Every finding on record at Seaside Health and Rehabilitation Center

Based on observations, interviews and record review, the facility failed to maintain an effective past control program to ensure that the facility was free of pests. This failure affected the facility's kitchen, room [ROOM NUMBER] and the adjoining hallway. The findings include: 1.On 5/11/2026 at 10:50 AM, during the initial kitchen tour, two live insects were observed crawling behind the dishwasher machine near the water drainage pipe. (Photographic evidence obtained) On 5/13/2026 at 11:32 AM, during a follow-up tour of the kitchen, food items were being delivered by the vendor. The facility's back door remained open during the delivery. There was no device in place to help keep pests and flying insects from entering through the doorway into the kitchen. Flies and other flying insects were observed coming in through the open doors. On 5/13/2026 at 11:36 AM, holes were observed in the walls and ceiling near the food serving station. Holes were observed over the frame of the back door. Several potential pest entry points were observed over and behind kitchen equipment and service areas. (Photographic evidence obtained) On 5/13/2026 at 11:54 SM, during an interview with [NAME] D, he stated he had been employed at the facility for about 4-5yrs. There are issues with bugs. There isn't a bug zapper. He said he had never seen a bug zapper since he began working there. Flys and bugs come in through the back door, especially when we get deliveries because they (vendors) keep the door open. We try to keep the door closed and there is a sign to keep the door closed. There are no other procedures to keep them (pests) out; we just have to make sure the door stays closed. Staff are aware of this. On 5/13/2026 at 12:28 PM, a live roach was observed crawling on the metal serving station in the kitchen as food was being plated. (Photographic evidence obtained) There were four kitchen staff members present. The Dietary Director was present and assisting on the tray line by putting the plated meals on the carts for delivery to the nursing units. He used a napkin to grab the crawling roach from the serving station and discarded it into a nearby garbage can. 2. On 5/12/2026 at 10:00 AM, an interview was conducted with several residents in room [ROOM NUMBER] who complained of multiple roaches coming out at night in their room. On the same day at 10:30 AM, a live roach was observed crawling on a picture and went behind the picture in the hallway outside of room [ROOM NUMBER]. A review of the facility's pest control logbooks on 5/14/2026 at 2:45 PM, revealed reports from the Pest Control Provider as follows: 1/2/2026: Treated and inspected all interior areas, common areas, hallways, logbook, and treated room [ROOM NUMBER]. The kitchen was also treated. Need to fix baseboard tiles in kitchen to keep roaches from getting in behind. (Photographic evidence obtained) 2/12/2026: Pest control treated and inspected all common areas, kitchen areas, hallways, and inspected logbook. Rooms treated for roaches were #68, #66, #67, #32 and #40. The rooms need cleaning and sanitized to help with roaches and general pests. 2/20/2026: Pest control provider Inspected logbook and reported room [ROOM NUMBER] and #37 was treated for roaches, along with all common areas including kitchen. A note was included that doorways need grouting in the kitchen and must be fixed and sealed due to retaining water on floor. 4/17/2026: Pest control provider inspected the logbooks. Treated room [ROOM NUMBER] for roaches, and all common areas, dining areas, and kitchen. Broken tiles and baseboards need to be fixed and sealed in the kitchen. 5/12/2026: Baited rooms #64, # 68, # 63, # 62 for ants and roaches. Holes in walls and baseboards need to be fixed and sealed. On 5/14/2026 at 3:20 PM, an interview was conducted with the Maintenance Director and the Administrator. The Maintenance Director stated he had worked in the facility for six years and had two assistants. He reported that logbooks were checked daily the nursing stations. Logbooks were located at all nursing stations. Staff documented maintenance and pest issues and communicated with Maintenance staff. The facility had a long-standing contract with a pest control service who came to the facility twice a month and as needed. He stated there was a problem with gnats and flies, so he asked the pest service provider for recommendations/suggestions. We take the worst room and fix broken coves and baseboards. A contractor was hired for the kitchen who replaced broken tiles by the dish room and grouting was used for loose tiles. Some tiles were replaced in the kitchen 2-3 weeks ago. The Administrator stated he was working with the facility's corporate representatives regarding facility renovations and there was a plan. The renovations were usually done in phases due to expenses. The Administrator stated a roach was coming in the building in front of a surveyor and he killed it. All of the maintenance staff had caulking guns and frequently re-caulked holes, baseboards etc. The Administrator was advised of the observations of multiple places in the kitchen where tile was broken and open areas where pests could enter the facility. The Maintenance Director confirmed the areas observed and mentioned above needed repair.

Based on observations, interviews, record review and a review of the facility's policies and procedures, the facility failed to ensure each resident a dignified experience and self-determination, by failing to ensure adequate communication interventions were available for one (Resident #38) of 30 residents whose care plans were reviewed. This failure contributed to Resident #38's expression of feeling ignored and forgotten by staff. The findings include:On 05/11/2026 at 12:37 PM, an observation of Resident #38's room revealed no communication board, dry erase board, iPad/tablet, or other communication aid present, despite the resident exhibiting difficulty verbally communicating.On 05/11/2026 at 12:37 PM, an interview with Resident #38 revealed he felt staff often could not understand him, making it difficult to communicate his needs. He further stated he felt ignored and forgotten by staff.On 05/13/2026 at 11:30 AM, a follow-up interview with Resident #38 revealed that in the past, he used an iPad tablet to communicate his needs with staff. When he was asked if he still had access to the iPad, he shook his head, no. When he was asked what happened to the iPad, he frustratedly shook his head no and was unable to answer. Resident #38 stated he was unable to write on the dry erase board in his room. A dry erase board was observed on his dresser without a dry erase marker present. (Photographic evidence obtained)On 05/13/2026 at 12:47 PM, a telephone interview with Resident #38's family member/representative revealed he had provided Resident #38 with an iPad mini (tablet device) to communicate with the staff. The family member stated this method of communication with staff was effective because it was difficult for Resident #38 to type on a smaller screen such as his cell phone. The family member stated the iPad worked well because the keyboard was large enough for him to easily type on. He stated Resident #38 had difficulty speaking and was unable to write.On 05/14/2026 at 12:39 PM, during an interview with Licensed Practical Nurse (LPN) C, she stated the resident had a dry erase board in his room. When she was asked if Resident #38 used the dry erase board to write messages to staff, LPN C replied, Well, it could be used for writing.On 5/14/2026 at 12:45 PM, during an interview with LPN A, she stated she was not aware that Resident #38 had an iPad or tablet for communication. She stated Resident #38 had a communication board and a dry erase board available for communication. LPN A stated the communication board contained pictures the resident could point to in order to communicate his needs, and the dry erase board allowed the resident to write messages. On the same day at 1:18 PM, LPN A stated a communication board had been placed in Resident #38's room.A review of Resident #38's medical record revealed an admission date of 09/19/2024 with diagnoses including hemiplegia/hemiparesis following cerebrovascular disease affecting the left non-dominant side, hereditary and idiopathic neuropathy and neurosyphilis (a potentially life-threatening complication of syphilis that occurs when the Treponema pallidum bacterium invades the central nervous system, affecting the brain and spinal cord). A review of Resident #38's Minimum Data Set (MDS) assessment, dated 03/27/2026, revealed he had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition, and required partial to moderate to total assistance with most activities of daily living.A review of Resident #38's active care plan revealed a focus area for Communication Problems related to slow, low-tone speech, which also stated, can type messages on iPad. The goal for this care plan focus area was to maintain the resident's current level of communication through the review date. The interventions included: use alternative communication tools as needed.A review of the facility's policy and procedure titled Resident Rights (issued: 9/2021, revised: 1/2024), revealed:Standard: A facility must . care for a resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.Procedure: Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the residents' right to:a. A dignified existencee. Self-determinationh. Be supported by the facility in exercising his or her rightsee. Retain and use personal possessions to the maximum extent that space and safety permit

Based on observations, record review, interview and a review of the facility's policies and procedures, the facility failed to ensure that a resident who was fed by enteral means received appropriate treatment and services to prevent complications of enteral feeding by failing to ensure that enteral nutrition was administered in accordance with the physician's orders for one (Resident #123) of two residents reviewed for enteral nutrition services from a total of three residents receiving enteral nutrition. Resident #123 was ordered an enteral nutritional formula to be administered at 65 ml per hour and instead was receiving her enteral nutrition at 75 ml per hour. This increases the risk of gastrointestinal discomfort and stomach-emptying delays, which could lead to aspiration pneumonia.The findings include:On 5/12/2026 at 12:04 PM, an observation of Resident #123 revealed that her enteral nutrition bag hanging at bedside was labeled for administration at 75 milliliters (mL) per hour. (Photographic evidence obtained)On 5/13/2026 at 11:25 AM, a follow-up observation of Resident #123 revealed that a new enteral nutrition bag hanging at bedside was labeled for administration at 75 ml per hour. (Photographic evidence obtained)A review of Resident #123's medical record revealed an admission date of 2/21/2017 and diagnoses including anoxic brain damage, gastrostomy status, gastroesophageal reflux disease, and aphasia.A review of Resident #123's active physician's orders revealed an active order for: Enteral feed, three times a day via Percutaneous Endoscopic Gastrostomy (PEG) (feeding tube) Jevity 1.5 @ 65 ml/hr. (milliliters per hour) until total daily volume (1300 ml) is infused. The order had a start date of 4/22/2026 at 1:00 PM. (Photographic evidence obtained)On 5/14/2026 at 11:45 AM, an interview with Licensed Practical Nurse (LPN) C revealed that Resident #123 was nonverbal, received enteral nutrition via a feeding tube, and was totally dependent on staff for activities of daily living (ADL) care. LPN C stated the nurse was responsible for monitoring, setting, administering, and labeling the enteral nutrition for all residents receiving enteral nutrition services. LPN C stated she knew the frequency and the amount of enteral nutrition to administer based on the physician's orders in residents' electronic health record. When she was asked the rate Resident #123 was supposed to receive, she replied, 65 ml per hour. On the same day at 11:55 AM, LPN C was accompanied to the resident's room, where she acknowledged that Resident #123's enteral nutrition was labeled for administration at 75 ml per hour.A review of the facility's policy and procedure titled Physician's Orders (effective: 10/2020, revised 01/2024), revealed:Guideline: Orders and administration of medications and treatments will be consistent with principles of safe and effective order writing.Procedure:9. Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated.

Based on observations, record review, staff interview and a review of the facility's policies and procedures, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for one (Resident #145) of one resident reviewed for respiratory care from a total survey sample of 40 residents. The facility failed to obtain a physician's order for oxygen prior to its administration, and Resident #145's oxygen flow rate was inconsistent with what the physician stated in his 5/8/2026 progress note and what LPN B stated during a 5/13/2026 interview.The findings include:On 5/12/2026 at 10:09 AM, an observation was made of Resident #145 in bed wearing a nasal cannula with oxygen infusing. His oxygen concentrator was set at a flow rate of 2.5 liters per minute (LPM). (Photographic evidence obtained)On 5/13/2026 at 11:33 AM, a follow-up observation was made of Resident #145 in bed wearing his nasal cannula with oxygen infusing . His oxygen concentrator was set at a flow rate of 2.5 LPM. (Photographic evidence obtained)On 5/13/2026 at 2:31 PM, an interview with Licensed Practical Nurse (LPN) B revealed that physician's orders for a resident's oxygen could be found in the resident's electronic medical record (EMR) under the Orders section. LPN B stated Resident #145's oxygen was supposed to be set at a flow rate of 2.0 LPM. When she was asked to verify the physician's order in the resident's EMR, she stated there was no oxygen order in Resident #145's EMR. She confirmed that the resident's physician had spoken to her about Resident #145 and advised her to begin weaning him off of his 2.0 LPM supplemental oxygen. On the same day at 2:53 PM, LPN B was accompanied to Resident #145's room and she verified that the resident was receiving oxygen without a physician's order. On 5/13/2026, a review of Resident #145's medical record revealed an admission date of 10/3/2024 and diagnoses including congenital tracheomalacia (condition present at birth making it difficult to breathe), extrapyramidal and movement disorder (involuntary movement). Further review of Resident #145's record revealed a progress note dated 5/8/2026 at 11:53 PM, which read, Pulmonary medicine was consulted due to recent acute, hypoxic respiratory failure. The patient is being worked up by the primary team for the underlying etiology of respiratory failure. He has had two chest x-rays that were reportedly clear; however, the most recent chest x-ray shows worsening diffuse opacities, concerning for pneumonia versus pulmonary edema (excess fluid in the lungs making it difficult to breathe). His lab workup showed mild leukocytosis (elevated level of white blood cells), as well as mild hypercarbia (abnormally high level of carbon dioxide in the blood). There is suspicion of aspiration (accidental inhalation), and of significance, there is mention of tracheomalacia in his EMR (electronic medical record), although the extent is unclear.The patient was seen and examined lying in bed. He was on 2 L nasal cannula. His upper breath sounds were clear, diminished at the bases. No overt edema appreciated in his lower extremities.The case was discussed with the primary APRN (advanced practice registered nurse). Will follow along closely as well.His last oxygen saturation was 96%. Discussed with the bedside nurse that it is okay to wean off the supplemental O2 as long as his threshold is greater than 92%. After discussing with the nurse, it sounds that the patient is moving in the right direction.A review of Resident #145's physician's orders revealed an active order for oxygen: Respiratory-Oxygen: NC (nasal cannula)/Mask Continuous. Encourage and assist resident to use O2 (oxygen) @ 2 Liters via NC continuously for hypoxia (inadequate oxygen). The start date recorded for this order was 5/14/2026 at 3:00 PM, after the observations of Resident #145 receiving oxygen at 2.5 LPM on 5/12/2026 and 5/13/2026. No orders for oxygen were found in the medical record prior to 5/14/2026.A review of the facility's policy and procedure titled Oxygen Administration (effective: 10/209, revised: 12/2023), revealed:Standard:The purpose of this procedure is to provide guidelines for oxygen administration.Procedure:1.Review the physician's order for oxygen administration.General Guidelines:1.Oxygen is administered . per physician's orders. A review of the facility's policy and procedure titled Physician Orders (effective: 10/2020, revised: 01/2024), revealed:Guideline:Orders and administration of medications and treatments will be consistent with principles of safe and effective order writing.Procedure:1.Medications shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state as soon as practicable.3.Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's electronic chart.5.Verbal orders should be recorded in the resident's chart by the authorized person receiving the order and should include the prescriber's name, credentials, the date and the time of the order.8.Orders for medications should include: a. Name and strength of the drug; b. Number of doses, start and stop date, and/or specific duration of therapy; c. Dosage and frequency of administration; d. Route of administration; e. Clinical condition or symptoms for which the medication is prescribed.

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that a resident who was unable to carry out activities of daily living, received necessary care and services to maintain good grooming and personal hygiene for one (Resident #25) of two residents reviewed for ADL care from 30 residents in the total survey sample. The findings include: On 8/19/24 at 11:44 AM, Resident #25's fingernails were observed to be long and soiled. (Photographic evidence obtained) On 8/21/24 at 3:23 PM, the resident's fingernails were observed to be long and soiled. When he was asked who usually cleaned and trimmed his fingernails, he replied, The girls take care of my nails. (Photographic evidence obtained) A review of the resident's medical record revealed diagnoses including, but not limited to, osteoarthritis, cataracts, major depressive disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the quarterly minimum data set (MDS) assessment, dated 7/30/24, revealed a brief interview for mental status (BIMS) score of 9 out of 15 possible points, indicating moderate cognitive impairment. The resident was also documented as dependent on staff for personal hygiene. A review of the resident's care plan (initiated 3/15/2024, revised 8/2/2024) revealed the following Focus Areas: Resident needs assistance with ADL (activities of daily living) care related to general weakness and impaired mobility. ADL needs and participation vary. Extensive assistance is required for transfers/toileting with increased incontinence noted. Intervention: ADL Care: the resident may need limited assistance x1 or x2 for ADL care. This may fluctuate with weakness, fatigue, and weight bearing status. Impaired visual function related to cataracts, glaucoma. Has had surgery to the right eye but with little improvement to vision. On 8/21/24 at 3:27 PM, an interview was conducted with Certified Nursing Assistant (CNA) F. When she was asked who was responsible for the residents' fingernail care, she replied, We are, the CNAs, it's part of our daily care. She was asked to observe Resident #25's fingernails to determine whether he needed fingernail care. Upon observation of the resident's hands, she stated, Yes he does. On 8/21/24 at 3:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) G. When she was asked who was responsible for providing the residents' fingernail care, she replied, The CNAs do nailcare on the residents' shower days and as needed. A review of the facility's policy titled ADL Care and Services, Quality of Care (issued: 4/2020, revised 1/2024), revealed the following: Guideline: Residents who are unable to carry out activities of daily living independently will recieve the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Procedure: 1. Residents will be provided with care , treatment, and services to ensure that their activities of daily living(ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, nail care and oral care)

Based on observation, interview, and record review, the facility failed to ensure that one (Resident #51) of two residents sampled for respiratory therapy review, from 30 residents in the total survey sample, received oxygen according to their physician's order. The findings include: On 8/19/24 at 11:49 AM, an observation was made of Resident #51 with her oxygen flow rate set at 1.5 liters per minute (L/min). (Photographic evidence obtained) The resident reported that she was not physically capable of adjusting the oxygen concentrator flow rate. On 8/20/24 at 9:49 AM, another observation was made of Resident #51's oxygen concentrator. The oxygen flow rate was set at 1.5 L/min. (Photographic evidence obtained) On 8/21/24 at 3:41 PM, another observation was made of Resident #51's oxygen concentrator. The oxygen flow rate was set at 1.5 L/min. (Photographic evidence obtained) A review of Resident #51's medical record revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), hemiplegia affecting the left non-dominant side, cerebral infarction, epilepsy, schizoaffective disorder, hypertension, depressive disorder, anxiety disorder, and bipolar disorder. A review of the 6/25/24 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. The resident was documented with upper and lower extremity impairment on one side. She was documented with shortness of breath. A quarterly MDS conducted on 3/26/24 documented the same information. A review of Resident #51's care plan revealed Focus Area for [NAME] for Altered Respiratory Status/Difficulty Breathing related to chronic obstructive pulmonary disease (COPD), at risk for respiratory complications, continuous oxygen (O2) via nasal cannula (NC). Date Initiated: 04/02/24. Revision: 06/28/24. The care plan goal documented the resident would maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rat/pattern through the review date. Date Initiated 04/02/24. Revision: 06/27/24. Care plan interventions included the following: Administer oxygen as ordered. Monitor O2 saturations as ordered and as needed. Change tubing per facility protocol/physician order and as needed. Notify physician as indicated. Date Initiated: 04/02/2024. A review of the resident's physician's orders revealed an active order for: Oxygen (O2) at two liters (L) via nasal cannula (NC) continuous, with a start date of 11/10/22. A review of the medication administration record (MAR) for August 2024 revealed O2 2L NC continuous every shift was documented as having been administered according to the physician's order. A review of the facility's policy titled Oxygen Administration (Issued: 10/2019 and Revised 12/2023), revealed: Review the physician's order or facility protocol for oxygen administration and General Guidelines 1: Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device per physician't order. On 8/22/24 at 11:10 AM, an interview was conducted with Certified Nursing Assistant (CNA) A, who reported that she had worked at the facility for eight and a half years. She confirmed that Resident #51 had an order for oxygen at a flow rate of 2 L/min. The standard process for checking residents on oxygen was to conduct a visual check to ensure that the oxygen flow rate was set as ordered by the physician. She also noted that Resident #51 was not physically capable of adjusting the oxygen flow rate herself. On 8/22/24 at 11:44 AM, an interview was conducted with Licensed Practical Nurse (LPN) B, who reported that she was an agency nurse and had worked at the facility for three weeks. Her responsibility for residents' oxygen was to follow the physician's order to ensure the oxygen flow rate was set according to the physician's order. She reported that she checked the liter flow for all of her assigned residents receiving oxygen when she started her shift. If the flow rate was not set correclty, she would check the physician's order to see if the order had changed. LPN B could not recall Resident #51's oxygen order. She checked the electronic medical record for the resident and verified the physician's order for oxygen was for two liters per minute.

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that its residents had a means of directly contacting caregivers for one (Resident #13) of 30 residents in the total survey sample. The call bell must be placed in a way that makes it accessible to the resident while in their bed. The findings include: On 8/19/24 at 11:52 AM, Resident #13 was observed in bed. She was alert to her name and able to express her needs. She complained of left foot pain. She stated she informed the nurse that she was in pain. When she was asked if she knew how to get help if she needed it, she replied, Yes, I have a bell. When she was asked where her call bell was located, she tried to reach for it. It was observed to be out of her reach on the left side of the bed. (Photographic evidence obtained) On 8/21/24 at 10:39 AM, Resident #13 was observed in bed, alert and able to express pain on her left side, especially her left foot and ankle. On a pain scale of 1-10 with 10 being the highest level of pain, she described her pain as 15. She stated, I get pain medication every four hours, but I need something right now. I'm hurting. The resident's call bell was observed on the left side of her bed. She was unable to reach it. (Photographic evidence obtained) A review of Resident #13's medical record revealed diagnoses including hemiplegia/hemiparesis following cerebrovascular disease affecting the left non-dominant side, and contractures of the left elbow, left ankle, left hand, left wrist, and left shoulder. A review of her quarterly minimum data set (MDS) assessment, dated 7/2/2024, revealed she was able to make herself understood, and understand others. She had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. No behavioral concerns were documented, and the resident was dependent on staff assistance for eating, bed mobility, transfers, toileting, and personal hygiene. She was noted as complaining of frequent pain at a level 10 on a scale of 1-10 with 10 being the most severe pain, that occasionally interfered with sleep. She was also noted as receiving hospice services. A review of the resident's care plan (initiated 4/3/2024, revised 7/3/2024) revealed the following Focus Areas: Hospice: admitted to service of [hospice provider name] related to coronary artery disease, CVA (cerebrovascular accident) left side effect. Resident is at risk for general decline. (initiated 9/21/2023, revised 7/3/2024) ADL/Self-Care Deficit: Needs assistance with all ADLs (activities of daily living). Prefers to stay in bed related to chronic pain. Resident has pain and/or is at risk for pain related to old CVA. Under care of [hospice provider name]. Resident presents with chronic pain, neuropathy, hemiplegia with associated pain to left side, pain left leg, ankle, arm. Continues with routine opioid pain medication. A review of the resident's physician's orders revealed that the resident was receiving Furosemide (diuretic) 20 mg (milligrams) by mouth daily (6/08/24 10:39 AM), Baclofen (muscle relaxer) 10 mg by mouth three times daily (1/26/22), Lexapro (antidepressant) 20 mg by mouth daily (1/27/22), Morphine Sulfate (narcotic pain medication) 5 mg by mouth every 4 hours for pain/DC Norco (narcotic pain medication) when morphine sulfate arrives (7/31/0224), DNR (do not resuscitate) (7/19/2028), Under care of [hospice provider name] for a diagnosis of CAD (Coronary Artery Disease) (4/8/2024), Monitor pain every shift (4/29/2017). On 8/21/24 at 10:43 AM, an interview was conducted with Housekeeper C. She was observed conversing with Resident #13. The housekeeper was asked about her conversation with the resident. She stated, She told me she was in pain. She was asked what she usually did when a resident told her that they were in pain. She stated, I tell the nurse. Housekeeper C was observed at the nurses' desk reporting Resident #13's complaint of pain at 10:46 AM. On 8/21/24 at 10:52 AM, Licensed Practical Nurse (LPN) E responded to the resident's complaint of pain. The nurse was asked if Resident #13 was able to use her left arm or hand. She stated, No, she had a stroke and has no use of her left side. The nurse was asked if the resident was able to reach her call light if she needed help. The nurse moved the call light from the left side of the bed where it had been since the surveyor entered the room, and stated, It's usually on her right side so she can use it. A review of the facility's policy titled Call lights, Quality of Care (issued: 03/2018, revised: 01/2024), revealed the following: Standard: Resident will have a call light to summon facility personnel to ensure the resident's needs will be met. Guideline: Resident's call light is to be within reach and answered promptly by the facility personnel.

Based on observation, interview, and record review, the facility failed to ensure that one (Resident #109) of two residents receiving oxygen therapy, from a total of 47 residents in the sample, was administered oxygen at the flow rate ordered by the physician. The findings include: On 8/22/2022 at 11:02 am, Resident #109 was observed lying in bed with his covers pulled to his chest and was receiving oxygen via nasal cannula. He complained that he was not receiving enough oxygen. The resident stated he should receive 3 liters per minute (L/min). The oxygen concentrator located at bedside was observed to be set at 1.5 L/min. (Photographic evidence obtained) A review of Resident #109's physician's order, dated 4/07/2022, revealed he was to receive oxygen at 2 L/min continuously every shift. On 8/23/2022 at 11:58 am, another observation of Resident #109's oxygen concentrator revealed it was set at 1.5 L/min. (Photographic evidence obtained) A medical record review revealed the resident was admitted into the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the August 2022 Medication Administration Record (MAR) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained) Resident #109's vital signs revealed oxygen saturations for August 2022 ranging between 96 to 98 percent for both room air and oxygen via nasal cannula. A review of the quarterly minimum data set (MDS) assessment, dated 7/11/2022, revealed Resident #109 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 points, indicating moderately impaired cognition. The assessment also documented that he was receiving oxygen therapy. A review of the active care plan, dated 4/11/2022, revealed he was at risk for respiratory complications related to obesity, history of respiratory issues, and continuous oxygen via nasal cannula. Interventions included: check oxygen saturation levels as needed, and oxygen as ordered via nasal canula at 2 L/min. A review of Resident #109's vital signs for August 2022, revealed oxygen saturations ranging between 96 to 98 percent for both room air and oxygen via nasal cannula. A review of the medication administration note dated 8/6/2022 at 1:41am, revealed oxygen 2 L/min continuously every shift. Resident using oxygen only when he wants. On 08/25/2022 at 10:00 am, accompanied by Licensed Practical Nurse (LPN) A, observed the oxygen concentrator for Resident #109 set to administer oxygen at 1.5 L/min (Photographic evidence obtained). LPN A confirmed that Resident #109's physician's order was for oxygen at a flow rate of 2 L/min. She stated the resident's oxygen saturation was between 96 to 97 percent and he had no distress. Changes in Resident #109's condition regarding his respiratory care was communicated to the Director of Nursing (DON) and his physician. Correct oxygen settings were communicated from one staff person to another by reviewing the medication administration record and through shift reports. On 08/25/2022 at 11:38 am, the DON confirmed that the correct oxygen settings were identified in the MAR and reviewed on the shift-to-shift report. She stated, We have some residents that play with them. Staff respond by educating the residents on their oxygen therapy. It is the nurse's responsibility to ensure that oxygen therapy is provided as ordered. A review of the facility's policy and procedure for Oxygen Administration (undated), revealed procedures for preparation included: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation and interview, the facility failed to maintain the ice machine in the facility kitchen to prevent the spread of foodborne illness and ensure the safety of the 138 residents that resided at the facility. The findings include: During a tour of the facility kitchen on 2/08/2021 at 11:09 AM, the interior of the ice machine was observed. The metal running across the interior top of the ice machine was covered with spots of a brown substance that ran the length of the metal. There was water condensation on the metal that could drop into the ice below. (Photographic evidence obtained) The Certified Dietary Manager (CDM) was asked at the time of observation if she could wipe the substance off. She obtained a paper towel, wiped the surface of the machine, and the substance transferred to the paper towel. During the interview with the CDM, she stated the maintenance department cleaned the interior of the ice machine once a month and the kitchen staff wiped it each day. .

Based on observations and staff interviews, the facility failed to promote resident dignity by leaving a urinary catheter bag uncovered for one (Resident #85) of three residents observed with urinary catheters, from a total sample of 43 residents. The findings include: During an interview with Resident #85 on 2/8/21 at 2:30 pm, he was observed sitting in his wheelchair in the hallway. A urinary catheter bag was hanging from the underside of the chair. There was urine observed in the tubing and in the bag. There was no privacy cover on the catheter bag. On 2/10/21 at 9:18 am, Resident #85 was observed sitting up in his bed finishing breakfast. His catheter bag was hanging on the side of the bed facing the doorway. There was no privacy cover on the catheter bag. An interview was conducted with Employee C, Certified Nursing Assistant (CNA), at 10:05 am. He confirmed there was no cover on the catheter bag. On 2/11/21 at 9:14 am, Resident #85 was observed sitting up in bed. The catheter bag was hanging at the side of the bed facing out to the hallway. Neither the catheter tubing or the catheter bag had a privacy cover. An interview was conducted on 2/11/21 at 9:24 am with Employee D, Licensed Practical Nurse (LPN), who confirmed there was no cover on the catheter bag.

Based on observations, interviews and record review, the facility failed to implement interventions in a fall risk care plan to ensure appropriate use of restraints for one of one (Resident #70) resident reviewed for restraints in a total sample of 43 residents. The findings include: On 02/08/21 at 11:00 AM, Resident #70 was observed sitting in his wheelchair on the secure unit of the facility. He was observed wearing a cloth-type lap belt that tied behind the wheelchair on both sides and went between his legs. Resident #70 did not respond to questions and spent the majority of time that he was observed looking up toward the ceiling with his eyes both open and closed. Record review for Resident #70 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the 1/11/2021 Quarterly Minimum Data Set (MDS) assessment found that he had a Brief Interview for Mental Status (BIMS) score that could not be assessed. He was severely impaired for decision making. He had short- and long-term memory problems. He required extensive, two-person physical assistance for bed mobility and transfers. He required extensive assistance of one person for eating. Record review of the current physician's orders [REDACTED]. It was to be released for medications, activities of daily living (ADLs), meals and activities. Record review of the fall risk care plan found the 2/11/2020 intervention of slider seat belt when in wheelchair release for meals, ADLs, toileting, and supervised activities. On 2/09/2021 at 2:44 PM, Resident #70 was observed sitting in his wheelchair in the small dining/activity room on the secure unit. The TV was on. Resident #70 had the cloth lap belt on. An interview was conducted at the time of observation with Employee A, the certified nursing assistant (CNA) that was in the room. She stated Resident #70 wore the lap belt at all times except when he went to sleep. She stated she gave him lunch today and she kept the lap belt on. On 2/10/2021 at 11:50 AM, Resident #70 was observed sitting in the dining room on the secure unit waiting for lunch. The restorative nurse (Employee B) was observed placing a food tray in front of Resident #70. A few minutes later, she was observed sitting down next to the resident. She informed Resident #70 it was time to eat and removed his mask. She then began assisting him with the meal. Employee B was asked if the resident's slider belt needed to be removed while he was eating. She stated, I thought someone else had removed it. She was asked if she was aware there were physician's orders [REDACTED].

Based on observations and staff interviews, the facility failed to ensure all emergency drug boxes were kept locked at all times for one of four medication rooms. The facility also failed to ensure there were no expired over-the-counter medications on the medication carts for one of six medication carts. The findings include: An observation of the medication room on Station 3 was conducted on [DATE] at 10:45 am with the Unit Manager (UM). There was a bag of intravenous fluid (IV) 0.9% Sodium Chloride (NaCl) solution 1000 ml (milliliters) found on the counter. The bag did not have a resident's name. The UM was asked if there was a resident currently receiving IV fluids. She said there was a resident that was ordered fluids and IV antibiotics. She stated she assumed the nurse who took the order removed the IV fluid from the IV emergency box. She was asked what date it was removed, and she said she would need to check the Medication Administration Record [REDACTED]. She was asked how the facility documented when medications were removed from the emergency boxes. She provided a log book that contained entries for medications removed from the emergency boxes. She was asked if there was an entry for the removal of the NaCl fluid. She said she could find no entry. Inspection of the IV emergency box found that the box was not locked. The UM verified that the IV box was unlocked and had not been resealed after opening. An inspection of the front hall medication cart on Station #3 was conducted on [DATE] at 11:00 am with Licensed Practical Nurse (LPN) F. During the observation of the over-the-counter medications in the top drawer, an opened bottle of Aspirin 325 mg (milligrams) that expired in [DATE] was found. She immediately removed the bottle.

Based on record review and interviews, the facility failed to ensure routine and 24-hour emergency dental care was provided for one (Resident #107) of two residents reviewed for dental services, from a sample of 43 residents. The findings include: During an interview with Resident #107 on 2/9/2021 at 9:28 AM, he stated, I've been asking to see a dentist for eleven months. I chipped my tooth last month while eating rice and beans. They keep blaming COVID and putting it off. I've asked different people more than once. A tooth on the right upper side of the resident's mouth was observed with a chip in it. Resident #107 was asked whether the chipped tooth was causing him any pain. He stated, Yes, off and on, not constantly. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 1/18/2021, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating the resident was cognitively intact. No oral pain was reported during this assessment reference period. A review of the Annual MDS assessment, dated 4/20/2020, revealed the following documentation under the dental section: Obvious or likely cavity or broken natural teeth? Yes. Inflammed or bleeding gums or loose natural teeth? Yes. Mouth or facial pain, discomfort, or difficulty with chewing? No. Unable to examine? No. A medical record review for Resident #107 revealed a care plan conference sign-in sheet, dated 4/3/2020, was signed as having been attended by the Minimum Data Set (MDS) Nurse, the Social Services Director, Life Enrichment Director and Dietary Manager. There were hand-written notes on the sheet, one of which was concern about teeth. Further review of the medical record revealed a nurse's note written on 4/7/2020 that read, Pt (patient) complains of a rough tooth, appears that a tooth on upper left region of mouth is broken. Dental consult recommended. No evidence of a dental consult was found in the doctor's orders in the resident's chart. A review of the care plans revealed no focus, goal, or interventions related to the resident's dental status. The facility's dental services policy was reviewed: Dental Services Policy (November 2001) Dental services shall be made available to all residents requiring such services. Policy Interpretation and Implementation: 1. Dental services are available to all residents requiring routine and emergency dental care. 2. Social services or designee will be responsible for assisting the resident (and family) in making necessary appointments. 3. All requests for routine and emergency dental services should be directed to the social services department or designee as soon as possible so that adequate arrangements can be made. On 2/10/2021, during an interview with the Social Services Director (SSD), he was asked to explain how dental services worked at the facility. He stated, Yes, we have two dental programs. One works with residents who have liability insurance, and one is for residents who have no dental insurance. We make sure all residents who want dental services can get them. When asked whether dental services were an admission order, or did they need to be requested, the SSD stated, It needs to be requested, it's not an admission order. It was explained to the SSD that no dental orders, dentist notes, referrals, consults or appointments could be found in Resident #107's medical record. When asked whether the SSD could show when the resident had been seen by a dentist in the past 11 months, he stated,I have this roster from (dental provider) that his guardian refused a dental consult. It's not dated, but it's a report for May 19, 2020 thru July 7, 2020. She is no longer his guardian. She was relieved of all guardian duties in the state of Florida. He has a new guardian, and I'll approach him to ask if he wants (Resident #107) re-enrolled in dental services. I'll also talk to (Resident #107) and ask him if he wants to re-enroll in dental services. When asked whether the SSD had any documentation verifying that the resident had a dental appointment at any time during his stay of almost three years, the SSD stated, No, I don't see anything in his chart. I looked at my notes, and I don't have anything written about him having seen a dentist since he's been here. A review of additional documentation submitted by the facility on 2/16/21 regarding Resident #107's dental status revealed the following: 1. A Notice of Declined Dental Services dated 1/27/2020. 2. A 4/7/2020 nurse's note indicated the resident complained about his tooth and a dental consult was recommended. 3. An 8/16/2020 nurse's note indicated the resident had no complaints of pain or discomfort. Nothing specific to oral status/pain was mentioned in the note. 4. A list of resident weights indicated no significant weight loss from April 2019 through Febryuary 2021. 5. A Social Services note dated 2/12/21, after the survey, revealed that the SSD spoke with the resident that day about his dental concerns and arranged a dental appointment for 3/3/21, after speaking with the resident's guardian, whose name was not the same as the guardian documented on 1/27/2020 Notice of Declined Dental Services. 6. Four hand-written statements, dated 2/12/21, after the survey, from two nurses and two other unidentified facility employees indicated Resident #107 had never complained to them of tooth problems or pain. 7. A statement from the Social Services Director, dated 2/15/21, indicated that he spoke with Resident #107 on a regular basis, and the resident made him aware of any concerns he had. The SSD stated the resident never complained about any dental problems. The SSD went on to say that Resident #107 and his guardian had been encouraged to sign up for the facility's dental plan, but the resident and his guardian declined. No date was provided indicating when this conversation occurred. There was no indication that there had been a change in the resident's guardian. After the 1/27/2020 Notice of Declined Dental Services and the change in the resident's guardian, there was no documented evidence that the SSD ever approached either the resident or his new guardian about emergent or routine dental services, even though the SSD stated he spoke with the resident on a regular basis. The resident's previous guardian may have declined services, but the new guardian was not approached until after this survey. The resident was alert and oriented and complained about intermittent oral pain and having asked repeatedly for a dental appointment when he was interviewed on 2/9/2021. The facility must assist residents in obtaining routine and emergent dental services as per the regulation. The facility's policy and procedure supports that. When the SSD was prompted by the surveyor at the time of the survey, he then approached the resident and guardian, dental services were not declined by this guardian or the resident, and the SSD was able to arrange dental services.

Based on observations, record reviews and interviews, the facility failed to ensure a medication error rate of less than 5%, for two (Residents #2 and #3) of four residents observed during medication administration. The facility had 30 opportunities with two errors, resulting in a medication error rate of 6.67%. The findings include: 1. Observation of medication administration was conducted with Employee A, Registered Nurse (RN), on 2/10/2020 at 9:55 AM for Resident #2. Employee A administered the following medications (except she failed to pull the [MEDICATION NAME]): 1) [MED]e 30 cc (cubic centimeters) (Protein supplement) 2) [MEDICATION NAME] (anti-psychotic medication)15 mg (milligrams) 1 tablet 3) [MEDICATION NAME] (diuretic) 2 mg 1 tablet 4) [MED] [MEDICATION]) 25 mg 1 tablet 5) [MED] (blood thinner) 5 mg 1 tablet 6) Potassium (supplement) 20 mEq 1 tablet 7) [MEDICATION NAME] (blood pressure medication) 25 mg - Did not pull medication, signed off as administered 8) [MED] (supplement) 1000 mg 2 tablets Employee A entered the resident's room and handed the pill cup to Resident #2. When Resident #2 was asked how many pills she had in her medication cup, she counted the pills and stated seven. Employee A checked the cup and confirmed there were seven tablets inside. Resident #2 asked the nurse where the little yellow one ([MEDICATION NAME]) was and the nurse stated that they had discontinued that one for now. Resident #2 took the seven pills whole with water. 2. Observation of medication administration was conducted with Employee A on 2/10/2020 at 10:05 AM for Resident #3. Employee A administered the following medications: [REDACTED] 1) [MEDICATION NAME] (depression medication) 20 mg 1 tablet 2) [MEDICATION NAME] (anti-psychotic medication) 25 mg IM - Medication not available, ordered STAT from pharmacy 3) [MEDICATION NAME] (blood pressure medication)20 mg 1 tablet 4) [MEDICATION NAME] 2 puffs (asthma inhaler) Employee A entered the resident's room and handed Resident #3 her medication cup with two pills in it. Resident #3 took the medications whole. The nurse then handed the resident her inhaler and Resident #3 sat there talking incoherently and rocking back and forth. Employee A instructed the resident to take her inhaler and Resident #3 continued to sit there rocking back and forth speaking nonsensically. The nurse asked the resident if she wanted to take her inhaler herself or if she preferred that the nurse help her. Resident #3 stated, I can do it. She took two puffs immediately back to back. Employee A stated, You know you are supposed to wait in between. She then instructed the resident to swish and swallow. Resident #3 took a sip of water and swallowed it. She took a second sip and swallowed. The nurse stated, I meant swish and spit, however the resident continued to drink the water. Employee A placed the inhaler back in the box and placed the box in the left pocket of her scrubs. She left the resident's room and went to the nursing station where she called the pharmacy for the IM (intramuscular) Medication ([MEDICATION NAME]) that was not available. She returned to her cart after pharmacy stated that the medication was being sent over STAT (immediately). Employee A stated, I need to go see what my Unit Manager wants me to do. When she returned, she removed the inhaler from her pocket and placed it back in the cart drawer with all of the other inhalers. An interview was conducted with Employee A on 2/10/20 at 10:40 AM regarding the medication administration for Residents #2 and #3. She confirmed that she had failed to pull the [MEDICATION NAME] 25 mg as ordered for Resident #2. When asked about administering the inhaler for Resident #3, she stated that on some days the resident would do it herself and on other days she would have to administer the medication for the resident. The nurse confirmed that the resident took the doses back to back and stated, Yes, I know she did that is why I reminded her that she needs to wait. She confirmed that the resident did not swish and spit. When Employee A was asked about Resident #3's cognitive level she stated, Actually, I don't know her cognitive level. A review of the clinical record revealed that Resident #3's Minimum Data Set (MDS) assessment had not been completed yet, so her Brief Interview for Mental Status (BI[CONDITION]) score could not be verified. The resident was recently admitted to the facility. Resident #3 had a [DIAGNOSES REDACTED]. Her chart was reviewed for any orders for self-administration of medications and/or any assessments to determine that she was capable of administering medications herself and none were found. A review of the facility's policy and procedure for medication administration revealed the following: Administration of Drugs Policy: Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the center's Medical Director. Policy Interpretation and Implementation 2. Drugs must be administered in accordance with the written orders of the attending physician.

Based on record reviews and interviews, the facility failed to document accurately and appropriately for two (Residents #3 and #6) of three residents reviewed for [MEDICAL CONDITION] screening. The findings include: 1. A record review was conducted for Resident #3 which revealed an admission date of [DATE]. The Medication Administration Record [REDACTED]. The PPD was not administered and a progress note was written indicating the medication was on order. The February 2020 MAR indicated [REDACTED]. It was then documented that the PPD was administered on 2/4/20 twice (0.5 ml (milliliters) at 9:00 AM and 0.1 ml at 5:00 PM). It was then documented that the results were read on [DATE] dayshift and 2/8/20 evening shift. No results were documented, there was only a check mark. A review of the resident's immunization record revealed that step one of the tests was administered on 2/4/2020 and results were pending. 2. A review of Resident #6's record revealed an admission date of [DATE]. The physician's orders [REDACTED]. 2 Step PPD or chest x-ray upon admission and [CONDITION] screening annually thereafter. No time was scheduled for the order. Resident #6's Medication Administration Records for January and Februray 2020 were reviewed revealing the following: January 2020: [MEDICATION NAME] PPD inject 1 dose intradermally (under the skin) one time a day every Wednesday for per protocol until 2/5/20 23:59 document in immunization chart, order date [DATE]. It was documented that the medication was not administered as ordered on [DATE], however, it was documented that the test was read on [DATE]. An interview was conducted with the Director of Nursing (DON) on 2/10/20 at 1:59 PM regarding the documentation related to Resident #3's PPD testing. She confirmed that the medical record was incorrect. She stated she had called and spoken with the nurse, and he stated that he had not administered the PPD. He stated he would strike it out when he arrived at work tonight due to the documentation being incorrect. The EMAR (electronic medication administration record) was reviewed for Resident #6 and the DON confirmed that they had not administered or read the PPD test for him correctly according to the electronic documentation. She stated the facility's policy was for a 2-step to be administered upon admission. They administered the PPD then read it after three days. Then they completed the second step and performed a [MEDICAL CONDITION] assessment annually thereafter. A review of the facility's policy and procedure revealed the following: [MEDICAL CONDITION] Screening - Resident Policy: All residents must comply with our established [MEDICAL CONDITION] screening procedures. Policy Interpretation and Implementation 1. Prior to, or upon admission, residents will be assessed for M. [MEDICAL CONDITION] infection. Should the assessment or medical history reveal no chest x-ray or PPD test has been provided, such test (as appropriate) must be conducted within seventy-two ([AGE]) hours of admission to the Center.

Based on observations and interviews, the facility failed to provide group and/or individual activities to meet the interests of and support the physical, mental and psychosocial well-being of each resident, including Residents #9 and #10. This had the potential to affect all 136 residents residing in the facility. The findings include: A review was conducted of the facility's activity calendar, and it revealed the following activities scheduled for the current day on 9/27/19: 9:00 AM Walk N Roll 10:00 AM Giant Crossword 11:00 AM Move & Groove 1:00 PM Unit Activities 2:00 PM Dart Tournament Observations of activities were conducted on 9/27/19 at 11:15 AM and revealed that two unsampled residents were taken outside for the Walk N Roll, one resident was present in the Giant Crossword, Move and Groove was not completed; however, there were thirteen residents observed in the dining room where the activity was scheduled. They were waiting for lunch. On 9/27/19 at 11:16 AM, interviews were conducted with Residents #9 and #10. They stated they were sitting in the dining room waiting for lunch. When asked about the scheduled activity, they stated the facility never provided the activities according to the calendar. The residents stated the facility wrote the Move and Groove activity on the calendar, but there was no staff to do it. On 9/27/19 at 2:17 PM, an interview was conducted with the Activity Assistant regarding today's activity schedule and the activities that were observed. She stated that there was only one resident in the 10:00 AM Giant Crossword, because the Activities Department had a hard time in the morning with aides getting the residents up for the morning activities, or residents not wanting to get up. She stated she had gotten the resident up and brought him to the activity herself. When asked about the Move and Groove, she stated, That did not get done today, because I am the only one here. When asked about the 2:00 PM scheduled dart tournament, she stated, Oh, I am going to set up for that now.

Based on observations and interviews the facility failed to store and serve food in accordance with professional standards for food service safety. This had the potential to affect all 136 residents residing in the facility. The findings include: An observation of the kitchen was conducted on [DATE], starting at 9:08 AM and the following concerns were identified: Opened and undated mayonnaise, cole slaw dressing, relish, and sweet and sour sauce. Prepared and undated bowls of macaroni salad, cottage cheese fruit plates, and sandwiches. Expired container of ham salad (dated [DATE]), and beef base (dated ,[DATE]). Personal/employee food stored in the refrigerator and microwave. Thawed deli style turkey meat, undated, lying on wet tray with pack of pudding cups. Meat slicer on gray three shelf stand. Stand was noted to have leaves and other outside debris on it. Blue scoop holder (next to ice machine) on the wall had a growth in it. Two scoops were in the holder. Photographic evidence was obtained of all concerns identified above. On [DATE] at 9:17 AM an interview was conducted with Employee E, Dietary Aide and she confirmed the concerns with the expired foods, personal foods being stored with residents foods, and all of the undated foods. She was asked when the macaroni salad was prepared and she was unable to say. On [DATE] at 9:21 AM an interview was conducted with Employee D, Cook, regarding the macaroni salad, and he reviewed the monthly menu and was unable to determine when it was served/prepared. He stated, Looks like last Sunday was when it might have been prepared for an alternate for the potato salad. On [DATE] at 12:51 PM a test tray was observed with the Dietary Manager (DM) and the food temperatures were obtained. All the hot foods were within range; however, the cold peaches were measured at 78 degrees F. On [DATE] at 4:19 p.m. an interview was conducted with the Dietary Manager regarding cleanliness of the kitchen. He stated that he is currently going to make up some assignment sheets to determine who is assigned to clean what on each shift. He was asked about what had happened with the peaches and why they were so warm, and he stated that he was not sure. They had scooped them all up before he had arrived. He confirmed that they were too warm and should not have been served.

Based on observation, interview, Medication Administration Record [REDACTED]& #3) whose medical records were reviewed for accuracy. The findings included: During the tour of the facility on 9/27/2019 at 9:05 AM Employee B, Licensed Practical Nurse (LPN) was observed with two medication cups that had multiple pills dispensed from the original packaging and placed in the top drawer of the medication cart. An interview was conducted with Employee B on 09/27/2019 at 9:15 AM. Employee B, LPN, confirmed the names observed on a handwritten piece of paper included medication that was dispensed by Employee B and was for Resident #2. The medication included crushed medications dispensed for the 9:00 AM medication administration, and Employee B confirmed that she had not provided the medication at 9:00 AM because Resident #2 was not ready at that time. The second dispensed medications were for Resident #3 and had multiple pills dispensed into the medication cup. Both medication cups were observed in the top drawer of the medication cart next to each other. (Photo evidence obtained) An interview was conducted with Resident #2 on 9/27/2019 at 9:15 AM. The resident confirmed that she had just been provided her medication by Employee B, LPN, at 9:15 AM. Physician orders [REDACTED].#2 and documented a 9:00 AM order for [MEDICATION NAME] 2.5 milligram tablet two times a day, [MEDICATION NAME] 20 milligram tablet one time a day, [MEDICATION NAME] 10 mg tablet two times a day and Senna S tablet 8.6-50 milligrams two times a day. A review of the physician order [REDACTED]. A review of the administration audit report for the medications observed in the medication cups at 9:15 AM was conducted and documented that Resident #2 was administered the 9:00 AM medications at 8:33 AM on 9/27/19. A review of the medication administration audit report for Resident #3 documented that Employee B, LPN, administered the observed medications at 8:35 AM on 9/27/2019 to Resident #3. Employee B, LPN, confirmed that the medication was not administered until after it was documented as administered. An interview was conducted with Employee A, Assistant Director of Nursing (ADON), on 9/27/2019 at 4:07 PM and she confirmed that nursing staff should not document medication administered until after the medication was administered. The facility policy and procedure was reviewed and documented at line 7, Drugs must not be set up in advance and that the staff should document administered medications prior to moving to the next resident.

Based on record reviews and interview, the facility failed to provide two (Resident's #288 and #109) of three residents reviewed for Baker Act discharges with bed-hold policies, specifying the duration of the bed-hold policy, at the time of transfer of the resident for hospitalization . The findings include: A record review was conducted for Resident #288 and revealed that he was Baker acted (sent to hospital for behavior evaluation without consent) on (MONTH) 20, (YEAR), and again on (MONTH) 11, (YEAR). Further review of his medical record revealed no indication that the facility had notified the resident's responsible party of the bed-hold policy. The Assistant Director of Nursing at the facility, marked his paperwork Unable to sign. A record review was conducted for Resident #109 and revealed that he was Baker acted on (MONTH) 24, (YEAR). Further review of his medical record revealed no indication that the facility had notified the resident's responsible party of the bed-hold policy. The Assistant Director of Nursing at the facility, marked his paperwork Unable to sign. On 2/7/19 at 2:41 PM, an interview was conducted with the Director of Nursing, and she confirmed that they had not provided and/or sent a bed hold policy to the Baker acted residents' representatives. .

Based on observations, interviews and record reviews, the facility failed to provide health care services which met professional standards of quality by failing to ensure that one (Resident #36) of one resident requiring [MEDICAL TREATMENT], received such services, consistent with professional standards of practice and the resident's person-centered plan of care. Failure to adhere to a prescribed fluid restriction can lead to fluid overload, resulting in high blood pressure, shortness of breath and heart problems. The facility also failed to ensure that one (Resident #136) of four residents receiving oxygen, received the correct number of liters of oxygen ordered by the physician. This could have resulted in oxygen toxicity and death of lung tissue. Finally, the facility failed to appropriately assess pain and provide interventions for pain relief for one (Resident #135) of one sampled resident reviewed for pain management, out of a total facility sample of 49 residents. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. The findings include: 1. A record review was conducted for Resident #36 revealing a [AGE] year-old male, initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was dependent on [MEDICAL TREATMENT], and had a current order for fluid restriction as follows: 960 ml (milliliters) fluid restriction: nursing 7:00 AM - 3:00 PM shift: 120 ml, 3:00 PM -11:00 PM shift: 110 ml, and 11:00 PM -7:00 AM shift: 80 ml. On 2/5/19 at 9:35 AM, Resident #36 was observed to have a white Styrofoam cup with fluids in it at bedside. A second observation on 2/6/19 at 10:14 AM, revealed a white Styrofoam cup of fluids at bedside. (Photographic evidence obtained) On 2/6/19 at 10:14 AM, an interview was conducted with Employee D, Registered Nurse (RN), regarding Resident #36's fluid restriction order. The nurse confirmed the resident was on a fluid restriction, and stated that he was only to receive 960 ml per day. She was asked whether he was compliant with his fluid restriction, and she stated, Yes, he is. He's compliant. When asked where nursing documented the amount of fluids they gave him each shift, she stated, I will write it on my report sheet, or enter it in the progress notes. There is really no place to document it. When asked whether the resident should have a cup of fluids at bedside, she replied, No, he should not have fluids at bedside, but the facility requires everyone to have a cup of water at bedside. On 2/6/19 at 10:17 AM, an interview was conducted with Employee E, Certified Nursing Assistant (CNA), regarding Resident #36 having fluids at bedside. She stated, I am not his usual aide, but I know his normal aide keeps his water cup on his dresser behind his TV. She was asked if it was typical to see a cup of water in his room, and she stated, Yes, because it is 11-7 shift's responsibility to give everyone a cup. On 2/6/19 at 3:40 PM, an interview was conducted with the Assistant Director of Nursing (ADON) regarding Resident #36's fluid restriction order, that she had ordered on [DATE]. She stated the fluid amounts had been changed for the times, but the resident was still getting the same amount of fluids overall. When asked whether nursing was to document how much fluid was given to the resident, she replied, No, we do not document how many CCs (cubic centimeters) anymore. Back in the day we used to have sheets that we would document it on, but we do not do that anymore. When asked whether there was a policy and procedure for fluid restriction, she stated, No, I don't think that we have a policy specific to fluid restriction, but I will ask. When she was shown the policy and procedure previously provided by the facility (this morning), she stated, I don't know. I will have to ask someone. A review of the facility's policy and procedure for fluid restriction revealed the following: Nutritional Services; Nursing Services Procedures 11/27/17 Page 2 of 39 Encouraging and Restricting Fluids Purpose - The Purpose of this procedure is to control the amount of fluids the resident drinks. Key Procedural Points 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate in recording fluid intake. 3. Record fluid intake on the record fluid intake in cc's (cubic centimeters). 4. Be supportive of the resident's fluid intake. Encourage the resident to follow specific instructions. 5. Encourage the resident's family and visitors to stay within the limits of his or her intake. 6. Substitute other liquids (i.e., tea, broth, soda, gelatin, milk, ice cream, etc.) as permitted by the resident's diet. 7. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. 8. Check your daily assignment sheet for any change in the procedure. Page 3 of 39 Steps in the procedure Restricting Fluids 1. Remove the resident's water pitcher and cup from the room. Store in designated area. 2. Take fluid container to resident's room. 3. Knock before entering the resident's room. 4. Identify yourself. 5. Encourage the resident to drink the fluid. Should the resident refuse, report such information to staff/charge nurse. 6. Record the amount of fluid consumed on the record fluid intake in cc's (cubic centimeters). 7. Remove fluid container. According to the National Kidney Foundation at https://www.kidney.org/atoz/content/fluid-overload-[MEDICAL TREATMENT]-patient: Having too much water in your body is called fluid overload or hypervolemia. One of the main functions of the kidneys is to balance fluid in the body. If too much fluid builds up in your body, it can have harmful effects on your health, such as difficulty breathing and swelling. When you are on [MEDICAL TREATMENT], your kidneys are no longer able to keep the right balance of fluid in your body. They cannot remove enough. That ' s why it ' s so important to limit how much sodium (salt) and fluid you have between [MEDICAL TREATMENT] treatments. This helps your body maintain the right amount of fluid, and it makes it easier for your [MEDICAL TREATMENT] treatment to remove extra water. How does fluid overload affect you? Swelling: Swelling in your feet, ankles, wrist, and face is a sign of too much fluid in your body. This is called [MEDICAL CONDITION]. Discomfort: Cramping, headache and abdominal (stomach) bloating can make you feel uncomfortable. High blood pressure: The excess fluid in your blood stream makes it difficult for your body to keep a healthy blood pressure. Shortness of breath: The extra fluid in your body can enter your lungs, making breathing difficult. Heart problems: The extra fluid can affect your heart rate, the muscles of the heart, and may increase the size of your heart. 2. An observation was made of Resident #136 in her room on 2/4/19 at 10:45 AM. She was not wearing her nasal cannula. It was observed on the bed rail, and her oxygen concentrator was set to dispense 3 liters of oxygen. The resident was asleep. An observation was made of Resident #136, lying in bed in her room watching TV, on 2/5/19 at 2:13 PM. She was unable to state how many liters of oxygen she was receiving. She was wearing her nasal cannula and the oxygen concentrator was set at 2.75 liters. An observation was made of Resident #136 on 2/6/19 at 9:11 AM. She was in her room in her bed. She was wearing her nasal cannula, and her oxygen concentrator was set at 2.5-2.75 liters. A medical record review was conducted for Resident #136. The resident was admitted on [DATE] with a re-entry date of 12/22/18. [DIAGNOSES REDACTED]. A review of the (MONTH) 2019 (current) physician's orders [REDACTED]. A review of the policy and procedure for Oxygen Administration (dated (MONTH) (YEAR)) noted under Step #12 in the procedure to Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being administered. A review was of the policy and procedure for Physician order [REDACTED]. An interview was conducted with Employee B, Registered Nurse (RN), on 2/6/19 at 10:51 AM concerning the oxygen rate for Resident #136. Upon entering the resident's room with Employee B, the nurse reported that the oxygen concentrator was set at 2.5 liters. The nurse reviewed the physician's orders [REDACTED]. The nurse returned to resident's room and changed the concentrator setting to 2 liters. 3. An observation was made on 02/06/2019 at 1:57 PM while wound care with multiple dressings was being performed on Resident #135's lower extremities. Resident #135 was observed grimacing, groaning and with garbled speech stated No, while Employee C, Registered Nurse (RN), removed the dressings. Employee C did not stop removing the dressings when the resident began groaning in order to assess the resident's pain level or to offer the resident pain medication. Instead, she told the resident, It's okay and continued removing the old dressings. During the same observation, Employee D, RN, continued to provide wound care to Resident #135's right leg, even while the resident was groaning and reaching down her leg near the wound. Employee D failed to stop providing wound care to assess the resident's pain level and to administer pain medications as needed for pain. A clinical record review was conducted for Resident #135, revealing that she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recently completed minimum data set (MDS) assessment (5-day Admission (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that this resident was unable to participate. Further documentation indicated problems with the resident's short- and long-term memory, recall ability, and she was coded as severely impaired with regard to daily decision-making. Section G revealed the resident required extensive assistance from one staff member for bed mobility, dressing, personal hygiene, toileting and transferring. It was documented that the resident had sustained one fall without injuries since her admission. A review of the care plans revealed she was care-planned for alteration in skin integrity related to skin tears on the right leg and right arm that were acquired before admission. Geri sleeves were to be applied to both lower extremities every shift, starting on 01/14/2019. The Medication Administration Record [REDACTED]. There were no as needed doses of [MEDICATION NAME] administered in February. The resident was also receiving a scheduled dose of [MEDICATION NAME] HCI 50 mg, 1 tablet by mouth daily at 9:00 AM for chronic pain. Documentation revealed all scheduled doses had been administered. The Treatment Administration Record (TAR) for (MONTH) 2019 was reviewed, and multiple dressing change orders were documented as follows: 1. Dressing change to cleanse skin tear to right leg with normal saline, apply triple antibiotic ointment and apply dry dressing once a day and as needed. 2. Dressing change to cleanse wound to mid forearm with normal saline, apply triple antibiotic and apply dry protective dressing once a day and as needed. 3. Cleanse wound to right lower forearm with normal saline, apply triple antibiotic ointment and apply a dry protective dressing once daily and as needed until healed. 4. Cleanse skin tear to left lower extremity with normal saline, apply triple antibiotic ointment and cover with dry dressing every evening shift until healed. The nursing progress notes were reviewed, revealing no documentation of administration of any as needed pain medications prior to dressing changes. An interview was conducted with Employee D on 02/06/2019 at 2:15 PM, immediately following wound care for Resident #135. Employee D reported she usually assesses for pain prior to providing wound care, and also pre-medicates residents with pain medication as needed for pain prior to providing wound care. Employees C and D confirmed they failed to assess the resident's pain level prior to and during wound care, and they failed to administer pain medication as indicated.