Every finding on record at Seaside Healthcare LLC

Based on record review, policy review and interview, the facility failed to notify the residents representative of a significant change in condition and hospital transfer for 1 of 3 sampled residents reviewed. (Resident #1) Finding: Review of the facilities Change in a Resident's Condition or Status policy, revised March 2025, revealed a significant change in condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.Impacts more than one area of resident's health status.The policy further states that unless otherwise instructed by the resident Unless otherwise instructed by the resident, a nurse will notify the residents representative when there is a significant change in the residents physical, mental, or psychosocial status and when it is necessary to transfer the resident to a hospital/treatment center. Review of Resident #1's clinical record revealed that on 7/2/26 at 9:30 p.m., the resident was difficult to arouse, did not respond to verbal or tactile stimuli, had a temperature of a 103.9, and was transferred to the hospital via Emergency Medical Services. (EMS) Review of Resident #1's hospital discharge summary indicated the resident was admitted to the hospital on [DATE] and diagnosed with pneumonia requiring intubation and mechanical ventilation. Documentation dated 7/3/26 at 12:36 p.m. indicated that Resident #1's legal representative called the facility requesting information regarding the events from the previous evening and informed the nurse that the resident had pneumonia and was intubated. Further review of the clinical record reveals no documented evidence that the resident's representative was notified of the resident's significant change in condition or transfer to the hospital on 7/2/26. On 8/5/26 at 4:00 p.m., the Director of Nursing (DON) confirmed the resident's representative was not notified of the resident's significant change in condition or transfer to the hospital on 7/2/26. The DON acknowledged the resident's representative should have been notified.

Based on record reviews and interview, the facility failed to ensure written bed hold and transfer/discharge notices were provided to the resident or their legal representative for a facility-initiated transfer/discharge for 2 of 3 sampled residents who were transferred to an acute care facility (Residents #1 & Resident #2). Findings: Review of the facilities Bed Hold and Return policy revised 3/20/25, indicates residents and/or their legal representatives are provided with written information regarding the facility and state Bed Hold policies. Written notice is provided at the time of transfer, or within 24 hours for an emergency transfer. The policy further indicated multiple attempts to provide the notice to the resident's representative should be documented when staff are unable to reach the representative1. Review of the clinical record revealed that on 7/2/26 at 9:30 p.m., Resident #1 was difficult to arouse, did not respond to verbal or tactile stimuli, had a temperature of 103.9, and was transferred to the hospital via emergency medical services. Hospital records dated 7/2/26 indicated Resident #1 was admitted from the skilled nursing facility after being found unresponsive with hypoxemia and hypercapnia and required emergent intubation for airway protection and mechanical ventilation. Resident #1's Bed Hold Notification/ Authorization Form, dated 7/2/26 and signed by a facility representative, indicated Resident #1 was provided information regarding the facility's bed hold policy and his/her rights to return to the facility following hospitalization. The form indicated Resident #1 was verbally notified of these rights. Resident #1's Notice of Resident Transfer or Discharge indicated the reason for transfer and provided information regarding the residents right to appeal. The form indicated the notice was documented in the resident's medical record. However, it did not indicate the notice was sent with Resident #1 or sent to the resident's legal representative. Additionally, Resident #1 was transferred to an acute care hospital and subsequently admitted on [DATE]. The clinical record lacked evidence that the facility provided a written bed hold and transfer/discharge notices to the resident and/or legal representative.2. Review of Resident 2's clinical record indicated that he/she was transferred to an acute hospital on 7/3/26 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice and a transfer/discharge notices for the resident and/or legal representative.During an interview with the surveyor on 8/5/26 at 4:00 p.m., the Director of Nursing (DON) was unable to explain how Resident #1 could have been verbally informed of his/her bed hold rights on 7/2/26 while unresponsive and was unable to confirm that the bed hold notice and a transfer/discharge notices were provided to the resident's legal representative. In addition, the DON was unable to provide documentation the facility provided a written bed hold and transfer/discharge notices for Resident #1's second hospitalization on 7/18/26 and Resident #2's hospitalization on 7/3/26.

Based on review of the facility's incident report, internal investigation, clinical record, and interviews, the facility failed to ensure that a resident had a choice about his/her care in the area of bathing for 1 of 1 residents reviewed (R1).Findings: On 3/4/26, the Division of Licensing and Certification received an on-line report concerning a resident being made to take a shower despite having refused and requesting a bed bath instead. On 3/16/26, a review of the facility's internal investigation noted on 2/27/26, R1 had an episode of incontinence. Staff were reported to have asked if R1 wanted to shower at which time he/she declined. R1 requested to speak to the unit manager. However, the unit manager was involved in a clinical meeting. The charge nurse was reported to have interrupted the meeting and asked if there was any reason R1 could not have a shower, to which the leadership team responded no, there were no contraindications they were aware of. The charge nurse informed the resident that management was ok with R1 having a shower. A CNA (certified nursing assistant) and the charge nurse proceeded to use a mechanical lift to transfer R1 to a shower chair. Staff wrapped R1 in bath blankets and transported him/her to the shower room where the CNA proceeded to bathe him/her. Afterwards, R1 was returned to his/her room and assisted back to bed. R1 was reported to thank the CNA and fell asleep. R1 reported the incident to family and stated that staff had informed him/her that he/she could not refuse the shower and was denied the request to speak with the unit manager. R1 stated the charge nurse had placed him/her naked on a sheet before transfer to the shower chair and rolled R1 down the hall to the shower room, where he/she was bathed by a staff while crying and yelling no, no, I don't want one. A review of R1's clinical record revealed diagnoses including Major Depressive Disorder, Anxiety, and Post Traumatic Stress Disorder (PTSD). A review of the Minimum Data Set (MDS) 3.0 Quarterly Assessment, dated 2/20/26, Section C - Cognitive Patterns, revealed a BIMS (brief interview of mental status) score of 14, indicating R1 was cognitively intact. R1 required partial/moderate assistance on staff for activities of daily living and transfers. R1 was primarily bed bound. The care plan indicated R1 required substantial/maximum assist by 1 staff with bathing/showering. On 2/27/26, the care plan was revised to state Resident is to have bed baths only per request. On 3/16/26 at 9:00 a.m., in an interview with two surveyors, the Administrator and the Director of Nursing discussed the internal investigation. The Administrator stated the staff felt they were doing a good thing when they provided the shower as R1 hadn't had one for a long time. On 3/16/26 at 12:15 p.m., in an interview with a surveyor, the unit manager stated she had not been aware that R1 had requested to speak with her before receiving the shower and was not aware of the situation. The unit manager stated she met with the R1 and discussed the situation. She stated R1 had been care planned for a shower, but usually refused and received a bed bath instead. The unit manager stated the minute he/she said no, he/she didn't want a shower, that should have been it. On 3/16/26 at 12:40 p.m., in an interview with a surveyor, the CNA stated R1 had been incontinent of a bowel movement and the CNA asked how about a shower? And it was like he/she was scared to be seen being taken to go down to take a shower. Once he/she was in the chair, he/she said no, I don't feel like it. I told him/her it would be quick and then he/she said thanks, I feel good now. The CNA stated R1 had stated don't push, don't take me down, like he/she was scared to take a shower. The CNA stated he/she had encouraged R1 it would be ok and the shower would not last a long time. On 3/16/26 at 12:45 p.m., in an interview with a surveyor, R1 stated the charge nurse had checked with administration and they required R1 to take a shower. R1 stated staff would not allow him/her to speak with the unit manager. R1 stated When you have to get in the shower chair, they put a sheet over you and take you down the hall. I had always had a bed bath. I started swearing and crying no, no! I don't want a shower! I hated every minute of it. The whole time I was screaming I hate it, let me out! I still have nightmares. It all was so traumatic. After the shower they put a johnny on me and brought me back to bed. I cried a long time afterwards. I was crying and sobbing. I don't like to be completely naked. With a bed bath, I'm not, I'm covered up. A review of the facility's policy, Summary of Federal Residents' Rights, dated 12/30/17, states in section 2. Notice of Rights and Services - The resident has the right to refuse treatment. Section 21. Dignity - The facility must promote care for residents in a manner that maintains or enhances each individual's dignity and respects his or her individuality. Section 25. Accommodation of Needs - The resident has the right to receive services with reasonable accommodation of individual needs and preferences. As a result of the facility's investigation the following corrective actions were taken:-Incident reported to the appropriate State Agencies.-Education on resident rights was provided to staff on 3/4/26.-The CNA received a written reprimand and was reassigned. -The charge nurse was suspended for 3 days, received a written reprimand, and was reassigned.

Based on interviews and record review, the facility failed to ensure resident records contained information regarding the transfer or discharge of a resident to a hospital, and failed to provide transfer, discharge and bed hold information to the resident, or designated representative, for 3 of 9 residents reviewed for hospitalization (R1, R6, R11).Findings:1.On 9/30/25 at 9:35 a.m., in an interview with a surveyor, Resident #6 (R6) stated he/she had been sent to the hospital since initial admission but was unable to remember why and did not remember if he/she had received transfer, discharge or bed hold notices at the time of transfer.On 11/17/25, a review of R6's medical record noted an admission date of 8/29/25. R6 was discharged home on 9/30/25. The provider's Discharge summary, dated [DATE], stated Had Emergency Department visit on 9/27/25 at his/her request due to vomiting. The surveyor was unable to locate evidence of nursing progress notes, assessments, or transfer, discharge and bed hold notices having been completed. R6's record contained no information regarding R6's return or the outcome of the ER visit. On 11/18/25 at 9:40 a.m., in an interview with a surveyor, the Director of Nursing confirmed R6's record lacked documentation of the circumstances surrounding the resident's transfer to the hospital and return to the facility, as well as lacked evidence that transfer, discharge and bed hold notices were provided to R6 or the designated representative.2. On 9/29/25 at 11:46 a.m., in an interview with a surveyor, R11 stated he/she had to go back to the hospital 1 week ago but did not know if he/she had received transfer, discharged or bed hold notices.On 10/1/25, a review of R11's clinical record revealed an admission date of 8/22/25, and a discharge to the hospital on 9/22/25, with a readmission to the facility on 9/26/25. The surveyor was unable to locate evidence that transfer, discharge or bed hold notices had been provided to the R11 or the designated representative.On 10/1/25 at 2:55 p.m., in an interview with a surveyor, the Skilled Nurse Manager reviewed R11's record and confirmed transfer, discharge and bed hold notices had not been provided.3. On 11/17/25 at 1:30 p.m. the surveyor reviewed R1's medical record and identified that the facility failed to provide transfer, discharge, and bed hold information to the resident, or designated representative prior to his/her emergency transfer to the hospital on 5/17/25.On 11/17/2025 at 3:05 p.m. during an interview with a surveyor, the Administrator confirmed the missing transfer, discharge, and bed hold notice for R1.

Based on interviews and record reviews, the facility failed to ensure care plans were developed and implemented in the areas of accident hazards, unnecessary medications, and urinary tract infection, for 3 of 7 residents reviewed for care planning (R11, R29, R39). Findings: 1. On 9/29/25 at 11:43 a.m., in an interview with a surveyor, R11 stated he/she goes outside to smoke 2-3 times daily.A review of R11's clinical record noted an admission date of 8/22/25. A Smoking Assessment completed on 8/22/25 indicated R11 demonstrated balance problems while sitting or standing, unable to hold tobacco products safely, unable to extinguish tobacco safely, does not follow facility's policy on location and time of smoking. On 9/26/25, staff completed a Late entry for 9/21/25-Smoking and Safety, which stated Smoking status: Resident uses tobacco products. Resident has balance problems while sitting or standing. Resident follows the facility's policy on location and time of smoking. Smoking safety note: wheelchair baseline for transfers. A review of the current care plan, last revised on 9/29/25, did not include interventions to address safety and R11's smoking. On 10/1/25 at 12:58 p.m., in an interview with a surveyor, the Administrator, confirmed R11 is on the facility's smoking list. The surveyor advised that R11's current care plan does not include smoking and a previous assessment found R11 to be unsafe to smoke. The Administrator stated a safe smoking assessment would be completed that day and R11's care plan updated. 2. On 9/29/25 at 12:17p.m., a surveyor observed a Personal Protective Equipment (PPE) station outside of R29's room. On 11/17/25, review of R29's clinical record noted a re-admission date of 9/15/25. R29 was transported to the ER on [DATE] and again on 10/15/25, at which time R29 was admitted to the hospital with a diagnosis of hemorrhagic cystitis. A review of the hospital admission noted a history of ESBL (Extended Spectrum Beta Lactamase) and VRE (Vancomycin Resistant Enterococci), multi-drug resistant organisms.A review of R29's hospital Discharge summary, dated [DATE], stated Principal diagnoses: Hemorrhagic Cystitis - Polymicrobial urinary tract infection with Escherichia coli and Enterococcus faecalis. Precaution Alert: ESBL, MRSA (Methicillin Resistant Staphylococcus Aureus), VRE. Updated culture results on 10/19/25: Enterococcus faecalis VRE resistant to tetracycline and vancomycin. Escherichia coli resistant to tetracycline.A review of R29's care plan, initiated on 9/16/25, and revised on 10/31/25, did not address R29's requirement for Contact Precautions due to the current infection with multi-drug resistant organisms. On 11/17/25 at 10:25 a.m., in an interview with a surveyor, CNA2 stated R29 is on precautions for VRE and staff wear full PPE when providing care, especially for toileting. On 11/17/25 at 11:40 a.m., in an interview with the Director of Nursing and the Assistant Director of Nursing, the surveyor discussed R29's history of VRE and ESBL and staff's use of full PPE when providing care. However, the need for precautions and the history of MDRO's was not included in care plan. The Director of Nursing and Assistant Director of Nursing confirmed the need for enhanced barrier precautions should be included in the care plan. 3. On 9/30/25, R39 was observed receiving an intravenous antibiotic for a surgical site infection of the leg. R39 was discharged home later the same day. A review of the clinical record for R39 noted an admission date of 9/3/25. Diagnoses included: Infection of deep incisional surgical site, displaced bimalleolar fracture of left lower leg, polyneuropathy, anxiety disorder, attention deficit hyperactivity disorder, alcohol use, depression and insomnia. A review of provider orders noted R39 was receiving Hydromorphone (a narcotic for pain), Quetiapine (an antipsychotic medication for anxiety and insomnia), Daptomycin (an intravenous antibiotic for infection), Gabapentin (an anticonvulsant for nerve pain), Mirtazapine (an antidepressant), Hydroxyzine (an antihistamine used for anxiety), Atomoxetine (used to treat attention deficit hyperactivity disorder), and Lovenox (an anticoagulant used to prevent blood clots). Provider orders revealed on 9/22/25, Lovenox was discontinued due to multiple episodes of bleeding from the nose. A Minimum Data Set (MDS) 3.0 admission Assessment, completed on 9/9/25, Section N. Medications, noted the use of antipsychotic, antidepressant, antibiotic, anticoagulant, and opioid medications. A review of R39's care plan, initiated on 9/3/25, did not include the use of psychotropic or anticoagulant medications, and did not include any revisions to address changes. On 11/18/25 at 9:40 a.m., in an interview with a surveyor, the Director of Nursing, confirmed R39's care plan did not address the use of psychotropic medications.

Based on observation and interview, the facility failed to ensure that residents were served a meal in a homelike setting and treated with dignity and respect during a meal service observation on 1 of 6 units (400 unit).Findings: On 10/1/25 at 8:15 a.m., two surveyors observed the breakfast meal service in the common dining area on Unit 400. All residents received their meals on a serving tray placed on the table in front of them, with no dishes being removed. In addition, surveyors observed CNA1 (Certified Nursing Assistant) standing over a resident feeding them. A surveyor asked CNA1 if the residents always have the dishes left on the trays and CNA1 stated, Yes. When a surveyor asked CNA1 if this was the residents' choice, CNA1 stated, I never asked them. A surveyor brought this to the attention of the Nurse Manager for Unit 300, who confirmed the findings.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 10 sampled residents reviewed for new admissions (#27). Findings: On 9/29/25 at 3:29 p.m., in an interview with a surveyor, R27's family member stated an interdisciplinary meeting was held on 9/15/25, but they had not been invited. A copy of the care plan was provided on 9/19/25. The family member stated there had never been a formal meeting with the family and the whole team. A review of the clinical record for Resident #27 (R27) revealed an admission date of 9/10/25 with diagnoses including acute cystitis and fall. R27's base line care plan was not initiated until 9/15/25. A revision was completed on 9/29/25. A copy of the care plan conference from 9/29/25 indicated the family was invited but did not attend. On 11/18/25 at 1:20 p.m., in an interview with a surveyor, the Director of Nursing confirmed the baseline care plan had not been initiated within 48 hours of admission.

Based on record review and interviews the facility failed to ensure that physicians' orders were obtained for treatment of an existing wound for 1 of 1 resident who was admitted on [DATE] resulting in a delay of treatment for the wound (R165).Findings: 1. On 11/18/25 at 1:34 p.m. the surveyor reviewed R165's medical records that contained a pre-admit nurse to nurse note dated 2/13/25 that states the resident has a stage II coccyx wound that occurred at home.On 11/18/25 at 2:16 p.m. the surveyor reviewed R#165's medical record that contained a consult from the hospital with a date range of 2/2/25 to 2/3/25 that states, skin concerns; noted small 0.3 cm (centimeter) open area over gluteal cleft. On 11/18/25 at 1:45 p.m. the surveyor reviewed orders for wound treatment dated 2/27/25, written 14 days after admission to the facility.On 11/18/25 at 1:45 p.m. the surveyor interviewed the Wound Nurse who presented pictures of the resident's wound that was evaluated 2/26/25 and confirmed the finding that orders for treatment of the wound were not written until 2/27/25.On 11/18/25 at 3:49 p.m. during an interview with the Administrator the surveyor confirmed these findings.

Based on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week on 1 of 61 days reviewed for RN coverage. Finding: On 10/3/2023, during review of Auguest and September 2023 staffing records, it was discovered that there was no Registered Nurse (RN) coverage on Saturday, 9/23/2023. On 10/3/2023 at 10:15 a.m., during an interview with the Director of Nursing (DON) she reviewed the documentation and stated that she was unaware of that information. The lack of RN coverage on 9/23/2023 was confirmed at 10:20 a.m.

Based on record reviews and interviews, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 3 sampled residents (Residents #3). Finding: Documentation in Resident #3's clinical record stated that the Physician signed the Physician Orders (block orders) on 12/8/22. These orders were in effect for 60 days. The next Physician Orders (block orders), including a 10-day grace period, needed review and the Physician's signature by 2/16/23. The medical record lacked evidence that Physician reviewed and signed orders on or around 2/16/23. On 3/22/23 at 1:05 p.m., the finding was confirmed with the charge nurse. On 3/22/23 at 1:30 p.m., the finding was discussed at the exit interview with the Administrator and Director of Nursing.

Based on record review and interviews, the facility failed to ensure that a resident's choice in the area of dental were being followed for 2 of 4 sampled residents reviewed for dental (Resident #15 and #26). Findings: 1. On 1/10/23 at 10:02 a.m., during an interview, Resident #15 stated that his/her teeth are not brushed daily stating, my daughter comes in and brushes my teeth, but she only comes in once a week. I need it at least once a day, maybe twice. Review of the Certified Nursing Assistant (CNA) documentation for the personal hygiene task, which includes shaving, applying makeup, washing/drying face and hands, combing hair and brushing teeth indicates Resident #15 did not receive personal hygiene a total of 16 days from November 2022 through January 12, 2023. On 1/12/23 at 2:49 p.m., the above finding was discussed with the Director of Nursing. 44047 2. On 1/9/23 at 1:28 p.m., during an interview, Resident #26 stated that his/her teeth had not been brushed in months. Review of Certified Nursing Assistant (CNA) documentation for personal hygiene task, which includes shaving, applying makeup, washing/drying face and hands, combing hair and brushing teeth indicates Resident #26 did not receive personal hygiene (either morning, evening, or both) for a total of 28 days from October 2022 through January 12, 2023. On 1/13/23 at approximately 12:45 p.m., the above finding was discussed with the Administrator.

Based on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 3 of 24 sampled residents (#10, #26 and #53). Findings: 1. During review of Resident 10's medical record, the surveyor noted the following Minimum Data Set (MDS) Assessments: Significant Change in Status assessment dated [DATE], Quarterly Review assessments, dated 7/20/22 and 10/18/22 and another Significant Change in Status assessment dated [DATE]. The clinical record lacked evidence that a care plan meeting was held by the IDT for the above assessments. In addition, the last documented IDT meeting was held on 1/21/22. 44047 2. During review of Resident 26's medical record, included a MDS Quarterly assessment dated [DATE]. The clinical record lacked evidence that a care plan meeting was held by the IDT for the10/26/22 Quarterly assessment. 3. On 1/9/23 at 11:17 a.m., Resident #53, stated the facility had not had recent care plan meetings with him/her and They don't tell me about my care plan. I want one. During review of Resident #53's medical record, the surveyor noted the following MDS Assessments: Quarterly Assessments dated 2/06/22, 5/06/22, 7/20/22 and 1/4/23 and the Annual assessment dated [DATE]. The clinical record lacked evidence that a care plan meeting was held by the IDT for the above assessments. On 1/12/23 at 11:38 a.m. these findings were discussed with the Director of Nursing.

Based on observations and interviews, the facility failed to ensure that medications were stored properly by having unlocked and unattended medication cart with medication stored on top of the cart allowing residents and unauthorized persons access to them on 1 of 5 days of survey. In addition, the facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 2 of 4 units observed (Unit 2 and Unit 5). Findings: 1. On 1/13/23 at 12:00 p.m., on Unit 2, a surveyor observed an unlocked and unattended medication cart in the hallway outside of a resident room. On top of the cart was 2 plastic bins both containing various insulin vials, insulin pens and pen needles, in individual plastic bags labeled with the resident names. The RN walked out of a resident's room took something off the cart and stated, I forgot to lock it. She then locked the cart and walked back into a resident's room, leaving the insulins an needles unattended on top of the cart. At approx. 12:02 p.m., 2 surveyors observed the insulins and needles on top of the unattended cart. When the RN returned to the cart, she confirmed she always leaves them on top of the cart stating, I was told I could leave it there as long as a half an hour. On 1/13/23 at 12:18 p.m., during an interview with the Director of Nursing, the surveyor discussed the above observation. 2. On 1/9/23 at 9:48 a.m., observation of Unit 5's medication room refrigerator with the Registered Nurse unit manager. Refrigerator contained and open vial of Pfizer-Bio/Tech COVID-19 Vaccine Bivolent original and Omicron BA 4/BA.5, labeled with expiration date of 1/2/23. At this time, the RN discarded the expired vaccine. 3. On 1/9/23 at 9:52 a.m., observation of Unit 5's nurse treatment cart with the RN, the surveyor noted an opened Kwikpen containing insulin, labeled with an open date of 10/20/22. At this time, the RN stated the order for this particular insulin was discontinued on 11/16/22 and should've been discarded. 4. On 1/9/23 at 1:16 p.m., observation of Unit 5's medication cart with the Certified Medication Technician (CNA-M), the surveyor noted and open bottle of one a day multi vitamin with iron with a best by date of 10/22. 5. On 1/10/23 at 8:22 a.m., observation of Unit 2's Nurse treatment cart with the Licensed Practical Nurse (LPN), surveyor noted the following: > One open vial of Lantus insulin not labeled with an open or discard date with manufacturer's directions to should be discard after 28 days after opening. > One opened vial of Novolog insulin not labeled with open or discard date with manufacturer's directions to should be discard after 28 days after opening. > One opened Victoza pen not labeled with open or discard date, with manufacturer's instructions to discard pen 30 days after first use. On 1/10/23 at approx. 4:00 p.m., during an interview with the Director of Nursing, the above findings were discussed.

Based on observations and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of infections related to the storage of residents' personal care items for 3 of 5 days of survey on 3 of 5 units (Unit 2, Unit 4 and Unit 5). Findings: Unit 4: On 1/9/23 at 4:00 p.m., observation of room [ROOM NUMBER] with an unlabeled urinal hanging from the bathroom handrail. On 1/11/23 at 9:14 a.m., an additional observation of a basin on the bathroom floor with a urine hat in the basin. On 1/10/23 at 9:52 a.m., and on 1/11/23 at 9:09 a.m., observations of room [ROOM NUMBER] with a basin on the bathroom floor and 2 labeled urinals hanging from the handrails. On 1/10/23 at 10:28 a.m., and on 1/11/23 at 9:28 a.m., observations of room [ROOM NUMBER] with a urinal hanging from the bathroom handrail. On 1/10/23 at 10:39 a.m., observations of room [ROOM NUMBER] with a urinal hanging from the bathroom handrail, a basin with a bed pan on top of it on the bathroom floor. On 1/11/23 at 9:16 a.m., an additional observation of a bed pan stored on top of the toilet and a basin on the bathroom floor. Unit 5: On 1/9/23 at 10:56 a.m. and on 1/11/23 at 8:59 a.m., observations of room [ROOM NUMBER] to have the commode bucket on the bathroom floor. On 1/11/23 from 11:12a.m., to 11:29 a.m., an Environmental tour was conducted on Unit 4 and Unit 5 with the Administrator and the Director of Nursing, in which the above concerns were observed by all parties. 44047 Unit 2: On 1/9/23 at 1:25 p.m., observation of room [ROOM NUMBER] with an unlabeled bedpan sitting on the floor with an unlabeled pink plastic wash basin in the bedpan. On 1/9/23 at 10:43 a.m., on 1/10/23 and on 1/11/23, observation of room [ROOM NUMBER] with an unlabeled cushion seat stored on the floor with an uncovered with bedpan stored on top of it. On 1/10/23 at 9:15 a.m., observation of room [ROOM NUMBER] with a basin stored on the floor. On 1/10/23 at 9:15 a.m., observation of room [ROOM NUMBER] with a bed pan stored on top the toilet seat. On 1/10/23 at 11:38 a.m., observation of room [ROOM NUMBER] with 3 labeled urinals hanging from the bathroom handrail. On 1/11/23 at approximately 12:15 p.m. observation of room [ROOM NUMBER] had brown feces looking material smeared on the floor. On 1/11/23 from 12:05 p.m. to 12:19 p.m., an Environmental tour was conducted on Unit 2 with the Administrator and the Director of Nursing, in which the above concerns were confirmed.

Based on interview and record review, the facility failed to follow physician orders for 1 of 24 sampled Residents (#53) . Findings: On 1/11/23 at 9:37 a.m., during an interview, Resident #53, reported that he/she was recently given a dose of oxycodone and then given another dose approximately 3 hours later and he/she had slept the majority of that day. The clinical record showed the following: Physician orders for Oxycodone HCL 5mg (milligram) tablet, Dose: (0.5 tablet/2.5mg) by mouth every 6 hours as needed for acute pain, pain level 3-6 and Oxycodone HCL 5mg tablet, (1 tablet/5mg) by mouth every 6 hours as needed for acute pain, pain level 7-10. The Treatment Administration indicates on 12/1/22 the residents pain level was 5. The Medication Administration Record (MAR) indicated on 12/1/22 the resident recieved Oxycodone 5mg at 4:52 a.m. and 8:00 a.m. The facility's narcotic count book indicates on 12/1/22 the resident recieved Oxycodone 5mg at 4:52 a.m., and 8:00 a.m. On 1/11/23, at approximately 3:00 p.m. a surveyor confirmed the above findings with the Director of Nursing.

Based on record reviews and interviews the facility failed to adequately monitor residents receiving antipsychotic medications for tardive dyskinesia and/or other movement disorders for 2 of 5 residents reviewed for unnecessary medication. (#21 and #50) Findings: 1. On 1/11/2022, Resident 50's clinical record, contained a physician's orders, dated 11/16/22 for Abilify an antipsychotic medication, used to treat a psychiatric/mood disorder. The Consultant Pharmacist's Medication Regimen Review dated 10/1/22-10/31/22 states Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. Recommend movement test such as AIMS [Abnormal Involuntary Movement Scale] or DISCUS [Dyskinesia Identification System Condensed User Scale], be performed at least every six months while this resident continues on antipsychotic therapy. The resident continues on Abilify. The last AIMS/DISCUS located in the chart was dated 3/28/22. Additionally, this document has a handwritten note which states scheduled Q 6 months [months] start 12/16 The surveyor could not locate evidence of a completed AIMS or DISCUS in the clinical record after the 3/28/22 date as recommended by the Consultant Pharmacist. 2. On review of Resident 21's clinical record, the record contained a physician's order, dated 12/22/22 for Zyprexa an antipsychotic medication, used to treat akathsia related reactions (agitation, restlessness or distress related reactions). The last AIMS/DISCUS located in the chart was dated 2/18/22. The surveyor could not locate an AIMS/DISCUS test completed after the 2/18/22 dated. On 1/11/2023, at approximately 4:00 p.m. This was confirmed with the Administrator and the Director of Nursing.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition on 3 of 5 Units. (Unit 4, Unit 5, and Unit 2). Findings: On 1/11/23 from 11:12 a.m., to 11:29 a.m., an Environmental tour was conducted on Unit 4 and Unit 5 with the Administrator and the Director of Nursing, in which the following was observed by all parties. Unit 4 > room [ROOM NUMBER]-1 behind the headboard was a large gouge exposing sheetrock, on the wall. > room [ROOM NUMBER] beside the recliner was a large gouge area of wall with sheet rock exposed and the fall mat was completely torn/ripped on both ends with the foam coming out. Unit 5 > room [ROOM NUMBER] behind the recliner chair was 2 large gouges, exposing sheetrock, on the wall. 44047 On 1/11/23, at approximately 12:05-12:19 p.m., an environmental tour was conducted on unit 2 with the Administrator and Director of Nursing in which the following was observed or discussed: Unit 2 > room [ROOM NUMBER] the toilet is cracked in the front near the bottom. > room [ROOM NUMBER] the window shade was torn and would not stay down. Staff tapes the shade shut. There is a draft from the window and it does not open or close easily. The Resident reported that there is a cold air breeze.

Based on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week on 3 of 40 days reviewed for RN coverage. Finding: On 3/31/22 during a review of Daily Staffing Postings and nursing working schedules from 12/27/21 - 1/3/22 and from 2/27/22 - 3/27/22, they indicated that on 1/2/22, (Sunday) 2/27/22, (Sunday) and 3/27/22, (Sunday) the facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours. On 3/31/22 at 11:50 a.m., the findings were confirmed with the Director of Nursing and Administrator.

Based on record review, the facility failed to provide respiratory care consistent with professional standards of practice and the facilities own policies and procedures for 1 of 2 sampled residents. (Resident #1). Findings: During Residents #1's medical record review, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 6/9/2021 at approximately 10:30 a.m., a surveyor observed Resident #1's [CONDITION(S)] suctioning procedure with a Registered Nurse #1 (RN #1) and observed the following: - RN #1 opened [CONDITION(S)] suction kit, donned the right sterile glove. Retrieved the suction tubing from the kit and connected it to the suction machine. Then donned her left sterile glove while brushing it against her uniform to apply the glove. Performed the suction technique handling the tubing with her left hand and doffed the dirty sterile gloves and discarded the gloves in the trash. - RN #1 then opened and removed the contents of the [CONDITION(S)] dressing kit, washed her hands in the sink in the bathroom, returned to the resident and removed the drain sponge from the resident's [CONDITION(S)] site, then donned sterile gloves from the [CONDITION(S)] dressing kit. RN #1, with his/her sterile gloved hands, then picked up a container of sterile water and peroxide from the top of the residents bureau, opened each bottle with sterile gloved hands and poured equal parts of sterile water and peroxide into the [CONDITION(S)] kit container. He/she then removed the inner cannula from Resident #1's [CONDITION(S)], placed it in the sterile/peroxide water and began to cleanse the outside area around Resident #1's [CONDITION(S)] site and scrubbed the inner cannula with a pipette. With the same gloved hands, RN #1 then dried the inner cannula with a dry gauze and placed the inner cannula back into the resident's [CONDITION(S)]. RN#1 then removed his/her dirty gloves and washed his/her hands. The surveyor confirmed the break in sterile procedure donning sterile gloves, handling the sterile water bottle and peroxide with sterile gloves with RN #1 during the suctioning procedure and [CONDITION(S)] dressing change. RN #1 stated that it was difficult to perform both suctioning and the [CONDITION(S)] dressing change completely sterile. The facilities [CONDITION(S)] Care Policy and Procedure effective date 6/2016, revised date 11/2017 indicates in section (2) Clean the Removable Inner Cannula. 1. Open [CONDITION(S)] cleaning kit. 2. Set up supplies on sterile field. 3. Maintaining sterile field, pour equal parts [MEDICATION(S)] and normal saline in one compartment of opened kit. Pour normal saline in another compartment. 4. Open four gauze pads and saturate with [MEDICATION(S)]. 5. Open two gauze pads and saturate with antiseptic solution. 6. Open two gauze pads and saturate with sterile saline. 7. Open two gauze pads; keep them dry. 8. Put on sterile gloves. 9. Secure the outer neck plate with non- dominate gloved hand. 10. Unlock the inner cannula with gloved dominate hand. 11. Gently remove the inner cannula, rotating it counterclockwise while lifting away from the resident. 12. Soak the cannula in [MEDICATION(S)]/saline mixture. 13. Clean and brush. Rinse with saline and dry with pipe cleaners. 14. Remove and discard gloves into appropriate receptacle. 15. Wash hands and put on fresh gloves. 16. Replace the cannula carefully and lock in place. Facilities Policy and procedure for Suctioning the Lower Airway ([CONDITION(S)] Tube) Effective date 6/2016, revised dated 11/2017 indicates in Steps in the Procedure: 10. Open suction catheter kit 11. Place sterile drape across the resident's chest. 12. Remove sterile cup, touching only the outside. 13. Fill cup with 100 cc sterile saline or sterile water. 14. Apply sterile gloves. The dominate hand will remain sterile. 15. Holding the catheter in dominate hand and the tubing in the non-dominate hand, connect the catheter to the tubing. The above findings were discussed in an interview with the Director of Nursing on 6/9/2021 at 1:57 p.m.

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 4 of 6 units (100, 200, 300, and 400) for 1 of 1 Environmental tours. Findings: On 3/19/2021 from 8:10 a.m. to 8:35 a.m., a surveyor and the Environmental Services Director conducted a tour of the facility in which the following findings were observed: Unit 100: - The patient lift had a dirty/dusty base and chipped/missing paint on the swing arm and the base creating uncleanable surfaces. - There were 2 (two) sit-to-stand lifts that had dirt/debris in the foot base, which was rusty. - Resident Room 103- The box fan, on the floor, was dirty/dusty. - Resident Room 107- The bathroom exhaust fan was dirty/dusty. Unit 200: - The left side and right side wall heating units, at the end of the unit by the exit door, were rusty. - Resident Room 210-B - The privacy curtain was in disrepair and an outlet cover was broken at the head of the bed. - Resident Room 213 - The privacy curtain was in disrepair. - The wall mounted fan, at the nurse's station was dirty/dusty. - The floor behind the nurse's station was missing 2 (two) large sections of flooring, exposing sub-flooring and creating uncleanable surfaces. - The floor in the kitchenette, behind the nursing station, had numerous broken floor tiles. Unit 300: - The hallway ceiling vents, by the nurse's station and Resident Room 304 were dirty/dusty. - The patient lift had broken leg guards and chipped/missing paint on the mast and base, creating uncleanable surfaces. - The left side and right side wall heating units, at the end of the unit by the exit door, were rusty. - Resident Room 302 - There were holes in the wall by the clock and the sheetrock under the window was gouged, creating uncleanable surfaces. - Resident Room 304 - The bathroom faucet was leaking and would not shut off, the floor mats ripped/worn on edges by Bed-B, the fan was dirty/dusty, and Bed-A privacy curtain had brown stains on it. - Resident Room 305 - The fan was dirty/dusty. - Resident Room 306 - The fan was dirty/dusty. - Resident Room 307 - Bed-B's wheelchair had rubber stretch bands and tape wrapped around wheels creating uncleanable surfaces, the was a dark brown dried substance on the floor in front of the bureau, and the fan was dirty/dusty. - Room 308 - The bedside fan for Bed-A is dirty/dusty and Bed-B privacy curtain is soiled. - Resident Room 309 - The fan is dirty/dusty, the baseboard heater had chipped/missing paint creating an uncleanable surface, and the bathroom door is chipped/gouged on the lower edge. - Resident Room 310 - The paint, on the wall above the baseboard heater, was peeling creating an uncleanable surface. - Resident Room 312 - The cove base by the closet was coming off, the bathroom door was gouged, the fan was dirty/dusty, the wall was gouged and had holes in it to the left of the fan, and the privacy curtain was soiled. - Resident Room 313 - The bathroom door was gouged. - Resident Room 314 - The light was out in the bathroom, the bathroom door was gouged, and the closet door was gouged. - Resident Room 315 - The privacy curtain was soiled and the fan was dirty/dusty. - Resident Room 317 - The cloth covering of the chair in room is soiled, wall is marred by the fan. - Resident Room 318 - The fan was dirty/dusty. Unit 400: The 5(five) hallway ceiling vents were rusty and dirty/dusty. On 3/19/2021 at 8:35 a.m., the Environmental Services Director confirmed the findings.