Every finding on record at Solaris Healthcare Lake City

Based on record review and interview, the facility failed to ensure residents with allergies were provided foods that were free from allergens for 1 (Resident #89) of 13 residents sampled who had food allergies. Resident #89 had a documented severe seafood allergy. On 8/16/2024 at approximately 12:15 PM, Resident #89 was served a meal that consisted of a fish entree by Staff O, Certified Nursing Assistant. Staff O reviewed Resident #89's meal ticket that documented seafood and shellfish allergy. At approximately 12:30 PM Resident #89 consumed a bite of the fish and began to experience shortness of breath and coughing. Resident #89 notified facility staff and was treated with medication for an allergic reaction. At approximately 1:40 PM Resident #89 experienced shortness of breath, was transferred to a local hospital and treated for an allergic reaction/anaphylaxis. Findings include: Review of Resident #89's medical record documented the resident was admitted on [DATE] with diagnosis to include paraplegia (loss of sensation and movement in the lower half of the body); anemia; major depressive disorder, recurrent, unspecified; personal history of pulmonary embolism; dizziness and giddiness; type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy; ulcerative (chronic) proctitis without complications; other chronic pancreatitis; gastro-esophageal reflux disease without esophagitis; obstructive sleep apnea; anxiety disorder unspecified; heart failure unspecified; long term current use of anticoagulants; personal history of other venous thrombosis and embolism; IVC (inferior vena cave) filter. Review of Resident #89's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA [Agency for Health Care Administration] Form 5000-3008) dated 8/15/2024 revealed documentation in Section G. Patient Risk Alerts that read, Allergies - Yes, list below: Seafood, shellfish, derived [products]. Review of Resident #89's Matrix data entries for the facility for allergy report documented allergies of Anaphylaxis/Severe: Seafood, Iodine; Rash/Severe: Shellfish. Review of Resident #89's nursing progress note dated 8/16/2024 at 12:20 PM read, Patient called this nurse into room. Patient asked what kind of meat was on her tray. Meat appeared to be fish. Patient states she is allergic to fish. Patient states she did touch the fish. Meal tray was removed from patient's room and patient washed hands. No s/s [signs and symptoms] of allergic reaction at this time. Review of Resident #89's nursing progress note dated 8/16/2024 at 12:30 PM read, CNA [Certified Nursing Assistant] called nurse into room. Patient noted to be coughing and appeared short of breath. Patient alert and oriented x [times] 4. Vitals 176/84 hr [heart rate]; 109. Spo2 [peripheral oxygen saturation] 90% [percent] on room air. Patient placed on non rebreather at 15L [liters], spo2 up to 99%. [Medical Doctor #1's name] in on rounds and assessed patient, gave orders for epi. Epi [Epinephrine] noted to be effective, patient respirations even and non labored. Denies SOB [Shortness of Breath]. Vitals 127/74 hr 95 spo2 99% on room air. Patient states she feels better. Review of Resident #89's physician order dated 8/16/2024 read, Epinephrine solution;1 mg/ml [1 milligram/milliliter]; amt [amount]: 0.3 ml intramuscular special instructions: dx [diagnosis]: anaphylaxis food once-one time 12:30 PM. Review of Resident #89's physician order dated 8/16/2024 read, Epinephrine solution;1 mg/ml; amt: 0.3 mg intramuscular special instructions: dx: anaphylaxis food once-one time 12:30 PM. [NOTE: This is not a repeat, the order was written twice, once for 0.3 ml and the second for 0.3 mg]. Review of Resident #89's Medication Administration Record (MAR) documented epinephrine solution 0.3 mg was administered on 8/16/2024 at 12:30 PM. Review of Resident #89's nursing progress note dated 8/16/2024 at 12:36 PM read, Cart nurse made this nurse aware that patient touched fished on plate. Cart nurse called kitchen and made aware of fish on plate and seafood allergy. MD [Medical Doctor] on rounds and made aware of patient touching fish. MD gave orders to monitor patient. Cart nurse had patient wash her hands with soap and water. CNA made nurse aware patient eyes itching and having SOB. This nurse came down hallway to observe patient having SOB. MD made aware of situation and came to observe patient. Patients stated she ingested small amount of fish with potatoes. MD gave orders for epi pen [a hand-held, self-injectable device used to administer epinephrine in emergency situations, particularly for severe allergic reactions like anaphylaxis]. MD made aware of no epi pen in [name of the medication dispensing system] and ordered epinephrine 0.3 ml IM [Intramuscular] injection and wasted 0.7 ml. Review of Resident #89's nursing progress note dated 8/16/2024 at 1:40 PM read, CNA called patient into room [Sic.]. Patient SOB [short of breath], able to talk. Alert and oriented x 4. Pt [Patient] placed on non [re]breather [used to deliver a high concentration of oxygen to patients who are breathing on their own but need additional oxygen support]. [Medical Doctor #1's name] contacted with no answer. 911 activated. Patient observed until EMS [Emergency Medical Services] arrived. Pt transported to [Name of local hospital] for evaluation. [Resident #89's family member's name] made aware. Review of Resident #89's Nursing Home Progress Note from Medical Doctor #1 dated 8/16/2024 read, HPI [History of Present Illness]: recent admit sec [secondary] to GIB [gastrointestinal bleed]; incidentally was having lunch and took a bite of fish which she is allergic to; had SOB/dysphagia [difficulty or discomfort swallowing]; epi 0.3 mg given . Assessment/Plan: 1. GIB-Prothrombin Time [a blood test that measures how long it takes for blood to clot], CBC [complete blood count]. 2. DM [Diabetes Mellites] - HgbA1C [glycated hemoglobin test measures the average blood sugar level], lipids 3. PE [Pulmonary Embolism]-stable. 4. Anaphylaxis - await response from epi Review of Resident #89's nursing progress note dated 8/16/2024 at 11:30 PM read, Patient (PT) returned from [name of local hospital] at this time. New orders for Benadryl 25 mg tid PRN [three times a day as needed] for allergic reaction and famotidine 20 mg BID [twice a day]. Review of Resident #89's Emergency Department note dated 8/16/2024 at 2:21 PM read, 8/16/24 - 14:21 [2:21 PM] diphenhydramine (Benadryl) 25 milligrams (mg) IV [intravenous] x1; famotidine (Pepcid) 20 mg; sodium chloride 0.9% (Normal Saline 10 ml) 3 ml IV x 1. Indication: Anaphylaxis/Allergy - methylprednisolone sod succ [sodium succinate] SOLU-Medrol [used for severe allergic reactions] 60 mg water for injection, sterile (Sterile water for injection 10 ml) 1 ml IV x1. Review of Resident #89's Emergency Department Note dated 8/16/2024 at 2:45 PM read, HPI notes - past medical history hypertension, brought by EMS from assisted living facility after patient developed an allergic reaction patient allergic to fish and accidently fish went into her food since then experience mild shortness of breath nurse personal [Sic.] prior to arrival administer atropine, vital signs remained stable brought here for further evaluation at this time patient denies fever, chills, chest pain, palpitations, GI [gastrointestinal] symptoms. Review of Systems - Respiratory: Reports shortness of breath; Psychiatric: Denies agitation, anxiety or homicidal ideation . Re-Evaluation/Progress: Time of re-evaluation: 15:46 [3:46 PM]: well appearing, no distress patient received IV methylprednisolone, IV Pepcid, IV Benadryl symptoms improved. Need close PCP [primary care physician] follow-up, warning signs and ED [emergency department] recommendations given. Review of the Risk Management Witness Statement - SF [Statement Form] read, I [Staff L, Cook's name] was serving the lunch tray line on 8/16/2024. In the process of making lunch plates, I did over look one allergy diet to fish. However, I did notice the other fish allergies and those meal tickets were given hamburgers instead of fish. The statement was signed by Staff L, Cook, and dated 8/16/2024. Review of the Risk Management Witness Statement - SF read, I CNA [Staff O, CNA's name] brought patient [Resident #89's name] her meal tray to her room about 12:15 PM. [Resident #89's name] asked me to place tray on the table, and that she would eat when she is ready. The patient meal slip did not say anything about allergies to fish. The statement was signed by Staff O, CNA, and dated 8/16/2024. Review of the Risk Management Witness Statement - SF read, I was informed that [Resident #89's name] received a tray with seafood and she is allergic to it and I was told by her nurse to make sure she washes her hand with soap and water. I put soap and water in a rag and let her wash her hands off. I came back and told the nurse she was rubbing her eyes and I was told to go back in and let her rinse her eyes. When I was wetting the rag in the bathroom I asked [Resident #89's name] was she itching and she told me yes, her eyes hands and throat were itching and right after that she started to breathe hard and lean over while grabbing her chest and I ran to the hallway to call for a nurse. The statement was signed by Staff N, CNA and dated 8/16/2024. Review of the Risk Management Witness Statement - SF read, When the ticket came to me I did not notice the allergy listed I will do better with reading the tray card completely. The form was signed by Staff M, Dietary Partner and dated 8/16/2024. Review of the Risk Management Witness Statement - SF read, This nurse was made aware by cart nurse that patient touched fish on plate. Medical Doctor (MD) on rounds and made aware of patient touching fish. Orders given by MD to observe patient. Cart nurse told patient to wash hands. Patient eyes began to itch and SOB. CNA made cart nurse aware. This nurse made MD aware and MD observed patient. Patient stated she ingested some fish with potato and states it happened before at other facility. The other facility gave her fish and was out to get her. MD gave orders for epi pen. MD was made aware that there was no epi pen in [name of the medication dispensing system]. MD gave order for epinephrine 0.3 ml and wasted 0.7 ml in the [name of the medication dispensing system]. MD verified 0.3 ml epinephrine. The form was signed by Staff P, Registered Nurse (RN). Review of the Notice of Disciplinary Action read, Employee Name: [Staff O, CNA's name]; Department: NSG [nursing]; Position: CNA; Supervisor: [Staff T, Risk Manager's name]; Position: Risk Manager; Date 8/16/24; Written Warning Documented; Supervisors' Statement: patient [Resident #89's name] received fish on her lunch meal tray. Patient has an allergy listed to shellfish and seafood. CNA gave patient meal tray with fish on tray despite listed allergy. Employee's Plan of Correction: Please read meal tray ticket prior to giving patient's meal tray. If patients have a food allergy listed on meal tray, ensure food is not on meal tray being delivered for patient. If food allergy is on meal tray, do not give patient meal tray. Supervisor's Response: CNA stated he placed tray in front of resident and resident stated to 'leave it.' CNA did not lift lid on plate to see fish that had been delivered. Reiterated to CNA to check meal tray before delivering tray to residents. The notice was signed by Staff O, CNA, and Staff T, Risk Manager, and dated 8/16/2024. Review of the Notice of Disciplinary Action read, Employe Name: [Staff L, Cook's name]; Department: Dietary; Position: Cook; Supervisor: [the Food Service Director's name]; Position: Food Service Director; Date: 8/16/24; Supervisor's Statement: On 8/16/24 Patient received fish on her meal tray. Pt tray card has allergy to shellfish, seafood, in bold print on tray card, item baked fish was not listed on tray card. Employee was person that plated food on patient's meal tray. Employee's Plan of Correction: Employee will slow down and read tray ticket thoroughly before plating food. Employee will also read list of patients with specific food allergies. Employee will complete educational Inservice on food allergies. Supervisor's Response: Employee will read tray card and plate food as directed insuring that any patient with food allergies do not receive any foods that may cause them to have a reaction. Any further disregard for listed allergies will result in termination. 8/16/2024 Employee suspended x 3 days. The notice was signed by Staff L, Cook, and the Food Service Director, and dated 8/16/2024. Review of the Notice of Disciplinary Action read, Employe Name: [Staff M, Dietary Partner's name]; Department: Dietary; Position: Diet Aide; Supervisor: [the Food Service Director's name]; Position: Food Service Director; Date: 8/16/24; Supervisor's Statement: On 8-16-24 - Patient received fish on her meal tray. Patient tray card has allergy to shellfish, seafood in bold print on tray card, item Baked Fish was not listed on tray card. Employee was the person that is to check all trays for accuracy before being sent. Employee's Plan of Correction: Employee will slow down and read tray ticket thoroughly and check for accuracy before placing tray on tray cart. Employee will complete Educational Inservice on Food Allergies. Supervisor's Response: Employee will read tray card and check tray for accuracy as directed insuring {sic} that any patient with food allergies do not receive any foods that may cause them to have a reaction. Any further disregard for listed allergies will result in termination. 8-16-24 - Employee suspended x 3 days. The notice was signed by Staff M, Dietary Partner, and the Food Service Director, and dated 8/16/2024. During an interview on 6/4/2025 at 2:48 PM, the Administrator stated, The CNA came into the room and the resident stated to please leave the tray, so he did not get to check the tray. The kitchen staff missed it [the allergy] and the staff did not get an opportunity to check the meal since the resident said to leave it there. The staff should have been checking, whoever lays hands on the tray needs to check. It can be done before or after entering the resident room as long as they are checking and laying eyes on the meal. During an interview on 6/4/2025 at approximately 4:30 PM, Resident #89 stated, The first day after I was admitted , I was eating lunch, and I thought the meat was chicken, but it was fish. I took one bite and within a few minutes I swelled up, my lips got swollen, and my throat started to close. I broke out in hives. I got the nurse who then called the doctor, and they gave me a shot of Epi. They did not have an Epi pen in the facility. They had to call the ambulance and when they got there, they had to give me another Epi shot. They then took me to the hospital, and I got another shot of Epi in the ER [emergency room ]. During an interview on 6/5/2025 at approximately 10:00 AM, Staff L, Cook, stated, I recall the incident with [Resident #89's name] receiving fish, but I can't recall all of the details. I was working on the tray line for lunch on 8/16/24 as the server, putting the hot food on each plate. The server is the second person on the line, putting the hot foods on and then the tray goes to the bottom of the line, where the third person puts on desserts and drinks. The process had been that the first or top person on the tray line would set-up the tray, putting on the utensils, condiments, and the meal tickets, and then calling out all the important things [diet, allergies]. The third person on the line is supposed to check to make sure everything is on the tray that is supposed to be there as well as serving as the last check to make sure there is nothing on the tray that should not be there. [Resident #89's name] allergies may have been on the meal ticket, but I do not recall. During an interview on 6/5/2025 at approximately 10:40 AM, Staff M, Dietary Partner, stated, I was working on the tray line during the lunch shift on 8/16/24, as an EA2, which is the third position on the line. The normal process was for the bottom or third position on the tray line included reading the meal ticket to make sure it is right, make sure everything is complete, which included looking at the type of diet and if there were allergies; to make sure they don't get it [an allergic food item]. During an interview on 6/5/2025 at 11:03 AM, the Medical Doctor #1 stated, I do not recall the specific details regarding the incident on 8/16/24 with [Resident #89's name] other than she had a reaction. [Resident #89's name] was given epinephrine, but I do not know if it was one dose or two. [Resident #89's name] came into the facility with the allergy to fish and seafood. I do not know if [Resident #89's name] allergies were life threatening, and I have never seen a life-threatening food allergy. [Resident #89's name] did believe that her food allergies were life threatening. During an interview on 6/5/2025 at 11:33 AM, Staff N, CNA, stated, I remember the incident with [Resident #89's name] on August 16, 2024, having an allergic reaction. The resident was passed a tray that had a food on it that she was allergic to. The nurse instructed me to assist the resident to wash her hands because she had touched the fish, and when I went into [Resident #89's name] room the resident was rubbing her eyes, but she said she was fine. [Resident #89's name] appeared to not be able to breathe well and that she was choking, and I went to get the nurse. The process was for the CNAs to double-check the ticket and the meal, to make sure none of the allergens were on the tray. During an interview on 6/5/2025 at 12:50 PM, Staff D, Licensed Practical Nurse (LPN), stated, A CNA alerted me that there was an issue with Resident #89. She discovered that the resident had fish on the tray and she [Resident #89] was allergic. The resident told her that she had touched the fish, so she had her wash her hands and they washed the surface, and removed the tray. I alerted [Staff P, RN's name] who then contacted the doctor. When I entered the room the second time I was alerted by the CNA, that the resident appeared to be short of breath, but I do not recall the resident having any swelling or discoloration. During an interview on 6/5/2025 at 12:53 PM, Staff P, RN, stated, I was notified of the situation with [Resident #89's name] and I got the doctor, as he was in the building. The doctor assessed the resident and stayed in the room until the resident was breathing normal and was stable. He gave an order to administer an epi pen, but there was not an epi pen in the [name of the medication dispensing system], so I got the order to give the epinephrine and once I had a filtered needle I administered the medication. The resident had a second incident [signs and symptoms after the epinephrine administration] and I attempted to contact the doctor. He returned my call and gave an order for a second dose of epinephrine, which I administered. The doctor also gave an order to call 911, which I did. During an interview on 6/5/2025 at 2:10 PM, the Corporate Risk Manager stated, I was notified immediately of [Resident #89's name] incident on 8/16/24, and I came to the facility on [DATE] to do a follow-up Ad Hoc [means for this: created or done for a particular purpose] QAPI [Quality Assurance Performance Improvement] and follow-up education with the staff. As I understood it, the Resident had a BIMS [Brief Interview for Mental Status] score of 14 [cognitive function is largely intact] and had instructed the CNA when he delivered her lunch tray not to remove the lid, just to leave it until she was ready to eat. The resident had requested to have the lunch tray left with her for her to be able to eat other food items, the potatoes, off of the plate, because she knew she was allergic to the fish and would not eat it. During an interview on 6/5/2025 at 5:32 PM, the Medical Director stated, I remember the case with [Resident #89's name] being served a meal where she ate something off of the plate and had an allergic reaction, due to human error. [Medical Doctor #1's name] was on site, and the resident was treated for the allergic reaction. I believe that the allergic reaction was a rash and that it was classified as severe. I am not at my computer and am not able to refer to the documentation from the emergency room regarding whether the reaction was anaphylaxis. Anaphylactic reactions could be fatal. We discussed the situation in QAPI right after it happened and addressed what could be done to avoid it [residents receiving food items to which they were allergic]. Food allergies could cause a fatal reaction, but I believe that the resident did not present as such. Review of the Allergy & Asthma Network at https://allergyasthmanetwork.org read, Epinephrine will treat a life-threatening allergic reaction immediately. Review of the Mayo Clinic webpage at https://www.mayoclinic.org/drugs-supplements/epinephrine-injection-route/description/drg-20072429, on 6/15/2025 read, Epinephrine (injection route) Epinephrine injection is used for emergency treatment of severe allergic reactions (including anaphylaxis) to insect bites or stings, medicines, foods, or other substances. Review of the Mayo Clinic webpage at https://www.mayoclinic.org/diseases-conditions/food-allergy/symptoms-causes/syc-20355095, on 6/15/2025 read, Food allergy - Symptoms and causes - Anaphylaxis: Constriction and tightening of the airways. A swollen throat or the sensation of a lump in your throat that makes it hard to breathe, shock with a severe drop in blood pressure, rapid pulse, and dizziness, lightheadedness or loss of consciousness. Review of the facility policy and procedure titled Food Allergies and Intolerances with the last review date of 1/28/2025 read, Policy Statement. Resident with food allergies and /or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to the allergen(s). Policy Interpretation and Implementation: 4. Meals will be prepared for resident with food allergies to prevent cross-contamination as needed. 5. Resident with food intolerances and allergies will be offered appropriate substitutions of equal nutritive value for foods they cannot eat. 6. Nursing staff and food service employees shall be trained in the signs and symptoms of allergic reaction to foods and basic first aid measures in the event of a food allergy reaction. Review of the facility policy and procedure titled Resident Nutrition Services with the last review date of 1/28/2025, read, Policy Statement - Each resident shall receive meals, with preferences accommodated, prompt meal service and appropriate feeding assistance. Policy Interpretation and Implementation - 1. The Food Service Director, Dietitian, Dietetic Technician and the interdisciplinary team will collaborate to obtain resident food likes, dislikes and eating habits and develop a resident care plan based on this information as needed. 2. Nursing personnel will ensure that residents are served the correct food tray. The Immediate Jeopardy (IJ) was removed on 8/20/2024. On 8/16/2024 through 8/20/2024, the facility conducted an investigation into the incident. The RCA/PIP [Root Cause Analysis/Performance Improvement Plan] resulting in the findings of Resident #89 was served fish on the lunch tray and has an allergy to seafood. Dietary department put fish on the lunch tray and did not identify the allergy listed on the ticket, the CNA did not check the lunch tray, and the tray was served to Resident #89. The facility implemented and completed the following steps. On 8/16/2024, full house audits for all residents were conducted for accuracy of food allergies. A second check was added to the tray line for the verification of all meal tickets. Training/education was mandatory for all clinical and dietary staff in food safety, resident food allergies, meal tickets, and checking trays for allergens to include alert and oriented residents, prior to leaving the meal tray with the resident. Audits for accuracy with meal trays. Physician orders for residents who may ingest or come in contact with a food allergen for emergent use are in the unit medication room. QAPI meeting was held on 8/29/2024 to verify effectiveness and efficiency of the corrective action plan. Review of the QAPI agenda verified meetings were held on 8/16/2024 and 8/29/2024 and the corrective actions related to the allergic incident were reviewed. Review of the in-service sign in sheets dated 8/16/2024 documented 123 of 124 LPNs, RNs, and CNAs signed as having attended the training. Education for dietary staff was conducted 8/16/2024 through 8/20/2024 to include education packets of handouts, food allergens, allergic reactions signs and symptoms, and a quiz were completed by 17 of 17 dietary staff. Observations were conducted of the kitchen and dining room during lunch and dinner meal service on 6/4/2025 and 6/5/2025 of double checks of the meal tray tickets, the meal tickets were verified and documented food allergies in large, bold print. Dietary Tray Audits and Food Allergy Audits were conducted for the period of 8/16/2024 through 10/22/2024. Interviews were conducted with three LPNs, three RNs, eight CNAs, and five Dietary staff to verify education and training. The facility corrected the noncompliance on 8/29/2024.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle in 1 of 3 units. Findings include: During an observation on 6/2/2025 at 9:36 AM, Resident #168 was sitting at the edge of her bed. There was one large bottle of Tums on top of the resident's bedside table. During an observation on 6/2/2025 at 10:02 AM, Resident #170 was lying in bed. There was one inhaler on top of the resident's bedside table (Photographic evidence obtained). During an interview on 6/2/2025 at 10:02 AM, Resident #170 stated, I usually keep the inhaler in my purse. I am not allowed to use it unless the nurse is in the room with me. During an observation on 6/2/2025 at 10:09 AM, Resident #42 was not in her room. Resident #42's Sister-in-law was sitting in a chair in the resident's room. On top of the air conditioning unit, there was one medication cup with white cream and spoon (Photographic evidence obtained). During an interview on 6/2/2025 at 10:09 AM, Resident #42's Sister-in-law stated, I do not know why that [medication cup with cream] is there. I know the nurses apply the cream under [Resident #42's name] breast. During an interview on 6/2/2025 at 12:41 PM, Staff S, Licensed Practical Nurse (LPN), stated, I do not see an order for Tums for Resident #168. I will keep the medication in my cart and call the ARNP [Advanced Registered Nurse Practitioner] to see if we can get an order for it. I am not sure why there was a medication cup with white cream in [Resident #42's name] room. I did not leave it there. [Resident #42's name] does have orders for Nystatin, but no orders to self-administer medication. During an interview on 6/5/2025 at 1:49 PM, the Director of Nursing (DON) stated, We evaluate if they have capacity and we do self-administration observation and if they have an order, they can self-administer. It should not be sitting out if they leave. They should have it locked and it should not be left unattended. [names of Resident #168, Resident #170, and Resident #42] did not have an evaluation for self-administration prior to the observations. Review of the facility policy and procedure titled Medication Storage in the Facility with the last review date of 1/28/2025 read, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures . B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on observation and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis. Findings include: During an observation on 6/2/2025 at 9:00 AM, the nurse staffing information posted under the AED (Automated External Defibrillator) machine upon entering the resident area did not include a resident census (Photographic evidence obtained). During an interview on 6/2/2025 at 9:10 AM, the Administrator stated, The facility census is 118. During an observation on 6/2/2025 at 9:18 AM, the nurse staffing information showed a resident census of 115 (Photographic evidence obtained). During an interview on 6/5/2025 at 5:27 PM, the Director of Nursing (DON) stated, On Monday, I posted the Federal Staffing information, but it did not include the census. The scheduler was here on Monday and she changed the form. She updated the staff working but did not update the census. The census posted was the one from Friday. Federal Staffing should be posted every day by 8:30 AM and it should include the date, census and staffing information and it should be accurate. During an interview on 6/6/2025 at 12:15 PM, the Administrator stated, The Federal Staffing report should include a census when it is posted and the census should be accurate. I believe there were new admissions that did not reflect on the census that was added to the report later that day.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 9 residents reviewed for dining (Resident #165). Findings include: Review of Resident #165's physician order dated 4/14/2025 read, [Name of liquid nutritional supplement]. Record % [percentage] Consumed. Special instructions: Give Vanilla [Name of liquid nutritional supplement] BID [twice a day], Poor intake. Review of Resident #165's Medication Administration Record (MAR) for May 2025 for administration of liquid nutritional supplement showed no entries for the consumed percentage on 5/7/2025 at 6:00 PM, 5/8/2025 at 6:00 PM, 5/19/2025 at 6:00 PM, 5/28/2025 at 6:00 PM, and 5/30/2025 at 6:00 PM. Review of Resident #165's MAR notes for 5/7/2025 read, Not Administered: Other Comment: previous shift did not complete. Review of Resident #165's MAR notes for 5/8/2025 read, Not Administered: Other Comment: previous shift. Review of Resident #165's MAR notes for 5/28/2025 read, Not Administered: Other Comment: previous shift. Review of Resident #165's MAR notes for 5/30/2025 read, Not Administered: Other Comment: previous. During an interview on 6/5/2025 at 1:09 PM, Staff P, Registered Nurse (RN), stated, The nurses are supposed to document the percent of [Name of liquid nutritional supplement] that [Resident #165's name] is taking, but sometimes the resident takes a longer time to drink the [Name of liquid nutritional supplement] and the nurse will not be here to document. During an interview on 6/6/2025 at 10:16 AM, Staff U, RN, stated, The previous shift gives her the [Name of liquid nutritional supplement] and when I come in, I cannot 100 percent say what amount she took. It might be passed down on report, but if it is picked up before, then I miss it and cannot document how much she took. Review of Risk Management Witness Statement authored by Staff V, Licensed Practical Nurse (LPN) on 6/5/2025 read, [Name of liquid nutritional supplement] given on previous shift and percentage not documented on 7pm-7am shift because system will not allow me to. Review of the facility policy and procedure tilted Charting and Documentation with the last review date of 1/28/2025 read, Policy Statement: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident medical record. Policy Interpretation and Implementation: 1. All observations, medications, administered, services performed, etc., must be documented in the resident's clinical records.

Based on observation and interview, the facility failed to ensure resident dignity while assisting with feeding for 1 of 9 residents reviewed for dining (Resident #165). Findings include: During an observation on 6/2/2025 from 12:23 PM through 12:40 PM, Resident #165 was sitting in her wheelchair. Staff Q, Certified Nursing Assistant (CNA), was standing over the resident while assisting the resident with feeding. During an observation on 6/3/2025 from 12:05 PM through 12:22 PM, Resident #165 was sitting in her wheelchair. Staff R, CNA, was standing over the resident while assisting the resident with feeding. During an interview on 6/4/2025 at 1:26 PM, Staff Q, CNA, stated, I normally sit while I am feeding or assisting the resident with feeding. I was standing because I just want to be able to see any call light that went off, but I normally sit. During an interview on 6/4/2025 at 12:28 PM, Staff R, CNA, stated, If we were in the dining room, I would sit but if I am in a resident's room, I stand because I do not want to sit on her [Resident #165] bed. During an interview on 6/4/2025 at 12:42 PM, the Director of Nursing (DON) stated, I do not expect staff to pull a privacy curtain or sit while feeding a resident in their room. We do not have a policy that talks about the guidelines staff should follow when feeding a resident. During an interview on 6/4/2025 at 4:45 PM, the Registered Dietician (RD) stated, I think seating at eye level is preferred instead of standing over a resident in order to facilitate meal assistance.

Based on record review and interview, the facility failed to ensure the physician/prescriber documented the rationale for declining the pharmacist's recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident #89). Findings include: Review of Resident #89's Medication Regimen Review (MRR) showed the consultant pharmacist's recommendation dated 12/20/2024 that read, Findings/Recommendations . The current medications listed below may have contributed to the fall. Concurrent use of these medications may increase side effects such as dizziness, drowsiness, confusion, falls, impaired judgement/motor coordination, and difficulty concentrating. Psychotropic Medications: Trazodone 50 mg [milligram] qHS [every day at bedtime] . Cardiovascular Medications . Flomax 0.4 mg q [every day] 8AM . Anticonvulsants . Gabapentin 200 mg at 8AM-8PM . Please consider the following recommendations to reduce risk for falls . Consider changing administration time of Flomax 0.4 mg to qHS due to increased risk of orthostatic hypotension, Consider re-evaluating and try decreasing Gabapentin to 100 mg at 8[A]M - 8PM, Consider a trial D/C [discontinuation] of Trazodone therapy. There was a line drawn through the recommendations, and the form was signed by Medical Doctor #1. The form also documented, MD response acknowledged, and included nurse initials. The form included no comment or rationale. Review of Resident #89's Medication Regimen Review (MRR) showed the consultant pharmacist's recommendation dated 4/18/2025 that read, Findings/Recommendations: New Admission Medication Regimen Review . #2) Excessive Duration/ Beers Drug/ Potentially Inappropriate Medication: Meloxicam 7.5 mg. There is an increased risk of GI [gastrointestinal] bleeding or peptic ulcer disease in high-risk groups, including those taking oral anticoagulants; use of proton pump inhibitor reduces but does not eliminate risk. Also, it can increase blood pressure and induce kidney injury . Consider discontinuation and prescribe: Acetaminophen 500 mg 2 tablets (2,000 mg) twice daily scheduled for pain. The physician disagreed and signed the form. There was no comment or rationale documented. Review of Resident #89's physician orders showed an order dated 4/16/2025 for Flomax Capsule 0.4 mg by mouth once day. Review of Resident #89's physician orders showed an order dated 4/16/2025 for Gabapentin Capsule 100 mg, 2 capsules by mouth twice daily at 8:00 AM and 8:00 PM. Review of Resident #89's physician orders showed an order dated 4/16/2025 for Trazodone 100 mg by mouth at bedtime. Review of Resident #89's physician orders showed an order dated 4/16/2025 for Meloxicam tablet 7.5 mg by mouth once a day. During an interview on 6/5/2025 at approximately 1:00 PM, the Director of Nursing (DON) stated, The pharmacist gives me the monthly medication reviews, and I give the pharmacist recommendations to the provider. There is not a specific time frame for the provider to return them, but [Medical Doctor #1's name] usually returns them in a timely manner. Unless it is indicated or requested on the form, no rationale is given by the provider. There was a discussion with the provider about the recommendations, but she only initialed the forms. she did not document any discussion. She believed it was on the provider to document the rationale [for not accepting the pharmacist's recommendations.]. During an interview on 6/6/2025 at 10:20 AM, Medical Doctor #1 stated, I believe I provided the rationale on the forms [Consultant Pharmacist's Report] regarding why I did not accept the pharmacist's recommendations regarding medication changes. The forms do not always ask for a reason, and sometimes I may not remember to provide a rationale. If I was giving an order [verbally] there was a discussion with a nurse, and I expect the nurse to write down the discussion, but for the recommendations I disagreed with, there is no discussion. Review of the facility policy and procedure titled Consultant Pharmacist Reports- IIIA1: Medication Regimen Review with the last review date of 1/28/2025 read, Policy: The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MMR also involves a thorough review of the resident records, and may include collaboration with other members of the interdisciplinary team, collaboration with the resident, family members or other resident representatives. MRR also involves reporting of findings with recommendations for improvement. All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the administrator. Procedures . B. The consultant pharmacist reviews the medication regimen of each resident at least monthly . G. Recommendations are acted upon and documented by the facility staff and/or the prescriber. 1) Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.

Based on observations, interviews, and policy and procedure review, the facility failed to ensure the kitchen and nourishment room equipment was maintained in a safe and clean operating manner. (Photographic evidence obtained). Findings include: During a walk-through tour of the kitchen conducted on 03/04/24 beginning at 9:20 AM with the Certified Dietary Manager (CDM) an observation was made of the top confection oven and showed a large amount of a brown, black, and rust colored buildup of dirt and food debris. During a tour of the kitchen on 03/05/2024 beginning at 7:20 AM with the CDM an observation of the bulk sugar bin was made and showed there was a scoop with a clump-like buildup of a golden-brown discoloration visible on the scoop. There was a large area of dust/debris on the base of the insulated food carts. There was an electrical plug box the height of the tray line around the pellet and plate warmers and directly under an air vent that had a buildup of dust/dirt surrounding the entire box. In the bulk bin that contained food thickener there was a buildup of dirt and food debris around the handle and lid. During an observation on 03/06/2024 at 12:15 PM of the nourishment rooms with the CDM, in the Royal Terrace hallway nourishment room there was a microwave oven with a large build-up of food debris of tan, black, gold, and brown splotches and splatters on the interior top of the microwave. During an interview on 03/05/2024 at 7:30 AM the CDM verified the buildup of dirt, debris, and food particles on the equipment. The CDM confirmed the dirty scoop in the bulk bin containing sugar. The CDM stated, The discoloration and clump-like buildup is due to staff adding sugar to the iced tea urn and the tea splashing up on the scoop. The dirty scoop should not be placed back in the bin. The CDM confirmed the food thickener bin had food particles and debris on the handle and lid, the buildup on the electrical plug box next to the tray line, and the buildup on the food carts. The CDM stated, All equipment should be cleaned according to the policy and cleaning schedule. During an interview on 03/06/2024 at 12:20 PM the CDM confirmed the microwave in the nourishment room should be cleaned according to facility policy. Review of the policy titled, Cleaning Schedules read, Cleaning schedules are posted in the kitchen area. Procedures for cleaning are outlined in easy-to-read form, and follow a daily, weekly, and monthly routine. 4. The Food Service Director spot checks to ensure that proper procedures are followed. Review of the policy titled, Food Receiving and Storage read, 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. Review of a document titled, Daily Cleaning Schedule read, Sunday Late Cook, clean top convection oven. Early Aide 1, clean pellet warmer, Monday, early prep position, all white bins and scoops, Thursday early cook, clean plate warmer, Saturday late prep, clean all push carts.

Based on observation, record review, and interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 2 residents, Resident #60 reviewed for peripherally inserted central catheter/mid-line device. Findings include: Review of resident #60's clinical record documented the resident was admitted [DATE] with diagnosis that included respiratory failure, congestive heart, and pleural effusion (fluid in the tissue of the lungs). During an observation on 3/4/2024, at 9:18 AM of Resident #60 it showed a peripherally inserted central catheter/mid-line device (PICC/MID) line in the resident's upper left arm. There was a clear dressing over the site that was dated 2/22/2024. During an observation on 3/4/2024, at 2:22PM of Resident #60 it showed a PICC/MID line to the resident's left upper extremity. There was a clear dressing over the site that was dated 2/22/2024. During an interview on 3/4/2024 at 9:18 AM Resident #60 stated, That line was placed when I was admitted to the facility and the dressing has not been changed since it was placed. Review of Resident #60's physician orders dated 2/22/2024 read, Midline to LUE [left upper extremity]. Change midline dressing every week and as needed, ensure dressing is initialed and dated. Once a day on Thu [Thursday] 7:00 AM - 3:00 PM. Measure external catheter length of midline with each dressing change. Once a day on Thu 7:00 AM - 3:00 PM. Measure upper arm circumference midline site Q [every] week with each dressing change. Once a day on Thu 7:00 AM - 3:00 PM. Monitor LUE midline site Q shift and PRN [as needed] for indications of infection or infiltration such as redness, drainage, swelling, etc. Notify MD [Medical Doctor] as indicated every shift. Observe Midline insertion site and dressing every shift. Ensure dressing is dated and initialed, every shift. Review of Resident #60's Medication Administration Record (MAR) for the period of February 22, 2024, through March 6, 2024, did not contain documentation the midline dressing change and measurements were conducted as ordered by the physician. During an interview on 3/6/2024 at 1:41 PM Staff D, License Practical Nurse (LPN) stated, Intravenous catheters dressings should be changed every 3 days. During an interview on 3/6/2024 at 1:53 PM Staff E, Registered Nurse (RN) stated PICC/MID lines are changed after initial insertion within 24 hours and every 7 days. The measurement of the circumference of the arm and length of line observed are to be completed when the dressing is changed and documented on the MAR for comparison. During an interview on 3/6/2024 at 8:20 AM the Director of Nursing (DON) stated, The mid-line was inserted here at the facility on 2/21/2024 with a bio-occlusive dressing dated 2/22/2024. The PICC/MID line dressing should have been changed within 7 days or as needed. We do catheter dressing changes on Thursday and as needed. This dressing should have been changed on 2/29/2024. The order did not show up on the MAR because it was written in error as a start date of 3/1/2024. Review of the policy and procedure titled, Midline Catheter Dressing Change dated 1/17/2024 read, Guidance: 1. Sterile dressing change using transparent dressings is performed: 1.1 24 hours post-insertion or upon admission. 1.2 at least weekly. 1.3 If the integrity of the dressing has been compromised (wet, loose or soiled). 6. Assessment of entire arm with indwelling vascular access device (VAD) for infusion related complications is to include, but is not limited to, the absence or presence of . 6.3 Swelling or induration (compare to baseline measurement to detect possible catheter - associated venous thrombosis; a 3-cm [centimeter] increase in arm circumference and edema were associated with upper-arm deep vein thrombosis.) 7. Length of external catheter is obtained: 7.1 24 hours post insertion or upon admission 7.2 During dressing changes. 8. Arm circumference (10 cm above antecubital fossa) is obtained: Compare to baseline measurement to detect possible catheter-associated venous thrombosis; 3-cm increase in arm circumference and edema were associated with upper-arm deep vein thrombosis.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 4 residents, Residents #43 and #107, reviewed for continuous oxygen administration. Findings include: During an observation on 3/4/2024 at 9:02 AM, Resident #43 was lying in bed wearing an oxygen nasal cannula. The oxygen concentrator was set to 4 liters per minute for oxygen administration. (Photographic evidence obtained). During an observation on 3/5/2024 at 7:45 AM, Resident #43 was lying in bed wearing an oxygen nasal cannula. The oxygen concentrator was set to 4 liters per minute for oxygen administration. (Photographic evidence obtained) During an interview on 3/5/2024 at 7:50 AM Resident #43 stated, I am supposed to be on 3 liters of oxygen. I am not able to adjust it myself. Review of the physician order for Resident #43 dated 12/1/2023 read, Humified Oxygen @ 3 L/Min (at 3 liters per minute) via nasal cannula. During an interview on 3/6/2024 at 11:35 AM Staff A, RN (Registered Nurse) stated, [Resident #43's name's] order calls for 3 liters per minute, and the oxygen concentrator is set to 4 liters per minute. During an observation on 3/4/2024 at 9:42 AM, Resident #107 was lying down in bed wearing an oxygen nasal cannula. The oxygen concentrator was observed to be set to 4 liters per minute for oxygen administration. (Photographic evidence obtained). During an observation on 3/5/2024 at 8:10 AM, Resident #107 was sitting up in bed wearing an oxygen nasal cannula. The oxygen concentrator was observed to be set on 4 liters per minute of oxygen administration. (Photographic evidence obtained). Review of the physician order for Resident #107 dated 2/8/2024 read, Oxygen @ 2 L/Min via nasal cannula. During an interview on 3/6/2024 at 11:30 AM Staff C, LPN (Licensed Practical Nurse) stated, That is an incorrect oxygen setting. [Resident #107's name's] oxygen should be on 2 liters per minute. During an interview on 3/6/2024 at 11:40 AM the Director of Nursing stated, My expectation is that the nurses are to follow the physicians' orders when administering oxygen.

Based on observation and interview, the facility failed to ensure updated nurse staffing information was posted daily. Findings include: During an observation on 3/4/2023 at 9:00 AM, the facility's Direct Care Staffing Report was observed posted on the wall and was dated 2/28/2024. During an interview on 3/6/2024 at 9:00 AM the Administrator stated, We are to post our Direct Care Staffing Report daily at the beginning of the shift.

Based on observation, interview, and record review, the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 4 of 7 residents reviewed for respiratory care, Resident #158, #82, #21 and #80. Finding include: Review of Resident #21's medical record noted the resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's medical record revealed an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/2022 at 11:27AM, Resident #21's passive nebulizer treatment mask was observed to be hanging from the resident's lamp located to the right side of the bed table. The nebulizer tubing was disconnected from the machine and was laying on the floor. There was no date labeled on the nebulizer tubing. On 09/20/2022 at 8:35AM, Resident #21's passive nebulizer treatment mask was observed laying on top of the dresser. There was no date labeled on the tubing. On 09/20/2022 at 11:35AM, Resident #21's passive nebulizer treatment mask was observed laying on top of the dresser. There was no date labeled on the tubing. During an interview on 09/20/2022 at 11:54 AM, the Unit Manager stated passive nebulizer treatment masks should be stored in plastic bag, labeled with the resident's name and dated. Nebulizer tubing should also be dated. Review of Resident #82 's medical record noted the resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/19/2022 at 11:25AM, Resident #82 was observed sitting in her wheelchair with oxygen being administered at 3 liters per minute via nasal cannula. On 09/19/2022 at 1:30PM, Resident #82 was observed resting in bed with oxygen being administered at 3 liters per minute via nasal cannula. On 09/20/2022 at 8:30AM, Resident #82 was observed resting in bed with oxygen being administered at 3 liters per minute via nasal cannula. On 09/20/2022 at 10:00AM, Resident #82 was observed resting in bed with oxygen being administered at 3 liters per minute via nasal cannula. During an interview conducted on 09/20/2022 at 11:52AM, the Unit Manager stated, It [the oxygen for Resident #82] is running at 3 liters. Review of Resident #158 's medical record noted the resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #158's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/2022 at 11:24 AM, Resident #158's bed was observed to have nasal cannula and oxygen tubing laying on top of the bed. The oxygen tubing was not property stored and was not labeled. On 09/19/2022 at 12:24 PM, Resident #158 was observed resting in bed with oxygen being administered at 3.5 liters per minute via nasal cannula. On 09/19/2022 at 2:00 PM, Resident #158 was observed resting in bed with oxygen being administered at 3.5 liters per minute via nasal cannula. On 09/20/2022 at 8:00 AM, Resident #158 was observed resting in bed with oxygen being administered at 3.5 liters per minute via nasal cannula. On 09/20/2022 at 11:30 AM, Resident #158 was observed resting in bed with oxygen being administered at 3.5 liters per minute via nasal cannula. During an interview conducted on 09/20/2022 at 11:50 AM, the Unit Manager stated, It [the oxygen] is running at 3.5 liters. Review of the policy and procedure last reviewed on 01/24/22 titled, Specific Medication Administration Procedures reads, T. Store equipment in a plastic bag with the resident's name and the date on it. U. Change equipment and tubing every [seven days]. Review of the policy and procedure last reviewed on 01/24/22 titled Oxygen Administration reads, Steps in procedure: 2. Turn on the oxygen. Unless otherwise ordered, start flow of oxygen at ordered rate. 4. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of Resident #80's medical record documented the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #80's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 09/19/22 at 10:35 AM of Resident #80 showed the resident was sitting on the side of the bed. Oxygen was being administered at 2 liters via nasal cannula. There was no date labeled on the oxygen tubing. An observation on 09/20/2022 at 09:35 AM showed Resident #80 was sitting on the side of the bed. Oxygen was being administered via nasal cannula at 2 liters per minute. The oxygen tubing is not dated. During an interview on 9/20/2022 at 11:44 AM the Unit Manager confirmed Resident #80's oxygen tubing is not dated.

Based on observation, interview, and record review, the facility failed to store food and maintain a clean and sanitary environment in accordance with professional standards for food service safety. Findings include: During an observation conducted on 9/19/2022 at 9:55 AM, in the dry storage room on a shelf was an open box of sweet potatoes with several potatoes oozing a liquid. Several small black flying insects were observed in the box of potatoes. Water was observed dripping from the door of the upright steamer causing a puddle of water on the table that was dripping onto the floor in the main kitchen. During an interview conducted on 9/19/2022 9:55 AM, the CDM stated; We hadn't had time to check that [box of sweet potatoes] over the weekend. That [upright steam table] shouldn't do that. During an observation conducted on 9/19/2022 at 10:15 AM in the East Nourishment room, on a shelf in the refrigerator there was a pitcher with liquid that was red in color that was not dated. There was a plastic bag containing what appeared to be lasagna that was not dated or labeled with a resident's name. During an interview conducted on 9/19/2022 at 10:15 AM, the Certified Dietary Manager (CDM) stated; That [red liquid] is not dated. It [the plastic bag of food] should be dated, and the nurses are responsible for checking the dates on food in the refrigerators. Review of the policy and procedure titled Storage of Foods Brought to Residents by Family/Visitors dated 1/12/21 and reviewed on 1/24/2022 reads; Perishable foods must be stored in a manner which minimizes risk of cross contamination in the designated resident refrigerators. The foods will be labeled with the resident's name and dated. Review of the policy titled Storage of Nonperishable Foods dated 1/12/21 with an annual review date of 1/24/2022 reads; Storeroom shall be maintained free from dirt, dust, insects, rodents, or any potential source of contamination. Review of the policy and procedure titled Preventive Maintenance-Kitchen Equipment reviewed on 01/24/2022 read; Preventive maintenance of kitchen equipment designates specific requirements to provide a reasonably safe environment for staff during normal operating times in both new construction and existing buildings. Conduct safety and operation inspections 1.) Visually inspect all appliances for damage. Document findings in log book 1). remove damaged items from kitchen use.

Based on observation, interview, and record review the facility failed to implement fall prevention care plan interventions for 1 of 4 residents, Resident #26, reviewed for accidents. Findings include: On 9/19/2022 beginning at 10:34 AM, Resident #26 was observed in her room. Resident #26 was initially observed walking without an assistive device from her restroom to her bed. A three-prong cane was available for use on Resident #26's side of the room. There was no wheelchair in Resident #26's room available for her use. During the initial observation, Resident #26 attempted to sit on the top of the in-room air conditioning unit, lost her balance and leaned over forward onto cardboard boxes. A staff member standing nearby assisted Resident #26 up off of the cardboard boxes onto the in-room air conditioning unit. During an interview on 9/19/2022 beginning at 10:34 AM, Resident #26 stated she falls real easy and when she falls, she falls backwards. Resident #26 added that she had fallen 3 times and busted my head, I'm supposed to be in a wheelchair or use a walker. I have doctor's orders not to walk without a wheelchair. During an interview on 9/21/2022 at 8:36 AM, Staff A, Physical Therapist, reported Resident #26 had been provided a high back wheelchair with a cushion and anti-roll back device. On 9/21/2022 at 8:39 AM, an observation of Resident #26 and her room was completed with the Director of Rehabilitation. There was no wheelchair in Resident #26's room available for her use. During an interview on 9/21/2022 beginning at 8:47 AM, Staff B, Registered Nurse, stated, I always see her ambulating in her room, even when she goes out with family, I see her ambulating. I did not know she [Resident #26] did not have one [a wheelchair]. Staff B reported Resident #26 had taken a leave of absence from the facility on 9/2/2022 and returned to the facility on [DATE]. During an interview on 9/21/2022 beginning at 9:02 AM, Staff C, Certified Nursing Assistant, stated therapy had taken Resident #26's wheelchair when Resident #26 left the faciity on leave of absence. Staff C confirmed Resident #26 did not have a wheelchair available for her use on 9/19/2022 so she got her one for transport. Review of Resident #26's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's care plan, start date 8/8/2022, revealed Resident #26 was at risk for falls related to weakness/debility and a history of [CONDITION(S)] and collapse. Resident #26's care plan documented fall prevention interventions that included OOB [Out of Bed] in Standard Wheelchair with cushion, ARBD [Anti Roll Back Device] as tolerated.

Based on observation, record review, and interview, the facility failed to provide drainage tube dressing care and services to meet professional standards of quality of care for 1 of 3 residents, Resident #263, sampled for drainage tube care, and failed to provide Foley catheter drainage management for 1 of 3 residents, Resident #458, sampled for catheter care. Findings include: Review of the medical record for Resident #263, documented the resident, age 82, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #263's physician orders documented an order dated 9/14/22 which read, clean around chole tube w/ NS [with normal saline] apply non-stick [MEDICATION(S)], cover w/ 4 x 4 and top with green opsite [a wound care dressing] daily. During an observation conducted on 09/19/22 at 11:34 AM, Resident #263 was observed to have a cholecystostomy [gallbladder] tube. The dressing surrounding the tube was not labeled or dated. During an observation conducted on 09/19/22 at 1:54 PM, Resident #263 was observed to have a cholecystostomy tube in place with the dressing not labeled or dated. During an interview with Staff D, LPN (Licensed Practical Nurse) conducted on 09/19/22 at 1:55PM, she confirmed Resident #263's dressing was not labeled or dated. During an interview with the Director of Nursing conducted on 09/19/22 at 2:35 PM, she confirmed her expectation is for all dressings to be labeled with the date applied and initials. Review of the facility policy and procedure dated 01/2022, titled, Dressings, Dry/ Clean, reads, 10. Label tape or dressing with date, time, and initials. Review of the medical record for Resident #458 documented the resident was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders dated 9/13/2022 read, 24 fr [French] 30cc [cubit centimeter] Urinary Catheter to BSD [bed side drainage] due to retention; Check Q [every] shift & PRN [as needed] to ensure draining properly. An observation on 09/19/2022 at 10:35 AM showed Resident #458 was lying on her left side. There was a urinary catheter drainage leg bag observed attached to her right leg. The Foley tubing and the Foley catheter urinary drainage leg bag were full of urine which did not allow for drainage from Resident #458's bladder. An observation on 9/20/2022 at 11:35 AM showed Resident #458 was lying flat on her back across the bed with her feet flat on the floor. There was a Foley urinary drainage leg bag observed attached to the right side of her upper leg. The Foley catheter tubing and the Foley catheter urinary drainage leg bag were full of dark yellow colored urine which did not allow for drainage from Resident #458's bladder. During an interview on 9/21/2022 at 09:10 AM the Director of Nursing (DON) stated the orders need to be followed and the standard of care for foley leg bags are for when residents are up and about not laying down or sleeping. During an interview on 9/21/2022 at 09:16 AM with Resident #458's sister, who resides in the facility, Resident #258 stated, I want the leg bag taken off and I did not request a leg bag to be worn all the time. During an interview on 9/21/2022 at 10:22 AM Staff E, Certified Nursing Assistant (CNA) stated, Foley bags are emptied once a shift and if needed. The amount is documented in the Metrics if the nurse needs the information. During an interview on 9/21/2022 at 12:50 PM Staff F, CNA stated, Bags are emptied once a shift, leg bags are more frequently because they don't hold much. Review of the policy and procedure dated 1/24/22, titled, Catheter Care, Urinary reads: Unobstructed urine flow - 1) Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 2) unless specifically ordered, do not apply clamp to the catheter. 3) The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Infection Control section 2: c - Empty the drainage bag regularly using a separate, clean collection container for each resident. Avoid splashing and prevent contact of the drainage spigot with the nonsterile container. d. Empty the collection bag as needed.

Based on observation, interview and record review the facility failed to ensure fall prevention devices were available for 1 of 4 residents, Resident #4, reviewed for falls/accidents. Findings include: On 9/19/2022 beginning at 10:34 AM, Resident #26 was observed in her room. Resident #26 was initially observed walking without an assistive device from her restroom to her bed. A three-prong cane was available for use on Resident #26's side of the room. There was no wheelchair in Resident #26's room available for her use. During the initial observation, Resident #26 attempted to sit on the top of the in-room air conditioning unit, lost her balance and leaned over forward onto cardboard boxes. A staff member standing nearby assisted Resident #26 up off of the cardboard boxes onto the in-room air conditioning unit. During an interview on 9/19/2022 beginning at 10:34 AM, Resident #26 stated she falls real easy and when she falls, she falls backwards. Resident #26 added that she had fallen 3 times and busted my head, I'm supposed to be in a wheelchair or use a walker. I have doctor's orders not to walk without a wheelchair. During an interview on 9/21/2022 at 8:36 AM, Staff A, Physical Therapist, reported Resident #26 had been provided a high back wheelchair with a cushion and anti-roll back device. On 9/21/2022 at 8:39 AM, an observation of Resident #26 and her room was completed with the Director of Rehabilitation. There was no wheelchair in Resident #26's room available for her use. During an interview on 9/21/2022 beginning at 8:47 AM, Staff B, Registered Nurse, stated, I always see her ambulating in her room, even when she goes out with family, I see her ambulating. I did not know she [Resident #26] did not have one [a wheelchair]. Staff B reported Resident #26 had taken a leave of absence from the facility on 9/2/2022 and returned to the facility on [DATE]. During an interview on 9/21/2022 beginning at 9:02 AM, Staff C, Certified Nursing Assistant, stated therapy had taken Resident #26's wheelchair when Resident #26 left the faciity on leave of absence. Staff C confirmed Resident #26 did not have a wheelchair available for her use on 9/19/2022 so she got her one for transport. Review of Resident #26's physician's orders, revealed a physician's order, start date 5/6/2022, for Resident #26 to use a standard wheelchair with cushion and anti-roll back device. Review of Resident #26's care plan, start date 8/8/2022, revealed Resident #26 was at risk for falls related to weakness/debility and a history of [CONDITION(S)] and collapse. Resident #26's care plan documented fall prevention interventions that included OOB [Out of Bed] in Standard Wheelchair with cushion, ARBD [Anti Roll Back Device] as tolerated.

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. Findings: A tour of the facility's walk-in freezer on 3/29/2021 beginning at 9:30 AM showed an opened bag of Italian frozen vegetables, an opened bag of baking dough wrapped in saran wrap, an opened bag of frozen chicken strips and a partially uncovered box of opened un-iced sponge cake on the shelves of the freezer, which did not have open dates written on them (Photographic evidence obtained). During an interview on 3/29/2021 at 9:54 AM, the Assistant Food Service Director stated the opened food items in the freezer should have been covered, closed completely and marked with an open date. Review of the facility's policy titled Food Receiving and Storage dated 1/12/2021 read, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated.

Based on observation and interview, the facility failed provide a sanitary environment for residents for two of four water fountains. Findings: On 9/10/11 starting at 2:33 PM a tour of the facility was conducted. The following concerns related to environment and cleanliness were observed: [NAME] The water fountain located at front of building (near wash rooms) was observed with brownish substance around the water spout. B. The water fountain located on Royal Terrace (across from the nurse station) was observed with black substance in the base of the water fountain. On 9/11/11 starting at 8:58 AM a tour of the facility revealed: [NAME] The water fountain located at front of building (near wash rooms) was observed with brownish substance around the water spout. B. The water fountain located on Royal Terrace (across from the nurse station) was observed with black substance in the base of the water fountain. On 09/11/19 at 10:01 AM, a tour of the facility was conducted with the Environmental Service Director. She observed and confirmed the brownish and black substance on the two water fountains. The Environmental Service Director stated we clean the water fountain daily and admitted that she was not sure why the water fountain had brownish and black substance present.

Based on observation, interview and record review, the facility failed to ensure that it was free from expired medication and medications that were opened and undated in 2 of 4 carts out of a total of 8 medication carts in the facility. The facility also failed to ensure that nutritional supplements were not expired in 1 of 2 medication storage rooms. Findings: An observation on [DATE] at 9:40 AM on the ,[DATE] hallway. 2 bottles of [MEDICATION NAME] R Insulin were in the working stock drawer of the medication cart. The Insulin bottles did not have a date opened on the bottle or the box the Insulin was stored in. 1 [MEDICATION NAME] Flex-pen was in the cart that did not show the date the Insulin was opened. During an interview on [DATE] at 9:48 AM with Staff A Licensed Practical Nurse (LPN) stated he was unsure why the Insulin was in the medication cart in the working stock drawer and did not have the date the Insulin was opened. The nurse stated some Insulin expires in 28 days and some in 42 days. Continued observation on [DATE] at 9:57 AM showed the ,[DATE] hallway medication cart contained 1 [MEDICATION NAME] Insulin Pen, that did not show the date the Insulin was opened. 1 bottle of [MEDICATION NAME] eye drops was opened and did not show the date the eye drops were opened. 1 tube of [MEDICATION NAME] eye drops was opened in the drawer without an open date on the tube or the bag. During an interview on [DATE] at 10:05 AM with Staff B LPN she stated, she was not sure why the medications in the working stock drawers of Insulin, [MEDICATION NAME] eye drops or the [MEDICATION NAME] eye ointment was opened in the medication cart without showing a date the medications were opened. The nurse stated the Insulin and eye ointments should show a date they were opened. An observation on [DATE] at 10:12 AM of the Royal Terrace medication storage room showed that 2 out of 3 (46) fluid ounce cartons of thickened apple juice expired on [DATE]. During an interview on [DATE] at 10:20 AM with Staff C Registered Nurse (RN) Unit Manager stated, the facility still uses the thickened apple juice for residents. The Unit Manager confirmed the thickened apple juice was expired as of [DATE]. A review of the storage and expiration dating of medications, biologicals, syringes and needles policy and procedure last revised [DATE] read, once any medication or biological package is opened. Facility should follow manufacturer/supplier guidelines, with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened.

Based on observation, facility documentation and interview, the facility failed to ensure food was prepared for resident service that was maintained at the appropriate temperatures, (hot foods at or above 135 degrees Fahrenheit (*F)), to prevent the potential for the spread of food borne illness and to be in compliance with established Food Code regulatory standards. Findings: An observation of the resident tray line lunch meal service was conducted on Wednesday 10/24/2018 beginning at 7:45 AM. A calibrated facility thermometer was utilized by facility during the temperature validation conducted by the Food Services Director. All foods on the steam table checked for temperature compliance to include: Scrambled Eggs 122.9*F Sliced Ham 132.8*F Sausage Link (top of pan) 119.0*F Sausage Ground 122.1*F Scrambled Eggs Pureed 126.3*F An interview was conducted with the Food Services Director on 10/24/2018 at 8:04 AM regarding the discrepancies in the temperatures compared to what they documented. She confirmed temperatures were checked once their pans came from either oven or production to the serving line (steam table) for beginning service at 7:15 AM. It was confirmed when checked 30 minutes later, there had been a 30-40*F drop in the temperatures between the two readings and with the compliance reading, bringing the food to temperatures well below the allowable hot holding temperature for service. A review of the facility policy dated 1/18/2018 revealed: Meal Delivery: 1.) Hot food shall leave the kitchen at a minimum of 135 degrees F. 2.) Hot foods are served hot.

Based on observation, record review, interview and policy and procedure review the facility failed to ensure proper care and services for 1 of 9 residents with catheters, Resident #170. Findings: During an observation of the Lunch meal on 10/22/18 beginning at 12:00 PM in the 200 hall Dining Room, Resident #170 was observed sitting in his wheelchair about eight feet from the open door. It should be noted the long wall of the room is in front of the Nurse's Station. It is made of glass with no obstructions in view. Resident #170's catheter bag and tubing were observed to be hanging low under his chair, partially laying on the floor, visual from the door upon entry to the room. Both Certified Nursing Assistants and Nurses attended to the resident during the meal. When the resident finished, the Resident's spouse pushed him out of the dining room and down the hall, back to his room, passing staff, all while in a straight line of vision from the Nurse's station. During an interview with Resident #170 and his spouse on 10/22/18 at approximately 12:40 PM, he stated he did not receive any training from the staff regarding catheter care. His wife stated they did not receive any training by the facility for catheter care. They stated they did not need additional training, they know how to use the catheter safely. Staff has not asked them if they wanted training. They don't call for assistance when the resident transfers or moves from the bed or the wheelchair. The wife stated sometimes she cannot find the best place to put the catheter bag so she just puts it anywhere. She stated, sometimes I just hang it on the side. They do not see the problem with the bag and the tubing laying partially on the floor at this time. They stated that's ok regarding the bag and tubing dragging on the floor when she moves him through the facility. The Foley indwelling catheter was inserted about a week earlier, during his stay in the hospital. They stated they did not receive any training at the hospital either. During an observation of Resident #170 with the Licensed Practical Nurse/Staff A on 10/22/18 at approximately 12:45 PM she donned gloves and corrected the placement of his catheter bag and tubing. She confirmed the catheter bag and tubing should not be on the floor or dragging the floor while moving through the facility. She confirmed the catheter bag had not been hung in a proper manner. She confirmed she was not aware of any training for the resident regarding the catheter care. Review of the Occupational Therapy assessment dated [DATE] revealed Resident #170 was admitted on [DATE]. Under Cognition it stated Safety Awareness-Impaired. Under Risk Factors it stated due to the documented physical impairments and associated functional deficits, the patient is at risk for anxiety, falls, behavioral outbursts, decrease in level of mobility, increased agitation, immobility and [MEDICAL CONDITION] insufficiency. His summary stated he presents with impairments in balance, gross motor coordination, mobility and strength resulting in limitations and /or participation restrictions in the areas of domestic life, general tasks, mobility and self care. Review of Resident #170's Progress Notes completed by Nursing on 10/17/8, stated Patient is able to stand and transfer with Supervision. Patient has a 16 FR (French) Foley Catheter placed on 10/15/18 R/T (related to) Chronic [MEDICAL CONDITION]. Patient has a recent UTI (urinary tract infection), continuing ABT (antibiotic) [MEDICATION NAME] 3 more days. He received an indwelling catheter due to obstruction/retention during his hospital stay. Progress Notes written on 10/18/18 state Transfers and stands with staff assist. His Bowel and Bladder Data Collection form dated 10/17/18 states the resident is not free from urinary tract infection, they checked yes for assistance with toileting upon request. Under Cognition, on his Original Admission Review, it stated observe patient behavior and formulate methods to anticipate needs and under Immediate Needs it stated to be free from any further skin breakdown, decrease size of existing pressure ulcer, and under Ambulatory it states walks with help. Under Gait and Balance they checked not able to perform function Review of the Care Plan under Chronic UTI's it stated , under #4, Observe for s/s (signs/symptoms) UTI and under #7 it stated Medication- 10/18/18-urinary catheter to BSD (bed side drainage) and 10/18/[MEDICATION NAME]. Under Falls, it states observe for unsafe practices and urinary catheter to BSD, Remind (assist with positioning). There was no documentation, including the Medication Administration Record [REDACTED]. During an interview with the assigned daily Certified Nursing Assistant /Staff B on 10/23/18 at approximately 10:00 AM, she stated no training had been provided to her for Resident #170. She stated she was not scheduled for work when he was admitted on [DATE] and again on 10/18/18. She stated he has told her he did not need help. She stated she noticed the Resident and his spouse hook the catheter bag in unusual places, she did not know if the couple had received training for catheter care or safety practices. She stated no further action was taken. Review of the Nursing Assistant Flow Sheets for Resident #170 beginning 10/17/18 there should be initials for each shift. There were blank boxes on 10/17/18, 10/18/18 and 10/19/18. The rest are labeled FC (Foley catheter). There was no documentation provided for any description of the care provided or the checks of the bag placement and urine. No further information was provided. Review of the Caring for your Urinary Catheter policy and educational information, it stated under Preventing Infection-Keep the drainage bag below the level of your bladder and off the floor at all times and don't lie on your catheter or block the flow of urine in the tubing. No information was provided noting anyone was trained for this care.