Dietary Note for Resident #90 dated 09/05/24 included the following: Resident's care plan meeting today with resident's husband, MDS nurse, Therapy director and this RD. Tube feeding regimen reviewed with resident's husband. Resident has been tolerating tube feeding. He is in agreement with poc [plan of care] regarding tube feeding at this time. Weight gain desired as husband stated that the resident has lost weight prior to admission. Current tube feeding will provide enough calories for gradual weight gain. F/U [follow-up] for weekly weight x 3. Adjust poc as needed. Review of the Nutrition / Dietary Note for Resident #90 dated 09/09/24 included the following: Resident's weight on 9/5/24 was 82lbs. Admit weight recorded as 92lbs. Resident is NPO on tube feeding which is providing adequate nutrition / hydrations. F/U with resident's husband who stated she is definitely not 92. He stated that she was 78 in the hospital and that he observed her being weighed in this facility on standing scale at 82lbs. 92 lbs may have been an error in recording the weight. Will request reweigh as gradual weight gain is desired. Current estimated needs = 37 x 35-40 = 1295-1480 calories/day, 37 x 1.2 -1.3 = 44-48 gm protein /day, 37 x 30-35 = 1110-1295 ml fluid. F/U for reweigh. Per nursing resident is tolerating tube feeding well. Adjust poc as needed. Review of the Nutrition / Dietary Note for Resident #90 dated 09/26/24 included the following: Resident's tube feeding to be adjusted. Recommend changing to Osmolite 1.5/1000ml @ 62ml/hour via G Tube. Start at 5pm and run until complete (~16 hrs) H2O flush/1000ml @ 31ml/hour via G tube with total of 500ml H20. Start at 5pm and run ~16 hrs. Tube feeding will provide 1500 kcal, 62.7 gm protein, 1262 free H20. Recommend H20 flush 120ml once daily via G tube. Total free water 1382ml Weight 82lbs. Tube feeding provides 40 kcal/kg, 1.6 gm/kg protein, Total free water 37ml/kg. F/U for tolerance/weight/changes. Adjust POC as needed. On 10/01/24 at 10:00 AM, an observation was made of Resident # 90 lying in bed asleep with no tube feeding hung or infusing. On 09/30/24 11:35 AM, an observation was made of Resident #90 lying in bed with the tube feeding Osmolite 1.5 (formulary type) at 350 mark out of 1,000 milliliter capacity bottle. The tube feeding bottle was labeled with a start date of 09/29/24 at 6:00 PM, infusing at 62 milliliters per hour. On 10/01/24 at 4:23 PM, an observation was made of Resident #90 lying in bed with Osmolyte 1.5 (formulary type) tube feeding connected to the resident with tube feeding just above the 1,000 mark out of a 1,000-milliliter capacity bottle and infusing at 62 milliliters per hour via pump. The tube feeding bottle is labeled with a start date of 10/01/24 at 4:00 PM. On 10/02/24 at 8:45 AM, an observation was made of Resident #90 sitting up in bed with bottle Osmolite 1.5 tube feeding at the 200 mark out of a 1,000-milliliter capacity bottle. The tube feeding was infusing via pump at 62 milliliters per hour. The tube feeding bottle was labeled with start date of 10/01/24 at 4:00 PM. On 10/02/24 at 10:31 AM, an observation was made of Resident #90 sitting up in bed with bottle Osmolite 1.5 tube feeding below the 200 mark out of a 1,000-milliliter capacity bottle. The tube feeding was infusing via pump at 62 milliliters per hour. The tube feeding bottle was labeled with start date of 10/01/24 at 4:00 PM. An interview was conducted on 10/01/24 at 12:12 PM with the husband of Resident # 90 who stated his wife's normal body weight was 135 pounds. The last time she weighed her normal body weight was in March. He said this disease is terrible and now she cannot swallow so she has to be on tube feeding. He said they had some kind of meeting when his wife first arrived at the facility just over a month ago. He expressed his concern over his wife's weight and does not want her to lose any more weight and hopes she can gain weight. He said during that meeting was the only time he talked to the dietician, and they told him they would adjust the tube feeding as they went along. He stated he was never told she had any weight loss since being in the facility. He was under the impression she would have gained weight, but nobody really talks to him or answers question when he asks. He said he comes to the facility just about every day and he sees the tube feeding bottle off and still has about 3 inches of tube feeding left in it and they throw it away and start a new bottle later. He feels she may not be getting all of the tube feeding she is supposed to for this reason. An interview was conducted on 10/01/24 at 10:30 AM with Staff J, Restorative Aide, who stated she has worked at the facility for just over 1 year and has been the Restorative Aide for about 1 year. She said she is the one to do the weights for residents unless she is not scheduled to work, then other staff fill in to do the weights. She said she gets a list of the newly admitted residents and will do admission weights weekly for 4 weeks then monthly unless the dietician instructs her otherwise. She then gives the list of residents with their weights to the dietician once she obtains them and the dietician puts the weights into the resident's medical record. She added sometimes the dietician will asks her to reweigh the residents and she gives the dietician the reweight to enter into the resident's medical record. When asked about the scales she said there is 2 mechanical lifts, one for the second floor and one for the third floor and they have a standing scale that can also accommodate a wheelchair, and that scale is located on the first floor. She said the scales are maintained by maintenance and have just been serviced before she returned from a leave on 08/19/24. When asked about the process for weighing residents with a scale, she said she zeros out the scale the resident is to be weighed on then weighs the resident; if the resident is weighed on the mechanical lift, she will then take the sling used for the resident and weigh it immediately after weighing the resident and subtract the weight of the sling from the weight of the resident and that net weight is what she submits to the dietician. An interview was conducted on 10/03/24 at 11:18 AM with the Registered Dietician (RD) who stated she has worked at the facility for [AGE] years and has been full time since June 2024. When asked what would constitute a significant weight loss she said, a weight loss of 5% or greater in 1 month, or 7.5% or greater in 3 months, or 10% or greater in 6 months. When asked how often residents are weighed, she said they are weighed on admission by someone from nursing department who will enter the admission weight for the resident. They do not take the weight from the hospital. The resident is weighed on admission, then the Restorative Aide will weigh the resident within next 3 days. Then the resident will be weighed weekly x 4 weeks, then evaluated for what the frequency will be based on any trend and usually will monthly thereafter. When asked about residents who receive tube feedings, she said she would generally not expect to see weight loss. She stated she ensures tube feeding orders are followed by doing rounds to spot check the resident to make sure the tube feeding orders are followed as ordered. When asked about the estimated needs for Resident #90, she said on 08/26/24 according to her calorie and protein the estimated needs of the resident were 1470 -1680 calories per day and 50-55 grams protein per day. When asked what was prescribed for the resident at that time, she said it was 1500 calories per day and 62.7 grams of protein per day (this was on the lower end of the estimated calories per day). When asked about Resident #90's weight, she said the resident weighed 92 pounds on admission to the facility on [DATE]. When asked if she put any interventions in place to address the significant weight loss of 10% in only 9 days, she said no because on 09/09/24 she spoke to the husband who stated his wife was not 92 pounds, she was 82 pounds, and he had witnessed her being weighed on a standing scale. The resident's husband stated his wife had weighed 78 pounds in the hospital and there was no way she could have weighed 92 pounds. She added that on 09/05/24, they had a IDT meeting, and she did not change the tube feeding orders because the tube feeding was meeting the resident needs. When asked if she thought the tube feeding was meeting the resident's needs even when the resident had an unexpected / unanticipated and undesirable significant weight loss of 10 pounds (10%) in less only 9 days, she said even though she had a 10% weight loss after her conversation with the resident's husband he reported her weight from the hospital was 78 pounds and she definitely could not have been 92 pounds because he had observed her being weighed on the standing scale at 82 pounds. The RD then acknowledged the resident's next weight was on 09/21/24 and she was 82 pounds. On 09/27/24 she was 83 pounds, which she acknowledged was a significant weight loss of 9% if you base it on the facility admission weight, but she was basing weight loss on what the husband had informed her was 82 pounds that he saw his wife being weighed on the standing scale. The RD insisted she did not change the tube feeding orders because she felt it was meeting her needs and was actually above her needs. When asked about the witnessed weight on 10/01/24 of 77.6 pounds, she insisted there was no need to adjust the tube feeding because the current tube feeding was above her needs. The RD stated on 10/02/24 she weighed the resident again on the standing scale and she weighed 79.6 pounds which still was a significant weight loss of 13% (12.4 pounds) based on the facility admission weight of 92 pounds but she still did not adjust or change the tube feeding because she was going by what the husband had told her was a weight of 82 pounds he had seen on the standing scale in the facility. She discussed the weight loss and tube feeding with the resident's husband, and he said his wife conveyed to him that she was feeling a little hungry and asked the nurse to start the tube feeding about an hour early. The husband informed her he was going to move his wife to an Assisted Living Facility (ALF), and she needed to be on bolus feeding to be admitted to ALF. The RD said the order for the tube feeding will be the same formulary and was to be 1 carton (355 calories per carton/14.9 grams of protein per carton) and she would receive 5 cartons per day starting in the evening around 4:00 PM on 10/03/24. When asked what the total calories and protein was for the day the resident would be receiving while on the 5 cartons a day, she said it would be 1775 calories per day and 74 grams of protein per day. When asked if the resident had any issue with tolerating the tube feeding, she said the resident has had no issue with tolerating the tube feeding since admission. When asked if she addressed the significant weight loss, she said no. When asked if she updated the care plan for the significant weight loss, she said unfortunately no. 38893 2. Record review revealed Resident #199 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, an admission MDS, dated [DATE], documented Resident #199 had a BIMS score of 04, indicating Resident #199 was severely cognitively impaired. The MDS documented Resident #199 was dependent upon staff for all activities of daily living (ADLs). Resident #199's diagnoses at the time of the assessment included: Anemia, Hypertension, Obstructive uropathy, Non-Alzheimer's dementia, Seizure disorder, Malnutrition, Gastrostomy malfunction, Guillain-Barre syndrome, Metabolic encephalopathy, Dysphagia following cerebral infarction, Speech/Language deficits following cerebral infarction, Sarcoidosis, and Pressure ulcer of sacral region stage 2. Resident #199's orders included: On 09/23/24 with a start date of 09/24/24 for, Enteral Feed Glucerna 1.2/1500ml at 83ml/hr (milliliters per hour). On 09/19/24, Head of Bed (HOB) elevated at 30-45 degrees while tube feed is running. On 10/02/24 at 7:20 AM, Resident #199 was observed in bed with the supplement being provided via an enteral pump. During the observation, Resident #199 was noted to be laying in a nearly supine position. When the concern was brought to the attention of Staff G, LPN, and Staff H, Staff H confirmed that Resident #199 was not positioned properly. Staff G stated, she should be at 45 degrees.

Based on observations, interviews, and record review, the facility failed to ensure residents with a Post-Traumatic Stress Disorder (PTSD) received trauma-informed care in accordance with professional standards of practice and failed to account for the resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 sampled resident reviewed for PTSD, Resident #70. The findings included: Review of the facility's policy, titled, Trauma-Informed and Culturally Competent Care, dated 05/19/23, included the following purpose: To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Resident Screening 1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. 3. Screening may include information such as: a. Trauma history, including type, severity and duration; b. Depression, trauma-related or dissociative symptoms; f. historical mental health diagnosis Resident Assessment 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. 2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. Record review for Resident #70 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Malignant Neoplasm of Endometrium, Bipolar Disorder, Psychosis Not Due to a Substance or Known Physiological Condition, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of section I revealed Resident #70 diagnosis included: Bipolar Disorder, Psychotic Disorder, Depression, Post-Traumatic Stress Disorder (PTSD), and anxiety disorder. Review of the Physician's Orders showed that Resident #70 had an order dated 05/23/24 which included: [NAME] psychology to evaluate and treat as needed. An interview was conducted on 10/02/24 at 1:43 PM with DON. He acknowledged that Resident #70 has not been seen by a psychologist since she was admitted in 05/15/24. An interview was conducted on 10/02/24 at 4:48 PM with Resident #70. She stated she was seeing a psychologist before she was admitted to the facility because of her diagnosis of bipolar disorder and depression. Resident #70 stated she would like to be seen by the psychologist. She does not recall being monitored for any behaviors. An interview was conducted on 10/02/24 at 4:59 PM with the Social Services Director (SSD). She stated the resident's diagnosis are derived from the hospital documentation when the resident is transferred to the facility, and the physician would be the one to diagnose the resident with PTSD. She acknowledged not questioning Resident #70 about her PTSD since the resident had no change in mood and did not express any sign of PTSD. The SSD acknowledged that Resident #70 should have had a psychology evaluation upon admission due to her psychological diagnosis including PTSD. She stated she was unable to find any psychology consultation at all for Resident #70.

Based on observations, interviews and record reviews, the facility failed to obtain orders for bed rails, failed to develop and implement a care plan for bed rails, and failed to regularly inspect rails for fit and function for 2 of 2 sampled residents reviewed for bed rails, Residents #197 and #199 The findings included: Review of the facility policy, titled, Bed Safety and Bed Rails, with a revision date of August, 2022, documented, in part: Facility Statement: The use of bed rails is prohibited unless the criteria for use of bd rails have been met. Policy Interpretation and Implementation 2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping havits and bed environment 6. Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. 7. the maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection result and QAPI committee recommendations are maintained by the administrator and/or safety committee. Use of Bed Rails 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment and informed consent. 4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards b. foam bumpers c. lowering the bed d. use of concave mattresses to reduce rolling off the bed 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails b. The residents' risks from the use of bed rails and how these will be mitigated c. The alternatives that were attempted but failed to meet the residents' needs d. The alternatives that were considered but not attempted and the reasons. 1. Record review revealed Resident #197 was admitted to the facility on [DATE]. Review of the resident's most recent full Minimum Data Set (MDS) assessment, a Medicare 5-day MDS, dated [DATE], dcoumented Resident #197 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The assessment documented Resident #197 required partial / moderate assist for bed mobility and transfer and ambulated independently with use of a manual wheelchair (w/c). The resident was observed walking behind a w/c on multiple occasions during the 4-day survey. Resident #197's diagnoses at the time of the assessment included: Hypertension, Depression, and Chronic Lung Disease. Review of Resident #197's medical records revealed that there were no orders for bedrails and no care plan for the use of the rails. During an interview, on 10/01/24 at 12:50 PM, with Resident #197, it was noted that the resident had bilateral rails in a raised position from the head of the bed to approximately the middle of the bed. When asked about the bed rails, Resident #197 replied, I don't use them, they just put them here. During an interview, on 10/03/24 at 10:51 AM, with the Therapy Director and the Occupational Therapist, when asked about the use of bedrails for Resident #197, the Occupational Therapist replied, he is high-functioning, I see them working with safety orientation and things like that. The Therapy Director stated, we do the bedrail assessments, the nurse does the order for the bedrails, we recommended that he have them. 2. Record review revealed Resident #199 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, an admission MDS, dated [DATE], documented Resident #199 had a BIMS score of 04, indicating that Resident #199 was severely cognitively impaired. The MDS documented Resident #199 was dependent on staff for all activities of daily living (ADLs). Resident #199's diagnoses at the time of the assessment included: Anemia, Hypertension, Obstructive Uropathy, Non-Alzheimer's dementia, Seizure Disorder, Malnutrition, Gastrostomy Malfunction, Guillain-Barre Syndrome, Metabolic Encephalopathy, Dysphagia, Speech / Language deficits, Sarcoidosis, and Pressure Ulcer of sacral region Stage 2. Resident #199 was not interviewable. Review of Resident #199's medical records revealed that there were no orders and no care plan for the use of bedrails. An interview was conducted on 10/01/24 at 10:44 AM with Resident #199's family member. Resident #199 was observed in bed with a supplement being provided via an enteral pump. It was noted the resident had bilateral siderails, from the head of the bed to approximately the middle of the bed. When asked about the benefit of the use of the bed rails for Resident #199, the family member stated the resident would not be able to use them as the resident did not have enough upper body mobility to grab and hold onto the rails. On 10/02/24 at 7:20 AM, Resident #199 was observed in bed with a supplement being provided via an enteral pump. During the observation, it was noted that the resident had bilateral siderails from the head of the bed to approximately the middle of the bed in a raised position. Review of the Siderail / Bedrail Review (assessment), dated 09/15/24, documented: Recommendations - none. Side rails are not indicated at this time. An interview was conducted on 10/03/24 at 10:51 AM with the Therapy Director and the Occupational Therapist (OT). When asked about the use of bedrails for Resident #199, the OT provided documentation of recommendation for the resident to not have rails. The OT stated, the concern would be that the resident could get caught in the rails by involuntary movement. The OT stated Resident #199 did not have upper body mobility to use the rails or be a benefit from the use of the rails. The OT stated the resident was not at risk for falling from the bed due to the limited mobility. 3. An interview ws conducted on 10/03/24 at 8:39 AM with the Maintenance Director, who when asked about monitoring and inspecting bedrails for fit and function, the Maintenance Director replied, every time someone is discharged , we check the rails to make sure they are not loose and that they fit the bed properly. When asked about inspecting the rails for residents that have not been discharged and are long term, the Maintenance Director replied, quarterly. On 10/03/24 at 11:19 AM, the Maintenance Director reported to the surveyor that there were no audits being done and provided a blank spreadsheet that was to be used to conduct audits of the bed rails.

Based on observations, interviews, and record review, the facility failed to accurately reconcile controlled medications and failed to ensure discontinued controlled medications were removed from the medication cart for 2 of 5 sampled residents reviewed for controlled medications reconciliation, Resident #33 and Resident #41. The findings included: Review of the facility's policy, titled, Controlled Substances, dated November 2022, included the following: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. 14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. 15. The consultant pharmacist or designee routinely monitors controlled substance storage records. Review of the facility's policy, titled, Administering Medications, dated April 2019, included the following: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders 22. The individual administering the medication initials the resident's Medication Administration Records (MAR) on the appropriate line after giving each medication and before administering the next ones. 23 .As required or indicated for a medication, the individual administering the medication records in the resident's medical record. An observation of medication storage and reconciliation of controlled medications was conducted on 10/02/24 at 10:12 AM on the third-floor [NAME] hallway with Staff Q, Licensed Practical Nurse / LPN. 1. Record review for Resident #33 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Unspecified Fracture of Right Femur and Dementia. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated that she was rarely / never understood. Review of the Physician's Orders revealed Resident #33 had an order dated 08/21/23 for Tramadol HCL tablet 50 mg to give 1 tablet by mouth every 6 hours as needed (PRN) for moderate and severe pain. Non-Acute pain. Review of the September Medication Administration Records (MAR) revealed Resident #33 was administered Tramadol 50 mg PRN on the following dates: 09/01/24 at 4:44 PM with a pain level of 5 of 10. 09/04/24 at 3:12 PM with a pain level of 0 of 10. 09/07/24 at 10:50 AM with a pain level of 0 of 10. 09/13/24 at 9:00 AM with a pain level of 5 of 10. 09/16/24 at 8:43 PM with a pain level of 5 of 10. 09/18/24 at 2:58 PM with a pain level of 0 of 10. 09/25/24 at 1:05 PM with a pain level of 0 of 10. 09/25/24 at 8:47 PM with a pain level of 6 of 10. 09/28/24 at 5:40 PM with a pain level of 7 of 10. However, review of the Medication Monitoring / Control Record revealed Resident #33 was administered Tramadol 50 mg PRN on 09/07/24 at 9:00 PM and 09/20/24 at 3:50 PM. 2. Record review for Resident #41 revealed the resident was readmitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus, Immunodeficiency, and End Stage Renal Disease. Review of Section C of the MDS assessment dated [DATE] revealed that Resident #41 had a BIMS score of 07, which indicated that he was severely cognitive impaired. Review of the Physician's Orders showed that Resident #41 had an order dated 04/09/24 for monitor for Pain every shift; and on 04/19/24 an order was added for Tramadol HCL tablet 50 mg to give 1 tablet by mouth every 6 hours as needed (PRN) for pain, with a discontinued date of 09/06/24. Review of the September Medication Administration Records (MAR) revealed Resident #41 was not administered Tramadol 50 mg PRN prior to the discontinued date 09/06/24. In addition, the MAR also revealed on 09/08/24, Resident #41 was monitored for pain reporting a pain level of 0 for every shift. Review of the Medication Monitoring/Control Record revealed Resident #41 was administered Tramadol 50 mg PRN on 09/08/24 at 0100 [AM]. An interview was conducted on 10/03/24 at 2:20 PM with Staff R, Registered Nurse (RN), who stated he has been working at the facility for 7 months. He stated if a resident requests pain medication, such as Tramadol, he would conduct a pain assessment and check physician's orders for pain medication. Staff R stated if there's no order for pain medication, he would contact the doctor for an order and administer the medication. He then will document almost at the same time in the MAR and in the Medication Monitoring/Control Record. An interview was conducted on 10/03/24 at 3:59 PM with the Director of Nursing (DON). He stated that per protocol the nurse will check physician's orders for the controlled medication and document when administered in the MAR and in the Medication Monitoring/Control Record. The DON was asked about a policy for reconciliation of controlled medications and was not sure if a policy existed. He stated the nurses do counts of the controlled medications on every change of shift with the incoming nurse. The DON stated as per protocol the count of the controlled medications in the medication cart drawer is compared to the number in the Medication Monitoring / Control Record, and this is done every shift. When asked if any unit manager/DON randomly conducts periotic reconciliation of controlled medications, he stated, no.

Based on observations, interviews, and record review, the facility failed to adequately monitor for side effects and behaviors for resident receiving antipsychotic medication and the consultant pharmacist failed to recommend the monitoring for side effects and behaviors for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #70). The findings included: Record review for Resident #70 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Malignant Neoplasm of Endometrium, Bipolar Disorder, Psychosis Not Due to a Substance or Known Physiological Condition, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that she was cognitively intact. Review of section I revealed Resident #70 diagnosis included: Bipolar Disorder, Psychotic Disorder, Depression, PTSD, and anxiety disorder. Review of Section N revealed that Resident #70 was on antipsychotic, antidepressant, and anticoagulant. Review of the Physician's Orders revealed that Resident #70 had an order dated 05/16/24 which included: Aripiprazole tablet 2 mg, give 1 tablet by mouth one time a day for psychosis. There was no evidence of a physician's order for monitoring side effects and behaviors for antipsychotic medication such as Aripiprazole. Review of the Care Plan dated 08/12/24 documented Resident #70 uses psychotropic medications to r/t [related to] Bipolar, Psychoses, and Anxiety. Goals included: resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation / impaction or cognitive/behavioral impairment through next review date; and the resident will reduce the use of psychoactive medication through the review date. Interventions were to: Administer medications as ordered and to monitor/document for side effects and effectiveness. Review of the September Medical Administration Record (MAR) revealed no documentation that Resident #70 was monitored for behaviors and side effects for the antipsychotic medication, Aripiprazole. Review of the medication Regimen Reviews performed by the consultant pharmacist since the admission of Resident #70 (May-September 2024) reported no recommendations for monitoring of behaviors or side effects for the antipsychotic medication, Aripiprazole. An interview was conducted on 10/02/24 at 12:47 PM with the consultant Pharmacist. She stated Resident #70 should have been monitored for behaviors and side effects since she is taking an antipsychotic medication. She acknowledged no behavior or side effect monitoring orders from the physician or psychologist for Resident #70. An interview was conducted on 10/02/24 at 1:31 PM with the Staff O, MDS Coordinator. She stated that she was unable to find any psychology notes or orders for monitoring behaviors for Resident #70. However, she acknowledged Resident #70 is on antipsychotic medications and should be monitored for behavior and side effects. An interview was conducted on 10/02/24 at 1:43 PM with Director of Nursing (DON). He stated he was unable to find the order for behavior monitoring for Resident #70's or monitoring for side effects for the antipsychotic medication. He also acknowledged that Resident #70 has not been seen by a psychologist since she was admitted in May 2024. An interview was conducted on 10/02/24 at 4:48 PM with Resident #70. She stated she has never been asked about her behavior or side effects of medications. An interview was conducted on 10/02/24 at 4:59 PM with the Social Services Director (SSD). She acknowledged that Resident #70 should be monitored for behavior due to her medications. She mentioned that she was unable to find any psychology consultation at all for Resident #70. The SSD stated she does not know why Resident #70 was not followed by psychology.

Based on observations, interview and record review, the facility failed to ensure medications were stored securely for 1 of 4 sampled residents observed for medication administration, Resident #246, and 1 of 25 sampled residents, Resident #8. The findings included: Review of the facility's policy, titled, Medication labeling and Storage, with a published date of 08/06/24, included, in part, the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1. Record review for Resident #246 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on 08/19/24. The resident's diagnoses included, in part, the following: Cerebral Infarction Unspecified, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Immunodeficiency, Other Idiopathic Peripheral Autonomic Neuropathy, Other Speech and Language Deficits Following Cerebral Infarction, and Type 2 Diabetes Mellitus with other Specified Complication. Review of the Minimum Data Set (MDS) for Resident #246 dated 09/19/24 documented in Section C a Brief Interview of Mental Status score of 12, indicating moderate cognitive impairment. Review of the Physician's Order for Resident #246 revealed an order dated 09/23/24 for Voltaren Arthritis Pain External Gel 1 % (Diclofenac Sodium (Topical). Apply to right knee topically two times a day for arthritis pain Apply 4 grams. Review of the Physician's Order for Resident #246 revealed an order dated order dated 08/19/24 for Gabapentin Capsule 300 MG give 1 capsule by mouth three times a day for Neuropathic Pain. During an observation of a medication pass conducted on 10/01/24 at 4:30 PM with Staff A, Registered Nurse (RN), for Resident #246, Staff A brought the following medications into the resident's room to be administered: Carvedilol 12.5mg tab, Buspirone hcl 5mg tab, Metformin 1,000mg tab, Elder tonic 15milliliters, Magnesium Oxide 400mg tab, and Diclofenac sodium (Voltaren Arthritis) topical gel 1%. Staff A then placed all of the medications on the resident's overbed table, next to him and went into the resident's bathroom (out of sight of the medications) to wash her hands, she then proceeded to administer the medications to the resident. After Staff A administered the medications, she left the Diclofenac Sodium topical gel 1% on the overbed table, next to the resident, and entered the resident's bathroom a second time leaving the medication out of her sight, while she went into the bathroom to remove gloves and wash her hands. An interview was conducted on 10/01/24 at 4:50 PM with Staff A who stated she has worked at the facility for about 1 month. When asked about leaving the medication at the bedside next to the resident and out of her sight to wash her hands in the resident's bathroom, she said she should not have left the medications unattended. 2. On 09/30/24 at 12:19 PM, an observation was made of Resident #8 lying in bed with the overbed table in front of her. It was noted that on the overbed table was Systene Complete PF eye drops. On 10/01/24 at 10:15 AM, a second observation was made of Resident #8 lying in bed with overbed table in front of her. It was noted that on the overbed table was Systene Complete PF eye drops, still in plain sight. An interview was conducted on 10/01/24 at 10:15 AM with Resident #8 who was asked about the eye drops, she said she uses them every night for her dry eyes. An interview was conducted on 10/01/24 at 10:30 AM with Staff B Registered Nurse / Unit Manager (RN/UM) who was asked about medications (meds) at the bedside, she said residents should not have meds at the bedside. During a side-by-side observation with the RN/UM of Resident #8 with the Systene Complete eye drops on the overbed table, she acknowledged the resident should not have those and they needed a doctor's order. She then informed the resident she could not have the eye drops at the bedside and removed them.

Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from mental and physical abuse by staff for 3 of 3 cognitively impaired residents, Resident #1, #2, and #3. The residents who remained at the facility, Resident #2 and Resident#3, were unable to provide information regarding the events due to their cognition levels. Resident #1 has since passed away due to unrelated causes, per family interview. Based upon the video surveillance of the incident, a reasonable person would conclude the residents suffered physical and/or mental harm. The findings included: The facility's policy, titled, Identifying Types of Abuse (revised September 2020) had a section with the heading Policy Interpretation and Implementation. The following items pertain to the findings: 1. Abuse of any kind against residents is strictly prohibited. 4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. c. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Under the heading Physical Abuse the following apply: 1. Physical Abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. 4. Examples of injuries that could indicate physical abuse include, but are not limited to: d. bite marks, scratches, skin tears, and lacerations with or without bleeding, including those that are in locations that would unlikely result from an accident . Under the heading Mental and Verbal Abuse the following apply: 1. Mental Abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 2. Verbal Abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communications, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. 3. Examples of mental and verbal abuse include but are not limited to: c: yelling or hovering over a resident, with the intent to intimidate. Review of the record for Resident #1, who was admitted on [DATE], had a comprehensive assessment, dated 05/09/24, and was assessed with a Brief Interview for Mental Status (BIMS) score of 00/15, indicating he was severely cognitively impaired. Resident #1's active diagnoses included but were not limited to the following: Atrial Fibrillation (irregular heartbeat), Hypertension (High Blood Pressure), and Anxiety Disorder. Resident #1 was transferred to the hospital, due to an unrelated health issue, on 05/09/24. Resident #1 did not return from the hospital. On 05/08/24 at approximately 8:00 PM, Resident #1 had been brought to the third floor from the second floor because there were no other residents on the second floor who required direct observation during the timeframe that led up to and included the abuse incident. The facility has an initiative to protect residents who have cognitive issues and are at risk of falling. The moving of Resident #1 up to the third floor allowed him to be observed without having to add extra staff. Review of the record for Resident #2, who was admitted on [DATE], had a comprehensive assessment, dated 04/26/24, and was determined to have a BIMS score of 05/15, indicating he was severely cognitively impaired. Resident #2's active diagnoses included but were not limited to the following: Dementia, Parkinson's Disease, and Anxiety Disorder. Review of the record for Resident #3, who was admitted on [DATE], had a comprehensive assessment dated [DATE], and was determined to have a BIMS score 02/15, indicating she was severely cognitively impaired. Resident #3's active diagnoses included but were not limited to the following: Hypertension, Dementia, Anxiety Disorder, and Psychotic Disorder. On 05/20/24 at 10:18 AM, an interview was conducted with the Nursing Home Administrator (NHA), who had reported, via AHCA reporting system, an Abuse incident that occurred on 05/08/24 with Resident #1, #2 and #3. The NHA reported Abuse based upon video surveillance. The NHA explained that she was trying to determine how Resident #1 had gotten a laceration to his forehead, which occurred on 05/08/24 as reported by a Certified Nursing Assistant (CNA), Staff A. The NHA stated Staff A informed the NHA that Resident #1 had been in her care in the third floor dining / activities room on the day of the incident, 05/08/24. The NHA stated Staff A reported that Resident #1 banged his head on a table which caused Resident #1's injury. The NHA stated she was trying to verify the validity of the claim because the type of behavior described for Resident #1 was unusual. The NHA stated she reported the abuse incident within 24 hours of the discovery. The NHA stated she immediately suspended Staff A, who was observed in the video abusing the residents, and had the nurses fully assess the 3 residents for injuries. The NHA stated each resident's doctor and representative was contacted regarding the Abuse. The NHA stated she notified Department of Children and Families and the Sherrif's office, who both came to investigate. The NHA stated she had the Director of Nursing (DON) and Assistant DON (ADON) initiate abuse and neglect training for the entire staff. On 05/20/24 at approximately 10:30 AM, the surveyor viewed the video recording of the incident of 05/08/24. The date and time of the incident began was 05/08/24 at 20:31 (8:31 PM). To capture the appropriate time and sequence of events, the surveyor viewed the events from the time stamp of 20:23 (8:23 PM). The following paragraphs represent the events that occurred on 05/08/24 at the time indicated: At 20:23 (8:23 PM), the video showed Resident #1, #2, and #3 sitting around a table with 2 other residents and a CNA, not Staff A. The residents appeared to be engaged with the CNA. At 20:26, Staff A came into the room and the other CNA was observed taking two residents, one at a time out of the room. The remaining residents, Resident #1, Resident #2, and Resident #3, were left behind with Staff A. Staff A rearranged the tables in the room, putting tables together in the middle of the room. At 20:31 (8:31 PM), Staff A pushed Resident #1 in his wheelchair to the far-right table where Staff A pushed Resident #1 up to the table as close as possible but at an angle. Staff A then readjusted Resident #1 and when she could not adjust the wheelchair to a position she wanted, she pulled the wheelchair back and forcefully tipped the wheelchair up in the front. At this time, Resident #1's legs appeared to strike the underside of the table. The wheelchair was then pushed in as far as it could go with Resident #1 sitting close to the table. Resident #1 attempted to stand, and Staff A grabbed him by the back of his shirt and left shoulder. Staff A violently pushed Resident #1 forward toward the table and then pulled him back in his wheelchair. Resident #1 did not strike his head on the table. At 20:31 (8:31 PM), Resident #2 was noted at a table in the far-left corner of the room from the viewpoint of the camera. Staff A was observed roughly moving Resident #2's left arm back to the armrest of his wheelchair. Resident #2 leaned forward in his wheelchair and appeared to be reaching for something on the floor. Staff A then roughly pushed Resident #2 back into his wheelchair. Staff A then wheeled Resident #2 to the tables in the middle of the room. Staff A pushed Resident #2 as close to the table as physically possible locking the wheelchairs wheels. At 20:33 (8:33PM), Resident #1 attempted to rise from his wheelchair. Staff A was seen violently hitting Resident #1 in the back with her elbow and forearm to control Resident #1 and keep him from standing. Staff A then went and retrieved Resident #3 from the same area Resident #2 had been. Resident #3 was wheeled to the table group and was placed at the table group facing Resident #2. Resident #3 was pushed as close to the table as physically possible. Staff A locked Resident #3's wheelchair. Staff A then walked away from the residents but when Resident #3 attempted to push herself away from the table, Staff A went back to Resident #3 and stopped her from moving and made aggressive hand gestures close to Resident #3's face. Staff A went to a table and chair in the far-right corner of the room and was involved in her own activity instead of trying to engage the residents. The television was playing in the background. At 20:36 (8:36 PM) Resident #1 was seen attempting to stand again, when staff A made threatening gestures which caused Resident #1 to throw up his hands and try to bat Staff A away in a defensive manner. Then Staff A started poking Resident #1 in his arm and toward his face, with enough force to knock his glasses to the floor. After picking up the glasses and placing them on the table, Staff A was seen going to a table or cabinet to get an unidentified item to wipe Resident #1's face. This was done with a swift wipe up Resident#1's face and across his forehead. There was no attempt made to place a bandage and the video did not capture any nurse involvement at this time. On 05/20/24 at 12:18 PM, an interview was conducted with Staff D, CNA. Staff D stated she has [AGE] years on the job at the facility. Staff D stated that the facility had re-education on Abuse and Neglect. She stated the facility explained that the residents are to be treated kindly and with dignity. She stated that the staff must remember that the residents are in the facility because they need care and assistance. The CNA expressed that she reminds herself of this whenever she feels frustrated. She stated she refocuses herself and continues to provide the best care possible. On 05/20/24 at 12:35 PM, an interview was conducted with Staff B, Registered Nurse (RN) and Nursing Supervisor, who stated she was on duty the day the event occurred, but she did not witness the abuse. Staff B performed the first aid for Resident #1. Staff B stated Staff A never showed any signs or tendencies toward abusive behavior. Staff B stated the CNAs usually have between 10-11 residents to care for on the 3PM-11PM shift. Staff B stated that she did not note Staff A as being stressed on the day of the abuse. Staff B stated all staff were provided with education regarding Abuse and Neglect. On 05/20/24 at 2:43 PM, an interview was conducted with Resident #4 regarding treatment by the staff and abuse. Resident #4 had a BIMS of 15, indication cognition was intact. Resident #4 stated she had not experienced any staff that made her feel uncomfortable or that were threatening to her or others, stating she would report it (abuse) to her nurse or other staff immediately. On 05/20/24 at 2:53 PM, an interview was conducted with Staff C, Licensed Practical Nurse (LPN), who stated she had been employed at the facility for [AGE] years. Staff C stated she was very surprised when she was informed who the person was that was alleged to have been abusing residents. Staff C stated the CNA (AP) was usually smiling and friendly with the residents. Staff C stated that if you see someone else who doesn't act right or doesn't look right, you try to help them. Staff C stated if she saw abuse, she would immediately contact the Administrator who is the Abuse Coordinator. On 05/20/24 at 3:20 PM, an interview was conducted with Resident #5, who had a BIMS of 14/15, indicating he was cognitively intact. Resident #5 stated he had not had any issues with staff making him feel threatened. Resident #5 stated he had not heard of any staff threatening residents or witnessed any abuse like behaviors. On 6/14/24 at 9:20 AM, the Administrator confirmed that Staff A was suspended on 5/10/24, pending the outcome of the facility's investigation. Staff A was terminated on 05/13/24. On 06/17/2024 at 3:36 PM an interview with the Nursing Supervisor, Staff B. Staff B confirmed that the wound suffered by Resident #1 was small and did not require emergency intervention. Staff B stated she followed first aid protocol in cleaning and dressing the wound. Staff B stated she was informed by Staff A that Resident #1 struck his head on the table.